Understanding menopause is every doctor’s business

The hormonal changes that occur in perimenopause and menopause impact all systems in women, writes Dr Mary McCaffrey

At a recent Food and Drug Administration seminar on menopause, one lecturer stated, “Women are whole human beings; not just heart, brain, and breast.” The statement reflects how all clinicians should be aware of the impact of hormonal changes during menopause and perimenopause on all systems in the body.

Menopause is no longer the exclusive domain of gynaecologists. Healthcare providers across every specialty will encounter women who should be supported, and appropriately directed, for management of menopause- related symptoms.

Women now spend a significant part of their lives, including their years in the workplace, in both perimenopause and post-reproductive health.

Currently, life expectancy for an Irish female is 84.6 years. With improvements in healthcare, it is likely that this will increase by at least five years over the next three decades.

Definitions

By definition, menopause occurs with the final menstrual period and thus is known with certainty only in retrospect one year after the event. The average age of natural menopause is 52 years of age.

Induced menopause occurs when ovarian function ceases due to surgical removal of the ovaries or cessation of ovarian function due to chemotherapy or radiation.

Perimenopause is more imprecise and includes the period of time beginning with the first clinical, biological, and endocrine features of the approaching menopause, including vasomotor symptoms and menstrual irregularity. Symptoms may be subtle and may fluctuate for many years prior to actual menopause, making this diagnosis quite challenging. It is currently somewhat misunderstood.

Premature ovarian insufficiency (POI) describes a menopause that occurs before age 40. This category of women is so important to identify as, if untreated, the risks of osteoporosis, cardiovascular disease, cognitive decline, dementia, and Parkinsonism are increased. The mean life expectancy of women with menopause before the age of 40 years is also shorter when compared to those who enter menopause at age 52 years.

Lack of oestrogen may impact the gastrointestinal tract with effects on smooth muscle, and joint pain may be exacerbated. Any system in the body may be affected.

However, most importantly the impact of menopause on cardiovascular, skeletal/MSK, and brain can contribute to significant morbidity in later life.

The symptoms of menopause intersect medical specialties:

• Joint pain – is it rheumatology, menopause, or a combination of both?

• Brain fog – is it menopause, burnout, mental health issues, or some other condition?

• Dry eyes/burning mouth – would people think of menopause?

• Anxiety – mental health, burnout, or perimenopause?

• Bloating and altered bowel habit – could it be something sinister? Is it more likely to reflect changes in oestrogen on smooth muscle function slowing down the digestive process?

• And symptoms of recurrent UTIs – have clinicians thought about genitourinary syndrome of menopause (GSM) which could benefit from topical oestrogens rather than repeated courses of antibiotics.

• Dental issues can even become important such as gum disease, dry mouth, and increased risk of tooth decay.

On the other side of the coin, those managing menopause and prescribing hormone replacement therapy (HRT) can become overly focused on any symptom being purely related to oestrogen deficiency.

It is not uncommon for a woman to open a consultation with: “I need to increase my oestrogen please. I am still completely exhausted. My sleep is still terrible.”

Taking the time to explore the possibility of sleep apnoea or completing a burnout questionnaire can be very enlightening for your patient. Exploring sleep hygiene, alcohol intake, and diet could completely alter the management plan.

Cardiovascular disease

Let us reflect on cardiovascular disease and stroke in older women.

While most women believe that cancer is the most likely cause of death, in fact, cardiovascular disease (CVD) and stroke are the leading causes of death among women worldwide.

Oestrogen plays a protective role by maintaining healthy blood vessels, influencing cholesterol levels,
and inflammation.

CVD presents 10 years later in women than in men. Symptoms may be different in women, which may lead to a delay in diagnosis. Women are also more likely to present with coronary artery spasm and microvascular disease rather than plaque lesions. Patients and healthcare providers may be inappropriately reassured by normal imaging in women.

Women with a history of pre-eclampsia (PET), gestational diabetes, or gestational hypertension are at increased risk of CVD in later life.

Since January 2025, women who had a history of gestational diabetes or PET since 2023 are now eligible to be incorporated into the chronic disease programme, providing a great safety-net for future care.

Risk factors for CVD such as poor nutrition, physical inactivity, smoking, hypertension, dyslipidaemia, diabetes, obesity, and psychosocial stress should be addressed across multiple specialties many decades in advance of menopause.

Women also have strokes at an older age and have a worse prognosis than men.

Recently, through the work of researchers such as Rebecca Thurston (University of Pittsburgh), there is greater awareness that childhood and early adult trauma in females are contributory factors to risks of stroke in later life.

The Study of Women’s Health Across the Nation (SWAN) and the MsHeart/MsBrain studies have revealed that both childhood and adult trauma exposure are associated with poorer cardiovascular and cerebrovascular health in women, including greater subclinical cardiovascular disease, indicators of cerebral small vessel disease, and increased risk for clinical cardiovascular disease events. Yet currently it is less likely that women who fall into this group will be identified and proactively supported to reduce their future risk of CVD/stroke.

More recently, there is a trend of ‘female cardiology’ evolving as a subspecialty within cardiology.

The interface of mental health and perimenopause/menopause

Mental health and menopause is a complex interface. Women with previous mental health issues such as premenstrual dysphoric disorder or postnatal depression/anxiety may develop a re-emergence of symptoms in the menopause transition. Major mental health issues may worsen. Conditions such as burnout may be a missed diagnosis.

ADHD may become recognisable de novo at this time. Hormonal regulation with continuous oestrogen can be very helpful as part of therapy for this group of women.

While guidelines recommend that antidepressants and psychotherapies remain frontline treatments for major depressive disorders (MDD) during the menopause, it is crucial that their role is explained clearly to women as they often feel that they are being denied HRT which they believe is the real solution.

HRT may also assist with depressive symptoms during the menopausal transition.

Treatment of vasomotor symptoms (VMS) in women with MDD is important as these symptoms can exacerbate mood problems and impact on sleep. VMS can increase the risk of elevated depressive symptoms.

While HRT may have positive benefits on mental health when administered to perimenopausal women with clinical depression, research suggests it is not as effective in postmenopausal women.

Pauline M Maki is Professor of Psychiatry, Psychology, and Obstetrics and Gynaecology at the University of Illinois, US, and has a special interest in women, cognition, mood, and dementia, with a particular focus on the menopause. Recently at the European Menopause and Andropause Society’s Congress, she led a number of sessions on mental health. Her publications are a useful resource for health practitioners managing mental health at menopause.

Collaboration between gynaecology, primary care, and mental health practitioners is very valuable when caring for mental health concerns in perimenopause and beyond.

Dementia

Worldwide, around 50 million people have dementia, and there are nearly 10 million new cases every year.

Dementia and CVD have many common risk factors, including hypertension, hypercholesterolaemia, obesity, and diabetes which could be identified, and health education provided at a much earlier stage in our lives.

The work of the aforementioned Rebecca Thurston around the area of trauma and subsequent risks of stroke and cardiovascular disease is an interesting read.

Awareness among our patients on risk reduction and cognition needs to improve.

Osteoporosis

One third of women over the age of 50 will have an osteoporotic fracture with all of the ensuing morbidity.

Knowing the clinical risk factors for fracture such as POI, previous fragility fracture, parental history of hip fracture, current smoking and current glucocorticoid treatment could shape health advice and preventative strategies for women at an earlier age.

Key messages

• The hormonal changes that occur in perimenopause and menopause impact all systems in women.

• It is incumbent on all doctors to be educated in the care specific to menopause in their individual specialty.

• To this end, education should be a fundamental module during both undergraduate and postgraduate training.

• Identifying areas of chronic disease prevention should contribute to improved health for women over several decades.

• With increased longevity and more women becoming centenarians, management of the menopause and post-reproductive health is of growing importance as it has the potential to help promote health over several decades.

Educational resources

• International Menopause Society – Essential Menopause Curriculum Healthcare Professionals Position Statement.

• The Menopause Society | Homepage Home – International Menopause Society.

• AMS Symptom Score Card – Australasian Menopause Society.