Hot flashes, mood swings, "brain fog," joint pain, insomnia and weight gain.
Most women in their late 40s and 50s will immediately recognize the symptoms of menopause. While up to 80 per cent of menopausal women will experience some symptoms, up to 25 per cent will suffer enough to seek medical relief.
And yet, not only are far too many women not prepared for "the change of life" when it comes, say experts in mature women's health, widespread ignorance is causing unnecessary harm.
It prompted U.K. women's health activist Diane Danzebrink to launch a national awareness campaign called #MakeMenopauseMatter, devoted to providing training for physicians, guidance in the workplace and curriculum in sex education.
"There's not enough awareness, especially on the mental health issues, and we need to be talking more about it," said University of Alberta pharmacy professor Nese Yuksel, who is on the board of the Canadian Menopause Society and a menopause clinic team member at the Lois Hole Hospital for Women.
"Many women talk about issues with concentration and memory. They can't think of words, can't focus or remember things," said Yuksel. "Some women, especially during perimenopause when the hormones are fluctuating, may deal with depression or mood swings. Some have severe enough symptoms that they need to take time off from work.
"Others think they're having a panic attack when hot flashes and heart palpitations hit them for the first time in the middle of the night."
Finding a menopause specialist or clinic can be hard, and waiting for a consultation can take up to 18 months.
"We need to educate health professionals," said Yuksel. "There are lots who are open to it, but some feel uncomfortable with the topic, or with the use of hormone therapy, because there's still a lot of fear of the unknown," around a subject long considered taboo.
Definition
The word menopause originates from the Greek words "mens" and "pausis," meaning monthly and cessation. It denotes the phase in a woman's life when her ovaries produce lower levels of the hormones estrogen and progesterone, periods cease and she can no longer become pregnant.
The average age of menopause in North America is 51, but it can vary between 45 and 55. Many women will start experiencing symptoms during perimenopause, which can occur up to five to 10 years before menopause.
In some cases, women can go into menopause early, said Yuksel, which is defined as before age 45. Early menopause can occur from surgery, when both ovaries are removed, or from the use of chemotherapy or radiation to treat cancer or autoimmune diseases.
"Often those women have more difficulty as their symptoms can be sudden and severe. They describe their condition as crashing-major mood swings, hot flashes, night sweats-and they feel their life has fallen apart.
"Women often feel they lack adequate resources to help them deal with the symptoms of early menopause."
Men also go through a midlife decline in testosterone, called "andropause," which may cause many of the same symptoms, mainly night sweats, fatigue and loss of libido. However, it usually happens more gradually and is less pronounced. Treatment is required only in extreme cases.
Mental health impact
In a 2018 BBC survey of women in the U.K. in their 50s, half reported that menopause adversely affected their mental health. And while 41 per cent said it interfered with work, 70 per cent of them were unwilling to tell their employers when suffering symptoms. One in four considered resigning.
"Though we have not done a similar study in Canada, the same is likely true of Canada," said Yuksel. "We need more workplace understanding, just as we do for mental health issues."
When women have pre-existing mental health issues, the onset of menopause can be compounded.
"Maybe they're doing OK coping with the stresses in their life, and then the hormones come into play, the 'earthquake' strikes and they can't control the mood symptoms they are experiencing," said Yuksel. "But it's important to remember, it's not just in your head-there is a physiological reason for it."
There is also a strong relationship between estrogen and the neurotransmitter serotonin. As estrogen falls, it can decrease serotonin levels as well as affect the serotonin receptor, which can lead to depression and other mood problems.
Women may have worse mood swings during perimenopause, when hormone levels are fluctuating.
"Women who've had clinical depression, postpartum depression or depression linked to PMS in the past may have more mood issues during the menopause," she said.
According to a study published in the U.S. National Library of Medicine, the suicide rate among women jumps between the ages of 45 and 54, since "mental health disorders can have devastating impacts on women as they approach menopause."
U of A researcher Sue Ross, the Cavarzan Chair in Women's Health Research, said a common complaint she hears in focus groups with menopausal women is the absence of a sympathetic ear.
"They talk about getting an eye-rolling response when they try to talk about it," said Ross. "People just say 'get over it.'
"But those focus groups were the most animated I've ever seen. You learn about things in people's lives you'd never expect them to speak about in public. Because they were experiencing the same things, they found it therapeutic … somebody else is suffering to the same degree."
Treatment options
According to Yuksel, the biggest health risks come with early menopause.
"If women go into it before the age of 45, and especially before 40, they're at much bigger risk for osteoporosis and cardiovascular events later in life," she said, because estrogen normally provides protection to the heart and bones at that age.
For most women with severe symptoms such as hot flashes, night sweats and fragmented sleep, hormone therapy is the best solution, said Yuksel. But it has suffered from a bad, largely unjustified, reputation.
"Back in the 1980s, we had many women on hormone therapy," she said. "The estrogen drug Premarin was the number one prescribed drug. At that time the practice was to use hormone therapy for long-term health benefits, like protection against heart disease and osteoporosis."
But a 2002 study by the Women's Health Initiative, launched to find evidence for long-term health benefits of hormone therapy such as heart disease, found instead an increased risk of heart disease and breast cancer with the use of estrogen and progestin. It caused many women to stop using hormone therapy, and health professionals to stop prescribing it out of fear.
However, in Yuksel's estimation the results have been misinterpreted, overstating the risks, particularly to younger women. In the WHI study, hormone therapy was provided to older women who were not symptomatic.
"The average age was 63, so they were mostly in their 60s without menopausal symptoms," she said. "But the likelihood of these risks increases as you age anyway. The misinformation spread through the media continues to this day and still causes fear."
Wary of estrogen drugs, many women will experiment with complementary and alternative medicines (CAMs). But their effectiveness is limited, largely unproven and some treatments come with their own risks, according to Tami Shandro, a menopause clinic team member at the Lois Hole Hospital for Women.
"The success of those will vary from woman to woman. And while they may help, most women should lower their expectations around menopause symptom improvements obtained by CAMs," said Shandro.
CAMs are not well researched, and the studies that have been done tend to look only at vasomotor symptoms such as hot flashes, flushing and night sweats, explained Shandro.
In Yuksel's estimation, hormone therapy is the most effective treatment for menopause symptoms, especially for hot flashes and night sweats, and it can also help with sleep, she said. For perimenopause, some studies have shown benefit in mood improvements.
Current menopause guidelines recommend hormone therapy for symptomatic women under 60 years of age or within 10 years of entering menopause.
The treatment uses estrogen and progesterone: estrogen is used to help with the menopausal symptoms. If used alone, it can build up the lining of the uterus and put a woman at risk of uterine cancer.
The progesterone is added to counteract the effects of the estrogen on the uterine lining and reduce the risk of uterine cancer. In women who have had a hysterectomy, estrogen can be used by itself.
Yuksel admits hormone therapy may not be an option for women with a strong family history of breast cancer or if they have had a blood clot in the past. Alternative treatment options include non-hormonal prescription medications. She suggests women talk to their physician or health-care provider to determine which option is best.
Lifestyle measures such as cooling and avoiding triggers, quitting smoking, exercise, weight loss, mindfulness and cognitive behavioural therapy can also help women dealing with symptoms.
Cultural component
According to the Canadian Women's Health Network, the experience of menopause can vary across cultures, depending partly on how it is perceived. In Japan, for example, women report fewer hot flashes, while Greek women report more. Thai women have more headaches, Scottish women report fewer severe symptoms and Mayan women report no symptoms at all.
One study in the journal BMC Women's Health notes that because women in Islamic and African societies no longer have to observe strict gender roles, they "appear to have lower reporting of symptoms, possibly due to the positive role changes associated with the menopausal transition."
The study also showed that social disadvantage has been associated with earlier menopause, and lower educational attainment has been linked with an increase in symptoms.
In her own work with Indigenous women in Maskwacis, a community about 45 minutes south of Edmonton, Ross found that women elders valued menopause because it signalled a new, more meaningful role in life.
"They have positive sayings like, 'May you have gray hair.' That doesn't happen in our culture, where everyone is trying to avoid it," said Ross.
"They talk about how they're not able to dance when they're menstruating, and there are other restrictions on the cultural things they can do. The Elders I work with are the most hard-working people you could ever meet-they know they're needed in their community."
While they may be more accepting of the aging process, the women of Maskwacis still felt they weren't well enough informed about what to expect, and weren't able to pass on reliable knowledge to their daughters, said Ross. So she worked with them to develop pamphlets for the community's health centres.
Ross is also working with U of A psychiatrist Vincent Agyapong on a text-messaging program to help women through menopause. Similar to "Text4Mood," already available on the Alberta Health Services website for mental health support, it would send out encouraging text messages along with advice from the Canadian Menopause Society on how to deal with symptoms.
Both Ross and Yuksel agree the big challenge is public education. They say there's a lot more we could be doing to finally shed light on a natural consequence of aging.
But it won't happen without sufficient political will.
"Public education is all fine and well, but somebody has to organize and pay for it," said Ross.
The Cavarzan Chair in Women's Health Research and Ross' study are funded by supporters of the Lois Hole Hospital for Women through the Women and Children's Health Research Institute.