‘You don’t have to feel like this’: Emilie Pine on starting HRT

I started leaking. A little when I sneezed. A little if I laughed too hard. It was only tiny amounts, I told myself, barely noticeable. But I was only 46. The idea of leaking at all filled me with horror.
By then, I’d been in perimenopause for a few years. I’d got used to waking in the night, my pyjamas soaked in sweat. I’d got used to frequent bouts of tearfulness. I’d even got used to the too-tight feeling of my trouser waistbands. This was just midlife, I told myself, and, besides, there are lots of things I love about getting older. But when I started leaking, I knew I needed help.
I was scared about asking for help, because when I’d previously tried to discuss it at my usual GP practice, I had felt completely shut down. A few years ago, when I’d mentioned my bodily changes to a doctor, he glanced at me then said, “You’re far too young. Give it another decade.”
My next consultation was with a female doctor. Once more, I mentioned my symptoms, but this doctor said, “I don’t know what to tell you, it only gets worse.”
I should have tried harder, or asked again, or more insistently. But I accepted these dismissals, not least because I, too, wanted to ignore how my body was changing.
It was a friend’s story that made me think again. She is a year older than me and, suffering with chronic muscle and joint pain, she’d gone to her GP and been prescribed HRT. She told me how much better she was feeling, how she could walk without pain for the first time in years. I resolved there and then to get better help for myself.
This time, I booked an appointment at a different GP practice, one that offered a menopause clinic.
Before I saw the doctor, the receptionist gave me an assessment form for menopause symptoms, asking me to tick any that applied. Out of a list of 30 options, I ticked 13 boxes. Daytime flushes, night sweats, change in periods, muscle ache, loss of libido, word-finding problems, weight gain around middle, urinary symptoms, tearfulness, poor sleep, fatigue, anxiety, irritability (I felt like ticking this last one twice).
In the doctor’s office, I gave her my form. She looked down the list and then went through them one by one. As we talked through my symptoms I felt like I was finally being given permission to see them as real and worth doing something about.
When the doctor asked me about urinary symptoms, I said this was what had driven me to ask for help. She nodded sympathetically.
I complained that since I hadn’t had children I assumed I wouldn’t encounter this particular problem. The doctor smiled, kindly. Then she explained that all the muscles in a woman’s body need oestrogen to function fully, and that the muscles around the bladder and abdomen are particularly oestrogen-dependent. I looked at her in a kind of shock. I only knew oestrogen as a hormone involved in fertility, the idea that it had other effects in my body was a revelation.
The doctor said I was a good candidate for HRT, then she outlined the effects, side effects, risks and benefits. As I had previously had breast lumps removed, I was particularly cautious in relation to breast cancer. The doctor explained that previous studies involved older women and used older oral HRT medications with different risks than current ones. She said she’d also refer me to a hospital breast clinic to double check everything.
But even with so many fears allayed, I hesitated. Perhaps I should just put up and shut up?
And then she said the magic words: “You don’t have to feel like this.”
A few weeks later, I was given the all-clear by the Breast Care team at St James’s Hospital and that afternoon, I got my first HRT prescription filled. I took the pharmacy bag home, feeling like I was taking agency over my life. And then – classic – I put the bag on a bathroom shelf and did not touch it for a week.
I knew HRT held the promise of feeling better, but a part of me still felt as if I was admitting to failure. And after years of trying to become pregnant, I felt I was admitting the end of that, too.
But one morning, after a sleepless, sweaty night, I opened the packet, peeled off the backing and stuck on my first oestrogen patch. That night I took my first progesterone pill. And had the best night’s sleep I’d had in ages (because – who knew? – progesterone has a sedative effect).
Within a month of starting HRT, my bodily symptoms lessened.
It was a relief to feel physically better, but the greater surprise lay elsewhere.
Over the past couple of years, I had started to suffer from serious anxiety. Small tasks could panic me completely. Some days, it took a huge act of will just to reply to a friend’s text message. There were friends I’d ghosted just because I couldn’t cope with the stress of planning where and when to meet up. I’d put this down, once again, to midlife and the after-effects of a pandemic. I got used to my life being a little smaller.
But within a couple of weeks of HRT, I felt my mood lifting. Low oestrogen was the cause of my anxiety.
Slowly, text by text, friend by friend, I began to climb out of the invisible silo that perimenopause had gradually trapped me in.
[ The Women’s Podcast – Claire Dinsmore on perimenopause: ‘Make this phase your power years’Opens in new window ]
After a year of HRT, I went for my first annual review. I told the doctor I was feeling much better but also that there were things that hadn’t improved. For a start, I was still having trouble finding the next word in a sentence or remembering ideas I’d had only a minute before.
“Is it like brain fog?” she asked.
I am a very literal person and so I tried to imagine my head filled with actual fog. I paused. “No,” I said, “it’s more like I’m losing my mind.”
She did not laugh, though she smiled. That’s brain fog, it turns out.
Next I brought up my loss of libido. The doctor nodded.
And then I mentioned the thing that still filled me with dread – the fear of losing bladder control. I made a joke about it, and immediately realised I was trying to make light of this thing that scares me most. I forced myself to speak a little louder, a little more definitely. “Because,” I said, “the thing is, I’m still leaking.”
It was strange to say these things out loud. Strange, and also a release.
In response, the doctor and I agreed to increase my HRT dose and also prescribed me testosterone.
Testosterone comes as a gel, a tiny blob of which I rub into my skin every morning. For such a small amount, it has made an incredible difference to both my sense of desire and my cognitive focus. I feel like I am more in my body. And I feel like I am more myself. There are days when I could weep with combined relief and joy at these changes.
But it hasn’t all been simple – the higher HRT dose did not agree with me. So at my next appointment, I went back down to the original, lower dose and, in addition, the doctor prescribed vaginal oestrogen, and referred me to a women’s health physiotherapist.
At the physiotherapy clinic, I was nervous of describing all over again how often I needed to go to the loo, and I was nervous too of the physical exam that lay ahead. But the physiotherapist was so straightforward, so matter-of-fact, that I quickly became comfortable. Even the examination, when she inserted gloved fingers into my vagina and gently pressed to test my muscle response, could not make me red-faced.
The physiotherapist focused her diagnosis on my pelvic floor muscles, which are tight from being over-engaged. I had always feared the spectre of a loose pelvic floor, but apparently my job as a lecturer, which entails being on my feet for long periods without a bathroom break, has given me the opposite problem.
My physiotherapist told me that tight pelvic floor muscles can cause pelvic pain or pain with sex. She told me that I need to learn to release the muscle, and gave me instructions on pelvic breathing exercises. I left her clinic with a real sense of knowledge about my body – and with a sense of hope.
On the way home, I sent a voice-note to a close friend about the experience. “Classic,” my friend replied, “your pelvic floor is trying to be an overachiever.” I relayed this judgement to my sister, and when she cackled appreciatively, it felt like another weight lifting.
Three months, and three appointments later, the physiotherapist gave me the all clear. No more leaking.
I share these stories with my sister, with my female and male friends, because it was other women’s stories that gave me the encouragement I needed in order to ask for help. Menopause can still feel like a topic mired in silence, and so these can be difficult conversations to start. But any difficulty is worth it because, even though menopause is no longer a dirty word, so many women are still suffering needlessly.
[ Work and menopause support must tread a fine line between awareness and stigmaOpens in new window ]
It’s hard not to read the scarcity of knowledge about menopause as an extension of the general shame and stigma surrounding female bodies, sexualities and reproductive systems.
It’s hard to understand why both education and agency around women’s healthcare are still so limited.
And though both society and the medical profession are changing, it’s really hard to accept the slow pace of that change.
In the face of all this hardness, the only route open to many of us is the softer one – of talking to our friends, of asking around about good GPs, and of daring ourselves to risk the public embarrassment of confessing to anxiety, dry sex and leaking bladders.
Because all we’re saying, really, is that we have female bodies.
Emilie Pine is the author of the memoir Notes to Self.