Women, hormones and their personalitiesDr EV Rapiti – July 13, 2025, Cape Town

Women's in menopause have been sorely neglected when there is good treatment available.

Women, hormones and their personalities
Dr EV Rapiti – July 13, 2025, Cape Town

Menopausal women often experience emotional turbulence and outbursts due to hormonal deficiencies. However, when hormone replacement therapy fails to ease these outbursts of rage, it may point to deeper psychological or personality issues that require urgent attention—issues that no amount of hormones can resolve. If left unaddressed, these vitriolic outbursts can abruptly and unnecessarily bring an end to once-happy, long-standing relationships.

Women experience over 32 symptoms associated with menopause that their doctors and gynecologists are unaware of or are unfamiliar with, so many women throughout the world go through life undiagnosed with the problem. The only treatment they would receive is treatment for symptoms for the menopause but not the menopause itself [1].

Perimenopause Symptoms

Perimenopause is the transitional phase before menopause, often beginning in a woman's 40’s (sometimes late 30’s), and can last several years.

1. Menstrual Changes

2. Irregular periods (shorter or longer cycles)

3. Skipped periods

4. Heavier or lighter bleeding

5. Vasomotor Symptoms

6. Hot flashes (sudden feelings of warmth, often in the face and chest)

7. Night sweats [2]

8. Sleep Disturbances

9. Difficulty falling asleep or staying asleep

10. Waking up early

11. Insomnia due to night sweats

12. Mood and Cognitive Changes

13. Irritability

14. Anxiety

15. Depression or low mood

16. Mood swings

17. Difficulty concentrating (brain fog)

18. Memory lapses [3]

19. Physical and Metabolic Symptoms

20. Weight gain, especially around the abdomen

21. Fatigue or low energy

22. Breast tenderness

23. Headaches or migraines

24. Joint and muscle aches

25. Palpitations

26. Dizziness [4]

27. Urogenital and Sexual Symptoms

28. Vaginal dryness

29. Pain during intercourse (dyspareunia)

30. Decreased libido

31. More frequent urinary tract infections (UTIs)

32. Urinary urgency or incontinence [5]
    

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Menopause Symptoms

Menopause is defined as 12 consecutive months without a menstrual period. The average age is around 51 [6].

1. Persisting or Intensified Symptoms

2. Hot flashes and night sweats often continue

3. Vaginal atrophy (thinning and inflammation of vaginal walls)

4. Urinary tract changes (infections, urgency, incontinence)

5. Sleep disturbances may persist
   Mood disorders can become more pronounced

Additional Symptoms Due to Estrogen Deficiency

1. Bone loss (increased risk of osteoporosis)

2. Dry skin and thinning hair

3. Increased cholesterol levels

4. Cardiovascular disease risk increases

5. Joint stiffness and pain [7]

Oestrogen Deficiency does not always Occur in Perimenopause.

While oestrogen plays a central role in the menopausal transition, oestrogen deficiency is not always present in the early phases of perimenopause. In fact, the hallmark of early perimenopause is often hormonal imbalance, rather than deficiency. Typically, progesterone levels decline first, while oestrogen levels may remain stable or even rise intermittently, resulting in oestrogen dominance [8].

As perimenopause progresses into its later stages, oestrogen production becomes erratic and gradually declines. It is only at this point—often just before or after the final menstrual period—that consistent oestrogen deficiency becomes a dominant feature [9].

Hormonal Changes as Women Approach Menopause

As women near menopause, the ovaries begin to shrink (ovarian atrophy) and their ability to produce hormones declines. The ovarian follicles become fewer and less responsive to hormonal signals from the brain (LH and FSH) [10].

Why Progesterone Declines First

Progesterone is produced only after ovulation. As ovulation becomes infrequent, corpus luteum formation declines, and progesterone production drops well before oestrogen [11].

Oestrogen Fluctuation and Eventual Decline

Initially, oestrogen levels may remain normal or even spike. But over time, oestrogen production becomes inconsistent and gradually declines, leading to oestrogen deficiency symptoms [12].

Perimenopause and its Treatment

It's commonly mentioned that it's not wise to use HRT during perimenopause because oestrogen levels fluctuate. However, clinical symptoms should take precedence over single lab tests [13].

Why I Would Advocate a Trial of Low Dose HRT

Because oestrogen levels fluctuate unpredictably, a single blood test may be misleading. A therapeutic trial of low-dose HRT can be safe and beneficial, especially considering oral contraceptives—containing higher oestrogen doses—are used routinely without major adverse effects [14].

Inappropriate Use of Psychotropics

Doctors’ reluctance to prescribe HRT has led to excessive prescribing of psychotropics: antidepressants, benzodiazepines, antipsychotics. These do not address the cause and carry risks of side effects, addiction, and weight gain [15][16].

Consequences of Untreated Hormone Deficiency

Loss of libido, erratic moods, and unexplainable emotional outbursts strain marriages. Trivial arguments become relationship-breaking issues, leading to divorce, infidelity, gender based violence and/or substance abuse [17].

Medical Inconsistencies

Other deficiencies (thyroid, insulin, cortisol) are promptly treated, but oestrogen replacement is avoided due to an outdated and misinterpreted study (Women's Health Initiative) that erroneously linked HRT to breast cancer [18].

Perineal Dryness and Urogenital Disorders
Due to oestrogen deficiency:

1. Frequent UTIs

2. Burning micturition

3. Fungal infections

4. Painful intercourse

5. Incontinence [5][19]

Cardiovascular and Bone Health Risks
Menopausal women lose the cardioprotective benefit of oestrogen, increasing their risk of heart disease. Stress-related illnesses—diabetes, hypertension, sleep deprivation, and fractures due to osteoporosis—compound the issue [20][21].

Common Myths That Must Be Debunked

1. HRT is only for hot flushes

2. Once flushes stop, HRT is unnecessary

3. Oestrogens are unsafe in hypertension

4. Oestrogens cause cancer — no strong evidence supports this [22]

Vaccine-Related Cancer Surge

Young women on oestrogen blockers post-vaccination have reported rapid cancer progression ("turbo cancers")—an alarming trend observed in recent years, though causality remains under review [23].

Treatment with HRT can either be oral or topical.

Vaginal application is probably best because

1. It avoids the heaptobilliary circulation and allows for good absorbition

2. It is not affected by sun exposure or being rubbed off onto the clothes

Personal Practice Reflection

I treated a 42-year-old woman with panic attacks and chest pain misdiagnosed previously as cardiac.
She suddenly decided to end a 14 year relationship because of her spouse’s infidelity three years back.
This left the spouse puzzled. He moved into the other room but wanted to make amends and reconcile but the lady expressed the fear of it happening again.
When she was explained that it was hormonal imbalance and deficiency that was the cause of her somatic symptoms, panic disorders and erratic behaviour, she felt relieved and was glad that there was treatment for the condition.

Cost of HRT

Most insurers refuse to cover HRT, deeming it non-essential, while covering ineffective symptomatic treatments. This decision is uninformed and unjust [24].

Personality Disorders and Menopause

Some women with premenstrual mood disorders or irritable temperaments from their younger days may need HRT plus regular counseling for their personality disorder. Unfortunately, denial of personal flaws hinders healing, because good counselling and behaviour modification can make a major change in their lives and that of their families.

Conclusion
Women should not be denied treatment for menopause. It's not a mild condition that can be wished away for 30 years. Denying women treatment for menopause is a grave injustice to women as a whole by the medical profession.

Dr EV Rapiti

Cape Town, July 13, 2025

Dr Rapiti is a family physician practicing in Mitchells Plain, a poor suburb in Cape Town for over 42 years. He has a special interest in life style medicine, child, women and men's health, couple counselling and addiction. robertrapiti@gmail.com; www.drrapiti.com; 0825811846

Bibliography

1. Santoro N. Mechanisms of Premenstrual Syndrome: Evidence and Implications. Am J Obstet Gynecol. 2016.

2. Freeman EW. Symptoms Associated with Menopause and Hormonal Treatment. J Women's Health. 2010.

3. Maki PM, et al. Menopause and cognitive decline. Endocr Rev. 2019.

4. Thurston RC. Menopausal Symptoms: Prevalence and Impact. JAMA. 2022.

5. North American Menopause Society (NAMS). Genitourinary Syndrome of Menopause: Management Guidelines. 2020.

6. Gold EB, et al. The Menopause Transition: Symptoms and Experiences. Menopause. 2000.

7. Greendale GA, et al. Bone Loss and Estrogen Decline in Menopause. J Clin Endocrinol Metab. 1999.

8. Prior JC. Progesterone and Perimenopause: Hormonal Basis of Cyclical Symptoms. Endocrine. 2005.

9. Hale GE, et al. Hormonal Changes in Perimenopause. Climacteric. 2009.

10. Burger HG. Diagnostic Hormonal Patterns in the Menopause Transition. Menopause Int. 2008.
11. Santoro N. Ovulatory Dysfunction in Perimenopause. Fertil Steril. 2005.
12. Prior JC. Estrogen Levels in Perimenopause. J Steroid Biochem Mol Biol. 2009.

13. NAMS. Clinical Recommendations on Menopause Diagnosis and Management. 2022.

14. de Villiers TJ, et al. Revised Global Consensus Statement on Menopausal Hormone Therapy. Climacteric. 2016.

15. Gartlehner G, et al. Comparative Risks of Psychotropics in Women. JAMA Psychiatry. 2015.

16. Olfson M, Blanco C. Benzodiazepine Use in Women: Trends and Hazards. Am J Psychiatry. 2014.
17. Hickey M, et al. Relationship Stress in Menopausal Women. J Psychosom Res. 2010.

18. Manson JE, et al. WHI Study Reevaluation. N Engl J Med. 2017.

19. Bachmann G, Nevadunsky NS. Diagnosis and Treatment of Atrophic Vaginitis. Am J Med. 2000.

20. Mendelsohn ME, Karas RH. The Protective Effects of Estrogen on the Cardiovascular System. N Engl J Med. 1999.

21. NIH Osteoporosis and Bone Health Initiative. Estrogen and Bone Strength. 2021.

22. Løkkegaard E, et al. Risk of Breast Cancer and HRT: Reassessing Evidence. Climacteric. 2021.

23. Seneff S, et al. Vaccine-Associated Cancer Risks. Med Hypotheses. 2023.

24. British Menopause Society. Cost-Benefit of HRT Coverage. BMS Bulletin. 2022.