There’s a meme featuring a confident, suave, smiling Henry Cavill – the actor best known for playing Superman – posing for photographers on the red carpet. Sneaking up behind him is wild-looking, maniacally gleeful 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’s about to get crash-tackled by a capricious and unpredictable force.
Is it a disease? Is it a normal biological event? No, it’s menopause!
Menopause is the curveball your ovaries pitch at you when you’re born that, 40 or 50 years later, you have to work out how to catch without dropping everything.
I count myself lucky that – thanks to the advice, humour and wisdom of my wonderful female friends – I’ve been given a glimpse of that curveball coming. Instead of being caught completely off-guard by the unexplained mood swings, exhaustion, anxiety and lack of motivation, I’m able to understand them a little more.
But despite being a science journalist for more than two decades, including writing extensively about women’s health and hormones, I’m as baffled as the next ovary-owner when it comes to my options at this time of life.
Ask 20 women what perimenopause is like and you’ll get 30 different answers: “One moment you’re fine, and then you want to kill someone”; “It didn’t really affect me”; “I’m crying, laughing, panicking, furious and sweaty”; “It feels like jogging in molasses”; “I asked my GP for a brain transplant for the forgetfulness”, for example.
Even the medical establishment can’t agree on the symptoms of perimenopause. “It’s a really, really critical question in menopause, which is what symptoms does it actually cause?”, says Prof Martha Hickey, director of the Women’s Gynaecology Research Centre at the Royal Women’s Hospital in Melbourne. “The list is getting longer.” The two (excellent) GPs I have discussed menopause with have used different symptom checklists, albeit covering similar territory.
That’s a problem for anyone experiencing menopause, and for their clinicians. Because while menopause is clearly not a disease – “it’s a biological life event; ageing is not a disease,” says Prof Davis, an endocrinologist and researcher at Monash University – it shouldn’t be dismissed as something people should just endure without help because it’s ‘natural’. “Osteoporosis is age-related bone loss, but we still treat it,” Davis says.
The question dominating the conversation about menopause is when and how should we treat perimenopausal symptoms? This debate is particularly pointed when it comes to menopausal hormone treatment, or MHT.
MHT – which works by boosting and stabilising the falling levels of oestrogen and progestin – has had quite the reputational rollercoaster over the past half century. In particular, the controversial and misreported 2003 Women’s Health Initiative study, which 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 unjustified.
“Over the 20 years there have been numerous papers that have been critical of the deficiencies of that study,” says Dr Silvia Rosevear, an obstetrician and gynaecologist 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 substantially since the study; which means 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 suggests doctors are still reluctant to prescribe MHT except for severe symptoms of menopause, preferring instead to tacitly endorse use of complementary and alternative therapies for which there is questionable evidence. Davis says we need new studies to give 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”.
That’s slowly changing and funding is starting to flow for those studies. But to properly assess the long-term risks and benefits of MHT, these studies will need to go for many years. So what do perimenopausal people do in the meantime, and whither MHT?
***
It’s a confusing time for menopause therapy. On one hand Davis’s study found that healthcare providers, while knowledgable about menopause, were uncertain about how to treat it, and limited MHT to people with severe symptoms that lifestyle changes and alternative therapies had failed to alleviate.
On the other hand many people experiencing perimenopausal symptoms are clamouring for a treatment that, both clinical and anecdotal evidence suggests, has a good chance of relieving those symptoms and helping them to feel “normal”.
“If a clinician commences MHT appropriately for moderate to severe symptoms, you are most likely to find that your patient comes back finding the symptoms have gone away completely and they feel normal,” Rosevear says. In her experience most people on MHT like being on it.
Between those two parties are gynaecologists, psychiatrists, psychologists, endocrinologists, feminist scholars and menopause specialists arguing about whether menopause is being over-medicalised, overdramatised and over-treated, or whether women experiencing perimenopause are having their symptoms minimised, mocked, under-recognised and under-treated.
“Broadly, we should be really thinking about this as a life phase 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 whole population of women experience illness and disability because of this natural life change is actually really unhelpful.”
Hickey, who co-authored a series of papers raising concerns about the medicalisation of menopause, worries that the public discourse about symptoms is scaring younger women, and feeding into the persistent damaging trope of older women being “washed up”. “I can think of nothing good about those two words – ‘old woman’,” Hickey says. “We have to change how we view ageing in women, and that includes not pathologising them.”
But Prof Jayashri Kulkarni, a psychiatrist and director of the HER Centre Australia at Monash University, thinks it’s patronising to suggest that women “just put on a happy face” and don’t talk about the challenges of menopause. “That’s not the era that we’re in.”
She sees the women in her clinic struggling with low mood, mood swings, anxiety, insomnia and other mental health impacts that they know 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 very distressed women who say, ‘There must be a solution, let’s work together and let’s get something to help me because I do have a million-dollar business that I want to get back to running,’” Kulkarni says. “If the problem is a mental health problem caused by hormone fluctuations, then hormone treatment is common sense.”
Generally, clinical guidelines agree with this. A review published last year by Davis and colleagues found most high-quality guidelines recognise that MHT can be used for both vasomotor symptoms – hot flushes and night sweats – and “mood disturbances”.
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 of comparing HRT or MHT with standard antidepressants, to see where the actual evidence lies,” Kulkarni says.
***
In the meantime, the growing public and private conversation about menopause suggests women are reclaiming this transition, celebrating its positives, commiserating and finding the humour about its negatives, and – most importantly – choosing how they want to experience it.
My choice – and one many women I speak to have chosen without regret – is to seek medical help to manage those psychological curveballs, so I can get on with the successful career I love and have worked hard to achieve. My GP is understanding and supportive, while also outlining 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 turbulent, devastating, dangerous period in human history, or being the parent of teenagers and daughter of elderly parents, or panicking about global heating. But I don’t think it’s just those.
Kulkarni says she always comes back to the individual woman’s voice. “The lived experience voice is what we need to really listen to, because she will tell you,” she says. “Most women I met don’t get to 45 without knowing a thing or two about themselves.”
