The lead up to and the period of menopause in our youth obsessed western culture is most often a time that many women fear. It is imbued with so many negative connotations – of ‘being old’, ‘dried up’, and no longer vibrant. In contrast the menopause in many other cultures around the world represents a time of great freedom, wisdom and respect within the community. The way we view menopause in our society is sadly outdated, awash with misinformation and in dire need of a sexy new makeover!
Menopause is also a time that may bring with it distressing physical symptoms for many women. While menopause is a natural part of life and almost fifty percent of women will breeze through the menopause with minimal symptoms, the other half may suffer considerably.
The perimenopause – the time in the lead up to the last period, can be a time of complete hormonal chaos. This time is much like a reverse puberty and can be different for everyone. Hormones can be erratic before menopause. Symptoms can include irregular and heavy periods, muscle and joint aches and pains, depression, irritability and changes in libido. Peri-menopause can last anywhere from 2- 10 years before the final period. It is impossible to tell who will experience severe symptoms or how long they will last But we know that the extent to which a woman may suffer symptoms depends upon cultural, genetic and lifestyle factors. We know that interestingly a woman’s fear of ageing and the negative societal view of menopause makes it more likely for women to have troubling symptoms, than a woman who views menopause as a time of freedom and positive change. Women who are overwhelmed with chronically elevated stress hormones and the responsibility of being the ‘sandwich generation’ – caring for children and elderly parents, balancing work and leaving little time for self care may also be more vulnerable to experience symptoms.
Menopause itself is defined as the last period, and the post-menopausal period is defined as being 12 months after the last period. Debilitating menopausal symptoms due to a decline in oestrogen can include severe hot flashes, disrupted sleep, difficulty concentrating and a decrease in mental acuity, as well as depression, vaginal dryness, sexual pain and loss of libido. These symptoms can last up to 10 years post the menopause in some women and can obviously massively affect their relationships, work performance and general quality of life.
In a recent publication by Prof Sue Davis in Melbourne, it was found that 29% of menopausal women under the age of 55, 15% of women aged 55- 59, and 6.5% of women from 60 – 69 suffered from severe symptoms. Only a very small percentage of these women sought or were given effective treatment.
For a problem that affects such a large proportion of Australian women it is astounding that so many women are not treated with effective treatments that are proven to decrease symptoms and improve quality of life. Instead, they think they simply must put up with it.
There are options that may help many women that do not involve medications or hormones in the first instance.
All women should be encouraged to have a healthy diet high in fruits and vegetables, omega three fats and adequate protein and minimise sugar, caffeine, alcohol and refined and processed foods. A Mediterranean diet is recommended.
Some women may find eating foods high in phytoestrogens such as whole grains, legumes, tofu and soy products to be helpful although evidence on effectiveness of phytoestrogens is minimal.
Regular exercise to help maintain healthy bones, metabolism and the cardiovascular system is important and there is a wealth of evidence that exercise has positive mood promoting benefits.
Mindfulness and mediation can help with mood changes and anxiety. Some women find other stress relieving methods like massage, or acupuncture to be beneficial and acupuncture has also been shown to give some relief with hot flushes (although so does sham acupuncture) which just goes to show the amazing powers of the mind and could be due in part to reducing stress levels which is so important in minimising menopausal symptoms.
Getting adequate sleep – 7 to 8 hours a night is really important for keeping stress down – so sleeping with sheets you can throw off, and a window open can help if hot flushes are disrupting sleep.
In the same vein, dressing in layers and wearing natural fibres that breathe can help minimise the impact of hot flushes.
Maintaining connection to others, purpose and meaning in their lives and taking time for self care – often women I see at this stage are trying to look after everyone else and they are last on their list. Feelings of increased stress and overwhelm can increase negative mood symptoms so self care is super important.
Giving up smoking – smokers are more likely to go though menopause earlier and may be more likely to suffer more debilitating hot flushes.
Being aware of possible endocrine disrupting chemicals in the environment – BPA, plastics, Phlalates and parabens in cosmetics, chemicals in pesticides. These chemicals which are ubiquitous in our modern society have been linked to premature menopause and so are worth thinking about and avoiding throughout our reproductive life.
There is a broad misconception both amongst the general public and even still amongst some medical doctors that treatments for menopause such as HRT (hormone replacement therapy) are dangerous. This is because of the Women’s health initiative study published in 2002, now widely known to be flawed in its study design and reporting of data. It was reported in the media at the time that women who were taking HRT had a 26% higher risk of developing breast cancer and also that the risk of stroke or blood clot were higher in women taking HRT. The media reporting of this study resulted in huge numbers of women going off their HRT and now almost two decades of women being shockingly under-treated.
The fear around HRT also brought about a rise in women using ‘bio-identical’ hormone preparations under the impression that they are natural and must therefore be safe. These preparations are compounded in various pharmacies and the problem is that due to lack of regulation, standardisation and rigorous testing, neither safety or efficacy of these hormones can be guaranteed.
The real facts about HRT are that increased rates of breast cancer were only seen with the use of synthetic progesterone not with the use of oestrogen alone, and only after 5 years of treatment. Even in the group of women given synthetic progesterone, the absolute risk of breast cancer was still only 8/10000 women per year. There is a new body identical form of progesterone available to Australian women now which is not associated with an increased risk of breast cancer at all, and has been show in large French studies over many years to be completely safe.
The study also did not take into account the route of treatment. While HRT taken in tablet form does cause an increase in blood clot/stroke in women over 60, patches and gels show no increased risk. In women under 60 there is no increased risk of stroke or blood clot whether HRT is taken orally or transdermal. In fact, the same study that scared so many women off HRT actually showed that there was a decreased risk of dying in women taking HRT under 60 compared to those not taking HRT!
Therefore, HRT is safe and effective for the vast majority of women under 60 years old and transdermal HRT is safe in women over 60.
Vaginal oestrogens are a safe and effective treatment for painful sex and dry vagina in the majority of women.
Transdermal testosterone has been shown to be effective and safe for improving libido.
For women who prefer non hormonal therapies or for whom hormonal therapies may be contraindicated, antidepressant medications are very effective in controlling hot flashes, and the mood symptoms of menopause.
Of the alternative therapies – black cohosh or remifemin has been shown to be better than placebo in a recent review.
The oral contraceptive pill can be used safely and effectively for many women to help alleviate some of the symptoms of the perimenopause such as heavy, irregular periods for a short period of time, as can the Mirena intra-uterine device.
It is obviously important that any decisions about treatment for menopause symptoms be individualised for each woman, and also include a detailed review of other important lifestyle factors such as diet, physical activity, sleep, and stress relieving strategies. Treatment should always be holistic and take into account the full biological, psychological and social circumstances of each woman.
Although it can be a tumultuous time for many women, it can also be a time of reflection, and a time of opening up to new possibilities in life. Far from the idea of a dried up, over the hill old woman – menopause is more often a time when women are at the peak of their careers having amassed many years of experience in their chosen fields. They may have older more independent children or children that are leaving home, meaning that they suddenly have more freedom and time to do the things that they enjoy. Menopause can and should be a time where women are at their peak, where they come into their own, where years of experience turn into wisdom and confidence that many younger women simply don’t have.
As a gynaecologist who is passionate about helping to inform and treat women during this time, I would love to see women reclaim this incredibly important and transformative time in their lives. Yes it can be unpredictable in terms of physical symptoms and may be uncomfortable as any transformative process is, but it is also a great opportunity for growth. It is a time where the world can come into sharper focus for many women and where other people’s expectations and things that aren’t really important may fall away if we let it. It’s an opportunity to really know ourselves. And as attitudes to ageing effect our experience of menopause, imagine the difference we might see if there was a positive marking of this stage in our journey rather than keeping it invisible or something to fear as it is now.
The new Lancet study suggesting that breast cancer risk increases with MHT has worried many of my patients – many who have chosen to take MHT (HRT) for debilitating menopausal symptoms or because of the benefits of MHT. This study looked at old preparations we no longer use and already knew about breast cancer risk and did not include many studies looking at body identical hormones, which we know to be much safer when it comes to breast cancer risk. It is always a balance of risks versus benefits for any woman and this study failed to take into account the benefits such as reduced cardiovascular disease, reduced osteoporosis, other metabolic effects and symptom relief. The decision to go on HRT is not one-dimensional but must include all these factors. Please see https://www.menopause.org.au/about-ams/media-info/1468-mht-and-breast-cancer-risk-lancet-29-august-2019 to read the Australasian Menopause Society statement on this article, and if you have any concerns or questions please ask your doctor.
If women have the facts, and we can take away many of the debilitating symptoms, women can get on with seeing menopause as the great time for self-discovery and mastery that it should be, and become the confident, powerful women that they are. And there is nothing sexier than a confident, enlightened and powerful woman!
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