Comfort Is Not Evidence - SSRIs, Hot Flushes, and the Perimenopause Anxiety Trap

What if the thing that makes you feel safest… isn’t actually helping you?

In this episode of On the Mones, Kate unpacks a deceptively simple idea with enormous consequences: comfort is not evidence.

It starts with a respectful but confronting comment thread on a debunking video about naturopathy, vulnerability, and communication. From there, the conversation widens into something much bigger: why women in midlife are so often sold reassurance instead of rigour, validation instead of verification, and how “feeling heard” has quietly become a substitute for clinical outcomes.

Kate explores:

• Why warmth, charisma, and simplification can be persuasive, but dangerous, in healthcare
• The lack of regulation around naturopathy and why “my clients love me” is not a defence
• Real-world harm, including Australian regulatory cases involving banned health practitioners
• How wellness culture targets women, especially during hormonal vulnerability, and why that matters

From there, the episode pivots into a clear, evidence-based deep dive on SSRIs:

• How SSRIs actually work in the brain (and what they don’t do)
• Why they’re sometimes prescribed for hot flushes
• And how perimenopausal anxiety is frequently treated with antidepressants when estrogen deficiency may be the real driver

Through a clinical lens and a personal story, Kate makes the case for better questions, better context, and fewer lazy defaults when women in their 40s and 50s present with anxiety.

This episode also features a Wellness Woo of the Week takedown of “adrenal fatigue”, why it isn’t a diagnosis, why it feels comforting, and how it turns complex physiology into fast food.

If you’ve ever been told:

• “At least she listens”
• “It can’t hurt”
• “It makes people feel better”

This episode is your pause button.

Because feeling cared for matters, but only evidence protects you.

Whether you are in perimenopause, approaching menopause, or simply trying to understand your hormones, I've got you. 

Read more about this episode at Medication Clarity Clinic - Kate's own medication education and telehealth consulting site: https://medicationclarity.com.au

Transcript

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SPEAKER_01 0:00

You're listening to On the Moans, where we have conversations about hormones, midlife, and the moments that make us wonder is it just me? I'm Kate. I'm a 48-year-old pharmacist and newly minted perimenopausal oversharer. This is where we talk openly about the changes we aren't prepared for, so we never have to feel alone in them again. I acknowledge the Camaragle people of the Iora Nation, the traditional custodians of the land which I am recording today. I pay my respects to elders past and present, and I extend that respect to all Aboriginal and Torres Strait Islander peoples listening. Always was, always will be, Aboriginal Land. Hello friends, welcome back to On the Moans, the podcast where I talk about stuff that's going on in my life and in my mind in the hopes that something similar is going on in yours. This pharmacology lecture is on selective serotonin reuptake inhibitors, and there's a spifling woo-of the week. But I've been ruminating, which I know isn't healthy or helpful, so I want to get it off my chest. Worse, I've been ruminating because of a comment in one of my debunking TikToks that I posted of a naturopath making some bold claims. Now, I'm not at my best in this debunking video, as you will find out. I am snobbish about her pronunciation and make fun of her accent. Which makes the fact that these comments are not in any way bullying or harassing or even vaguely confronting even more amazing. It is a very respectful adult interaction via a social media platform. Actually, I would say that I rarely, hardly ever get negative or horrible comments on my TikToks or Instagram reels. My children like to tell me it's because I'm not big enough, which is likely true, but I also like to think it has something to do with the community of clever, like-minded, education focused people who engage with my posts. Either that or I haven't yet worked out how to find my hidden folded comments section. Anyway, I'll read the comment thread in its entirety for you, and then I want to discuss a few things. And I've used a pseudonym for the naturopath and not identified the commentators at all. First comment. Just a thought, if someone is sharing incorrect information, it's completely fair to correct it, but commenting on their pronunciation or the way they speak doesn't really add to the discussion. A person's tone or accent is irrelevant to scientific accuracy. It's always more helpful to focus on the evidence itself rather than making personal remarks. It keeps the conversation respectful and avoids discouraging people from learning or asking questions. I'm left wondering at this point, can there be incorrect information? If information is true facts, then incorrect information is an oxymoron, no? And it should be misinformation or disinformation rather than incorrect information. But I digress. My reply. That's a really fair point, and I agree, the evidence is always the most important part. But when someone is presenting themselves as a health professional and giving advice about symptoms, hormones, and the immune system, the way they communicate does matter. Clear professional language helps people recognize the difference between qualified medical information and content that's not. Especially when the claims themselves are incorrect or oversimplified. And honestly, preying on people who are vulnerable or desperate for answers really gets on my tits. Because it really does. A third person enters the discussion. I have seen Jay, the naturopath, not her real name, multiple times in person over the past year, and I actually appreciate the way she communicates. It's the reason I feel comfortable with her and am able to be vulnerable with her. Also, the way she explains things and simplifies them makes them a lot simpler for me to understand. What matters is how her actual clients feel with her communication style, not someone on the internet who will never be a client of hers. Someone else, a fourth person, joins the conversation. I disagree. It's no different than if you were educating people on ways to identify fraudulent scam emails. Be aware that emails containing terms such as urgent payment required, grammar and spelling errors is a way the public can identify scammers using simple fold terminology as she did, i.e. the naturopath, is a red flag that the public should be made aware of. As you can see, I did engage initially because I thought, well, if you're going to put your can't say balls because I don't have any so ovaries out there and call out misinformation, then you really owe it to the people who have taken the time to watch and reply, both for and against your position, to engage them in a dialogue. Not because it got under my skin, which it did, but not because they disagreed with me or were calling me out for being a snob about language, which I thought they did very respectfully, by the way. And if I'm being honest, they're right, I was mocking her and making fun of her bogan accent. If you have TikTok, go ahead and find my page at Prescribal Pass, and you can see the aforementioned video. Maybe then you will have some empathy for me. And not because I have a rebuttal fully formed in my head within six seconds, I thought long and hard and drafted a few different replies before finally settling on the one that I ended up posting. Let me tell you what happened. As I said, I did a debunking video on a naturopath. In the naturopath's original TikTok video, she is claiming that part of being a super fun female is that before your period your immune system dips, super fun, and that it is super common to get flu like symptoms and to get actually sick. So I took Umbrage, because if you're going to say something happens commonly, then it's a good idea to back it up with some numbers. Otherwise you're just saying stuff that suits you. Because, logically, the immune system doesn't drop for 50% of the population for a week every month. What actually happens is that in the luteal phase, fatigue, sleep disruption, and symptom awareness increases. So if you are already run down, stressed, not sleeping, and paying closer attention, then it might feel as though you have a viral illness. A better sentence could have been, some women notice they feel more run down in the luteal phase, but there's no good evidence that most women become immunocompromised before their period. Which is also why I'm allergic to the word common. I'm also allergic to the word allergic, but that's for another time. Because without numbers, it turns a normal variation into a monthly pathology, and suddenly everyone thinks their immune system is failing them twelve times a year. But if I'm being honest, and I try to be, I was snobby about it. I made fun of the way she spoke, the cadence, the affect, the pronunciation of certain words, although it is era and not error, but that's beside the point. Just to come to my own defences for a moment, I do get worked up by videos on social media that are peddling misinformation to vulnerable women. This isn't anecdotal, and since I've just made a song and dance about numbers, women make up around 80% of wellness product purchases, use dietary supplements at significantly higher rates than men, and spend nearly 30% more on health and personal care overall, which is why the wellness industry overwhelmingly targets women rather than men. Even industry analysts acknowledge that men's wellness is a smaller secondary market. The system is built, marketed, and monetized primarily around women's bodies, fears, and unmet needs. I'm also struggling to work out what lane naturopaths sit in. They aren't registered health professionals, they don't have a degree with an agreed-upon curriculum. I know there is the Bachelor of Health Sciences Naturopathy, but I could start a TikTok Instagram page, or better yet, open a physical clinic and call myself a naturopath, and there's no one to stop me. There is no single overarching statutory body like the RACGP for GPs or the Pharmacy Guild for Pharmacists that legally regulates naturopaths. You can make a complaint to the HCC and the HCC can find the conduct poses a risk to public health or safety. It can issue a prohibition order, but it can't deregister the person because, well, they weren't registered in the first place. If what they are offering had scientifically backed evidence, they'd be pharmacists or doctors or dietitians, wouldn't they? I mean if their claims that certain herbs balanced hormones were tested and trialed and showed robust evidence, wouldn't that then be taught in the medical degree? And wouldn't gynecologists or endocrinologists or GPs the world over be using the same treatment protocol? The comment from the person saying that this particular naturopath explains things simply so she feels like she can be vulnerable with her is crazy to me. Let me see if I have this right. I can hang a plaque, offer a service, offer a diagnosis, then offer the solution to said diagnosis, which I also handily have available, and charge some money. And to get away with this, all I have to be able to do is make vulnerable people feel comfortable. Isn't this manipulation, emotional and financial, disguised as healthcare? Come to think of it, since wellness is targeted at women, couldn't we even call it misogyny? Do the general public realise naturopaths are not registered health professionals? I have a number of comments on the same TikTok debunking video where people have said that health professionals don't make fun of other health professionals, to which I want to scream from the tallest tower, they are not health professionals. Sometimes people say, What's the harm? At least she listens. Even if it's not proven, it makes people feel better. But this isn't theoretical, there are consequences. In Australia, a woman was recently sentenced to imprisonment, supervision orders, and substantial fines for advertising and supplying so-called natural products under the business name Tickety Boo Herbal, Black Salve, and Blood Root Csules, and for making claims that they could treat serious conditions including cancer and anxiety. Black Salve is not gentle, it's corrosive. It destroys layers of skin, including healthy tissue. It can cause burns, ulceration, scarring, and infection. Blood root contains a substance so dangerous it is a Schedule 10 poison and prohibited from sale or use in Australia. There is no credible evidence that it treats anything, let alone cancer or anxiety. And yet people were persuaded through warm, reassuring language, to use it. The court found the conduct was deliberate and planned. The judge explicitly said the court had an obligation to deter this behaviour because it could cause great harm. And here is the line that should make all of us pause. There is a real potential for people to delay or avoid conventional treatment because of these claims. This person was sentenced to seven months' imprisonment, a community corrections order, and a $20,000 fine. And there's another high-profile example that shows this isn't slippery slope hyperbole, it's real-world enforcement. The New South Wales Healthcare Complaints Commission permanently banned Barbara O'Neill from providing any health services or health advice whatsoever. That means no consultations, no seminars, no lectures, no public speaking, no paid or unpaid services. This isn't a marketing arm wrestle, that's a regulator finding her claims, things like discouraging chemotherapy, discouraging vaccines, and suggesting unproven treatments dangerous enough to create a public health risk. The decision came after a formal investigation found she was misleading vulnerable people with information well beyond her training or evidence, including in areas like cancer treatment and infant nutrition. And yet she continues to lecture overseas, she tours internationally, she appears on social media platforms, her posturing continues to circulate online. Indirect harm counts too, and it's the subtle harm that often gets ignored. Even if someone isn't physically injured by a product, if they delay seeing an oncologist, if they postpone surgery, if they put off evidence-based treatment because they feel reassured by an alternative explanation, that harm is real. The court recognised that. The regulator recognised that. This is why the argument my clients love me, my clients feel safe, my clients feel better is not a defense. Patient satisfaction has never been a reliable marker of efficacy. If it were, antibiotics would still be used for viruses, opioids would still be handed out for everything, no one would hear uncomfortable truths. Feeling good during a process does not mean the process is safe, ethical, or effective. It means the experience was pleasant, and they are not the same thing. I will say this as well. Mocking how someone speaks isn't my best work. It muddies the message, it shifts focus from claims to personality, and this topic deserves better than snark, because it isn't about sounding smart, it's about keeping people safe. You can demand empathy and proof, you can want kindness and rigour. You don't have to choose. So the next time you hear she makes me feel so safe, pause and ask the next question. Safe to do what? Safe based on what evidence? Safe for how long? Because being comfortable might make the experience nicer, but evidence is protective. It begs the bigger question, which is why has science-based medicine evolved to such a degree that people feel they need this kind of reassurance and validation from someone unqualified. This isn't about one naturopath or one comment or one woman feeling helped. This is about something much bigger. Here's the core idea of today's episode. Feeling safe is not the same thing as being helped, and comfort is not evidence. And if that sentence made you bristle a little, good, because it should. We have quietly slid into a culture where how something feels has started to replace whether it works, where emotional resonance is treated as proof that commentator isn't wrong about her experience. Feeling safe with a practitioner is real, feeling heard is real, and feeling understood, especially when you've felt dismissed before, is profoundly real. And modern medicine has historically not been very good at this, especially when it comes to women, or people of colour, or really anyone who isn't a white man. Women have been treated as men with boobs for forever. And the system we are working with isn't perfect either. We rush, we interrupt, we medicalize without explaining, we sometimes forget there's a person attached to the body. And people are still people, and because of that, some are going to be better at their jobs than others, like in every profession. And I don't mean good clinically, although that too. I mean good at the soft skills that go alongside healthcare. So when someone finds a practitioner who listens slowly, who mirrors their language, who makes them feel calm and validated, of course that feels healing. Of course it does. But feeling safe is not a clinical outcome. Comfort is how trust is built, not how truth is tested. And we all understand this intuitively in other areas of life. A charismatic financial advisor can make you feel very safe, right up until you lose all your money you put into a tree plantation. A charming pastor can make you feel deeply held, right up until you realize you've outsourced your critical thinking. A bartender who listens beautifully can still overserve you. Warmth does not equal wisdom, charisma does not equal competence, and yet in wellness culture retreat it as if it does. There is a difference between simplifying and explaining. Explaining says, here's what we know, here's what we don't know, here's where the evidence is strong, here is where it is weak, here's the uncertainty. Simplifying in the grifty sense says don't worry about all that, this is what's really going on, and lucky for you, I understand it. Vulnerability raises the ethical bar. This is the part I wish people talked about more, because when someone is vulnerable with you emotionally, physically, hormonally, you inherit responsibility, not authority, responsibility. If someone trusts you enough to cry in your office, tell you about their exhaustion, their weight gain, their fear, their infertility, their rage, their loss of libido, their shame, that does not give you permission to make bigger claims. It means you must make smaller, more careful ones, because vulnerability amplifies influence, and influence without rigour is dangerous. Somehow science-based medicine has created the gap and wellness has stepped into that gap with time, language, ritual, and reassurance. There is a danger in at least she listens. Yes, listening matters. But listening without literacy, listening without accountability, and listening without boundaries, these things are not benign. They are persuasive, and persuasion feels very good when you're tired, scared, or dismissed. So here's what I would say calmly, gently, and without accusation. You don't have to be stupid to be taken in by this. You don't have to be desperate, you just have to be human. Humans trust warmth, confidence, and stories that make sense of chaos. And in midlife, when bodies change, hormones misbehave, and medicine sometimes shrugs, those stories are seductive. If you take nothing else from this episode, take this. Feeling cared for is not the same thing as being correctly treated. Both matter, but only one protects you. The comment that likened it to identifying email scams by using context and language clues is exactly right. When we teach people how to identify fraudulent emails, we're not mocking the sender. We're not saying everyone who writes badly is a scammer. We're saying that if certain communication patterns cluster around deception often enough, they're worth noticing. Tone becomes data, language becomes a signal, and in health, just like in scams, these signals matter because the stakes are high. Selective serotonin reuptake inhibitors or SSRIs are a super common prescription for middle-aged women. See what I just did then? I cracked myself up. More accurately, the PBS doesn't publish data on X number of SSRI prescriptions for women aged 35 and over, but they do give data on overall antidepressant use in Australia. In 2023 to 2024, 14% of Australians were dispensed at least one antidepressant script in that year, and women use antidepressants one and a half times the rate of men. 60% of antidepressants prescribed are in the SSRI class, so we can estimate that 2.2 million SSRI prescriptions were dispensed that year, and if women are one and a half times men, then it's reasonable to infer that a large share of those SSRIs went to women. So no, not super common, but also not nothing. How do they work in the brain? And why, if they are used for anxiety and depression, are they also sometimes prescribed for hot flushes? I want to tell you a story about a friend of mine. She's in her early 50s. I mean, this alone should be tickling some spidey senses in any GP. Long, stable, loving marriage. Kids finished school, doing well at university and life. Good job, lovely house, nice suburb, no major life stresses, no sudden grief, no obvious trauma. And yet, she started to feel anxious. Not I'm worried about something specific anxious, but that vague, low level, constant hum of unease. Heart racing, tight chest, poor sleep, a sense that something was wrong even though nothing was. Good girl that she is, she went to the GP, and the GP did what many well-meaning clinicians are trained to do. They suggested an SSRI. But my friend, who is also a health professional, paused and said something really important. She said, I'm in my early 50s. Could this be hormonal? And they talked it through, and instead of starting an antidepressant, they trialed estrogen with progesterone. And a few months later, she feels like herself again. Not euphoric, not medicated, not flattened, just herself. This story also matters not because SSRIs are bad, but because sometimes we are treating the smoke instead of the fire. Common examples of SSRIs include Certriline, fluoxetine, E cetaliam, cetaliram, peroxetine. They are primarily approved for depression, general anxiety disorder, panic disorder, OCD, PTSD. They are not sedatives or happy pills, they don't work immediately, and they don't add serotonin to your brain. Instead, they change how serotonin is recycled. Neurons communicate by releasing neurotransmitters into Tiny gaps called the synapse. Serotonin is one of those neurotransmitters. Normally, a neuron releases serotonin, it binds to the receptors on the next neuron, then it gets taken back up into the original neuron via a transporter. SSRIs block that transporter, so serotonin hangs around longer in the synapse. But the real effects don't come from that immediate increase. They come from downstream changes over weeks. Receptor sensitivity changes, neural circuits involved in mood and threat detection recalibrate, the amygdala becomes less reactive, the prefrontal cortex regains some control. That's why SSRIs take four to six weeks to really work. They are not a chemical on-off switch, they are a slow neurobiological nudge. Anxiety is not too much worry, it's a state of heightened threat perception. Your brain is constantly scanning for danger, your nervous system is primed, your stress response is easily triggered. SSRIs help by reducing amygdala reactivity, improving top-down regulation from the prefrontal cortex, dampening the stress response over time. For many people with primary anxiety disorders, this is genuinely life-changing. So why are SSRIs used for hot flushes? Hot flushes are not about heat. They are about thermoregulation in the brain. Estrogen plays a key role in stabilizing the hypothalamic temperature set point. When estrogen fluctuates or drops, the thermonutral zone narrows. Small changes in body temperature trigger vasodilation, Q hot flushes, sweating, palpitations. Serotonin and noradrenaline are also involved in this pathway. Certain SSRIs and SNRIs can modestly reduce hot flush frequency and severity by acting centrally on these neurotransmitters. That is why some are used off-label for vasomotor symptoms, particularly when estrogen is contraindicated or not tolerated or declined by the patient. They help some women but they do not replace estrogen's role. Estrogen doesn't just regulate periods and hot flushes, it also modulates serotonin synthesis, influences serotonin receptor expression, enhances dopamine signaling, calms the stress response, supports sleep architecture. When estrogen becomes erratic, the brain feels it, and the symptoms can look like anxiety, low mood, irritability, insomnia, loss of confidence, and a sense of I'm not coping. So a woman in her late 40s or early 50s presents with anxiety, and we say, here's an SSRI, without asking, has anything external changed? Is this new? Is she perimenopausal? Are there vasomotor symptoms? Has her sleep changed? Are her cycles changing or gone? Is she on HRT? Sometimes we are medicating a neurotransmitter consequence of estrogen deficiency instead of addressing the hormonal driver itself. Estrogen is not an antidepressant and it's not an anxiolytic, but it is a neuromodulator. When estrogen is restored in the right person, serotonin signaling improves, stress reactivity reduces, sleep improves, emotional regulation stabilizes. So women often say, I feel calmer, I feel like myself again, my anxiety is gone. Not because estrogen is magic, but because the system causing the symptoms has been supported. And sometimes, as with my friend, estrogen was the missing piece. Important caveat, estrogen is not a panacea. Not all anxiety in midlife is hormonal. Not all women will improve with HRT. Some women have long-standing anxiety disorders, have trauma histories, have depression that predates perimenopause, need SSRIs, psychotherapy, or both. And some women need both estrogen and an SSRI. This is not an either-or, it's horses for courses. But what we should not be doing is defaulting to antidepressants without considering hormones in women of perimenopausal age. The clinical sweet spot looks like this. We ask better questions, we contextualize symptoms, we acknowledge biology, and we avoid false binaries. Sometimes the answer is estrogen first, reassess, add an SSRI later if needed. Sometimes it's SSRI first or alongside HRT. And sometimes it's no medication at all, sleep, therapy, lifestyle, and time. The problem isn't SSRIs. The problem is diagnostic laziness in midlife women. If you are in your 40s, 50s and feeling anxious for no reason, your brain chemistry may be responding to hormonal change, and you deserve a conversation that includes that possibility. SSRIs are a powerful tool. Estrogen is a powerful tool. The art of holistic medicine is knowing which one you need and when. And when they fail, it's called adrenal insufficiency or Addison's disease. People don't feel a bit flat, they lose weight, their blood pressure drops, they collapse, and without treatment, they can die. That is not what most women being told they have adrenal fatigue are experiencing. What is happening is much more ordinary and much less marketable. They're not sleeping, they're chronically stressed, they're perimenopausal, they're juggling work, young family, aging parents, and a body that no longer behaves predictably. And they feel exhausted, anxious, wired, but tired, which is a real experience for many women, but is not a weary adrenal gland. Calling this adrenal fatigue feels comforting because it gives the chaos a name. It reframes suffering as physiology rather than weakness, and it quietly shifts the focus away from harder, messier conversations about sleep, hormones, mental health, relationships, and burnout. It also creates a problem that can be treated with supplements, herbs, saliva tests, and protocols often conveniently sold by the same person making the diagnosis. That should give us pause. Adrenal fatigue doesn't explain why you feel unwell, it explains why someone else feels confident selling you the solution. And that's why it earns its place in this segment. As I keep saying, comfort is not evidence, and adrenal fatigue is fast food for complex physiology. Next episode, we might talk clonidine, the quiet little alpha agonist that keeps getting dragged into sleep and hot flush conversations, or ViOza, the new non-hormonal treatment for vasomotor symptoms of menopause, hot flushes, or antihistamines and their place in PMDD. So much to talk about. If you have a topic you would like to include in the discussion, please send me an email. Onthemans at gmail.com and follow me on Instagram and TikTok at prescribe or pass. Lovely friends, be curious about yourself. Be sceptical of services offering both the diagnosis and the treatment neatly delivered with a reassuring vibe. And please, stop blaming your personality for your physiology. See you next time we get on the moans. Bye bye. Vulnerab vulnerable fun vulnerability. Vunnerability vulnerab vulnerability? Vulnerability.