Breaking the silence around ‘the menopause’

Vasumathy Sivarajasingam is a GP in West London and an Honorary Clinical Research Fellow at Imperial College London. She is on Twitter: @vasu27765631

Menopause is not a health condition, but a normal biological stage in a women’s life when menstruation ceases permanently due to the loss of ovarian follicular activity. It is a clinical diagnosis based on symptoms and signs, 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.1 As a result, 1 in 4 women have been struggling to cope with life due to menopausal symptoms. Another study established about two-thirds of women’s working lives being affected negatively by their symptoms, with a third losing self-confidence.2

…1 in 4 women have been struggling to cope with life due to menopausal symptoms…

With the increased life expectancy, women spend more of their life in a post-menopausal 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 incredibly challenging time for women, leaving women feeling confused and unable to cope at times.

It is imperative that any 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 unquestionably help the woman to feel in control and less overwhelmed by the changes she is experiencing, and be in a better position to meet any 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 whilst 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.3,4 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 occurs during the most crucial part of a woman’s working life.

How can the primary care team break the silence on menopause?

How can the primary care team break the silence on menopause? Firstly, 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 necessary support without feeling embarrassed or fear 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 any adjustments that could be made to help alleviate menopausal symptoms (e.g. good ventilation, access to cold water, providing desk fans), flexible working patterns including breaks when required.

Education of staff further increases the opportunity to raise patient awareness, inviting women to open up and discuss the potential 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 (e.g. blood pressure screening, attendance for mammograms, and cervical screening). Be aware, 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 every woman to have a health check on reaching the age of 50. Health-promoting lifestyle advice, such as regular aerobic exercise, safe alcohol intake, quitting smoking and caffeine intake can reduce the severity and frequency of vasomotor symptoms.5

Recognition and acknowledgement of menopausal symptoms is a positive step, but this is not enough. 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 HRT was not suitable for them.1 It is 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 perimenopause women who are potentially fertile is crucial to avoid unplanned pregnancies and terminations.

Menopause is an inevitable part of a woman’s natural life process. Typically, it is not a topic that is openly talked about in society. It is welcoming news that menopause is added to the school curriculum from September 2020, which will help a new generation of women to gain a better understanding of their bodies well in advance.6








Featured image by Simon Hurry on Unsplash

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2 years ago

Excellent article, raising awareness of important changes in women’s life. Well done 😊

2 years ago

Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan
I recently wrote an article here on BJGP Life about HRT shortages. The current issues with HRT supply are attributed to an imbalance between supply and demand, with a marked rise in the number of women using HRT. Part of that increased demand has been attributed to a TV documentary about the menopause released a year ago by Davina McCall, which has led to what some call the ‘Davina effect’. The follow-up to last year’s documentary aired recently on Channel 4, leading to industry and government warnings about further HRTshortages driven by demand.

What I find interesting about this kind of high-profile programme is the impact that it has on patient behaviour, and the resulting consequences for healthcare professionals.

What I find interesting about this kind of high-profile programme is the impact that it has on patient behaviour, and the resulting consequences for healthcare professionals. Celebrities influence how people think, and act. Jade Goody, a British reality TV star, died of cervical cancer in 2009, and the publicity surrounding her death is thought to have increased attendance at cervical cancer screening (the so-called ‘Jade Goody effect’).1 Similar short term effects were seen in increased rates of breast cancer screening following Kylie Minogue’s diagnosis of breast cancer (the ‘Kylie effect)2 and Angelina Jolie’s decision to have a risk-reducing mastectomy in the context of BRCA1 status.3 The makers of the more recent Davina McCall documentary say that they expect ‘another wave of women to go to their GPs’ asking about HRT. But what about the impact of these high-profile cases, or documentaries on us in general practice, and how do we as GPs respond?
Unfortunately, a high proportion of women will never seek help for their symptoms around perimenopause and menopause.4 Of those women who do seek help, the majority will see their GP as a first port of call. Let’s assume that, as a result of a high profile documentary on menopause, more women in the UK will try to speak to their GP about starting, or adjusting their treatment during the menopause. Is this in itself, a good thing? Vasumathy Sivarajasingam wrote here in BJGP Life about breaking the silence around the menopause, and makes the point that we don’t speak enough about the menopause with our patients, or offer HRT when its potentially indicated. While raising the profile of the menopause can hardly be seen as a bad thing, some in the health care profession find this kind of programme difficult, especially if coverage suggests that some GPs are incompetent or dismissive of women’s concerns.
My own scanning of social media and discussions with colleagues led me to categorise responses to Davina McCall’s programme as below:
– GPs who feel that this kind of programme portrays untruths and is ‘GP-bashing’. These GPs might feel defensive, or angered by anti-GP sentiments in the media or from patients.
– GPs who feel that they are effective advocates for their patients going through the menopause. These GPs might feel vindicated by their actions.
– GPs who feel that they want to advocate for women through the menopause and welcome this kind of programme. These GPs might feel a need to increase their knowledge in this area given that they expect to have more conversations with patients about the menopause and HRT.

Celebrity stories can influence health seeking behaviours, and using these narratives may be an effective way to communicate with patients about health promotion.

Our alignment with one or more of the above groups might be fluid or overlapping, but perhaps it is worth reflecting on our own responses. Negative stereotypes of GPs are entrenched in the media and can contribute to emotional exhaustion and subsequently impact decisions about whether to leave practice.5 Barry and Greenhalgh suggest that we should rise to the challenge, and develop our own counter-narratives when GPs are depicted in the media as clinically incompetent.6
Patients might have questions about the information provided in Davina McCall’s programme, and The British Menopause Society has produced a response which provides some information about indications for HRT, prescribing testosterone and specialist clinics. Can we harness the power of celebrity? Celebrity stories can influence health seeking behaviours, and using these narratives may be an effective way to communicate with patients about health promotion.7 At the very least it’s worth acknowledging the impact of high-profile stories on our patients, the portrayal of general practice in the media, and ultimately, our own responses and actions as a result.

Lancucki L, Sasieni P, Patnick J, Day TJ, Vessey MP. The impact of Jade Goody’s diagnosis and death on the NHS Cervical Screening Programme. J Med Screen. 2012;19(2):89-93.
Kelaher M, Cawson J, Miller J, Kavanagh A, Dunt D, Studdert DM. Use of breast cancer screening and treatment services by Australian women aged 25-44 years following Kylie Minogue’s breast cancer diagnosis. Int J Epidemiol. 2008;37(6):1326-32.
Evans DG, Barwell J, Eccles DM, Collins A, Izatt L, Jacobs C, et al. The Angelina Jolie effect: how high celebrity profile can have a major impact on provision of cancer related services. Breast Cancer Res. 2014;16(5):442.
Constantine GD, Graham S, Clerinx C, Bernick BA, Krassan M, Mirkin S, et al. Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries. Post Reprod Health. 2016;22(3):112-22.
Sansom A, Terry R, Fletcher E, Salisbury C, Long L, Richards SH, et al. Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England. BMJ Open. 2018;8(1):e019849.
Barry E, Greenhalgh T. General practice in UK newspapers: an empirical analysis of over 400 articles. Br J Gen Pract. 2019;69(679):e146-e53.
Marlow LA, Sangha A, Patnick J, Waller J. The Jade Goody Effect: whose cervical screening decisions were influenced by her story? J Med Screen. 2012;19(4):184-8.

Featured image by Francisco on Unsplash

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