Opinion | How to Have a Feminist Menopause
Menopause has long been treated as a pre-death, a metamorphosis from a woman to a crone with her exit ticket already punched. This is because a woman’s worth was measured by her reproductive ability and by extension her femininity, as defined by a narrow, misogynistic standard.
The medical language of menopause today reflects that trope. For example, it’s common to say that in menopause the ovarian supply of eggs has been “exhausted,” but the concept of failure or fatigue is never applied to the penis — otherwise the term would be “penile failure” or “penile exhaustion,” rather than the more euphemistic “erectile dysfunction.”
Many young girls who received no information about puberty woke up one morning covered in blood from their first period, terrified they were dying. This was my own mother’s experience in the 1940s. For many women, menopause is a mirror of that — an assortment of unexpected symptoms they may be embarrassed to discuss openly.
We can do better by embracing the idea of a feminist menopause. Women deserve to experience these changes in their bodies equipped with facts and free of fear, shame or secrecy. A feminist menopause rejects the patriarchal notion that a woman’s worth is tied to her ovarian function and that the end of her reproductive life represents the end of her productive life. The medical community should provide women with far more information about how their hormones change in middle life, what they should expect and what can be addressed with medical treatment.
The word “menopause” comes from the Greek words for month and cessation, referring to the final menstrual period. In reality menopause is a transition akin to puberty, a procession of hormonal changes that leads from one biological phase of life to another. Menopause is a consequence of changes in both the ovaries and the brain. Women are born with a finite number of eggs, or oocytes, and decades of ovulation cause the supply and quality of oocytes to decrease, affecting the production of estrogens and progesterone as well as the brain’s response to these hormones. Medically, this time is known as the menopause transition. These hormonal changes often begin in a woman’s mid-40s, can last for years and typically produce symptoms such as menstrual irregularities, hot flushes (or flashes), vaginal dryness, depression, difficulty sleeping and brain fog.
Eventually, a woman has her last menstrual period — an event that’s generally considered the hallmark of menopause. But in fact, that event plays a relatively small role in the process. The final menstrual period can be important for knowing when to stop contraception, and its arrival can determine how physicians investigate abnormal menstrual bleeding. But what really matters for the day-to-day lives of people with ovaries starts years before the final menstrual period and lasts a lifetime, as the hormonal changes of the transition can increase women’s risk of conditions such as heart disease, stroke, dementia and osteoporosis. Of course, women may also be relieved at the end of menstrual cramps and heavy or irregular periods, or fears of unexpected pregnancies.
But many women are unaware of the basic biology of menopause and don’t know what to expect when they are no longer expecting a regular period. They may worry that a hot-flush inferno will leave them dripping with sweat at work, or dread addressing the issue of vaginal dryness with their sexual partner. What woman wants to admit that she now plays for a team that society has deemed irrelevant? Throw in the fact that much of menopause happens “down there,” and the resulting information void is unsurprising.
The ramifications of both this lack of information and the taboos around menopause are significant. Women may not discuss bothersome symptoms with a medical provider, erroneously assuming there are no safe, effective therapies. As a physician and author who writes and speaks frequently about women’s health, I’ve heard from many women that they felt their doctors could not or would not answer their questions about changes in their bodies. They have described being dismissed with blank stares or platitudes such as “It isn’t that bad” or “That’s just part of being a woman,” or told to come back when they are “really in menopause.” Why does no one ever say that erectile dysfunction isn’t that bad, or that it’s just part of being a man?
So profound is the knowledge gap that many women aren’t sure of the markers of menopause. Are they in it or done with it? This confusion can be traced back to the misdirected emphasis on the last menstrual period as well as the confusing terminology: The menopause transition, the time leading up to the final menstrual period, is often called premenopause; perimenopause describes the menopause transition plus the first year without a period. But there is no last call announcing the final menstrual period, so a woman is considered to be postmenopausal (or sometimes just “in menopause”) once a year has passed without a period. Since that last period doesn’t typically affect how we manage most of the menopause experience, it’s common to describe the entire process as menopause.
The reliance on missed periods for a diagnosis can be frustrating, so it’s no surprise that an assortment of companies now sell tests that promise to tell a woman where she is in her menopausal transition. But the truth is that no single blood, saliva or urine test can accurately determine whether or not a woman is close to her final menstrual period. The hormonal chaos of the menopause transition is so great that one month hormone levels could suggest menopause, and two months later they could be normal. These tests are largely meaningless because they provide a snapshot of hormones that change constantly, and therapy for troubling symptoms doesn’t depend on hormone levels. These tests merely take advantage of the gaps in medicine for profit.
There are proven, effective treatments for many symptoms of menopause. Perhaps the most well known is menopausal hormone therapy, or M.H.T., which is often called hormone replacement therapy (a phrase that should be discouraged, as it suggests an abnormality where none exists). M.H.T. is typically a form of estrogen, and women with a uterus will also need a progesterone or a progesterone-like hormone to protect against an increased risk of cancer. Despite data that tells us that M.H.T. is low risk for most women who start before the age of 60, there is often a reluctance among medical providers to prescribe it and among women to take it.
The past two decades have seen a wealth of exciting new menopause research. Scientists have learned that some antidepressants and other treatments can reduce hot flushes. Hormonal treatments can help genitourinary symptoms (vaginal dryness and pain during sex) of menopause. Research has shown that brain fog is real — and temporary. We are in an era of a medical menopause renaissance, and yet many women are not benefiting from it.
As a result, women seeking information may turn to sources that appear to be knowledgeable, but that also, coincidentally, often offer products — many untested and even harmful — to treat the symptoms of menopause. Hence the growing market for over-the-counter supplements that are marketed to menopausal women and promise relief for symptoms like hot flashes and sleep difficulties, many with very little supporting data. In the United States, supplements are not tested for safety, and some “menopause supplements” contain ingredients that are either not proven to help with symptoms or may cause actual harm.
There is also a growing market for compounded, so-called bioidentical hormones. These products aren’t subject to adequate regulatory oversight, and a recent report from the National Academies of Sciences, Engineering and Medicine concluded that there is limited information about the safety and effectiveness of these products. Personally, I only trust my health to an estrogen that’s approved by the Food and Drug Administration. I want to know exactly what my body is absorbing, and I simply can’t have that precision and safety with a compounded product. That many women feel more comfortable using products that are not recommended by menopause experts says as much about the communication gaps in medicine as it does about those who prey upon women. These gaps are especially troubling given that the science is not lacking.
Western medicine has already found ways to educate patients about significant hormonal changes. After all, pediatricians routinely discuss puberty with their patients at annual checkups and tailor their conversations to age and symptoms. Doctors should have similar discussions with women in their late 30s, so that their patients are prepared. Menstrual irregularities, hot flushes, depression and brain fog can start several years before the final menstrual period, which typically arrives in a woman’s early 50s. These conversations can also spur women to take steps to protect their health in menopause by increasing exercise and ensuring adequate calcium intake, for example.
For too long, women have had to fight to learn the facts about menopause, to take up arms for their health and their sanity. Speaking up about the concerns of a female body as it ages should be considered normal, not brave.
Menopause isn’t a death sentence. We must dispel with the misogynistic notion that a woman’s worth is tied to her estrogen and her age. Instead we should think of menopause as a new phase of life and the last period as just one landmark along the way. When women need help navigating their symptoms and the health implications of menopause, clear, non-sexist information and proven therapies should be available. At some point getting help for menopause won’t require an act of feminism, but that will never happen if we stay silent.
Jen Gunter (@DrJenGunter) is an obstetrician and gynecologist and the author of “The Menopause Manifesto” and “The Vagina Bible.”
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