People worldwide don’t know enough about menopause. Here’s why that’s dangerous

By Sashikala VP, CNN

(CNN) — Thirty-eight-year-old Rosy Devi’s body aches most of the time, short walks have become difficult, she loses her breath easily, has chest pain and feels her health is generally getting worse. It has been a gradual decline, she says, since her hysterectomy in 2019 which led to her prematurely going through menopause.

“I am walking and suddenly feel intense heat in my body and start sweating. And I get chest pain, like someone has hit me in the back,” says the mother of four who lives in India’s eastern state of Bihar. She never imagined the menopause, the time of life a woman stops getting her period permanently, would take such a toll on her body. “Now I am really feeling old. I mean, I feel that I have really become old… The body, the face, everything has changed,” she says.

For Devi, menopause was also something she expected to experience much later in life, not because of surgery, so the whole thing came as quite a surprise, she admits.

But it’s a change that affects half the world’s population at some stage, and Devi’s symptoms are some of the wider-ranging and lesser-known effects that come with it.

Symptoms such as hot flashes and mood changes are well known, and often stereotyped, but experts worldwide want to highlight that women face a huge range of changes to their bodies during the menopause – and lack of awareness means many will start experiencing symptoms without knowing why.

Here’s what everyone needs to know.

What is menopause – and why don’t people know enough about it?

Menopause is when women experience an end to their periods, or menstruation, for more than 12 months, and it marks the end of their reproductive years.

Globally, most women experience menopause between the ages of 45 and 55, according to the World Health Organization (WHO). But a study of women in the United States and South Korea found that up to 9.4% of people (around 1 in 10) experience it between 40 and 44, while for up to 8.6% of people it happens before the age of 40. In very rare cases, women can go through menopause as early as their 20s. For some, it can occur following a full hysterectomy, including the removal of the ovaries, or due to other medical reasons.

In the case of natural menopause, the first stage is perimenopause. This is when the ovaries gradually produce fewer hormones, affecting menstrual cycles. Symptoms include irregular periods, hot flashes (also known as hot flushes), sleep disruption and mood changes.

Perimenopause can begin as early as in the mid-30s, lasting for about four to eight years, but many women can’t recall when this started for them, explains Gayathri Delanerolle, a researcher with Hampshire and Isle of Wight Healthcare NHS Foundation Trust in the UK. In qualitative interviews, some women remember the exact time they experienced a hot flash or their sleep began to get worse, but others have no idea, she tells CNN. “Menopause has not even been on the radar.”

Studies show that most women know little about menopause. One, which surveyed more than 800 postmenopausal women, the majority based in the UK, found that over 90% of them had never been taught about menopause at school, and almost half said they felt completely uninformed about it. The women also shared that their doctors lacked adequate knowledge, leaving them feeling “dismissed and unsupported” after their consultations. Other studies produced similar findings.

Joyce Harper, a professor at University College London’s Institute of Women’s Health, who co-authored the study, told the College news outlet, the result shows “women have a lack of education about this key life stage… Together with a reported lack of education from their healthcare professionals, women may be left undiagnosed and unsupported.”

Menopause can happen in many ways and at different times

Menopause is classified as “premature” when it occurs before age 40, and “early” before the age 45.

Research suggests, across low and middle-income countries, rates of early and premature menopause have risen and that the average age of menopause has fallen.

“If you get menopause early in your lifespan, you are struggling with that for a longer period of time,” says Nikita Rajput, a scientific officer at Tata Memorial Centre’s Centre for Cancer Epidemiology in Navi Mumbai, India. Her research found that women in rural India faced “limited healthcare access, low awareness and higher rates of premature menopause,” she tells CNN.

Other forms of menopause include surgical, which is triggered by a hysterectomy to remove the uterus and ovaries, and medical menopause, where treatments such as chemotherapy or radiation therapy may affect the functioning of the ovaries and result in the onset of menopause.

Health experts in India have raised concerns about high rates of premature and early menopause in the country with research indicating its link to hysterectomies. This is particularly the case among young women from low-income, less educated and rural backgrounds. Rajput tells CNN that when these women are suffering with gynaecological disorders such as excessive bleeding or fibroids, they feel forced into hysterectomies, possibly under pressure from their husband or in-laws, or even doctors who may suggest the surgery as the first course of action. Research shows many women are unaware of the extent of the procedures they’ve had.

The symptoms of menopause vary from person to person

The most common symptoms of menopause are hot flashes and night sweats, occurring in 80% of cases, according to The Menopause Society in the US, but other common symptoms include vaginal dryness, urinary urgency, insomnia, and mood changes, including depression and irritability.

“Lots of women have also reported headaches, migraines…and difficulty sleeping or staying asleep,” says Delanerolle. Many also experience incontinence which then impacts other aspects of their life, including work and exercising.

Additionally, women may face symptoms such as heart palpitations, joint and muscle ache, changes in sex drive, poor concentration, weight gain and hair loss, according to the Mayo Clinic.

Other less common symptoms include dry eyes, while some women also report changes to their vision. They may also find themselves bruising more easily and suffer dry mouth or acne.

Delanerolle says she has come across other symptoms in her research, including itchy scalp and itchy skin. Some women in India and the UK even reported an increase in libido, she adds.

“Menopause can be a highly individualized journey,” says Delanerolle, and because some symptoms are common in other health conditions, “sometimes it may not be possible to definitively think that these are related to menopause.”

She believes what’s needed is comprehensive research, public awareness campaigns, including in schools, and evidence-based training for health care professionals.

Why is it dangerous that women don’t know enough about menopause?

Menopause and its symptoms last for around seven years on average, according to the Cleveland Clinic, and it’s important for women to be able to understand and identify what they are going through.

Women also have an increased risk of cardiovascular disease following menopause, making it important that they become more active and manage their diet. This is because menopause causes a significant drop in estrogen – which works in regulating cholesterol and fat – increasing the risk of developing coronary heart disease or suffering a heart attack or stroke, according to the British Heart Foundation. Heart disease is the leading cause of death in women worldwide.

Multiple studies also show a greater risk of respiratory conditions such as chronic obstructive pulmonary disease (COPD) following menopause, particularly premature menopause.

Om Kurmi, associate professor in epidemiology and healthcare research at Coventry University in the UK, says greater awareness will help women get the correct support, and make the changes required in their lifestyle, to mitigate the health risks menopause brings with it.

For example, lifestyle changes like quitting smoking, reducing alcohol consumption, increasing exercise, reducing stress levels and losing weight can help with symptoms and combat the heightened risk of conditions such as osteoporosis and heart disease. Another area is mental health, which Kurmi says is “not discussed at all.” While symptoms of menopause such as irritability, mood swings and insomnia are well documented, there is also a heightened risk of depression and anxiety, as recent studies show.

Women “need to recognize, if you’re having menopause, the likelihood of having certain health problems is higher compared to those who don’t,” Kurmi tells CNN. “Once you understand your symptoms … (these) can be managed well.”

How can women manage menopause symptoms? And does this differ globally?

The most prescribed care option for menopause worldwide is hormone therapy, also known as hormone replacement therapy or HRT, which works by replacing the hormones that have decreased inside the body. One is estrogen therapy – typically given to women who have had hysterectomies – and a second type is a combination of the hormones estrogen and progesterone, offered to others. Hormone therapy is thought to help mitigate symptoms and risks associated with menopause, and treatment typically lasts between two to five years, sometimes even longer. Stopping treatment may bring back menopausal symptoms.

But these therapies are more available in high-income countries due to cost, access to health care services, and knowledge among practitioners to then prescribe it. However, disparity is also seen within high-income countries, with the financially better off tending to have greater access.

There are some known side effects of hormone therapy, including irregular vaginal bleeding and breast tenderness, and an increased risk of blood clots and gall bladder disease. There is also a slight increase in the risk of breast, ovarian and endometrial (womb) cancer, but according to Cancer Research UK, the risk remains small, and depends on many factors, such as the type of therapy, how long someone is on it, their age and their general health and lifestyle. Experts saythat women should weigh all their options and decide, which can only happen if they have choices and information to hand.

There are also medications which may be prescribed to manage specific symptoms, such as antidepressants to treat hot flashes. Many women prefer to take a more natural route, with several herbal supplements claiming to help manage symptoms like hot flashes and sleep disruption. However, these are not generally recommended by health authorities due to a lack of evidence as to their efficacy and safety. Other options include taking vitamin supplements and making lifestyle changes such as quitting smoking, losing weight and regular exercise, which may be easier options for women in low-income settings.

An analysis of research from the US and five European countries found that most women who had moderate to severe symptoms made lifestyle changes to manage them. The most prescribed treatment was hormone therapy, followed by anti-depressants.

In the US, a recent decision to remove “scary black box warning” labelling on HRT products may see more women choosing the treatment. The country’s Food and Drug Administration decided to remove the “black box” warning stating the increased risks of diseases like breast cancer and dementia, saying the move was “to stop the fear machine steering women away from this life-changing, even life-saving, treatment,” according to the FDA Commissioner Dr Marty Makary.

Why women (and men) and policymakers need to sit up and pay attention

“The population is increasing, the lifespan is increasing, and that means women, 50% of the global population, are increasing as well,” says Kurmi. And with women living longer than men, the UN’s World Population Prospects 2024 says there is a need to prioritize “gender-specific health care needs,” and build stronger “social support systems to mitigate potential caregiving burdens.”

With more women who “are over 40 years, 50 years nowadays,” Kurmi, who is part of a team of researchers looking at the urgent need for attention on menopause, tells CNN there will be an increase in menopause-related health issues.

Health services in many low and middle-income countries, like India, still focus most of their budget for women on sexual and reproductive health, due to problems such as high maternal mortality rates, which the Indian government says is a “critical public health issue.” But a growing number of older women are also in need of care, and policies are yet to address their needs. “The government only knows women as a reproductive person, not post-reproductive. She’s not a woman, or she is only defined by her uterus,” says Rajput. What is required is a post-reproductive health policy and scheme, she explains.

The persistent stigma around menopause also needs addressing.

“The perception around menopause needs to change. And a large part of that comes with awareness,” says Delanarelle of the UK NHS trust. She believes that teaching teenage girls about menopause in school can make a difference because “as they grow up…they understand that menopause is not the end of the line for them. It’s another chapter. You’ve got a book, and menopause is another chapter.”

Credits

Commissioning Editor: Meera Senthilingam

Writer: Sashikala VP

Copy Editor: Hannah Strange

Visual Editors: Carlotta Dotto and Elisa Solinas

Illustrator: Yukari Schrickel

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