Let’s talk about menopause

Once known as the change of life, menopause remains a neglected and misunderstood period in a woman’s life. Cathy O’Leary looks at efforts being made to normalise the conversation and better support women.

If the female reproductive life was depicted in a single social media post, it would probably have happy hashtags around baby ultrasound images and glowing mothers-to-be.

Dr Lesley Ramage

Considered less ‘Instagrammable’ would be pictures of older women struggling with hot flushes and sleepless nights – even though menopause is as much a part of life for women – if not more so – than having babies.

One of the biggest myths about menopause – held even by seasoned health professionals – is that it is a brief blimp in older life that the vast majority of women sail through.

But while menopause is often defined as a single event – marked by the final menstrual period as the ovaries’ egg supply comes to an end – symptoms associated with menopause can start years earlier – known as perimenopause – and extend years beyond.

Some women face early-onset menopause when they are only in their 20s and 30s.

The usual age of menopause is between 45 and 55 years, and with rising life expectancy in Australia, most women can now expect to live a third of their life – perhaps 30 years or more – in menopause.

While about 20% of women have no symptoms, another 20% experience severe symptoms such as hot flushes, sweats, sleep disturbances, mood fluctuations, vaginal dryness and urinary issues.

And despite half of the population going through menopause, it is a life stage that is not acknowledged or discussed enthusiastically like pregnancy and childbirth.

“About 20% of women will still have bothers in their 60s, and 10% will have ongoing bother, and it’s sort of implied that there’s something wrong with women if they haven’t ticked the magic box and graduated with flying colours.”

Dr Lesley Ramage, a UK-trained GP who morphed away from mainstream general practice to focus on midlife and menopause issues, feels the pain of women who struggle with menopause – both their physical symptoms and the dearth of awareness in the community.

“There is such a lack of information about menopause, so women suddenly find themselves in menopause and aren’t that prepared,” she told Medical Forum.

“I think as a gender, we’re reasonably well-prepared for things up until childbirth but beyond that there’s a gaping hole. Most of us will spend 30-plus years in menopause, but we’re badly prepared for it.”

Dr Ramage often gets asked by women when will they be through menopause, but often there is no finite end point.

“Symptoms often get better with time, but when you’re in menopause, you’re in menopause – you don’t graduate or get a certificate for going through it.

“About 20% of women will still have bothers in their 60s, and 10% will have ongoing bother, and it’s sort of implied that there’s something wrong with women if they haven’t ticked the magic box and graduated with flying colours.”

She brings her GP-perspective to the table at the newly-formed Menopause Alliance Australia, which aims to provide healthcare professionals with up-to-date and evidence-based education on perimenopause, menopause and post-menopausal health.

Part of her mission is to promote good communication between women and their GPs, and that includes developing education packages for doctors, so they are better informed about menopause and contemporary treatments.

While she consults at menopause clinics at King Edward Memorial Hospital and is involved in the teaching and training of medical undergraduates and doctors, she knows the pressures and challenges facing GPs.

“I have lovely fond memories of general practice but do appreciate that heart-sink moment when you’re running late on a Monday morning and a lady comes in with menopausal symptoms and you think ‘oh crumbs.’

“That in itself shows one of the problems. We need to advise women that if they think they’re entering menopause to, first of all, book a longer appointment.

“Otherwise, it can lead into snap decisions being made by doctors because, if they’re time-poor, they’ll take short cuts, and the problem with short cuts is that sometimes you don’t get to the correct point.

“Women may be offered blood tests to ‘confirm’ their menopausal status but if it’s not taken at an appropriate time in a cycle it can be very misleading, so women might be informed they’re not in menopause, and must be depressed so are given anti-depressants.

“I’ve probably done it myself, so I’m not critical of doctors. I don’t think there is anything malicious about it.”

Dr Ramage said some GPs had dated views about the use of hormone therapy, and their only exposure to gynaecology might have been a brief stint during their student life.

She is trying to get a special learning group to improve education for GPs, because that is where women are going to be heading as their first port of call.

“There are pockets of GPs who are interested and keen to work in this area, as well as specialised services, and of course there is the menopause clinic at KEMH where I triage, and while some of the referrals are really appropriate, others are really lacking in basic knowledge,” she said.

“But again, we’re not trying to be punitive – we’re trying to be educative and supportive.”

Dr Ramage said education about menopause also needed to be societal, and with a trend of more women working into their early 60s, it was important to have strong role models and high-profile women – not unhelpful stereotypes.

“We need women not to be caricatured as short, dumpy with a grey curly perm when they’re in menopause,” she said.

Natalie Martin

This is where the Menopause Alliance Australia’s chief executive Natalie Martin plays a crucial role. When she founded the charity in October last year, it was to help stamp out the shame and misinformation around menopause she recognised after talking to friends and colleagues, whose lives and careers had been affected by not only the symptoms, but reactions from family and workplaces.

“The majority of my friends, family and work colleagues have experienced symptoms of menopause and some have felt embarrassed to discuss it, so I felt it was important to have more information out there,” Ms Martin said.

“We’re the fastest growing demographic in the workplace, and women aged 45 to 55 represent an increasing part of the global workforce. Menopause symptoms often occur at the peak of a woman’s career, but can also affect women in their 20s and 30s, even though in workplaces it tends to be seen as an old woman’s problem.

“Businesses have made great strides around accommodating pregnancy and child-raising, but that attention stops at the onset
of menopause.”

Ms Martin said change had to start at the top down, with a menopause policy that was communicated effectively and where employers “walked the talk.”

It was important to educate managers and line managers about menopause and perimenopause, and have a workplace where women could speak openly about their needs. 

“Around 20% of women won’t have any symptoms but for others it can be very severe and incredibly disabling,” she said.

“I had one comment from a friend who works in the mining industry that it’s secret women’s business, and another, who is an engineer, felt she had to hide her symptoms because she was fearful of redundancy and being replaced with a male.

“The conversation is not yet normalised, and not many companies in Australia have a menopause policy – the UK is way ahead of us in supporting menopause.

“If a woman has had night sweats and difficulty sleeping, she should be able to come into a meeting and can say ‘I can participate but I might not be myself at this meeting’ and that should be okay.”

Some companies allowed flexible working hours so that women could work from home; others ensured cold water was available at work and used cotton uniforms. Some provided UV umbrellas for teachers out in the playground.

Ms Martin said the benefits of a menopause-friendly business included gender equality, retaining and developing talent, increased performance and financial success, employee engagement and lower absenteeism, while supporting a menopause-friendly culture could also avoid the potential for litigation.

The menopause alliance has good credentials, with an impressive board of directors, including some of the State’s leading medical practitioners in their field.

These clinicians have helped prepare a comprehensive range of information around perimenopause and menopause and effective treatments, aimed at the general public but also tools for doctors, particularly GPs.

Professor Roger Hart

Among them is Professor Roger Hart, an expert on fertility impacted by early-onset menopause caused naturally or by radical radiological or chemotherapy treatments.

His message is that menopause is not necessarily an old woman’s condition, and can start in women aged in their 20s or 30s, and completely blindside them when it comes to family planning. 

Professor Hart, who is medical director of Fertility Specialists of WA and Professor of Reproductive Medicine at KEMH and the University of WA, said early-onset menopause occurred in about one in 100 women before the age of 45, and one in 1000 women before the age of 40.

It was easy to miss, as many women might be on hormonal contraception, effectively masking any symptoms.

“Others may have a significantly reduced ovarian reserve, although they may get a regular, or intermittent, menstrual cycle so their GP does not consider premature ovarian insufficiency (POI) as a potential underlying concern,” he said.

“As is often the way, as ovarian function is failing at an unexpected time, most patients and clinicians will not think about this as a cause of their symptoms, hence leading to a delay in diagnosis.

“These women need hormonal support because delaying intervention can have longer term adverse health outcomes.”

Professor Hart said GPs needed to know that fertility was still potentially possible, but because the ovarian function was severely compromised the answer was not IVF.

“Very careful cycle monitoring, often looking for signs of rare spontaneous follicle development, with appropriate triggering of ovulation and good luteal phase hormonal support into pregnancy, can, in a young woman, often result in a pregnancy,” he said.

“It is frustrating and time consuming for the woman, and often leads to substantial emotional distress, and is not always successful. Obviously, a woman in her late 30s and onwards will have a substantially reduced chance of conception due to aneuploidy in the oocytes.

“Hence, it’s a place for the young woman with POI. Unfortunately, if not successful, the only remaining option is oocyte donation treatment.”

A/Professor Amanda Vincent, an endocrinology and menopause expert at Monash Medical Centre, is part of a consortium trying to identify the causes of POI among young women, to help with early diagnosis and management.

The group is updating POI management guidelines to be released next year.

She wants GPs to be aware of the significant psychological impact of this diagnosis for young women and the need for support and counselling. 

“I reiterate the problem that diagnosis is often delayed as women and clinicians think they are ‘too young’ for menopause,” she told Medical Forum.

“I also stress the need to start estrogen replacement and continue this until the usual age of menopause at about 50 years (unless contra-indicated due to estrogen sensitive cancer such as breast cancer) to manage symptoms and avoid long-term health issues such as heart disease or osteoporosis.

“I have had GPs cease HRT in women with POI after five years or so because they translate the findings of concerns about breast cancer risk seen in older women in the Women’s Health Initiative study to these younger women, but this is a different group of women.”

Back at the Menopause Alliance, Dr Ramage said the overall message when it came to menopause and treatment options was the importance of finding what was right for each woman.

“It’s about respecting their thought processes and providing good education, and certainly not trying to bully someone into a pathway they’re not comfortable with,” she said.

And Ms Martin said offering education online for GPs so they felt better-equipped to treat menopause was a key way forward.

“But only 20% of women in perimenopause will see their GP, and we want to see improved access to care in the public health system for people with menopause – for those who can’t necessarily afford to get help in the private system,” she said.

“It’s an ongoing journey but we will get there.” 

ED: For more details about Menopause Alliance Australia go to www.menopausealliance.au 

GPs can also refer women with early-onset menopause to the Ask Early Menopause app, which is available freely from Android or Apple stores or at https://www.askearlymenopause.org/