In Midlife, Silent Suffering Has Become Normal
A conversation with Dr. Stephanie Faubion, one of the nation’s leading menopause experts
Menopause in popular culture is scarcely discussed but for millions of Americans it is a bookend to reproductive life that presents unique challenges — mentally, physically, and socially. Too commonly, women in midlife are left to navigate these changes with minimal support. Even those experiencing symptoms that impact their quality of life and long term health are dismissed. Three out of 4 women who go to see their doctor leave without their symptoms being treated.
Recently, I invited Dr. Stephanie Faubion, one of the world’s foremost experts on menopause, to educate our team at Maven about these unmet needs. Dr. Faubion is the Penny and Bill George Director for Mayo Clinic's Center for Women's Health and Medical Director for The North American Menopause Society. In addition to her work with patients, Dr. Faubion's research group has developed one of the largest clinical databases in this space, the Data Registry on Experiences of Aging, Menopause and Sexuality (DREAMS), which has supported numerous important projects to help increase our understanding of this under-studied and important part of millions of people’s lives.
Below is an excerpt of our conversation, which has been edited for clarity. Dr. Faubion and I will be continuing this discussion with a focus on how menopause and digital health intersect on October 6 with HLTH. If you’re interested in hearing more, you can register here.
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How did you become interested in women's health?
SF: I had a little bit of a sideways path and I actually did everything in my power to not go into it. I graduated with an internal medicine and pediatrics double board. In the first nine years of my career, I saw men and women. It wasn't until the Women's Health Initiative study came out in 2002 and women were not able to get hormone therapy anymore because their doctors were refusing to prescribe it that I changed course. It took me having to get a little mad about the situation and the lack of care available for these women.
There's a huge opportunity for education in menopause, both the general public and even physicians. I know in my own practice, people often think of menopause as like a light switch that goes off. One day you're pre-menopausal. The next day you're post-menopausal.
SF: I actually use that analogy to explain to patients that the ovaries aren't like that. During the timeframe of what we call perimenopause, the ovaries kind of flicker. It's a time where the ovaries are not functioning at 100 percent. You might miss a period, they might get closer together, they might get further apart. This could go on for two to six years before menopause actually occurs.
There’s also education on the other side of menopause. Some people think that they will go through menopause and then they should stop having symptoms. We now know that the mean duration of some of these symptoms, like hot flashes, is seven to nine years, and a full third of women will hot flash for a decade or longer. The symptoms can actually start in perimenopause. A recent study that just came out last year that I think was incredibly important documented that women in perimenopause have much the same symptoms as women in menopause, but they're not expecting to have them and these symptoms occur even before there's a significant change in the menstrual cycle length. That takes a lot of women by surprise.
I often marvel at the human capacity to normalize experiences, including suffering as part of it. When it comes to menopause, is there stigma or misinformation at work? Why isn't there more of a conversation?
SF: I think in the past discussions about menopause were done in private or not even happening. I didn't have a conversation with my own mother — and this is my field! We get a lot of education when we start our periods. We learn about it in school. Everybody gets “the talk.” Nobody gives you “the talk” when you're about to stop your periods. And if you think about it, it's the same sort of hormonal disruption, just in reverse. There's also ageism. In the workplace in particular, women are hesitant to bring up menopause because it implies that you're at a certain age. Certainly, if you're having trouble with your symptoms, you don't want to be discriminated against. So I think there are a number of reasons why this has been taboo in the past. I'm happy to see that people are starting to talk about it.
What do we know today about what works for treating menopausal people?
SF: When patients come to see me, the first question I ask is, ‘What problem are we trying to solve here?’ I have heard descriptions from patients that are nothing short of horror stories for their symptoms and I think a lot of women suffer without realizing actually how much they are suffering. I remember asking one woman, ‘Tell me about your hot flashes.’ She said something along the lines of they were not that much trouble, they're just happening ‘a couple of times an hour.’ I said that sounds like it's a problem. Once women do receive treatment, and hormone therapy is the best treatment that we have, they realize how much their symptoms were disrupting their lives. They say their mood is better, their joints don't hurt, they sleep better.
On hormone therapy, there is a lot of misinformation out there with regards to its link to breast cancer. What do we know about the risks?
The increased risk of breast cancer from undergoing hormone therapy treatment is very small. It is about the same as what would result from a person having one to two glasses of wine a night, being overweight, or being inactive, some of those lifestyle factors that we don't even really think about in terms of breast cancer risk. To put it in numbers: the incidence of breast cancer in the general population is three women out of 1,000. Hormone therapy of the kind used to treat menopausal symptoms increases that to 3.8 per 1,000 per year.
You talked about ageism as an important equity dimension when it comes to menopause, for women in the workplace in particular. What do we know about how menopausal symptoms or treatment play out from a disparities perspective?
SF: It’s a great question and one I'm really personally interested in. We know from the Study of Women's Health Across the Nation (SWAN) that Black and Latina women tend to start having hot flashes earlier and tend to have more severe hot flashes than white women, for example. So the question would be why? Why is that? Are they receiving less care? There's a lot we have to learn about what are the factors that are contributing to these inequities and health disparities that are no doubt intersecting with other factors, like the social determinants of health.
You've been focused on menopause for about 17 years. Have you seen any changes in the way that the people in your practice engage with these issues or come to you to talk about their symptoms?
SF: I don't know that the woman in my office has changed a whole lot because from the first day we opened the clinic, we had a lot of frustrated women in our office saying, ‘This is not okay.’ That's self-selecting for the women that actually get to a menopause clinic, which may be the ones that just aren't going to put up with it. But we're about to publish an update to our menopause book next year. Last time we were writing to the Baby Boomers. This time we're writing to the Millennials. That is a totally different conversation. We actually had the word ‘chastity’ in the last book!
I will tell you that Millennials aren't afraid to talk about menopause. They will tell you exactly what the heck is going on with them. They're not willing to suffer. This is a group of women that isn’t going to just deal with it and be patted on the head and told that their symptoms will go away eventually. And you know what? Good for them.
What my team is reading, considering, and building against
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Thank you for reading this edition of The Preprint. Subscribe below to receive posts like these as soon as they are published. Have thoughts or feedback? We’d love to hear from you — reach out at thepreprint@mavenclinic.com. And if you'd like to be a part of our work here at Maven Clinic, check out our open roles (including several on our clinical team) here. You can also follow me on Twitter @neel_shah.