M is for menopause

UNTIL fairly recently, it was spoken about in a hushed voice behind closed doors. A bit pitiful, as if your life is ruined, over and done with along with the ability to bear a child. And even then, only euphemistically: Flows. The Transition. The Glows. Otherwise, as a tired and offensive joke about women becoming cranky or dumb or screwed up and ending up with less hair on top of her head and more on her chin.

(Your mother is so stupid that she thinks menopause is a button on the TV remote control, is a line that often crops up. But the American comedian Joan Rivers was quite funny: “Had a friend going through menopause come to lunch today. Her hot flush was so bad, it steam-cleaned my carpet.")

Now menopause is having its day in the sun. Panic attacks, vaginal dryness, sleepless nights, itching, dry skin, lack of interest in sex and belly fat are all the rage, at least on social media and in magazines, and when discussed by someone with cheekbones like glaciers, toned upper arms and a hefty bank balance.

On Marine One

Angelina Jolie, Emma Thompson, Cynthia Nixon, Dawn French and Gillian Anderson have all talked about it. Michelle Obama recounted in her podcast how she experienced a hot flush on Marine One, the presidential helicopter, before attending an event with her husband, Barack. “It felt like someone had put a furnace inside me and turned it up high. And then everything started melting. And I thought, ‘Well, this is weird, I can't, I can't, I can't do this'."

We live and act as if menopause doesn't exist, Obama said in the podcast. And for the vast majority of ordinary women, that is indeed the case, confirms Dr Trudy Smith, president of the South African Menopause Society, a group of experts in fields such as obstetrics and gynaecology, nursing and psychology.

“I want to make the facts about menopause accessible to everyone," says Smith, an obstetrician and gynaecologist who specialised as a gynaecological oncologist. (It's blissfully cool in her office in Parktown, Johannesburg. The air conditioning is set to 16°C because the average office temperature of 22°C feels like 40°C when you're having hot flushes, Smith explains.)

“There are myths and stereotypes and old wives' tales, but not enough knowledge and accurate information about menopause. Then there are a bunch of people and companies trying to make money out of it by selling all sorts of products, creams and powders. But we need to return to science."

It is inevitable that every woman above a certain age will go through menopause — that's about half of humanity. It is generally a gradual process that can last for months or even years but is technically defined as a period of 12 months without menstruation. The average age at which menopause occurs is 51, although about one in 100 women experience it before their 40th birthday.

Fluctuating symptoms

About 75% will experience symptoms that include weight gain, mood swings and incontinence. Menopause is preceded by the perimenopause, often a more tumultuous period. As you approach your late 30s, your ovaries begin producing less oestrogen and progesterone, the hormones that regulate menstruation. Your fertility then declines.

In your 40s, your menstrual cycles may become longer or shorter, heavier or lighter, less or more frequent until the ovaries eventually cease producing eggs and your periods stop.

But even in science, there is not always clarity. There are still questions about why menopause occurs and how it works. Furthermore, there are different opinions and conflicting research on how to treat the symptoms.

The stigma 

I have always been clumsy. There was the time when I had to do a lightning interview for a men's magazine with the reality TV star, survivalist and macho guy Bear Grylls in a hotel on Leicester Square in London. A long line of journalists had only 10 minutes each in the softly lit conference room with Grylls, his camera crew and a horde of publicists. With phone and recorder ready for action in one hand and notebook and pen in the other, I aimed purposefully towards a chair. I didn't see that it was standing on a platform.

Suddenly, I lunged forward as my foot got caught. Notebook, phone, and recorder scattered in different directions. Grylls halted my fall by catching me. All I remember of the next nine minutes is that his expression was like the one he had when he drank the urine of some animal — maybe a camel.

If there's one pebble in an arena, I will trip over it. If there's a pole in a shopping mall, I will walk into it. If there's coffee within a radius of 100m, I will spill it or pour it over myself.

Menopause accentuated the clumsiness and laid a thick layer of fuzzy fog over my exhausted brain. Every night became a long struggle with panic, darkness and sweat-soaked bedding. (A menopause mattress — the advertisement said it helps regulate body heat — and a matching menopause duvet were desperate and unaffordable purchases that unfortunately provided little relief. A silent fan, however, was the best Christmas gift I ever received.)

A crooked plate in the dishwasher or a towel on the floor would trigger a white-hot rage or a desperate burst of tears. A toad had the same effect, as did an empty coffee tin or a toilet roll holder. A neighbour's cat visiting the garden was so beautiful that I would ugly-cry and sob uncontrollably, much to the bewilderment of the teenagers.

The shame

And while we're on the topic of confessions: The interview with Smith in her lovely cool office was months ago. I simply couldn't get past the first sentence of writing about it until now. Women work hard enough on their careers; did I want to perpetuate the stereotype of the crazy cat lady?

Is it wise to admit that a sense of hopelessness has filled your head and that there is a feeling of impending, inevitable doom in your stomach? That you can barely remember your own name? And that your knees hurt? That a sneeze can become an embarrassment? That in the middle of a meeting or interview, you can get soaked in sweat within seconds, with mascara running, your shirt sticking to you like a wet cloth and a damp spot on the chair?

As colleague Elmari Potgieter says: “At one point, my head would sweat profusely every day, so much so that the water would drip from it as if I had just dunked my head under a tap. I eventually started carrying a small towel in my handbag. It went on like that for months, and it was embarrassing when I saw people looking at me; they wondered what was going on with me.

“I now carry a little fan with me to keep cool and I don't really care what people think when I take it out of my handbag."

The liberation

But the absence of menstrual periods is a physical freedom for her; you also don't have to struggle with stomach cramps, bloating, headaches, and irritability.

Many women welcome the end of contraceptives, tampons and other sanitary products, says Smith. In some cultures, such as the Rajputs in India, menopause means the opportunity to get rid of veils and interact more freely with men.

Not that any two women experience menopause exactly the same, emphasises Smith. Culture and geography, as well as diet, lifestyle and fitness, can all have an effect on it. Not to mention your genes; we usually undergo menopause around the same time as our mothers.

Even in Vrye Weekblad's virtual office, everyone's experience is different. The writer and language editor, Madeleine Barnard, says she was never slim but could always be proud of a small waist and flat stomach. “After 50, there were almost overnight love handles just below my breasts. Let's not dwell too much on the breasts. What once were my ballet boobs now resemble two unsuccessful jelly rolls squeezed into a contraption that can't be described by the word ‘bra'. And was most likely manufactured somewhere in an industrial area."

The heat in the town where Madeleine moved forced her to lie on the bathroom tiles because it was the coolest place in the house. “It was the only spot where my overheated 50-plus body could find a little relief. Did I mention that I lay there and cried? Because my emotions also ran wild after the big five-oh."

Lifestyle editor Annelize Visser says she was raised with the idea that there is almost nothing that can't be fixed with two Disprin tablets, “plus a mind-over-matter attitude towards physical passages like menstruation and menopause. It's not an illness, it's biology. You simply bite your lip, or you grit your teeth."

Annelize remembers a female boss who openly delved into her menopause. “When a hot flush hit her, she would invariably halt a meeting and everyone had to sit in respectful silence while the flush rose and fell.

“My mother's parenting style didn't prepare me for such a spectacle, and I made a silent vow then and there that when my turn comes, I will glow in silence."

Unruly bodies

The word “menopause" comes from the French word ménèspausie, which in turn comes from Latin and Greek (mens, month and pausis, an apparent pause or standstill). Menopause has been explained by men for centuries. As Louise Foxcroft writes in her excellent book Hot Flushes, Cold Science: A History of the Modern Menopause, the philosopher Aristotle (384-322 BCE) believed the apparent abundance of menstrual blood compared to seminal fluid was proof of man's dominance.

For Hippocrates (460-370 BCE), the cessation of bleeding meant the rebellious female body became more in line with the superior male version. Galen of Pergamum (129-c. 216 CE), whose work influenced Western medicine until the 18th century, believed women were imperfect and flawed versions of the ideal male form and became more “manly" when their menstrual cycles ended.

Physicians defined women based on their reproductive abilities — in the Hippocratic Corpus, a distinction was made between the “womb-woman" and those who were "outside the logic of regeneration".

Biblical texts affirm that menstruating women are “unclean" and “polluting" (Leviticus), and Ezekiel advises that a good man should not lie with a menstruating woman.

The idea that menstrual blood is a disgusting discharge was often repeated in the Middle Ages. According to the medieval French writing Secrets des Dames, whoever takes a hair from a woman's pubis, mixes it with menstrual blood and places it in a hole will find evil, poisonous creatures there at the end of the year.

The Victorian surgeon Lawson Tait believed the best cure was to confine women. Mental illness was generally attributed to “problems with the uterus". Throughout history, postmenopausal women have been considered genderless, quarrelsome, promiscuous, dangerous, hysterical and useless, writes Foxcroft.

Us and the whales

Science has graciously progressed along with our understanding and knowledge. But why does menopause occur?

Of all species, only Homo sapiens, killer whales (Orcinus orca) and short-finned pilot whales (Globicephala macrorhynchus) experience menopause. Why is that, when elephants, which also have long lifespans, can continue to bear offspring until they die?

One line of thought it is a product of recent evolution that happened to become fixed across generations. However, scientists from the University of Exeter, who have studied killer whales for years in their quest for answers, believe there is overwhelming evidence that menopause is a development stemming from our past.

The “grandmother hypothesis", formulated in the 1960s, suggests older women play a crucial role in raising, teaching and providing food for their children and grandchildren. In doing so, they ensure the wellbeing of their descendants and the preservation of their genetic heritage. This contribution is so valuable that it has led to the evolution of women's long lives after reproduction is over.

A study conducted in Finland and Canada found that women who live the longest after menopause have more grandchildren because their daughters fare better in having and raising children.

The Exeter team suspects the answer lies in the information being transmitted. They studied hundreds of hours and 35 years' worth of video footage of orcas off British Columbia and the state of Washington in the US. The findings were seen as a significant breakthrough: menopausal orcas were usually at the forefront of hunting expeditions, especially when salmon were scarce. “This finding is of utmost importance because the availability of salmon determines mortality as well as reproductive success in [these] killer whales," the study states.

Large male killer whales typically stayed closest to their mothers, the researchers found, probably because they needed to consume more than their sisters to stay alive.

This means menopausal killer whales retain and use their ecological knowledge and experience to help their families find food, the researchers wrote. The study explained why women continue to live long after menopause but not why they cease reproduction.

In a second study in 2017, the same researchers provided an explanation: animals in groups do not have unlimited resources, and having more offspring can disadvantage the group. If a female were to continue having children, she would be in direct competition for resources, including food, with her daughter and her daughter's children. The mortality rate among descendants of older mothers who gave birth during the same period as their daughters was 1.7 times higher than that of younger mothers.

“It's a high cost," says researcher and ecologist Darren Croft. "[It] has led to the evolution of menopause."

It doesn't make sense for the older mother to invest time and energy in a new calf that could potentially die. She preserves her genetic legacy better by helping her older children and their children to survive by sharing food and knowledge about hunting and by helping to care for her grandchildren.

The great hormone debate

Naturally, menopausal symptoms can be alleviated by staying healthy. The right diet and exercise, preferably with weights to strengthen your bones against osteoporosis, are essential. An oestrogen cream applied twice a week in the vagina works wonders for dryness and is not absorbed into the rest of the body, says Smith.

Cognitive behavioural therapy is used with success, there are increasing anecdotal reports about the benefits of cannabis, and a wide variety of natural products are available. (Though unconventional products are not subjected to studies or regulated, registered or licensed.)

However, hormone treatment — it is no longer called hormone replacement therapy because hormones cannot be replaced, says Smith — is still the most effective treatment for the most severe symptoms of menopause.

Hormone therapy is probably the most controversial medicine yet developed, especially due to the fear that it can cause cancer. In 1942, Premarin, a drug containing conjugated oestrogen derived from the urine of pregnant horses, was introduced. Dr Ginni Mansberg, an Australian gynaecologist, writes in the book The M Word: How to Thrive in Menopause, about how popular the treatment became. Promotional material created the impression that hormone therapy would allow a woman to retain her youth — and her man. “It was seen as a lifeline for women who wanted to stay younger and healthier."

Smith says this fountain of youth was prescribed worldwide, but at a time when the science wasn't necessarily sound. This combination of oestrogen and progesterone was the top-selling medicine in America, and it was widely prescribed until 2002 for women who still had a uterus.

Then the research from a programme called the Women's Health Initiative, conducted in the US since 1991, was published. It was shocking, and the headlines scared women worldwide. There was a drastic decline in all prescriptions, even though synthetic versions of the hormones were developed to counter the symptoms.

“HRT linked to breast cancer," said the Daily Mail. “HRT study cancelled over cancer and stroke fears," trumpeted The Guardian.

The initial reports found a relative increase of 26% in the risk of breast cancer with the use of a combination of oestrogen and progesterone. But the findings were flawed: the researchers did not distinguish between relative risk — in other words, the risk for the specific study group given the combination relative to the risk for those given a placebo — and excess risk or the actual increase in risk between the two groups. The excess risk was only eight additional strokes per 10,000 person-years and eight additional cases of breast cancer in the same period.

Furthermore, the average age of participants was 63, and a quarter of them were over 70 when they started hormone treatment. Healthy women in their late 40s and early 50s should have participated in the study, writes Avrum Bluming, an oncologist and co-author of the book Estrogen Matters. The older participants were already unhealthy: half of them were obese, almost half smoked, and more than a third had high blood pressure.

Smith explains that there were fewer cases of breast cancer among women who used oestrogen alone compared to the placebo, but this finding was never emphasised.

And if one looks at the numbers from the study now, Mansberg writes, there are clear benefits associated with hormone therapy when used by women between the ages of 50 and 59. They had fewer cases of cancer, bone fractures and deaths compared to the women who used the placebo.

Window period

Several studies since have contradicted the Women's Health Initiative findings, but women understandably remained sceptical. Finally, in 2017, a large and respected study in America found that the chance of death among  women using hormone therapy was no higher than among those who did not use it.

According to Smith, we now know there is a window period that is the ideal time to start hormone treatment. “It should be during the peri-menopause or early menopause. Definitely not after the age of 60."

And no hormone treatment should be prescribed before a mammogram is done, she warns.

“Look, it's a time in a woman's life when the children are likely already out of the house or on their way out. You can now be at your most productive. Don't suffer in silence. There is help, just ask. Talk about it. Go see your doctor," says Smith.

“You are now in the prime of your life. Firstly, it's fantastic that you no longer have your periods, and secondly, you now have all the knowledge and energy to do what you want. Your life is not over."

As Annelize Visser says: “My friends in their 50s are full of new courage and even making drastic life-changing decisions. They start (or resume) writing or painting, say goodbye to their employers and work for themselves, travel to other countries and sometimes stay there.

“It makes me believe that a great wave of creative energy emerges more or less simultaneously with menopause. It may not be a symptom, but nevertheless it is something to look forward to."

* This article originally appeared on September 11, 2020, in Vrye Weekblad.

♦ VWB ♦

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