Inability to sleep, painful sex, and hot flushes There is a proven remedy for some of the worst symptoms of menopause. Why aren’t more women given the chance?
Many of my acquaintances, especially women in their early 50s, have been experiencing unanticipated suffering for the past two to three years. Even though they were aware of the impending menopause as the source of their misery, it was not any simpler for them to choose how to address it due to their shared experience.
The symptoms they had were many and bothersome. A few lost hours of sleep each night, disturbances that sapped their energy and attitude, and the enormous amounts of goodwill required to parent and partner. One of my friends had to miss work due to menstrual periods that lasted for weeks at a time. Another acquaintance experienced up to 10 hot flashes per day, while a third was so worried by her irrational outbursts their severity was unfamiliar to her—that she sat her 12-year-old son down to explain that she was not feeling well and that she was going through menopause. Another had constant dryness in her skin, nails, throat, and even eyes.
I experienced the similar stage of adjustment while the previous year. The physiologically tumultuous interval preceding a woman’s final period, when her reproductive cycle makes its final, shaky runs, is known medically as perimenopause. The change, which lasts four years on average, often begins when women are in their late 40s, when the quantity of egg-producing sacs in the ovaries begins to decline. In response, several hormones, including progesterone and oestrogen, fluctuate irregularly as their normal signalling mechanisms break down. A woman’s menstruation may be either thicker or lighter than usual during this time.
Women are more likely to have severe depression symptoms as the levels of oestrogen, a key chemical messenger, decline. Bone loss quickens. In women who have a hereditary predisposition for Alzheimer’s disease, the earliest plaques are thought to develop in the brain during this period. As the body struggles to hang on to the oestrogen that abdominal fat cells make, women either gain weight fast or see it move to their middles. Similar to a machine that originally functioned on gas and is now striving to adapt to solar power, the body is temporarily in a stage of adjustment and even reinvention.
My period would go away for weeks at a time before coming back for no apparent reason, and this is how I knew I was in perimenopause. I had severe abdomen pain in the weeks before my period, and I decided to get an ultrasound to be sure I didn’t have a cyst that was constantly expanding. Hot flashes would occasionally wake me up during the night and send me right into the types of nervous thoughts that come to life in the wee hours of the morning. Even more upsetting was the sharp decline in my memory.
I was always forgetting what I said just after I said it and was constantly fumbling for words or names.a change that was noticeable enough that my friends and family mentioned it. I was plagued by a discussion I had with a writer I respected who left the field quite early. I questioned her why at a small gathering. She answered me without hesitation, “Menopause.” “I was at a loss for words.”
It implies that our culture has a high threshold for the pain of women. It is not thought to be significant.
According to my friends’ accounts of their most recent doctor appointments, there was no evident treatment for these problems. One of my friends’ gynaecologists dismissed her complaint that she was waking up once per night with hot flashes, saying it wasn’t really worth talking about. My coworker was given a prescription for bee-pollen extract to help with her hot flashes; she took it faithfully but had no relief. Another acquaintance who had worries about decreased libido and dry vaginal passages could sense that her physician felt awkward discussing these topics. She said, “I thought, Hey, aren’t you a vagina doctor. (I have sex with that thing!)
I was inspired by their physicians’ reactions to consider a thought experiment that, although not precisely novel, is still interesting. Imagine if over several years, a sizable section of the male population began to frequently wake up in the middle of the night soaked in perspiration. Take into account the fact that these men routinely tore off their coats or hoodies during meetings and excused themselves to take a breather outside a window.
They were likely weary, had low morale, and stumbled into work. Imagine that many of them started to experience discomfort during sexual activity, became more prone to urinary tract infections, had dryness and irritation in their penises, and even began to exhibit what their physicians referred to as “atrophy” in their penises.
Imagine if many of their physicians had little to no training in how to treat these symptoms and, when the matter came up, occasionally informed their patients that this process was normal, as if that should be comforting enough.
Imagine if there was a cure for all these symptoms that medical professionals frequently ignored. The scenario paints a depressingly true picture of menopause care for women even though it seems implausible. Menopausal hormone therapy is a medication that alleviates hot flashes, sleep disturbance, and maybe depression as well as hurting joints. It reduces the chance of developing diabetes and guards against osteoporosis.
Additionally, it aids in the prevention and treatment of menopausal genitourinary syndrome, a group of symptoms that affects almost half of postmenopausal women and includes discomfort during sex and urinary tract infections.
In the past, menopausal hormone therapy was the most often prescribed medication in the US. Around 15 million women a year were being prescribed it in the late 1990s. However, a single research from 2002, with a flawed design, discovered associations between hormone treatment and increased health risks for women of all ages.
Fear took hold, and within a year, the number of prescriptions fell drastically. Hormone treatment and other drugs used to treat severe pain have dangers, to be sure, but several studies conducted since 2002 have shown that for healthy women under 60 who are bothered by hot flashes, the advantages of using hormones exceed the risks. However, the treatment’s reputation has never fully recovered, and the results have had a significant impact.
The sheer number of humiliations that have been unnecessarily endured over the past 20 years is painful to think about: the inconvenient trips to the restroom, the loss of sleep, the promotions that seemed out of reach, the changing of all those wet sheets in the early morning, and the depression that has hung over the days of so many women.
Menopausal symptoms are experienced by about 85% of women. Rebecca Thurston, a professor of psychiatry at the University of Pittsburgh who specialises in menopause, considers the undertreatment of menopausal women to be one of medicine’s worst blind spots. According to Thurston, “it shows that we have a high cultural tolerance for women’s pain.” It isn’t seen to be important.
Although hormone treatment, the single greatest choice for women, has a past that highlights the difficulties the medical culture has in keeping up with research. It also symbolises a missed chance to better the lives of women.
Robert Wilson, a physician, argued in 1966 that “every woman has the right, indeed the obligation, to resist the chemical castration that befalls her during her middle years.” The first hormone treatment medication was licenced by the U.S. Food and Drug Administration in 1942, but Wilson’s best-selling book.
A type of historical turning point, “Feminine Forever” marked the beginning of a contentious connection between women and hormone treatment. In that it acknowledged women’s priority for sexual pleasure, the book was daring for its time. However, it also showed open disdain for the ageing bodies of women and promoted the use of hormones to fulfil male sexual fantasies: Women using hormones would be “more generous” sexually and “easier to live with.” Even cheating would be less likely. Premarin, a combination of oestrogens made from pregnant mares’ urine, became the fifth-most-prescribed medication in the US within ten years of the book’s release. (Decades later, it came to light that Wilson had received funds from the drug maker that distributed Premarin.)
Alarming studies halted the drug’s ascent to popularity in 1975. Endometrial cancer risk was dramatically elevated in menopausal women using oestrogen. Researchers quickly discovered that by prescribing progesterone, a hormone that slows the proliferation of cells in the uterine lining, they could almost remove the elevated risk, which led to a decline in prescriptions. Over the following two decades, the number of women using hormones increased once more, especially as more doctors began to think that oestrogen shielded women from cardiovascular disease. Until menopause, when their risk for cardiovascular disease swiftly increased to reach that of age-matched men, women were believed to have better heart health than males.
Those who used hormones had a 50% reduced risk of heart disease than those who did not, according to an observational study of 48,000 postmenopausal nurses conducted in 1991. The FDA received a recommendation from an advisory group the same year that “nearly all” menopausal women would benefit from hormone treatment. Hadine Joffe, a professor of psychiatry at Harvard Medical School who specialises in menopause and mood problems, recalls that when she first began, she had a slide that stated that oestrogen should be present in the water. “We assumed it was similar to fluoride,”
Diverse feminist viewpoints exist on hormone treatment. Some regarded it as a chance for women to take control of their own bodies, while others saw it as the needless medicalization of a normal process, or as a useless product made to keep women sexually accessible and aesthetically pleasing. Many felt that its safety was the problem: Without enough research, hormone treatment had previously been heavily sold to women in the 1960s, and many proponents of women’s health thought that the past was repeating itself. The trials that proved its health advantages were observational, which means that the participants were not given a medicine or a placebo at random.
That made it impossible to determine whether hormones were making women healthier or if healthier women were selecting them. Women’s health groups urged the National Institutes of Health to conduct lengthy, randomised, controlled trials to definitively establish whether hormones enhanced women’s cardiovascular health, with the backing of the feminist congressman Patricia Schroeder.
The Women’s Health Initiative, which continues to be the largest single-gender randomised clinical trial in history, was launched in 1991 by Bernadine Healy, the first woman to lead the National Institutes of Health. Its goal is to examine the health outcomes of 160,000 postmenopausal women over a 15-year period in some cases. The hormone experiment, one component of its research, would ultimately cost $260 million. About eight years were anticipated for the hormone experiment, however in June 2002,
The trial’s one arm, in which women received a combination of oestrogen and progestin, a synthetic type of progesterone, was abruptly terminated, according to news that quickly circulated. Reproductive doctor Nanette Santoro told me she was so curious about why the research was stopped that she could hardly sleep. She had great hopes for hormones’ positive effects on heart health. She remembers asking her spouse, “What do you think?” repeatedly in the middle of the night. Unfortunately, her husband, an optometrist, was unable to adequately explain the issue.
Since I first started, I had a slide that recommended adding oestrogen to the water. We believed it to be similar to uranium.
Delgado had to wait only a little while. A week before the study’s findings would be made publicly available for doctors to read and interpret, the steering committee of the Women’s Health Initiative organised a significant news conference on July 9 in the ballroom of the National Press Club in Washington to announce both the study’s termination and its conclusions. The research identified both negative impacts and positive effects of hormone therapy, but “the negative consequences surpass and outnumber the positive effects,” said Jaques Rossouw, an epidemiologist and the interim director of the W.H.I.
In contrast to what many people had hoped, the trial, according to Rossouw, revealed that hormone therapy carried a minor but statistically significant increased risk of cardiac events, strokes, and clots, as well as a higher chance of breast cancer. He stated that the increased risk of breast cancer for a specific woman was “extremely modest,” or more accurately, “less than a tenth of 1 percent every year.”
What followed was a lesson in bad communication that would have far-reaching effects for decades. Researchers and news presenters presented the data in a way that sparked concern throughout the course of the following several weeks.
Sylvia Wassertheil-Smoller, an epidemiologist and one of the leading investigators for the W.H.I., was interviewed by Ann Curry on the “Today” show. What rendered the study’s continuation unethical? Curry questioned her. Well, in the interest of safety, we discovered there was an extra risk of breast cancer, Wassertheil-Smoller retorted. Curry gave some shocking statistics, saying: “And to be really explicit here, you actually discovered that heart disease, the risk jumped by 29%. The likelihood of having a stroke increased by 41%. The chance of blood clots increased by double. The risk of invasive breast cancer rose by 26%.All of those facts were true, but they were hard to understand by laypeople and consequently sounded more ominous than necessary.
For instance, the rise in the risk of breast cancer might be explained as follows: Between the ages of 50 and 60, a woman’s probability of developing breast cancer is around 2.33 percent. That danger would rise to 2.94 percent if it were raised by 26%. (Smoking, in comparison, doubles the chance of developing cancer.) Another way to look at it is that eight more women will develop breast cancer for every 10,000 women who use hormones. Setting that danger and others in perspective is crucial, according to Avrum Bluming, a co-author of the 2018 book “Estrogen Matters.” “
According to reports, postmenopausal women using oestrogen run the risk of developing pulmonary embolism. “But what exactly is risk? Embolization risk is comparable to that of using oral contraceptives or becoming pregnant.
The design of the research had what would later be recognised as a serious weakness. Since these conditions may not manifest until women are in their 70s or 80s, W.H.I. researchers wanted to be able to monitor health outcomes, such as how many women ended up suffering strokes, heart attacks, or cancer. Only 812 years were allotted for the research to last. As a result, they favoured recruiting ladies who were 60 years old or older.
Due to this decision, women in their 50s, who often experience more menopausal symptoms and tend to be healthier, were underrepresented in the research. Rossouw began the news conference by stating that the findings had “wide relevance,” highlighting the fact that the experiment revealed no variation in risk by age. Years would pass before scientists realised how incorrect that was.
One of several media events that led to a flurry of terrified phone calls from women to their physicians was the “Today” piece. Mary Jane Minkin, an OB-GYN in practise and a clinical professor at Yale School of Medicine, told me she was exasperated because she couldn’t reassure her patients—if reassurance was even necessary, as she later came to believe it was because the results weren’t yet made available to the general public. Minkin recalls, “I remember where I was when John Kennedy was shot. “I recall being there on September 11th. I also recall where I was when the W.H.I. results were announced. That day, I received more calls than at any other time in my life.
On the day of the “Today” interview, she estimates that she spoke to at least 50 patients, but she also realises that a great number of others either chose not to call or abruptly stopped taking their hormone medication.
Insurance claims for hormone treatment decreased by 30% after six months, and by 2009, they had decreased by more than 70%. One of the study’s principal scientists, JoAnn Manson, is the head of Brigham and Women’s Hospital’s division of preventive medicine. She called the consequences “the most profound sea change in clinical medicine that I have ever seen.” The reaction was described as “near panic” by Newsweek.
Hormone treatment is harmful for women, was the word that spread back then and has lasted ever since. This message was based on a distorted interpretation of the studies.
It is now understood that hormone treatment encompasses a far more complex and comforting picture. The Mayo Clinic Center for Women’s Health director, Stephanie Faubion, often responds the same way when patients say they’ve heard hormones are harmful. Faubion said me, “I sigh. She is aware that she has to clarify a lot of things.
The first thing patients typically ask Faubion, who is also the medical director of the North American Menopausal Society (NAMS), an association of menopause experts, is about the danger of breast cancer. In the W.H.I. experiment, she says, women who received a combination of oestrogen and progestin observed an elevated risk appear only after five years on hormones; even after 20 years, the death rate of women on those hormones was no greater than that of the control group. (Some experts are optimistic that new hormone treatment formulations will reduce the risk of breast cancer. A significant observational study that was released last year made this claim, although it was just suggestive.)
The most important lesson learned from the past 20 years of study is that age matters: Hormone treatment is advised for women who experience early menopause before age 45 since, if they don’t take hormones up to the traditional age of menopause, they run a higher risk of developing osteoporosis. Life-threatening incidents like clots or stroke are uncommon in healthy women in their 50s, so the elevated risks from hormone treatment are likewise rather minimal. Women under 60 in the experiment showed no heightened risk of heart disease, according to Manson and Rossouw’s reanalysis of the W.H.I. data.
“I recall being in that location when John Kennedy was killed.” I can very clearly recall where I was on September 11, 2001. I also recall where I was when the W.H.I. results were released.
However, the results showed a higher risk for women who start hormone therapy after the age of 60. Manson’s analyzes showed that women had a slightly higher risk of coronary artery disease if they started taking hormones after age 60, and a significantly higher risk if they started after age 60. 70 years old.
The researchers hypothesized that hormones might work more efficiently over a period of time, maintaining the well-being of systems that are still healthy but accelerating damage to those already in decline. (Studies have not yet been conducted on women starting at age 50 and continuing continuously through age 60.)
Researchers also have a better understanding of the benefits of hormone therapy.Although W.H.I. When the results were released, the data showed at least one significant improvement over hormone therapy: women had 24 percent fewer fractures. Since then, more positive results have surfaced.For example, it was found that the incidence of diabetes was 20% lower in women taking hormones than in women taking a placebo. at W.H.I.
In 2007,hysterectomized women 30 percent of American women in their 60s received estrogen alone because they did not need progesterone to protect against endometrial cancer, and this group had lower breast cancer rates than the placebo group.”Even so,” write Bluming and co-author Carol Tavris in Estrogen Matters, “we have not seen an NIH press conference called to reassure women of the benefits of estrogen exist from.
The positive reports about hormone therapy for women in their 50s started rolling in as early as 2003 and have never really slowed down. But the revelations leaked out, and no story has garnered as much publicity or momentum as W.H.I. A press conference.In 2016, Manson attempted to correct this in an article in the New England Journal of Medicine, using an explicit course correction from W.H.I. the results were for women in their 40s and 50s. Since publishing this article, she feels that mindsets have changed, but too slowly.Manson speaks frequently to the press, and over the years — and accumulating data to suggest the risks weren’t as alarming as they first were — his growing frustration can almost be traced back to his public statements.
“Women who are good candidates are denied hormone therapy to treat their symptoms,” she told me in a recent interview. She was dismayed that some doctors were not offering relief to women in their 50s based on Study which had a median age of 63 and in which risk assessments were largely based on women in the 1960s. “We’re literally talking about tens of thousands of doctors who are reluctant to prescribe hormones.”
Despite the new information, doctors continue to find themselves in a difficult situation.By relying on WHI, they benefit from a landmark study, but one that focused primarily on older women and used higher doses and different hormone formulations than those most commonly prescribed today. The new formulations better mimic the natural hormones found in the female body.There are also new delivery methods: Taking the hormone with a transdermal patch instead of a pill allows the drug to bypass the liver, which appears to eliminate the risk of blood clots.
But the studies supporting the safety of the new options are observational; they have not been studied in long-term randomized controlled trials.
The NAMS guidelines emphasize that physicians should base recommendations for hormone therapy on each patient’s personal medical history and risk factors. Many women under 60 or within 10 years of menopause already have a higher baseline risk of chronic disease because they are already trying to manage obesity, high blood pressure, diabetes, or high cholesterol.
However, Faubion says that “there are very few women who have absolute contraindications,” meaning that hormones are out of the question for them.Women most at risk of using hormones are women who have ever had a heart attack, breast cancer, stroke or blood clots, or women with a number of serious health conditions. “For everyone else,” Faubion says, “the decision will depend on the severity of the symptoms, as well as personal preference and risk tolerance.”
For high-risk women, there are other sources of relief: Paroxetine, a selective serotonin reuptake inhibitor, is approved for relieving hot flashes, although it’s not as effective as hormone therapy. Cognitive-behavioral therapy has also been shown to help women realize just how bothered they are by hot flashes. Menopause doctors await the F.D.A.A review of the drug is due to be approved this month: a non-hormonal drug that targets a complex of neurons thought to be involved in triggering hot flashes.
Discussing the risks and benefits of these different treatments often takes longer than the typical 15 minutes that health insurance usually pays for a routine doctor’s visit.
“If you weren’t my chairman, I would be blamed for not doing things that make more money, like childbirth and IVF.says Santoro, now chief of the Department of Obstetrics and Gynecology at the University of Colorado School of Medicine, who often deals with complex cases in postmenopausal women. “General practitioners usually don’t want to deal with this, because who wants to have a 45-minute conversation with someone about the risks and benefits of hormone therapy? Because it’s nuanced and complicated.”
Some of this conversation needs to make it clear that hormones aren’t a panacea. “Ifwomen come to me and tell me they’re taking hormones for anti-aging or general prophylaxis, or because they have a vague feeling it will return them to their pre-menopausal state — and they won’t even be hot — I say, “Hormone therapy does not rejuvenate and should not be used for that purpose,” says Faubion.
Too many physicians are unwilling to analyze these complex pros and cons even if they wanted to. Medical schools were quick to abandon menopausal education in response to the GHI.”No treatment was considered safe and effective, so they decided there was nothing to teach,” says Minkin, a Yale obstetrician.
Approximately half of all practicing gynecologists are under the age of 50, which means they complete their W.H.I. try and may never have received any meaningful education about menopause.”When my younger partners see menopausal patients, they refer them to me,” says Audrey Buxbaum, a 60-year-old gynecologist who practices in New York City. Buxbaum, like many doctors in his 50s, prescribed hormone therapy for menopause before the WHI. and it never stopped.