Why Do We Replace Thyroid Hormone Without a Second Thought, but Not Oestrogen?
If you go to a doctor with an underactive thyroid, you get thyroid hormone. Nobody suggests you try yoga for 6 months first. Nobody asks whether you've considered reducing stress. The conversation takes about 4 minutes and nobody in it thinks anything controversial has happened.
Change the hormone to oestrogen and the room changes with it.
Suddenly there's a list to get through first. Exercise. Sleep. Stress. Supplements. Wait and see. Come back in 6 months if it hasn't settled.
It's a fair question why the running order is different, and it has a real answer. Part of that answer is reasonable. Part of it is a hangover from a headline.
The argument that actually holds up
The easy answer is that women's health gets taken less seriously, and that's partly true. But there's a real argument underneath it, and it's worth knowing, because you'll be answered with it.
Menopause happens to everybody with ovaries. It isn't a disease. It's a stage of life that arrives whether anything has gone wrong or not.
An underactive thyroid doesn't work like that. Neither does type 1 diabetes. Those are things that have gone wrong in a particular person, and medicine is comfortable stepping in and correcting them.
Medicine is more cautious about intervening in something universal, something that happens to everybody as part of being alive. That caution isn't stupid and it wasn't invented to annoy you. It runs through a lot of medicine and most of the time it's sensible.
Where that argument runs out
The trouble is that it doesn't survive contact with the rest of medicine.
Bone thinning after menopause is universal. We treat it, and we screen for it, and nobody argues you should tolerate a fractured hip because it was natural.
Long sight arrives for everyone somewhere in their 40s. Nobody suggests you sit in dim light squinting at menus because reading glasses would be interfering with a normal process.
So universal has never actually meant untreatable. It has never meant not worth treating. The principle gets applied to menopause more strictly than it gets applied almost anywhere else, and that inconsistency is fair to point out.
And then there is the headline nobody corrected
The other half of the answer is history rather than logic.
A very large trial of hormone therapy was stopped early and reported in a way that was, to put it kindly, not careful. The coverage was enormous and alarming. Prescribing collapsed within months, across whole countries. Women who were doing perfectly well on hormone therapy stopped it, sometimes overnight, sometimes without ever being told why.
An enormous amount of that trial has since been re-read, re-analysed and qualified. The women in it were older than the women most of us are talking about. The hormones used weren't the ones typically used now. The absolute risks, once you look at them as numbers of women rather than percentages, were smaller than the headlines suggested.
But the correction never got the airtime the alarm did. And a generation of doctors trained in the middle of it. That's a large part of why the running order still looks the way it does, and it's a historical accident rather than a clinical principle.
Related reading
A study on hormones and dementia went round recently and almost every post about it overstated what it found. Here's how to read one of these properly. A study on hormones and dementia just made headlines →
The distinction that actually matters
I want to be careful here, because there's a version of this argument that becomes hormones for everybody immediately, and that isn't what I think.
Sleep, movement, protein and stress aren't a fob-off. They genuinely change how women feel, sometimes dramatically. They belong in any plan worth the name, and for some women they're enough on their own. If somebody suggests starting there, that's a reasonable thing to suggest.
What isn't reasonable is starting there and never looking again.
A plan with no review date isn't a conservative plan. It's a delay with good manners. The difference between the 2 is a single question, and it's the most useful one you can ask in that room.
The 3 questions
If the conversation isn't going where you want it to, these move it along better than frustration does.
"Is there a medical reason I shouldn't have this, or is this a general caution?"
This one is quietly powerful. It separates a genuine reason specific to you, which you need to know about, from a broad hesitancy that may be about an old headline rather than about you.
"What are we trying to change, and how will we know whether it worked?"
This turns a vague plan into something measurable. It also makes it much harder for the answer to be "see how you go".
"If we try it this way first, when do we look at it again?"
The most important of the 3. It accepts the suggestion, which keeps the conversation friendly, and it puts an end date on it. You're not refusing to try lifestyle changes. You're refusing to try them indefinitely with nobody checking.
The thing I would leave you with
You're allowed to ask why the order is that way. It's a fair question, it has a real answer, and the answer is partly reasoned and partly a hangover from a headline written when you were at school.
Knowing which part is which is what lets you ask a good question instead of having a bad conversation.
A few things worth having alongside the conversation
These are the guides people ask about most before an appointment. They're free.
FREE High Cortisol Guide What sustained stress looks like day to day, and where it overlaps with perimenopause. Get it free → |
FREE Iron Deficiency Guide Why a normal blood count doesn't rule out low iron stores, and what to ask for. Get it free → |
FREE Blood Pressure & Bloating Guide Two things that change quietly in your 40s and rarely get connected. Get it free → |
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This is general information, not advice about your own health.
Keep reading
If you're not sure whether what you're feeling is perimenopause at all, this one goes through what tends to change first. Perimenopause: the early signs and what changes first →
