‘I’m as baffled as the next owner of ovaries’: Navigating the science of menopause treatment
There’s a meme featuring a confident, friendly, smiling Henry Cavill – the actor best known for his role as Superman – posing for photographers on the red carpet. Sneak after him is the wild-looking, maniacally cheerful co-star Jason Momoa.
To me, this is the perfect metaphor for perimenopause. Cavill is at the peak of his career, looking great, clearly feeling great, radiating confidence, strength and poise. And he’s about to be tackled by an erratic and unpredictable force.
Is it a disease? Is it a normal biological event? No, it’s menopause!
Menopause is the curveball your ovaries throw at you when you’re born and which you have to figure out 40 or 50 years later without dropping everything.
I consider myself lucky that – thanks to the advice, humor and wisdom of my wonderful girlfriends – I was able to catch a glimpse of that curveball coming. Instead of being completely overwhelmed by the inexplicable mood swings, exhaustion, anxiety, and lack of motivation, I can understand them a little better.
But despite being a science journalist for more than twenty years and having written extensively about women’s health and hormones, among other things, I’m as baffled as the next ovarian owner when it comes to my options at this time in life.
Ask twenty women what perimenopause is like and you’ll get thirty different answers: “One minute you’re doing well, and then you want to kill someone”; “It didn’t really affect me”; “I’m crying, laughing, panicking, furious and sweaty”; “It feels like jogging in molasses”; “I asked my doctor for a brain transplant because of the forgetfulness,” for example.
Even the medical community can’t agree on the symptoms of perimenopause. “It’s a really crucial question in menopause: what symptoms does it actually cause?” says Prof. Martha Hickey, director of the Women’s Gynecology Research Center at the Royal Women’s Hospital in Melbourne. “The list is getting longer.” The two (excellent) GPs I discussed menopause with used different symptom checklists, even though they cover similar ground.
That’s a problem for anyone going through menopause, and for their doctors. Because while menopause is clearly not a disease, “it is a biological life event; Aging is not a disease,” says Prof Davis, endocrinologist and researcher at Monash University – it should not be dismissed as something people simply have to endure without help because it is ‘natural’. “Osteoporosis is age-related bone loss, but we still treat it,” says Davis.
The question dominating the conversation about menopause is when and how should we treat perimenopausal symptoms? This debate is especially targeted when it comes to menopausal hormone treatment, or MHT.
MHT – which works by boosting and stabilizing declining levels of estrogen and progestin – has had quite the reputation rollercoaster over the past half century. Particularly the controversial and misreported ones 2003 Women’s Health Initiative studywhich found a small but significant increase in the risk of breast cancer, heart disease, stroke and blood clots, cast a shadow over MHT’s reputation and availability for decades, but it is widely accepted that the shadow is not warranted.
“Over the past two decades, there have been numerous articles criticizing the shortcomings of that research,” says Dr. Silvia Rosevear, an obstetrician and gynecologist in Auckland, New Zealand, and president of the Australasian Menopause Association. The average age of the women in the study was 63 years, most were postmenopausal, and MHT formulations have evolved and improved significantly since the study; meaning that the results have limited applicability to the use of modern MHT formulations for symptom relief in younger perimenopausal people.
Despite this criticism, Davis’ research suggests that physicians are still reluctant to prescribe MHT except for severe menopausal symptoms, preferring instead to tacitly condone the use of complementary and alternative therapies for which there is questionable evidence. Davis says we need new studies to provide more relevant, timely information, but the Women’s Health Initiative “provided a lot of information that essentially killed funding in this field for a decade.”
That is slowly changing and funding for those studies is starting to flow. But to properly assess the long-term risks and benefits of MHT, these studies will need to continue for many years. So what do perimenopausal people do in the meantime, and where is MHT headed?
IIt’s a confusing time for menopause therapy. On the one hand, Davis’ research found that although providers were well informed about menopause, they were uncertain about how to treat it, and limited MHT to people with severe symptoms who needed lifestyle changes and alternative therapies. could not alleviate.
On the other hand, many people with perimenopausal symptoms insist on treatment that, both clinical and anecdotal evidence suggests, has a good chance of relieving those symptoms and helping them feel “normal.”
“If a doctor appropriately initiates MHT for moderate to severe symptoms, there is a good chance that your patient will return and find that the symptoms have completely resolved and they feel normal,” says Rosevear. In her experience, most people on MHT enjoy being on it.
Between these two parties are gynecologists, psychiatrists, psychologists, endocrinologists, feminist scientists and menopause specialists who debate whether menopause is overmedicalized, overdramatized and overtreated, or whether the symptoms of women experiencing perimenopause are minimized, mocked and discounted. . and undertreated.
“Broadly speaking, we should really think of this as a stage of life of opportunity, not disability,” says Prof Jane Fisher, clinical psychologist and Director of Global and Women’s Health at Monash University. “To suggest that the entire population of women experiences disease and disability as a result of this natural life change is actually unhelpful.”
Hickey, co-author of a series of articles raising concerns about the medicalisation of menopause, worries that public discourse about symptoms is scaring younger women and contributing to the ongoing harmful trend of older women becoming ‘washed up’. “I can’t think of anything good about those two words: ‘old woman,'” Hickey says. “We need to change the way we view aging in women, and that includes not pathologizing them.”
But Prof Jayashri Kulkarni, a psychiatrist and director of the HER Center Australia at Monash University, says it is condescending to suggest women “just put on a happy face” and don’t talk about the challenges of menopause. “That’s not the era we’re in.”
She sees the women in her clinic struggle with low mood, mood swings, anxiety, insomnia and other mental health impacts that they know are not simply the result of ordinary life stressors – of which there are many at this stage of life.
“My clinical experience is that I have very concerned women who say, ‘There has to be a solution, let’s work together and find something that can help me because I have a multi-million dollar business that I want to get back into running.’ says Kulkarni. “If the problem is a mental health problem caused by hormone fluctuations, then hormone treatment is a matter of common sense.”
In general, clinical guidelines agree with this. a review published last year by Davis and colleagues found that most high-quality guidelines recognize that MHT can be used for both vasomotor symptoms – hot flashes and night sweats – and “mood disorders.”
But for an experience that affects half the population, good quality studies – especially on the effects of perimenopause on mental health – are scarce. “We really need funding to do a proper trial comparing HRT or MHT with standard antidepressants, to see where the actual evidence lies,” says Kulkarni.
IMeanwhile, the growing public and private conversation about menopause suggests that women are reclaiming this transition, celebrating its positives, commiserating and finding humor in its negatives, and, most importantly, choosing how to experience it.
My choice – and one of many women I speak to who has chosen without regret – is to seek medical help to manage those psychological curveballs so I can continue with the successful career I love and work hard for have worked. My GP is understanding and supportive, but also outlines the risks.
I know that MHT may not be the miracle cure I’m hoping for; After all, my fear and exhaustion could be the result of this turbulent, devastating, and dangerous period in human history, or parenting teenagers and the daughter of elderly parents, or panic over global warming. But I don’t think it’s just those.
Kulkarni says she always comes back to the voice of the individual woman. “The voice of lived experience is what we really need to listen to, because it will tell you,” she says. “Most women I’ve met don’t live past 45 without knowing anything about themselves.”