Medicalizing menopause may be unhelpful for some women

Treating menopause as a hormone deficiency requiring treatment is inaccurate and fuels negative expectations which might be harmful to women, argue experts in The BMJ today.

Menopause is a natural event for half the population, but the experience varies considerably between women and in the same woman over time, writes Martha Hickey from the University of Melbourne and the Royal Women’s Hospital Victoria, Australia and colleagues.

Whilst women with severe hot flushes and night sweats often benefit from menopausal hormone therapy, most women consider menopause a natural process and prefer not to take medication.

The authors see an urgent need for a more realistic and balanced narrative that actively challenges gendered ageism. For example, qualitative studies show that women report both positive and negative consequences of menopause. Positive outcomes include freedom from menstruation, premenstrual symptoms, and requirement for contraception.

Social and cultural factors play a major role in women’s expectations and experiences of menopause they argue. In societies where women are valued for their youth and fertility, menopause is synonymous with decline. The belief that ageing can be delayed or reversed by hormone replacement therapy (HRT) persists and is reinforced by the media, medical literature, and information for women, often driven by marketing interests, they write.

Furthermore, medicalisation with its narrow focus on symptoms leads women to expect the worst. This may directly affect how they experience menopause, since women with negative expectations are more likely to have troublesome symptoms. After menopause, women have more positive attitudes, “suggesting that negative socially mediated expectations do not always match the reality of women’s experiences,” the authors note.

Studies also suggest that most women feel unprepared for menopause and lack important knowledge about what to expect and how to optimise their health. “Together with limited public discussion, poor education and shame attached to ageing in women, this leads to embarrassment and negative expectations about menopause,” they write.

As such, they call for efforts to raise public awareness and reduce stigma around menopause and ageing to help improve women’s experience.

“Normalising ageing in women and celebrating the strength, beauty, and achievements of older women can change the narrative and provide positive role models,” they write.

They applaud new developments in the UK, such as teaching about menopause in the high school curriculum, menopause policies in the workplace, and online resources to help employers support their employees managing menopausal symptoms.

“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,” they conclude.

In her regular column, Dr Rammya Mathew discusses recent criticism of GPs after a documentary series on the menopause by popular TV presenter Davina McCall reported that “caseloads” of women had suffered at the hands of their GP, after being told that they didn’t need HRT or that they weren’t menopausal.

“I don’t deny that individual women have been let down, and I applaud Davina for raising awareness of what’s often still considered a taboo subject in society,” writes Mathew.

However, she says the more nuanced truth is that many U turns have been made regarding the safety of HRT, which have had a lasting impact on practitioners’ confidence in the available evidence. Women’s symptoms can’t always be attributed to the menopause, and although the benefits of HRT outweigh the risks in most women, this is not always the case

“Many of my female patients claim that I’ve given them back their sense of wellbeing after we’ve discussed the menopause and reached a joint decision about HRT,” she writes. And she believes that GPs all over the country are doing exactly the same and receiving similar positive feedback.

[Free text quote not found in the text] “My experience is that as GPs we spend a lot of time reassuring women that the plethora of symptoms they are experiencing are explained by the menopause and not a sign of something more worrying. Over the years we are also offering HRT more readily, but many women still feel apprehensive about it, even when we try and put the risks into context for them.”

A linked editorial discusses the latest evidence on HRT and suggests that healthcare providers should take an individualised approach to assessment and empower women to make informed decisions based on unbiased, evidence based information applied effectively.