Are we in danger of over-medicalising the menopause?
Last month an article in the British Medical Journal (BMJ) questioned the ‘medicalisation of menopause’ and spelt out the risks of doing so
A year on from 's five-days-straight discussion on menopause, the conversation on this pivotal time in a woman’s life has taken a sudden swerve.
So many women queued up to air the devastating impact of menopausal symptoms last summer that Liveline created a dedicated phone line. The RTÉ radio show marked an upswing in women coming forward for help. Many wanted HRT, so much so that earlier this year the HRPA warned Ireland faced shortages in HRT medication, citing an ‘unexpected increase in demand’.
Sallyanne Brady, co-founder of Facebook group, The Irish Menopause, spoke about individual women trying as many as 17 pharmacies – unsuccessfully – for HRT.
Britain saw a similar surge in HRT demand after Davina McCall’s C4 documentary aired in 2021 – in the following month, one pharmaceutical company reported a 30% uptick in demand for HRT products.
The momentum was all in one direction – until the publication last month of an article in the (BMJ) that questioned the ‘medicalisation of menopause’ and spelt out the risks of doing so.
The article, titled Normalising Menopause, described menopause as ‘a natural event for half of humankind’. The authors, led by obstetrician-gynaecologist Martha Hickey, said there’s no ‘universal experience of menopause’. Most women, they stated, prefer not to take medication unless their symptoms are severe.
Hickey and her team warned that medicalising menopause ‘risks collapsing the wide range of experiences associated with this natural process into a narrowly-defined disease requiring treatment’. They felt medicalising it might increase women’s anxiety about a ‘natural life stage’. And they looked to change the narrative – by emphasising positive or neutral aspects of menopause, e.g. freedom from menstruation, pregnancy, and contraception.
The reaction was swift. Pointing to a BMJ facility that allows people respond to an article, Dr Deirdre Lundy, clinical lead at the Complex Menopause Service at National Maternity Hospital, observed that the article received largely negative feedback. “I respect Martha Hickey as an academic, but I think the word ‘natural’ was ill-advised. Heart disease is natural. Cancer is natural. That doesn’t mean a doctor stands by and says ‘you’re 65, you’re supposed to have heart disease now – what do you expect us to do?’ A doctor’s job is to tweak natural life events to make them more tolerable.”
In Britain, high-profile menopause specialist Dr Louise Newson, who runs a menopause and wellbeing clinic, made a similar point. “Just because something occurs ‘naturally’ doesn’t make it good. The problem for too long has been one of women not being listened to, of women being undermined and belittled, of women being told to put up with symptoms that we now know can lead to [them] leaving their jobs, partners and suffering with horrendous symptoms affecting their quality of lives.”
But does Hickey have a point? While Newson believes it’s “absolutely vital menopause is recognised as a female hormone deficiency with real health risks”, an expert statement also issued in June argued otherwise. “Menopause is a life stage and does not represent a deficiency state,” said the British Menopause Society, Royal College of Obstetricians and Gynaecologists and Society for Endocrinology in a joint statement on best practice recommendations for care of women in menopause.
More than 75% of women experience menopausal symptoms – one in four describe them as severe. And one in three experience long-term symptoms, possibly lasting as long as seven years or more. Just one look at the vast range of menopausal symptoms and it’s easy to see – depending on symptom number and intensity – that the menopause experience can vary considerably. Symptoms include night sweats, hot flushes, sleep disruption, mood changes, cognitive issues, palpitations/dizziness/headache, loss of vaginal elasticity/lubrication, decline in sex drive, decrease in metabolism, joint and bladder complaints.
Menopause workplace consultant and creator of the Menopause Success Summit Catherine O’Keeffe says individuality is the cornerstone of understanding menopause. “I say to work managers you could have two women on your team with completely different experiences of menopause – it could be worlds apart. One might get one hot flush a day, the other 30. One might have crippling anxiety – the other, memory loss and poor concentration.”
Menopause, she says, is a deeply physical and psychological process and transition. “I’ve heard so many women say ‘give me some of the physical symptoms over the psychological any day’.”
At the Complex Menopause Clinic, Lundy sees women referred by GP/consultant, who perhaps have had breast cancer, blood clots or serious immunity problems. “These are women who have a medical problem that would make it tricky for normal prescription medicine to be used.”
But, says Lundy, the number one international guideline is that there are no broad strokes when it comes to menopause. “There’s no algorithm. Everybody sitting in front of you gets different advice. We believe in the medical phrase ‘concordance’ – we don’t tell patients ‘this is what you do’. We give them the information and let them decide what they want.”
When Dr Mary Ryan, consultant endocrinologist and senior lecturer in University of Limerick Medical School, travels around Ireland educating on menopause, she meets many women who ask: ‘But why didn’t I know this before?’
“They don’t know about the restless legs that prevent sleep, or the severe vaginal dryness that can cause multiple kidney infections, or the brain fog or memory problems. They think they’re losing it.”
A certain percentage of women will “sail through menopause”, but some will get more severe hormonal fluctuations than others, says Ryan.
Describing a patient with severe anxiety, Ryan recalls the woman’s husband in the initial consultation saying his wife was like a new person. “Her mother had been institutionalised at menopause so she was terrified of the same.”
Prescribed HRT, along with medication for restless legs and neuropathy (nerve damage), the difference once treatment started was “phenomenal”, says Ryan. “I saw both sides of the rainbow – in her anxious state and then back to health.”
Lundy says most women in menopause won’t need prescription medicine, but a significant number will. “If you’re in bad shape and have already broken a bone falling off a footpath, or if you haven’t slept more than two hours in five years, you need hormones.”
While HRT was prescribed widely in the West from the 1970s, things changed with the 2002 publication of the Women’s Health Initiative study. This created concern about a possible link between using HRT and finding breast cancer. Use of HRT plummeted – and stayed like that until the National Institute for Clinical and Healthcare Excellence published a review in November 2015.
“This reaffirmed: if your patient’s suffering and needs HRT to control troublesome menopause symptoms, she should feel confident to use it and you should support her in her choice,” says Lundy.
Lundy says HRT isn’t a magic wand for every malaise, a point endorsed by The British Menopause Society, Royal College of Obstetricians and Gynaecologists and Society for Endocrinology just last month. While the society cited some key HRT benefits – it has an effective role in preventing/treating osteoporosis, and if started younger than 60 or within 10 years of menopause, it may result in reduction in coronary heart disease – it also stated it ‘should not be used for the sole purpose of disease prevention’.
And it was very specific when it came to dementia: ‘National, as well as international recommendations, do not support the use of HRT for the primary or secondary prevention of dementia.’
Do all women want HRT? “It’s a mixed bag,” says O’Keeffe. “Some really lucky women get HRT nailed. Many will say they’re not interested.”
She has seen women feeling isolated if HRT is contra-indicated for them. “They can feel they’re missing out. That shouldn’t be. It should be: ‘OK, I know HRT is contra-indicated for me but here’s what I can do – I have other options’.”
And whether you try herbs, acupuncture or HRT, you’ve got to do the lifestyle bit, says O’Keeffe. “You’ve got to have a balanced diet. Women are scared of protein, but it’s really important in these years. So is fibre.
“Movement on a daily basis is critical. You must have cardio work in your life, weight-training, and strength-bearing exercise. Ensure you look after your bone health – one in three women over 50 will experience an osteoporosis fracture.”
Sleep, she says, is the bedrock of thriving in menopause – get it right and it has a knock-on effect on all other aspects. “If you’re not sleeping, what’s causing it? Stress? Night sweats? Hot flushes? It might mean supportive herbs, or a conversation about HRT depending on the severity, or perhaps just looking at sleep hygiene.”
While HRT is very good at combatting hot flushes, so is cutting down caffeine, wearing lighter clothes – and cognitive behavioural therapy, says Lundy. “With CBT, you can get an over 50% reduction in hot flushes. We usually recommend a CBT app – SilverCloud – free through GPs.” For hot flushes and night sweats, she also cites Oxybutynin, a medicine for overactive bladder. “After a few months, there’s almost 70% reduction in hot flushes and night sweats.”
O’Keeffe says it’s important to remember menopause isn’t something evolution has got wrong. And being informed about it can remove fear. “Having the right balanced information: here’s what happens in the body, here are the possible symptoms and here’s how I can support myself. Knowing that for every symptom there’s a treatment option – however that might look for you – removes the fear and encourages a positive attitude.”
Menopause, she says, can be a whole new chapter, when – though you’ll still have responsibilities – you’re free of the constraints of your earlier reproductive years. “Your body wants you to stop and take stock of where you are in your life. It’s an opportunity to future-proof your life – to take stock of your brain, bone and heart health for your later years.”
While acknowledging many women face challenges, O’Keeffe says menopause can bring you home to a strong sense of self that brings with it a sense of freedom.
Whether over-medicalisation of menopause, or non-acknowledgement of the horrendous symptoms many experience, we can’t let the scales tip in any direction, says O’Keeffe. “We need to calm and centre things, have a balanced conversation.”
Every woman is an individual in how she experiences menopause. It’s about being respectful – and allowing individuality of choice in negotiating that experience.
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