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Menopause: How ‘the change’ has changed

By Dr. Suzanne Koven
Globe Correspondent / January 23, 2012
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Don’t talk to my patient Shelley about hot flashes. Don’t mention mood swings, racing heart, or mental fogginess, either. Though Shelley had all these - and more - at about 52, they don’t begin to describe the disability she experienced at menopause.

For Shelley, a bright and fit businesswoman, menopause was not the gentle life transition it is for many, nor a time in which various symptoms, inconvenient but transient, occurred. For Shelley, menopause was, as she put it, “horrific.’’

In the months before and after her last menstrual period, Shelley had every known physical and psychological symptom of menopause except migraine headaches: hot flashes, drenching sweats, palpitations, gastrointestinal distress, difficulty concentrating, low libido, and anxiety.

Especially unbearable was heat intolerance. Shelley’s inability to stand being outside in warm weather dominated her travel and social plans: She scrapped her dream of going on safari, and even a day trip on a friend’s boat was out of the question.

Perhaps even harder to handle than any of these symptoms, though, was Shelley’s sense that she had lost control over her own life. Patients who are ill often express a feeling of helplessness, but Shelley wasn’t ill. A perfectly normal physiological process had sent her into a tailspin in which she felt betrayed. “My body,’’ she declared, “turned against itself.’’

For much of human history, menopause wasn’t a problem because most women didn’t live long enough to reach it. A 100 years ago, the average age at which women in the United States died was 50 - tuberculosis and other infections were the most common killers. It’s only in the last few decades that the majority of women have survived well beyond their childbearing years.

A woman is menopausal when her menstrual periods have stopped for one year. The average age of menopause is 51, but many women have symptoms related to falling or erratic hormone levels for years before menopause, during what’s called perimenopause. Even though many women are not much bothered by menopausal or perimenopausal symptoms - some women even feel better than ever during this time - doctors have long thought of this normal decline in ovarian function as something to be “fixed.’’

Estrogen supplements were available as early as the 1930s and became wildly popular after a bestselling book, “Feminine Forever,’’ by Dr. Robert Wilson, appeared in 1966. The message of this book was that menopause is preventable, and that women who do not take estrogen after menopause are unhealthy and unattractive, and no longer truly women.

The women’s movement, not to mention the fact that women given high doses of estrogen developed blood clots and uterine cancer, dampened enthusiasm for Wilson’s argument, but hormonal treatment of menopause remained widespread for decades.

By the 1980s and ’90s, doctors no longer thought of menopause itself as a disease, but they did consider it a risk factor for diseases, including osteoporosis and coronary atherosclerosis. Combinations of estrogen, often derived from pregnant mare’s urine (hence the brand name Premarin), and progesterone became among the most frequently prescribed drugs in the Western world. When I entered practice in 1990, many of my patients had been started automatically by their gynecologists or previous internists on hormones at menopause, whether they had symptoms or not, because it was “good preventive medicine.’’

In 2002, research findings of the Women’s Health Initiative caused millions of women to tear up their hormone prescriptions overnight. The WHI found that hormone treatment did not prevent heart disease and, in fact, increased women’s risk for heart attack, stroke, and breast cancer (but it decreased risk of colon cancer and osteoporotic fractures). Researchers recommended that only women with severe menopause symptoms take hormones, and then only for up to five years.

Researchers are now revisiting the WHI results because the average age of the women in the study was 62 - well past the average age of menopause - and also because the hormones studied, including Premarin, were synthetic. It’s not clear whether younger women who take so-called “bioidentical’’ hormones will have the same cancer risk. Meanwhile, though, the WHI-based recommendations stand.

What’s fascinating about the evolution of knowledge about hormone replacement is that it has contributed to an evolving concept of menopause itself. In 50 years menopause has gone from a disease, to a risk factor for disease, to a set of relievable symptoms. Feminists such as Germaine Greer, in “The Change,’’ and Dr. Christiane Northrup, in “The Wisdom of Menopause,’’ have urged a reframing of menopause entirely. They would like to see menopause removed from the exclusive realm of medicine and returned to women to manage as they see fit: with alternatives such as meditation, acupuncture, and homeopathic remedies, or not at all.

In a recent essay in The Atlantic magazine marking the 10th anniversary of the publication of “The Wisdom of Menopause,’’ writer Sandra Tsing Loh suggests that perhaps menopause is a “return to normal’’ - that the years of fluctuating hormone levels associated with menstrual cycles are the “abnormal’’ part of a woman’s life and that in menopause, a woman is, as in childhood, her truest self.

But where does all this interpretation and reinterpretation leave a woman like Shelley? Alternative therapies and talk of female empowerment did not make a dent in her misery. She elected a trial of hormone treatment and, within days, felt much better. That was two years ago, and she is now trying to taper off hormones.

Shelley recently told me that it wasn’t only the hormones that relieved her symptoms, though. Reassurance that she wasn’t crazy and that she was going through a difficult but finite phase seems to have helped, too.

“What kept me going was the idea that there was an end game,’’ she said, “that it wouldn’t last forever, and that I would get back to being myself. Because that’s the hardest part: not being yourself.’’

Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. She writes a monthly column about the uncertainties, dilemmas, and stories that patients and doctors share in practice. Read her blog on Boston.com/Health. She can be reached at inpracticemd@gmail.com

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