“I had a woman who came in with a testosterone implant. Its rate was three times that of a man! It took him six months to get back to normal,” says Dr. Céline Bouchard, who is a gynecologist.
Just like Dr. Bouchard, who practices in Quebec, gynecologist and obstetrician Sophie Desindes, head of the Menopause Clinic at the CIUSSS de l’Estrie, does not hide her exasperation at seeing private clinics “making money on their backs women” by 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’ve 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 bodies could expose them to thromboembolism and cancer, for example.
“I also see many women who have been privately prescribed DHEA tablets [a steroid hormone in the category of testosterone], a product not approved in this form by Health Canada for menopause. Lots of women are on this, without knowing why. »
Dr. Desindes believes that many women confuse premenstrual syndrome – which can actually get worse as we move through our forties – and the arrival of menopause.
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 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.
The problem is that there is no consensus among specialists on the approach to treating premenopause and menopause.
In 2021, Loto-Méno, the 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, bluntly admits Dr. 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 had the merit of allowing the reimbursement of certain bioidentical hormones, “which is a step forward,” notes Dr. Jeanne Bouteaud.
This is also what Dr. Desindes believes, and she would have even hoped that more products would be reimbursed.
But it was a documentary, “not a medical consultation,” insists Dr. Bouteaud. Too many women thought what was said applied to their situation.”
“Women between the ages of 35 and 42 tell us they are tired, that they sleep less well than in their 20s, and they attribute these symptoms to perimenopause [the period before menopause],” explains Dr. Jeanne Bouteaud. “Our society was not ready to hear this, but it must be said anyway: sleep and energy are not the same in your 40s as 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, as is society. 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 Dr. Bouteaud.
In short, a hormonal problem happens, but there are sometimes other causes, she observes.
Dr. 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 incorrectly hormones – bad professionals, it doesn’t 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.
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 a bit 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” .
Contradictions around menopause
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 a clinical tool this summer “to support the management of the clinical manifestations of perimenopause and postmenopause using the ‘hormone therapy’.
Will the guide from this public organization in Quebec provide enlightening answers? Dr. 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 what is known 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 general guidelines, she explains, he must be able to justify it.
Dr. Demers fears that the advisory body remains too closed to hormone therapy and too insensitive to the severity of women’s symptoms well before menopause.
But beyond case by case, does research provide answers?
We know, responds Dr. Jeanne Bouteaud, that hormonal treatment can “relieve vasomotor symptoms and hot flashes associated with menopause.”
Estrogen is also known to have “bone-protective benefits” to prevent osteoporosis. One important benefit: Women are twice as likely to fracture their hips as men, according to the Public Health Agency of Canada.
But the risks of hormone therapy are not zero – in particular of developing a clot or having an increased risk of breast cancer with certain hormones –, observes Dr. Bouteaud.
Dr. 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 working and if treatment is adequate.
A menstrual and hormonal cycle comes with fluctuations, by definition, recalls Dr. Desindes.
Fluctuations which can, for some women, be very inconvenient, we submit. “But hormone therapy is not going to prevent hormonal fluctuations,” replies Dr. Desindes. She will add hormones to a patient who already has them, often, particularly, with high estrogen levels in their forties.
To find out, the doctor, she says, relies on her symptoms, her age, her state of health.
Dr. 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 do not measure [the 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 the [proposed] hormonal treatment. »
Dr. Bouchard will only recommend a dosage in the face of early menopause or fertility problems.
Dr. Sylvie Demers says she recommends dosages for a small proportion of premenopausal women in their early 40s who have intensified PMS (heavy bleeding, typically clots, etc.).
But during “the hormonal chaos of perimenopause” (the period before menopause when there have been 12 months without periods), blood tests are unnecessary, in her opinion.