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Menopause: ‘We need to swing the pendulum to the middle and normalise it’

New series challenges recent trend to medicalise the experience

Series in the Lancet argues that an over-simplified narrative of the menopause as a health problem that can be solved by replacing hormones is not based on evidence. Photograph: Liudmila Chernetska

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Sylvia Thompson
Mon Apr 8 2024 - 05:01

“The pendulum has swung from ‘put up and shut up’ about the menopause to sensationalising it,” says Rachel Weiss.

“It’s good that we are talking more about the menopause,” says the founder of the Menopause Café charity, commenting on a new series on the menopause from the Lancet medical journal. “Now we need to swing the pendulum to the middle and normalise menopause so that anyone who wants to talk about it can, so that people are not scared of it, and so that a diverse experience of the menopause is depicted in the media, not just celebrity horror stories.”

In Ireland many people will remember the outpourings from women on live radio about their menopause experiences on RTÉ’s Joe Duffy Liveline programmes in May 2021. Since then, the Department of Health has set up menopause clinics in Irish maternity hospitals. Annual menopause summits billed as “education, empowerment and advocacy” events have been highlighting everything from workplace policies on the menopause to research into the perimenopause.

However, this new series from the Lancet argues that an over-simplified narrative of the menopause as a health problem that can be solved by replacing hormones is not based on evidence. The authors – led by Prof Martha Hickey from the University of Melbourne and the Royal Women’s Hospital in Melbourne, Australia – say this approach “deflects attention from the need for substantial societal shifts in how menopause and midlife/older women in general are viewed and treated around the world”.

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Prof Martha Hickey.

“A new approach to menopause that better prepares and supports women during midlife is needed – going beyond medical treatments to empower women using high-quality information on symptoms and treatments, empathetic clinical care and workplace adjustments as required,” they write.

“The misconception of the menopause as always being a medical issue, which consistently heralds a decline in physical and mental health should be challenged across the whole of society,” says Prof Hickey. She says that many women live rewarding lives during and after the menopause, contributing to work, family life and wider society. “Changing the narrative to view menopause as part of healthy ageing may better empower women to navigate this life stage and reduce fear and trepidation among those who have yet to experience it.”

The Lancet series also questions the view that menopause often causes mental health problems, while identifying specific at risk groups who may need additional support. For example, women who experience early menopause or cancer treatment-induced menopause often do not receive optimal care.

The Lancet papers call for an individualised approach where women are given accurate, consistent and impartial information to make informed decisions that are right for them over their menopause transition. “This may include taking menopause hormonal therapy (HRT) for symptoms such as hot flushes and night sweats which can range from mild to extremely debilitating, after a discussion with their doctors about the risks and benefits,” says Prof Hickey. Some women may also opt for psychological therapies such as cognitive behavioural therapy to reduce the psychological impact of hot flushes and night sweats and to improve sleep.

Everyone can play a part in shifting society’s view of older women by engaging in conversations

The authors accept that countries across the western world are experiencing a “menopause moment” with more open discussion across politics, workplaces and the media. But they berate the media’s tendency to focus on extreme negative experiences of the menopause, depicting it as an unfortunate and distressing experience, heralding a critical downturn in women’s health that can only be solved by hormone replacement.

“Whilst it is certainly the case that some women have extremely negative experiences of menopause and benefit from hormone therapy, the reality is much more complex and varied with some women reporting neutral experiences and others highlighting good aspects such as freedom from menstruation and menstrual pain,” says Dr Lydia Brown, co-author from the University of Melbourne.

A review of 12 studies that investigated the association between the menopause transition and depression did not confirm the widely-held belief that menopause is associated with poor mental health. Two of the 12 studies report increased depressive symptoms over menopause but three found no such increase and the remaining seven studies reported mixed results. After reviewing the 12 studies, the authors concluded that “there is no robust evidence that risk of anxiety, bipolar disorder, psychosis or suicide increased for all women over the menopause transition”.

[ ‘There’s too much talk about menopause? We’re just making up for the last 20 goddamn years when women suffered in silence’ ]

A review of the evidence on menopause symptoms found that the most effective treatment for hot flushes and night sweats is hormone therapy. Treating hot flushes may also improve sleep and mood and prevent fractures in weak bones. However, evidence on the benefits of hormone therapy on other symptoms associated with menopause and ageing is lacking.

“No medication can reliably resolve all the negative experiences during menopause and commercial interests have influenced how menopausal hormone therapy is presented – overshadowing evidence-based alternative options,” says Dr Andreas La Croix, from the University of California San Diego Herbert Wertheim School of Public Health and Human Longevity Science. The authors argue that organisations marketing menopause products, including pharmaceutical companies and private providers, “have strongly influenced media messaging about menopause and hormone therapy”.

Prof Myra Hunter.

Another author of the Lancet series, Prof Myra Hunter from King’s College, London says clinicians should discuss additional ways to manage some menopausal symptoms such as cognitive behavioural therapy and lifestyle changes addressing diet, smoking and exercises that can benefit sleep and mood whilst improving long-term health.

[ Jennifer O’Connell: Why don’t we want to talk about menopause? ]

The authors also call for more research into aspects of the menopause that are a priority for women. For example, a global Menopause Priority Setting Partnership is under way across more than 40 countries to develop a new, patient-focused research agenda.

“There is a lot we can learn about attitudes to menopause and growing older in general from communities such as many Asian cultures where ageing in women confers respect and status rather than stigma. Everyone can play a part in shifting society’s view of older women by engaging in conversations,” says Weiss.

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