Women entering the menopausal transition deserve up-to-date science that reflects their lived experience.
Menopause is gaining attention in the media and highest levels of government, including the White House—but we still have a long way to go to ensure women get the support they need. A recent series issued by a respected journal, The Lancet, proves this point.
The Lancet series claims to promote an “empowerment model for managing menopause.” To us—more than 250 obstetrician-gynecologists, family medicine physicians, cardiologists, internists, urologists, medical oncologists, psychiatrists, orthopedic surgeons, nurse practitioners and licensed therapists—this was an unexpected and welcome opportunity. Our daily work focuses on these same goals.
Despite the encouraging headline, the series was awash with misstatements that do not reflect the lived experience of women in this stage of life or our clinical experience in treating them. In several cases, The Lancet authors relied on outdated data to make their case.
Among our rebuttals:
“Most women navigate menopause without the need for medical treatments.”
The more accurate statement would be that most women navigate menopause without being given the option of medical treatments.
During the menopausal transition, women should “challenge self-critical beliefs, which can … make [hot] flushes worse.”
This tone-deaf suggestion perpetuates the “it’s all in her head” narrative that has been used for decades to dismiss women who present with physical symptoms in the clinical setting. The fact is that hot flushes (flashes), like heart palpitations, are a vasomotor symptom of menopause—a biologic change with known causality due to declining levels of estrogen, disruptions in hypothalamus activity trigger blood vessel dilation and cause a sensation of heat to spread from the chest towards the extremities. These symptoms result from disruptions in the body’s thermoregulatory system and are not psychological in nature.
Psychological and behavioral tools and treatments fulfill a critical role in healthcare, but they are not a panacea, nor should they be the gold standard for menopausal treatments.
“On the basis of scarce data, we found no compelling evidence that risk of anxiety, bipolar disorder, or psychosis is universally elevated over the menopause transition.”
This quote was perhaps the most shocking to those of us in clinical practice. There is ample published literature that has clearly established the menopause transition as a time of vulnerability to impacts on mental health.
Research has shown a four-fold increase in risk of depressive symptoms, and a two-and-a-half-fold increase the diagnosis of major depressive disorder—risks greatest in women with vasomotor symptoms. Also, the rate of antidepressant use for women has been shown to double after age 40.
“Over-medicalization of menopause can lead to disempowerment and over-treatment.”
This confusing statement smacks of misogyny; it seems to critique the idea that the menopausal transition—a life phase associated with the dysregulation of multiple biological systems that introduce heightened vulnerability to many organ systems due to the decline in circulating sex hormones—is something that women should endure without medical interventions.
There is no debate in medicine whether other processes associated with aging should be offered treatment with modern medical solutions. A notable double standard seems to emerge regarding female aging and menopause. While we acknowledge and routinely address erectile dysfunction in men, the same level of attention is not extended to menopause and the ensuing sexual dysfunction.
Why is it that using hormonal therapies to help prevent osteoporosis, the degeneration of bone tissue due to aging and estrogen loss, often leading to an osteoporotic fracture and increased mortality, is labeled as “over-medicaliz[ing]” but other pharmaceutical offerings aren’t similarly maligned? If the entire medical system is set up to serve patients, practice evidence-based care, and improve health span, why, we ask, is menopause any different?
The painful reality for many patients is that clinicians repeatedly fail to recognize their symptoms of menopause that extend beyond the classic vasomotor symptom of hot flashes. These include inflammatory conditions, cardiac and neurological issues, sexual dysfunction, and sleep and mood disorders. Women frequently find themselves referred to numerous specialists to address the multitude of symptoms associated with menopause, with each symptom being tackled individually; clinicians unable to connect the dots, akin to playing a game of whack-a-mole with symptoms.
How is this reality not the ultimate in over-medicalization?
If and when doctors do engage their patients in discussions of menopausal hormone therapy—a proven treatment to both allay and prevent many of these conditions—many of them overemphasize the risks and downplay the benefits of hormone-based treatment. And in the series, alternative pharmaceuticals, such as anticholinergics, SSRIs, statin therapy, pain medications, osteoporosis drugs, neurokinin receptor agonists are painted as all benefit and little risk. Patients then are left with a cabinet full of prescription medications, costly medical bills and negligible relief. This is the true over-medicalization of menopause, just not in the way the authors of The Lancet series suggest.
We will continue to prioritize patient empowerment, based on up-to-date science and further work to elevate standards of care for women entering the menopausal transition. They deserve nothing less.
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