More structured healthcare to support women through menopause is needed, GPs say, and providing it could improve women’s health for the rest of their lives.
Dedicated GP consultations would better arm women to recognise and manage menopausal symptoms. Targeted investment at midlife would improve women’s quality of life, reduce their risk of illness and improve life expectancy.
“Structured care for women in perimenopause and beyond would allow for adequate control of menopause symptoms, but it is also a really good opportunity for preventing disease down the line,” says Dr Ciara McCarthy, the Irish College of General Practitioners’ clinical lead in women’s health.
“Not only does it present an opportunity to discuss menopausal symptoms, but it is a huge health promotion and health prevention opportunity in terms of optimising bone health, cardiac health and ensuring cervical screening is up to date,” she says.
At menopause, a woman stops having periods due to lower hormone levels. It usually starts between the ages of 45 and 55. The average age for a woman to reach menopause is 51.
GPs and practice nurses are very stretched, so while we want this to become part of our structured care programme, we need to make sure there is adequate staffing to do it
Perimenopause, the time directly before menopause, can coincide with the onset of numerous health issues including heart disease, osteoporosis, type 2 diabetes, and trigger neurological symptoms such as hot flushes, disturbed sleep, mood changes and forgetfulness.
Low self-esteem, depression, anxiety, tiredness, irregular and heavy periods, joint pain, vaginal dryness and decreased sex drive can also occur. These things can have a significant impact on women’s quality of life, impacting their relationships, careers and life expectancy. Some 20 per cent of women will not experience significant menopausal symptoms.
“We are finally putting women’s health at the top of the agenda in the past two years. We have made significant strides in terms of free contraception, termination of pregnancy, and I think this is an opportunity to say we are prioritising menopause and recognising the importance of it”, says Dr McCarthy.
A dedicated healthcare programme for midlife women could be modelled on the existing structured HSE programmes, delivered in general practice, aimed at preventing and managing heart disease and type 2 diabetes.
The Department of Health’s Women’s Action Plan 2022/23 published in March commits to increasing menopause support for women.
While the aspiration would be for structured menopause care to be delivered by GPs, the workforce crisis there would need to be considered, says Dr McCarthy. “GPs and practice nurses are very stretched, so while we want this to become part of our structured care programme, we need to make sure there is adequate staffing to do it.”
HRT (hormone replacement therapy) is not appropriate for all women, but is a very safe medication and suitable for a wide variety of women, says Dr McCarthy. “The benefits of HRT go beyond managing menopausal symptoms, there are significant health benefits for some patients. It offers protection against osteoporosis, particularly if it is started in younger women, it can be protective against heart disease and stroke as well.”
Menopause now for women is often at the midpoint of their lives, they often have another 30 or 40 years of post-menopausal life. We want to see good quality of life
Rates of osteoporosis are highest among women and those experiencing hip fracture have a 20 per cent risk of dying within a year. Structured care at menopause will not prevent all hip fractures, but it will prevent some, says Dr McCarthy.
“The leading cause of death in women is cardiac disease and that really ramps up after menopause — we are relatively protected prior to menopause because of the protective effect of oestrogen — so again, this is an opportunity to optimise blood pressure and cholesterol,” says Dr McCarthy.
“We know that women between the ages of 50 and 65, while they are eligible for cervical screening, there is a fall off in uptake,” she says. Better care for women in perimenopause and beyond could prevent disease.
“Menopause now for women is often at the midpoint of their lives, they often have another 30 or 40 years of post-menopausal life. We want to see good quality of life,” she says.
Irish attitudes to menopause are linked to a history of shame and silence around women’s health and fertility, says broadcaster Gráinne Seoige. She will present a new documentary on menopause set to air on TG4 on November 2nd at 9.30pm. Meanapás: Meon Nua will be ground-breaking, according to the station.
“There has historically been a lot of shame around women’s sexual health in this country, whether it’s to do with fertility, having children outside of wedlock, abortion, contraception — everything has been weighted with shame and a lack of knowledge,” says Seoige. “Menopause is no different.
“So many women have the same experience of loneliness and nervousness and fear because they don’t know what’s happening to them.”
In the documentary, Seoige calls for a national information campaign about menopause and she is campaigning for a National Menopause Policy. Minister for Health Stephen Donnelly is interviewed in the documentary in what Seoige describes as “a positive conversation” with him about such a policy.
“A lot of women leave the workplace at this time because they are struggling with symptoms like brain fog and memory loss,” says Seoige. “These women have experience, they have knowledge, they are trained. They are valuable in the workforce.”
Featured in the TG4 documentary is a former director in investment banking for over 20 years, Catherine O’Keeffe. Her experience of perimenopause inspired her to change careers and she now works as a workplace menopause consultant.
In a TEDx talk, O’Keeffe describes an experience of flooding, or heaving menstrual bleeding that soaked through her clothes. “For what seemed like an eternity, I sat frozen in fear ... I left the restaurant on a freezing night with my jacket around my waist and my head hanging in embarrassment, I was only 44,” says O’Keeffe. After that, she took a change of clothes with her everywhere, including keeping spare clothes at work.
In a routine work presentation to management, she experienced further symptoms. “Just moments into my presentation, every piece of information I was hoping to present just flowed out of my head — cue brain fog, memory loss, anxiety and menopause in collision. My stomach sank, I felt shame in front of my peers.”
It would be great for the Government to support a routine visit for women with their GP from your mid- to late-40s to talk about mammogram screening, breastcheck, bone and cardiovascular health
O’Keeffe says she experienced “rage and frustration” with what was happening in her body. “My own journey made me think, what’s going on here and why is nobody talking about it?”
Her company Wellness Warrior has provided menopause consultancy in over 250 workplaces, and she says early perimenopause in particular is catching women off guard. “Women don’t tie up the symptoms to what is going on in their life, the first thing they think is, what is wrong with me?”
“If you are not feeling supported in your workplace, that is going to exacerbate any kind of overwhelm.”
Workplace occupational health policies need to include menopause, says O’Keeffe. “Not every woman is going to get pregnant, but every woman is going to go through menopause.”
Members of Fórsa, the largest trade union in Irish civil and public service, have adopted a motion calling on employers to do more to address stigma around menstrual health through “period and menopause-friendly” workplace policies.
More than 70 per cent of 1,800 respondents to a survey by the union said they had to take time off work due to menstrual issues. Taboos around periods and menopause, however, mean just four in 10 felt able to tell their line manager the real reason for their absence.
Training for managers and workplace education about menstrual and menopause health, improved toilet facilities and temperature control for those who experience hot flushes were some of the measures sought by women.
The Oireachtas Committee on Gender Equality was established to consider the recommendations of the report of the Citizens’ Assembly on Gender Equality in Ireland. The 140-page report however makes no reference to menopause. As a result, the Committee has not sought submissions or arranged meetings specifically on the topic, it says.
Giving these women access to evidence-based information, setting them up with really good screening for the remainder of their lives benefits society as a whole
In Britain, the House of Commons women and equalities committee by contrast has held enquiries into menopause and the workplace, exploring whether the law adequately protects women experiencing menopause symptoms.
This follows a British Menopause Society national survey that found 45 per cent of women felt their menopause symptoms had a negative impact on their work. MPs are examining the case for reforming existing legislation or introducing new laws.
The Minister for Health and the Women’s Health Taskforce is committed to “changing the approach to menopause care to increase public support for women”, the department says.
The taskforce was established after an inquiry into the CervicalCheck Screening Programme recommended women’s health be given more consistent, expert and committed attention.
The taskforce identified that many women feel isolated in menopause and that there is a gap in resources and information to support them, the department says.
These are women who are pillars of the workforce, they are pillars of the community, they are the mums holding schools together and who are so essential to other parts of our community
Specialist menopause clinics in Dublin, Limerick, Galway and Cork will be developed for those requiring “complex, specialist care”, the Department says. One of these clinics, at the National Maternity Hospital, is already operational.
Dr Caoimhe Hartley is the clinical lead of another commencing at the Rotunda Hospital. The GP also runs the private Menopause Health clinic in Dalkey, Co Dublin where women receive a 45-minute initial consultation with follow-ups. Demand is high with a five-month waiting list for private appointments.
The majority of women who seek support for their menopause can be effectively supported within primary care by their GP, the department says. GPs, however, are stretched, Dr Hartley says.
“It would be great for the Government to support a routine visit for women with their GP from your mid- to late-40s to talk about mammogram screening, BreastCheck, bone and cardiovascular health and to get an overview of HRT and other options if they are symptomatic,” says Dr Hartley. “The issue is funding. GPs are completely flat out. I don’t know how that would work. It would have to be really well supported and funded by Government.”
Targeted health interventions for midlife women pays off, says Dr Hartley. “These are women who are pillars of the workforce, they are pillars of the community, they are the mums holding schools together and who are so essential to other parts of our community. Giving these women access to evidence-based information, setting them up with really good screening for the remainder of their lives benefits society as a whole.”
I wait with trepidation at the beginning of the month to see if I can manage with my patients
Meanwhile demand for HRT has increased exponentially, says Irish Pharmacy Union (IPU) member Kathy Maher. GPs are more confident in prescribing it and greater public awareness means more women are requesting it. The removal of VAT on HRT products in the budget will bring a substantial drop in cost for women.
While HRT shortages have stabilised, they are still having an effect. Supplies of some products are allocated to pharmacists based on the previous month’s usage. “This doesn’t allow for dose increases or new patients,” says Maher. “I wait with trepidation at the beginning of the month to see if I can manage with my patients.”
The IPU is calling on the Minister for Health to permit a serious shortage protocol, already in place in the UK. This would enable pharmacists to dispense equivalent products without the need for a woman to return to her prescriber, says Maher. “We need to make sure a woman’s quality of life does not become impacted by a shortage of medicine.”
World Menopause Day is on Tuesday, October 18th