February 3, 2021

It’s Time for a Mood Change on Menopause

Older women laughing with yoga mats

By Megan Snair, SGNL Solutions

With the U.S. population living longer than in the past, most women can spend from a third to half of their lives postmenopausal, plus up to 10 years in the menopausal transition. Yet much of the attention around women’s health tends to focus on the earlier reproductive years.

When a woman is pregnant, she visits with her provider at least once a month and is encouraged to take classes and prepare for the major life change that pregnancy brings,” said Karen Giblin, founder and president of Red Hot Mamas, a national menopause education program. “But why is it that during menopause, the average American woman receives minimal, if any, care or preparation for a phase of life that also brings significant change?”

Perimenopause is the natural transition to a person’s final menstrual period and typically begins in a woman’s late 30s or 40s. During this time, estrogen production in the body fluctuates before eventually decreasing until a woman has gone 12 months without a menstrual period (after which a woman is considered postmenopausal). Perimenopause is associated vasomotor symptoms like hot flashes and night sweats, as well as brain fog, anxiety, fatigue, and sleep problems. Although some women have no symptoms, most experience at least one symptom and many have symptoms that last for several years.

Menopause is understudied in research, often misunderstood by providers and patients, and unaddressed in many areas of health care policy. To explore these issues, SWHR recently convened a roundtable of experts to identify knowledge gaps and unmet needs related to the menopausal transition across areas of education, clinical care, research, and policy.

Patient and Provider Education

Improving patient education can empower women to take ownership of their menopause journey and advocate for the care they deserve. For example, many women are unaware of how early symptoms may begin or that mental health symptoms may be associated with the menopausal transition. Because the menopause transition is gradual, understanding the range of symptoms and experiences will assist women in addressing their health needs as they evolve.

Women are also at higher risk for certain medical conditions after menopause, such as bone loss, heart disease, depression, diabetes, dementia, and sexual dysfunction. Knowing this information ahead of time can give women the confidence to talk to their health care providers about preventative measures to address these conditions as they age.

Even clinicians may be unfamiliar with menopause needs and symptoms due to the lack of training that general health care providers receive on the topic in medical school and residency, the experts noted. Improved medical curriculum on menopause is needed not only for OB-GYNs, but also for the variety of health care providers who see women in midlife. For instance, an educational pathway structured similarly to curricula designed for the reproductive years could bring the same level of clinical attention and preparedness to the menopausal phase.

Clinical Care

Current treatments for managing menopause symptoms include hormone therapy (HT) for hot flashes and vaginal discomfort, low-dose vaginal estrogen for vaginal dryness and painful sex, antidepressants for mood disorders, and other nonhormonal medications and behavioral strategies for related symptoms and health conditions.

Rebecca Thurston, PhD, immediate past president of the North American Menopause Society, noted that interventions such as cognitive behavioral therapy and brief behavioral therapy for insomnia may positively impact sleep. Others options such as meditation and clinical hypnosis may help women cope with vasomotor symptoms.

HT is one of the main treatments approved to manage vasomotor symptoms and vaginal dryness, but it has been the subject of much misinformation. In 2002, a study by the Women’s Health Initiative (WHI) that aimed to examine the effectiveness of HTs for chronic disease prevention found an increased risk of coronary heart disease, invasive breast cancer, stroke, and venous thromboembolism in postmenopausal women who took a combined estrogen-progestin therapy. As a result, patient use and provider prescription of HTs significantly decreased.

Analyses of the WHI results conducted since then have noted large variations in outcomes based on age and have concluded that HTs should be considered an appropriate treatment of moderate to severe menopause symptoms, especially in healthy women under age 60. Unfortunately, distrust among providers and patients still exists, preventing women from accessing effective treatment to relieve menopause symptoms.

SWHR’s roundtable experts stressed the need for increased dissemination of updated research so that health care providers and patients can make informed, shared decisions about menopause treatment options that consider medical evidence and individual patient goals and concerns.

A patient’s age, symptoms, and type of menopause (e.g., natural or surgically-induced) are integral factors that should be considered in menopause care. For example, though hot flashes are the most well-known symptom, “stiffness and sore joints are actually the highest reported symptoms, followed by hot flashes, forgetfulness, and sleep problems,” said Pauline Maki, PhD, professor of psychiatry, psychology, and obstetrics and gynecology at the University of Illinois at Chicago.

Research shows that trauma in early life as well as chronic discrimination such as racism is associated with more severe menopause symptoms. “Many patients experience bias in treatment due to societal biases and systemic oppression,” said Omisade Burney-Scott, creator of Black Girls’ Guide to Surviving Menopause. In addition, not all people who experience menopause will identify as a woman, so clinicians must be receptive and understanding of treating diverse symptoms across all populations — including trans and genderqueer individuals. Being conscious of seeing the whole person can lead to an optimal, personalized care plan for each patient.

Research Gaps

During SWHR’s roundtable, CheMyong Jay Ko, PhD, a professor of comparative biosciences at the University of Illinois at Urbana-Champaign, highlighted the current state of menopause research and called attention to knowledge gaps. Specifically, research is needed in understanding the full effects of estrogen depletion as women age — not just in reproductive and bone health, but in various tissues throughout the body — and how that can influence health conditions associated with menopause. Additionally, the interactions between endocrine-disrupting chemicals from the environment and menopause onset and symptoms is a less understood topic of emerging interest.

Although menopause is a natural life stage, it can occur earlier than normal due to primary ovarian insufficiency, premature or early-onset menopause, or removal of ovaries by oophorectomy or total hysterectomy. Experts agree that HT should be recommended until the typical age of natural menopause for almost all women experiencing early menopause. To better understand and care for women experiencing these conditions, researchers are studying underlying causes for differences in cellular aging across populations, as well as mechanisms that can promote menopause delay.

The experts also discussed the noticeable gaps in longitudinal data that incorporate diverse populations, especially among Hispanic and Native American women. Menopause onset and symptom presentation vary across racial and ethnic subpopulations, and differ by age and medical history. Risk factors for potentially severe postmenopausal complications warrant further genetic and epidemiological investigation to fully understand incidence and implications in different individuals. Overall, a more robust evidence base, supported by increased federal funding for menopause research, can assist in advancing menopause care more widely.

Policy Considerations

Beyond gaps in education and unmet needs in clinical care, women encounter barriers to menopause treatments and information that could be addressed through policy changes at more systemic levels. Accessing some menopause treatments can be difficult due to dated guidance from government agencies, and many women struggle financially to obtain therapies their doctors prescribe, the experts said.

For example, about 50% of postmenopausal women experience vaginal dryness and painful sex, yet vaginal estrogen therapies are unaffordable for many women. Many insurance policies place these treatments in high-tier formularies, which means patients are stuck with high out-of-pocket costs. Generic options and manufacturer coupons offer some relief, but for patients facing economic hardship, this still leaves an effective treatment option inaccessible.

Lisa Satterfield, senior director of health economics and practice management for the American College of Obstetricians and Gynecologists, noted that in order to drive improvements in insurance coverage for such treatments, clinical guidance and recommendations must be updated to reflect the most current and accurate research on menopause care.

U.S. workplace policies are another area where the needs of women experiencing the menopausal transition should be considered. The experts pointed to the examples set in countries such as United Kingdom, where advocates have published reports on the effects of menopause on women’s economic participation and numerous organizations have developed comprehensive policies that consider menopausal symptoms experienced by employees. Until there is a clear path for such policies in the U.S., advocacy organizations must continue efforts to provide individuals with resources on managing menopause across different life experiences.

Optimizing Menopause Care

Moving the field of menopause forward will require a stronger evidence base in the physiology and epidemiology across diverse populations, as well as the efficacy of treatments for symptom management. Better education is necessary for medical students and residents, who currently receive minimal training in menopause. Improved menopause awareness to empower patients as well as equitable and supportive insurance and workplace policies are also priority areas of need.

Women deserve to live high-quality lives through this transition and into their postmenopausal lives. It’s time to stop treating menopause like a disease. When we treat it as the important life stage it is, with the appropriate knowledge, support, and proactive health care that is inclusive and considerate of an individual’s life goals and desires, half the global population will benefit — and so will all the people they care for.