Why menopause is more than just a natural transition

Balance founder Dr Louise Newson responds to The Lancet series on menopause, and argues that framing menopause as a natural transition or part of healthy ageing ignores the very real suffering of many women with menopausal symptoms

With our ageing population, there are around 1.2 billion menopausal women worldwide – yet only 5% of them are receiving evidence-based treatment to improve their symptoms and their future health. Menopause is a long-term deficiency of the hormones oestradiol, progesterone and often testosterone with health risks associated with it.

We’re living longer than ever before, and there is more to longevity than the age we reach. Successful ageing includes maintaining good health. Cardiovascular diseases are the most common cause of death in menopausal women worldwide.

The question as to whether menopause is a disease been debated for many years and the answer is more relevant than ever now that women are living longer. The average life expectancy for women in UK is 81 and worldwide it is 72 years. This age was decades younger 100 years ago – meaning that women now are often living for several decades being menopausal.

What is disease?

The definition of disease is a condition of a living animal or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms. Alternatively, it can be defined in the scientific paradigm of modern medicine, as an abnormality in the function and/or structure of body organs and systems.

Menopause fulfils these criteria: the vast majority of menopausal women experience distinguishing symptoms which include low mood, anxiety, memory problems, poor sleep, fatigue, headaches, muscle and joint pains, palpitations, vaginal dryness, urinary symptoms, hot flushes and night sweats.

In addition, menopause is more than a collection of symptoms: it is a cardiometabolic and inflammatory condition which leads to an increased risk of numerous diseases including heart disease, dementia, type 2 diabetes, clinical depression, osteoporosis, schizophrenia, kidney disease, auto-immune diseases, cancers, non-alcoholic fatty liver disease, multiple sclerosis, Parkinson’s disease and even earlier death.

Medicalisation in perspective

Menopause has been ‘medicalised’ for years – including with antidepressants, antipsychotics, painkillers, sleeping tablets, anticholinergics to treat bladder symptoms and heart medications to lower cholesterol, reduce blood pressure and control palpations.

The first-line treatment for menopausal symptoms is body-identical hormone replacement therapy. Simply put, women replace the missing hormones with hormones that are chemically identical to those same hormones that women produce before their menopause.  Studies have shown that when women are given the right dose and type of hormones, their symptoms improve and they have a lower future risk of numerous long-term inflammatory diseases associated with menopause including diabetes, cardiovascular disease, osteoporosis, dementia, and depression as well as early death.

Unlike the old-fashioned types of HRT, body-identical HRT is very safe and for most women, the benefits of body-identical hormone replacement will significantly outweigh any risks. For most women there are no risks of replacing their missing hormones.

Yet globally only around 5% of menopausal women are prescribed HRT.  This means that the majority of women with menopausal symptoms are suffering unnecessarily – with symptoms and health risks.

Women deserve to have access to unbiased and evidence-based information so they can make proper choices about treatment. Talking about menopause as being a ‘natural transition’ or part of ‘healthy ageing’ ignores the very real suffering of many women with menopausal symptoms.

References

Hill, K.  (1996), ‘The demography of menopause’, Maturitas, vol. 23,2: 113-27. doi:10.1016/0378-5122(95)00968-x

Faubion S.S., Shufelt C.L. (2023), ‘Why is everyone talking about menopause?’ Maturitas, Nov;177:107777. doi: 10.1016/j.maturitas.2023.05.001. PMID: 37268456.

Behrman S., Crockett C. (2023), ‘Severe mental illness and the perimenopause’, BJPsych Bull,13:1-7. doi: 10.1192/bjb.2023.89. Epub ahead of print. PMID: 37955045.

El Khoudary, S.R. et al. (2020), ‘Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association’, Circulation, 142 (25), e506-e532. doi:10.1161/CIR.0000000000000912

Newson Health (2023): Understanding the benefits and risks of HRT: downloadable visual aids

Manson J.E., Aragaki A.K., Rossouw J.E. et al. (2017), ‘Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the Women’s Health Initiative randomized trials’, JAMA, 318(10):927-938

Chlebowski R.T., Anderson G.L., Aragaki A.K., et al (2020), ‘Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the Women’s Health Initiative randomized clinical trials’, JAMA, 324(4):369-380

Boardman H.M., Hartley L., Eisinga A. et al. (2015), ‘Hormone therapy for preventing cardiovascular disease in post-menopausal women’, Cochrane Database Syst Rev, 2015 Mar 10; 3: CD002229

M. Gambacciani, M., Cagnacci A, Lello S. (2019), ‘Hormone replacement therapy and prevention of chronic conditions’, Climacteric, 22:303-306