Why an HRT shortage is a mental health issue

Picture a woman sitting in the boardroom of a business. She’s worked in this organisation for several years and, up until now, has brought energy, decisiveness and confidence to the table. But today, for the first time in her career, this woman is riddled with anxiety and self-doubt. She’s thinking: I can’t do this. 

What she might not know is, that’s her lack of oestrogen talking. 

Menopause specialist Dr Fatima Khan says that while physical indicators such as heart palpitations and joint aches can accompany a decline in reproductive hormones, about 80 percent of symptoms experienced by women going through perimenopause and menopause involve their mental health.  

“It’s the fatigue, the lack of motivation, the brain fog,” says Dr Khan. “Not being able to get out in the morning and do the things that they’ve done without even thinking, like getting dressed in the morning, going to work and dropping the kids to school. 

Dr Fatima Khan, pictured second from the left, speaking at the 2024 FW Leadership Summit.

“We know 40 per cent of women aged between 45 and 55 will be offered an antidepressant when they present to their GP with perimenopause symptoms. It is not really a mental health disorder. It’s a decline in oestrogen and progesterone which causes anxiety, low mood, brain fog, fatigue and sleep disturbance amongst other symptoms”.

Dr Khan supports women through this transition and often prescribes hormone replacement therapy (HRT) products, including oestrogen or “estradiol” tablets, gels and patches – the latter of which can be hard to come by. While supply of HRT products to Australia has been inconsistent since 2020, in mid-2023, pharmaceutical companies flagged global shortages of multiple brands of estradiol patches due to “manufacturing issues”.

“These are the body-identical estradiol patches – so they’re the more natural type of patches. We’re not talking about ethinyl estradiol or Premarin, which are synthetic. We’re talking about plant-extracted estradiol, which is exactly like your own body, which is what women want to use for perimenopause or menopause,” Dr Khan explains. 

“I get so many CEOs and really high executive-suite women coming to me saying, ‘I don’t think I can do this role anymore. And I say, ‘But you’ve been doing it for 20 years’.”

Estradiol patches are waterproof adhesives that can be placed anywhere on your body and only need to be applied twice a week. “So they’re fantastic and commonly used by women of all ages – but particularly those in perimenopause, ages 40 to 50, who’ve got young kids and don’t want to be using gels and other things,” says Dr Khan.  

Recent years have seen a rise in women using HRT – what Dr Khan calls “a menopause revolution” – which the industry didn’t anticipate. As a result, people are scrambling to access products, sometimes driving for hours to rural and country-based pharmacies. Every day, Dr Khan receives emails from 10 or so patients who can’t source their estradiol patches. 

“Unfortunately, Australia tends to be at the end of the supply chain,” says Dr Khan. “The patches are also PBS [Pharmaceutical Benefits Scheme] subsidised. That means they are much more affordable than the non-PBS versions of the body-identical oestrogen, so that further adds to the shortage.” 

How is this impacting women? In a word, cognitively. 

“Oestrogen is very important for the brain,” says Dr Khan. “It impacts executive function and memory, so when women can’t get their patch, there’s a sense of anxiety and panic. Physically and emotionally, the symptoms of low oestrogen are debilitating, which we don’t want, because most women [in this age demographic] have full-time jobs and families. They need to function.”

This month, an Australian Senate inquiry held the last of a series of public hearings into issues relating to menopause and perimenopause. The top agenda item has been to investigate the economic consequences of menopause and perimenopause, including reduced workforce participation.

“If this was a male medication serving some kind of male medical issue, we would not have this issue,” says Dr Khan. “We need to do better for women.” 

“We know from the Association of Superannuation Funds of Australia (ASFA) that women are retiring five years earlier than they’re meant to,” says Dr Khan. “They’ve looked at this data from health insurance companies that have certificates from doctors, which normally states ‘sickness’, ‘illness’ or ‘disability’. They can’t put menopause in there because it doesn’t classify as any of these things.” 

According to research from the ASFA, women who leave the workforce five years earlier than expected potentially forego about $60,000 in lost retirement savings. One in seven Australian women transitioning through menopause will pay a superannuation savings penalty by taking time out of the workforce or retiring prematurely. 

“I get so many CEOs and really high executive-suite women coming to me saying, ‘I don’t think I can do this role anymore’,” says Dr Khan. “And I say, ‘But you’ve been doing it for 20 years. You have so much wisdom and so much power to make positive change. This is not the time to leave’. And normally, when we give them oestrogen, the light bulb turns on. They’re back and they’re thriving in their workplace and personal lives.”  

Amid ongoing shortages of body-identical estradiol patches, Dr Khan is guiding Australian women toward this same hormone replacement in gel or tablet form. 

“It’s important to know you have choices,” she says. “You can ask your GP for an oestrogen gel, which is body-identical, in a pump dispenser that’s not on the PBS, or a foil sachet that’s PBS-subsidised. We also have an estradiol tablet which is PBS-subsidised. We have a significant, undisturbed supply of the gel and the tablets – there’s no shortages. And sometimes, they’re cheaper.”

Dr Khan recommends keeping an eye on the Therapeutic Goods Administration (TGA) for supply updates and encourages people seeking advice, along with health professionals prescribing HRT, to visit the Australasian Menopause Society.  

The Senate inquiry into perimenopause and menopause released its findings in mid-September. It shed light on how this life transition impacts professional women and their working capacity. With growing awareness, hopefully we will also see suppliers of HRT products stepping up to meet demands.  

“If this was a male medication serving some kind of male medical issue, we would not have this issue,” says Dr Khan. “We need to do better for women.”