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Something is changing in the menopause narrative. On the street and in science. The silence around a vital process that half of the planet has experienced, is experiencing or will be experiencing has begun to crack among public opinion and the scientific and medical perspective is also beginning to question its mode of operation. A series of investigations published this Tuesday in The Lancet warns of the risks of excessive medicalization of menopause and calls for a paradigm shift in care for this stage of life, with more information for women and shared decisions. “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,” summarizes the author of the article, Martha Hickey, professor of Gynecology and Obstetrics at the University of Melbourne (Australia).
The approach to menopause has been swinging between extremes, like a kind of pendulum that never balances. “From putting up with it and keeping quiet to sensationalizing it,” describes Rachel Weiss, founder of the charity. Menopause Cafe, in a statement from The Lancet. She, who has not participated in the study, assures that “it is good to talk about menopause, but it must be normalized so that people are not afraid of it.” Along these lines, the authors of the series emphasize the dangers of turning menopause into a health problem: “A medicalized view of menopause can disempower women, lead to excessive treatment, and overlook possible positive effects.” , such as better mental health with age and the absence of menstruation, menstrual disorders and contraception.”
Sooner or later, half the world ends up going through menopause. In most cases, around the age of 50, this process begins where ovarian activity ceases, menstruation disappears and reproductive hormones stop being generated. But each experience is unique: there are women who make this transition without any problem and others who present symptoms of hot flashes, night sweats, vaginal dryness or other symptoms that damage their quality of life. All of these discomforts are usually temporary, but according to the studies included in Hickey’s article, in rich countries, vasomotor symptoms affect up to 80% of women at some point during the process and can last between four and seven years.
In this context, the world is caught in a crossfire, between those who regret that a natural process is being pathologized and those who criticize the lack of access to effective treatments. A scientific review indicated a few months ago that 85% of women with menopause symptoms do not receive effective therapy. “The recognition that menopause, for most women, is a natural biological event, does not exempt the use of interventions to alleviate symptoms,” the scientists stated.
This new article in The Lancet takes up the topic and puts the controversial hormone therapy back in the spotlight, which during the sixties was provided globally to women with menopause with the promise of treating symptoms and even preventing diseases. In a scenario in which it was believed that femininity and health “depended on hormonal balance” and in the midst of the rise of anti-aging movements, hormonal therapies were quickly accepted in rich countries—in the mid-sixties, a third of British women between 50 and 64 years old took these drugs, the authors recall. However, their use plummeted when, in 2002, a trial (WHI) was suspended when it was detected that these drugs could increase the risk of stroke and cancer.
“We are trying to give the message that menopause is about more than taking hormones.”
Martha Hickey, Professor of Gynecology and Obstetrics at the University of Melbourne (Australia)
In the last 20 years, the scientific community has been refining the real risks of these drugs and their indication is limited to a very specific profile: to relieve serious symptoms in young postmenopausal women without risk factors, but it is not recommended to prevent diseases. The authors admit that, “although long-term follow-up [del ensayo WHI] showed no increase in all-cause mortality after five to seven years of hormone therapy, uptake has never returned to previous levels in most countries.”
Empowerment
The authors advocate for “additional strategies beyond medication” to support the menopause transition. 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 give the message that menopause is about more than taking hormones. Hormones are useful for hot flashes or sweats that are problematic but have no other clinical function. For example, they do not independently treat sleep or mood disorders and are not as good for vaginal dryness (topicals are better),” says Hickey. The scientist advocates an “empowerment” approach: “We want to stop focusing on hormones and challenge the stigma and ageism that older women experience, recognizing and celebrating their value in our communities and workplaces, improving access to empathetic 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, underlying the lack of knowledge that still persists about this vital process. Due to not knowing, 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. of concurrent life events, such as caring for children at home or responsibility for aging parents. In particular, changes in mood and cognition and sexual difficulties commonly attributed to menopause may be caused or exacerbated by these life stressors.”
No more risk of poor 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. “Physicians should not assume that psychological symptoms during the menopause transition are always attributable to hormonal changes and should offer evidence-based treatments. “Hormone therapy may improve concurrent depressive symptoms in patients with problematic vasomotor symptoms,” conclude the authors, who also found “convincing evidence” of increased risk of anxiety, bipolar disorder, or psychosis.
The influence of economic sectors also hovers over this debate. “Pharmaceutical companies have been very influential from the beginning, suggesting that all menopausal women should take hormones for the rest of their lives. Pharmaceutical approaches have now changed, but still strongly promote hormone therapy. The new commercial interests that can work through social networks are private clinics that charge high prices for care and often prescribe high doses of hormones where the risks are known to be greater,” Hickey denounces.
“Knowledge gaps”
However, Silvia P. González, spokesperson for the AEEM, rejects such influence on the use of hormonal therapy: “I do not believe that it is a matter of commercial interests, or not only, but that hormonal therapy is an etiological treatment, of the cause: that is, everything that is due to a lack of hormones, anyone can intuitively understand that it will be fixed by adding hormones. The difficult thing here is to define to what extent each symptom is exclusively due to the drop in hormones.”
The series of The Lancet, which also includes other articles focused on menopause after cancer and early menopause, admit that there are still “substantial gaps in the knowledge” of this vital process, but invite the promotion of 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 to apply “judgment and common sense” in decision-making. “The symptoms are unique and their experience varies enormously because we are biopsychosocial entities and it will depend on you biologically, but also psychoemotionally and on the culture in which you are immersed. And we cannot know in advance what your menopause will be like and it cannot be that a woman faces this stage with terrible fear,” she agrees. However, Susan Davis, director of the Women’s Health Research Program at Monash University (Australia), criticizes, in statements to Science Media Centerthat “the authors seem determined to minimize the important role” of hormonal therapy and “ignore,” he says, systematic reviews that point to these drugs as the most effective against vasomotor symptoms.
Gino Pecorano, president of the National Association of Specialist Obstetricians and Gynecologists of Australia, also points out to SMC that, “although it is laudable that menopause and its multiple manifestations are finally being talked about more openly, we must be careful not to undo the good that has already been done: Instead of trying to impose one treatment model over another, wouldn’t it be great if women and their doctors were aware of all the therapeutic options and individualized the treatment to the particular needs of each woman who seeks their help? ?”, he asks.