Given how many women are affected by menopausal symptoms (about experience hot flashes, for example), menopause is an important subject to talk about. There seems to be a renewed popular interest in this, and recently, a certain widely-disseminated podcast episode was dedicated to the subject. In an effort to share high-quality, accurate information, the podcast hosts interviewed a physician who is regarded as a menopause expert. (For simplicity, I'll refer to the podcast hosts as The Host and the physician they interviewed as The Physician.)
However, in both this particular podcast episode and in the broader sociocultural conversation about menopause, some claims are shaping the narrative in concerning ways. As clinicians, we need to be aware of the messages influencing our patients. I'm not suggesting the messages are ill-intentioned -- in fact, quite the opposite. The push to demystify menopause and empower women are worthy goals that go hand-in-hand. But the history of medicine when it comes to menopause is incredibly fraught, and the subject warrants careful scrutiny.
Claim: Concerns about breast cancer have unduly robbed women of the benefits of hormone therapy
"Every time someone dares to whisper 'hormone therapy,'" The Host says, "[...] the reflexive response is, 'But it causes breast cancer!'" She laments how, according to her understanding, "the premature release of that early data [from the Women's Health Initiative] and the media frenzy caused millions of women to go off hormone therapy overnight and [...] robbed a generation of women from 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 in order to help facilitate evidence-based medical decision making, conducted a to help clarify the clinical effects of hormone therapy (HT) in perimenopausal and postmenopausal women. The review, which included 22 double-blinded randomized controlled trials, found: "In relatively healthy postmenopausal women, using combined continuous HT for 1 year increased the risk of a heart attack from 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 level of the individual can be complex, and we're always working with imperfect information. Some women experiencing intolerable menopausal symptoms may decide the benefits of hormone therapy outweigh the risks, and this could be a completely reasonable decision. But there's a big difference between destigmatizing an individual's well-informed medical decision and re-popularizing the use of hormone therapy at 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, The Host reports, "73% of women are never treated for their menopause symptoms." Curious where this number came from, I googled it and found a Forbes with the headline, "73% Of Women Don't Treat Their Menopause Symptoms, New Survey Shows."
Scanning the article, I looked for the original source of the statistic and found it almost immediately. The Forbes article indicates this number comes from "new research from Bonafide, a company that sells products to treat women's health conditions, 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 . What I found was not a research paper published in a reputable scientific journal but a polished set of slides that looked like a pitch deck.
Women need access to healthcare and deserve to have their menopausal symptoms taken seriously, but it's worth being aware of the bigger picture. Emerging direct-to-consumer health tech companies are seeking to broaden the market for their products and services, and women who are interested in treatment for menopause are a prime target. There's an unjust void, these companies claim. But no need to worry! We're prepared to step in and fill it. This isn't good medicine, it's Marketing 101.
Claim: Seeking treatment for menopause is a feminist act
The Host compares the way society treats erectile dysfunction and the way it treats menopause. She notes that information about the treatment options for erectile dysfunction is pervasive, whereas women are told that menopause is a natural process and they should "just deal." Because of the patriarchy, she argues, men experiencing erectile dysfunction are assured that they don't have to live like this. Meanwhile, women experiencing debilitating symptoms due to menopause are expected to adjust to a lower quality of life.
The Host has a point here, but framing menopause in this way runs the risk of undermining the patient/provider relationship. Consider a typical scenario: a woman presents to the clinic, tells her doctor about the menopausal symptoms she's experiencing, and lets him* know she'd like to start HT. He's reluctant due to the risks, and he uses the rest of the short 15-minute appointment to explain that, in her case, the risks of HT actually outweigh the benefits. Although the patient understands what he's saying, she mostly feels like he isn't taking her symptoms seriously. When she leaves without the prescription she came in 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 tech companies to step in. You don't have to deal with all that patriarchal nonsense. There's an easier way! Yet, although getting treatment for menopause through these companies may be easier, they may not be offering patients what's best.
Claim: 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 a great resource. A little while later, she adds, "[NAMS] has their guidelines for physicians [...] so if you have a doctor who is not willing to follow those guidelines, then you need another doctor." However, what most podcast listeners don't realize is that these kinds of guidelines are often heavily influenced by pharmaceutical companies' interests. Of the 20 clinicians and researchers recruited to be on the NAMS 2017 Hormone Therapy Position Statement , 10 of them reported financial conflicts of interest. More generally, the concedes that the organization's funding comes in part from "charitable contributions from corporations" -- i.e. pharmaceutical companies.
Unfortunately, the messages our patients end up hearing about menopause are often carefully crafted by companies that are prioritizing their own best interests -- whether pharmaceutical companies or health tech companies. Although the narrative presented sounds empowering, it's only part of the story.
As clinicians, we need to equip our patients with a more well-rounded understanding of the various factors and forces that are shaping these messages. Knowing the whole story is what's truly empowering.
*Him in this case because most are male.
Shannon Casey, PA-C, is a physician assistant and former assistant teaching professor in the Department of Family Medicine at the University of Washington. She writes at .