One in eight people is postmenopausal, and about 50 million women enter menopause every year. A new essay published on Tuesday in The Lancet argues that it’s time to stop treating them like patients suffering from a disorder.
The article calls for a reframing of menopause and a management approach that is not simply focused on medical interventions that relieve symptoms. The essay’s authors call for better education, more non-medical ways to address menopause, and more research into all available treatments, not just products that drug companies are eager to promote.
The essay is part of a new Lancet series on menopause, and it is followed by papers sharing strategies to improve mental health during the menopause transition, optimize health after early menopause, and manage menopause after cancer treatment.
Alongside the series, for the first time in its centennial history, The Lancet published a visual arts project: portraits of naked women at 50 selected from a series of 500 such photos, to encourage a different, more empowered portrayal of older women.
“For most people, [menopause] is a normal transition and a normal part of their lives and aging. And like many periods of transition, there are good things and bad things,” said Martha Hickey, a professor of obstetrics and gynecology at the University of Melbourne and lead author of the article.
Long left outside of public discourse, menopause has gained visibility in recent years in the U.S., leading to a surge in health services and new medications tailored to its management. Much of this discussion is focused on menopause’s most bothersome symptoms, such as hot flashes or vaginal dryness, and the medications available to address them.
But that framing is unfair to women, Hickey said. “We preach the message that every woman at a certain age is going to get a particular disease all the way around the world. Is that actually, first of all, accurate? And, secondly, is that the right thing to do for women?”
She argues this messaging doesn’t reflect the wide variety of experiences of menopausal women — some of whom may experience debilitating symptoms or have jobs where it’s harder to manage symptoms without medications, while others won’t.
“I think women have been misled … by not getting accurate information about all of the medicines that are available to help them with menopause, as well as old behavioral therapy, so that they can decide what they want to do for themselves,” said Andrea LaCroix, one of the essay’s authors and an epidemiologist at the University of California, San Diego.
LaCroix, a longtime menopause researcher, helped write the landmark 2002 Women’s Health Initiative report, which raised concerns about the long-term effects of hormone replacement therapy and its links to certain cancers. After the report was published, the popularity of hormone treatment decreased significantly, though it has regained popularity lately after further research suggested the cancer risk was smaller than first feared.
Many doctors who treat people in menopause advocate for a broad increase in estrogen prescriptions, but LaCroix and her colleague believe that is simplistic and disempowering.
“There are many ways to make it through the menopausal transition with greater comfort … and each of them involves a different set of risks and benefits and effort and cost,” said LaCroix, adding that there’s a scarcity of large and diverse studies comparing treatments head-to-head. “It’s a biased statement to say hormone therapy works the best.”
Even the evidence we do have about the effectiveness of certain treatments, in particular hormones, is only limited to studies done on women with severe symptoms, which may not be as frequent a scenario, she said.
This doesn’t mean hormonal therapy should never be recommended, the authors caution. “Some people do have a terrible time. And some of those people decide that they would like to take medications to manage their symptoms. And that’s fine — that’s great,” said Hickey. “But, those treatments … have complications in the short term with bleeding and small but very serious health risks in the long term. Plus eventually you have to stop them. And then you often get the symptoms back again.”
Reproductive health advocates also lamented that doctors receive little training on menopause symptoms and how to manage them with both medications and non-pharmacological techniques. “You medicalized something as a problem, but then you don’t prepare medical students or doctors to actually see it as a comprehensive health situation,” said Omisade Burney-Scott, the creator and chief curator of Black Girl’s Guide to Surviving Menopause, a guide, podcast, and community dedicated to menopause management and education in the Black community.
Like Hickey and LaCroix, Burney-Scott, who was not involved in the Lancet papers, calls for more research into menopause, with a focus on the historic and environmental stressors that impact women and individuals of color, especially Black people. As an example, she notes that the Study of Women’s Health Across the Nation, a landmark survey of the health of middle-aged women, was conducted on women born between 1944 and 1954, a time when institutional racism was codified by Jim Crow laws and Black Codes. But researchers did not look at how the elevated level of stress Black women experienced at this time manifested later in menopause.
Part of what makes menopause treatment complicated is that the condition is intertwined with societal attitudes toward women and aging, said Rachel Weiss, a counselor and founder of Menopause Café, an international charity where people of all genders and ages meet to discuss menopause, learn about it, and share experiences. “If society’s attitude to older women was better, we would be less likely to feel depressed realizing we’ve had menopause,” she said. “As women have said in the cafes, ‘I’ve got my menopause, that means I’m old. That means I’m past it, that means I’m worthless.’”
Instead, Weiss said, “imagine if we talked about menopause like we do about pregnancy or puberty.” She added that, for some women, menopause can have mental health benefits, such as worrying less about pleasing others, a change linked to a drop in oxytocin, plus the physical benefits of freedom from periods and contraception worries.
She pointed out that studies done in the few societies where older women are treated with greater respect, such as some Australian Aboriginal tribes, show that they tend to experience much less debilitating symptoms. That’s a sign to her that the very framework for menopause treatment reflects in some way cultural views of women and aging.
“We wouldn’t dream of giving a child hormones because they’re going to have those hormones when they get older,” Hickey said. Yet hormone replacement therapy gives women hormones they used to have when they were younger, rather than conceding that changing hormone levels are just part of a woman’s life.
“Older women are not just estrogen-starved versions of younger women,” she said.