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NEWS BRIEFING and EXPERT REACTION: Are we over-medicalising menopause?

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***Briefing recording now available*** Viewing menopause as a health problem to be solved with hormone therapy is an over-simplified narrative and not based on evidence, according to Australian researchers. A series of literature reviews and opinion pieces publishing in The Lancet suggest we may be over-medicalising menopause and argues that a broader approach to empower women and go beyond a focus on specific medical treatments is required.

Across four papers, the series explores:

  • Evidence around symptoms commonly attributed to menopause and their treatments
  • How women can be empowered to navigate menopause
  • Gaps in research and support for those experiencing early menopause or cancer treatment-induced menopause
  • The assumption that menopause often causes mental health problems and how to identify at-risk groups in need of support.

Journal/conference: The Lancet

Link to research (DOI): 10.1016/S0140-6736(23)02799-X

Organisation/s: The University of Melbourne, The University of Queensland

Funder: This Series lead author, Martha Hickey, is funded by an NHMRC Investigator Grant. See individual papers for more funding information

Media release

From: The Lancet

Speakers:

  • Professor Martha Hickey, Department of Obstetrics and Gynaecology at the University of Melbourne and Head of Menopause Services at the Royal Women’s Hospital in Melbourne
  • Professor Gita Mishra, NHMRC Leadership Fellow at the University of Queensland School of Public Health
  • Dr Lydia Brown, Senior Lecturer of Psychological Sciences at the University of Melbourne

Date: Tue 05 Mar 2024
Start Time: 10:00am AEDT
Duration: Approx 1 hour
Venue: Online - Zoom

**Embargo: 19.00 [UK time] / 2.00pm [ET] Tuesday 5th March 2024 / 06:00am [AEDT] Wednesday 6th March 2024**

***Please note the unusual embargo time***

Peer-reviewed / Literature review, opinion / People

Embargoed access to the papers and contact details for authors are available in Notes to Editors at the end of the release. There is an embargoed Australian Science Media Centre press briefing on the Series, details in Notes to Editors. 

The Lancet: Experts warn about the overmedicalisation of menopause and call for a new approach to how society views menopause and supports women as they age

  • Menopause is a life stage for half the world’s population and is generally depicted in a negative way. However, women’s experiences of menopause are unique and vary hugely. 
  • The Lancet 2024 Series on menopause argues that an over-simplified narrative of menopause as a health problem to be solved by replacing hormones is not based on evidence and deflects attention from the need for substantial societal shifts in how menopause, and midlife/older women in general, are viewed and treated around the world.
  • The Series highlights how some groups, such as those who experience early menopause or cancer treatment-induced menopause often do not receive optimal care.
  • The Series questions the assumption that menopause often causes mental health problems and identifies specific at-risk groups who may need additional support.
  • The authors argue that a change in the narrative to view menopause as part of healthy ageing would reduce stigma and overmedicalisation, empowering women to navigate this life stage, acknowledged and supported by clinicians, researchers, workplaces, and wider society.

A new approach to menopause that better prepares and supports women during midlife is needed – going beyond medical treatments, to empower women using high-quality information on symptoms and treatments, empathic clinical care and workplace adjustments as required, says a new four paper Series published in The Lancet.  

Series co-author, Professor Martha Hickey, University of Melbourne and Royal Women’s Hospital (Melbourne), says “The misconception of menopause as always being a medical issue which consistently heralds a decline in physical and mental health should be challenged across the whole of society. Many women live rewarding lives during and after menopause, contributing to work, family life and the wider society. Changing the narrative to view menopause as part of healthy ageing may better empower women to navigate this life stage and reduce fear and trepidation amongst those who have yet to experience it.”  

She continues, “The experience of menopause differs for every person. Our Series calls for an individualised approach where women are empowered with accurate, consistent and impartial information to make informed decisions which are right for them over the menopause transition. This may include taking menopause hormone therapy (aka HRT) for symptoms such as hot flushes and night sweats, which can range from mild to extremely debilitating, after a discussion with their doctor about the risks and benefits. Whilst some women may also choose psychological therapies such as cognitive behavioural therapy to reduce the psychological impact of hot flushes and night sweats and improve sleep.”  

Menopause as a part of healthy ageing

In many societies the topic of menopause has long been a taboo subject. Now, countries such as the UK, the USA and Australia are experiencing a ‘menopause moment’, with more open discussion across politics, workplaces and the media.  

Whilst welcoming the increase in awareness of menopause, the Series’ authors raise concern about the media’s tendency to focus on extreme negative experiences of menopause, depicting it as an unfortunate and distressing experience heralding a critical downturn in women’s health which can only be solved by hormone replacement.  

“Whilst it’s certainly the case that some women have extremely negative experiences of menopause and benefit from hormone therapies, that isn’t the whole picture. The reality is much more complex and varied, with some women reporting neutral experiences and others highlighting good aspects, such as freedom from menstruation and menstrual pain. Menopause is having a cultural moment, and this is an opportunity for it to be recognised as a natural part of healthy ageing for women which, with the right preparation and support, is not something to fear,” says Dr Lydia Brown, University of Melbourne. 

There is a widely held belief that menopause is associated with poor mental health, however a review of 12 studies, published as part of the Series, which investigates the association between the menopause transition and depression does not confirm this. Two of the 12 studies report increased depressive symptoms over menopause, but three found no such increase and the remaining seven studies report mixed results. After reviewing these studies and others, the Series’ experts conclude there is no robust evidence that risk of anxiety, bipolar disorder, psychosis or suicide increases for all women over the menopause transition. 

Empowered women with support across society 

The Series calls for healthcare professionals, researchers, workplaces, and wider society to support the empowerment of women during menopause, ensuring they have the knowledge and self determination to make informed decisions and can seek effective help if needed. 

Healthcare workers can support their patients by validating their experiences and providing balanced and consistent information about symptoms and treatment options if required, encouraging women to discuss their individual preferences to reach shared decisions. 

A review of evidence on menopause symptoms highlights that hot flushes and/or night sweats affect up to 80% of women, with over a third (38%) describing these symptoms as moderate to severe at age 50 years. [1] 

The most effective treatment for hot flushes and night sweats is hormone therapy - often referred to as Menopausal Hormone Therapy (MHT) or Hormone Replacement Therapy (HRT). Treating hot flushes may also improve sleep and mood and MHT prevents fractures in weak bones. However, evidence on the benefit of menopause hormone therapy on other symptoms associated with menopause and ageing in women is lacking. [2] 

“There are several medications for menopause symptoms available as prescriptions that can be crucial tools in helping some women manage hot flushes and night sweats, possibly also leading to improved sleep and quality of life. These include menopause hormone therapy and non-hormonal alternatives, including newer agents targeting the neurokinin receptor such as fezolinetant. Information about these treatments, their benefits, risks, and comparative effectiveness should be made readily available to women seeking medication with the support of healthcare professionals. MHT is the best-known medication and data suggests it’s slightly more effective than alternative medications for treating hot flushes and night sweats. However, no medication can reliably resolve all negative experiences during menopause and commercial interests have influenced how MHT is presented - overshadowing evidence-based alternative options,” says Dr Andrea La Croix, University of California San Diego Herbert Wertheim School of Public Health and Human Longevity Science. 

“As well as menopausal hormone therapy, clinicians should discuss additional ways to manage some menopausal symptoms, such as cognitive behaviour therapy for hot flushes and night sweats. CBT may also reduce stress and improve sleep and mood. Lifestyle changes addressing diet, smoking and exercise may additionally benefit sleep and mood and improve long-term health. Some don’t wish to take menopause hormone treatment unless their symptoms are severe and prefer to use other approaches. Our Series is all about increasing awareness of evidence-based options for women, so they can choose how they wish to navigate menopause, free from judgement and stigma,” adds Professor Myra Hunter, King's College London. 

Unfortunately, commercial interests, such as organisations who are marketing menopause products to consumers including pharmaceutical companies and private providers, have strongly influenced media messaging about menopause and MHT. In this messaging, across both news media and social media, the small but serious risks of MHT are often downplayed or ignored. This Series argues that women should have access to accurate and evidence-based information about menopause in a form they can understand, created without undue commercial influence, such as the NIH funded My Meno Plan website in the USA. [3] 

The authors also call for more research into aspects of menopause that are a priority for women. For example, a global Menopause Priority Setting Partnership is underway across more than 40 countries to develop a new, patient-focused research agenda. [4]  

Workplaces, by the creation of open, inclusive and supportive cultures, have a role to play in supporting women during menopause. According to the UK Health and Safety Executive, women aged 45-54 report more work-related stress than men or women of any other age group, associated with high job demands, lack of control and lack of support. [5] A qualitative study of 137 women reported that women want their managers to be informed and empathetic about menopause and understand how the work environment might exacerbate their symptoms. [6]  

The authors highlight how, through resources such Menopause at Work, employers can implement evidence-based and practical policies to support their employees including via education, conversations and flexible working hours. [7]  

In addition to clinicians, researchers and workplaces, the authors highlight the need for a substantial societal shift in the views of midlife and older women, with a greater appreciation of their considerable contribution to society, their skills in the paid and unpaid workforce and how they often care for families across generations, 

"There is a lot we can learn about attitudes to menopause and growing older in general from communities, such as many Asian cultures, where ageing in women confers respect and status, rather than stigma. Everyone can play a part in shifting society’s view of older women by engaging in conversation - such as those organised by the Menopause Cafe where people of all genders and ages gather to discuss menopause and share tips, questions and experiences,” says Rachel Weiss (not an author), founder of Menopause Cafe charity. [8] 

She continues, “The pendulum has swung from 'put up and shut up' about menopause to sensationalising it. It's good that we are talking more about menopause, now we need to swing the pendulum to the middle and normalise menopause, so that anyone who wants to talk about it can, so that people are not scared of it and so that a diverse experience of menopause is depicted in the media, not just celebrity horror stories.” 

Some women need specific care 

Globally, around 10% of women experience menopause prematurely (under age 40) or early (between the ages of 40 and 44). There are often delays in diagnosis and some women experience feelings of distress and isolation. There is also evidence to suggest women who enter premature or early menopause may have an increased risk of conditions such as cardiovascular disease, and osteoporosis (fragile bones). Use of MHT may reduce these risks. 

People with cancer are more likely to experience early menopause or menopause symptoms due to treatment. For example, endocrine therapy for breast cancer can cause hot flushes and/or night sweats that may be more severe and prolonged than natural menopause. Women with cancer often report a lack of centralised care and access to safe and effective treatments for their menopause symptoms. 

Menopause does not usually cause mental health problems, but those with severe hot flushes/night sweats, previous clinical depression or recent stressful life events are at an increased risk of depression. There should be greater awareness and support for this group. Whilst MHT helps with hot flushes and night sweats, it is not a treatment for depression and clinicians should offer evidence-based treatments depending on severity and patient preference. [9] 

Greater awareness, better understanding of mechanisms, new treatments and additional support for people who experience early menopause, menopause after cancer treatment and/or who are at a higher risk of depression over the menopause transition, is urgently needed.  

The Series concludes all women should have access to realistic and balanced information about menopause and possible experiences, effective treatment as needed and shared decision-making to better equip them to navigate this life stage.

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Expert Reaction

These comments have been collated by the Science Media Centre to provide a variety of expert perspectives on this issue. Feel free to use these quotes in your stories. Views expressed are the personal opinions of the experts named. They do not represent the views of the SMC or any other organisation unless specifically stated.

Associate Professor Michelle Wise FRANZCOG, Department of Obstetrics and Gynaecology, FMHS, University of Auckland, comments:

"I am pleased that such a prestigious journal has chosen to focus on menopause, given it affects half the population. The quality of the writing and such an excellent summary of current research evidence makes this a must-read for all clinicians."

Comments on Paper 1

"I could not agree more with the premise that we should support women going through menopause in a holistic manner and consider all aspects of health and well-being, rather than regarding this phase of life as a disease. As a Gynaecologist in a large urban hospital, I  unfortunately hear from many of my patients that they are initially dismissed by their families, friends and health practitioners when they present with menopause symptoms. In New Zealand, a good source of evidence- based information is the Australasian Menopause Society (www.menopause.org.au).

"It is crucial to have information on all aspects of menopause; a decision aid takes women and their clinicians through a values- and preferences-based exercise that can be the basis for a shared decision-making model about best treatment options. A great resource to prepare for these conversations can be found at https://mymenoplan.org. Many women will not want treatment per se, but can be empowered with balanced information, empathy, validation and unbiased help with making decisions.

"For women who seek treatment, Menopausal Hormone Therapy (MHT) is the most effective treatment for hot flushes and night sweats, alongside many other symptoms that are attributed to menopause such as difficulty sleeping and decline in memory and concentration. MHT also improves overall quality of life. Not all MHT formulations are funded in New Zealand; some are partially funded (such as Kliovance) and others not at all (such as EstroGel, Vagifem, Duavive).

"The most effective non-hormonal therapy for improving hot flashes, sleep and mood is cognitive behaviour therapy, but this is usually available only in the private sector. Other non-hormonal therapies with research evidence supporting their use to improve hot flashes are clinical hypnosis, SSRI, gabapentin, and oxybutynin. The newest medication is Fezolinetant, but this is not available in New Zealand.

"What concerns me is the amount of inaccurate information found all over the internet and social media, and the amount of money spent by women on all kinds of supplements and therapies that have not been tested at all or have been tested and found to be not helpful for menopausal symptoms. It behooves us to do better by women. We are increasing teaching about menopause at University of Auckland medical school and developing a short course to upskill and train General Practitioners in menopause care."

Last updated: 06 Mar 2024 8:08am
Declared conflicts of interest:
No conflicts of interest declared.
Professor Jayashri Kulkarni is the Director of HER Centre Australia at Monash University

Menopausal mental ill health can be serious and debilitating for many women. Women’s lives are busy and complex but the hormone changes in the brain can be a ‘tipping factor’ causing anxiety, depression and ‘brain fog’. Of course most women do not experience adverse mental health issues related to menopause, but there is a significant group of women who experience severe depression, anxiety and brain fog that impairs their functioning at work or in their relationships.

There is considerable brain biology research showing the impact of fluctuating gonadal hormones changing brain chemistry and circuitry causing mental ill health. Population surveys are the wrong method to tackle menopause mental illness. Hormone therapy has been shown clinically to be effective in treating menopausal mental ill health thereby helping women resume a good quality of life.

Women with menopause-related mental illness demand and deserve better treatment than standard antidepressants that only provide partial respite. The voice of these women must be heard, and effective treatments must be offered to her, so she can make an informed decision about her best options.

Last updated: 05 Mar 2024 1:46pm
Declared conflicts of interest:
None declared.
Gino Pecoraro OAM is Associate Professor of Obstetrics and Gynaecology at the University of Queensland and President of the National Association of Specialist Obstetricians and Gynaecologists (NASOG). He is also a practising obstetrician and gynaecologist in private practice in Brisbane.

Every woman on the planet will eventually go through menopause. For some this is a relatively benign normal transition and routine part of healthy ageing but for others, debilitating symptoms can adversely affect daily living and functioning.

While it is laudable that menopause and its many presentations is finally being spoken about more openly in both the medical literature and the general population, we must be careful not to undo any good that has already been done and throw out the baby with the bathwater.

No doctor treating a woman suffering from menopausal symptoms would deny the role of empowerment and nonpharmacological treatments to help sufferers better deal with this transition. However, there remains a place for symptom control with hormonal and nonhormonal medical therapies. We must not forget that HRT [hormone replacement therapy] can have other incidental beneficial effects such as a 50% reduction in osteoporotic fracture.

Rather than trying to pitch one model of treatment over another, wouldn’t it be great if women and their doctors were aware of all treatment options and individualise treatment to the particular needs of each woman seeking their help?

Last updated: 05 Mar 2024 1:46pm
Declared conflicts of interest:
Gino has given presentations for a wide range of pharma companies that make HRT products and has run workshops and lectures for GPs that have been organised and funded by multiple pharma companies
Professor Mark L Wahlqvist AO is Emeritus Professor and Head of Medicine, Monash University and Monash Medical Centre. He is also Past President of the International Union of Nutritional Sciences

In this first of 4 Lancet papers in review of the menopause, Martha Hickey and colleagues challenge its societal stigmatisation which has been developed and reinforced among health care professionals. It has also been underwritten by products and approaches to correct what has been regarded as an endocrine deficiency disorder, primarily of oestrogen.

What are normal phases in a woman’s, a family’s and the community’s intergenerational reproductive life course merit more integrative socioecological recognition and support. Hence the framing of the present report as that to do with ‘empowerment ‘in menopause management. It has become evident why so many studies of interventions before, during or after the menopause have been found controversial, ineffective, or of limited value. It is because it manifests with a high degree of individualism, cross-cultural difference, and with multifactorial and multisystem modulation of any pathophysiology of the cessation of ovulation. 

As one involved in the recognition and development of food phytoestrogenicity in my early career, it has been instructive to learn that single food factors are rarely if ever superior to foods and dietary patterns in accounting for any healthful nutritional biology; and that, throughout life, except when we require and benefit from breastfeeding, there is not more reliable nutritional guidance than that dependent on sufficient physical and social activity and a biodiverse diet dependent on sustainable food and ecosystems.

Women, since perinatal mortality has been minimised, consistently live longer than men. If not impoverished and hungry, they are experiencing marked improvements in disability-free longevity, irrespective of the menopause. The empowerment of women during their reproductive transition benefits them and those who look to them for their changing, not lesser, place in households, workplaces and community, and in generations to come!

Last updated: 05 Mar 2024 1:45pm
Declared conflicts of interest:
None declared.
Professor Susan Davis is a NHMRC Investigator and Professor and Director of the Women's Health Research Program at Monash University

Four papers published pertaining to menopause in The Lancet are not about new research findings but offer opinions as to how menopause might be viewed and how the experience of menopause might be optimised. 

It is disappointing that the lead article states that 'the principles of health empowerment have not been applied to menopause' when empowerment of women to best navigate their menopause, through the provision of credible health information to support informed and shared decision-making, has been the focus of national and international organisations (such as the Australasian and International Menopause Societies and Jean Hailes for Women’s Health) for many years. 

The papers raise the important concern of potential misattribution of an array of psychological symptoms to menopause. While this is also not a new concept, it is consistent with other recently published reviews and highlighting this concern reinforces the message to women and clinicians not to blame every symptom on menopause.  

The authors stress that most women will not experience debilitating menopausal symptoms. Nevertheless, they acknowledge that 60-80% of women will have menopausal flushes and sweats that can last, on average, about 7 years, and that for 1 in 3 women these can be quite severe. 

The authors caution against 'over-medicalisation' of the menopause but the messaging regarding [hormone] therapy is mixed, and potentially confusing. For example, it is stated that 'The North American Menopause Society recommends specific MHT [menopausal hormone therapy], gabapentin and oxybutynin which have mild to moderate efficacy and reduce hot flushes by 1-2 per day with no significant improvement in menopause-related quality of life'.  But, further on it is stated that MHT is effective (reduces flushes by 2-4/day) and improves health-related quality of life. Of concern is the promotion of gabapentin and oxybutynin, neither of which are approved in any country for the treatment of menopausal flushes/sweats (vasomotor symptoms) and data for oxybutynin is notably scant.  In contrast fezolinetant, which has been approved in the UK, EU, Australia and the US specifically for vasomotor symptoms, has been downplayed to being only modestly effective despite robust evidence which is lacking for these other nonhormonal therapies.

The importance of bone loss at menopause is also recognised together with the effectiveness of MHT for fracture prevention, but other long-term effects of menopause on health are called to question. This conflicts with other highly regarded expert opinions [see here and here] and this in turn demonstrates that this Lancet series needs to be seen as only one interpretation of the published research. 

The authors seem determined to minimise the important role of MHT in helping many women as they reach menopause. They ignore other published systematic reviews which all agree that MHT is the most effective treatment for vasomotor symptoms, is as effective as other bone-specific therapies (antiresorptive agents) in reducing postmenopausal osteoporosis and associated fractures and, unlike some antiresorptives, is not associated with an increased risk of fracture upon stopping treatment.

Current guidance from international and national menopause societies, including Australia and New Zealand all speak to empowerment of every woman at this pivotal stage of her life. They also stress the importance of an evidence-based approach and, importantly, offering each woman the care, support and, where required, treatment she seeks to help her on her journey.

Nonetheless, in general these papers align with, and support the latest internationally and nationally endorsed best practice guidance for menopause published in 2023, Practitioner Toolkit for Managing Menopause, with open online access for women and clinicians to facilitate health empowerment, as recommended by these papers.

Last updated: 05 Mar 2024 1:43pm
Declared conflicts of interest:
Susan is a past President of the International Menopause Society and Australasian Menopause Society and a NHMRC Leadership 3 Investigator. She has prepared and delivered educational presentations for Besins Healthcare, Abbott, Mayne Pharma, has been on Advisory Boards for Theramex, Astellas, Abbott Laboratories, Mayne Pharma and Gedeon Richter and has received institutional grant funding for Que Oncology and Ovoca Bio research.
Rodney Baber is a Professor of Obstetrics and Gynaecology at the University of Sydney
Last updated: 05 Mar 2024 1:41pm
Declared conflicts of interest:
Rodney is a past President of the International Menopause Society and Australasian Menopause Society. Rodney has prepared and delivered educational presentations for Besins Healthcare, Abbott, Viatris, and Pfizer Australia and has served on medical advisory boards for Theramex, Mayne Pharma, Astellas and Besins Healthcare.

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