There’s a meme featuring a confident, friendly, smiling Henry Cavill – the actor best known for playing Superman – posing for photographers on the red carpet. Crawl after him is a wild-looking, maniacally cheerful co-star Jason Momoa.
To me, this is the perfect metaphor for perimenopause. Cavill is at the peak of his career, he looks great, clearly feels great, exudes confidence, strength and self-possession. And he is about to be trapped by a fickle and unpredictable force.
Is it a disease? Is this a normal biological event? No, it’s menopause!
Menopause is the orb your ovaries throw at you when you’re born that you have to figure out 40 or 50 years later how to catch without dropping everything.
I consider myself lucky to have – thanks to the advice, humor and wisdom of my wonderful female friends – caught a glimpse of that curveball to come. Instead of being completely caught off guard by the inexplicable mood swings, exhaustion, anxiety and lack of motivation, I can understand it a little more.
But despite being a science journalist for more than two decades, including writing extensively on women’s health and hormones, I’m as confused as the next ovary owner when it comes to my options at this time of my life
Ask 20 women what perimenopause is like and you’ll get 30 different answers: “One minute you’re fine, and then you want to kill someone”; “It didn’t really affect me”; “I cry, laugh, panic, rage and sweat”; “It feels like jogging in molasses”; “For example, I asked my family doctor for a brain transplant for the forgetfulness.
Even the medical establishment cannot agree on the symptoms of perimenopause. “It’s a very, very critical question in menopause, which is what symptoms does it actually cause?”, says Prof Martha Hickey, director of the Women’s Gynecology Research Center at the Royal Women’s Hospital in Melbourne. “The list is getting longer.” The two (excellent) GPs I discussed menopause with used different symptom checklists, although they covered similar ground.
This is a problem for anyone experiencing menopause, and for their clinicians. Because while menopause is clearly not a disease – “it is a biological life event; aging is not a disease,” says Prof Davis, an endocrinologist and researcher at Monash University – it should not be dismissed as something people just have to endure without help because it is “natural”. “Osteoporosis is age-related bone loss, but we still treat it,” says Davis.
The question that dominates the discussion about menopause is when and how should we treat perimenopausal symptoms? This debate is especially shown when it comes to menopausal hormone treatment, or MHT.
MHT – which works by boosting and stabilizing the declining levels of estrogen and progestin – has had quite a reputational roller coaster over the past half century. Especially the controversial and misreported ones 2003 Women’s Health Initiative Studywhich found a small but significant increase in the risk of breast cancer, heart disease, stroke, and blood clots cast a decades-long shadow over MHT’s reputation and availability, but it is widely accepted that shadow is unwarranted.
“Over the 20 years there have been numerous papers critical of the shortcomings of that study,” says Dr Silvia Rosevear, an obstetrician and gynecologist in Auckland, New Zealand, and president of the Australasian Menopause Society. The average age of women in the study was 63, most were post-menopausal, and the MHT formulations have evolved and improved significantly since the study; meaning that the results have limited applicability to the use of modern MHT formulations for symptom relief in younger perimenopausal people.
Despite these criticisms, Davis’s research suggest that physicians are still reluctant to prescribe MHT except for severe symptoms of menopause, preferring instead to tacitly endorse the use of complementary and alternative therapies for which there is questionable evidence. Davis says we need new studies to provide more relevant, up-to-date information, but the Women’s Health Initiative “provided a lot of information that basically killed funding in the field for 10 years.”
This is slowly changing and funding is beginning to flow for those studies. But to properly evaluate the long-term risks and benefits of MHT, these studies will need to last for many years. So what do perimenopausal people do in the meantime, and where does MHT go?
Iit’s a confusing time for menopause therapy. On the one hand, Davis’ study found that health care providers, while well-informed about menopause, were uncertain about how to treat it, limiting MHT to people with severe symptoms that lifestyle changes and alternative therapies could not relieve.
On the other hand, many people experiencing perimenopausal symptoms ask for a treatment that, according to both clinical and anecdotal evidence, has a good chance of alleviating those symptoms and helping them feel “normal.”
“If a clinician starts MHT appropriately for moderate to severe symptoms, you will most likely find that your patient comes back and finds that the symptoms are completely gone and they feel normal,” says Rosevear. In her experience, most people on MHT love being on it.
Between these two parties are gynecologists, psychiatrists, psychologists, endocrinologists, feminist scholars, and menopause specialists who argue over whether menopause is over-medicalized, over-dramatized, and over-treated, and whether women who experience perimenopause, their symptom, are minimized. and undertreated.
“Broadly, we really need to think about this as a life stage of opportunity, not of disability,” says Prof Jane Fisher, a clinical psychologist and director of Global and Women’s Health at Monash University. “To suggest that the entire population of women experiences illness and disability as a result of this natural life change is actually very unhelpful.”
Hickey, who co-authored a series of papers raising concerns about the medicalization of menopause, worries that the public discourse about symptoms scares younger women and feeds into the persistently harmful trope of older women being “washed out.” “I can’t think of anything good about those two words – ‘old woman’,” says Hickey. “We need to change how we view aging in women, and that includes not pathologizing it.”
But Prof Jayashri Kulkarni, a psychiatrist and director of the HER Center Australia at Monash University, believes it is condescending to suggest women “just put on a happy face” and not talk about the challenges of menopause. “That’s not the era we’re in.”
She sees the women in her clinic struggle with low mood, mood swings, anxiety, insomnia and other mental health impacts that she knows are not simply the result of ordinary life stressors – of which there are many at this stage of life.
“My clinical experience is that I have a lot of distressed women who say, ‘There has to be a solution, let’s work together and let’s find something to help me, because I do have a million dollar business that I’m running again. want to get going,'” says Kulkarni. “If the problem is a mental health problem caused by hormone fluctuations, then hormone treatment is common sense.”
In general, clinical guidelines agree with this. A review published last year by Davis and colleagues found most high-quality guidelines recognize that MHT can be used for both vasomotor symptoms – hot flashes and night sweats – and “mood disorders”.
But for an experience that affects half the population, good-quality studies—especially of the mental health impacts of perimenopause—are sparse. “We really need funding to do a good trial to compare HRT or MHT with standard antidepressants, to see where the real evidence lies,” says Kulkarni.
IMeanwhile, the growing public and private conversation about menopause indicates that women are reclaiming this transition, celebrating its positives, relishing and humoring its negatives, and—most importantly—choosing how they want to experience it.
My choice – and one many women I talk to have chosen without regret – is to seek medical help to manage those psychological curve balls so I can continue with the successful career I love and have worked hard to achieve. My GP is understanding and supportive, while also explaining the risks.
I know MHT may not be the silver bullet I’m hoping for; after all, my anxiety and exhaustion could be the result of this tumultuous, devastating, dangerous period in human history, or being the parent of teenagers and daughter of elderly parents, or panicking about global warming. But I don’t think it’s just them.
Kulkarni says she always comes back to the individual woman’s voice. “The voice of lived experience is what we really need to listen to, because she will tell you,” she says. “Most women I’ve met don’t make it to 45 without knowing a thing or two about themselves.”
