We’ve never been more open about menopause. High profile women from Davina McCall to Mariella Frostrup are making books, films and podcasts, and campaigning to improve life for women at this stage of life.  

Last week saw a bill before Parliament seeking to make hormone replacement therapy (HRT) more affordable. The move has been welcomed by women and doctors up and down the country, many of whom say HRT, for so long a dirty word, is a life-changing treatment that should be more widely available. But should everyone take HRT – and what do you need to know if you’re considering it?

The menopause – defined as happening one year after your last period – occurs on average at the age of 51 in the UK. But the peri or pre-menopause, when you’re still having periods but are no longer likely to get pregnant, can also bring weird symptoms that accompany major hormonal shifts.

I’m 49, and for the past couple of years, my usual mildly annoying PMS has ramped up from a couple of grumpy days a month to at least a week of sobbing, yelling and generally feeling that life is a wasteland of despair.

Last winter, I finally called my GP to ask whether I could be prescribed HRT. The first doctor I spoke to (male) suggested a coil, which I didn’t want (“I assure you, it’s the sensible option,” he said, testily.) Then I spoke to a nurse who was a somewhat better listener, and suggested a combination of oestrogen gel and 2 weeks a month of progesterone pills.

But after several months of this combination, I found myself feeling much more stressed and depressed than usual. It seemed to me to coincide with the weeks when I took progesterone, and online research suggested a possible link.

Studies show progesterone can trigger the amygdala – the ‘threat system’ in the brain, which releases stress hormones. Experts say HRT, and especially progesterone, can sometimes have an effect on mood – though the causes can be complicated.

“There is certainly a significant minority of women who find their mood is negatively impacted by progesterone,” says Dr Hannah Short, a GP and specialist in menopause and premenstrual disorders. “Either their own, released during the post-ovulation phase of the menstrual cycle, or by the progestogenic component of HRT.”

If a woman is sensitive to the synthetic progestogens in some hormonal medication then these symptoms can be experienced whenever she is taking them, with “low mood, depression, anxiety, rage, tearfulness and – in severe cases – suicidal thoughts,” she explains.

Experts say that side-effects such as mood changes are more likely when a woman is given a synthetic version of progesterone, rather than a body identical or ‘natural’ type, which is chemically identical to the hormone your body produces naturally. Both types can be prescribed on the NHS.

“When women are on conventional HRT, which contains a synthetic progestogen, it can cause mood changes, high cholesterol and depression”, says Dr Jan Toledano of The London Hormone Clinic.

The real hormone is recommended by the British Menopause Society, and “has exactly the opposite effect to synthetic progesterone”, she says. “It’s actually the body’s happy hormone. It’s anti-anxiety, helps you sleep, and protects breast tissue from abnormal changes.”

Tania Adib, consultant gynaecologist and head of The Menopause Clinic at The Lister Hospital, agrees that side-effects of HRT are usually caused by synthetic progestens. “The structure of the hormone is not exactly the same as the kind the body produces, so it’s associated with a greater number of side-effects,” she explains.

“Some women react with bloating, weight gain, headaches and depression,” she adds. “Using a combination of bioidentical oestrogen, progesterone, testosterone and DHEA, I can usually find a combination which suits the patient.”

I was not taking synthetic progesterone, however – so what was making me feel depressed? According to Toledano, in my case it may have been the oestrogen. She says if you’re still having regular periods, you’re still producing enough oestrogen and probably don’t need it – though many perimenopausal women are wrongly offered it.  

“Unless you’re actually menopausal, you may only need natural progesterone,” she says.

I am indeed feeling better since stopping taking the oestrogen, though for some women, the hormonal havoc proves too much – and quitting seems easier than experimenting further.

“I was prescribed norethisterone (a synthetic progestogen) several times between 2018 and 2019 to stem my constant periods, one of which was so bad I took myself to A&E,” says Lucy Sweet, 48, a writer from Glasgow. “It made me feel terrible – tearful, depressed, highly anxious and at one point, during a holiday in Spain last summer, I started having thoughts that everybody would be better off without me.”

Not surprisingly, Sweet stopped taking it – and has since discovered her heavy periods were due to a polyp. But she would not be tempted to try HRT again, she adds. “There are still very few treatments for women in menopause that are suitable for everyone, and synthetic hormones are the absolute worst.”

Short recommends speaking to your GP before stopping HRT or changing the dose. It can also be worth discussing your earlier hormone history, she adds. “Any experience you had with the pill can be relevant, or whether you have had premenstrual syndrome or the more serious premenstrual dysphoric disorder. If you had symptoms of post-natal depression, that can mean HRT may have more negative symptoms.”

But, she points out, that doesn’t mean you can’t be helped. “I have found that there is a very tiny handful of women who can’t get on with any type of HRT; about five per cent or so.”

Amid the current debate about improving treatments for the menopause, some women who missed out on early HRT may be wondering if they are too old to try it now.

“There are more benefits to starting younger – and slightly increased risks if you start later in life,” says Short. “But there is no hard and fast rule. All HRT should be on a case-by-case basis; I have patients who started in their 70s; one doctor told a menopause conference that they have a woman of 104 still taking HRT.”

That also clears up confusion about how long you can take HRT for. “There used to be a guideline of no longer than five years, but now it’s down to individuals; as long as benefits outweigh risks, there is no reason to stop ever.”

The menopause revolution and the liberation of HRT is something to be celebrated, but it’s important to remember that we’re all very different – and with HRT, one size does not fit all.

Says Adib: “Every woman is unique, with a different experience of the menopause, and requires an individual approach.”