Graceful Transitions: A Doctor's Menopause Advice

Menopause is becoming a much talked about issue in the workplace. Creating equality for women in corporations is not just about having women present in important roles, it’s about creating important roles that allow women to be present mothers, wives, and friends. While the feminist activists that changed our gender equality landscape made many victories, there is often a masculinised women embodying these victories - sometimes at the expense of the other beautiful roles many women are called to fulfill in their lives. We have started to dress like men and behave like men. I believe the next dawn of feminism will be the added nuance of flexibility in the workplace - softness, a divine feminine that nurtures and inspires and creates community over competition. 

Studies support that more than 50% of women are significantly affected by their menopause in the workplace. Some go as high as 73%. One study showed a significant relationship between depression and anxiety in working menopausal women and the severity of their menopausal symptoms. A large percentage of women resign from their jobs during this transition because they don't have the support that they need. I was delighted to hear that Australia is forging the way with Menopause leave for employees!

While it feels obvious to honour life transitions and allow space and support for menarche, pregnancy, miscarriage, and menopause, the masculinised role of women in the workplace doesn't always allow for this. I hope that conversations like these open the minds of both men and women to a new world, even a matriarchy!

What is Menopause?

Menopause is the cessation of ovulation. It arrives, on average, at around age 51 but the normal range is between 45 to 55 years of age. As you pass your 35th - 40th birthday, the decade preceding your menopause, your ovaries start to run out of viable eggs. As a result, your progesterone and then oestrogen levels start to decline. Before coming to a standstill, these levels can fluctuate immensely and erratically, potentially leaving you feeling a little mad, irritable, or frustrated. These changes can bring with them some turbulence and irregularity to your cycle too, and are often associated with heavier cycles and sometimes more pain. For some, this shift in balance can be very subtle and short lived, and for others it can be a very difficult time of adjustment. 

Some women experience changes in mood, weight, energy, anxiety, or sleep disruption. Later, this may begin to manifest as hot flushes, depression, irregular and erratic cycles, and cognitive changes like poor memory and brain fog. You are officially over the Menopause line when you are 12 months beyond your last period. Many of our other hormones are affected in this changing period too and it’s important to have a global picture of your wellbeing that includes other endocrine organs.

In contrast to some of this unpleasantness, women in their fifth decade can enjoy the accomplishments of a full life. Moving into menopause is often a time when the nest is emptying and your energies can shift away from maternal and domestic obligations to a little more self-care and enrichment. With the wisdom and knowledge of a life well spent, this can be a time of great growth, enjoyment, and adventure. What is apparent to me is that self-knowledge certainly deepens with time. At almost 40, I am the most myself that I have ever been. While a present lived experience is key to calm and serenity, it also lays a path for your future self. If you sow the right seeds in your thirties, you will reap the rewards in every decade to follow.

What is in Your Nest?

It doesn’t matter how old you are as you read these words. Having your death and your menopause and your motherhood as a companion in this moment is powerful. It’s so easy - in every phase of life - to become immersed or overwhelmed with one piece of your wellbeing. Whether it is your job, your love life, your children or your academic pursuits, the hallmarks of a contented life are a diversity of experience that includes relationships, nature, physical health, and creativity. We are multidimensional, creative creatures and if we are full, in the deepest sense, with meaningful connection and expansion, then these transitional times will be fortified by the choices we made ten years ago.

Why is Oestrogen So Important?

Oestrogen not only contributes to keeping our urogenital organs healthy, but it also plays an important role in bone integrity, breast, skin, brain, and cardiovascular health. You have oestrogen, progesterone, and testosterone receptors throughout your body, this is what makes the symptom profile of this time so diverse.

What is tricky about this time (and all hormonally fluctuant times) is that there is no holy grail. Some women thrive in menopause and others wilt. Some women glow under the hormonal deluge of pregnancy and others experience weight gain, anxiety, depression, and exhaustion. Because this terrain is so unique to every woman, an individualised approach is asked for and a western paradigm of medicine doesn’t always accommodate this. Pharmaceutical medicines don’t often allow for dose adjustments, but this is also what makes them accessible and affordable. Working with functionally trained professionals gives a patient more access to the nuanced approach sometimes needed. 

Menopausal Hormone Therapy

The women’s health initiative study in the 90s was a landmark study looking at hundreds of thousands of women on hormones. We learned some valuable things from this study, but one of the published outcomes that was manipulated by the press was that HRT causes breast cancer. When we look back on this study, we see that almost a third of the women in the study were significantly overweight, another third were obese and another third were ex or current smokers. This alone introduces a whole host of other risk factors for cancer creation.

The media can distort data in a way that tells a certain story. And data analysts can do the same in the way that they express findings. It’s important, when we interrogate a new question, that we are not attached to a certain outcome.

According to the absolute risk expressed in that study looking at a specific synthetic progestogen, the increased risk of breast cancer for women on HRT was only 2% more than the control group. Other studies show that women on HRT live longer and those with breast cancer have better outcomes, too. 

The most important message we can give patients is not to approach hormone therapy with an air of fear, but rather to embrace all the knowledge that is out there and, with an informed practitioner, to make a decision that is “right for you”. Your decision is highly individual and will depend on current symptoms, past medical history, family history, and your preference. What is clear and current thinking is that oestrogen and progesterone replacement in the decade following your menopause protects your bones, your brain, and your cardiovascular system in a very significant way. The benefit after the age of 60 is uncertain, and some data suggests that the risk of the intervention outweighs the benefit in some, but this may change in the future. We also don’t have any large scale studies looking at oestradiol and micronised progesterone except for the work of Professor Prior, which doesn't look at large populations of patients. 

The “safest” forms of the hormones are the ones that are molecularly the closest to the hormones our own bodies produce - body-identical hormones. Most of the newer oestrogen preparations out there are oestradiol, but not all “progesterone” formulations are body-identical.Hormone therapy is valuable for its assistance with the symptoms of menopause, but also for the prevention of long-term health risks associated with the prolonged absence of these hormones like Alzheimer’s, osteoporosis, and heart disease. These risks are not measured by the presence of hot flushes, and so hormone replacement should not only be considered in those with hot flushes! If you have no symptoms at all, a bone density scan to appraise the health of your bones is a helpful indicator as to whether you should replace your hormones. 

Who Shouldn’t Be on Hormones? 

There are both genetic and environmental risk factors that one needs to consider before deciding on hormone therapy. There is always some risk when starting a medicine, and this needs to be weighed up against the potential benefit. 

Comorbidities like hypertension, obesity, or diabetes may discourage your healthcare provider from prescribing hormones, as all of these diseases increase your risk for a blood clot independently. A history of blood clots, moderate to severe endometriosis, enlarging fibroids, gallbladder or liver disease, unexplained vaginal bleeding, atypical hyperplasia of breast tissue, breast, endometrial or ovarian cancer histories might deter your doctor.

Giving oestrogen transdermally (through the skin) bypasses metabolism via your liver and reduces the risks of clotting associated with taking oral estrogen. Taking micronised progesterone orally is the safest way to protect your uterine lining from becoming overstimulated by oestrogen. These hormones need to be prescribed together in order to prevent the possibility of endometrial cancer which is associated with unopposed oestrogen. You can think of progesterone and oestrogen as sunscreen and the sun. You need both!

What Natural Supplements or Practices Might Help?

Several studies have appraised the difference in effects of natural supplements versus placebos, and the placebos and supplements mostly fare similarly. This is not to say that they have no effect. Using phytoestrogens like soya can help blunt hot flushes. Evening primrose oil is known to relieve some of the symptoms of PMS and menopause. Agnus castus is a plant that supports the body to make progesterone and testosterone, and often helps with the irritability characterised by this time. There are also non-hormonal interventions that your doctor could prescribe. Some antidepressant drugs, like Venlafaxine and Clonidine, an alpha adrenoreceptor agonist, can both help to reduce flushes. 

Wear light clothing and dress in layers, avoid hot drinks, and keep your environment cool. Keep your diet clean, eating whole foods (mostly plants) and avoiding animal products containing hormones and antibiotics. Exercise is the elixir of life, and you should integrate this into your social and everyday life. Weight training is important not just because we lose muscle mass (which impacts our metabolism), but also because it helps to strengthen our skeletal system and improve our balance, independently reducing our fracture risk. Make sure that you are surrounded by loving, supportive people and relationships, and aim to optimise all the aspects of your health. Ensure that you keep a sense of purpose close.

The most important take-home message is that you need your own individualised care programme. A well-informed and caring practitioner should be able to guide you through this time, taking into consideration all the aspects of health outlined in this article, while at the same time balancing the benefits and risks of the interventions available to us. There are sometimes differing schools of thought in the medical community, and that’s ok. Connecting with a practitioner who shares your wellbeing point of view is half the battle won.

We wish you a fifth decade of insight, self-awareness, and goddess energy; in which you harness your life knowledge and skills for greater contentment and the spreading of light on earth. 

ABOUT THE AUTHOR

Dr Skye Scott is a family GP, and co-owner of Health with Heart - a holistic wellness solution that includes a warm-hearted practice in Sandton; bespoke corporate wellness programmes; unique retreats and medical travel experiences; an educational podcast and portal; and a community outreach initiative. For more information or to get in touch, follow @drskyescott or @health_w_heart on Instagram or @HealthwithHeartDoctors on Facebook, or visit www.healthwithheart.co.za.