Hot flushes are trending. One British celebrity has registered to trademark the term ‘menopausing’ to complement her book.[1] Scotland’s first minister has referred to the stigma surrounding the climacteric, admitting anxiety about coping in her public role once symptoms intensify.[2] In the last month the Guardian has published 8 articles on the menopause ranging from the possibility of it destroying mental health to how to live better at this stage of life. In addition, the latest example has the headline: ‘HRT ‘potentially important’ in reducing women’s dementia risk.[3] But read on to see that this reduction relates to women with a specific gene only and is speculative prior to further research.
Some years ago, I consulted a recently qualified general practitioner (GP) because of prickling sensations and drenching sweats. Knowing I was a doctor, she asked what I would like to do, explaining she had little experience of prescribing hormonal replacement therapy (HRT). I can’t fault her – she was honest and empathic. Reading the recent articles in the lay press, I realise that many women continue to face similar challenges finding appropriate health care professionals to meet their needs and discuss their concerns. GPs are generalists and know a little about a lot, unless they have a special interest in certain areas of health. Moreover, in my experience, a consultation focusing on the perimenopause (the time during which the ovaries gradually stop working but periods continue, if the woman has a womb) or menopause requires at least 15 minutes if not more. Long consultations, however, may be difficult to access in a pressurised health service. Specialist services, if required for women with complex needs, may be over-subscribed and costly in some countries.
In the 1990s I considered myself something of an expert on HRT as its indications evolved and observational studies indicated benefits beyond tackling hot flushes.[4] In consultations it was important to counter misinformation suggesting that HRT was an anti-ageing panacea. However, following preliminary findings of the Women’s Health Initiative (WHI) in 2002[5], HRT prescribing dropped dramatically in the UK and elsewhere.[6] The WHI data indicated that HRT containing the hormones oestrogen (estrogen) and progestin (a synthetic progesterone) raised the risk of breast cancer and coronary heart disease. Demand slowed; doctors became cautious about prescribing. Pharmaceutical companies responded by reducing their production of treatment options while perimenopausal knowledge amongst consumers and health professionals also seemed to shrink.
The 2002 WHI conclusions, based on an older group of women (60s) than would typically take HRT (50s) and with other design faults, have been largely overturned by more recent research. Women are again seeking solutions but not necessarily in terms of medication. Many are interested in discussing options and understanding more about their bodies. However, consumers with lower health literacy may not have the vocabulary to broach their experiences, without their health professionals starting the conversation.
What should women expect from their employers and health professionals? It is important to advocate for women’s rights, while avoiding the sexist dismissal of women of a certain age as being ‘hormonal’. As 77% of its workforce is female[7], this is also an issue for the UK National Health Service (NHS), and for other health systems with a high proportion of women employees. Indeed, the UK’s Royal College of Nursing has highlighted that pandemic personal protective equipment appears to have exacerbated menopausal vasomotor symptoms.[8] With adequate training, health professionals in primary care/general practice should be able to have conversations about the perimenopause and menopause and refer to a more experienced colleague as necessary.
It is important, however, that this natural stage of a women’s life is not over-medicalised. Shared decision-making is important as part of a woman-centred approach to better understanding and optimal management.
[1] Trademarkia 2021.
https://www.trademarkia.com/uk/trademark-UK00003653389.htm
https://www.bbc.com/news/av/uk-scotland-61162428
[3] https://www.theguardian.com/society/2023/jan/14/hrt-potentially-important-in-reducing-womens-dementia-risk
[4] Cagnacci A, Venier M. The controversial history of hormone replacement therapy. Medicina (Kaunas) 2019; 55(9): 602. https://dx.doi.org/10.3390%2Fmedicina55090602
[5] Rossouw J.E., Anderson G.L., Prentice R.L., LaCroix A.Z., Kooperberg C., Stefanick M.L., Jackson R.D., Beresford S.A., Howard B.V., Johnson K.C., et al. Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288:321–333. doi: 10.1001/jama.288.3.321.
[6] Menon U., Burnell M., Sharma A., Gentry-Maharaj A., Fraser L., Ryan A., Parmar M., Hunter M., Jacobs I., UKCTOCS Group Decline in use of hormone therapy among postmenopausal women in the United Kingdom. Menopause. 2007;14:462–467. doi: 10.1097/01.gme.0000243569.70946.9d.
[7] NHS Digital. NHS workforce statistics – Equality and diversity NHS trusts and CCGs. NHS Digital 2019 Mar. https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/nhs-workforce-statistics—march-2019-provisional-statistics
[8] Kydd A. Menopause and personal protective equipment: How does this meet acceptable working condition? Case Rep Womens Health 2021; https://dx.doi.org/10.1016%2Fj.crwh.2021.e00356
Health professional education and practice 