Medicalization of Menopause
Right off the bat, I feel that the terminology medicalization concurs up a negative outlook on menopause. It's as though menopause is a condition or a disease to be treated rather than a natural transition that a woman will go through in her lifetime, provided, of course, she lives to midlife.
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The term menopause - a pause or cessation of the menses - was finally coined by a French physician in 1821 (Singh, Kaur, Walia, 2002). Women’s reproductive health and menopause became the subject of great controversy by the Victorian era leading physicians to deduce that there was a link between the womb and the brain, thereby "making all women susceptible to insanity" (Ageless Restoration, N.D. The History of Menopause).
The term midlife, ironically, as well as the years beyond post menopause are referred to, according to Ayurveda practitioners, as the age of wisdom. Tell me, what was wise about linking menopause with insanity and locking women up with "climateric insanity" or removing her ovaries to prevent onsent extreme neurosis?
We've jumped leaps and bounds since that time of very little understanding about hormones, but our western culture lags behind in its attitdue and outlook on midlife transition. Until recent, far too much negativity surrounded perimenopause and menopause experience — from the media to the medical community - casting a shadow of misunderstanding, fear and confusion on what should be an important and natural transition in a woman's life.
Leading researchers and experts in the field have worked hard in the past few decade to change the narrative. The paradigm shift is upon us as we see the rise in menopause specific topics in fields related to holistic health, including nutrition, exercise, and stress management. As well, we have greatly advanced our knowledge and understanding of hormone replacement therapy (HRT) including bioidentical hormone treatments. But until you inquire with a knowledgeable medical practioner or educated healthcare provider, or take a deeper dive on your own, medical treatment for symptom management often remains clouded, even daunting for many women.
I chose to address this particular subject because of a personal experience I encountered with a physician. Without a doubt, this life-altering experience, subconsciously or consciously, set me on my course to pursue studies in the field of menopause. It happened when I was 46. My menses were like clockwork. Predictable and on time, almost to the hour. There was no concerns to be noted and perimenopause seemed so far into the distant future it was furthest from my mind. My visit to the clinic was nothing to do with hormones and all to do with intenstinal pain and ongoing discomfort.
However, my first introduction to the notion that I might need midlife support was from this young male locum who diagnosed my gut health as depression and insisted I be prescribed antidepressants while completely ignoring my abdominal pain. Sadly, this young lad looked strictly at my age and concluded that since his mother had been prescribed medication at about the same age that I was at the time, I should too. I was flabberghasted, annoyed and made it very apparent how disappointed I was in him and his perception of women's health, noting that he made no attempt to examine my abdomin to draw any other conclusion to my health concern.
After a few years of further analysis it turned out, I had mesenteric lymphadenitis, an inflammation of the lymph nodes in the mesentery - a fold of membrane that attaches the intestine to the abdominal wall and holds it in place. Nothing to do with menopause and all to do with a hereditary condition that, had I not advocated on, could have resulted in a very invasive surgery. I addressed my gut health with a nutritionist and implemented a holistic approach to manage it. Fortunately, I was also able to lean in on my 30-year side hustle as a fitness instructor and yoga teacher, as well as my passion for health and nutrition to develop an individualized strategy.
Imagine if I turned to medication instead? Unbeknownst to me, before I began my menopause doula studies and delved into the research, antidepressants are commonly prescribed along with estrogen and progesterone to address menopause symptoms. Nevertheless, I struggled at the time to find the correlation between severe abdominal pain and perimenopause.
I did an internet search on the title “The Medicalization of Menopause” and the first reference found was a powerful article written by Pallabi Munsi, CNN, June 17, 2022, titled “Menopause is not a disease. Experts call for new narrative for this natural stage of a woman's life.” The article is focused on the positive aspects of menopause from the standpoint that advocacy and lobbying for better support and research is needed.
I will hang my entire doula business on the opening paragraph of this article,
Women are not a monolith, their experiences of menopause are not all negative, and this stage of life should not be medicalized.
Munsi, 2017
Hormone replacement therapy (HRT) is, in fact, a medical treatment to replace the lost hormones during menopause and, in turn, ease symptoms, which are often experienced as moderate to severe for between 16 and 40 percent of women (Munsi, 2017).
But leading expert Martha Hickey of the Royal Women's Hospital in Victoria, Australia notes that while HRT is important for addressing those severe symptoms, "medicalization may increase women's anxiety and apprehension about this natural life stage."
This is worrisome. If a physician encourages a woman to go on HRT without thoroughly understanding her signs and symptoms and just blankets the menopause transition into a single diagnosis for all by prescribing hormone replacement, what service are we doing to the community? Is it a service to the patient or being served by the pharmaceutical industry? Concluding that a woman’s natural progression through this stage needs to be treated with medication amounts to a huge profit for the drug companies to say the very least and, as Hickey attests, reduces her ability to cope with menopause as a “normal part of life and even can render her fearful," (Munsi, 2017).
Fearful indeed when considering the Women’s Health Initiative l(WHI) launched in 1991 by the U.S. National Institutes of Health (NIH). The WHI included a clinical trial to evaluate the risks and benefits of HRT, administered orally, and to evaluate the impact on heart disease, breast cancer, colorectal cancer, and bone fractures.
The clinical trials were conducted on 16,000 post-menopausal women between the ages of 50 to 79, with no hysterectomy and who took an oral dose daily - either a combination of estrogen (equine conjugated estrogens and progestin), or a placebo. The second part of the study involved more than 10,000 women who had a hysterectomy and who took estrogen pills alone or a placebo.
In July 2002, WHI ended the estrogen and progestin HRT trails prematurely because of an independent monitoring board had concluded that there were more risks than benefits among this group using the combined HRT. As well, the incidence of disease per 10,000 women on combined HRT were on the rise, including coronary heart disease, stroke, rate of total blood clots in the lungs and legs, invasive breast cancer, and colorectal cancer. Bone fractures declined, (Health Canada, 2004).
However, the study made serious headlines resulting in a negative narrative around HRT and possibly causing many women to conclude that HRT is risky business. We have come a long way since that study with new findings in the field of HRT that conclude the benefits can outweigh the risks. Still, the literature from Health Canada, dating as far back as 2004, have made clear, "a decision to use HRT should be based on particular needs and health of the patient and after a careful medical evaluation." In other words, talk to a physician.
Here’s the conundrum, a doctor may not be spending time on research to know if HRT is right for their patient. In fact, in a recent survey, nine percent (9%) of general practitioners (GPs) in the United States indicated they feel qualified to support women in their menopause transition (Dr. Fiona Lovely, Not Your Mother’s Menopause podcast, Ep. 102). Only nine percent!
So, what can women do to get the support and the answers she needs to know whether HRT is right for her and to feel confident that she is being properly assessed as a candidate for HRT and not just another cash grab for pharmaceuticals?
Dr. Sarah Rice, MD in her presentation, Know Before You Say No: Hormone Replacement Therapy & Menopause (2019), attests that HRT can be a confusing topic to navigate, noting that knowing whether to prescribe hormones to women has been a controversial topic for decades. She describes it as the “pendulum effect,” a conversation that swings between risk and benefit.
Prior to the 1960s, menopause was viewed as a normal life transition that women ought to get on with. But then oral estrogen medication was introduced and regarded as a solution for solving many problems such as hot flashes and mood swings. That was until widespread use began to reveal adverse effects, including blood clotting and uterine and breast cancers. Over time, science learned that when taken with progesterone, HRT did not cause uterine cancer (Rice, 2019). Breast cancer incidents, however, raised alarm bells for women and their doctors.
Rice shares that five to 10 percent of women are on HRT, a very small percentage, most notably because doctors are following the guidelines of the 2002 WHI study. A study that generalized all women even though the clinical trials involved many women who had long since gone without hormones and were well into their post-menopause years.
We are at the dawn of a new era of how we think, talk and act about menopause and it comes on the heels of many women, two of which are mentioned in this article, who are advocating for broader access to better, more current resources on the topic. Leading experts want to debunk myths associated with HRT, and that menopause should not always be evaluated as being a time to medicate women. Far from it, HRT is a normal and often necessary solution for addressing some symptoms and improving quality of life for many women and that the midlife transition is normal, natural and to be celebrated rather than shamed.
Alternatively, holistic treatments such as following Ayurveda lifestyles choices, can give women a sense of control over their symptoms using a natural approach, Ayurveda, known as the science of life, has a wide variety of tools and treatments for restoring balance during menopause, which is described as the Vata time of life (Leshem, N.D.). By bringing balance to the imbalances of the Vata through diet, herbal remedies and daily habits, to name a few, this will help pacify the Vata dosha, thereby enabling women to naturally manage symptoms without medication.
Knowing which strategy to follow takes time, energy and research, not all of which women have at their disposal. There is a plethora of information to turn to from podcasts and YouTube videos, to online medical resources and journals.
A menopause doula, also referred to as a menopause support practitioner, has a deepened knowledge about the physiological changes and cognitive effects of midlife. We research leading experts in the field of women’s health to gather options for midlife well-being, including medical possibilities and holistic strategies. The doula’s role is to bring this all together for clients who may have many questions or concerns about their midlife change and to bring about a sense of empowerment and a sense of ease without the negative connotations that surround menopause and medicalization.
Disclaimer: This original paper was prepared as an assignment for the Menopause Doula certification training with the Doula Training Centre based in Toronto, Canada. It has since been revised to add more references to well-researched material including medical journals. The views presented are mine but are supported with references and attributed accordingly. The original article had been reviewed by the DTC lead instructor.
It should also be noted that medicalization is not to be confused with a medical menopause or medically induced menopause. Medicalization refers to hormone replacement theory. It should also be noted that this article is not anti-HRT. There are many HRT options including bioidentical hormones to restore imbalances and improve a woman's quality of life. The decision to pursue HRT is entirely at the discretion of the client. Women are best served by the healthcare industry if she is empowered and supported to make informed decisions. Most GPs are not well-versed and current on menopause health.
