In search of a well-balanced narrative of the menopause momentum

Menopause is a reproductive milestone marking the beginning of a new biopsychosocial era in each woman’s life trajectory. The evolutionary significance of this universal experience, occurring most often naturally in women between the age of 45 and 55 years, remains uncertain [1]. Ecology research considers menopause as an advantage most likely serving positive and altruistic purposes, without any negative stigma [2,3]. As a natural life event, menopause is certainly not a disease. However, there is no doubt that the biological changes that occur at menopause may greatly influence quality of life and general health [4].

With improved knowledge, leading to disease prevention and treatment, and cultural change, not only are more women living long enough to experience menopause, but women’s post-reproductive lifespan has been significantly extended worldwide and menopause has become less natural [5]. While women constitute 51% of the population, they have greater longevity but fewer disability-free years compared with men [6,7]. Today, women also constitute a significant part of the workforce yet maintain their roles as mothers and homemakers. It is estimated that more than one billion women globally will be in menopause by 2025. Therefore, it is vital that women are supported to optimize their quality of life and long-term well-being in this World Health Organization (WHO) decade of healthy aging. For all these reasons, menopause is in the public arena, with the medical community, politicians, workplace managers and social media recognizing that menopause specifically, and women’s health in general, must be prioritized.

The mission of the International Menopause Society (IMS) is to work globally to promote and support access to best-practice health care for women through their menopause transition and post-reproductive years, enabling them to achieve optimal health and well-being [8].

The most common symptoms of menopause, and risk factors for non-communicable diseases associated with the hormonal changes of menopause, are highly dependent on genetic and epigenetic factors, and a certain amount of good or bad luck [9]. Notably, an array of pathological conditions may cause premature cessation of ovarian function [10]. Consequently, the narrative of the menopause is highly autobiographic, and every woman has her own individual need for care [11]. Whether this translates into menopause-specific treatment should be the result of an effective health-care professional (HCP)–woman dialog. Shared decision-making has the ultimate goal of tailoring the most suitable strategies, be they hormonal or non-hormonal therapies, or lifestyle and behavioral approaches, to alleviate symptoms and/or optimize health [12]. Clinical consultations should be guided by evidence-based data, available as practice guidelines, recommendations or diagnostic and therapeutic algorithms, taking into account differences between countries and health systems [13]. Equally, women should be empowered to make personalized choices that are right for them, through effective evidence-based communications and education about menopause.

The work of menopause researchers, scholars and clinical practitioners is not agism [14] or disease mongering [15]. It is, therefore, very disappointing that we continue to see polarized views regarding menopause in both the academic and popular media. These contrasting views often leave women more confused and disempowered, rather than supporting them through their menopause transition.

The latest tranche of four publications in the Lancet [16–19], which offer a view on the perception of menopause and women’s experiences, including an empowerment model for managing menopause, and the accompanying editorial [20], claim that menopause is at risk of being over-medicalized and that the principles of health empowerment have not been applied to menopause. We agree with the authors that misattribution of a host of symptoms to the menopause transition can be misleading and raises unrealistic expectations of the effects of menopause hormone therapy (MHT) or non-hormonal options.

However, failure to attribute symptoms to the menopause transition, and sadly too often trivialization of these symptoms, can result in undertreatment, unnecessary suffering, poor quality of life and adverse long-term health effects. We must not forget the legacy of the Women’s Health initiative (WHI) and Million Women’s publications where women were left underserved due to their exaggeration of risks of MHT, particularly for women in the early postmenopausal years (50–59 years) [21,22]. Meanwhile, the claim being proffered by some medical and social media influencers that there is insufficient prescribing of MHT, and that it should routinely be offered to women, not only to manage distressing symptoms but also to prevent non-communicable diseases [23], represents the other extreme of the polarized views.

Our view aligns with that expressed by the Lancet papers [16–19] that women should be counseled and have access to the full armamentarium of treatment options such as lifestyle, diet, exercise, cognitive behavioral therapy, complementary therapies, MHT and non-hormonal pharmacological options. However, the claim that the principles of health empowerment have not been applied to menopause [16–19] is not only inaccurate, but also derogatory to the many menopause HCPs who take great care in ensuring that that their patients are intimately involved in the decision-making process during counseling. It also shows lack of recognition of the work that the IMS and many national organizations have been undertaking for more than a decade to provide accessible, credible information about menopause to empower women. The limited review of the treatment options in the Lancet papers, particularly of non-hormonal pharmacotherapy, does not meaningfully add to the scientific literature, or to the existing menopause society recommendations and guidelines.

The United States Preventive Services Task Force (USPSTF) recommendation for MHT not being used for primary prevention [24] is quoted in the article [19], but there is global recognition that MHT prevents bone loss and fracture [25] and is associated with a risk reduction in cardiovascular disease and premature death in women with early menopause [26]. It is to be commended that one of the papers emphasizes that the early menopause population has been largely neglected and deserves special consideration because of potentially higher non-communicable disease risks, as per women with premature ovarian insufficiency [18]. While more research is needed, the emerging data for maximizing benefits and minimizing risks through refining MHT choices with body identical options [27] should have been discussed in more detail.

Comprehensive reviews of the state of the art on menopause and tools for implementation and empowerment of HCPs and women are expected in the near future through updates of the European Society of Human Reproduction and Embryology (ESHRE) premature ovarian insufficiency guideline and the new release of IMS recommendations on menopause and MHT, which also incorporate women’s viewpoints.

In conclusion, the IMS is uniquely positioned to disseminate balanced, evidence-based information on menopause care through its Council of Affiliated Menopause Societies (numbering 64 and growing) and its members across 89 countries. We are aware that the factors which determine care pathways for women experiencing menopause are often beyond the control of the average HCP, and depend on in which region they practice. These include poor access to education, inadequate resources, cultural and religious influences, and governments not prioritizing women’s health care. Nonetheless, our primary objective is to empower HCPs, women and those close to them about menopause, without underplaying or over-sensationalizing this life period.

We remain firmly convinced that the aim of scientific information is to provide a well-balanced narrative of the menopause momentum. Women deserve it!

Disclosure statement

N.P. has acted in an advisory capacity and has lectured for the following companies: Abbott, Astellas, Bayer, Besins, Gedeon Richter, Lawley, Mithra, Novo Nordisk, Se Cur, Theramex, Viatris and Yes Company. He currently serves as President of the International Menopause Society (IMS).

R.E.N. has past financial relationships (lecturer, member of advisory boards and/or consultant) with Boehringer Ingelheim, Eli Lilly, Endoceutics, Exeltis, HRA Pharma, Novo Nordisk, Organon & Co, Palatin Technologies, Pfizer, Procter & Gamble, Teva Women’s Health, and Zambon; and has ongoing relationships with Abbott, Astellas, Bayer HealthCare, Besins Healthcare, Fidia, Gedeon Richter, Merck & Co, Shionogi, Theramex, Viatris, and Vichy laboratories. She currently serves as President Elect of the International Menopause Society (IMS).

S.R.D. reports honoraria from Besins Healthcare, Mayne Pharma, Health Ed and Theramex,. She has served on Advisory Boards for Mayne Pharma, Gedeon Richter, Astellas Pharmaceuticals, Theramex, Besins Healthcare and Abbott Pharmaceuticals, and has been an institutional investigator for Ovoca Bio. She is an Executive Council Member of the Australian Academy of Health and Medical Sciences and served as President of the International Menopause Society (IMS).

Additional information

Funding

Nil.