The Feel Good Guide to Menopause

Nicola PhD Gates

• Publisher: ABC Books
• Year: 2019
• Print ISBN: 9780733338748
• eBook ISBN: 9781460709030
• Topic: Medicine
• Subtopic: General Health

How understanding the brain-hormone connection can help women to navigate menopause.

PART 1

HER-STORY

Women have profoundly different health lives from men. Our female health story is largely dictated by our sexual reproductive hormones – which direct our sexual development through puberty, support menstrual cycles and pregnancy, and ultimately leave us during menopause. They also impact our entire wellbeing, influencing physical and mental health. However, until recently our biology has often been confused with other forces.

Ancient and patriarchal beliefs about women and their bodies have significantly influenced medical practice for generations, and account for the lack of information and research on the health journey of women. The menopause transition is only one part of the bigger tapestry of women’s unique health. To nurture and cherish our female bodies and confirm our access to appropriate medical diagnoses and treatment we need to understand menopause in this broader context of medical practice in the past as it still impacts today.

Women’s health and access to services has continually been complicated by prejudice, and theological and socio-political influences. Women bear new life, a truly remarkable capacity; however, rather than being celebrated women’s reproductive bodies have largely been viewed pejoratively. Women were believed to be inferior to men, physically, mentally, emotionally and spiritually, and ‘femaleness’ has been seen as a weakness and a curse, and significantly misunderstood.

The leadership of state and religion and the practice of medicine were dominated by men and, as men do not have periods, pregnancies or menopause, their lack of experiential knowledge, coupled with prejudice, has had a huge impact on the diagnosis and treatment of women’s health issues for centuries.

Hysteria

The first word we know of being given to singularly female health issues was ‘hysteria’, from the Greek word hysterika, meaning womb (uterus). It is believed the term was first used in ancient Egypt and then in a gynaecological text in the fifth century BC by Hippocrates. It referred to the ‘wandering womb’, as the uterus was believed to be free floating within the body and its movement the cause of women’s disorders. The uterus was prone to ‘get sick’, especially if deprived of sex and pregnancy, which acted to tie the organ in place. The direction in which the womb wandered was believed to explain the diversity of symptoms and complaints reported by women.

The next major influence on women’s health was Christianity. Through the prism of Christian theology, women’s health issues were perceived as ‘the curse of Eve’ and therefore could be justifiably ignored. When biblical Eve took a bite of the apple and offered it to Adam, and he chose to eat it, Eve was held responsible for their expulsion from the Garden of Eden and for the sinful downfall of humans. Pain during childbirth and menstruation, and presumably menopausal discomfort, were seen by early physicians as God’s well-earned punishment of women and a constant reminder of Eve’s error. As a result, there was no significant push to address the unique health issues women face. They were simply a woman’s lot in life.

In the seventeenth century Descartes had a major impact upon western medicine as he demonstrated that actions previously ascribed to the soul were due to the body’s organs and brain, and by the eighteenth century, symptoms of hysteria were linked to the brain rather than the uterus. Thankfully, because in severe cases of hysteria women underwent hysterectomies to remove the uterus to cure them.

The conflation of physical/sexual reproductive and psychological symptoms, however, continued.

Hysteria became an exceedingly common diagnosis of female psychological disorder or ‘nervousness’. The understanding was that ‘excessive emotional reactivity’ was converted into multiple and diverse symptoms including faintness, nervousness, irritability and non-compliant behaviour along with the more physical ones of fluid retention, shortness of breath and loss of appetite. Many female concerns were therefore dismissed as heightened ‘emotionality’ rather than being legitimate medical or health issues.

By the twentieth century the diagnosis of hysteria was in decline for two primary reasons. First, the number of symptoms ascribed to hysteria were so broad and could be applied to so many recognised medical conditions that it was no longer helpful. Second, the development of medical investigative and scientific procedures enabled the identification of more specific physical and psychiatric conditions.

Freud reclassified many of the symptoms linked to hysteria into a new set of diagnoses called ‘female neuroses’. This female-specific set of disorders remained in diagnostic manuals until 1980 when it was replaced with the non-sex-specific term ‘hysterical neurosis’. Diagnostic terms have continually been superseded and the latest is ‘functional neurological disorder’ (FND), which represents the crossover between neurological, physical and psychiatric symptoms, and is largely applied to women.

Medical symptoms reported by women continue to be arbitrarily attributed to their emotionality rather than to a medical health issue. For example, I had a client who felt ‘not quite right’ and excessively tired after completing a major work project and was told by her treating doctor that it was stress, she had ‘overexerted’ herself and needed to see a psychologist. I might work in brain and mental health, but I do not make assumptions. I suggested she have blood tests to exclude an underlying health issue. She called me a week later to say thanks. The blood tests revealed an elevated white cell count: she had breast cancer.

Medical bias

Women outnumber and outlive men. Women also use more health and medical services than men. Yet there is a significant disconnection between women’s health, longevity and their use of medical services, and the amount of female-oriented medical research. This is because until recently women have not been involved in, or the subject of, medicine. The lack of women in medical science has had far-reaching implications for women’s health and wellbeing. For example, menstrual cramps (dysmenorrhoea) were considered psychological or psychosomatic complaints right up to the 1940s. The lack of scientific knowledge regarding the female body and hormones meant there was no medical evidence to contradict the psychiatric interpretation with a biological explanation.

The United Nations states that health equality is necessary for gender equality so understanding female hormones and improving women’s health is crucial. However, most medical research, including that into alternative and complementary therapies, has involved men to the exclusion of women: men perform the research and are also the subject of that research. Until very recently it was rare for women to practice medicine or to be involved in medical research. Less well known has been the lack of female animals in experimental research, and the failure of medical research to include women in clinical and treatment trials. Although women take more medication than men, until recently drug or pharmacological research and clinical trials have predominantly been conducted on men only. For example, in the initial studies of aspirin in preventing heart attacks in the UK, over twenty-two thousand men were studied. No women were included at all. Consequently, when the research results were extrapolated, and treatment recommendations applied to women, they were wrong. It is now understood that low-dose aspirin has different beneficial effects in women than it does in men because of the positive influence of our sex hormones. Given we now understand oestrogen has a protective role in cardiovascular health – and that women in child-bearing years produce significantly more oestrogen than men – the absence of women in heart studies has been a notable oversight. There are recognised sex differences in the effect of medication, but we still do not understand if there are possible differences in the effect of aspirin on women’s cardiovascular health across their reproductive stage, including pre-, peri- and post-menopause. The exclusion of women from clinical research is bad for women’s health and does not help medical science progress either, especially in terms of developing oestrogen-based treatments for diseases such as dementia.

Guidelines directing researchers to include women were not mandated in most countries until the 1990s. One of the most common reasons given for the exclusion of women from medical research is that our hormonal changes, during our fertile years and menopause, complicate research! As a result, research continues to neglect the effect that a woman’s reproductive status may have on medication and treatment.

As mentioned earlier, medical research has also been biased in that traditionally only male animals have been included in cell and preclinical research. These trials are used to guide human clinical trials, and the absence of female animals helps in part to explain why the findings from cellular and bio-medical studies are not replicated in trials using women.

Ideology has also influenced research. For example, in the 1990s it was suggested by the first female tenured medical scientist at Harvard, Professor Ruth Hubbard, that there was great overlap between men and women in ‘all traits except those directly involved with procreation’. At that time some medical research was influenced by the socio-political need to prove there were no differences between men and women to ensure equality. This belief has limited the understanding of how sex hormones impact health.

We are now developing an understanding of hormones and how the sexual reproductive hormones significantly influence brain development and contribute to the physiological, emotional and behavioural differences seen between men and women. As a result, there is now recognition that sex-specific health and sex-specific treatment are crucial to maximise individual health and wellbeing.

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Science bite: What are hormones?

Hormones are chemical messengers in the body and were discovered in the early twentieth century. They are made in endocrine glands. The brain signals their release and they travel in the bloodstream to their target receptor tissues and organs. They are involved in growth, metabolism, brain function and reproduction, as well as mood and behaviour. Sex hormones are those responsible for sexual reproduction. In women, the significant sex hormones are oestrogen and progesterone, and were first isolated in 1939. See Part 2 Hormone Health for more.

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Medicine and menopause

In addition to medical biases there are more excuses as to why medical research specifically into menopause has been so patchy to date. First, symptoms vary between women, they can change in frequency, intensity and duration, and whether the menopause was natural or medical makes a significant difference to the experience and the risks for other health conditions. Second, many symptoms are not linked just to menopause but are also associated with increasing age and other medical conditions. Third, the age that we start having periods (menarche) and then the age we stop having them due to menopause has also been found to have different health consequences for women in later life. Lastly, as a result of differences in our genes, environment, life experiences, lifestyle and mindstyle, we become more unique with age.

These factors make research difficult to navigate, but not impossible. Significant funding is necessary, along with medical curiosity and rigour. For example, research into coronary heart disease in post-menopausal women, their biggest killer, remains inconclusive because of a lack of well-designed studies. In contrast, well-funded research into alcohol-related cancer, which shares similar confounds of age, hormones, lifestyle and genes, along with frequency, amount and duration of alcohol consumption, has established that the consumption of fifty or more grams of alcohol per day leads to two to three times greater risk of developing alcohol-related cancers than not drinking. Alcohol is a lifestyle choice, and excessive alcohol intake concerns a minority of individuals, predominantly men. It’s ridiculous that this even needs to be said, but more money and interest in women’s health could considerably improve the quality and sophistication of research, and provide health recommendations to improve cardiovascular health in post-menopausal women.

Most of the available information regarding menopause concerns the number and frequency of menopause symptoms. This research is not particularly helpful because the frequency rates of given symptoms are often no better than chance, and because the studies are often poor quality. Nevertheless, they form the foundation for information upon which health professionals and women rely.

Identifying symptoms does not isolate cause and effect, which is necessary to determine the best treatment strategies and develop suitable management options. The limited research, along with a lack of comprehensive understanding of symptoms, has implications for investigations into the risks for diseases associated with oestrogen loss, such as the abovementioned cardiovascular disease, along with diabetes mellitus, osteoporosis and the number-two killer of women, dementia. Understanding the relationships between lifetime exposure to endogenous oestrogen (which women make within their bodies), the intake of exogenous oestrogens (from external sources such as hormone therapies and the environment) and possible health risks may lead to more effective prevention and management.

Things are changing. Women are now present in all areas of medicine – as treating health professionals and in research, training and leadership positions. In many countries there has been a positive shift to specifically investigate women’s health issues and to identify the best forms of treatment for women. Western medicine is also on the verge of practising individualised medicine, which will not only consider sex but also individual characteristics including genes, hormones and history. Therefore, awareness and acceptance of female hormonal differences in body, brain and mind represent a crucial step towards improved and individualised health care. My hope is that medical and health practices will change rapidly now and that our female reproductive lives become integrated into our health care.

Being female

Menopause may concern both women and men, but it only occurs in those born biologically female. Our sex hormones are different from male sex hormones, so our bodies, brains, emotions and behaviour are also different. We have a lot in common with men but the differences between us are significant and the biological evidence is concrete.

All human embryos start to develop the same, then sexual differentiation appears according to our sex chromosomes. In women our XX chromosomes dictate that the gonads carry on developing into ovaries. In men, the XY chromosomes change the development path so that the gonads become testes and the pattern of masculinisation begins.

Once the ovaries have developed, our primary and secondary sex characteristics are determined according to gene instruction and the sex hormones produced at specific points in development. Our female sex hormones trigger an incredible cascade of biological and physiological changes that give rise to...

Table of contents

• Dedication
• Contents
• Introduction
• Part 1: Her-Story
• Part 2: Hormone Health
• Part 3: The Change
• Part 4: Menopausal Brain and Mind
• Part 5: Sex, Relationships and Roles
• Part 6: Menopause Management Map
• Final Words
• References
• Acknowledgements
• Index
• About the Author
• Copyright