Content warning: This article mentions suicide.
It’s over thirty years since Linda died.
I still feel terrible about her death.
Because it didn’t have to happen. It was entirely preventable.
A bright, vivacious lady in her early fifties, Linda had come to see me as her GP for help with some troubling symptoms. They were bothering her a lot, so after taking some further history, performing an examination and arranging some blood tests, we discussed the most likely diagnosis.
Linda was menopausal and had probably the worst hot flushes I had ever seen someone experience. The sweat ran down her face and neck in rivulets, her hair looked like she’d just come out of the shower, and she was exhausted from her lack of sleep.
She began taking HRT and after a couple of weeks, her symptoms had subsided significantly. She appeared much brighter, said she felt a whole lot better in herself and agreed to come in for a follow-up in a few weeks’ time or sooner if she was having any problems.
She failed to keep her appointment and then I heard the terrible news that she had died by suicide.
Menopausal depression is not something often talked about.
But it needs to be because the menopause transition is a time of significant hormonal change that reaches far beyond oestrogen and progesterone. Mood changes, including anxiety and or depression, are common, as are cognitive changes, increasing forgetfulness and difficulties organising thoughts.
It’s little wonder that women can struggle during this phase in their lives. Not every woman has issues, some sail through this time without any trouble, but for the 25% of those that do, it can be a nightmare.
Menopause accounts for 1/3 of a woman’s life.
The average age for menopause is 51-53 years. That’s after the perimenopause that can start in our forties. Menopause is the cessation of periods and is deemed to have occurred when it’s been 12 months since your last period.
Imagine. You’re at the peak of your career. The kids are growing up, and you’re finally arriving at that place when you expect to have a bit more time to yourself.
Except you’ve noticed you’re not quite on the ball as usual, you’re a bit slower in working things through, your joints are aching, you’re always tired, you’re feeling a bit low, you’re stacking on the weight despite exercising and watching what you eat, and sleep appears to be something only the wicked achieve.
Your boss is making comments about your performance and some of your younger colleagues are looking at you sideways.
You start to worry.
“Am I dementing?”
“Am I past my use-by date?”
Menopause is a common reason for leaving the workforce prematurely.
Depending on which study you read, many, up to half of the women surveyed, express difficulty in doing their work due to menopause. That’s true for those who recognise their symptoms as being due to this, but what if it’s unrecognised or unacknowledged by your boss or the organisational culture?
Up to 13% of Australian women stop work at this time because of symptoms.
Menopausal depression and suicide.
The highest age-specific suicide rate for women in 2015 was in the 45–49-year age group.
The second highest was in women aged 50-54 years.
By contrast, men over the age of 85 years have the highest age-specific suicide rate.
Why isn’t this setting off alarm bells?
Menopause and increased risk of heart disease and osteoporosis.
Women are more at risk of developing heart disease after menopause, partly because of the accompanying drop in oestrogen levels. Also, your lipid profile starts to change. Your total cholesterol creeps up along with the so-called ‘bad” cholesterol LDL cholesterol while the good stuff, HDL falls. Then there is the dreaded middle-age spread. You might never have had a “tummy” before, but now you’ve developed those rolls and love handles as you gain adipose tissue around your middle. The average weight gain in menopause is between 2 and 8 kgs.
Other changes like vascular stiffness lead to hypertension, your ability to regulate your glucose metabolism decreases, you may develop insulin resistance, and your liver function is impacted as you gain more liver fat.
The loss of oestrogen’s protective effect on bones leads to osteopenia, loss of bone mass, and an increased risk for osteoporosis, where your now more brittle bones break more easily after a simple slip or trip.
We lose roughly 10% of our bone mass in the first five years of menopause.
This implies that it becomes essential to include sufficient calcium in your diet (1300mg/day), which is equivalent to three to four servings of dairy each day.
Non-dairy milk, unless fortified with calcium, does not help. And for my lactose intolerant friends don’t forget you can get calcium from eating fish, firm tofu, Brazil nuts, almonds and dark leafy greens. And don’t forget to ensure you have enough Vitamin D to absorb it. A couple of minutes of sunlight each day on your skin helps, and if necessary, get your level of Vitamin D checked by your doctor.
Preventing osteoporosis through dietary management, appropriate exercise, and better-quality sleep ensures a better quality of life.
Then it’s time to put the trainers on for some walking, weight-bearing exercise and strength training, which are all important for keeping your bones strong in menopause.
Who should manage symptoms of menopause?
Your GP is usually the first port of call. But many of my colleagues like me, received woefully little training in this area in medical school. If you were lucky, you might have learned a bit more during your general practice placements.
If you don’t feel that your doctor understands what you’re going through, seek a second opinion.
Menopausal hormone therapy and some non-hormonal treatments are highly effective at treating symptoms, yet as Professor Susan Davis, Endocrinologist and women’s health researcher, says, 85% of women with bothersome symptoms are not on effective, approved therapies.
The myth of MRT being associated with an increased risk of breast cancer, though long debunked, persists.
While 50% of menopausal women are putting up with problems of lower libido, painful sex and urinary problems, only 7% are prescribed effective local oestrogen therapy.
Perhaps the biggest issue is that many women remain unaware of their increased risk of heart disease after menopause. Did you know it kills more menopausal women than men? And that because heart disease presents differently in women it’s not infrequently misdiagnosed, or the woman presents late for management.
Towards improved health at menopause.
Things are improving. The knowledge gap is being filled by a number of passionate specialists, GPs and health practitioners determined to make sure that every woman can access the information and guidance needed to help them optimise their health.
Last weekend I attended The Women’s Life Cycle Summit in Perth hosted by Menopause Alliance Australia.
MAA is a registered charity helmed by the passionate Natalie Martin who seeks to ensure no woman is left behind.
I left feeling inspired and hopeful, we’re on the right track.
Professor Jayashi Kulkani AM, a practising psychiatrist, neuroscientist and women’s health researcher from Monash, delivered an impassioned presentation about menopause and the mind, sharing how menopausal depression occurs due to fluctuations in oestriol levels in the brain. These fluctuations are what destabilise mood.
Prescribing oestrogen is good for symptoms of depression, and micronized progestins are good for settling anxiety.
But MRT alone may not always be enough. Sometimes combining MRT and an antidepressant is needed.
We also heard from a number of amazing local talent from KEMH in Subiaco including Professor Roger Hart, Gynaecologist, Endocrinologist and Fertility, Specialist, Associate Professor Bernadette McElhinney Gynaecologist and Endometriosis Specialist, Dr Lesley Ramage GP, Women’s’ Health Specialist and Menopause Specialist and Dr Jennifer Pontre Gynaecologist and specialist in the menopause and heavy periods.
It was a fantastic event.
My biggest takeaways were:
- There is a pent-up demand for women to have a greater understanding of the changes that occur at menopause and a desire to have a say in how they manage any accompanying symptoms.
- Employers are waking up to the fact that they run the risk of losing their most experienced female staff if they are not “menopause ready” and how to best to support their female employees. It was fantastic to see some of these employers attend the summit to learn more.
- More education is required for health practitioners. Some specialist GP practices are already popping up. Still, more time must be given to helping medical and other student health practitioners, including nurses, physiotherapists, exercise physiologists, psychologists, and dieticians, to learn what they need to know about current recommended treatments.
Medicine is constantly evolving, and there is so much good scientific evidence available to help the 51% of the population who will, at some point in their life, transition through menopause.
As Professor Kulkarni reminded us, we currently focus on menopause for the physical symptoms it can bring, forgetting the significant psychological impact of anxiety or depression.
This needs to change.
Kathy Lette, MAA Ambassador, author, and wickedly funny speaker, encouraged each one of us to “Go Forth and Be Fabulous!” along with all our female Wonderbras, our feminine heroes who are always uplifting and supportive and whose love makes us feel so much better.
So, I say thank you to each and every one of my Wonderbras. We can get this sorted together.
If you or someone you know needs mental health support, you can contact any of the services below:
Beyond Blue Support Service – Support. Advice. Action.
Information and referral to relevant services for depression and anxiety-related matters. Phone: 1300 22 46 36
www.beyondblue.org.au/get-support/get-immediate-support
Headspace
Headspace is the National Youth Mental Health Foundation. We help young people who are going through a tough time.
www.headspace.org.au/
Lifeline
24-hour telephone counselling service. Phone: 13 11 14 or Text: 0477 13 11 14 6 pm – midnight AEST
www.lifeline.org.au/
Mensline Australia
A dedicated service for men with relationship and family concerns. Phone: 1300 78 99 78
www.mensline.org.au/
SANE Australia
SANE Australia is a national charity helping all Australians affected by mental illness lead a better life – through campaigning, education and research. SANE conducts innovative programs and campaigns to improve the lives of people living with mental illness, their family and friends. It also operates a busy Helpline and website, which have thousands of contacts each year from around Australia. Phone: 1800 187 263
http://www.sane.org/index.php
Relationships Australia
Relationships Australia is a leading provider of relationship support services for individuals, families and communities. Phone: 1300 364 277
http://www.relationships.org.au/
