Study warns of excessive medicalization during menopause

Something is changing in the narrative of menopause, both in women’s homes and in science. The silence around a life stage that half the planet has experienced, is experiencing, or will experience is being broken, and the scientific and medical gaze is also beginning to examine its modus operandi.

A series of studies published recently in The Lancet warns of the risks of excessive medicalization of the menopause and calls for a paradigm shift in care at this stage of life, with shared decisions and more information available for women. The article’s author, Martha Hickey, a professor of Gynecology and Obstetrics at the University of Melbourne (Australia) summarizes: “Menopause is not a disease, so it does not necessarily need to be diagnosed or treated. We propose that this be seen as a normal life change that can sometimes cause problematic symptoms that require medical intervention.”

Sooner or later, half the world ends up going through menopause. In most cases, around the age of 50. The process begins when mature eggs stop being released by the ovaries, menstruation ceases, and reproductive hormones stop being produced. But each experience is unique. There are women who make the transition with no problems whatsoever, and others who present symptoms of hot flashes, night sweats, vaginal dryness, or other symptoms that negatively affect their quality of life. All these symptoms are usually temporary, but according to the studies included in Hickey’s article, vasomotor symptoms affect up to 80% of women in rich countries at some point during the process, and can last between four and seven years.

In this context, the world is caught in the crossfire between those who regret that a natural process is being pathologized and those who criticize the lack of access to effective treatments. A few months ago, a scientific review stated that 85% of women with menopause symptoms do not receive effective therapy. “The recognition that, for most women, menopause is a natural biological event, does not exempt the use of interventions to alleviate symptoms,” the scientists explained.

This new article inThe Lancet returns to the topic and puts controversial hormone therapy back in the spotlight. During the 1960s the therapy was dispensed globally to women with menopause with the promise of treating symptoms and even preventing diseases. However, its use plummeted after 2002, when a trial (WHI) was suspended when it was detected that these drugs could increase the risk of stroke and cancer.

“We are trying to convey the message that menopause is about more than taking hormones.”

Martha Hickey, profesora de Ginecología y Obstetricia de la Universidad de Melbourne (Australia)

In the last 20 years, the scientific community has been refining the real risks of these drugs and prescribing them is limited to a very specific profile: to relieve serious symptoms in young postmenopausal women with no risk factors, and they are not recommended to prevent diseases.

The controversy remains, although use of the therapy varies between countries. In an email conversation with EL PAÍS, Hickey agrees that “there is great variation in the use of hormone therapy for menopause around the world,” but her article states that 13% of women in high-income countries receive this therapy. In Spain, a survey by the Spanish Association for the Study of Menopause (AEEM) estimates that just over 5% of postmenopausal women with vasomotor symptoms take these drugs.

Empowerment

The authors advocate “additional strategies beyond medication” to support the transition to menopause. Their study highlights the role of cognitive behavioral therapy or hypnosis as effective non-pharmacological alternatives against vasomotor symptoms and also mentions fezolinetant, a non-hormonal drug, with “modest” results, they point out.

“We are trying to convey the message that menopause is about more than taking hormones. While hormones are useful for problematic hot flashes or night sweats that are problematic, they have no other clinical function.” The scientist advocates an “empowerment” approach: “We want to stop focusing on hormones and remove the stigma and age discrimination that older women experience. We want to recognize and celebrate their value in our communities and workplaces and improve access to sympathetic doctors and realistic and balanced information, preferably before menopause. Hormone therapy can be part of this approach, but it is not the complete solution.”

In this change of outlook and in all the ups and downs that menopause care has suffered in recent decades, there is an underlying lack of knowledge about this vital process that persists. It is not known with certainty what all the symptoms associated with this hormonal decrease are. There is a consensus that vasomotor symptoms, such as hot flashes, vaginal dryness, and “possibly” sleep disorders, are attributable to this vital process, but the authors admit: “The effects of hormonal changes can be difficult to differentiate from concurrent life events, such as caring for children at home or looking after aging parents.”

No more risk for mental health

In fact, research from this series rules out that menopause is irrevocably associated with a greater risk of poor mental health. “Women are not universally or uniformly at risk for psychological symptoms during the menopause transition,” the study concludes, after reviewing 12 prospective investigations. Risk factors for depressive symptoms are having a previous history of depression, experiencing severe and prolonged vasomotor symptoms, persistent sleep disturbances, or experiencing a stressful life event.

‘Knowledge gaps’

The Lancet series, which also includes other articles focusing on menopause after cancer, and early menopause, admits that there are still “substantial gaps in [the medical] knowledge” of this life stage, but invites scientists to take a new approach “beyond specific symptoms,” they say. With expert patients and shared decisions within the framework of healthy aging, without stigma.

González sees this approach as “interesting,” since “menopause is intimate and non-transferable,” but asks that “judgment and common sense” in decision-making be applied. “The symptoms are unique and experiencing them varies enormously because we are biopsychosocial beings, and it will depend not only on who you are biologically, but also psychoemotionally, and on the culture you are surrounded by. And we cannot know in advance what your menopause will be like, but it cannot be that a woman has to face this stage with great anxiety,” she says.

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