Progress in the Management of the Menopause: Proceedings of the 8th International Congress on the Menopause, Sydney, Australia

B.G. Wren

• Publisher: CRC Press
• Year: 2020
• Print ISBN: 9781850707998
• eBook ISBN: 9781000144529
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

This is a comprehensive, up-to-date, authoritative research text and clinical reference work the menopause. It contains over 90 contributions covering every conceivable topic in the management of the menopause in women and related issues in the aging male. The book contains many illustrations and a wealth of references.

Pieter van Keep Memorial Lecture

Menopause: a modern perspective from a controversial history

W. H. Utian

---

Introduction

The purpose of this paper is to convey one message — all women should have the right to postmenopausal wellness, and it is the responsibility of the medical profession to make it happen.

Exactly 20 years ago in June 1976, 165 people of varying disciplines and backgrounds, but all with one common interest, the female menopause, gathered in the resort town of La Grande Motte in the south of France to attend the First International Congress on the Menopause. The discussions were clustered around subjects like defining the climacteric syndrome, endocrinology of menopause, psychosocial aspects, and estrogen therapy in relation to bones, lipids and endomeuial cancer. Representing 22 countries, there were some 40 contributions. While menopause was defined, there was virtually no focus on women’s health-care delivery.

Two decades later in Sydney, Australia, at the Eighth International Menopause Society meeting, there are almost 20 times as many participants from over double the number of countries. The enormously expanded program includes topics such as epidemiological studies, management of the well menopausal woman, possible reduction of the risk of developing new breast cancer, the consequences of longevity, the media and the menopause, and alternative therapies — all representing a dramatic change of focus.

This is a record of phenomenal growth and development. The events leading to that first meeting, the establishment of the International Menopause Society (IMS), the journal Maluri las, the evolution of research and health care relating to the menopause, and the future role of the IMS within that context are the topics covered by this paper.

Above all, I stand before you as the outgoing IMS President to pay tribute to the memory of Pieter van Keep, to recall some special moments during our years of close friendship, and to challenge you all to continue the dreams we developed almost 25 years ago.

History: where we were

Attitudes to menopause

The major milestones in the history of menopause provide a fascinating background to the understanding of current attitudes and the prediction of future trends in the management of this event through which all women will inevitably pass.

‘Menopause’ is a word of multiple meanings. It was once the subject of taboo, but now almost in danger of overexposure. Once neglected, it is now recognized by multiple groups as the entry to a ‘market’. The result is a new level of confusion and even exploitation in the minds of the health profession and the public alike.

Menopause as a life event was recognized far back in history. Aristotle (384-322 ac) noted menstruation to cease at age 40 years, and references to the cessation of the age of fertility continue to pepper the literature over the next 2000 years¹. The Greek words men and pausis were first utilized to describe the cessation of menstruation, although a Latin basis can also be argued². Climacteric appears to be of Greek derivation representing the word for ladder or steps of a ladder.

The review of the attitudes expressed in the literature over the last century makes one wonder whether women were meant to be climbing up or down the ladder! Viewpoints in one extreme were particularly negative; in the other extreme there were some balanced observers attempting to define the normality or universality of the phenomenon of menstrual cessation.

Colombat de L’Isere in a chapter on ‘Change of Life’ in his Treatise on the Diseases of Females (1845)³ stated:

‘Compelled to yield to the power of time, women now cease to exist for the species, and henceforward live only fez themselves.’

Further, he stated

‘She now resembles a dethroned queen, or rather a goddess whose ffers no longer frequent her shrine. Should she still retain a few courtiers, she can only attract them by the charm of her wit and the force of her talents.’

Charles Meigs, in a letter to his class in 1848 entitled ‘Change of Life’⁴ asked

‘What has she to expect save gray hairs, wrinkles, the gradual decay of these physical and personal attractions, which heretofore have commanded the flattering image of society . . . The pearls of the mouth are become tarnished, the hay-like odor of the breath is gone, the rose has vanished from the cheek, and the lily is no longer the vain rival of the forehead or neck. The dance is preposterous, and the throat no longer emulates the voice of the nightingale‘.⁴

There are numerous other examples of similar negative attitudes.

The association of menopause and symptoms was also noted long ago. John Leake in 1777 attempted to explain the cessation of menstrual blood flow through a Harveian mechanism, namely, insufficient pumping force through the blood vessels. He also noted the association between menopause, vaginal atrophy and bladder symptoms⁵. It was a British physician, Edward Tilt, in one of the first full-length books on the subject, who noted that ‘Women at the change of life are frequently affected with cancer, gout and rheumatism’, and also noted that ‘Well localized nervous affection sometimes occurs at this critical epoch’⁶.

It is only fair to note in passing that men were not immune to writings of the late 19th and early 20th century. An example comes from Syvanus Stall writing in 1901 in What a Man of 45 Ought to Know⁷ — ‘It is usually at the age of 50 or 60 that the generative function becomes weakened. It is at this period that man, elevated to the sacred character of paternity, and proud of his virile power, begins to notice the power decreased, and does so almost with a feeling of indignation. The first step towards feebleness announces to him, unmistakably, that he is no longer the man he was.’

On the other hand, some remarkably astute comments were made by physicians who were really attempting to present the menopause in a positive light and as a natural event. For example, Tilt made the following observation: ‘The change of life does not give talents but it often imparts a firmness of purpose to bring out effectively those that are possessed, whether it be to govern a household, to preside in a drawing room, or to thread and unravel political entanglements’⁶. Borner in 1887, over 100 years ago, expressed this point of view best in a statement almost as fresh as the day it was written⁸:

‘The climacteric, or so-called change of life in women, presents without question, one of the most interesting subjects offered to the physician, and especially to the gynecologist, in the practice of his profession. The phenomena of this period are so various and changeable, that he must certainly have had a wide experience who has observed and learned to estimate them all. So ill-defined are the boundaries between the physiological and the pathological in this field of study, that it is highly desirable in the interest of our patients of the other sex, that the greatest possible light should be thrown upon this question.’

The narrow boundary between normal physiology and pathology had not been fully defined nearly 100 years later. Nor had the many negative and largely unsubstantiated statements ceased to be made as evidenced by the following

In 1963, ‘A large percentage of women . . . acquire a vapid cow-like feeling called a ‘negative state’. It is a strange endogenous misery. ... the world appears as though through a gray veil, and they live as docile, harmless centures missing most of life’s values’⁹.

In 1963, ‘The menopausal woman is not normal; she suffers from a deficiency disease with serious sequelae and needs treatment’¹⁰.

In 1966, ‘Often busy mothers or energetic careerists who are unwilling or unprepared to acknowledge the termination of the repro- ductive phase of their lives and the inception of a new era are thrown into considerable turmoil by this event’¹¹.

In 1967, ‘Many women are leading an active and productive life when this tragedy strikes. They are still attractive and mentally alert. They deeply resent what to them, is a catastrophic attack upon their ability to earn a living and enjoy life’¹².

Management of menopause

Historical treatments were aimed either at attempting to cure specific diseases which were claimed to be associated with menopause, or to alleviation of psychological symptoms which were likewise blamed on ‘this critical time of life’ (Leake, 1777)⁵,¹³. They varied from blood- letting to purgatives, from crushed powdered penis of the ass to raw eggs. Leake recommended ‘At meals she may be indulged with a half of pint of old clear London Porter or a glass of rhenish wine’.

Clearly perimenopause by the late 19th century had been recognized as a potential syndrome, and orthodox and unorthodox treatments were applied. Again, men were not immune from the concept of a ‘male climacteric’, and Haller and Haller reported ‘Whether real or imaginary, permanent or temporary, sexual impotency was a source of great anxiety for the nineteenth century male and his apprehensions furnished a lucrative market for unscrupulous quacks, clairvoyants, mesmerizers, natural healers, faith-curers, anatomical museums and layers-on-hand in his search for his recovery of his sexual powers’¹⁴. Nothing seems to be different today!

The concept of treatment was, however, about to heat up. In early 1896, exactly 100 years ago, three published reports represent the first on a new concept, the ‘dawn of hormone replacement therapy’¹⁵. Separately, three groups in Germany reported trials to alleviate menopause-related symptoms by means of substitution with ovarian therapy¹⁵.

Butenandt, a Nobel Prize winner for this work, succeeded with other research workers in 1929 in isolating and obtaining in pure form a hormone from the urine of pregnant women which was eventually to be called estrone¹⁶. The structural formulae of this and related hormones were worked out by Butenandt (1930) and others.

A logical development in the expanding history of glandular therapy was the substitution of the newly available estrogens in place of crushed ovaries and the like. By the early 1930s many reports began to appear on the use of ‘amniotin’ for hot flushes, sweats, nervousness and libido¹⁷. This form of treatment became popular from the early 1960s onwards, under the general description of estrogen replacement therapy. Initially, reports of this new therapy, the era of ‘feminine forever’, followed a similar pattern. They generally began with extremely negative statements about the menopause, which were then followed by dramatically positive descriptions for reversal of such effects by the treatme...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of principal contributors
• Foreword
• 1 Menopause: a modern perspective from a controversial history
• Section 1 Plenary papers
• Section 2 Reports of epidemiological trials
• Section 3 Management of the well menopausal woman
• Section 4 Hormone replacement therapy and osteoporosis
• Section 5 Hormones and breast cancer
• Section 6 Hormone activity in the endometrium
• Section 7 Androgens and the menopause
• Section 8 Phytoestrogens and their influence on menopause
• Section 9 Hormones and brain function
• Section 10 Management of women with chronic medical diseases
• Section 11 The aging male
• Section 12 Menopausal medicine under difficult conditions
• Section 13 Hormones and mood change
• Section 14 Hormones and the cardiovascular system
• Section 15 Compliance with hormonal therapy
• Section 16 Hormone replacement therapy in women over 60
• Section 17 Towards better recognition of urogenital aging
• Index