Menopause was previously seen as a source of ageist shame, an unexploded bomb, or a suspicious parcel. But it is a natural phase which marks the end of childbearing years and, at last, we have the science and the knowledge to resolve a lot of the surrounding mental and physical health issues. Now is the time to embrace menopause, rather than fear it, and tackle the changes holistically.
As the actor Gillian Anderson – who wrestled with an early menopause herself – once said: “Perimenopause and menopause should be treated as the rites of passage they are and, if not celebrated, then at least accepted and acknowledged and honoured.” And the aftermath can be amazing; when hormones are steady, your moods stabilise and periods have gone for ever.
In the UK we are starting to care properly for women facing this massive life shift and empowering them to prioritise their health. Women know more about helpful lifestyle changes – the importance of exercise and diet, for example. In the past two years, GPs and patients have become much better informed about the science, too, which is why I’d encourage people to ignore menopause, and its dastardly little sister perimenopause, at their peril.
If you want to move into a better second half, action is required when the ovaries stop producing eggs and the hormones oestrogen and progesterone start to drain away. This happens at the average age of 51 in white women, and often younger for Asian and Black women, or those who experience early menopause. The chaos begins in perimenopause, usually in your 40s but younger for some, as oestrogen hits unpredictable highs and lows.
This is often when women experience sleeplessness, become forgetful, suffer heart palpitations and inexplicable bouts of irritation. Progesterone promotes calm and helps us sleep; with lowered oestrogen, serotonin (the “happy hormone”) decreases too. Just as the pressures of looking after elderly parents and irascible teenagers intensify, the hormones that have kept us on an even keel disappear, and prescriptions of antidepressants start to rise.
If hot flushes have not yet begun, puzzled women tend to blame themselves for emotional outbursts or failing concentration, rather than their hormones. Hot flushes are experienced by 85% of women, but around half get them before periods even stop. They vary in frequency and intensity, but a few women find themselves drenched in sweat.
Hot flushes are visible, and many women find them excruciating in public. But it is the invisible effects of failing oestrogen and progesterone, and testosterone (which is also a female hormone), that we need to understand, as they can contribute to increased risk of osteoporosis, type 2 diabetes and cardiovascular disease. Research is ongoing into the contribution of falling oestrogen levels on the risk of developing Alzheimer’s. Oestrogen helps maintain bone density and improves control of cholesterol, reducing the risk of fat building up in your arteries.
Women, and some trans men and non-binary people, need to seize this moment for a health upgrade, including simple changes such as taking more exercise, eating more green foods, and finding ways to destress. This is also the time to consider hormone replacement therapy (HRT), and find out which version could be the safest for you. When properly prescribed (and that may involve revisiting your GP to get the dose right, as every woman’s hormones are different), HRT does not just get rid of symptoms, but can provide long-term health protections.
Menopause has historically been seen as a loss of fertility – the word technically means 12 months after your last period – but we now understand it as a loss of hormones, which work in every part of your brain and body.
In the past few years, awareness and education have taken off in the UK. Along with the growing medical literature, in 2022, the Fawcett Society published Menopause and the Workplace, its survey of a sample of 4,000 UK women aged 45-55, which provides revelatory data. The issues most reported, apart from hot flushes, were related to mental health: 84% said they were sleepless or exhausted, 73% had brain fog – memory loss, difficulty concentrating – and 69% had experienced anxiety or depression. Migraine headaches can also increase in perimenopause, set off by hormonal fluctuations.
While this is a time of life when stresses can pile up, which may affect the ability to think clearly, women’s brains can be significantly affected by hormone loss, and so, often, is their confidence in holding down a job. Sudden memory blockages can be terrifying, if temporary – retrieving a name or a fact 10 minutes afterwards is no use if you’re in the middle of a meeting or PowerPoint. Although some men may suffer from memory problems in middle age, the impact on women seems to be more devastating: one in 10 women said they had left work because of menopause symptoms, and 28% had either reduced their hours at work or gone part time.
When we look at pre- and postmenopausal brain scans, the transition reveals temporary chaos, as the energy metabolism in the brain changes. The ever-plastic brain then relies more on blood flow to keep firing on all cylinders, compensating for the hormonal losses. But this takes time – hence the foggy midlife transition. The Weill Cornell neuroscientist Dr Lisa Mosconi explains these changes – and what to do about them – in her new book, The Menopause Brain. “I like to say menopause is a renovation project on the brain,” explains Mosconi. “The brain has all these neuronal connections that link to the ovaries but, with menopause, many aren’t needed and so can be discarded. And that leads to these brain changes which can also manifest as vulnerabilities.” But it’s important to see this as a transitional phase, Mosconi adds: the brain will “rewire, so a woman can get on with the next phase of her life”.
What about the body? In perimenopause, 44% of women surveyed suffered extra-heavy periods (underreported in traditional medical literature), the “perimenopausal tsunami” which can sometimes last for over a week. This can create major difficulties at work, since timings are unpredictable. If you’re, say, working in an Amazon warehouse or in an operating theatre, flooding periods are a nightmare.
Painful joints, arthritis and sports injuries often flare up in menopause, since oestrogen protects joints and decreases inflammation, and 67% of women surveyed reported joint pain. This can be helped by HRT – a study of almost 5,000 postmenopausal women showed knee osteoarthritis was reduced by a third during the treatment.
When I was helping to write questions for the Fawcett survey, we stuck in one on heart palpitations, since for me this had been the first unexplained sign of perimenopause – waking at 4am in pure panic every morning, my heart suddenly battering away. I went for an electrocardiogram and was told I was just fine, but “drinking too much coffee”. There was nothing on the NHS website back then connecting low hormones with palpitations. But the survey mirrored my own weird experience: 44% reported heart palpitations. Women were filling in the gaps in medical knowledge. It turns out that lower oestrogen levels can overstimulate your heart, making it beat up to 16 times more per minute. My own heart palpitations disappeared within a day of starting HRT.
Not enough is written about sex in menopause, and it turns out that 54% of women told the Fawcett survey they had “little or no interest in sex”. Topical vaginal oestrogen, in a dose small enough to be safe even for breast cancer patients, increases the general joy of sex. We are also learning about the vaginal microbiome, filled with good lactobacillus bacteria. Oestrogen helps prevent the urinary tract infections that affect 55% of women post menopause.
Next we come to a key part of menopause knowledge: as oestrogen and testosterone disappear, bone breakdown outpaces formation, and women can have bone loss of up to 20% in the 10 years following menopause. With one in three women suffering a fracture after 50, it’s worth addressing that with regular weight-bearing exercise, a good diet, and vitamin D. But for women with a family history of osteoporosis, HRT has been shown over two years to increase bone density by 3%, and as much as 7% in the spine. When you stop taking HRT, the beneficial effect on your bones begins to decrease straight away, but the NHS now says “there is no fixed limit on how long you can take HRT”.
There’s a lot going on in the menopause space, and knowledge is power. There is a school of thought that lifestyle changes will help most women pull through the hormonal desert after menopause. The reality on the ground is that most women this age are already struggling – around 70% of women over 50 in the UK are overweight or obese, with all the health risks that entails, and antidepressant use is highest for women aged 50-59. HRT can often be the first step up to a healthier life. For many, like me, it’s far more than that. Waking up every day with steady hormones, and no menopause symptoms whatsoever, is an extraordinary gift that this generation needs to use well.
• Kate Muir is the author of Everything You Need to Know About the Menopause (Gallery UK), and producer of two menopause documentaries including Sex, Myths and the Menopause for Channel 4
