Journal Scan: A review of case series of immediate clinical significance, harvested from major international journal

From the desk of the Editor-in-Chief

 

(1) Menopause 2024. The Lancet series, Published: March 5, 2024,
https://www.thelancet.com/series/menopause-2024

Executive Summary

Menopause is an inevitable life stage for half the world’s population, but experiences vary hugely. Some women have few or no symptoms over the menopause transition while others have severe symptoms that impair their quality of life and may be persistent. Many women feel unsupported as they transition menopause. To better prepare and support women, the Lancet Series on menopause argues for an approach that goes beyond specific treatments to empower women with high-quality information, tools to support decision making, empathic clinical care, and workplace adjustments as needed. Targeted support is needed for groups who experience early menopause or treatment-induced menopause, and for those at increased risk of mental health problems. The authors recognize how gendered ageism may contribute to negative experiences of menopause and call for reduced stigma and greater recognition of the value and contribution of older women.

Editorial

Time for a balanced conversation about menopause

For most women, menopause is a natural phase of life that they transition as part of biological ageing. However, as highlighted in a Series of four papers in today’s Lancet—published ahead of International Women’s Day on March 8—commercial companies and individuals with vested interests have over-medicalised menopause. The framing of this natural period of transition as a disease of oestrogen deficiency that can be eased only by replacing the missing hormones fuels negative attitudes to menopause and exacerbates stigma. Furthermore, appropriation of feminist narratives by commercial organisations, which position use of menopausal hormonal therapy (MHT) as a way to empower women to regain control of their bodies, while downplaying risks, further endorses the framing of menopause as a disease.

As described in the Series, women’s experience of menopause varies hugely and there is no one-size-fits-all approach to management. Many women transition this stage of life uneventfully, whereas some experience prolonged or severe symptoms and need information, support, or medical treatment. The most common symptoms associated with menopause include vasomotor symptoms such as hot flushes and night sweats, sleep disturbances, vaginal dryness, and muscle and joint pain. Menopause is commonly perceived to be associated with poor mental health. However, there is no strong evidence that the risk of first-onset clinical depression is increased over the menopause, although this can be a vulnerable period for recurrence in those with previous clinical depression.

MHT is the most effective treatment for vasomotor symptoms, but it is not without risk: robust epidemiological evidence suggests that one additional case of breast cancer will occur for every 50 women taking systemic, combined MHT from age 50 years, and one in 70 for estrogen-only MHT. There is no excess risk from vaginal estrogen. All women who request MHT, after weighing up the short-term and long-term benefits and risks with their clinician, should be offered treatment unless contraindicated. Acute shortages of MHT, as seen in many parts of the world, could have a detrimental effect on women’s quality of life. Not all women wish to, or can, take MHT however, and treatments such as cognitive behavioral therapy can also help to counter vasomotor symptoms and potentially improve mood and sleep. Easy access to impartial information—not from those who are marketing a product or service—both before and during the menopause transition, as well as an informed, engaged clinician who will listen with empathy, are crucial to facilitate shared decision making.

Historically, women have been poorly served by both the research community and by society. At The Lancet, we are redoubling our efforts in this regard by designating Women and Health as one of our areas of focus in 2024, with the aim of showcasing important work and promoting sex and gender equity in research. Increased awareness and advocacy of women’s health are crucial to reverse the long-standing gender biases in medicine. But over-medicalization of menopause and promotion of MHT as a panacea is unhelpful and only serves to divide opinions further. It is time for a sensible conversation about menopause to enable informed, individualized decision making on optimal management of this transition.

Greater diversity in research that addresses priority areas for women is needed. A paucity of information and education on menopause has led to symptoms being dismissed by uninformed health-care professionals and a lack of understanding in the workplace. After failed attempts in the UK to make menopause, like pregnancy, a protected characteristic under the 2010 Equality Act, the Equality and Human Rights Commission released guidance recently suggesting that menopause symptoms could be considered a disability if disruptive enough to interfere with everyday activities, and that employers are legally obliged to make reasonable adjustments. However, interpreting menopause more broadly as a disability risks further fuelling the ageism and stigma that older women already face. Menopausal women can be strong, healthy, and happy—as highlighted by the selection of inspirational images of older women that accompany the Series. Menopause can also be a time for women to reassess their identities, to embrace this next phase in their lives and the freedom from menstruation and menstrual pain, and to challenge negative perceptions of older women, which are prevalent in some societies. We need to send a realistic, balanced message to women and to society: menopause does not herald the start of a period of decay and decline but is a developmental life stage that can be negotiated successfully with access to evidence-based information as well as appropriate social and medical support. Women deserve nothing less.

The Series

  • An empowerment model for managing menopause. Martha Hickey et al
  • Optimizing health after early menopause. Gita D Mishra et al
  • Promoting good mental health over the menopause transition. Lydia Brown et al
  • Managing menopause after cancer. Martha Hickey, Perspectives. Martha Hickey et al
  • 500 Strong: celebrating older women’s bodies in menopause and beyond. Ponch Hawkes et al

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