Home Therapeutic relationship The traditional narrative of menopause misleads women

The traditional narrative of menopause misleads women

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With so many women affected by menopausal symptoms (about 75% of women suffer from hot flashes, for example), menopause is an important topic to discuss. There seems to be a resurgence of popular interest in it, and recently a certain widely circulated podcast episode was dedicated to the topic. In an effort to share accurate, high-quality information, the podcast hosts interviewed a doctor who is considered an expert on menopause. (For simplicity, I’ll refer to podcast hosts as The host and the doctor they interviewed as The physicist.)

However, both in this particular podcast episode and in the broader socio-cultural conversation about menopause, certain claims shape the narrative in disturbing ways. As clinicians, we need to be aware of the messages that influence our patients. I am not saying that the messages are malicious – in fact, quite the contrary. Demystifying menopause and empowering women are laudable goals that go hand in hand. But the medical history of menopause is incredibly charged, and the subject deserves careful consideration.

Claim: Concerns about breast cancer have unduly deprived women of the benefits of hormone therapy

“Whenever someone dares to whisper ‘hormone therapy’,” the host says, “[…] the reflexive answer is: “But it causes breast cancer!” She laments how, according to her understanding, “the premature publication of these first data [from the Women’s Health Initiative] and the media frenzy caused millions of women to stop hormone therapy overnight and […] deprived a generation of women of the therapeutic benefit of hormone therapy.”

But it’s not just breast cancer, and it’s not just one study.

Cochrane, an independent organization that synthesizes evidence to facilitate evidence-based medical decision-making, conducted a systematic review to help clarify the clinical effects of hormone therapy (HT) in perimenopausal and postmenopausal women. The review, which included 22 double-blind, randomized controlled trials, found: “In relatively healthy postmenopausal women, use of combined continuous HT for 1 year increased the risk of heart attack by about 2 per 1000 to between 3 and 7 per 1000, and increased the risk of venous thrombosis (blood clot) from about 2 per 1000 to between 4 and 11 per 1000. With longer use, HT also increased the risk of stroke, breast cancer, gallbladder disease and death from lung cancer.

That being said, assessing the risks and benefits of hormone therapy at the individual level can be complex, and we are still working with imperfect information. Some women experiencing intolerable menopausal symptoms may decide that the benefits of hormone therapy outweigh the risks, and that might be a perfectly reasonable decision. But there’s a big difference between de-stigmatizing an individual’s well-informed medical decision and re-popularizing the use of hormone therapy on a large scale.

Claim: Menopause is undertreated

Historically, hormone therapy for the treatment of menopausal symptoms was one of the most widely prescribed drug therapies of all time. But these days, reports The Host, “73% of women are never treated for their menopausal symptoms.” Curious where this number came from, I googled it and found a Forbes article with the title, “73% of women don’t deal with their menopausal symptoms, new survey finds”.

Scrolling through the article, I looked for the original source of the stat and found it almost immediately. The Forbes The article says that number comes from “new research from Bonafide, a company that sells products to treat women’s health issues, including menopause.” In other words, a company with a vested interest in selling menopause-related products is actively promoting the message that menopause is extremely undertreated. Digging a little deeper, I clicked on the link to Bonafide’s study. What I found was not a research paper published in a reputable scientific journal, but a neat set of slides that looked like a pitch deck.

Women need access to health care and deserve to have their menopausal symptoms taken seriously, but it’s worth being aware of the big picture. Emerging direct-to-consumer health technology companies are looking to expand the market for their products and services, and women interested in menopause treatment are a prime target. There’s an unjust voidsay these companies. But no need to worry! We are ready to step in and fill it. It’s not good medicine, it’s Marketing 101.

Claim: Seeking treatment for menopause is a feminist act

The host compares how society deals with erectile dysfunction and how it deals with menopause. She notes that information about erectile dysfunction treatment options is ubiquitous, while women are told that menopause is a natural process and that they should “just cope”. Because of patriarchy, she argues, men with erectile dysfunction are assured that they don’t have to live like this. Meanwhile, women who experience debilitating symptoms due to menopause have to adjust to a lower quality of life.

The host is right here, but framing menopause in this way risks undermining the patient/provider relationship. Let’s take a typical scenario: a woman comes to the clinic, tells her doctor about the symptoms of menopause she is experiencing, and lets him know* that she would like to start HT. He’s reluctant because of the risks, and he uses the rest of the short 15-minute date to explain that, in his case, the risks of HT actually outweigh the benefits. Although the patient understands what he is saying, she mostly feels that he is not taking her symptoms seriously. When she leaves without the prescription she came for, she feels frustrated. In her mind, she didn’t get the treatment she needed and deserved.

Again, this dynamic creates the perfect opportunity for direct-to-consumer health technology companies. You don’t have to deal with all that patriarchal nonsense. There is an easier way! Yet, while it’s easier to get menopause treatment through these companies, they may not be offering patients the best.

Affirmation: You need a doctor who will follow the guidelines

At one point during the interview, The Physician recommends the North American Menopause Society (NAMS) as an excellent resource. A little later, she adds:[NAMS] has its guidelines for doctors […] so if you have a doctor who doesn’t want to follow these guidelines, then you need another doctor.” However, what most podcast listeners don’t realize is that these types of guidelines are often heavily influenced by pharmaceutical company interests 20 clinicians and researchers recruited to serve on the 2017 NAMS Hormone Therapy Position Statement Advisory Committee, 10 of whom reported financial conflicts of interest. NAMS admits that the organization’s funding comes in part from “corporate charitable contributions” — that is, pharmaceutical companies.

Unfortunately, the messages our patients end up hearing about menopause are often carefully crafted by corporations that put their own interests first, whether it’s pharmaceutical or health technology companies. Although the narrative presented seems empowering, it is only part of the story.

As clinicians, we need to equip our patients with a more complete understanding of the various factors and forces that shape these messages. Knowing the whole story is what’s really empowering.

*Him in this case because most family doctors are men.

Shannon Casey, PA-C, is a physician assistant and former assistant professor in the Department of Family Medicine at the University of Washington. She writes to The medical atlas.