Enriching the conversation about menopause
Two OBGYNs with two health psychologists just penned a thought-provoking article.
An article in the BMJ (British Medical Journal) freshly unwraps the experiential, medical, and psychological aspects of menopause.
Menopause is directly experienced by half of us and all the rest of us are indirectly affected through them. That makes the well researched and articulated thoughts in this article of interest to anyone. Since it was published in BMJ Open, the whole paper entitled Normalizing Menopause can be read without a subscription. I encourage everyone to do so, but here are a few compelling highlights to whet your appetite.
Menopause is a personal, human experience. The authors state:
“Menopause is a natural event for half of humankind. The term “menopause” denotes the final menstrual period but is often used to describe the menopause transition, starting with changes in the menstrual cycle and finishing one year after the final menstrual period. While media attention in in the UK may give the impression that growing numbers of women are struggling to cope with menopausal symptoms and are seeking hormonal treatment,1 there is no universal experience and most women prefer not to take medication unless their symptoms are severe.2 In fact, socioeconomic status, education level, and social and cultural attitudes to menopause act with biological factors such as hormonal changes, smoking, diet, and body mass index to determine the experience of menopause, including the nature and severity of symptoms.”
Medicalization of menopause
‘Industrial’ medicine can erase the important details and nuances of a person’s biology and experience.
“We argue that medicalisation of menopause risks collapsing the wide range of experiences at the average age associated with this natural process into a narrowly defined disease requiring treatment. Medicalisation tends to emphasize the negative aspects of menopause and, while effective treatments are important for those with troublesome symptoms, medicalisation may increase women’s anxiety and apprehension about this natural life stage. Changing the narrative by normalising menopause and emphasising positive or neutral aspects such as freedom from menstruation, pregnancy, and contraception, together with information about managing troublesome symptoms might empower women to manage menopause with greater confidence.”
Experiencing menopause differs around the world
And the experience can differ significantly for the same woman over time.
“During the menopause transition women may experience body changes such as vasomotor symptoms (hot flushes and night sweats), sleep difficulties, changes in mood, and aching muscles or joints. These are usually time limited, and their nature and severity vary substantially between women and within the same woman over time.
Women with severe vasomotor symptoms often benefit from menopausal hormone therapy, which may also improve sleep.6 For those who are symptomatic, a cross sectional study of 354 US women reported that their main priorities for treatment were vasomotor symptoms, sleep, concentration, and fatigue.7
It’s astounding to observe how divergent the experience of menopausal symptoms can be around the world.
Furthermore, a systematic review of qualitative studies found that menopause is experienced in different ways globally. Specifically, women’s expectations and experiences of menopause are strongly influenced by personal, family, and sociocultural factors.10 Even within countries, social factors modify the experience of menopause.
Cross cultural studies show substantial geographical and ethnic variation in the experience of menopause.13 Whereas women in high income countries tend to report more vasomotor symptoms,5a review of menopausal women in 11 Asian countries found that body and joint pains were the most problematic symptoms, affecting 76% of Korean women and 96% of Vietnamese women.13 Only 5% of Indonesian women reported hot flushes.
Women’s experience of menopause is also strongly influenced by social values around reproduction and ageing, with positive or negative ramifications. For example, women tend to have worse experiences of menopause in countries where their value is predicated on youth and reproductive capacity and ageing is associated with decline.10 In contrast, in a critical review of midlife embodied change, women identified freedom from menstruation, premenstrual symptoms, and contraception as positive consequences of menopause.14 Where menopause marks the end of restrictions such as purdah during menstruation, menopause may bring freedom, elevated social status, and a “second youth.”15 Together, these findings argue against a universal menopause syndrome since women’s experiences are strongly influenced by social context and cultural beliefs and expectations.
Negative expectations fed by medicalization
The potency of the negativity expressed is daunting and it has been distorting experience for ages.
“Negative views about reproductive ageing in women have pervaded the medical literature for centuries. In the 19th century menopause was thought to cause a nervous disorder with multiple physical and psychological manifestations. The ovaries regulated women’s identity (femininity) and their physical and mental health were contingent on the balance between ovarian excess or deficiency. This model was clearly articulated in Feminine Forever by the gynaecologist Robert Wilson, who recommended oestrogen for all menopausal women to treat their “serious, painful and often crippling disease” and avoid the “untold misery of alcoholism, drug addiction, divorce and broken homes caused by these unstable, oestrogen-starved women.”16.”
The deluge of media and marketing is withering.
“The message that menopause signals decay and decline, which can potentially be delayed or reversed by hormonal treatments, persists and is reinforced by the media, medical literature, and information for women, often driven by marketing interests. Marketing menopause as a disease is a lucrative business: the industry manufacturing unlicensed “compounded” bioidentical hormones accounts for around 28-68% of all menopausal hormone therapy prescriptions in the US with an estimated worth of around $2bn.17 ... Women who see this marketing might understandably believe that menopausal hormone therapy is important for maintaining long term health.
This narrative of loss and decline may amplify women’s health concerns as they age.18 Although long term use of menopausal hormone therapy confers some benefits such as reduction in fractures, it also carries risk. In 2017 the US Public Services Task Force recommended against prescribing menopausal hormone therapy for the prevention of chronic disease.19”
Negative expectations and an overly narrow focus on symptoms naturally ensure a worse outcome.
Furthermore, medicalisation and its narrow focus on symptoms may fuel women’s negative expectations of menopause and influence what physical and emotional experiences they attribute to menopause.20 Negative expectations of menopause make for a worse experience. For example, a systematic review found that negative attitudes and expectations before menopause predict the likelihood of distressing menopausal symptoms.21 In a UK study of 140 women with vasomotor symptoms, those with negative beliefs about menopause were more likely to rate their vasomotor symptoms as “troublesome” and report embarrassment and shame.22
It’s distressing to consider the extent to which our culture tends to ignore the positive aspects of growing older in general and even menopause in particular.
“However, the positive aspects of menopause are rarely discussed in the medical literature. A systematic review of standardised menopause questionnaires found only questions asking about negative symptoms and experiences. Hence, there was no opportunity for women to report positive experiences of menopause.27”
The paucity of helpful information doesn’t help matters.
“Population based surveys in the US and Ireland found that most women (65-77%) feel unprepared for menopause and report that they lack important knowledge about what to expect and how to optimise their health.2829 Together with limited public discussion and education and shame attached to ageing in women, this may contribute to embarrassment and negative expectations about menopause. Women in the US seeking medical advice at menopause also report wishing to be heard and better supported by their healthcare providers.30 They prefer to hear that their symptoms are normal and not to take prescribed treatments unless necessary.”
Menopause as a normal part of life
Creating a more positive experience entails understanding when to treat versus when to support and enrich.
“Balanced, evidence based information about the spectrum of normal changes to expect over the menopause transition—in both clinical and community settings—may help women prepare, empower them to manage menopause and instil confidence in navigating this life stage.
For example, perimenopausal and postmenopausal women randomised to a psychoeducational and health promotion programme showed greater knowledge about menopause, more positive attitudes, less discomfort, and greater engagement in healthy habits compared with those who did not participate.32 Understanding the normal changes of menopause may also help women differentiate menopausal symptoms from other conditions such as depression, which require different management.”
All of us health care providers ought to be on board with this.
“Medical education should normalize the physical changes of menopause. Clinicians should provide reassurance about symptoms and their likely time course. Clinicians are also well placed to challenge their own and others’ negative views that menopause is a deficiency disease that leads to decline. Women who adopt a medicalized view of reproductive events, including menopause, are more likely to report distress and attribute physical and mental changes to menopause rather than other causes.2 For women requesting treatment for troublesome symptoms, clinicians should offer effective strategies using a shared decision making approach.”
A positive way forward
The authors, while recapitulating the challenge, end on an inspiring note.
“Medicalization of menopause as a disease requiring treatment prepares women to expect the worst. Since social meanings and expectations commonly shape women’s actual experiences, there is an urgent need to disseminate a more realistic and balanced narrative that challenges stigma around ageing in women, prepares women for expected changes, and recognises menopause as a natural process with both positive and negative aspects.
Normalizing ageing in women and celebrating the strength, beauty, and achievements of older women can change the narrative and provide positive role models.36 In the UK, women who have been through the menopause have raised the profile of menopause through media campaigns and within the workplace.37 Menopause is now included in the UK high school curriculum, and organisations have developed menopause policies and online resources for employers to better support their employees managing menopausal symptoms.38 Though outcomes of these policies will need to be carefully tracked, continuing to raise awareness through public health and education campaigns can support women to expect—and enjoy— more positive experiences of menopause.”
See the article itself for examples of evidence-based resources and ‘bullet points’ of the key messages.
