Breaking the silence around the menopause

Vasumathy Sivarajasingam

doi:10.3399/bjgp22X719093

Menopause is not a health condition, but a normal biological stage in a woman’s life when menstruation ceases permanently because of the loss of ovarian follicular activity. It is a clinical diagnosis based on symptoms and signs, at a single point in time, diagnosed in retrospect 12 months after the last menstrual period.

A study carried out by Nuffield Health Group highlighted that women experiencing menopause are hardly getting the support they need with diagnosis and/or treatment. As a result, 1 in 4 women are struggling to cope with life because of menopausal symptoms. Another study established that about two-thirds of women’s working lives are negatively affected by their symptoms, with a third losing their self-confidence.

With increased life expectancy, women spend more of their life in a postmenopausal state, making it a necessity to understand this natural process. Perimenopause is the transition phase of life, equivalent to puberty, but in reverse. Fluctuations in hormone levels result in a host of physical and psychological symptoms, and can be an incredibly challenging time for women, leaving them feeling confused and unable to cope at times.

It is imperative that a woman has a good understanding of the physiological changes in her body — from perimenopause to postmenopause. In particular, all women should be aware of the potential long-term health issues caused by changes in hormone levels, and the options available to help manage menopause symptoms to maintain a good quality of life. This would help women feel more in control and less overwhelmed by the changes they are experiencing, and be in a better position to meet the challenges of this life stage.

The mean age of natural menopause is 51 years in the UK, although this can vary between different ethnic groups. Every woman is different, and has her own journey as she transitions through to menopause. The symptoms experienced will be unique to her, to the extent that some experience severe symptoms while others experience no disruptions to their life. Vasomotor symptoms (hot flushes and night sweats) are the most commonly reported menopausal symptoms — affecting 75% of postmenopausal women with 25% being severely affected, decreasing the quality of life and level of self-respect. Other symptoms occurring during the transition include mood changes, musculoskeletal symptoms, cognitive problems, urogenital symptoms, and sexual disorders. Along with chaotic bleeding, these symptoms can be distressing, embarrassing, and cause sleep deprivation, lethargy, and low mood during perimenopause. The menopausal transition also occurs during the most crucial part of a woman’s working life.

HOW CAN THE PRIMARY CARE TEAM BREAK THE SILENCE ON MENOPAUSE?

First, we can raise awareness and create a culture where staff feel comfortable talking openly about menopause at work. This would encourage clinical and non-clinical members of the team to receive the necessary support without feeling embarrassed or fearful of judgement. Each staff member’s privacy should be respected, especially following disclosure of their symptoms. Consider implementing a menopause policy for the staff, to emphasise that you care about their wellbeing. Be considerate and make adjustments to help alleviate menopausal symptoms (for example, good ventilation, access to cold water, providing desk fans); flexible working patterns including breaks should also be implemented.

Education of staff further increases the opportunity to raise patient awareness, inviting women to open up and discuss menopausal symptoms, management, and the long-term effects of reduced oestrogen. This should be supported by resources/leaflets on information about menopause and its management. Furthermore, we should highlight the importance of lifestyle changes that could modify long-term health and promote wellbeing (such as blood pressure screening, attendance for mammograms, and cervical screening). Be aware that this is the time in a woman’s life when she takes charge of her overall health and is keen to take opportunistic lifestyle advice for health promotion.

The British Menopause Society recommends that every woman should have a health check on reaching the age of 50. Following health-promoting lifestyle advice, such as regular aerobic exercise, safe alcohol intake, quitting smoking, and reducing caffeine intake, can reduce the severity and frequency of vasomotor symptoms.

Recognition and acknowledgement of menopausal symptoms are positive steps, but this is not enough. The primary care team has a central role in supporting menopausal women in managing their symptoms. Despite the evidence that hormone replacement therapy (HRT) significantly improves the quality of life and protects younger women from long-term diseases including osteoporosis, a third of women visiting a GP were not made aware of HRT, with another third being told that HRT was not suitable for them. It’s not uncommon that menopausal symptoms are treated as separate issues in primary care when they should be addressed holistically. Symptoms such as urogenital symptoms due to atrophy are hugely under-recognised and undertreated, though they respond well to local vaginal oestrogen. Additionally, raising awareness of the continued need for contraception in perimenopausal women who are potentially fertile is crucial to avoid unplanned pregnancies and possible terminations.

Menopause is an inevitable part of a woman’s natural life process but it’s not a topic openly talked about. Thus, it is welcoming news that menopause was added to the school curriculum from September 2020, helping a new generation of women to gain a better understanding of their bodies well in advance.