The conversation around menopause is growing louder, backed by increasing awareness and policies that are challenging decades of silence and misinformation.
For generations, menopause has been a topic few women dared to talk about openly; an unavoidable stage in life that society taught us to simultaneously dread and ‘deal with’. Despite being experienced universally by middle-aged women, many women are unprepared for their journey into menopause – which isn’t surprising, really, considering this important area of women’s health has been woefully neglected in both medical research and product development.
But things are changing. Menopause is finally stepping into the spotlight. It has become one of the most talked about health topics and is now being recognised as the urgent matter of public policy that it is.
The recent Australian Senate Inquiry into Senate Inquiry into Issues related to menopause and perimenopause is paving the way for greater understanding and support for women. It’s clear: this is not just a personal health issue, but a national health priority.
For women approaching or experiencing menopause, it’s no longer something to suffer through in silence. There are more resources, conversations and treatments available to help navigate this stage than ever before.
Beyond the hot flashes: what really happens during menopause
Menopause marks the end of a woman’s reproductive years, but it’s so much more than the end of periods. It usually happens between the ages of 45 and 55, though perimenopause – the transitional phase leading up to menopause – can start as early as a woman’s mid-30s.
During this time, levels of oestrogen and progesterone, the hormones that have regulated so much of a woman’s body for years, begin to drop. This hormonal decline doesn’t just signal the end of fertility, it sets off a cascade of changes throughout the body.
The symptoms can range from the familiar hot flushes and mood swings to brain fog, sleep disturbances and vaginal dryness. Less well-known symptoms include heart palpitations, joint pain, hair loss and tinnitus. Menopause also brings with it significant changes to skin, hair and body composition. Weight gain, particularly around the abdomen, is common, as is a loss of muscle mass and strength. Many women also notice changes in their hair texture and increased dryness of their skin.
It’s not just about hormones. Menopause is a complex process that affects nearly every system in a woman’s body. Oestrogen, in particular, has far-reaching effects on the body. It influences how the body uses calcium, maintains cholesterol levels in the blood, and protects against cardiovascular diseases. The decline in oestrogen levels and its association with accelerated bone loss and decreased bone mineral density are well established. It has also been linked to increased risk of cardiovascular disease, diabetes and some cancers.
Genitourinary syndrome of menopause (GSM) affects 45 to 63 percent of postmenopausal women in Western populations. It encompasses a range of symptoms affecting the genital and urinary systems and is characterised by vaginal dryness, irritation, burning and itching, decreased lubrication and discomfort during intercourse. Urinary symptoms, including urgency, dysuria and recurrent urinary tract infections, are also common.
Mental health can take a hit, too, with as many as 68 percent of women going through perimenopause developing depressive symptoms. Anxiety can creep in as well, adding to the rollercoaster of emotional and physical changes happening during this time. While there are few studies about anxiety and perimenopause, some evidence finds the incidence of anxiety disorder in menopausal women is as high as 25 percent. Changes in physical health, such as thyroid issues or sleep disturbances due to night sweats, can also contribute to anxiety and depression.
71% of Australian women unprepared for menopause
A 2023 report from health fund HCF found that 71 percent of Australian women aged 45 and over do not feel well informed or prepared for menopause and its symptoms.
The report, which surveyed more than 1,600 Australians also found:
• The majority (92%) of Australians feel there are benefits to perimenopause and menopause being talked about more / being normalised
• More than a third of Australian women aged over 45 are concerned that talking about menopause in the workplace could have a negative impact on the perception of their productivity
• More than 50% of women sourced information from their GP/doctor about perimenopause/ menopause, while 40% turn to female friends
• Less than two in five (38%) women feel comfortable speaking to their partner about perimenopause and menopause.
‘In Australia, while there is increasing awareness among women about common menopause symptoms like hot flushes and brain fog, understanding of more complex aspects – such as genitourinary syndrome of menopause (GSM) [which includes vaginal dryness, painful intercourse and incontinence] and the effects of oestrogen deficiency on the brain, cardiovascular system, gut microbiome and skin is minimal,’ says Dr Judy Craig, medical director of Natural Looks Cosmetic Medicine in Perth. ‘Also, few women are aware that perimenopause may begin as early as 35 years of age and present with symptoms of anxiety, impaired cognition, depression and insomnia.’
‘I have often raised the topic of menopause and in particular GSM with my patients during a cosmetic consultation, explaining that the changes that they are seeing on their face are also occurring in the intimate area. Many will then open up about symptoms of dryness, dyspareunia, incontinence and reduced sexual desire, intimacy and the impact on their relationship.
‘I find very few of my patients are aware of the brain changes associated with changes in oestrogen and progesterone and the impact of this on memory, mood, anxiety, sleep quality, executive function and fatigue. These changes often undermine their work confidence, prompting many to contemplate or make career changes.
‘Few are also aware of the changes in the gut microbiome with menopause and its impact on weight and mood, or the latest results from studies on body-identical hormone therapy. Discussing these changes resonates with many women negotiating the menopausal changes.’
Dr Craig says while there is an increase in awareness of the need for menopausal hormonal therapy (MHT), amongst women, many women still leave their GP appointment without a prescription and continue to suffer.
‘Improving education and creating more open dialogues about menopause could help bridge these gaps, enhancing both understanding and support for women navigating this stage of life,’ she says.
Busting myths about HRT and MHT
‘There are 3.28 million Australian women aged 40-59 years old today going through varying stages of perimenopause and menopause,’ says Dr Liz Golez, GP-obstetrician and principal cosmetic doctor at Lift Aesthetics in Sydney. ‘Twenty-eight percent of women will experience severe vasomotor symptoms such as hot flushes (the hallmark of menopausal transition/perimenopause and early postmenopause). Despite available safe treatments (hormonal MHT or non-hormonal therapies), more than 85 percent of Australian women bothered by these symptoms fail to receive approved therapy.
‘Genitourinary syndrome of menopause (vaginal dryness, vulvovaginal atrophy, itching, laxity, and incontinence) affects 50 percent of post- menopausal women but only seven percent are prescribed oestrogen therapy.’
For years, hormone replacement therapy (HRT) was the go-to treatment for menopause symptoms – until one flawed 2002 study created mass confusion.
‘I think there are a couple of reasons we have got menopause so wrong,’ says Dr Ginni Mansberg, an Australian GP and television presenter with a special interest in menopause and women’s health. ‘For years menopause was perhaps overmanaged, at least in the US. Premarin – an old-school synthetic form of oestrogen – was the top-selling pharmaceutical in the US in the early 1990s! But a few things happened.
‘First, the 2002 Women’s Health Initiative (WHI) study was reported as showing a link between HRT and breast cancer. Sure, it did – for women with an average age of 63 when starting synthetic high-dose HRT. The quantum of risk? For every 10,000 women on a placebo, we saw 30 breast cancers, but we saw 38 in the takers of HRT. Not a big increase. If you took the group of women who started taking HRT before age 60, there was no increase in risk. But the finer details were just missed by reporters.
‘After this, journalist Barbara Seaman wrote The Greatest Experiment Ever Performed on Women: Exploding the Estrogen Myth. The prevailing view became that taking HRT is deadly and basically an indulgent beauty treatment, that to ask for it showed weakness. Women shut up. Doctors stopped learning about menopause and the whole thing fell under the cone of silence.’
This misinformation has led to decades of confusion and fear around a treatment that could actually help many women. In fact, modern research shows that bioidentical oestrogen therapy can reduce the risk of breast cancer and other serious conditions when managed carefully.
Dr Judy Craig says, ‘A large barrier to positive action to address the medical and economic consequences of oestrogen deficiency (menopause) is a reluctance of organisations, including medical advisory bodies and governments, to embrace the latest research data showing the positive health benefits of menopausal hormonal therapy (MHT).
‘Until health professionals advising government accept data from recent studies that show that body-identical oestrogen alone reduces the risk of breast cancer, and combined with micronised progesterone has not been shown to increase the risk of breast cancer, changes in the management of menopause will not occur, or will change very slowly as many doctors are reluctant to go against the recommendation of advisory bodies. Greater confidence in the safety of body-identical MHT will result from further studies if they confirm the findings in the study by Emilie Cordina-Duverger et al.
‘Globally, MHT prescribing in women aged 45 to 64 averages only 5%, and in Australia, 14%. This is despite studies showing reductions in all-cause mortality and an increase in longevity for women on body-identical MHT.’
She argues that only by improving awareness, increasing research funding and fostering open dialogue can we begin to address the gaps in menopause care and support as well as the broader economic and social costs associated with menopause.
‘For change to occur, I believe we need more women in all aspects of management, government, research and education at an executive level and we need them to be informed on the issues facing menopausal women and be aware of the latest research and economic impact,’ she stresses. ‘Increasing public and government awareness may in time precipitate change.’
Medical misogyny: why women’s health has been overlooked
Menopause has long been marginalised as a health concern, deemed insignificant when compared with other medical conditions. It can be argued this stems from societal tendencies to undervalue women’s health issues, particularly those related to ageing.
‘Historically, women’s health issues have been neglected, trivialised and underfunded,’ says Dr Craig. ‘While many are familiar with how the concept of “hysteria” was used to dismiss and pathologise women’s challenges in the 18th and 19th centuries, they may be shocked to realise that before 1993 women were rarely included in clinical trials, leading to a lack of proven data on the effects of many drugs and treatments on women.
‘In addition, there has been little investment in research into women’s health. A report from McKinsey and company stated that approximately one percent of healthcare research and innovation (2021) was invested in female-specific conditions beyond oncology. This neglect of women’s health research has also led to an ignorance of the prevalence of the medical, psychological and economic impact of menopause on women. In 2017 a review of the literature found that there were few studies assessing the impact of menopause transition on women’s careers. Studies addressing the economic impact of menopause transition have predominantly been published since 2022.’
According to a 2023 perspective in Nature Aging, less than one percent of published studies of the biology of ageing considered menopause. This gap in research must certainly translate to gaps in women’s health care.
‘When we look at age-related diseases, over 75 percent of them are likely influenced by menopause in one way or another. But the great majority of preclinical biology research studies in ageing fail to consider menopause in their experimental setup,’ said lead author Fabrisia Ambrosio, PhD.
‘Menopause is inextricably intertwined with ageing in female individuals. On average, females will live about a third of their lives postmenopausal. We lack data to understand how menopause affects ageing and how it might contribute to disease or age-related declines. In preclinical models, it’s something that we just haven’t effectively addressed, and so we haven’t been able to study it well.
‘The science has so much catching up to do. Hundreds of years of research studies have been dominated by male animal models and male humans.’
In February 2023 the Australian Government established a National Women’s Health Advisory Council to examine the systemic issues impacting gender inequities in health outcomes and improve Australia’s health system for women and girls.
The council will provide strategic advice to the government after looking at the healthcare offered in areas such as menstruation, reproductive healthcare, menopause, medical consent and pain management.
Dr Sarah White, CEO of Jean Hailes for Women’s Health and a member of the Women’s Health Council, wants the agency to address gendered gaps in research. ‘So much medical research has studied males and then generalised those findings to females,’ she told abc.net.au.
‘The Therapeutic Goods Administration (TGA) should not approve medicines unless there is sufficient data around quality, safety and efficacy for males and females separately,’ Dr White says.
‘As a society, none of us seems to have a problem understanding that we need paediatric research and children’s hospitals. We intuitively understand that small boys are not the same as men, but for some reason, we treat women as if they’re small men.
‘We also need different treatment guidelines and public awareness campaigns. If you look at something like menopause, it affects 50 percent of the population and, of those, 10 percent will have symptoms that really impact their ability to work, live, study and play. But we still don’t have anywhere near enough research on it.
‘We need to make sure there is equality of funding for conditions like endometriosis and menopause, and perhaps even more funding, to make up for injustices in the past.’
Tricia Currie, head of the Victorian Women’s Health Council and CEO of Women’s Health Loddon Mallee, told abc.net.au that women’s voices are not being heard in the healthcare system:
‘There’s unconscious bias within the healthcare system, which is why it is important that we have structures around decision-makers that ensure governments are hearing from women, and diverse women, about not only what the issues are but what some of the potential solutions are.’
Knowledge gap amongst HCPs
There remains a gap in knowledge of the complexities of menopause amongst healthcare practitioners, resulting in inadequate health care and/or a deficiency of care options for those who are menopausal or in the perimenopausal stage.
Dr Liz Golez says the menopause ‘knowledge gap’ started 20 years ago. ‘Research shows that GPs, gynaecologists and pharmacists mostly lack the skills and confidence in managing menopause,’ she says. ‘The medical knowledge gap began 20 years ago when the conflicting WHI study spread false and frightening information about HRT.
‘The knowledge gap trickles down to the consumer, the women who have been failed by the medical system, since they were never empowered by their women’s health provider to watch out for these symptoms of menopause or get started on MHT or non-hormonal treatments in a timely manner.’
‘We certainly have to acknowledge that treatment in this space is suboptimal,’ Dr Ginni Mansberg agrees. ‘It is not taught in medical school or even as part of GP, endocrinology or gynaecology training. For your doctor to be ‘up to date’, they need to invest a lot of time and money to join societies and upskill their knowledge on their own. That’s not to say that the experiences of serious medical gaslighting that I hear about every single day are okay; it’s just awful.’
In a 2023 perspective in the Medical Journal of Australia, the authors write that lack of clinician knowledge, poor access to services, negative attitudes and lagging research have led to substandard menopause‐related health care: ‘Irrespective of symptoms, menopause causes silent biological changes that may increase women’s risks of cardiovascular disease, diabetes, osteoporosis and some cancers. Consequently, it should be expected that health care providers, especially general practitioners, are equipped to provide evidence‐based menopause advice to the 3.28 million Australian women aged 40–59 years. Sadly, this is not the case.’
The authors argue that first-line management of menopause‐ associated issues should be occurring at the level of primary care, yet GPs and specialists are not equipped to confidently manage menopause and frequently recommend unproven, and often ineffective, complementary therapies before prescribing MHT or effective non‐hormonal therapy.
‘Contributing to this health care knowledge gap are two decades of widespread dissemination of conflicting, and often frightening, information about menopause treatment, and omission of menopause from most undergraduate and post‐graduate medical and allied health training. Thus, state‐of‐the‐art menopause care is not available to most Australian women,’ the authors state.
A new age of menopause awareness; upskilling of HCPs required
In Australia, there is a push for menopause to be more widely recognised as a significant health issue – and the recent Senate Inquiry suggests the issue of menopause is finally beginning to receive some attention.
Australian Senate Inquiry: Menopause care requires overhaul, upskilling
On November 6, 2023, the Australian Senate referred an inquiry into issues related to menopause and perimenopause to the Senate Community Affairs References Committee. Submissions closed 15 March 2024.
The Senate Inquiry will focus on the impact of menopause and perimenopause on:
• economic consequences
• physical health impacts and associated medical conditions
• mental and emotional wellbeing, including mental health, self-esteem, and social support
• cultural and societal factors influencing perceptions and attitudes toward menopause and perimenopause, including specifically considering culturally and linguistically diverse communities and women’s business in Aboriginal and Torres Strait Islander communities.
Another key area of the Inquiry is awareness among healthcare professionals and patients with symptoms of menopause and perimenopause and available treatments, including affordability and availability.
In its submission to the Senate Community Affairs References Committee, the RACGP says there is an urgent need for improved support and access to care for people experiencing menopause and perimenopause.
‘Upskilling of clinicians providing care for patients at midlife, concerning the indications for and prescribing of MHT, urgently needs to be addressed. Further education in recognising symptoms and signs but also a systematic evidence- based approach to management including non-drug therapy, MHT, and other management options is required,’ said RACGP President Dr Nicole Higgins. ‘Too many women are missing out on the care they need,’ she said.
‘One of the barriers to quality menopause care is patients having enough time to spend with their GP – current Medicare subsidies don’t adequately support people who need longer appointments. This care is complex, menopausal symptoms can have numerous physical and mental health impacts.’
Dr Higgins said another barrier to appropriate care is cost – many MHT products are not available on the PBS, making them too expensive for some patients.
The AMA has also submitted its response and calls on the government to take action. The submission focused on six key issues:
- The central role GPs play in helping women to make informed decisions about their healthcare during menopause and perimenopause.
- Access challenges for women prescribed Menopausal Hormone Therapy (MHT) medicines.
- All women experiencing symptoms have the right to seek and receive the care they need.
- Menopause and the workplace.
- Funding boost for new research into menopause and perimenopause.
- Development of a National Menopause Framework.
These submissions to the Senate Inquiry join other organisations, including the Australian Psychological Society, Department of Health Victoria, Australian and New Zealand College of Anaesthetists and Women’s Wellbeing Association.
How aesthetic clinics are getting involved
Interestingly, aesthetic clinics are emerging as an unexpected source of support for menopausal women. As menopause accelerates the ageing process – manifesting as sagging skin, loss of elasticity and increased dryness – many women turn to cosmetic treatments for help.
‘Menopause care aligns seamlessly with the mission of aesthetics and anti-ageing clinics, which focus on addressing the signs and effects of ageing,’ says Dr Judy Craig. ‘The hormonal changes associated with menopause, particularly oestrogen deficiency, contribute to accelerated skin ageing through collagen degradation.
By offering treatments that address both the hormonal imbalances and their aesthetic consequences, clinics can provide more comprehensive care and significantly benefit their clients.
‘In addition to facial treatments, many devices used for addressing facial ageing, such as radiofrequency or laser therapies, have been adapted to treat vaginal changes associated with menopause. Both areas experience similar issues; loss of mucosal and skin elasticity and thickness, and collagen degradation, making it possible to use these technologies to address concerns in both domains.’
As the conversation around menopause grows, one thing is clear: women deserve better care, more research and a louder voice in this conversation. Menopause isn’t the end – it’s the start of a new chapter. And with the right resources and support, it’s a chapter every woman can and should feel empowered to embrace.
