Janet Ko thought menopause was going to be great. She expected a few hot flashes but was looking forward to not having a period or worrying about pregnancy. She was at the peak of her career in a senior leadership position when she began having joint pain, palpitations, brain fog and up to 20 of those hot flashes a day.
“I went through that journey that many women go through of being confused, not knowing what’s happening,” she says.
It was a long, winding path back to health and wellness for Ko. Wanting to break the stigma and silence surrounding menopause, she co-founded the Menopause Foundation of Canada (MFC) with Trish Barbato.
It’s a universal experience for women who live long enough, yet patients and physicians often are not prepared for the menopausal transition. Last year, MFC released a report showing that nearly half of women said they felt unprepared. Seven in 10 women who sought medical advice found the information they received to be unhelpful or only somewhat helpful.
“Our needs related to menopause have largely been overlooked and ignored, and yet we can’t afford to do that because it’s not just women’s health that is impacted,” says Ko. “Women are, in so many ways, the heart of their families and the backbone of any highly functioning society. So, if women’s health suffers, their families suffer, their communities suffer, their ability to contribute at the highest levels at work suffers.”
Nathalie Gamache, a gynecologist who completed fellowship training in menopause, traces many of the current gaps in menopause care back to the Women’s Health Initiative (WHI) study that raised concerns about the safety of hormone therapy (HT). Published in 2002, the WHI’s findings were widely shared by the media. Gamache says she recalls her hospital’s menopause clinic fielding 2,000 worried patient phone calls in three days. Within months, the number of women taking HT worldwide had declined precipitously.
Instead, patients often were offered what Gamache refers to as “the cocktail of menopause,” consisting of antidepressants, anti-anxiety medications and sleeping pills to treat individual symptoms of menopause instead of the root cause.
“Every single day since that study, I’ve been faced with a patient who was told that this was the new normal and she should just get used to it,” says Gamache.
One woman, who asked not to be named because of potential job consequences, told Healthy Debate she believes she was fired due to severe brain fog. Initially, she focused on exercising, reducing alcohol and adopting a plant-based diet to address her symptoms.
She didn’t want to take HT because she had heard about the WHI study and was scared by the possibility of a heart attack. “I now regret [that] bitterly,” she says. After talking to friends who were taking HT, she did eventually try it and found it helpful. “I feel good again,” she says.
One of the issues with the WHI was that the average age of patients in the study was 63, but most women seek help for perimenopausal and post-menopausal symptoms in their 40s and 50s. Further research has shown that for patients without contraindications who are less than 60 or within 10 years of menopause onset, HT is effective and carries little risk.
Gamache wants to shift the perception of HT. “If you are having a perceived fear of risks of hormone therapy, what is the real risk of not doing it? What is the risk of having 20 years of insomnia on your health, for heart disease, diabetes, hypertension, stroke, cancer?” she asks. “We don’t think about it the right way.”
Gamache says that following the WHI’s publication, there was a ripple effect on how physicians were taught.
“I was told to stop teaching about menopause and hormones because what was the point if we could not do anything about it?”
“I was told to stop teaching about menopause and hormones because what was the point if we could not do anything about it?” she says. “We’re now on generation number three of doctors who keep perpetuating that hormones are dangerous … and it is so, so, so false. This was all corrected, but it never came back to the surface.”
Gamache adds that many health-care practitioners are still reluctant to prescribe HT. “Not because they can’t absorb the topic or concepts, but because we fail them in our medical education,” she says.
Shafeena Premji, a Calgary-based family doctor who holds certification from the North American Menopause Society and is one of only two family doctors on MFC’s medical advisory committee, agrees that education is key, not just within medical school and residency curriculums but also for practicing physicians.
Premji says MQ6 is an online resource that is easy to access and gives health-care providers and patients a simple way to assess menopausal symptoms. The website includes a treatment algorithm and decision tool to help counsel patients about treatment options. She tells patients that HT has a role but it is not a magic pill. “It is not going to treat all your symptoms, and sometimes your symptoms are not actually menopause related.”
Premji says that the need for better menopause care is a primary care issue. “We are on the frontlines seeing these patients needing help, needing support, and trying to figure out how to navigate the whole system,” she says.
Premji’s waitlist for menopause consultations is currently eight months long. She says that because there are so few providers of menopause care across the country, women are vulnerable to misinformation and may end up paying for unnecessary testing and treatments that are not safe or effective. She encourages women to look for providers who are certified by the North American Menopause Society and who follow NAMS guidelines, and to ask if they are being prescribed Health Canada-approved products.
Ko says that the gaps in menopause care are an injustice for women. “Women are being denied treatment because their health-care practitioners are either not confident in prescribing or don’t have the information to allow them to do that,” she says. “So that takes agency away from women.”
“The reality is that for the overwhelming majority of women, their situations are not complex. They shouldn’t be referred to a menopause specialist like an OB-GYN.”
Ko says that menopause is often viewed negatively because our culture devalues women as they get older, but she wants women to feel empowered and supported to be able to embrace this stage of life. Her foundation has three goals: closing the knowledge gap for women, improving access to menopause care and treatment and creating menopause-inclusive workplaces.
“We have to really change the conversation on aging, which means we change the conversation on menopause, which is all about empowering women to live their best life and unleash the incredible potential that is there,” she says.
“We’re in the prime of our lives, and we have so much to contribute,” she says. “I think Canada has an opportunity to lead the way. But it means that we need to make some changes, and I think women ourselves, we’re the ones who are going to be leading the change because we’re going to expect more.
“We’re not going to silently suffer through these symptoms and live a lesser quality of life when we know that there are things we can do to change that.”
Though gendered language is used in this article, the author acknowledges that not all people who experience menopause may identify with this language.