By Arunima Rajan

On World Health Day, Dr Vaishali Joshi, Consultant Gynaecologist at Kokilaben Dhirubhai Ambani Hospital, Mumbai, speaks with Arunima Rajan about hormone replacement therapy (HRT) and the urgent need for open, informed conversations around menopause and perimenopause. These topics are still often sidelined in mainstream healthcare.

Understanding Perimenopause: More Than Missed Periods

Perimenopause can feel like a long, bewildering road. The earliest signs are elusive: irregular periods, sudden hot flushes, or cognitive shifts like memory fog. Diagnosis remains murky. Why? Because symptoms vary. And there are no definitive lab tests. It is a clinical call, based on patterns rather than proof. Studies from the Journal of Clinical Endocrinology and Metabolism reveal how fluctuating hormone levels blur the onset, making a symptom-based approach not just helpful, but necessary.

Why Many Women Still Feel Unheard

In clinics across India, women walk in with mood swings, sleep disturbances, and brain fog, and often walk out feeling unheard. It is a familiar story. In urban areas, awareness has grown. But in rural and semi-urban settings, recognition is patchy at best. Most consultations focus on irregular periods. Vasomotor symptoms and cognitive complaints are often missed. A study in the International Journal of Gynaecology and Obstetrics notes cultural taboos and limited menopause training among doctors as key reasons for underdiagnosis.

HRT: Time to Rewrite the Narrative

Despite its rocky reputation, hormone replacement therapy remains the most effective treatment for perimenopausal symptoms. Yet hesitation persists. Understandably so, past controversies cast a long shadow. That is where good counselling matters. When risks and benefits are explained clearly, and patients receive reliable, evidence-based information, decisions become easier. National and global bodies, including the North American Menopause Society and British Menopause Society, support its use. Reanalyses of the Women’s Health Initiative underscore this: when used appropriately, hormone therapy can significantly improve quality of life with manageable risks.

Tailoring Treatment to the Woman

No two journeys through menopause are alike. Hormone therapy is not a one-size-fits-all prescription. It is a tailored response to a woman’s specific symptoms, health profile, and personal preferences. The presence or absence of a uterus, the desire to avoid withdrawal bleeding, and overall risk factors all shape the plan. For vasomotor symptoms, sleep issues, or bone density concerns, HRT remains first-line. Ideally, it should begin within five years of menopause to maximise benefit. Research in The Lancet confirms early initiation can reduce risks of cardiovascular disease and osteoporosis.

Choosing the Right Formulation

Patches. Gels. Tablets. Implants. Vaginal creams. The list is long, but selection is not guesswork. Clinical risks, availability, and personal comfort all play a role. Women with a uterus may opt for intrauterine devices like the Mirena coil with oestrogen patches. Those who have had a hysterectomy might need only oestrogen. A comparative study in the Journal of Endocrinology found that transdermal options may reduce thrombotic risk compared to oral formulations.

The Progesterone Question

Micronised progesterone is gaining ground, and for good reason. It closely mimics the body’s natural hormone, offering better bioavailability and tolerability with fewer side effects. Unlike synthetic progestins, it does not significantly elevate risks for thromboembolism or breast cancer. Findings in the British Medical Journal suggest its impact on breast tissue proliferation is also lower, shifting the safety balance in its favour.

Timing Is Everything

The “timing hypothesis” suggests hormone therapy is most effective and safest when started within a decade of menopause onset. Why the urgency? Past that window, the long-term effects of oestrogen deficiency are already at play. Bones are weaker. Arteries, stiffer. Delayed therapy not only dulls benefits, it increases risks. According to studies, prolonged use beyond ten years also raises concerns like breast and ovarian cancer, and thromboembolism.

Reframing the Risk Conversation

Is hormone therapy risky? For most women without a personal or family history of breast cancer, the answer is: not significantly. Research from the European Menopause and Andropause Society confirms that the absolute risk increase for breast cancer amounts to about two additional cases per 1,000 women after five years. And contrary to older concerns, there is no strong link between HRT and cardiovascular risk when used correctly.

Special Populations Need Special Consideration

Obesity. Hypertension. Migraines. Women with these conditions often face added risks. But transdermal hormone therapy, such as patches, bypasses the liver and reduces clotting risk. Studies in Circulation Research show that for high-risk groups, this method may offer cardiovascular benefits too.

What Ongoing Monitoring Looks Like

Starting hormone therapy is only the first step. Monitoring matters. Follow-ups should begin at three months, then shift to annual assessments. Doctors check for abnormal bleeding, monitor for thrombotic symptoms, and order routine screenings like mammograms and blood tests. The American Journal of Obstetrics and Gynaecology recommends yearly reassessments to evaluate continued need and safety.

Barriers Beyond the Clinic

Outside metropolitan cities, access to safe, modern HRT options is limited. Costs are high. Counselling is scarce. Many clinicians, unfamiliar with newer guidelines, still avoid prescribing hormone therapy. Non-hormonal alternatives, which are less effective, are more commonly offered. According to a survey by the Indian Menopause Society, fewer than 30 percent of gynaecologists actively recommend HRT.

A Missed Opportunity in Older Women?

Ultra-low-dose hormone therapy remains underutilised, especially among women in their seventies or eighties. When symptoms persist, this form may still offer relief, particularly for bone health. But it must be used with care, at the lowest effective dose. Journal of Geriatric Medicine research points to its potential with reduced side effects, if introduced cautiously.

Breaking the Silence, One Conversation at a Time

Menopause is still a taboo in many Indian homes. Gynaecologists have a pivotal role, not just in treatment, but in talking. Every clinic visit is an opportunity to normalise the conversation, offer emotional support, and educate. As the Journal of Women's Health points out, cultural stigma remains one of the biggest barriers to care.

Where Should Women Begin?

Start with the symptoms. Mood swings, poor sleep, forgetfulness, hot flushes — none of these should be ignored. Women navigating perimenopause without support need to know they do not have to suffer in silence. If symptoms are affecting your life, seek help.

The Future of Menopause Management

Wearables and bioelectronic devices are transforming the field. Real-time hormone tracking will soon enable personalised HRT regimens. Precision medicine is no longer theoretical — it is on the way. The Journal of Endocrinology and Metabolism highlights how these innovations could change everything.

Toward a Woman-Centric Model

Yes, we are getting closer. With more evidence, better tech, and growing awareness, menopause care is becoming more personalised, more nuanced, and more focused on women’s voices. The future is not just evidence-backed. It is woman-led.

One Last Word for Every Woman Approaching 40

Think holistically. Your hormones do not just affect your body — they shape your mood, your sleep, your energy. Do not dismiss what you feel. Be informed. Be open. And above all, know this: you have options.

Got a story that Healthcare Executive should dig into? Shoot it over to arunima.rajan@hosmac.com—no PR fluff, just solid leads.

World Health Day Spotlight: Why It’s Time to Talk About Menopause and Hormone Therapy in India