Why Did a Reasonable Menopause Article Cause So Much Outrage?

I fact-checked the Guardian piece, and the backlash reveals a larger problem in menopause discourse

Images say more about me than words./Getty Images

In the 1980s and 1990s, menopause hormone therapy (MHT) was not only prescribed for menopause symptoms, but it was also recommended for heart health and to slow aging based on lower quality evidence. And then, after the initial reporting of the Women’s Health Initiative (WHI) results, it was subsequently under prescribed as many clinicians feared they would be increasing the risk for their patients for breast cancer, blood clots, and cardiovascular disease. As a result, many women suffered terribly with symptoms that could have been treated with MHT.

It is possible to hold several intersecting ideas at once: MHT is the most effective treatment for hot flashes and night sweats, and it is recommended for bone health when there is an elevated baseline risk of osteoporosis or fracture. At the same time, we can also admit that we have varying degrees of data (ranging from not bad to virtually nonexistent) for the effectiveness of MHT for treating other symptoms that women may experience in perimenopause or menopause. And, we can also say there is no convincing evidence that we should be prescribing MHT to reduce all-cause mortality, prevent dementia, or for prevention of cardiovascular disease.

These conclusions are based on the totality of the published data, considering the quality of the evidence and being honest about what we know and what we don’t know. It is easy to cherry-pick observational studies, hold personal anecdotes up as proof, and craft any desired and much more simplified narrative, but that is marketing, not science.

There are also some other truths. There is a menopause gold rush in the form of expensive products, lab testing, clinic visits and memberships that costs thousands or even tens of thousands of dollars, and profitable influencer content. This has coincided with the pendulum swinging from under prescribing back to presenting MHT as a fountain of youth. Women are being led to believe that MHT has been proven to prevent heart disease, dementia, and premature death, and that it is a panacea for every symptom experienced by women aged 40 and over. Claims that go far beyond what the evidence can support.

This commercialization of menopause has been fueled by very real grievances about having symptoms minimized, lack of research, and being denied access to care. Those failures deserve to be acknowledged, but legitimate grievances can also create opportunities for exploitative monetization. When frustration with the healthcare system becomes the foundation for a business model, there are clearly incentives for some to amplify distrust an offer a single, simple solution for a complex biological transition that is also influenced by a myriad of social factors. The answer to historical neglect should not be replacing dismissal with a one size fits all solution that itself dismisses research that doesn’t support the preferred narrative.

This is why I was not surprised to see a recent Guardian piece in their Call the Doctor column titled, I’ve heard menopause hormone therapy fixes everything. Should I take it? dismissed as “badly researched and outdated” and “drivel” on Instagram. Truthfully, the article wasn’t on my radar until I saw it attacked on social media. I was not interviewed for the article, but as I was listed as a reputable source for information about menopause, I decided to read it myself and fact-check it. I wanted to know whether the criticisms were warranted based on factual errors, or whether it reflected something else: the growing tendency to dismiss any evidence that challenges the narrative of MHT as a near-universal solution.

Given the degree of vitriol, I expected to find some grievous errors. I did not.

The introduction presented us with the same concept I outlined above. The WHI dramatically affected prescribing, and many women suffered. The evidence was reevaluated and, “Now, many clinicians are comfortable prescribing hormones. In fact, some are a bit too comfortable hawking them as a cure-all.” In addition, the author, Keren Landman MD, writes of MHT, “Timely treatment provides immense relief of menopause symptoms, and has the added benefit of lowering fracture risk. But ascribing all your ills to menopause and expecting treatment to fix them is a set-up for disappointment.”

I can find no fault with this.

The author then explains that “Menopause is too often missed,’ citing a study that one-third of women have moderate-to-severe symptoms of menopause, and that more than 80% did not seek care for their symptoms. She also quotes one of the world’s experts on menopause, Dr. Nanette Santoro, who stated that fewer than that very low number probably seek care. This is a sadly fair indictment of the medical system, and the author specifically states that “lack of appropriate care” and being dismissed by clinicians are factors in under treatment.

Not sure what the issues could be here. All seems so far so good.

Landman then goes on to explain the growing trend of blaming menopause for everything and the issues with positioning MHT as the cure-all. She mentions the role of celebrity culture and social media and states the following:

But menopause isn’t the only thing that happens to women’s bodies with age. By the time women hit perimenopause, at least half already have a chronic medical condition. The same awareness that is finally getting women into doctors’ offices is also convincing them they need hormones for symptoms that may have other causes – or no cause at all.

Again, this is true as menopause does not happen in a vacuum. At the same time women are going through menopause, they are aging and also developing other medical conditions. This is why studies like SWAN that follow women over years are critical. Another factor to consider is that some symptoms of menopause are nonspecific and can have many causes. One that I repeatedly mention here in The Vajenda is low iron stores (low ferritin), which can cause brain fog and fatigue and it is more common in perimenopause. I have lost track of the number of women I have treated or heard from who have taken MHT for these symptoms, even sometimes escalating doses to concerning levels, only to find out the issue was serious iron deficiency. Recently, there was a personal essay in the Wall Street Journal by journalist Jessica Toonkel that detailed how her persistent symptoms were dismissed by multiple different doctors as perimenopause. This went on for two years when she finally received her actual diagnosis: Hodgkin’s lymphoma, a cancer.

If all you have is a hammer, then everything becomes a nail.

The article in the Guardian then went on to discuss some of the hype, pointing out that influencers, some of whom are credentialed physicians, are part of this new menopause gold rush. It includes links to this article about incorrect claims about menopause care on social media, and also explains that menopause is a $10-15 billion/year market. Honestly, at this point we should be calling it moneypause.

The author goes on to correctly point out that influencers often exaggerate the purported benefits of estrogen. She writes:

Most of the loudest public voices making those claims are cherrypicking data, says Streicher. Last November, the Department of Health and Human Services secretary, Robert F Kennedy Jr, and the then Food and Drug Administration commissioner, Marty Makary, announced the removal of the black box warning on hormone therapy. They made inaccurate claims based on low-quality studies about MHT’s ability to prevent Alzheimer’s disease, stave off cognitive decline, and extend life by 10 years.

“Women are left wondering, ‘Who do I believe? My clinician, who I’ve been going to for 20 years and who seems real smart, but he or she doesn’t seem to know any of this stuff, or the person on social media who’s got 2 million followers?’” Streicher says.

Again, there is nothing incorrect here. I have written multiple times on The Vajenda about cherrypicking as well as the fact that the data does not support prescribing MHT for prevention of dementia (read this and this for more). In fact, at the most recent Menopause Society meeting, we were told that prescribing MHT for prevention of dementia means the clinician is operating in a “data-free zone.”

The article then explains more about MHT (side note: I am also pleased to note the author uses the correct term, menopause hormone therapy, or MHT) stating that those who take estrogen and have a uterus need progesterone (this is not quite true, as progesterone is not a catchall term; progestins are also fine, as is bazedoxifene), that transdermal estradiol may be safer from a blood clot perspective, and that some women may need local, vaginal estrogen. Nothing to complain about here except conflating progesterone and progestins.

This following passage compresses a few ideas in a way that is not entirely consistent with the evidence, and this is my only major issue with the piece:

MHT can also have positive effects on cardiovascular and bone health, although it’s not recommended as first-line prevention for either.

I would exercise caution with the claim that MHT can have positive effects on cardiovascular health, because the phrase is ambiguous and many readers might interpret this as meaning that MHT reduces cardiovascular disease. The evidence is much more nuanced. There is no randomized controlled trial showing that MHT reduces heart attacks, stroke, or death from cardiovascular disease when prescribed as primary prevention for women in menopause. Unfortunately, some people get tripped up regarding MHT and the heart and mistakenly point to the Danish Osteoporosis Prevention Study, or DOPS to support their position. However, this study should NOT be considered evidence that MHT protects the heart, as it was not designed or powered to establish cardiovascular prevention. You can read about DOPS and a more in depth review of MHT and the heart here.

Another sticking point about MHT and the heart is that some claim that estrogen must be protective because it can positively affect some surrogate markers (stand-in measurements that may suggest benefit, but are not proof of benefit). First, the impact on surrogate markers differs between oral and transdermal, so speaking about MHT as a monolithic therapy for the heart is not supported by the data. In addition, most of the changes in surrogate markers are quite small. For example, the effect of oral estrogen on LDL and CIMT (carotid intima-media thickness) is small compared to the effect of statins. In addition, CIMT has fallen out of favor as a surrogate endpoint for demonstrating that an intervention reduces cardiovascular events.

The statements on bone are backed by the evidence. MHT can have positive effects on bone and this is supported by randomized clinical trial data. MHT is also not the first-line of prevention for bone health which is still fall prevention, adequate calcium and protein, and resistance training. Medications for bone health (both MHT and other medications, like bisphosphonates) are recommended for at-risk individuals.

The article ends with suggestions for finding good information, and I am actually mentioned as a source. I was not interviewed for the article, so it was a pleasant surprise to see my name with a link to The Vajenda.

One issue I did have with the article was that while it mentioned the risks of blood clots with oral MHT, it did not discuss the risk of breast cancer with combined MHT (estrogen and a progestogen). The risk depends on age, hormone type, duration, and personal risk factors for breast cancer, and so the risk for each individual woman will vary. In general, the majority of the risk is believed to be due to the progestogen component. I understand that there are some people who claim that progesterone-based regimens have no risk of breast cancer, but that is untrue. The same data that we use to say progesterone carries no increased risk of breast cancer for the first 6 years of use also tells us that the risk of breast cancer increases by about 30% from year six onwards. Premarin by itself is not associated with an increased risk of breast cancer. There have been a couple of recent scientific articles looking at breast cancer risk with MHT, so I think I am due to write an updated deep dive for all of you.

None of this means that women should avoid MHT because of the breast cancer risk. It does mean they should consider what MHT could do for them and weigh that against the risks. For someone who can’t sleep due to hot flashes, the risk-benefit ratio is almost certainly favorable. For someone with few to no menopause symptoms and it taking the medication because they believe it will protect their heart and prevent dementia, the data does not support that they will get the meaningful benefit they are hoping for, but they will be incurring the breast cancer risk.

Summary

Overall, it’s a good piece. The central message was MHT is an important, evidence-based therapy and accurately described the benefits for hot flashes and night sweats as well as bone health. The authors does not suggest at all that women should avoid MHT. The article also correctly states that we do not have good data (meaning randomized controlled clinical trials or a highly consistent body of strong observational evidence) to support using MHT for protecting the heart and preventing dementia. The author also accurately points out the rise of moneypause (my term for the menopause gold rush).

It’s not a deep dive, nor was it intended to be. It’s a “Hey, MHT has really valid uses, but stop and think a bit about the discourse that positions MHT as a panacea because you may not be getting the best advice and some people may be profiting from that misinformation.”

The anger over the Guardian article is a stress test of today’s menopause discourse and illustrates a larger challenge in menopause conversations: evidence-based discussions are often interpreted as criticism of women’s experiences rather than what they are, an effort to ensure women receive accurate information. I know this all too well as I am frequently criticized for writing about menopause through the lens of evidence where being factual and direct is confused in some circles with anger. This article’s mention of my work likely made it more of a target. Acknowledging uncertainty, distinguishing what we actually know from what we just hope to be true, and resisting the idea that a one-size-fits-all treatment is the answer for every symptom and for every woman is not a step backward. On the contrary, it is actually how medicine advances. It is the scientific process that women have long been denied.

References

1. The Menopause Society Statement on Misinformation Surrounding Hormone Therapy https://menopause.org/wp-content/uploads/2024/09/TMS-statement-on-HT-Misinformation.pdf

2. The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022

3. Davis SR, Taylor S, Hemachandra C, et al. The 2023 Practitioner’s Toolkit for managing Menopause Climacteric 2023

4. Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal Hormone Therapy and Long-Term All-Cause and Cause-Specific Mortality. JAMA, 2017.

5. Bofill Rodriguez M, Young LN, Mirkov D, et al. Long-Term Hormone Therapy for Perimenopausal and Postmenopausal Women. The Cochrane Database of Systematic Reviews. 2025.

6. Hodis HN, MAck WJ, Henderson VE wt al. Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol. NEJM. 2016

7. Miller VM, Taylor HS, Naftolin F, et al. Lessons from KEEPS: The Kronos Early Prevention Study. Climacteric, 2021.

8. Schierbeck L L, Rejnmark L, Tofteng C L, et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial BMJ 2012.

9. Roberts H, Hickey M. Should hormone therapy be recommended for prevention of cardiovascular disease?. Cochrane Database of Systematic Reviews 2015,

10. Eastell R, Rosen CJ, Black DM et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline. JCEM. 2019.

11. Lorentzon M, Johansson H, Harvey NC. Menopausal Hormone Therapy Reduces the Risk of Fracture Regardless of Falls Risk or Baseline FRAX Probability-Results From the Women’s Health Initiative Hormone Therapy Trials. Osteoporosis International. 2022

12. Shumaker SA, Legault C, Kuller L, et al Conjugated Equine Estrogens and Incidence of Probable Dementia and Mild Cognitive Impairment in Postmenopausal Women: Women’s Health Initiative Memory Study JAMA, 2004

13. Melville M, He L, Desai R, Nyamayaro P, et al. Menopause hormone therapy and risk of mild cognitive impairment or dementia: a systematic review and meta-analysis. Lancet Healthy Longev. 2025 Dec;6(12):100803.

14. Pourhadi N, Mørch LS, Holm EA, et al. Menopausal Hormone Therapy and Dementia: Nationwide, Nested Case-Control Study. BMJ. 2023.

15. Mosconi L, Nerattini M, Williams S, Fink M. New Horizons in Menopause, Menopausal Hormone Therapy, and Alzheimer’s Disease: Current Insights and Future Directions. JCEM. 2025.