The menopause is probably the least glamorous topic imaginable; and this is interesting, because it is one of the very few topics to which cling some shreds and remnants of taboo.
Ursula K. Le Guin, ‘The Space Crone’
EDINBURGH’S MENOPAUSE CLINIC is held in the Chalmers Sexual Health Centre – an old Victorian hospital first opened in 1864 at the bequest of a master plumber. George Chalmers specified in his will that he wanted a ‘New Infirmary or Sick and Hurt Hospital, or by whatever name it may be Designed’. The lower two wards were for the destitute, the upper two wards for those who could pay three shillings a day. ‘In 1887 a small apartment for nurses was opened,’ says the official history; ‘It lay between the wine cellar and the mortuary.’
Sometime in the 1950s the building amalgamated with the nearby Hospital for the Diseases of Women, and through slow metamorphosis shed its lying-in wards. In 2011 it was refurbished as the city’s sexual health centre, with a mixed bag of specialisms: venereal diseases, contraception, menopause, as well as the gender identity clinic. Queues lengthen outside every morning for the drop-in service. Jokers or prudes have prised the word ‘Sexual’ from its sandstone wall.
Most of the sexual health clinics I’ve worked in have a jaunty, informal atmosphere; their patients are fairly young, the diseases for the most part are treatable (now that even HIV is kept in abeyance), and the staff have a gentle irreverence that lends itself to a good working environment. All doctors hear stories that must remain private, but sexual health physicians hear more than their share.
When I went to learn more about the work of the menopause clinic I started in the coffee room, where students, trainees and consultants were all laughing together over stories from a staff night out. I was there to sit in with Ailsa Gebbie, a consultant gynaecologist and the senior clinician at the menopause clinic. Ailsa had been one of my tutors at medical school twenty years earlier – energetic and enthusiastic, with short blonde hair and a crisp, careful manner of speaking. She’s a former director of the UK’s Faculty of Sexual and Reproductive Healthcare.
Few women come to my clinic for advice about the menopause – I’m a forty-something man, and they generally prefer to consult a female colleague. But every so often someone going through what still gets called ‘the change of life’ asks me about hot flushes, insomnia, skin changes or mood swings. Oestrogen slows over years rather than months, making the name ‘menopause’ sound more abrupt than the reality. Meno-pause also suggests something temporary, even trivial. Symptoms of the menopause may be transient and often mild, but the phase it gives onto is enduring and hardly trivial. Menopause isn’t a disease, or a deficiency, or even a constellation of symptoms, but a natural consequence of having lived for four or five decades as a woman. All women see a dramatic drop in oestrogen levels around menopause, but only about one in fifty men sees a comparable drop in testosterone levels at the same age. Around a third of women suffer enough from it to want to see a doctor, ranging from those exhausted, distressed and depressed by their symptoms, to those who’d just like to attenuate their hot flushes. As a man, I see too few women in this situation to keep up with the latest advice, but too many to refer them all to a colleague. So I went to sit in with Ailsa to see what I could learn.
BEFORE ‘MENOPAUSE’ WAS COINED a little over a century ago, the clunky Greek term ‘climacteric’ was used more widely. The word means a step on a ladder – a phase to be transcended or surpassed – but ‘climacteric’ has been made to bear a heavy burden of meanings: a climax to life, a critical period, a storm successfully weathered. For much of its history it applied to men as much as it did to women, though men’s ‘climacterical year’ was traditionally thought to be the sixty-third – long after the forty-ninth year suggested for women. Pre-modern medicine was preoccupied with numerology and had an obsession with factors of seven that goes back at least to Solon of Athens, who in around 600 BCE wrote a long poem about the way that human life is divided into ages of seven years, each initiated by a rite of passage and occasioning a change in role. But the association with sevens is more ancient still: the Babylonians noticed seven celestial bodies (Sun, Moon, Mercury, Venus, Mars, Jupiter, Saturn) and built seven levels to their ziggurats; Greek language took seven vowels, and defined seven wonders of the world.
There are three columns of discussion in the Oxford English Dictionary devoted to ‘climacteric’, and only one entry refers specifically to the menopause: ‘Applied to that period in life (usually between the ages of 45 and 60) when the vital forces begin to decline (in women coinciding with the period of “change of life”).’ For the term ‘climacteric disease’ it offers: ‘a disease of unknown cause which often occurs at an advanced stage of life, characterized by loss of flesh and strength, sleeplessness, etc.’
Of the four hundred or so editors and contributors who worked on the OED, about seventy were women. The ‘C’ section that includes ‘climacteric’ was overseen by four.* But the exclusion of women’s voices from much of literature’s history means that every original source for ‘climacteric’ they recorded, written between 1590 and 1879, was written by a man.
The historian Louise Foxcroft, in her book Hot Flushes, Cold Science: A History of the Menopause, summarises the historical male take on menopause by quoting the sixteenth-century physician Giovanni Marinello: ‘as soon as the periods stop, pains arise … the disorderly uterus rises or descends all the time, or commits other actions difficult to endure.’ Foxcroft warns against thinking of the climacteric as a purely female phenomenon: ‘Men have hormones too,’ she observes, ‘and arguably, a menopause, if we think of it as a transitional phase which is part of the ageing process.’
The historian of medicine Roy Porter warned about the domination of masculine perspectives, particularly with respect to discussions of women’s bodies. Porter’s opinion was that menopausal problems, when they present at all, are overblown and the result of a male-orientated profession’s tendency to medicalise whatever it doesn’t understand. He reported that in many traditional societies there’s an absence of subjective problems with menopause – that, on the contrary, menopause was something that women celebrated, because it marked release from a part of their lives that was often ‘burdensome and dangerous’ (bearing children), as well as stigmatising (menstruation being viewed as polluting). Cross-cultural studies of women around the climacteric bear up Porter’s analysis: Finnish, Mayan, North African, Rajput, Chinese and Japanese women have all been found by researchers to suffer fewer physical or ‘somatic’ menopausal symptoms than, for example, American women. A 1980s study by Nancy Datan examined five ethnic groups in Israel – Muslim Arabs as well as Jews from North Africa, Persia, Turkey and central Europe – and found that each welcomed the menopause as a liberation. As human beings, wrote Datan, we are all in different states of transition, ‘immigrants in middle and old age to a changing world for which we are not prepared’. She concluded that each ethnic group had traditions which helped women adopt new and liberating roles in middle age, and that every culture finds ways of infusing life with love and with meaningful work.
In the twentieth century, medicine began characterising menopause as a deficiency disease, treatable by Hormonal Replacement Therapy (HRT) – first launched in 1942. Twenty years later, HRT was applauded into the pharmacies and stock exchanges of the world by a New York gynaecologist called Robert A. Wilson, whose book Feminine Forever suggested that women should consider HRT in their thirties or risk crumbling bones and collapsing libidos. Wilson called women who’d been through the menopause ‘castrates’.
In the final years of the medicalising twentieth century, 27,000 post-menopausal women took part in the ‘Women’s Health Initiative’ study, the results of which implied that women taking HRT had a slightly higher risk of strokes and breast cancer than those who didn’t. Then in 2003 a far larger study, appropriately named ‘The Million Women Study’, suggested that taking HRT as much as doubled the risk of breast cancer, though the absolute numbers remained small. Headline writers are prone to prioritise relative risk over absolute risk: an increase of 1 in 100,000 adverse events to 2 in 100,000 is an almost insignificant change, but a headline may still scream that risk has ‘doubled’. The effect was immediate – between 2002 and 2006 HRT prescription in the UK dropped by two-thirds. These trials were shown to be fundamentally flawed, using the same doses of hormones in women aged forty who’d gone into an early menopause as they did in women aged seventy who’d had a natural menopause twenty years earlier.
HRT remains controversial. Before going along to the menopause clinic I asked Iona Heath, former president of the Royal College of General Practitioners and for thirty-five years a practising GP, for her perspective on the merits and hazards of HRT. ‘When I meet a menopausal woman in clinic who wants help with her symptoms I tell her there are two ways to look at the HRT controversy,’ she told me. ‘The first is that HRT is a male-dominated conspiracy to medicalise a normal, natural process.’
‘And the second?’
‘That the scare stories about HRT are a male-dominated conspiracy to stop women getting the hormone supplements they need. The way they respond would tell me which way they wanted to go.’
WHEN CHALMERS’S HOSPITAL first opened in the 1860s a girl born in its wards would have had a life expectancy of about forty-one. By the late 1880s, when nurses’ quarters were opened by the mortuary, that life expectancy had risen to just forty-five. These figures were so low because of the terrible frequency with which women (and babies) died in childbirth. The majority of female children didn’t live to reach the menopause, and those who did were relatively rare – resilient survivors.
Ailsa led me from the coffee room along a whitewashed mezzanine corridor. The refurbishment had given this third phase of Chalmers’ hospital a new and repurposed life – it had gained a glass roof, they had rebuilt some walls, and natural light fell in shafts past a space where once there had been gynaecology and obstetric wards. ‘Will the clinic today be all new patients?’ I asked Ailsa.
‘A mixture – some of these women I check in on every few weeks while trying out different treatments. Some of them will be new to me – referred in because their usual doctor can’t get their symptoms under control.’
‘Will they all have been on HRT already?’
‘Most of them – though there are still a few GPs who are anxious about prescribing, particularly if there are complications – a family history of cancer, thrombosis, strokes.’
I sat beside Ailsa while she conducted her clinic, meeting her patients, discussing with her how I’d manage each in my own clinic, taking notes for my own future practice. Many of the women clearly knew and trusted Ailsa; there were discussions about hot flushes, sexual problems, urinary infections, incontinence, osteoporosis, libido, crashing mood swings. Some women had gone into the menopause gradually, others in abrupt consequence of treatments for breast or ovarian cancer. ‘In someone suffering severe hot flushes from cancer treatment there’s good evidence for cognitive behavioural therapy rather than HRT,’ Ailsa told me. ‘Some kinds of counselling can be as good as HRT, perhaps even better, at helping people adjust to mood and sleep problems. And without the risks.’
‘And what do you tell people about those risks?’ I asked her.
‘I show them a table that lays them out.’ She opened the UK bible of prescribing – the British National Formulary – to a page listing the statistical risks. ‘It shows how cancer and thrombosis risks begin to rise a little after ten years of continuous treatment. But those risks remain small.’ For women in their fifties who’ve taken HRT for over ten years, breast cancer rates rose from about 2 per cent to just over 4 per cent. For women in their sixties the incidence rose from 3 per cent to just under 7 per cent.
‘So it doubles, more or less,’ I said.
‘But it’s still small. When people know the actual risk at a population level, rather than the relative risk, and their symptoms are intolerable, they often prefer the HRT. And generally I don’t prescribe it beyond sixty years of age, because it’s then that the cancer and thrombosis rates begin to rise.’
I saw Ailsa prescribe antidepressants rather than hormones on occasion, and I asked her whether she thought that meant mood changes and sleep problems around the menopause were related to depression and anxiety. ‘Not always,’ she said, ‘but small doses of antidepressants can be helpful. No two women are the same.’ Sex hormones maintain bone strength, so with menopause can come a thinning and weakening of bones. Ailsa prescribed medications to slow that process, and she also encouraged a couple of the women to smoke less and exercise more (smoking weakens bones, and exercise strengthens them). While most of the HRT I’ve ever prescribed has come in tablets, Ailsa suggested alternatives. ‘If the only problem is that the skin of the vagina is getting thin and dry, or the bladder is getting too sensitive, it doesn’t make sense to take large doses of oestrogen by mouth. I prescribe a ring that women can put in the vagina and take out themselves, placing the oestrogen directly where it’s needed. Skin patches and gels that you can rub into the skin of your thigh or your chest can be useful too – lower doses, fewer risks.’
Perhaps it’s not possible, as a doctor, to make an objective judgement, but, in sitting for an afternoon with Ailsa, I didn’t see any evidence of an overbearing medical establishment attempting to convince women they were suffering a deficiency disease. I saw women with anxiety, unbearable hot flushes, sexual difficulties and insomnia, some of which may have been brought on by a slowdown of body oestrogen, receive careful, balanced and often life-changing advice.
‘AT MENOPAUSE as never before, a woman comes face to face with her own mortality,’ wrote Germaine Greer in The Change. ‘When a fifty-year-old woman says to herself, “Now is the best time of all”, she means it all the more because she knows it is not forever.’ The feminist psychologist Carol Gilligan noticed that the climacteric, as one of life’s most significant transitions, can occasion a kind of mourning that ‘can give way to the melancholia of self-depreciation and despair’. But there are other, more positive perspectives on menopause.
In 1976, the American novelist Ursula Le Guin wrote an essay both panoramic in scope and beautifully concise, reflecting on her own arrival at the change. I can’t speak with authority or experience on the menopause, but Le Guin can, and I’ve recommended her essay to patients. She argues in the essay that the traditional division of women’s lives into the triple phases of ‘maidenhood’, ‘maturity’ and ‘crone’ gave life a meaning and trajectory that was more than just a physical evolution – it was about social shifts in being. Le Guin views the late twentieth century as undervaluing virginity, with children acting more and more as young adults, while post-menopausal women are encouraged to take hormones to perpetuate youth. It is as if ‘the Triple Goddess has only one face: Marilyn Monroe’s, maybe,’ she wrote.
Her proposal was that women become more comfortable with accepting the third stage in their lives, valuing it for something uniquely feminine, and offering liberating opportunities: ‘The woman who is willing to make that change must become pregnant with herself, at last. She must bear herself, her third self, her old age, with travail and alone.’ Unlike the births she’d laboured with her own children, no male obstetrician would stand over this new transition, or suture up her lacerations. ‘Anyhow it seems a pity to have a built-in rite of passage and to dodge it, evade it, and pretend nothing has changed. That is to dodge and evade one’s womanhood, to pretend one’s like a man.’
Many readers know Le Guin through her body of science fiction and fantasy novels, and she concludes her essay with a sci-fi thought experiment: imagine some aliens asked to take ‘an exemplary person’ back to their planet Altair to teach them something of the nature of humanity. Le Guin wouldn’t pick a young cosmonaut, or a male scientist, or even a statesman like Henry Kissinger. Neither would she pick one of the many young women who’d volunteer, ‘some out of magnanimity and intellectual courage, others out of a profound conviction that Altair couldn’t possibly be any worse for a woman than Earth is.’ Instead she’d pick a woman over sixty – wise, patient, witty and shrewd – who’d worked hard all her life, given birth and raised her own children. She’ll be too modest to volunteer, says Le Guin, but we should insist, because as a woman in the third stage of life she ‘has experienced, accepted, and acted the entire human condition – the essential quality of which is Change.’