Precariously Perched
November 12, 2023
The Menopause Revolution: Why Menopause Is Having a Moment
Yes, it’s true and a long time coming, but menopause is having a moment. Even the North American Menopause Society is going through a rebranding. First in its name, now known as “The Menopause Society,” and also with a brand new website coming in early 2024. The Menopause Society incorporates the most up-to-date information on menopausal support for patients (and I send patients there every day!) and healthcare providers who join with a professional membership and have an opportunity to certify as experts status, which is fantastic. But what an explosion of perimenopause and menopausal information that is now all over social media as well as podcasts sharing all the latest research and symptom support. Listening to these podcasts with expert after expert physician weighing in on the topic of medical school education primarily on menopause, most share the same mantra, they had very little if any medical school education surrounding the subject of menopause, treatment, support, and hormone replacement. It’s shocking really when you consider women will spend on average 40% of their lives in menopause. Let's look back at the Women’s Healthcare Initiative (WHI) study that caused massive alarm and crisis around the country back in 2002 with a flood of estrogen essentially being flushed down the toilet, it makes you wonder how we’ve finally gotten some hold on the subject but why did it take more than two decades? And let’s not forget that during this time, bioidentical hormones coming from compounding pharmacies (non-prescription forms) surged and became a whole new cash-only business taking advantage of women in need. And can we blame them? Physicians and nurse practitioners at the time were all afraid to prescribe hormone replacement thanks to the WHI study and many women were suffering. Now we know that not all women need or are good candidates for hormone replacement but it’s incredibly disturbing to consider how many women have been denied hormone replacement over the last two decades, since the Women’s Healthcare Initiative (WHI). That's over two decades of women, millions of women who have suffered through menopausal symptoms without support. And that's shocking as a country! The research has always been lacking in all categories of women’s health but that tide is finally beginning to turn. Our post-COVID healthcare world has changed, and women are benefiting from a new surge of research. And it’s about time. Have you ever, in this lifetime, noticed so much attention on menopause? It’s everywhere we turn now and it wasn’t all that long ago that it was just another women’s health wall of shame word like ‘menstruation’ or ‘vagina.’ But now we see this MENOPAUSE song being sung with pride and fortitude, and flashing with sparkling lights, no longer shrouded in secrecy. And we'll take it!
Let's Here It for FemTech!
We can thank in part the FemTech revolution, which started giving us a nice infusion of money into new areas of women's health research beginning around 2016. Ida Tin, a Danish internet entrepreneur and CEO of the women's menstruation tracking app, Clue, was credited for coining the term “femtech." Femtech provides a wide range of solutions to improve healthcare for women across some female-specific conditions including maternal health, menstrual health, pelvic and sexual health, fertility, menopause, and contraception, as well as certain general health conditions that affect women disproportionately or differently (such as osteoporosis or cardiovascular disease). Also, the Bill & Melinda Gates Foundation and the National Institutes of Health (NIH) brought together the Innovation Equity Forum (IEF) to help investigate gender gaps in research and scientific innovation related to women’s health. The IEF is a diverse group of women’s health experts and researchers from across sectors and over 50 countries working together to develop a coordinated agenda to target global efforts, galvanize investment, and advance innovation in women’s health research and development. When we talk about these ‘gender gaps” it’s important to realize that up to approximately 25 years ago, women were actively excluded from clinical trials. Why, you ask? Because of the persistent idea that female hormonal cycles were too difficult to manage in experiments — including the fear of harming potential pregnancies — and that using only one sex would reduce variation in results. This exclusion of females in health research wasn’t just limited to humans. It extended to research on female animals, cells, and tissue. Researchers assumed that they could simply extrapolate their male-only study results to females, a dangerous precedent that overlooked fundamental differences between women and men. Thanks to the Society for Women’s Health Research and other groups, Congress passed the National Institutes of Health Revitalization Act of 1993, mandating the inclusion of women and minorities in NIH-funded clinical trials. In the same year, the Food and Drug Administration changed its policies to require the inclusion of women in efficacy studies and in the analysis of data on sex differences.
Finally, Women's Health Research!
Let’s begin with probably the most common menopause symptom in the world, hot flashes or vasomotor symptoms. I was over the moon excited this week listening to one of my favorite podcasts You Are Not Broken by Kelly Casperson MD interview Lisa Larkin MD, the newly named Menopause Society President who shared so many exciting points of research in women’s health and menopause that quite frankly lit this old girl on fire. After recently passing the national menopause provider certification exam, my gratitude to this incredible group of professionals in this organization who have worked tirelessly for decades with very little research money is finally getting its day in the sun. It may be day one in the sun but it's a start. And, there are some real advances in understanding the physiology of vasomotor symptoms: what they mean, where they come from, and how to stop them. Dr. Larkin reviewed vasomotor symptoms, hot flashes, and night sweats as previously assumed they’re all simply related to estrogen deficiency. While we know that estrogen has a role, the truth is that not all women get them or have the same degree of intensity, and African-American women often have much more intense and longer-lasting hot flashes. However, some good science has recently focused on understanding the neurons in the hypothalamus and the signaling that is related to estrogen. In the absence of estrogen through these things called “candy neurons” they oversignal into the hypothalamus and this causes a narrowing of a kind of temperature regulation zone. Now in the presence of estrogen, that same temperature zone is widened, and you can’t moderate your temperature very well. These small swings in ambient temperature cause you to have a hot flash and so they come and go. Now this is some amazing new understanding of pathophysiology and there is a new medication available that binds to these candy neurons to prevent hyper-signaling. I mean come on! VEOZAH is a nonhormonal selective NK3R antagonist that blocks NKB binding on the KNDy neuron to modulate neuronal activity in the thermoregulatory center. This action helps to reduce the number and intensity of hot flashes and night sweats and will be immensely helpful to women who are suffering from vasomotor symptoms and aren't good candidates for hormone replacement such as malignancies or other contraindications. This is just a small snippet of great things coming our way thanks to new research in women's health.
Perimenopause or Millenopause Era?
The perimenopausal crowd is welcoming the Millennials, and that just seems crazy right? After all, many of us Baby Boomers have (hello!) kids who are Millennials! The Baby Boomers are well into menopause, the GenZ crowd is moving out of perimenopause and smack into menopause, and here come the Millenials right behind us and they have their name called “The Millenopause Era.” Millenopause is here representing millennials who today are between ages 27 and 42, and that latter crowd is just entering into perimenopause. Millennials look a little different than GenX and Baby Boomers because they grew up with the internet, social media, and focusing on asking questions and accessing solutions immediately, and expecting answers to what they need immediately. They are tracking their cycles on apps, and they expect personalized explanations when the data is collected. New products are being launched related to aesthetic-forward brands like Glossier and Womaness with massive growth expected in the future as the retailers are more excited about this than the consumers. Our Millenial ladies just might be the generation to walk right into solutions and mainstream straight talk, the first generation to go through the entire journey without having been left behind. The United States Bureau of Labor Statistics says Millennials will make up 75 percent of the workforce by 2030. The experts are talking and recommending employers, insurers and brands should prioritize menopausal care as we look ahead. And since we Baby Boomers have kids in this Millennial crowd, this is playing tricks on our menopausal brain-fogged brains. But I digress!
And this is why: Midwives Rock!
Looking back on my midwifery education circa 2006-2010 at the University of Illinois at Chicago, we learned about menopause and I recall devices like vaginal dilators being shared around the room, all in all, it was pretty comprehensive. We had one hormonally gifted nurse midwife Lin whom everyone sent their menopausal patients for consultation. Lin knew a thing or two about hormones and how to safely replace what was missing and only now, looking back, realize she was way ahead of her time. I can still picture Lin at her desktop computer at the Board of Health in Englewood (a neighborhood on the southside of Chicago) analyzing the lab results like she was working in a chemistry lab analyzing the data. During these years, Lin was close to retiring and I was heading into perimenopause, working full-time at my community hospital as a labor & delivery nurse while going to school full-time with nothing but goals and dreams fueling my days. One day Lin shared a bit of wisdom about what happens to women in our culture once they go through menopause, often by way of disappearing. She shared that our culture (as well as our healthcare culture!) loves women who are filled with estrogen and who are fertile, glowing, and happy. And when women enter menopause, they find themselves experiencing many physical and emotional changes and sadly they feel they have become invisible even in a room full of people. Our younger counterparts tend to look right past us, as if to say, “Hey, you’ve worn out your welcome, you’re a ‘has been’ now.” Naturally, I listened and appreciated Lin’s words of wisdom although I didn’t fully understand what she was saying. I trusted in these words as wisdom and thoughts more of aging rather than menopause filled my mind. Until I was there myself, feeling like the old maid. So now I get it, but I also see some progress, and that circles right back to the women themselves. Women today are saying nope, don’t ignore me I’m not going anywhere. Women in this age group want to look good, feel good, and have healthy brains, hearts, and bones, is that asking too much? I think not! Women need all these experts on podcasts right now, they need to learn how to adjust their diet, lifestyle, sleep, work-life balance, and stress management in healthy ways that help women feel fulfilled and happy. So let's unlock the midlife magic!
Mary Kay Burke DNP APRN CNM WHNP