Menopause | Hormone doses too high, too soon?

Doctors are concerned that some of their colleagues are financially exploiting women by unnecessarily prescribing hormones, well before menopause, at sometimes risky doses, without clinical indication. In this context, the unveiling of a medical practice guide this summer in Quebec could be controversial

“I received a woman who arrived with a testosterone implant. Its rate was three times that of a man! It took him six months before he got back to normal,” says the D^D Céline Bouchard, who is a gynecologist.

Just like the D^D Bouchard, who practices in Quebec, the gynecologist and obstetrician Sophie Desindes, head of the Menopause Clinic at the CIUSSS de l’Estrie, does not hide her exasperation to see private clinics “making money on the backs of women” in prescribing often unnecessary and repeated blood tests, “at crazy prices”, and prescribing hormones without clinical indication to women who are still far from menopause.

She insists: she has nothing against hormone therapy, this treatment which aims to alleviate the symptoms of menopause by taking replacement hormones. “I prescribe it every day, I have never stopped doing it. »

But she is furious to see women being prescribed them well before they need them, with the risks that too many hormones in their body expose them to thromboembolism and cancer, for example.

“I also see many women who have been prescribed DHEA tablets privately. [une hormone stéroïdienne dans la catégorie de la testostérone], a product not approved in this form by Health Canada for menopause. Lots of women are on this, without knowing why. »

The D^D Desindes believes that many women confuse premenstrual syndrome – which can actually get worse as people reach their forties – and the arrival of menopause.

On social networks, on Facebook pages dedicated to menopause, hormones are the topic of the hour. Faced with the lack of consensus and the contradictory advice received by health professionals, “menopause influencers” have a good audience.

And many women also rely on the advice of simple Internet users to find out whether or not they should take this hormone that they have been prescribed or that they intend to request.

Julie* is one of those who asked their question on Facebook after being stunned, she said in an interview, to be prescribed the contraceptive pill by the doctor, at 53 years old and with a vasectomized husband. “My sister-in-law tells me to take hormones instead. »

Annie* has the impression that her doctor goes there “by trial and error”, with prescriptions which are sometimes then contested by pharmacists. “Health professionals should inform themselves and stop going on a whim,” she says in a telephone interview.

A future clinical tool

The problem is that there is no consensus among specialists on the approach to treating premenopause and menopause.

In 2002, after the publication of a study linking the use of hormones to breast cancer, cardiovascular disease or stroke – risks since then put into perspective – hormones were no longer popular and were rarely prescribed. .

In 2021, Loto-Ménothe documentary by Véronique Cloutier, helped to revive interest in hormones.

But these 20 years when hormone therapy was very rarely prescribed resulted in “a loss of expertise” among doctors, the D. bluntly admits.^D Jeanne Bouteaud, gynecologist and obstetrician at the University of Montreal Hospital Center.

She assures that the numerous training courses offered these days on these themes are very popular with doctors.

Loto-Méno and its aftermath

Loto-Méno had the merit of allowing the reimbursement of certain bioidentical hormones, “which is progress”, notes the D^D Jeanne Bouteaud.

This is what the D also believes^D Desindes, who would have even hoped that more products would be reimbursed.

But it was a documentary, “not a medical consultation, insists the D^D Bouteau. Too many women thought what was said applied to their situation.”

“Women aged 35 to 42 tell us that they are tired, that they sleep less well than in their twenties and they attribute these symptoms to perimenopause [la période avant la ménopause]explains the D^D Jeanne Bouteaud. Our society wasn’t ready to hear this, but it has to be said anyway: sleep and energy are not the same in your 40s as they are in your 20s. »

As a doctor, she says she listens very closely to women and for some, a hormonal problem is in fact to blame. “But in other cases, it’s multifactorial. Women are very demanding of themselves, society is too. You have to perform well at work, take excellent care of your children, exercise, be a good partner and have unbridled sexuality! It’s all tiring! », remarks the D^D Bouteau.

In short, a hormonal problem happens, but there are sometimes other causes, she observes.

The D^D Sylvie Demers, a family doctor who recently ceased her practice, who was at the origin of Loto-Méno and whose books and advice are widely read by women, believes that it is possible that doctors prescribe hormones incorrectly – bad professionals, this does not only happen in medicine – but that the real problem lies elsewhere.

She believes that much more often, doctors “psychiatrize” their patients by prescribing medications for their anxiety or sleep disorders, and that they also quickly refer them to cardiology for their palpitations or to gastrology for their digestive problems, without ever thinking that the problem could be one of female hormones.

“An inevitable self-diagnosis phenomenon”

Véronique Cloutier is not surprised that the impact of her documentary has resulted to a certain extent “in a phenomenon of self-diagnosis”. It’s somewhat inevitable, in her opinion, although she understands that it can be a problem for some doctors.

The message she wants us to take away from her documentary, two years later, is that bioidentical hormones are not a miracle “that suits everyone, but that doctors must be open to it” .

* As it concerns their health, the women interviewed about their menopause wished to remain anonymous.

Contradictions around menopause

A guide to enlighten doctors

Hormones. No hormones. Antidepressants. The pill. Above all, take nothing. Do blood tests. They are useless. Many women are lost as they approach menopause, faced with so many contradictory indications.

The National Institute of Excellence in Health and Social Services (INESSS) confirms that it will unveil this summer a clinical tool “to support the management of the clinical manifestations of perimenopause and postmenopause using the ‘hormonotherapy’.

Will the guide from this public organization in Quebec provide enlightening answers? The D^D Jeanne Bouteaud, gynecologist and obstetrician at the University of Montreal Hospital Center (CHUM), explains that the document will not be “an opinion” of a specialist, but “a summary of the scientific literature,” with the data that the we know about the risks and benefits” of certain treatments.

“Afterwards, each doctor will apply them on a case-by-case basis, depending on each patient,” she explains.

And when a doctor deviates from guidelines in general, she explains, he must be able to justify it.

The D^D Sylvie Demers, a family doctor who puts forward her long practice and her approach to experimental medicine, strongly doubts whether she will be able to join the INESSS clinical tool.

The D^D Demers fears that the advisory body remains too closed to hormonal therapy and too insensitive to the severity of women’s symptoms well before menopause.

But beyond the case-by-case basis, does research provide answers?

We know, replies the D^D Jeanne Bouteaud, that hormonal treatment can “relieve vasomotor symptoms and heat associated with menopause”.

We also know that estrogen has “benefits in terms of bone protection” to prevent osteoporosis. An important advantage: women are twice as likely to fracture their hips as men, according to the Public Health Agency of Canada.

But the risks of hormonal therapy are not zero – in particular of developing a clot or having an increased risk of breast cancer with certain hormones –, observes the D^D Bouteau.

Blood tests, necessary or not?

The D^D Sophie Desindes, head of the Menopause Clinic at the CIUSSS de l’Estrie, says that it is by studying the menstrual cycle and the symptoms of her patients that she determines whether hormones are indicated. Not by doing blood tests and hormonal assessments as too many doctors in private practice recommend, she believes. “Hormones vary from one day to the next, from one cycle to the next, even. We have a menstrual cycle, but also a hormonal cycle, with its rises and falls depending on whether we are near the start of our period or in full ovulation.

“It’s not like the thyroid gland,” she explains, where a blood test is necessary to find out if the gland is functioning and if treatment is adequate.

A menstrual and hormonal cycle comes with fluctuations, by definition, recalls the D^D Desindes.

Fluctuations which can, for some women, be very inconvenient, we submit. “But hormonal therapy will not prevent hormonal fluctuations,” replies the D^D Desindes. She will add hormones to a patient who already has them”, often, particularly, with high estrogen levels in their forties.

The D^D Jeanne Bouteaud notes that “there is no precise test” that will tell whether a patient needs hormones or not.

To find out, the doctor, she says, relies on her symptoms, her age, her state of health.

The D^D Céline Bouchard, also a gynecologist, notes that “it is not necessary to measure hormones when the menstrual cycle is regular, because the hormones work well”.

“We also don’t dose [les hormones] if there is amenorrhea, hot flashes, etc., at the age of menopause, because the diagnosis is then obvious. We rely on the patient’s comfort with hormonal treatment [proposé]. »

The D^D Bouchard will recommend a dosage only in the face of early menopause or fertility problems.

The D^D Sylvie Demers says she recommends dosages for a small proportion of premenopausal women, in their early 40s, who have intensified premenstrual syndrome (heavy bleeding, typically clots, in particular).

But during “the hormonal chaos of perimenopause” (the period before menopause when there have been 12 months without menstruation), blood tests are unnecessary, in his opinion.