Solving the mysteries of menopause, one conversation at a time

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“We are the only species that lives one-third to one-half of our life in non-reproduction.” – Dr. Lara Williams, The Oregon Clinic OBGYN North

Over the past few years, Claire Irvan has struggled with strange heart palpitations, mild hot flashes and most recently an irritated scalp that “felt like it was on fire.” She manages these mysterious mid-life symptoms, muddling her way through like being blindfolded in a maze, and wonders what could be around the corner.

So when the 50-year-old Portlander received a flyer from a friend about an event inviting women to gather and talk with each other about menopause, she had one thought.

“Hell yeah!”

The event was called Pause! What’s missing from the talk about menopause?, hosted in June by the Portland-based Women’s Foundation of Oregon (WFO). It was a rare opportunity for Irvan and the dozens of attendees—a chance to hopefully learn about what was happening to their minds and bodies, simply by talking with other women.

“It was a kind of warm, safe space I’d never experienced before,” Irvan said. “When young girls first get their period, we’re so prepared to have ‘the talk,’ and we talk at length, openly, about pregnancy or endometriosis or fibroids. But when all that ends, at menopause, nobody talks about it!”

The menopause journey brings a menu of seemingly unrelated symptoms that range from minor annoyances such as occasional hot flashes to debilitating, life-altering physical and mental turmoil that can last years, end marriages and careers, and lead to long-term chronic disease. Most women are somewhere in the middle, yet it remains a medical mystery to almost all.

What is clear, however, is most women are not getting the care they need.

According to a recent study published by Oregon Health & Science University (OHSU), more than 60% of people in Oregon who suffer moderate to severe menopause symptoms are not receiving treatment. That number goes up significantly among patients with public insurance, such as Oregon Health Plan (OHP/Medicaid).

The most common reasons for patients not receiving treatment for menopause: “Therapy was not recommended by a provider” and worries about safety or side effects of treatment.

What is menopause?

Menopause is defined as when a woman has gone 12 months without a period, and the average age for menopause in the United States is 52. Symptoms, however, usually begin 2-10 years prior and sometimes sooner (“perimenopause”) and can last for many years afterward (“postmenopause”).

An estimated 1.1 billion women worldwide will be postmenopausal by 2025.

Symptoms associated with the entire menopause journey include, but are not limited to:

Significant long-term risks of untreated menopause include cardiovascular disease, bone loss (osteoporosis) and Type 2 diabetes. These diseases may emerge later in life if menopause isn’t properly treated early on.

Research shows Black and Hispanic women begin experiencing menopause earlier, and for longer, than White, Chinese and Japanese women. Additionally, hot flashes and night sweats happen more frequently, and severely, among Black women than all other racial and ethnic categories. These disparities are largely attributed to the systemic and structural racism that contributes to poorer health outcomes among communities of color.

Hormone replacement therapy (HRT)

The primary treatment for menopause is hormone replacement therapy (HRT), which refers to replacing the hormone estrogen that is lost when ovaries stop producing it. HRT also usually includes replacing the hormone progesterone, when the uterus is still present. That’s because estrogen and progesterone work together to regulate and protect the uterus. Without progesterone, estrogen-only therapy can lead to endometrial cancer (cancer of the uterus).

For decades, HRT was the go-to choice for alleviating menopause symptoms. But in 2002, misinformation about a Women’s Health Initiative (WHI) study spread the idea that HRT caused breast cancer. As a result, HRT fell off the map, globally.

“In the few years that followed the WHI study, I regularly had primary care providers (PCP) taking people off the hormone prescriptions I was writing for them,” said Dr. Lara Williams, managing director of The Oregon Clinic OBGYN North in Portland. “Their PCPs would tell them it was bad for them.”

The WHI study led to a generation of doctors mostly refusing to prescribe HRT, alongside a generation of women with suddenly nowhere to turn for help with their misery. Dr. Williams was in her residency at the time.

“I felt like I was a drug dealer, because I’d have women whispering on the phone to me, begging me to put them back on their hormones,” Williams said. “Or their partner would be yelling in the background, ‘Put her back on!’ And interestingly, Viagra [sildenafil] was released around that same time [for erectile disfunction], so you had women being pulled off of their hormones, causing low libido and vaginal dryness symptoms to return, while their partners — who had lamented the loss of their ability to engage in an intimate relationship — were suddenly chasing them around the room.”

The truth about HRT, as research and evidence has since revealed, is that generally speaking its benefits for menopausal women far outweigh the risks. But it’s an incredibly complex solution. For starters, timing is critical, and the different phases of menopause require different approaches to HRT. Plus, every patient is different, with a unique set of contributing factors to consider, such as diet, physical fitness, smoking/drinking habits, family medical history, etc., that play a big role in menopause symptoms and treatment. And during the perimenopause phase, which is characterized by wild fluctuations in estrogen levels, HRT can worsen certain symptoms.

Additionally, some symptoms such as hot flashes, weight gain, heavy or irregular periods, anxiety/panic attacks and insomnia are more common during perimenopause and not necessarily related to estrogen loss, but rather a progesterone/estrogen imbalance. In these cases, estrogen levels can swing very high and progesterone lower than previously, so these symptoms must be addressed in other ways.

Talk to each other

Some of Dr. Williams’ patients have vivid and scary childhood memories of their mothers suffering around this time of life, and they had no idea why.

“They just remember their mother, you know, crying in a dark room, being depressed or yelling at them for no apparent reason, then sobbing her eyes out, and then the cycle began again,” Williams said.

These memories are powerful and common, and when combined with the scarcity of menopause care in Oregon revealed in the OHSU study, women are desperate for answers. Dr. Williams is thrilled that so many women are finally talking to each other about menopause—a traditionally taboo subject that most people have been uncomfortable discussing, until now.

“It’s my patients who are initiating the menopause conversation,” she said. “They say, ‘My girlfriends and I were talking, and they were telling me they’re on hormones and feeling so much better.’ Or, ‘My friend was talking about these symptoms, and she thought I needed to come get checked out.’”

The lesbian population, Williams adds, has a bit of an advantage in this way, because they often have a partner at home with whom they can compare and contrast experiences.

“My lesbian patients will often say things to me like, ‘My periods are so much worse than my wife’s, what’s going on?’ Or, ‘I feel like I’m losing my mind, but my partner seems fine. What’s happening to me?’ Whereas a lot of women who have male partners have no one to compare themselves to and are simply left to wonder.”

Some people end up turning to, or preferring, naturopathic medicine for menopause care, including those on public insurance such as Oregon Health Plan (OHP). Underserved rural and minority communities, which already face systemic and/or geographic barriers to health care, are especially starved for information about menopause.

Juniper Martin, ND, practices naturopathic medicine in Portland, and when it comes to community services related to menopause for underserved populations, Oregon is a desert.

“I don’t know of any organized menopause support at the community level for underserved patients,” Martin said. “It barely even exists for women who have more privilege. I am an assigned primary care provider (PCP) with OHP and have a large population of patients who are from traditionally underserved communities, and I can tell you that the situation is bad. It’s very sad and frustrating that in this day and age, women in this age range continue to be largely ‘forgotten,’ medically.”

Looking ahead

Despite historical setbacks, Dr. Williams and others are optimistic about the future of menopause care, as women are speaking up more and more, and the medical community works to expand knowledge and care.

OHSU’s Center for Women’s Health launched a menopause-focused virtual learning program for Oregon providers as part of an initiative called ECHO (Extension for Community Healthcare Outcomes). ECHO offers classes to a statewide network of primary care clinicians, community partners and academics, with a mission “to improve health outcomes and equity for all Oregonians,” particularly for those in rural areas.

The Oregon Clinic OBGYN North and OHSU’s Center for Women’s Health are at the forefront of menopause study and care in Oregon, and elsewhere the state’s supply of menopause specialists is growing, slowly.

Additionally, a small but growing number of employers are offering, to great enthusiasm, menopause-specific health benefits, which may include paid leave, hormone therapy, physical therapy and access to health care specialists.

Perhaps most importantly — women are starting to talk to each other, to their partners, to their families, and to their doctors.

The Portland Pause! event organized by the Women’s Foundation of Oregon (WFO) was billed as “an unfiltered and fun conversation about what’s missing from society’s conversation about menopause.”

It was inspired in-house, by a couple of WFO staff dealing with menopause who got to talking, then texted some friends, and before they knew it had a room full of women swapping stories, theories and doctors’ names.

“We described it as a kind of informational potluck,” said Libra Forde, WFO executive director. “We aren’t menopause experts, by any stretch, so we asked women to gather in one room for a couple of hours and bring all of their collective wisdom, experiences and questions.”

The Portland event was so popular, the WFO decided to host another one—in Baker City, where the conversation highlighted the lack of health care access in rural communities.

“These two events are just the beginning for us,” Forde said. “Through this initiative, we hope to not only empower women with information but also begin establishing a fund to support those without access to the medical care and solutions they need to manage menopause effectively.”

In addition to optimism, however, Dr. Williams offers a couple words of caution for women struggling to cope with menopause:

First, take care of your whole self.

“When it comes to menopause, there are definitely things that we can do to help smooth out the rough edges and make life better,” Williams said. “But I also tell people — nothing is simple where hormones are concerned. It’s not a magic pill. You must take an active role in your overall health with diet and exercise and proper sleep, for starters. Because if we don’t, as a society, start taking better care of ourselves, all of the things we can do for menopause won’t help.”

Second, buyer beware.

“We’re seeing more and more commercials for online pharmacies where people can purchase male and female hormones after a provider spends five minutes with them on a telehealth call. It’s easy and incredibly popular, but it’s a risk,” Williams said. “I would never in a million years prescribe hormones to a patient without fully evaluating them and taking care of their whole health. My advice to women going through menopause is to ask questions, find a practitioner who is genuinely interested in menopause care and listens to your concerns so you feel heard and cared for. It is possible.”

If you need help finding a provider that understands and specializes in menopause, visit The Menopause Society’s website, which includes a search tool to find a local provider. Oregon Health Plan members can also ask their coordinated care organization (CCO) to help them find a women’s health provider.

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• The Menopause Society is a national organization and leader in menopause information and resources for patients, as well as providers. People can also search for a provider with menopause expertise in their area using The Menopause Society’s provider search tool.
• WATCH Video: “Menopause & Perimenopause: Everything Is Not the Ovaries’ Fault!”– a 2024 lecture by Dr. Lara Williams for the George Washington University’s School of Medicine’s Resiliency & Well-Being Center.
• SWAN (Study of Women’s Health Across the Nation) is a long-term, multi-racial and ethnic research project that aims to understand the physical, biological and psychosocial changes that occur in women during the menopause transition.
  
  Explore the SWAN website to learn more about these and other topics related to menopause:
  • Depression
  • Gynecologic and sexual health
  • Racial and ethnic disparities
  • Cardiovascular risk and heart health
  • Physical functioning (muscles, joints, etc.)
  • Sleep problems
  • FACT sheets on the major findings from SWAN on bone health, memory and cognition, hot flashes, sleep, depression, urinary incontinence, sexual functioning and vaginal health.
    
    
• Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women’s Well-Being and Lengthen Their Lives — Without Raising the Risk of Breast Cancer is a well-regarded book written for everyone that can be checked out at public libraries, and is available on Amazon.
• “Women Have Been Misled About Menopause” (New York Times Magazine, Feb. 1, 2023)
• “How Menopause Affects Women of Color” (New York Times, Aug. 23, 2023)
• “Discrimination May Hasten Menopause in Black and Hispanic Women” (Scientific American, June 29, 2023)
• “The Surprising Biology Behind Menopause’s Worst Symptoms” (Scientific American, Jan. 23, 2024)