Menopause: Symptoms & Underrepresentation

Nothing in life can be said to be certain, except death, taxes, and for the world’s 3.905 billion women, menopause. The symptoms of perimenopause and menopause, which include hot flashes, insomnia, depression, anxiety, sexual and cognitive dysfunction, are experienced by 75% of women in midlife. The suffering associated with menopause can substantially undermine a woman’s health, quality of life, relationships and work. Despite this disproportionate and nearly universal impact, menopause has been largely ignored by the medical profession, leaving women without appropriate diagnoses or treatment options.

The precursor to menopause, perimenopause, begins with a dramatic drop in estrogen levels and usually begins 8-10 years prior to the official onset of menopause. Estrogen levels continue to decrease throughout perimenopause, as the ovaries slowly stop functioning, which leads to irregular periods and a plethora of other severe symptoms, such as mood changes, brain fog, changes in sexual desire, headaches, hot flashes, sleeping trouble, muscle aches, vaginal dryness, and heavy sweating. Symptoms can last for a few months or for as long as four years.

Menopause officially begins one year following a woman’s last period. The hormone changes accompanying the end of menstruation and fertility are dramatic, and include a drop in estrogen, progesterone, testosterone, follicle-stimulating hormone, and the luteinizing hormone. The drop in follicle-stimulating hormones causes the loss of active ovarian follicles, the core structure in producing and releasing eggs from the ovary wall, and effectively brings an end to both menstruation and fertility. The average age for the onset of menopause is 51, and the most common symptoms include “insomnia, vaginal dryness, weight gain, depression, anxiety, difficulty concentrating, memory problems, reduced libido, or sex drive, dry skin, mouth, and eyes, increased urination, sore or tender breasts, headaches, racing heart, urinary tract infections (UTIs), reduced muscle mass, painful or stiff joints, reduced bone mass, less full breasts, hair thinning or loss, and increased hair growth on other areas of the body, such as the face, neck, chest, and upper back” (Healthline, Everything You Should Know About Menopause). Different symptoms have been shown to be linked with different stages in a women’s menopausal journey. A study published online in Menopause, the journal of the North American Menopause Society, found that “the severity of menopausal symptoms, including depression, total psychological, sexual, and somatic dysfunction, were highest for individuals who are late postmenopausal, while anxiety and hot flashes were most prevalent in those in early postmenopause”. Conditions that affect the ovaries, such as cancer or hysterectomy, or lifestyle choices like smoking, usually increase both the severity and duration of these symptoms. There are also common medical complications that accompany menopause, including vulvovaginal astrophy, dyspareunia, a slowed metabolism, osteoporosis, cataracts, periodontal disease, urinary incontinence, and heart or blood vessel disease.

For most women, the first signs of menopause are interruptions in menstrual cycles and hot flashes. Doctors can use blood or urine tests to determine if a woman is in menopause by checking the levels of different hormones such as estradiol, follicle-stimulating hormones, and luteinizing hormones, but rarely do, unless specifically requested by the patient. Given that some women will experience perimenopausal symptoms for up to ten years, and one out of ten women will suffer through menopausal symptoms for twelve years, testing, diagnosis, and treatment for menopause should be standard procedure for medical professionals. However, in reality, most medical schools and residency programs do not educate aspiring physicians about menopause: “A recent survey reveals that just 20 percent of ob-gyn residency programs provide any kind of menopause training. Mostly, the courses are elective. And nearly 80 percent of medical residents admit that they feel “barely comfortable” discussing or treating menopause” (Sheryl Kraft, Why So Many Doctors Fail Women With Menopause Care). An article in a 2013 issue of Johns Hopkins Magazine cites that fewer than one in five U.S. obstetrics and gynecology residents receives formal training in menopause medicine. Research shows that among both primary care physicians and gynecologists, conversations about menopause are initiated by the patient 91% of the time. When women do initiate these conversations, due to the lack of information around menopause in the medical field, they are commonly met with dismissive responses that attribute symptoms to aging, or a fact of life, and advised to make lifestyle changes, such as “taking it easy”. According to Dr. Lauren Streicher, a clinical professor of obstetrics and gynecology at the Feinberg School of Medicine at Northwestern University, only about 6% of women receive counseling and treatment for the consequences of menopause. Women fortunate enough to receive treatment are usually prescribed hormone replacement therapy to replace and regulate the decreasing estrogen and other hormones in a women’s body during menopause, which can significantly lessen many debilitating symptoms. However, the vast majority of medical professionals lack the information and tools to properly treat menopause, and most women do not have the resources or knowledge to find help. James Woods, a professor of obstetrics at the University of Rochester, makes the point that even doctors who specialize in women’s health do not necessarily understand menopause: “Menopause is as different from obstetrics as surgery is from pediatrics”. To further complicate matters, every woman will experience menopause differently, and there is no “one size fits all” approach to treatment.

The healthcare system is clearly failing women. Gynecologist Tara Allmen, author of Menopause Confidential, writes that “We spend a lot of time in the health care profession teaching women how not to get pregnant, then we teach them how to have babies, and possibly we teach them how to breastfeed. But that is where the lectures end”. This singular focus on a woman’s reproductive capacity reflects a larger social issue - when women age out of their reproductive years, they become less valuable, easily ignored, stigmatized and shamed into suffering in silence. Women are embarrassed by menopause, especially in the workplace, where symptoms that impact cognitive function might be associated with incompetence. Menopausal women are becoming the fastest growing workplace demographic, and yet a recent study conducted in the UK found that menopausal symptoms caused nearly one million women to leave their jobs, resulting in a global productivity loss of $150 billion a year. The same study found that menopausal women who stayed in the workplace had to take an average of 32 weeks leave throughout their careers to manage their symptoms. Menopause is an epidemic, and the pressure women feel to hide symptoms, or attribute menopause to illness, only furthers the lack of awareness and support for menopause in the workplace. Women tend to reach menopause during their most productive professional years, when their decades of experience coincide with the freedom to focus on work that comes with an empty nest, and yet they are leaving the workplace in droves. As Rachel Western writes in Aon, “Employers need to be saying ‘we’re aware that menopause exists and we want you to feel able to tell us if you’re struggling, so we can support you through it’”. This exodus has wide ranging repercussions - because women of menopausal age are likely eligible for senior management roles, their exit directly impacts C-suite diversity, which in turn significantly contributes to gender inequality and furthers gender pay gaps.

Menopause is clearly a global health crisis, one which our healthcare system cannot continue to ignore. Medical students and practitioners need to be educated about menopause and trained to proactively recognize and treat symptoms. Women must be empowered to speak up, seek help, and demand support, without shame or fear of negative repercussions.