Jennifer Horgan: Women need to teach ‘experts’ what menopause really means

There are no hard and fast rules about how women react to menopause, with vastly differing symptoms possible between individual women.

Our culture likes to generalise women.

In the generalisation game, there are obvious winners and losers. Do everything a certain way, and you win! Don’t, and you’re made to feel like you, or your body, didn’t get it quite right — or when it comes to your hormones, that you’re imagining it.

I have two months of Hormone Replacement Therapy (HRT) gathering dust in my cupboard. I keep planning, and then failing to take it. I suspect it’s because there’s a little voice in my head telling me I should just do menopause better.

Why? Why am I feeling guilt and reluctance even though my period last month was so bad I could barely make it to work?

“The menopause is getting a cultural moment,” a male pharmacist said to me recently. And he’s right. The menopause is getting considerable media coverage. But HRT is not getting the same level of acceptance, and even among medical professionals, attitudes towards it remain murky.

Why? Well, one answer lies in its history. HRT in its original form was actually not human but equine oestrogen, and it was hugely popular until a study in the Noughties suggested a link with breast cancer.

Although more recent studies on non-equine oestrogen show different results, there is still a bias against it. And it’s a bias that rubs off on women like me.

It’s a bias that leaks into the press too. A recent article in an Irish outlet, referencing a study in The Lancet, began: “The menopause is not a disease and is being ‘over-medicalised’.” The Lancet article has a much broader reach than that and a much more nuanced message. 

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Indeed, the article is at pains to argue that menopause is different for every single woman. It also makes clear that there is little data available on menopause, and that for some women HRT is a very good idea.

‘Some’ women is not something we’re culturally comfortable with, even though according to The Menopause Hub, approximately 20% of women will experience severe symptoms in menopause.

Positing that menopause is not a disease is a predictable message, however. We struggle to accept that us women, half the global population, differ. Women endure the same waffle during pregnancy. Being pregnant is not being sick, right? Blah, blah, blah.

Say that to the bed-bound woman with intense girdle pain or body-crippling nausea. Some women do feel sick when pregnant. Yes, both menopause and pregnancy are natural conditions of being a woman, but let’s not confuse what is natural with what is good. 

And let’s not assume that what is easy and pain-free for one woman, is the same for another. The ‘natural birth’ gurus have done untold damage to women who encountered sometimes life-threatening difficulties giving birth. As have the militant ‘breast is best’ brigade.

This is what The Lancet article makes clear by highlighting that a disease-based model is inaccurate, given the variation in women’s experience of menopause.

They suggest a model of empowerment instead, based on education, so that this variety can be addressed meaningfully, something Maj Cunningham, pharmacist, and women’s health coach, also fundamentally believes.

“I watched that Davina McCall documentary in 2020. It was like my eyes had been opened. The more I learned, the more I realised how little I and people like me, doctors, and pharmacists, knew. Women in their middle years make up the majority of people who come into pharmacies, looking after children and parents. I had been giving them K-YJelly for vaginal dryness, not realising they needed vaginal oestrogen. 

I hadn’t connected urinary tract infections, fatigue, joint pain, any of it, with the menopause. It was like I was seeing the big picture for the first time.

Maj agrees HRT is not right or necessary for all women, but believes it is essential for some women.

“There is a lot of gaslighting around HRT, even amongst women. You’ll hear women say, ‘I never had a problem with menopause’ or ‘I don’t know what the fuss is about,’ that kind of thing. Well, that’s wonderful for the woman speaking, but some women really struggle. There is a reason the highest rates of suicide among women are found during those menopausal years.”

She reacts strongly to the claim that it is overly medicalised.

“It fascinates me how we see HRT as medicalising when we are less inclined to comment on the swathes of women being prescribed anti-depressants and anti-anxiety pills for issues relating to their hormones. I know of a woman who went to her doctor looking for HRT and came out with anti-depressants.”

Pharmacist and women’s health coach, Maj Cunningham, said her 'eyes had been opened' after watching a Davina McCall (pictured) documentary in 2020. File picture: Lorna Roach/Channel 4/PA

The bias against HRT relates to a lack of education, she argues.

“Doctors and pharmacists don’t get an education in hormones. All we learn is that a person with a womb requires oestrogen and progesterone, and a person without a womb needs just oestrogen. Our training is woeful, and it is only getting better now because women are demanding better. 

Women are educating themselves and that is a good thing. We know now that using body-identical oestrogen [as opposed to the old equine form] reduces breast cancer in patients without wombs. 

We know that you are more at risk from breast cancer if you are overweight, or drink too much, than if you take HRT. But there is still a strange reluctance to prescribe it.

HRT is also cardio-protective if taken within the first 10 years of menopause, she explains. It can also prevent and treat osteoporosis and reduces the risk of type 2 diabetes as well as Alzheimer’s.

I realise I have another block against taking HRT. The cost. It bothers me that I must pay close to €40 a month on something that is potentially indispensable for me to function, as I need to function, balancing, like so many women, a job, my parents’ care, and my children’s care.

Yes, it is true that more women are entitled to free contraception now, but what about free HRT? Surely the State can’t offer free contraception and child allowance and then leave women unsupported when their bodies lose the ability to produce children.

Women in Britain pay one small charge a year to get their HRT and vaginal oestrogen is available over the counter. Here, it is not. Here, men can conversely pop to their local pharmacy and get Viagra, or some variety of it, without any issue whatsoever.

Senator Pauline O’Reilly recalls getting significant kickback when she brought up how women are treated in the Seanad, shortly after the menopause got extended and unprecedented coverage on the Joe Duffy show. She is passionate about securing free HRT for Irish women.

Senator O’Reilly said: “The Drugs Payment Scheme is at a high level. Not everyone will reach the threshold and I feel particularly bad for women who just miss out on the medical card. But I do believe free HRT is coming down the tracks. The costs are small to the government. Medical Card users cost the State about €4m for HRT, and free HRT for all would only amount to about €10m. 

"The impact on healthcare could be considerable. Women are living much longer so it makes financial sense for the State to help women take the appropriate treatment for their bodies at the appropriate time.” 

The menopause asks us to trust women to make choices for themselves, as ungeneralisable individuals. It will be interesting to see how Ireland copes with it.

Menopause and pregnancy are natural conditions , but let’s not confuse ‘natural’ with ‘good’