When HRT Prescriptions Plummeted: The 2002 WHI Study and Women’s Mental Health

In July 2002, a medical study changed the way millions of women and their doctors thought about menopause.

The study was the Women's Health Initiative (WHI), one of the largest randomized clinical trials ever conducted in postmenopausal women. When researchers announced that the estrogen-plus-progestin arm of the trial was being stopped early, the news received enormous attention. The results appeared to show that the risks of this particular hormone regimen outweighed its benefits for the prevention of chronic disease.

The consequences for hormone replacement therapy (HRT) prescribing were immediate and enormous.But there is another part of this story that deserves attention: while HRT prescriptions were falling sharply, prescriptions for serotonergic antidepressants and anxiolytics were moving in the opposite direction.

That does not necessarily mean one caused the other. But the timing raises an important question:

What happened to the millions of women who had been using hormones for menopausal symptoms?

The WHI bombshell

The WHI estrogen-plus-progestin trial enrolled 16,608 postmenopausal women aged 50 to 79 who had not undergone hysterectomy. Participants received either conjugated equine estrogen plus medroxyprogesterone acetate or placebo.

The trial was stopped early after an average of 5.2 years because investigators concluded that the overall balance of risks and benefits had crossed the trial's stopping boundary.

The reported risks included increases in coronary heart disease, stroke, pulmonary embolism and invasive breast cancer, while fractures and colorectal cancer were reduced.

There was an important nuance, however: the trial tested one particular estrogen-plus-progestin regimen. It did not test every form, dose, route or formulation of menopausal hormone therapy.

Nevertheless, the public message in 2002 was remarkably simple:

HRT was dangerous. And prescribing changed accordingly.

HRT prescriptions fell off a cliff

Before the WHI announcement, hormone therapy prescribing had been relatively stable.

In the second quarter of 2002, approximately 22.4 million HRT prescriptions were dispensed in the United States.

Within nine months of the WHI report, that number had fallen by 32%.

By the fourth quarter of 2003, prescriptions had fallen approximately 43% from the pre-WHI level. The drug most directly represented in the WHI trial, standard-dose Prempro, fell even more dramatically.

This wasn't a small adjustment in medical practice. It was a seismic change.

But something else was happening

Here's where the story becomes particularly interesting.

Before July 2002, there wasn't a statistically significant trend in either direction.

After the WHI announcement, researchers observed a statistically significant decrease in HRT prescriptions accompanied by an increase in serotonergic antidepressant prescriptions.

That is an important observation.

It does not prove that women were simply taken off hormones and placed on antidepressants. It does not prove that antidepressants were inappropriate. And it does not establish that the WHI itself caused the increase.

But it does demonstrate that, at the population level, the collapse in HRT use occurred alongside a rise in serotonergic antidepressant use.

Why would antidepressant prescriptions rise?

There are several possible explanations.

Antidepressants can have legitimate uses during menopause. Certain medications can reduce hot flashes and other vasomotor symptoms, making them a reasonable nonhormonal treatment option for some women.

At the same time, menopause can be accompanied by profound changes in sleep, mood, anxiety, temperature regulation, cognition, sexual function and overall quality of life.

And this is where the conversation becomes particularly important in women's mental health.

Is it depression, or is something else going on?

When a woman in her 40s or 50s develops new anxiety, depression, irritability, insomnia, panic symptoms, brain fog or emotional changes, the answer isn't always as simple as diagnosing a psychiatric disorder in isolation.

Sometimes the psychiatric symptoms are the primary problem.

Sometimes they are occurring alongside perimenopause or menopause.

Sometimes sleep disruption, hormonal fluctuations, thyroid dysfunction, medication effects, nutritional issues, chronic stress, relationship changes or other medical and psychosocial factors may be contributing.

And sometimes there is more than one thing happening at once.

That doesn't mean psychiatric medication isn't appropriate. It absolutely can be. For many women, psychotherapy, medication, or a combination of both can be life-changing. But it does mean that a woman's symptoms deserve to be understood in context.

A root-cause approach to women's mental health

This is one of the reasons our practice has a particular passion for women's mental health.

In a telehealth private-practice setting, we have the opportunity to slow down and look beyond a symptom checklist.

Rather than asking only, "Which medication treats this symptom?", we believe it is also important to ask:

• When did the symptoms begin?

• Did they coincide with perimenopause or another major physiological transition?

• How is she sleeping?

• What medications and supplements is she taking?

• Are there relevant medical conditions that need to be evaluated?

• What is happening with stress, relationships, work and caregiving?

• Has she experienced similar symptoms at other points in her life?

• What treatments have helped, or failed, in the past?

• What does the patient herself think is happening?

This is what we mean by a root-cause approach.

It doesn't mean assuming that hormones are the answer to every mental health problem.

It means resisting the temptation to treat women as though their mental health exists separately from the rest of their physiology and life circumstances.

Women's mental health deserves a bigger conversation

For decades, women's symptoms have sometimes been minimized, misunderstood or attributed to "just hormones."

The answer isn't to swing to the opposite extreme and assume that every symptom is hormonal.

The better approach is individualized care.

A woman experiencing depression deserves an evaluation for depression.

A woman experiencing anxiety deserves an evaluation for anxiety.

And a woman experiencing new psychiatric symptoms during perimenopause deserves an evaluation that considers the whole picture.

Hormones may be relevant. Sleep may be relevant. Medical conditions may be relevant. Medications may be relevant. Trauma and stress may be relevant. Relationships and life circumstances may be relevant. Often, several factors matter at the same time.

Why this history still matters

The WHI changed medicine, and it changed the lives of millions of women.

The dramatic decline in HRT prescribing after 2002 is well documented. So is the simultaneous rise in serotonergic antidepressant prescribing in at least some populations.

But the biggest lesson may be broader than either medication.

When a woman's symptoms change, we need to understand why.

That is particularly important during the perimenopausal and menopausal years, when biological, psychological and social changes can intersect in complicated ways.

At our telehealth private practice, women's mental health is an area we care deeply about. Our goal is not simply to put a label on a symptom or automatically reach for a prescription. We strive to understand the individual woman sitting on the other side of the screen and consider the biological, psychological and environmental factors that may be contributing to how she feels.

Because good psychiatric care isn't just about asking, "What medication should we use?"

Sometimes the more important question is:

"Why is this happening in the first place?"

Women's mental health care through telehealth

If you're experiencing anxiety, depression, mood changes, insomnia, irritability, brain fog or other mental health symptoms during perimenopause or menopause, you don't have to navigate the process alone.

Our telehealth practice provides individualized psychiatric care with a particular interest in women's mental health and the complex relationship between mental health, hormones, sleep, physical health and life circumstances.

We believe treatment should be collaborative, individualized and grounded in understanding the person, not simply treating the symptom.

Because your mental health is connected to the rest of you.

To begin your journey, be it hormonal or emotional, maybe both, you can start here: thealchemy-institute.com/intake-form