This is personal. This is universal. This is unspoken. And it could start with something as inconsequential as sweating while the air conditioner is set to a freezing 16 degrees Celsius.
Of all the biological processes that women undergo, only two are universal―the onset and the cessation of menstruation. However, while the former―menarche―is celebrated in many cultures, menopause invites silence.
Strange. Given that as per some projections, by 2026, India will have 400 million menopausal women, if we consider the average age of menopause to be 47. Since the actual number of women experiencing or having experienced menopause is not recorded globally, the closest estimation that can be made is by calculating the number of women in the 45-60 year age group, during which the transition to menopause is most likely to occur or postmenopause (cessation of periods for 12 months) has been reached. An article―‘Menopause in a globalised world’―in the journal Maturitas uses United Nations data to put women in the 50-plus age group at 985 million in 2020.
In India, where the age of menopause is earlier than western countries and women’s life spans on an average are 69 years, as per the World Health Organization, a third of their lives are spent in this phase.
The silence then is baffling.
Dr Asna Ashraf, an obstetrician and gynaecologist from Lucknow with a special interest in menopause management, said that this was perhaps because menopause was not “as glamorous” as let us say IVF. She has been running a menopause clinic since 2011 after she cleared the credentialed menopause practitioners certificate exam of the Indian Menopause Society.
In 2021, the Society initiated the country’s first effort to put together a registry of menopausal women to record data to enable both fine tuning of clinical guidelines and publication of authentic India-centric research.
But let us get back to first understanding menopause. It is not a sudden cessation of periods―you could, in fact, bleed heavier and longer. It is a long road with many bumps, though each individual experience is varied.
In the book The Menopause Manifesto, American-Canadian gynaecologist Dr Jen Gunter writes, “Menopause is like being sent on a canoe trip with no guide book and only a vague idea of where you are headed....”
Dr Pramila Kalra
Dr Supriya Puranik, director, obstetrics, gynaecology and IVF, Sahyadri Hospitals Momstory, Pune, said: “The length of the menopausal stages differs from one woman to another, with the transition to menopause―perimenopause―lasting anywhere between four to eight years.”
There is a host of pesky symptoms―short- and long-term―and though post menopause the symptoms become less severe, health concerns increase as the risk of complications caused by low levels of oestrogen is high, she said.
A woman who has reached menopause will be at risk for multiple health complications for the remainder of her life. The number of potential problems is an unending laundry list, but let us start with the main protagonist―oestrogen―and its faithful sidekick progesterone. The former is the hormone that regulates the menstrual cycle, maintains breast and bone health and keeps low the risks of heart attacks and strokes. Progesterone supports menstruation and helps in the early stages of pregnancy. As the production of these hormones reduces and the cells in the ovaries die, there is a rise in the follicle stimulating hormone and the luteinizing hormone. The latter are feedback hormones for oestrogen and progesterone with which they become at loggerheads as a woman approaches the end of her reproductive life. One manifestation of this yo-yoing of hormones is very heavy menstrual bleeding in the perimenopausal years.
Dr Sneha Kothari, a consultant endocrinologist at Gleneagles Hospital, Parel, Mumbai said: “Women may experience hot flashes, chills, anxiety, palpitation (all of which fall under the umbrella term vasomotor symptoms), mood swings, difficulty in falling asleep, fatigue, nausea, body pain, vaginal dryness, and fluctuation in weight.” The decline in oestrogen levels can increase the risk of cardiovascular disease and osteoporosis, she added.
These symptoms may be worse for some women―for example, those who have had their uterus removed, undergone cancer treatment and have a history of heart disease.
Oestrogen itself is a tricky hormone. It acts as a catalyst for cancer growth as it stimulates and multiplies breast tissue―a process that can result in cancer causing mutations. More recent research suggests that oestrogen can directly cause changes in the structure of genomes (complete set of DNA) thus becoming both the cause and accelerator of breast cancer.
Dr Tripti Raheja
Dr Poonam Patil, consultant, medical oncology, Manipal Hospitals, said that a very important risk factor for developing breast cancer with increasing age is increasing lifetime exposure to oestrogen. “Extended exposure with increasing age gives oestrogen a higher chance to stimulate breast tissue and cause cancer,” she said. She added that women who have a longer menstrual history―those who started their periods earlier and reach menopause later―have a relatively higher risk of developing breast cancer.
One of the important preventive measures she highlights is keeping weight in check as obese women have generally higher levels of oestrogen. Avoiding tobacco and alcohol also help. A more aggressive approach is hormone replacement therapy (HRT).
Often perceived as a magic bullet in layman’s perception, HRT, as Kothari cautioned, is not for everyone. “Women with a history of breast cancer, blood clots, or heart disease should avoid it,” she said.
Hormone therapy usually involves oestrogen, often combined with progesterone if the woman has an intact uterus.
Dr Pramila Kalra, head of department and consultant, department of endocrinology, Ramaiah Memorial Hospital, Bengaluru, said that the benefits of hormone therapy include reducing the severity of the most common vasomotor symptoms. “In cases of premature menopause, it may also be considered for its beneficial effects on bone health and the cardiovascular system,” she said.
But then comes the catch. Women who experience menopause at ‘normal’ age will find that HRT only offers relief from vasomotor symptoms, while alternative treatments are necessary for bone or cardiovascular benefits.
HRT has an uncertain reputation. In 2002, the first results of the Women’s Health Initiative (in the US) showed that HRT had more detrimental than beneficial effects. Though later studies have shown that its use in younger women or in early postmenopausal women has a beneficial effect on the cardiovascular system, it remains a grey area.
The genesis of HRT itself is dodgy. One of its founding beliefs was that menopause was nothing but a hormonal deficiency. And if oestrogen could be replenished, women would be ‘feminine forever’.
Notice that emphasis on feminity. Women are so linked to their reproductive functions that once those are lost, they could well be invisible. Notice another pattern. At the age when women begin to approach menopause, they are secure in their careers, financially powerful, rich with life experiences, and, in many cases, the prime decision makers at home. Yet, just because a couple of hormones go missing, they are lesser women. Societal conditioning makes them ashamed of their changing bodies. And the changes to their mental state are often rubbished, for did their mothers and grandmothers not go through it without fuss?
Dr Tripti Raheja, lead consultant, obstetrics and gynaecology at the CK Birla Hospital, Delhi, pointed out that modern lifestyles―higher stress, less physical activity, rising obesity and higher screen time are all enhancing certain symptoms, when compared with previous generations. One of the culprits, she also pointed out, was “reduced social interactions” which often act as stress busters.
Then there is that dreaded cognitive decline. “Symptoms like memory lapses or difficulty concentrating, often referred to as brain fog, can also develop,” said Raheja. “While these changes are expected, it is important to monitor their severity and impact on daily life, as extreme cases may require medical attention.”
There are other symptoms that though not necessarily linked to menopause, can be aggravated by diminishing levels of oestrogen.
One of these is urinary leakage.
Dr Ashwin Shetty, consultant, obstetrics and gynaecology, Sir H.N. Reliance Foundation Hospital, Mumbai, said: “Oestrogen plays a crucial role in maintaining the strength and elasticity of the pelvic floor muscles, urethral lining and bladder tissues. As its levels drop, these muscles weaken, reducing bladder control.” The results―bladder overactivity requiring frequent urination; an inability to hold urine; leakage during physical activity such as coughing, laughing, exercising and jumping. Imagine being afraid to laugh.
He said that while not all women experience urinary leakage, it is “a prevalent issue”. Various factors such as genetics, number of childbirths, obesity, chronic constipation, and pelvic surgeries can increase the risk. Moreover, women who have had vaginal deliveries are more prone to developing weakened pelvic muscles, which may lead to incontinence later in life.
The solution: non-invasive approaches that include lifestyle changes, pelvic floor exercises and bladder training. HRT may be recommended in some cases or minimally invasive procedures such as a pessary (a device inserted into the vagina to support the bladder), urethral bulking agents or vaginal laser therapy. For severe cases, regular medication or surgical options like sling procedures and botox injections of the bladder may be considered.
Then there are the unspoken consequences.
Dr Seema Manuja, director, gynaecology, Sarvodaya Hospital, Faridabad, said that symptoms affect women in ways which can often be detrimental to relationships. “Healthy and active sexual life is impacted because of loss of libido, night sweats and vaginal dryness and soreness and this often results in differences or discord in marital relationships,” she said.
She lists a number of solutions―water-based lubricants, local hormonal creams, vaginal moisturisers, prioritising foreplay for adequate arousal and natural lubrication, yoga and meditation to alleviate stress, and, most important, open communication with one’s partner and exploring new forms of intimacy.
However, many experts that this reporter spoke to said that a majority of women simply stop being sexually active rather than seek solutions. “Our family is complete” is one often cited reason underscoring that for many women physical intimacy is never about pleasure to begin with.
This ties in with a general lack of awareness about reproductive health among women in the country. One recent survey conducted by Pristyn Care, which covered 9,100 women across urban and rural regions, found that women normalise gynaecological health issues and seek information from unverified sources, leading to potential long-term health risks.
Among the women surveyed, 57 per cent ignored gynaecological health concerns, assuming them to be a routine part of life, while 69 per cent attributed lack of family discussion and exposure as the key reasons for poor reproductive health knowledge. One of the alarming figures that the study uncovered was that two in five women over the age of 50 are unaware of menstrual phases.
Ashraf said that it was crucial that women start paying attention to their health even when all seems well. “When I tell patients to increase their calcium and protein intake, they often look at me as though I am going on about issues that bear no relevance to their current medical concerns,” she said. But these are buffers women must start building to cushion the inevitability of menopause’s life-changing symptoms.
Regular annual check-ups post the age of 40; screening for cancer and for non-communicable diseases like hypertension, diabetes, thyroid disorders, and reducing carbohydrate intake are non-negotiable.
There is also something to be said for gathering our information from the neighbourhood chemists or the internet. Online buys and over the counter supplements such as soy isoflavones and herbal remedies might promise relief, but their effectiveness varies. More important, they are not strictly regulated. Certain supplements may interact with other medications or have unintended side effects.
It is crucial that women do not think that it is just a downhill journey once menopause hits.
Dr Monika Sharma, senior consultant endocrinology, Aakash Healthcare, Delhi, said: “That is a very negative connotation. But yes, your body changes; it is a part of ageing.” There are certain challenges with every transition, she added, and the same is true for menopause. On the bright side, there is less chance of anaemia as blood loss reduces, the fear of an unwanted pregnancy is gone and there is a chance to reacquaint with your body and treat it with greater consciousness.
“It is just another chapter in your life that you need to embrace,” said Sharma.
Above and beyond all, we need to talk about menopause. We need to pull it out of its undeserved graveyard. It cannot remain buried as a “women’s only” issue. For when that AC set at 16 degrees seems ineffective, everyone must pay attention.