HOW TO MENOPAUSE: A Gynaecologist’s Guide to the Biggest Controversies in Hormone Health

If you’ve spent any time looking up menopause information online, you’ll know that it’s anything but a calm and coherent space.You’ll find one clinician saying you must start HRT as soon as perimenopause begins. Another says hormones are for symptom relief only.One influencer insists testosterone is essential for energy, cognition, and mood. Another suggests the evidence is not yet there.Other debates rage simultaneously regarding hormone testing, brain health, longevity…. The list goes on.I’ve had many women tell me the noise is just too loud; we’ve gone from famine to feast seemingly overnight, the divergent camps so fervent in their views. Some women tell me they end up feeling so paralysed with overwhelm, they do nothing. After a generation of women missed out on the benefits of having a hormone supported menopause transition because of the way evidence was translated back in the early 2000s, it feels particularly tragic that this is contributing to more confusion now.“Can’t you all just sing from the same hymn sheet and agree?”, is a question I’ve been asked. But the reality is, doctors have always disagreed, especially in areas in which the evidence is less robust and opinion prevails. But now, instead of those disagreements playing out in a passive aggressive letter to a journal editor or during the Q&A session in a conference room, the arena is now social media. A platform we know rewards black and white views over nuance, acerbic take downs, and exceptionalist opinions; in full view of the women watching. Camps have formed. And women are stuck in the middle.But there is also a second driver of controversy; the commercial interest. The menopause space has become a lucrative marketplace. And the evidence gaps have provided fertile ground for preliminary findings to be presented as fact in order to recoup investments; think facial oestrogen creams and menopause supplements. Non-medical, unregulated wellness products that make up 94% of the 20 billion dollars that is the current menopause market, projected to keep growing.That’s why I wanted to make this episode with Dr Vikram Talaulikar, specialist in reproductive medicine and certified British Menopause Society Specialist, to give women an understanding of the reasons behind some of these controversies, how to navigate the various uncertainties and approach these conversations with their doctors.Thanks for reading The Woman's Handbook! Subscribe for free to receive new posts and support my work.What We Cover in This EpisodeWe go through the major areas of controversy one by one:Hormone testing: why blood tests are largely unhelpful for diagnosing perimenopause in women over 45, what the fluctuating hormone landscape of perimenopause actually looks like, and why continuous hormone monitoring devices are interesting technology that is not yet clinically useful.Use of hormonal contraception in perimenopause: how the pill can actually stabilise wildly fluctuating hormones in ways that standard HRT sometimes cannot.Use of testosterone beyond libido: what the evidence does and does not support, why a trial to well counselled patients despite the guidelines may be the answer and why the assays most commonly used to test testosterone levels in women were never designed to measure the ranges relevant to women in the first place.Use of HRT as a longevity drug: what the cardiovascular data actually shows, why the timing window matters, what we can and cannot say about HRT and dementia prevention, and whether women without symptoms are missing out by not taking HRT.What I Hope You to Take from ThisWhat I loved about this episode was Vikram’s calm, knowledgeable and balanced approach to some of the most contested areas in menopause medicine, in which he champions putting women’s autonomy at the centre of decision making.Whilst his approach is firmly evidence informed, it isn’t puritanical, allowing room for individual preferences, priorities and context. This is of course something we do everyday in medicine behind clinic doors, but this nuance and flexibility can often get lost when discussing these topics online in short form content.If you’ve been confused about whether or not you need to add in testosterone or whether you should be taking HRT for long-term health even if you don’t have symptoms, I hope this episode gives you a good framework for how to approach these grey areas with your doctor.Episode Timestamps00:03:09 Why is there so much controversy in the menopause space, and how should women evaluate the information they encounter?00:07:43 What is actually happening hormonally during perimenopause, and how does that differ from postmenopause?00:10:55 Should women be testing their hormone levels? What the NICE guidelines say, and why blood tests are often misleading in perimenopause.00:13:05 Continuous hormone monitoring devices: interesting technology, not yet clinically useful.00:18:18 The pill in perimenopause: why hormonal contraception can stabilise symptoms in ways standard HRT sometimes cannot.00:28:50 Testosterone beyond libido: what the evidence supports, what remains uncertain, and how Vikram approaches prescribing in practice.00:37:00 HRT and cardiovascular disease: what the WHI got wrong, why modern HRT is different, and what the timing window actually means.00:43:00 HRT and dementia prevention: why this remains a genuinely contested area, and what we can say for women with premature menopause or genetic risk.00:48:44 The three things that are not controversial: premature and early menopause, ethnicity and menopause timing, and bone health.00:53:01 Cancer-related menopause: a group that deserves more support, and the evidence for vaginal oestrogen even in women with hormone-sensitive tumours.Thanks for reading The Woman's Handbook! 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