Amy Pearlman was 45 years old when she noticed weight gain, frequent periods and brain fog. She suspected the symptoms were related to motherhood. “I thought I was just dealing with my body after having a child,” she recalls. When symptoms persisted she raised concerns to her primary care doctor, who never mentioned menopause as a possible cause. Her gynecologist reinforced, “It isn’t menopause because you are still having periods.” In neither appointment were her symptoms attributed to hormonal changes.
Pearlman’s experience mirrors data around clinician and patient comfort with menopause. Only 31% of ob/gyn residency programs include menopause in their curriculum. Another study found 80% of women under age 40 had inadequate knowledge of menopause. “People don’t talk about menopause in my generation,” she says.
In a study of perimenopausal and postmenopausal women, 40% reported shame and 83% reported stigma surrounding their symptoms. The two-way avoidance of discussion—between patients and clinicians—has led generations of women to feeling isolated while having unmanaged or mismanaged symptoms.
A Cultural Shift
Social media has recently provided a source of unity, empowerment and education to this overlooked community. Influencers demonstrate aging positivity via posts on gray hair, nutritious eating, exercise, meditation, sex and fashion after menopause. They are building a culture where aging women can enjoy serenity over shame and stigma.
“Menopause is having a moment because women with a platform and authority do not want to ignore symptoms when treatments are available,” says Dr. Karen Tang, board certified gynecologist, author of It’s Not Hysteria and founder of Thrive Gynecology.
Women are realizing that the way menopause has been handled in the past is adequate. Tang says progress starts by debunking myths and embracing positive direction in education, research and advocacy within the medical community. She acknowledges that the symptoms of menopause are real and disruptive. And yet, she wants aging women to, “live their best life. Embrace being at the peak of your professional life, having less responsibility with raising young children and never worrying about periods.”
To sustain the ongoing cultural shift, we need to adjust how women’s health is described and researched. Though not all women experience motherhood, women’s health is often centered on prenatal and postnatal care. There is a need to recognize that women’s health still exists outside of pregnancy, labor and delivery.
Widening the perspective on women’s health needs to be reflected in academic research. “There are 1.1 million academic medical articles related to women’s health. Only 97,000 are related to menopause and 6,500 for perimenopause” says Dr. Mary Claire Haver, board-certified ob/gyn, author of The New Menopause and founder of Mary Claire Wellness.
“Physicians get little to no training on a process that affects 50% of the population for one third of their life,” she adds. Haver wants the field of medicine to understand that menopause treatment is multidisciplinary and involves education and care delivery from all specialties. Some menopausal symptoms are cardiac, such as palpitations, that might need evaluation by a cardiologist. Other symptoms are related to mental health and may need the support of a psychiatrist or therapist. Haver says women tell her they have lost their resilience and ability to cope, and their anxiety is interrupting productivity.
Education, for patients and clinicians, starts with the basics: understanding the difference between premenopause, perimenopause, menopause and postmenopause. Dr. Sharon Malone, board-certified ob/gyn, author of Grown Woman Talk and chief medical advisor to Alloy Health, shares that premenopause starts at puberty and represents peak fertility years. Perimenopause starts about five to 10 years before menopause. This transition is when symptoms may develop (e.g. hot flashes, weight gain, insomnia, mood changes, joint aches, night sweats, brain fog and dozens of others). Menopause is defined as the moment you had your last period. Technically, one must have no additional period for 12 months to confirm that was in fact one’s last period. Malone is less enthusiastic about the term postmenopause, as “it implies you are at some finite point over menopause. All of these symptoms that one has experienced before and during menopause can continue for years.”
There is an association between being unfamiliar with menopause and not prescribing hormone-replacement therapy to treat symptoms. In a study of multiple specialities, only 6.8% of physicians felt comfortable managing symptoms of menopause.
Women’s Health Initiative And Hormone Replacement Therapy
The use of HRT started in the 1960s and became popularized in the 1990s. “We were frequently prescribing hormones for menopause. HRT was the most effective treatment for the symptoms of menopause.” Malone shares.
There was also observational data that women who take HRT have a 50% decrease in risk of cardiovascular disease. Inspired by the observational trends, the women’s health initiative (WHI) hormone trials enrolled over 160,000 women ages 50 to 79 years old to study effects of HRT in postmenopausal women. It is one of the largest projects examining women’s health in the United States and is commonly credited for being largely responsible for the current under-prescribing of HRT.
Malone states that the trial was flawed from the beginning, as it selected patients who were older than the typical patient who would get HRT. “We prescribed them when symptomatic, usually around 50. The average age in the study was 63, and many were more than 10 years from their last period,” she explains.
The investigators of the trial stopped parts of the study when initial results fell flat: they didn’t find a decrease in cardiovascular disease. Worse, they reported a 26% increased risk in breast cancer.
After the WHI, patients returned to offices wanting to be taken off hormones. “That was the beginning of the end,” Malone says. “It cemented that the hormones cause cancer. And now new doctors in training now think hormones are harmful.”
Luckily, with the benefit of hindsight and reevaluation of the WHI data, research shows that the increase in breast cancer for that population was “not statistically significant”—a term used to clarify that the increased risk could be just by chance. Meaning, the initial report of WHI should not define the gold standard in directing care of menopause with HRT.
Instead patients should walk into their doctors offices and decide, based on their age, symptom burden and medical history, which, if any, hormone could alleviate symptoms. “This discussion is needed because we have magnified the cancer risk and forgotten about quality of life, the value of sleep and the challenges of hot flashes,” she adds.
Dr. Ashley Winter, a urologist and clinical educator for Midi health, has helped develop protocols for hormone therapy in menopausal women. “We have excellent data on low-dose vaginal hormones that begin in mid-life to control genitourinary symptoms of menopause.” she adds.
Infections, overactive bladder, incontinence, bladder pain syndrome and urethral burning are menopausal symptoms and can benefit from vaginal estrogen. When it comes to menopause, Winter adds, we “describe hot flashes and night sweats, but we don’t consider the bladder, which weakens with menopause.” Instead of only putting people on vaginal moisturizers, antibiotics or overactive bladder medications, she recommends dialing back those treatments and addressing the root cause from hormonal changes.
Self-Advocacy For Hormones
To give women hope, the field of medicine must provide women with evidenced-based solutions that are easily accessible. Hormone replacement therapy has been credited by expert gynecologists as life-changing during this phase of life. Individuals should speak with a doctor, ideally familiar with the latest menopause research, about their age, type of hormones available, duration of use and their personal or family history of cancer. Draft a list of questions, or an agenda, for an appointment. Read books on menopause, subscribe to podcasts on menopause and discuss the topic with friends and family.
Agency to gather information and adequate treatment is important for all, especially women of color. Studies show that Black women have symptoms earlier than white women and that their symptoms are more intense. Black women are less likely to get prescribed HRT, a trend cited decades ago that is still present in recent research.
“We have underserved an entire generation of Black women who have been symptomatic and have suffered,” Malone states. “For Black women in particular, we have gotten to the point where the expectation of aging is suffering and misery.”
Additional Solutions For Menopause
Another strategy to help with menopausal symptoms is one’s diet. Casey Farlow, M.P.H., R.D.N., registered dietician and founder of The Perimenopause Nutritionist, focuses on food and menopause.
“The fluctuations of hormones makes menopausal women insulin resistant,” Farlow explains. Insulin is a hormone that helps regulate glucose levels in blood. Without insulin functioning normally, glucose is preferentially stored in fat cells. Additionally with age, basal metabolic rate decreases, which means you burn less calories, making it easier to gain weight, especially in the abdomen.
“Women are eating the exact same thing now as when they were younger, but now the abdominal fat won’t go away,” Farlow says. She teaches the benefit of a diet that understands how their body is less sensitive to insulin with menopause. For instance, she encourages eating PFF foods: proteins every meal, health fats and diverse fibers. PFF foods helps to balance blood glucose and decrease inflammation, which can also lead to insulin resistance.
Resources such as a menopause doula can help women learn new content and become self-advocates. Grace Veras Sealy is a menopause doula at Elektra Health who works directly with patients during their menopause journey. She has one-on-one calls and assesses members’ needs upfront.
“As a doula, I’m there to provide information and support in a way that is clinically aware. Telling someone the acne, vaginal bleeding, palpitations, brain fog is from menopause can be a source of relief and could avoid money, time, stress,” Veras Sealy says.
Pearlman felt the hardest part of her menopause journey was that she recognized women’s health in this country is centered around maternal health. While a mother herself, a much larger part of her lifespan has been centered on perimenopause and menopause, which she feels has been looked over for far too long.
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