Sometimes, in women who are very sensitive to their own hormonal fluctuations, I use medication such as Zoladex to temporarily suppress ovarian hormone production.

The aim is usually stability. Rather than the ovaries producing fluctuating levels of oestrogen and progesterone, we suppress that cycle and then add hormones back in a more controlled way. And importantly I've often added a 'good' amount prior - so we know a bit about tolerance, absorption and side effects.  This “block and replace” approach can be very helpful for severe PMDD, hormone-sensitive mood symptoms, migraine, or other symptoms that clearly track with ovarian cycling.

But ovarian suppression is not something I think about casually, particularly when treatment continues longer term.

Zoladex suppresses ovarian oestrogen production, so without adequate replacement it can create a genuinely low-oestrogen state. That matters for symptoms, but also for longer-term bone and cardiovascular health. This is why add-back hormone therapy is such an important part of treatment.

It can also take time to get this right. We often need to gradually build up the replacement oestrogen, monitor how someone feels, and make sure they are actually absorbing enough before the 'block'. The dose written on the prescription does not necessarily tell us the amount reaching that individual woman.

So when I use ovarian suppression, I am thinking about bone health, cardiovascular health, overall wellbeing, and whether hormone replacement is genuinely adequate — not simply whether somebody is taking oestrogen.

We know that early permanent loss of ovarian function can be associated with longer-term health risks. However, that is not exactly the same situation as medically suppressing ovarian function while deliberately replacing oestrogen and progesterone. The intention with Zoladex is to remove the unpredictable ovarian fluctuations, not to leave someone chronically oestrogen deficient.

I am also continually asking whether ovarian suppression is still needed. Natural menopause usually occurs in the early 50s, so as someone moves further through the menopause transition, it becomes increasingly reasonable to reassess whether the ovaries are still generating the fluctuations that caused the original problem.

One practical approach can be to gradually extend the interval between Zoladex injections and monitor what happens. Do cyclical mood symptoms return? Do migraines come back? Does bleeding restart? Do vasomotor symptoms worsen? If someone remains well as injections become further apart, it may eventually be reasonable not to give another dose.

Stopping Zoladex does not automatically mean stopping MHT. These are separate decisions.

There is no requirement to routinely stop MHT at a particular age, and there is no need to keep reducing treatment simply to reach the smallest possible dose. Some women find they need less oestrogen as they move further beyond menopause, while others do not. Again, absorption and individual response matter.

My general approach is to use the lowest dose that adequately controls symptoms and supports wellbeing, rather than reducing treatment where there is no clinical need to do so.

So when I suppress someone’s ovarian hormones, I am balancing several things at once: symptom control, bone health, cardiovascular health, adequate hormone replacement, and whether suppression is still necessary over time.

The goal is not simply to “switch the hormones off”. It is to create stability when hormonal fluctuations are causing significant problems, then carefully replace the hormones we need to replace — sometimes building this up over time — and keep reassessing whether the treatment is still the right one.