Odds are you probably know someone who has told you that when she went through menopause, her doctor did not recommend estrogen. Likely she was told that estrogen has a lot of risks and it would be better for her to just put up with her hot flashes, or try some other type of non-hormone treatment. Women frequently get this advice and is one reason why only a small fraction of the 6,000 women entering menopause every day fill a prescription for estrogen.
Why is it that doctors are so reluctant to prescribe HRT?
Before answering this question, let’s talk about how doctors are trained to make decisions about treatment recommendations.
First of all, a doctor needs to learn about the disease or condition that warrants treatment and then learn all the various options for treatment. The next step is to be able to know which details about the patient may have a bearing on the choice of particular a treatment – such as the person’s age, whether they have certain other medical conditions, or if they are taking other medications that could affect the treatment. And finally, doctors need to asses whether or not the benefit of a particular treatment outweighs the risks.
Needless to say there is a lot to learn. New doctors coming out of training begin their practices armed with the knowledge they obtain during their medical school and residency programs. Even though most physicians spend anywhere from seven to eleven years in these training programs, the amount of information to be learned is so massive that it is impossible to master every subject. So it is not surprising that certain subjects receive less attention than others. This affects a physician’s familiarity and comfort with treating some conditions. Unfortunately, from my standpoint one of those conditions is menopause and hormone replacement therapy.
A number of studies have demonstrated that this appears to be the case. A study conducted about ten years ago by the John Hopkins School of Medicine surveyed 258 programs that trained doctors to become gynecologists to assess what they perceived as their competency and comfort level treating menopausal women.1 Mind you, the field of gynecology is basically a specialty dedicated to caring for women. This survey showed that almost 70% of the trainees felt they needed to learn more about menopause and hormone treatment. A large proportion of these doctors-in-training indicated not feeling comfortable managing a number of menopause-specific problems. This was even voiced among fourth-year residents, the ones who will go into practice the following year.
The reason for this can largely be understood by looking further at where these residents typically spend most of their time. As noted by the pie chart below, during the multi-year training program it takes to become a certified specialist in obstetrics and gynecology (OB/GYN) more than 90% of their experience involved obstetrics, with less than 10% in general gynecology and only a fraction of time having anything to do with menopause. This implies that these programs place a heavy emphasis on the needs of younger women. And while certainly being able to expertly manage pregnant patients and deliver babies safely is of paramount importance, where does that leave women over age 50?
Not surprisingly, and certainly from my personal perspective, it is those of us in primary care who take on that responsibility. In my practice, it was commonplace to “inherit” patients from their OB-GYNs after they finished having children. And this is generally about the time when women approach and enter menopause. Therefore you would hope that training programs in internal medicine and family practice devote quite a bit of attention to the needs of menopausal women. Unfortunately this is also lacking. 
A study published in 2009 concluded that most primary care residency programs in the United States don’t provide adequate education in menopause management.2 Although more than three quarters of the residents who responded to the survey considered that caring for menopausal women is a “very important” area that should be addressed as a core component of their training, about half reported a low comfort level managing menopausal symptoms, and more than three quarters indicated that training opportunities in this area were limited. In a similar study of family physicians 20.3% reported not receiving any menopause lectures during residency, and only 6.8% reported feeling adequately prepared to manage women experiencing menopause.3
What this means
If doctors in training are not being exposed to patients requiring menopause management, nor getting adequate information from their teachers about hormones, they are not going to be equipped with the expertise needed when they open their practices. And while it is imperative that doctors keep themselves updated about medical issues through rigorous continuing education, the amount of information generated each year is overwhelming. It is especially challenging for primary care physicians, who manage the “whole patient” and need to keep abreast of the advances in cardiology, diabetes, neurology, infectious diseases, and scores of other conditions. It goes without saying that some subjects invariably fall into the lower priority baskets. Unfortunately, the not-so-glamorous field of menopause seems to have achieved this status.
So when it comes to making a decision about whether or not to prescribe HRT for a patient, doctors rely on guidelines that have been published by various medical organizations. Sometimes these are referred as “cookbook” guidelines because they basically spell out an abbreviated one-liner summary of the prevailing “best” treatment for a condition.
Regarding hormone therapy for menopausal women, the “go-to” guidelines for the last two decades have been based on a landmark study, the Women’s Health Initiative (WHI). This study, which was published in 2002, concluded that HRT carries more risks than benefits – leading the FDA as well as many medical organizations to severely restrict the appropriate use of estrogen treatment. These guidelines essentially advise that “hormone therapy should only be prescribed to treat severe menopausal symptoms, when nothing else has worked, and to use only the lowest doses of hormones for the shortest period of time.” This language certainly casts doubt on the wisdom of using estrogen and sends the message that prescribing it may not be advisable – causing many doctors to simply decline treating menopausal women with hormone replacement.
Why the guidelines are problematic
The problem is that over the last ten years there has been considerable debate on certain aspects of the WHI study. A major issue is that the average age of the women in this study was 63 years old – much older than the age most women enter menopause. It is now clear that initiating hormone replacement therapy in older women, particularly with the drugs used in the study, likely was the basis for some of the adverse outcomes. Abundant data now confirms that treating younger women with hormones leads to more benefits than risks. (To learn more, see my article regarding the WHI.) Despite this, the guidelines do not make a distinction about the timing of when hormones are initiated, nor acknowledge that it may be only certain hormone regimens that lead to adverse effects.
Unfortunately, many physicians are not aware of these pertinent details regarding the WHI study – details that explain why its results should not apply to the typical women going through menopause at age 50. A survey taken of over 500 physicians revealed that primary care physicians on average could only correctly answer 25% of True/False questions regarding aspects of the WHI results. 
These questions dealt with the benefits and risks of HRT with respect to heart disease, breast cancer, and other potential outcomes. A large number of respondents did not realize that the women in the WHI were much older than the typical age of women entering menopause and incorrectly believed that all forms of HRT caused serious problems. In addition, there was a general impression that the magnitude of the risks was much greater than what was demonstrated in the WHI findings.4
This lack of awareness of the actual details of the WHI has led many physicians to simply assume that HRT in all forms causes more risks than benefits for all women. What this translates to is that physicians remain reluctant to prescribe, much less encourage HRT. This has been demonstrated in multiple surveys. As recent as two years ago a study assessing family physicians’ attitudes about HRT found that 34% indicated they would not prescribe HRT for women coming into the office complaining of hot flashes.4
Many physicians remain uninformed that the major menopause societies, such as the North American Menopause Society (NAMS), British Menopause Society (BMS), and the International Menopause Society (IMS) have published position papers that support the use of HRT for newly menopausal women. Doctors are encouraged to individualize their treatment decisions by taking into account a woman’s age, health status, and personal preferences.
The bottom line
The lack of training about menopause and hormone replacement in medical school and residency programs and a widespread lack of understanding of the controversial aspects of the WHI help explain why women find themselves unable to find a provider that embraces estrogen. This leaves menopausal women in a quandary. By being discouraged from taking HRT, they not only suffer needlessly from their symptoms, but lose out on a number of health benefits. Women need to realize that estrogen therapy is an effective and very safe treatment and does much more than just combat hot flashes. It behooves women approaching menopause to learn as much as they can regarding the benefits and risks of HRT and proactively make choices in their best interest. Organizations such as NAMS and IMS are working hard to provide this education and there are many helpful educational resources on their websites.
My book, The Estrogen Question: Know Before You Say “No” to HRT explains the role that estrogen plays in the body, and helps guide women through the choice of whether or not hormone replacement is right for them. 
Another thorough and thought provoking article by Dr. Rice.