I was a resident in 2013, eleven years after the first publication of the Women's Health Initiative trial results. The cohort I belonged to in residency had been taught — by a generation of attendings who had been taught — that menopausal hormone therapy was the kind of intervention you were obliged to talk patients out of. The conversation had a defensive shape. The conversation was, very often, the wrong conversation.
The 2022 Menopause Society position statement on hormone therapy — and the consistent body of work since the original WHI publications, including the re-analyses by age group showing a more favorable risk-benefit profile in younger postmenopausal women, and the subsequent careful work on transdermal estrogen and stroke risk — has reframed the calculus.[01] For most symptomatic women under age 60 or within 10 years of menopause onset, the benefit-risk balance for systemic hormone therapy is favorable.
The intake we had been using did not reflect this. The intake was a holdover from the 2010s. It treated hormone therapy as a last resort. It was the wrong starting point.
What the rewrite changed
The new menopause new-visit (CCH-004-MN) is 45 minutes instead of 30. The 30-minute version had been efficient for "ruling out" hormone therapy; the 45-minute version is structured for the conversation about whether and how to start. The structured agenda is:
- Symptom profile (vasomotor, urogenital, sleep, mood, joint), with the Menopause Symptoms Questionnaire completed before the visit.
- The risk-benefit conversation, organized around the three windows: age and time-since-menopause; baseline cardiovascular risk; baseline breast-cancer risk including family history.
- Formulation choice: oral estrogen vs transdermal patch vs vaginal estradiol-only for primarily urogenital symptoms; cyclic vs continuous progestin in patients with intact uterus.
- The starter prescription, if elected, with explicit follow-up at 6 weeks for initial titration and at 3 months for full evaluation.
The intake form for the visit now includes a structured field for "What is the goal of this visit?" with checkboxes (discuss starting hormone therapy, renew current hormone therapy, discuss stopping hormone therapy, address specific symptom without medication, other). The field is filled out by the patient before the visit. The clinician sees it before the room.
The patients we owe an apology to
Between 2019 and early 2024 there is a small cohort of patients in our panel whose perimenopausal symptoms — in particular, sleep disruption, vasomotor symptoms, and the kind of cognitive-fog complaints that are sometimes dismissed as "just age" — we treated with caution rather than with effective therapy. The conversation, in retrospect, took a defensive shape because the conversation we had been trained to have took a defensive shape.
I have written letters of apology to the eleven patients in this category whom I personally saw, with a specific offer to revisit the conversation now under a clearer evidence base. I have called the seven who did not respond to the letter. Two of the eleven have since started hormone therapy. Three declined. One was already in hospice for an unrelated illness. The rest are scheduled for an extended visit.
This paragraph is not unusual to write. It is unusually unusual to publish. The reason we publish it is the same as the reason we publish everything else here: we believe the practice of medicine improves when its mistakes are documented, dated, and answerable.
What the patient should expect now
If you are perimenopausal or postmenopausal and you come in for an evaluation: expect us to take the symptoms seriously. Expect us to discuss hormone therapy as one option among several rather than as a last resort. Expect us to ask about your cardiovascular and breast-cancer risk and to put numbers on the answer rather than adjectives. Expect us to give you a written copy of the discussion to take home. Expect a 6-week follow-up if you elect to start.
References
- The Menopause Society 2022 Hormone Therapy Position Statement — menopause.org.
- Rossouw JE et al., Postmenopausal hormone therapy and cardiovascular disease by age and years since menopause, JAMA 2007 — jamanetwork.com.
- Manson JE et al., Menopausal hormone therapy and long-term all-cause and cause-specific mortality, JAMA 2017 — jamanetwork.com.
- NICE — Menopause: diagnosis and management (NG23) — nice.org.uk.
- ACOG — Hormone Therapy in Primary Ovarian Insufficiency — acog.org.
- Endocrine Society Clinical Practice Guidelines on menopause — endocrine.org.