Goodbye, Youth

Why are we so fearful of the menopause?

I had my first injection last Friday - the 13th - to plunge me into the menopause. It is the most upset I have felt at any of the hospital appointments so far. I found myself crying in the waiting room, and when I was called, the nurse asked if I wanted to postpone the injection and speak to my oncology team first. I said no through the tears, and tried to pull myself together. I need to rid my body of its oestrogen and progesterone as soon as possible to reduce the risk of recurrence, because my breast cancer was hormone sensitive. But the head and the heart were really at odds on this one.

I haven’t usually minded going to appointments on my own because, as a doctor myself, I am used to hospitals. But I soon realised that I had made a mistake this time.

The injection really hurt. It is a huge needle that injects the slow-release medication under the skin of the lower tummy - I will need to have them monthly at first, along with daily tablets. I cried out in pain as it went in, and the nurse said, “Perhaps we’ll use some numbing spray for the next one, shall we?”

I thanked her then left the room and went straight into the end cubicle of the nearby toilets and cried my eyes out. In a way, the physical pain was at least consistent with the deep sadness I felt inside.

I realise this may seem like an over-the-top melodramatic reaction to something that is going to happen naturally anyway, at some point - more than one friend has pointed this out to me. And especially as a doctor myself - I almost feel like I am betraying my profession when I feel like this, and the emotions get the better of me. Nonetheless, this is how I feel, and I am going to be honest about it. We don’t become emotionless automatons when we join the medical profession, however it may seem sometimes to the world at large (which, while we’re on the subject, I don’t actually think is either helpful or healthy, and I don’t think patients do either).

But what is going on here? Why do I feel so sad about it all?

Firstly, despite being 48, I was not feeling at all perimenopausal before my cancer diagnosis. No hot flushes, brain fog or vaginal dryness. I still felt young and very healthy, and felt so so lucky for that. In retrospect, I now know that all those hormones may have been helping the cancer to flourish, but of course I was not aware of that back then.

Numerous friends have been experiencing those insidious “peri” symptoms and some have started HRT, sometimes at my suggestion. I have also seen many patients with the same. So I was very much aware of what lay ahead, and tried to really appreciate my premenopausal state.

Then of course, we are reading so much about the horrors of perimenopause in the press and on social media. It is so vitally important that we women talk about it openly now, as previous generations of women were unable to. But when you are not there yet, it does sound bloody awful.

At its worst, it sounds like you will lose your personality as you know it, and become a hot, dry, fat, miserable husk of your previous youthful self.

Is it any wonder I was sobbing in that toilet cubicle??

And then finally, to add insult to injury, that other ubiquitous topic: hormone-replacement therapy (HRT), which is apparently the panacea to which every woman should have a right to access no matter what…

I am not allowed to take it under any circumstances. Ever.

It has made me realise how unhelpful the menopause and HRT rhetoric can be to women in my position. If any of you are reading this: I am here, and I see you.

We hear so much about how HRT is crucial to prevent heart disease, diabetes, bone thinning, and possibly even dementia - Dr Louise Newson in particular is a strong advocate.¹ There is even evidence to suggest HRT increases longevity.² So imagine how one feels when it is a complete no-no.

I must make it clear at this point that I am writing this as a woman for whom HRT is a complete no-no, and I am absolutely not against or questioning the proven benefits of HRT to alleviate menopausal symptoms. When women have what can be extremely debilitating symptoms, HRT is the first-line recommended treatment and is highly effective. It is shown to increase mortality and reduce incidence of coronary heart disease if commenced within 10 years of the start of the menopause, and before age 60. Beyond age 60, more caution is advised as the risk vs benefit profile begins to shift less favourably. Also, HRT is not currently recommended as a preventative measure for those who do not have menopausal symptoms. This 2024 White Paper from the International Menopause Society gives an excellent overview of the history of attitudes to menopause and HRT, with clear guidance based on the latest evidence.³

HRT is absolutely contraindicated, as in my case, for an estimated 9-10% of menopausal women.^4,5 Reasons include hormone-sensitive cancers (breast, ovarian and uterine), history of blood clots, heart disease, and active liver disease.⁶ And HRT is relatively contraindicated (needs caution and special consideration) in, I believe, up to 40% of women, for similar and other reasons, which include migraine, fibroids, high blood pressure and diabetes.^5,6

Please note that it was very difficult to find exact up-to-date figures on the number of women who cannot have HRT. I had to go back to a paper published in 1995, so the percentages above are approximations only. This in itself, I believe, marks the lack of attention shown to the management of menopause in this important group of women, for whom HRT is not an option.

HRT is actually only taken by around 15% of menopausal women in the UK and the figure tends to be lower than this in other countries.⁷ So actually, there are many of us, who, like me, cannot or do not choose to take HRT. Yet there is a dearth of evidence and reliable information out there about HRT alternatives, and we mainly hear the loud voices telling us about the perils of the menopause and the benefits of HRT.

This demonisation of the menopause is really unhelpful and ethically questionable, in my opinion - and particularly from my new vantage point. The menopause is a natural part of every single woman’s life course, and yet we are constantly hearing how terrible it is - how the natural female ageing process is bad for us, and we should be fighting against it.

It reminds me of the pressure we feel to have needles stuck in our faces.

And my daughter pointed out to me that we receive similar messaging about periods, and they are similarly dreaded by young girls. “Oh no, poor you, have you got your period?” becomes a familiar refrain. The monthly cycle is shrouded in negativity. But again, this is another natural progression in every woman’s life, only at the opposite end of our reproductive phase when the hormones are first kicking in, heralding the ability to bear children and perpetuate the human race. Surely this is something to be celebrated?

Why are we conditioned to despise and fight against these transitions which define womanhood?

I think we need to reframe the whole thing, and I personally am going to attempt to do so from now on, while of course acknowledging the difficulties as they arise. Let’s grow old gracefully, and try to relish it. Ageing is a privilege which brings beauty, fulfilment and wisdom.

As for how I feel one week after my first menopause-inducing injection… I have had no symptoms, and feel great so far - but will keep you posted!

Sending lots of love to all 💖

P.S. As I said in an earlier post, I am working on building a resource about alternatives to HRT and will be posting about it soon.

References:

1. Dr Louise Newson. Understanding the benefits and risks of HRT. Available at: https://www.drlouisenewson.co.uk/knowledge/understanding-the-benefits-and-risks-of-hrt-downloadable-visual-aids

2. Paganini-Hill A et al. Increased longevity in older users of postmenopausal estrogen therapy: the Leisure World Cohort Study. Menopause, Nov 2018. Available here.

3. Panay M et al. Menopause and MHT in 2024: addressing the key controversies – an International Menopause Society White Paper. Climacteric, Vol 27(5), 2024. Available here.

4. Mikkelsen AP et al. Menopausal hormone therapy and long term mortality: nationwide, register based cohort study. BMJ 2026;392:e085998, Feb 2026. Available here.

5. Whitlock E et al. Prevalence of Contraindications to Hormone Replacement Therapy in Middle-Aged Women in a Managed Care Setting. Journal of Women’s Health. Vol 4(3). 1995. Available here.

6. NICE Clinical Knowledge Summaries. Menopause: Hormone Replacement Therapy (HRT). Last revised July 2025. Available at: https://cks.nice.org.uk/topics/menopause/prescribing-information/hormone-replacement-therapy-hrt/

7. Attitudes towards menopause: time for change. Editorial - The Lancet. Vol 399:10343. June 2022. Available here.