An old bias against hormone therapy is hurting Indian women

It felt like all the pieces of a puzzle finally falling into place. “Why didn’t all these specialists I saw connect the dots?” asks Dutta, who is now better and off BP medication after controlling inflammation through diet changes, supplementation and exercise. Though she feels it is too late for her to start Hormone Replacement Therapy (HRT) or Menopausal Hormone Therapy (MHT) as it is now referred to by the medical community, she is willing to try a functional medicine-led hormone reset. “If 10 years earlier someone had told me about HRT, I would have taken it,” she says.

An MHT prescription—medication to replace oestrogen and progesterone, which drop as one approaches menopause—is less than common, even in Indian metros, for women suffering through years ofdebilitating perimenopausal symptoms. Meanwhile, some drugs like Veozah (fezolinetant), an oral medication to specifically treat vasomotor symptoms (hot flushes) caused by menopause, approved by the US Food and Drug Administration (FDA) in 2023, are not available in India. This seeming reluctance to treat menopause medically can be traced to an old, lingering bias.

Dr Nandita Palshetkar, a Mumbai-based obstetrician and gynaecologist, recalls a time when menopausal symptoms were treated widely with HRT in India and globally. “Doctors were giving it left, right and centre,” says Dr Palshetkar, who is a former president of the Federation of Obstetric and Gynaecological Societies of India (FOGSI). “Then this study came and halted everyone in their tracks,” she says, referring to a report by the Women’s Health Initiative (WHI), a project funded by the US National Institutes of Health focused on menopause and its treatment.

In 2002, WHI released preliminary findings from a study undertaken to determine whether HRT protected women from heart disease and whether it increased the risk of breast cancer. The findings indicated that combined oestrogen and progestogen therapy showed elevated risks of breast cancer, heart disease, stroke and blood clots among the participating women, and the study was halted.

Later, meta-studies and clarifications repudiated many of the WHI findings, but a culture of over-cautiousness had set in—and continues to be an influential factor in the clinical treatment of menopause.

“Those women who need MHT should be given it,” says Dr Paleshetkar. “Women who suffer from frequent hot flushes, night sweats, anxiety, body aches and insomnia, for whom other methods of treatment such as lifestyle management and supplementation have not helped, they should definitely consider HRT. It’s not fair that women spend so many years leading a sub-optimal life,” she adds.

Doubts about the study arose within a few years of its publication. “The average age of participants was 63, and only 3.5% of the women were 50-54 years old, the age when women usually make a decision regarding initiation of MHT,” notes a 2010 statement by the Endocrine Society of the US. It also had other flaws, such as the type of hormones prescribed to women during the study. In response to the findings of the WHI trial, MHT usage declined by approximately 80%, notes the society. “The pendulum is now swinging back as a result of more careful assessment of the use of MHT shortly after menopause.”

Dr Palshetkar feels it’s not that doctors don’t want to prescribe it, it’s often patients who are reluctant. “Better awareness is needed,” she says.

However, anecdotal evidence suggests even women who actively seek it may find it tough to get a doctor to prescribe it or give convincing reasons as to why it’s not suitable for them. At least six women spoken to for this story who saw a doctor for menopause relief said one of three things: their doctors never recommended it;it was suggested by a doctor but they were reluctant to try it; or they asked about it and were discouraged.

Monika Manchanda, a Bengaluru-based co-founder of a health-tech startup, is aware of the controversies regarding MHT and changing attitudes towards it in many countries. A couple of years ago, the 47-year-old started experiencing peri-menopausal symptoms such as unpredictable periods, heavy bleeding, night sweats, insomnia, mood swings and brain fog. “I would be in the middle of a presentation and lose my strand of thought. I had not felt like this ever before,” she says.

She started looking into symptoms and causes, and her research threw up the work of doctors like US-based Mary Claire Haver. These are menopause specialists who have taken to social media to talk about the widespread ignorance regarding menopause even within the medical community. They evangelise the benefits of hormone therapy.

“If you go to Indian doctors, there are two standard responses: ‘this happens in menopause, you have to put up with it’, and ‘lose weight’. How can you be told, casually, to just suck it up?” asks Manchanda. Having access to medical professionals at her workplace, she became convinced that she would benefit from hormone therapy, but has not yet found a doctor who will prescribe it. A friend, who lives in Malaysia, is undergoing MHT, and Manchanda has started looking at the option of travelling there to seek treatment. “I have done video calls with her doctor, and am seriously considering visiting her to start HRT,” she says.

In her book The New Menopause, published in April, Dr Haver writes: “You deserve modern menopause care. The categorical denial, dismissal and refusal to discuss therapeutic options, including hormone replacement therapy, has no place in 2024.” The new way of thinking about menopause, backed by studies, is that it affects every organ system of the body, she writes.

Bengaluru-based menopause care specialist Dr Aruna Muralidhar agrees with Dr Haver’s views. “Approaching menopause with the seriousness it deserves is especially relevant in India, where the average age for menopause is 46-48,” she says. This is lower than the global average age at which women achieve menopause—48.8—and considerably lower than the 50-52 average for Caucasian women. Dr Muralidhar, who practised in the UK before moving to India a decade ago, says that in her opinion, “Indians gynaecologists are not as open to HRT as those in the UK and the US.”

She does caution that HRT is not a one-prescription-fits-all solution. “Doctors have to consider the patient’s medical history and lifestyle. Treatment of menopausal symptoms starts with basic awareness, lifestyle changes, nutrition and supplements, exercise and meditation. But lack of awareness or experience in prescribing HRT may make some doctors step back from prescribing hormones,” says Dr Muralidhar.

Attitudes are changing, but slowly. Since 2021, the Indian Menopause Society (IMS) has been conducting an exam to certify doctors as menopause practitioners, called Credentialed IMS Menopause Practitioners (CIMP). It also publishes an annual list of doctors who have cleared the exam, along with their location, on its website (indianmenopausesociety.org/CIMP-applications.html), and the number has been growing.

Dr Archana Dwivedi, who heads the Vadodara chapter of IMS and is on its website committee, agrees that the WHI study “created a scare” among doctors and patients for many years. “But the guidelines have changed and with the advent of better quality, bio-mimicking oestrogen and progesterone, people have started accepting that MHT is a good thing to offer to their patients because quality of life is important,” says Dr Dwivedi over WhatsApp voice notes in response to questions shared over email.

“Longevity has increased, women are now living up to 90 years, and we cannot live a compromised life. MHT is a gold standard therapy, and I would appeal to doctors to not let their patients suffer if they are eligible to receive it,” she says, only prescribing caution for those over 55 with comorbidities. “The earlier you start the better,” she says, adding that it is a myth that oestrogen therapy causes cardiac disease and obesity.

“In fact studies have shown that it plays a role in managing Type-2 diabetes and obesity if given at the proper time, as well as bone health, mental health—all these things improve.” With the availability of transdermal patches and sprays, “MHT is here to stay,” she says.