Are we over-medicalising menopause?
What's got the menopause influencers cranky?
Are we over-medicalising menopause?
This is the headline you might have seen around the place last week; you may also have seen your favourite menopause influencers loudly protesting the idea.
What are they all talking about? The well-respected medical journal, The Lancet, has published a series of articles on menopause. None of them, I should note, is titled as per the headline above – the article all the fuss is about is the one entitled: ‘An empowerment model for managing menopause’. It’s by a group of authors led by Australian gynaecologist and researcher, Martha Hickey. There’s also an article on menopause and mental health, one on early menopause and one on menopause after breast cancer.
They all make for interesting reading.
The reporting and social media response has been quite vocal. ‘How dare these people be so anti-HRT’ seems to be one of the main threads of criticism; ‘how dare they say we are over-treating menopause’ is another. Then there are those who have delved into the backgrounds of the authors and are suggesting all sorts of possible motives and dark conspiracies. It’s become quite confusing.
I’ve now spent several hours with these articles. I’ve read the main one twice, and I’ve sat and reflected on all the information covered. If you’re that way inclined – and I get that journal papers are not everyone’s idea of a fun read – I encourage you to read them, too. Here’s where you can access them.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)02799-X/fulltext#relatedDO-3226
Now, I offer my thoughts, for what they are worth, based on my knowledge of the menopause landscape (especially here in NZ); my own research for my two books; my conversations over the years with many experts and women’s experiences of menopause and their interactions with health care professionals as reported to me. (You can scroll down for a tl;dr bottom line if you like).
What’s all the fuss about?
I must say that reading some of the coverage and social media outcry, I have at times wondered if we were reading the same Lancet articles. My reading of it is not as the anti-women, anti-HRT disgrace that some would have you believe. Honestly.
But there is nuance here. There are bits of this paper that seem to me to add to the discussion around menopause in useful ways, and also bits I found bemusing and made me frown, too. I’ll give you a rough summary.
What are these new papers saying?
Four articles have been published; for brevity I’ll focus on the one that seems to have upset the most people; the empowerment model one.
What it’s doing is a more-or-less accurate summary of where the evidence is at on menopause and its treatment, from what I can see – though with some odd emphasis of some points and some odd omissions, which I’ll talk about in a minute. It does say this:
Over-medicalisation of menopause can lead to disempowerment and over-treatment.
And this:
In many high-income countries (HICs), menopause is commonly described as a medical problem and sometimes as a hormone deficiency disorder with typical symptoms and long-term health risks that are best managed by hormone replacement.
This is a bit jarring to me. They don’t really say who is saying menopause is a disorder or deficiency. While I am aware of a couple of prominent and popular overseas experts on social media who do seem to get close to this - to be honest, I’ve never heard an expert or doctor I have talked to, describe menopause this way. Most are at pains to say it’s not a disease. The authors in the Lancet paper reference this statement to a 2002 paper published in a feminist journal, which I looked up, but couldn’t find a way of accessing to read the full text. It’s a shame they didn’t cite a more recent source for that statement; to me it seems a bit of a straw (wo)man. Perhaps they are talking about media or marketing hype, in which case there’s definitely some substance there. Marketers love nothing better than finding a new ‘problem’ that needs solving with their products. And for sure, there are some social media meno-influencers who seem to think HRT is protecting us from all manner of future ills and we’d be mad not to take it.
I’ve written and said many times that I’m not comfortable with the framing of menopause as a deficiency state; it doesn’t sit well with me and it just doesn’t make sense, frankly, when we don’t consider pre-pubescent girls to be in deficiency. And I absolutely reject the idea of menopause as a disease or disorder. Just – nope. But that doesn’t mean many women don’t struggle and suffer with it.
The authors here also say, basically: menopause comes along at a time when there’s lots of other life stuff going on, and lots of those things can affect women’s experiences of menopause, and vice versa. Which I think we can all agree on.
And they say there’s no one solution to all the problems of menopause. Tautoko that too.
Then there’s this:
We argue that additional strategies beyond medication are needed to effectively support women as they transition menopause.
I agree with this, too – as we all know, there’s no magic pill. We need lots of things to support us through menopause; not just HRT but all the other stuff: exercise, diet, sleep and stress management, and – not least – societal and systemic change! More on that soon.
I think this bit, though, might be what some people are seeing as an anti-HRT slant. That, plus the slightly strange framing of the section on ‘Managing Menopause Symptoms’.
Here, the first thing on the list of treatments is ‘Psychological Therapies’ including Cognitive Behavioural Therapy and Hypnosis. They go into some detail around the evidence on these, and it takes several paragraphs before they get to the widely acknowledged most effective treatment for hot flushes: MHT/HRT. As the Australasian Menopause Society puts it in its response to the Lancet paper, this is ‘mixed and potentially confusing’. It’s also infuriating to some women, who rightly or wrongly infer that this seems to be saying: your menopause symptoms are in your head.
The AMS also notes:
The authors seem determined to minimise the important role of MHT in helping many women as they reach menopause. They ignore other published systematic reviews which all agree that MHT is the most effective treatment for vasomotor symptoms…
This seems an accurate assessment.
That said, there are some things I like in this paper. The authors make important points about shared decision-making between doctors and women seeking treatment, and about challenging gendered ageism and stigma about menopause, which can also affect our experiences of this transition.
I liked this:
Ageism is a powerful social determinant of health, and in countries where menopause is equated with physical and mental decline, it is not surprising that many find this transition daunting. Actively challenging ageism and encouraging a more positive discourse can help reduce anxiety for women approaching menopause.
I also really liked the accompanying art project 500 Strong: celebrating older women's bodies in menopause and beyond. It’s a series of nude portraits of women in their 50s and older, and is described as having ‘explored and challenged negative images of ageing in women and created emotive, affirming, and realistic portrayals of older women.’
See more here:
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)00369-6/fulltext
Side note: I think the infographic on the article was better than the article, tbh. Whoever did that did a pretty good job.
What are the paper’s authors not saying?
Though some might read this into it, the authors here are not saying: women should not have MHT/HRT or that doctors should not prescribe it. They are saying: there’s a range of treatments, and MHT is one. Despite my points above, they do stress this:
For those seeking treatment, clinicians should offer evidence-based information about the range of effective interventions for problematic symptoms, including non- pharmacological and non-hormonal methods, with a model of shared decision making. However, MHT is the only treatment that benefits both vasomotor and genitourinary symptoms and reduces fracture risk.
They’re also not really saying too much that’s different from the existing guidelines of the main menopause bodies around the world. They’ve chosen to emphasise and de-emphasise certain things in certain ways which are a bit weird, and they do seem to have excluded some evidence on MHT, as the AMS notes in its response; worth a read.
https://www.menopause.org.au/hp/gp-hp-resources/lancet-series-on-menopause-2024
Bottom line imho – and what it means for you
These articles have got people talking – and that’s ultimately good, I think. They add to the discourse around menopause and its treatment. I’ll leave the experts to debate the finer points of the evidence cited, but I will remind you also: it’s easy to cherry-pick papers and bits of research that support a particular viewpoint – whatever that is. It’s better to refer to overviews of all the research, which is what the global menopause bodies are very good at doing.
It annoys me that this whole thing has become an argument, when it really doesn’t need to be. I suspect the authors of this paper and many of their critics would actually agree about a lot of stuff! For example: HRT is an extremely useful and effective treatment that has helped many, many women. And: there are other treatments that can also be useful and effective. I think it’s possible to hold both those thoughts. But that has gotten a bit lost in the noise. Like I said: nuance.
All of that said: I don’t think we are in any danger right now of over-medicalising menopause in this part of the world. We can’t, really – when we still are struggling to get access to treatment a lot of the time. In a way, it’ll be good when we are at a point when we can have that debate for real.
I’ll also point out that debates around ‘over medicalising’ many aspects of health have been going on for decades. It’s been talked about in relation to childbirth; mental health; adhd; pregnancy, even death. And it’s been an ongoing discussion around erectile dysfunction, believe it or not. There are plenty of papers on that floating around, too. It doesn’t seem to have done the market for Viagra any harm.
What does it mean for me and you and all the real live women on the ground? Carry on. Keep doing whatever you’re doing that’s helping you to feel good and function. Whether it’s HRT or therapy or supplements or standing on your head – or all of the above - if you’ve found something that works for you and you can afford it and it’s not giving you side effects and it’s having a sustained effect – carry on.
Read the Lancet papers here
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)02799-X/fulltext