Menopause and pain, hormones and exercise: the aftermath!
I got into a bit of hot water for this late June blog post: “Menopause and pain, hormones and exercise: a beginning.” It mostly summarized and amplified a fresh editorial by Dr. Louise Tulloh. I try to be an ally to women; three quarters of my subscribers and members are women. I hoped I was playing it safe and respectful with a female physician’s seemingly evidence-based perspective in the British Journal of Sports Medicine.
It was not “safe”! 😜
Some of you were displeased. A few were even furious. And I just didn’t see it coming, because I was unaware of one of the major debates in women’s health. I carelessly promoted an editorial that came down strongly on one side of that debate, without acknowledging “who disagrees and why.” Because I didn’t know!
This is why life outside your own “lane” is perilous! It’s hard to know how much you don’t know! But now I know.
The gist of Dr. Tulloh’s piece was that menopause hormone therapy (MHT) can’t do everything that menopausal women need, and so they also need to consider taking exercise seriously as a long-term investment in their health — especially resistance training, which tends to get short shrift.
So … what’s wrong with that?! If you don’t know the controversy, you could blink and miss it.
The trouble with that post
The main problem for many readers was Dr. Tulloh’s premise that exercise needs to be emphasized because hormone therapy is “over-medicalized” or has a problem with “unrealistic expectations.” No one objected to promoting exercise, but many objected to doing it by apparently casting shade on MHT.
Tulloh did say that MHT has value for many women (for symptom relief), but those disclaimers were insufficiently reassuring: the damage was already done by the high-level framing. At best, critics argued, the editorial seemed to knock hormone therapy by contrasting it unfavourably with exercise. At worst? It could be harmful, discouraging women from even attempting to get MHT — which they think delivers benefits much more profound than mere symptom relief.
Clearly many women believe that long-term hormone therapy is actually vital for disease prevention.
They also argued quite forcefully that it’s offensively wrong to describe MHT as over-medicalized when women still have to fight to get it. One commenter suggested that just using the term “over-medicalized” was a clear sign of “medical misogyny.” Another called it “lazy and insulting.” Yikes!
Stock art older lady contemplates whether calling MHT “over-medicalized” actually constitutes an example of “medical misogyny,” given that many women experts think that there is legitimate ongoing scientific uncertainty about its benefits and risks.
The other side of the story
The objections were far from unanimous: many other commenters agreed that there is a problem with hormone hype. They are suspicious of the claim that estrogen is a fountain of youth. “I do not see it as a panacea the way many do,” one wrote. They argued that it’s not anti-woman to emphasize that MHT is not a panacea if it’s not actually a panacea, and unjustified hype is not the right way to combat the clinical neglect of menopausal women.
In short, they had no problem with Tulloh’s editorial or my summary of it. What’s a would-be ally to do?
Take the complaints seriously, learn the controversy, report the range of views, and (of course) dig deeper into the relevant science. Topics in this post:
- “Menopausal hormone therapy” versus “hormone replacement therapy”: the politics of the terminology.
- Why not both? Exercise and hormone therapy! And doesn’t hormone therapy provide critical support for exercise?
- Is menopause truly in danger of being “over-medicalized”? Has the pendulum actually swung too far, from the bogus safety concerns of the past to an over-hyped future?
“Menopausal hormone therapy” versus “hormone replacement therapy”
One reader criticized my use of the term menopausal hormone therapy, MHT. Why wasn’t I using the more familiar term, “hormone replacement therapy,” HRT?
Dr. Mary Claire Haver explains that “adding the word ‘menopausal’ to ‘hormone therapy’ clarifies that this type of therapy is intended for women in midlife and beyond,” and that HRT “has fallen out of favor because of concerns and controversies surrounding the risks and benefits,” especially because term “replacement” can imply that normal female physiology is deficient.
Why not both? Exercise and hormone therapy
The post was not, of course, saying that exercise should replace hormone therapy. But many readers were concerned about even the appearance of that, which highlights their strong concern about anything that de-emphasizes the value of MHT. Also, many women pointed out that they cannot imagine exercising without hormone therapy:
“MHT gives me some capacity to function. And that gives me the capacity to potentially lift.”
Hormone therapy might well make it easier to exercise, probably by easing symptoms that suffocate the effort. Alas, what evidence we have so far — not enough, but some — is actually negative. 😬
- Moriyama et al. found little or no effect of MHT on exercise: it did not enhance it.
- Cardoso et al. reported that exercise increased fitness in healthy postmenopausal women “regardless of estrogen therapy.”
- Sánchez-Delgado et al. reported that exercise alone, without hormone therapy, “seemed to have a better effect on physical fitness and DBP in postmenopausal women.”
- Peila et al. conducted the most substantial and relevant study to date, and it was particularly discouraging, showing that estrogen users were not more active: “The results from this clinical trial do not support the hypothesis that estrogen treatment increases physical activity among postmenopausal women.”
Unfortunately, no study has shown that MHT significantly improves any of the common objective measures of the benefits of exercise, over any time scale … or that it boosts objectively measured physical activity (e.g. with accelerometers). If hormone therapy supports exercise during menopause, even just by easing symptoms, it probably isn’t a strong effect.
Awkward! Please don’t shoot the messenger! There is still hope, more study actually needed. I want a prospective study of many symptomatic menopausal women, comparing activity levels and fitness outcomes after at least a year of exercise, with and without at least a couple different kinds of MHT, and eliminating various well-known exercise-killers like other health issues, lack of interest, and poverty. We don’t have anything remotely like that, and this will be an open question until we do.
Meanwhile, exercise can and should be promoted for its substantial benefits … but perhaps not by contrasting it with any alleged deficiencies of MHT.
Is menopause really in danger of being “over-medicalized”?
Perhaps in some ways, probably not in others … and therein lies the problem. It depends on what angle you look at it from.
There was a MHT boom in the 90s, and then a bust in the early 2000s. The question today is whether the pendulum actually swung too far from the bogus safety concerns inflamed by the 2002 Women’s Health Initiative, and is now being excessively re-medicalized… by anyone, in any sense. But Tulloh wrote only this about it:
the over-medicalisation of women’s midlife health threatens to eclipse foundational interventions like physical activity. … unrealistic expectations diverge from clinical evidence …
She cited no evidence or expert support for that position, unfortunately.
Nor did Hickey et al in a series of like-minded articles for The Lancet in 2024. They argued that menopause is “stigmatised as an unruly pathology requiring medical management and as a lamentable curse of womanhood” and that this “medicalised view of menopause can be disempowering for women, leading to over-treatment” and over-commercialization. They also suggest that menopause is “not a medical problem” and therefore not “best managed by hormone replacement therapy.”
Despite exploring this much more than Tulloh did, they also failed to make an evidence-based case that over-treatment has actually occurred, citing only a single UK survey showing a modest increase in prescribing in the UK by 2022. And if that case couldn’t be made in a whole series of recent articles in a prestigious journal, maybe it can’t be right now.
Meanwhile, there is stronger data showing that MHT declined steadily in the US in the 2010s, up to 2020 (see Baik). As summarized by Dr. Sharon Malone et al. on MyAlloy.com, “only 6% of women seeking treatment for their symptoms actually get it. How is this even possible? We think it’s total B.S.” That dismal figure might have changed dramatically in the last five years — a lot has changed since 2020! — but we don’t know, and it’s probably nowhere close to 100%.
It seems wise to err on the side of believing women when they say that doctors still fail to take their menopause symptoms seriously, that they are still brushed off as “just aging” or psychosomatic.
Estrogen to fight aging (and therefore pain)
Hormone therapy is mostly known as a relatively short-term treatment for some of the most uncomfortable symptoms of menopause. But in recent years a new scientific and medical question has emerged: do women need estrogen long-term as an anti-aging treatment that reduces morbidity and mortality, prevents the diseases of aging throughout the second half of their lives? Does my wife need estrogen to boost her vitality generally into her seventh decade and beyond? I want to know that just as much as she does, I think! I want the very best for her health!
If estrogen fights aging, that would be much more valuable than merely treating symptoms in and around menopause. And
But this is still a new scientific question! And it’s not like anti-aging claims have a stellar track record! Anti-aging claims are probably the single biggest source of false health hopes and empty medical promises over many decades — so general skepticism and caution is fully justified. If estrogen is being over-hyped and rushed into the marketplace, encouraging millions of women to seek unproven benefits with unknown risks to ”fix“ the woes of aging … that would certainly constitute a kind of “over-medicalization.”
And I suspect that’s exactly what Hickey et al. and Tulloh mostly meant by “over-medicalization.” They seem earnestly concerned about the pathologization of menopause and female aging by medical influencers, celebrities (e.g. Gwyneth Paltrow, Naomi Watts), and its over-commercialization. Those concerns aren’t coming out of nowhere. For better or worse, many companies and clinics are treating menopause and female aging like a hormone deficiency disease, and promoting excessive or dubious remedies under the guise of medical necessity: bioidentical hormones, pellets, testosterone, hormone testing.
And that trend would be problematic even if estrogen does have real anti-aging powers.
What do (female) experts have to say about all this?
Experts focussed on evidence-based women’s health advocacy are far from unanimous on this topic, and many would find no serious fault with Tulloh’s editorial. They all support individualized, conservative MHT for menopausal symptoms — that’s the common ground. Beyond that, however, they express a wide range of opinions about how useful and safe MHT is for other clinical goals like supporting exercise or long-term disease prevention. Some examples:
- Dr. Louise Newson is very pro-HRT for prevention, and vocal about the medical neglect of menopausal women … but she has also been criticized by her peers for pushing too hard in the direction of over-medicalization.
- Dr. Stephanie Faubion steers well clear of promoting MHT for prevention; instead, she argues for individualized prescribing, with nuanced exceptions to the general rule that prevention isn’t fully baked evidence-based medicine yet (and so hasn’t been endorsed by the North American Menopause Society).
- Dr. Jen Gunter’s position appears to be that MHT for symptom relief is legitimate and important, but general prevention of chronic disease is not yet a solid reason for, and she has criticized Estrogen Matters (Tavris) for cherry-picking hopeful evidence and downplaying risks that remain unknown. (And, full disclosure, I am biased in favour of Dr. Gunter’s take. I think she stands out in this community as being a particularly competent critical thinker, knowledgeable not only about the medicine but how knowledge works.)
And so on. It is clear that there’s a wide range of credible opinions on this topic. It’s obvious that Tulloh’s over-medicalization premise was not way out in left field.
Pseudoscience and grifting are never-ending threats
Ironically, the angry responses to my first post are exactly what you’d expect to see if hormone therapy is in fact being “over-medicalized” in some sense. Bogus benefits will be defended as fiercely as if they were real! If you believe that hormone therapy can safely protect you from disease, despite the incomplete evidence, then you’re going to fight for that.
And probably spend money at hormone therapy clinics that are racing ahead of the science.
But over-promising medical benefits never ends well. If the prevention power isn’t actually there, it will backfire on women in the long run.