I was delighted to deliver the closing keynote speech on the subject of menopause at the BACP Private Practice conference in September. Menopause is a subject very close to my heart and I am passionate about sharing what I have learnt, both personally and professionally, to ensure that women do not continue to struggle due to a lack of both education for health professionals and the public, and factual, evidence-based information.
My own experience of menopause began in 2012, considerably earlier than I had expected, when, due to concerns over my general health, I visited my doctor. As a result of our consultation, she ordered blood tests, which showed I was anaemic. I was prescribed an iron supplement and asked to return in a few weeks time if I had not improved. I was sitting in front of my doctor again less than two weeks later, as I felt considerably worse. More blood tests were ordered and a few days later my phone rang. As soon as I realised it was my doctor, I knew something was wrong. She explained that my CA125 was considerably raised. CA125 is a protein found in the blood, and while it can be raised for several reasons, it is currently the only indicator available for a possible diagnosis of ovarian cancer. As my mother had been diagnosed with ovarian cancer some years before, I completely understood my doctor’s concern.
Over the following weeks, I had a series of scans, hospital appointments and more tests, resulting in the decision to undergo a total hysterectomy, including both of my ovaries. While I was aware that this would put me straight into surgical menopause, I had no idea what that really meant, in terms of the possible symptoms and long-term health considerations; and, sadly, nobody explained it to me.
Having been given a possible ovarian cancer diagnosis, I was focused on the surgery happening as soon as possible. The day after my surgery, the gynaecologist told me she had discovered not just complex cysts on both of my ovaries, but that I also had stage four endometriosis, a painful condition where tissue similar to the tissue that lines the womb grows outside of the womb and causes lesions in the pelvic area, and adenomyosis, another painful condition where the lining of the womb grows into the muscle that surrounds it, and a huge fibroid. While it was shocking to hear that I had been living with all these conditions, it also explained why I had experienced so much pelvic and back pain for so many years, wreaking such a disruptive effect on my everyday life. The good news was that she felt she had performed the surgery just in time and that I should rest for a few weeks before visiting my doctor. I left the hospital less than 48 hours after my surgery, with no information about how the results of it could affect me in the future.
In an attempt to support my recovery and future health, I visited a nutritionist to explain what had happened to me. I left the appointment with seven different supplements and an assurance that the herbs, vitamins and minerals she had prescribed would help with any menopause symptoms and my general health. The next few months were very much focused on my recovery and getting back to normal and all seemed to be going well until I began waking in a state of panic in the early hours of the morning. I began to struggle with anxiety, which rapidly escalated to the point where I became nervous of leaving the house, driving, seeing friends, answering the telephone and even opening post. My world became very bleak, very quickly, and getting through the day felt like wading through chest-deep treacle. Despite repeated pleas from my husband and mother, who had to come to stay to care for me while my husband was at work, I refused to go back to the doctor, as I was terrified that they would offer me animal-derived hormone replacement therapy, the only option as far as I knew, or a lifetime of antidepressant medication.
Early in 2013, the decision to see the doctor was taken out of my hands when my husband became so concerned about my mental health that he made the appointment and took me himself. As I sat in front of her and sobbed, she explained that my surgery had resulted in a dramatic loss of hormones, which was responsible for my symptoms. I explained that I couldn’t possibly take medication that was animal derived and then she said the magic words, ‘You don’t have to. You have a choice. We now have plant-derived hormone replacement therapy.’ In that moment, I felt, for the first time, that there might be hope for the future. I started treatment the same day and began to feel an improvement in just 48 hours. But soon after, I felt really angry; I had needlessly suffered due to a lack of vital information, but had been so fortunate to have amazing family support. What about those women who were not so fortunate?
Once I felt well enough, I started to research and found an online world that I had no idea existed, full of women saying things like, ‘Please help, I think I’m going mad’; ‘I feel so alone’; ‘I don’t know who I am anymore’ etc. These women were invariably in their mid to late 40s, but only some of them were experiencing hot flushes, night sweats and changes to their periods; there was a plethora of other symptoms that they couldn’t understand. The common theme among these women was that many of them had been prescribed antidepressant medication for anxiety or depression, which generally had not improved their symptoms.
Menopause and mental health
Menopause matters because every woman will experience it at some point in her life. One in four will experience very few symptoms, but three in four will experience symptoms, with one in four describing them as debilitating.1 In a survey for the BBC in 2018,2 48 per cent of the women between 50 and 55 said that their mental health was affected by their menopause symptoms, and 25 per cent of the women surveyed said it made them want to stay at home, which corresponds with the one in four who experience debilitating symptoms. More recently, the Chartered Institute of Personnel and Development has released the results of a survey which tells us that 59 per cent of women between the ages of 45 and 55 experiencing menopause symptoms, say that they have a negative impact on them at work, and 30 per cent have taken sick leave because of their symptoms.3 In a 2017 survey for the British Menopause Society, 51 per cent of respondents said that their menopause symptoms had affected their sex lives, and 38 per cent of partners said that they felt helpless to support their partner going through menopause; 28 per cent said this caused arguments.4
Contrary to popular belief, menopause does not happen to women in their 50s. Perimenopause, which is the period from when symptoms begin, to the time when a woman has experienced 12 months without a period, typically begins in the early 40s and is rarely marked by the onset of hot flushes. The symptoms are much more likely to be anxiety, low mood, reduced concentration, broken sleep, fatigue, poor memory, irritability etc. The brain is full of oestrogen receptors and as the hormone levels begin to fluctuate, so can mood, self-confidence, self-esteem and cognitive function. It’s also important to point out that for those women in a premature, surgical or medical menopause, these hormone declines can be dramatic, as in my own example, and need medical intervention with hormone replacement at the earliest possible opportunity to protect both wellbeing and long-term health.
Oestrogen has a key role to play in every part of a woman’s body, and symptoms can be very different for every woman. The ones that are least likely to be spoken about are the urinary and vaginal symptoms, which can be embarrassing, debilitating and very painful if left untreated. In my own practice, I have counselled women who were at the end of their tether being given continual rounds of three days of antibiotics for repeated urinary tract infections, when, in fact, the cause was a reduced level of oestrogen.
The entire pelvic area is completely reliant upon oestrogen and without it up to 80 per cent of menopausal women are thought to suffer from vaginal symptoms, which can have a devastating impact on women and their relationships.5 There is a simple non-invasive localised treatment for these symptoms, but sadly very few women visit their doctors, partly due to embarrassment or because they feel it is just part of getting older. Those who self-treat for conditions like thrush are also potentially putting themselves at risk, as there is a skin condition called lichen sclerosus, which needs to be managed with medication, as in some cases, without correct treatment, it can increase the risk of getting vulvar cancer.
The costs of menopause
The costs of menopause can be devastating for women’s health and wellbeing, their work lives, family lives and personal relationships. Sadly, many of the women I have worked with have booked multiple GP appointments for their symptoms, and many GPs are simply not equipped to help, as they have not been given adequate menopause education. Unfortunately, some of these women find themselves being referred on to secondary care for cardiology appointments for palpitations; rheumatology for aching joints and, most worrying of all, psychiatry for what invariably turn out to be symptoms related to fluctuating hormone levels.
Approximately one in four women considers giving up work due to their symptoms.5 Those who take the decision to leave the workplace because of symptoms, often report feeling unsupported and unable to discuss their situation with managers.6 Some feel they were performance managed out of the workplace; others were made redundant. With hindsight, all believe that their menopause symptoms were key.
The most heartbreaking experiences I hear are of those women who have experienced a breakdown of their relationship as a direct result of their menopause symptoms. At workshops, when I have talked about the subject of intimacy during menopause, and how both physical and emotional symptoms can lead to a breakdown in communication when neither partner really understands what is happening, when I have described some of the common symptoms, I have had women tell me they wish they had known this earlier, as they think the information might have saved their marriage.
The menopause transition can be a challenging one for some women and couples, but therapists are ideally placed to offer support, guidance and, where appropriate, signposting when we are able to recognise these hormonal shifts in our clients. Clearly, every woman in her 40s and 50s seeking therapy will not be experiencing menopause symptoms – lives are complex and lived at increasing speed, with constant, often overwhelming, demands.
But perhaps, having read this far, you are now considering clients who you are currently working with, or those who you have worked with in the past. Perhaps you have had a personal light bulb moment, as I know many of those at the conference did who were kind enough to come and share their thoughts with me or to contact me afterwards.
Menopause can be a transformational time of life with the right help and support, and my own menopause experience prompted me to seek support, which set me on the path I am currently following. There is no doubt that the treatment from my doctor saved my life, but the therapy that I engaged in as part of my menopause experience was an important part of my journey, which helped me to reassess what is really important to me and how I wanted to use my experience to help others. Both were key in helping me to regain health, both physical and mental, but I would not have been able to engage in the therapeutic process without having first accessed the right medical treatment.
Therapists who understand menopause and the possible effects of hormone fluctuation have an ideal opportunity to close the current knowledge gap among both the public and healthcare professionals to empower their clients to seek out factual, evidence-based information to enable them to make informed choices about how they manage their symptoms. This can be life changing for some women. There is nothing more rewarding than somebody who begins their consultation by telling you that they think they are going mad, but closes it by saying that they no longer feel alone. If you support women in your work, menopause matters.
Diane Danzebrink is The Menopause Counsellor, a wellbeing consultant to individuals and organisations; she has professional nurse training in menopause and is a member of The British Menopause Society. As a result of her own experience, she created menopausesupport.co.uk and the #MakeMenopauseMatter campaign.
References
1. Nuffield Health. One in four with menopause symptoms concerned about ability to cope with life. [Online.] www. nuffieldhealth.com/article/one-in-four-with-menopausesymptoms-concerned-about-ability-to-cope-with-life (accessed 1 November 2019).
2. ComRes. BBC menopause survey. [Online.] www. comresglobal.com/polls/bbc-menopause-survey/ (accessed 1 November 2019).
3. CIPD. Majority of working women experiencing the menopause say it has a negative impact on them at work. [Online.] www.cipd.co.uk/about/media/press/menopause-at-work (accessed 1 November 2019).
4. British Menopause Society. British Menopause Society fact sheet. [Online.] thebms.org.uk/wp-content/ uploads/2016/04/BMS-Infographic-10-October2017-01C. pdf (accessed 1 November 2019).
5. Simon JA, Kokot-Kierepa M, Goldstein J, Nappi RE. Vaginal health in the United States: results from the Vaginal Health: Insights, Views & Attitudes survey. Menopause 2013; 20(10): 1043–8. [Online.] www.ncbi.nlm.nih.gov/pubmed/23571518 (accessed 1 November 2019).
6. ITV News. Quarter of women going through menopause 'considered leaving work'. [Online.] www.itv.com/ news/2016-11-23/quarter-of-women-going-throughmenopause-considered-leaving-work/ (accessed 1 November 2019).