Menopause is a normal part of aging that is becoming overmedicalized as the pendulum of popular sentiment swings back in favour of hormone replacement therapy, according to a group of international experts who say writing a prescription isn’t the only way to help women through the transition.
In a new series in the medical journal The Lancet, experts from Australia, India, the United States, Britain and elsewhere urge health professionals to empower women with accurate information about menopause that isn’t driven by pharmaceutical companies or other commercial interests.
The authors aren’t opposed to hormonal therapy, which they say can be a safe and effective way to relieve hot flashes and genitourinary symptoms such as vaginal dryness for women younger than 60 without certain risk factors. But the first paper in the series, published Tuesday, argues that treating menopause primarily as an illness to be medicated does women a disservice as they age.
“One problem is that a normal event that affects everyone has been turned into a disease, a hormone deficiency disease, which requires diagnosis and treatment,” said lead author Martha Hickey, a professor of obstetrics and gynecology at the University of Melbourne. “In a society that has very strong feelings about aging in women, this is a disease which is thought to herald decline and decay amongst them. This, not surprisingly, makes younger women quite fearful.”
Gen X is over having their menopause and sex concerns brushed aside
The Lancet series, which also includes papers on early menopause, menopause in cancer patients and mental health during menopause, is in part a response to the rising cultural saliency of menopause itself. The Lancet experts acknowledge that menopause, once a taboo topic, is now having a “moment,” one led by Gen X celebrities and ordinary women demanding better health care and more workplace accommodations as they navigate the end of their fertility.
This menopause moment is coinciding with a reappraisal of hormone replacement therapy, now commonly referred to in medical circles as menopausal hormone therapy, or MHT.
MHT is a medication that consists of either estrogen or a combination of estrogen and progestin, a synthetic form of the hormone progesterone. It was widely prescribed until 2002, when the initial findings of a large, randomized control trial called the Women’s Health Initiative led a generation of women and doctors to believe MHT was too risky for widespread use.
Since then, reanalysis and follow-up of the initial data have examined the differences between how women under 60 (or less than a decade out from menopause) and those over 60 in the large trial fared on MHT. Those studies found the benefits of relief from hot flashes and night sweats outweighed the risks if hormonal medication was started at the right age in women who don’t have specific risk factors, such as a personal history of breast cancer, coronary artery disease or stroke.
The new Lancet series notes that, in Britain, use of MHT increased by around 60 per cent between 2020 and 2022, particularly in affluent parts of the country.
It’s difficult to say whether a similar trend is happening in Canada; there are no reliable, publicly available national data on MHT use here. But one recent study, based on online surveys completed by postmenopausal women in seven countries, found that a little more than 10 per cent of Canadian respondents were on hormone therapy, less than in any of the other countries surveyed.
“I still feel we have a huge issue in Canada around access to care,” said Nese Yuksel, president of the Canadian Menopause Society and a professor in the faculty of pharmacy and pharmaceutical sciences at the University of Alberta. “Personally, I don’t think we’ve overdone it in Canada. I still think there’s room to continue to educate, especially health care providers and the public, about understanding what can happen during menopause – not to make people fearful.”
Michelle Jacobson, a menopause specialist at Women’s College Hospital in Toronto who also sits on the board of the Canadian Menopause Society, agreed it remains difficult for some Canadian women to find a primary-care provider willing to prescribe MHT. There are also long waiting lists to see menopause specialists.
“Quite paradoxically,” Dr. Jacobson said, “if there’s an overtreatment of menopause, it’s coming from non-medical doctors like integrative specialists and naturopaths who are selling a youthful prize where, if menopause is treated, women may be able to actually hold on to the looks of somebody younger, the energy of somebody younger.”
The Lancet experts recommend an “empowerment model” that would help women with severe perimenopause symptoms get the treatment they need without painting the transition as universally bleak. Perimenopause is the time period leading up to menopause, which is marked 12 months after a woman’s final period.
Although some women experience debilitating symptoms that disrupt their day-to-day lives, others feel no ill effects, and find menopause to be a positive experience that frees them from their monthly periods and the risk of unwanted pregnancies, Dr. Hickey said.
Lydia Brown, a clinical psychologist at the University of Melbourne and lead author of the paper on menopause and mental health, said her team’s review of past studies found no clear evidence that menopause raises the risk for depressive symptoms, clinical depression, anxiety or suicide in most women, although she conceded it is hard to disentangle the possible causes of mental distress in mid-life.
“There is a need to challenge outdated stereotypes of the menopausal moody woman,” Dr. Brown said.
Kelly Grant