Early menopause

Jessamy and Gavin are joined by Prof. Gita Mishra, life course epidemiologist at the University of Queensland, to discuss her work on understanding early menopause. How many women does early menopause affect? How can we improve gaps in care? What are the consequences of early menopause, and what does menopause onset look like around the world?

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Jessamy: Hello and welcome to The Lancet Voice. I'm Jessamy Bagenal, Senior Executive Editor at The Lancet, and I'm joined by my co host Gavin Cleaver. Today we talked to one of the authors on a recent series published by The Lancet on menopause. The series was made up of four papers and covered a wide range of topics.

It sparked some interesting conversations about how we think and talk about a natural part of a woman's life. Today we speak to Professor Geeta Mishra, who among many other things is a professor of life course epidemiology at the University of Queensland in Australia. Her paper focused on earning menopause in women and we spoke to her about how common it is.

What we do and don't know about it, how it affects women, and how we should be thinking about it. We hope you enjoy the episode, and as always, you can find Gavin and I on all your usual social media platforms. We'd love to hear from you about this topic. Professor Geeta Mishra,

Gavin: thank you so much for joining us on the podcast, and welcome to The Lancet Voice. Perhaps we could start with you introducing yourself. Thanks. 

Gita: So thank you and thank you for this opportunity. My name is Geeta Mishra. I'm a professor of life course epidemiology in women's health. I'm based at the Australian Women and Girls Health Research Centre at the University of Queensland in Brisbane.

Gavin: You're the author of, or one of the authors I should say, of one of the papers in our recent menopause series in The Lancet, and your paper specifically looked at health and the early menopause. So I guess very broadly then, to start off, how common is early menopause and how do we define it? 

Gita: Absolutely.

So good question. So let me put some things in context. First of all we know that in high income countries. The average age of menopause is between 50 to 51 years old, okay, but we know that around 8 percent of women in high income countries will experience what we call early menopause, and that is menopause between the ages of 40 to 44 years.

Globally, about 12 percent of women will experience early menopause, that is before, between 40 to 44 years. 

Gavin: It's a higher relative percentage in low and middle income countries. 

Gita: Absolutely. Yes. And that, we're thinking why that could be the reason, and I think it's important again to be thinking about the distribution of age at menopause.

We know that, as I mentioned before, in high income countries, the average age is between 50 and 51 years. But in low middle income countries, let's look at India for instance, their average age of menopause is 46 years. Okay. So in India, women have their average age of menopause is 46. So then you can imagine that if we define early menopause is between 40 to 44, most of the women will fall in the early menopause definition.

So that is why in low middle income countries, the prevalence of early menopause is higher. And that's because of our definition of early menopause. Which is 40 to 44 years. 

Jessamy: That does make sense. It would be really great to hear from you. What are some of the challenges that women who go through early menopause face?

What are the both on a psychological but also on a physical level in terms of short and long term, if you want to call it complications or at least effects? 

Gita: Okay, so the first of all, the diagnosis of early menopause is often not straightforward. Unless there is a clear medical course is identified.

So for instance, for some cancers, the women might have complete removal of both ovaries. Okay? So the diagnosis usually is being made on symptoms that the women experience and also some biomedical assessment. The challenges there is that currently there is no consensus criteria for diagnosing early menopause.

In terms of what are the challenges that women are facing, first of all, just that uncertainty or not knowing if they're going through early menopause, and yet they're getting all these symptoms. If we think about women generally going through menopause, okay regardless of their age at menopause, people commonly experience vasomotor symptoms, that is hot flushes, night sweats, They also may experience sleep disturbances and vaginal dryness.

There's also been studies to show that women going through menopause will, might experience depressed moods and also usually people from Asian background complain of joint and joint pulse. Okay. So these are women going through menopause at the average age of, 50, 51 years. We actually don't know if these symptoms are more severe in women going through early menopause.

We don't know that. We also don't know if their symptoms persist for a longer period of time or longer duration. We don't know that. So that is really unmet need. But we do know that, they may, women going through early menopause may have additional distress as they are experiencing these symptoms.

several years earlier than their peers, right? And in some cases, they're experiencing all these symptoms between 5 to 10 years earlier than what they may have expected. If you think about the average age of 50 to 51. So we believe that there is additional psychological distress that women may go through.

But also, exactly the severity of the symptoms, how long they experience, what else do they experience? We actually don't have a lot of data on it. So that's the challenge. Interesting. 

Jessamy: And can we just dig into the kind of epidemiology? Like it's very interesting that you were saying the age of what's considered early menopause.

Differs around the world. Do we know that the definition or what we think of as early menopause is actually early menopause? Or are we pathologizing a kind of normal range of what would be acceptable? 

Gita: And this stage, the definition of early menopause is based on data from high income countries.

Basically, it's based on some American data. And they think that, early menopause is about one or two standard, two standard division away from the average age of menopause. So they work it out. They say, okay, this is within 40 to 44. Yeah. And this is being used to define early menopause, regardless of where you come from, which cultural background.

This is a, it's a hard number. And I think there's, again, we need to challenge that concept. Because what is early in high income countries may be just average in other parts of the world. And I think that's another question, another thing that we should be thinking about from the epidemiology of age at menopause.

Jessamy: Does that make sense? Yeah, it does. It does. It's really helpful. And I think obviously it has implications for how women manage their symptoms, because also when you say. In different countries, the provisions for women are going to be different. So if and presumably do we have different ways of suggesting management to women who are going through early menopause to late menopause, or does that vary a lot as well?

Gita: One thing we can say and studies, large epidemiological studies shown that women who go through early menopause obviously, apart from experiencing all these short term symptoms and all that, in the long term, they are at higher risk of cardiovascular disease. We've shown our study using the interlace consortium that they may be at 30 percent higher risk of cardiovascular disease after menopause.

That we know. The second thing is that we also know that they are at increased risk of osteoporosis. And I think the take home message here is that there is a lot of There's a lot of lifestyle interventions that can be done a lot earlier on to monitor these things. For instance, we can help advise women on, healthy lifestyle that would prevent them from having cardiovascular disease.

We can, advise women on, doing weight bearing exercise for their bone density. There's a lot of lifestyle management that can be done a lot earlier on for this woman. I think that's important because they are at an increased risk. 

Jessamy: Yeah, I really like that, this concept of using the menopause as a sort of stage to connect with women and intervene in terms of long term prevention for other complications.

You really using it as an opportunity to make those interactions with healthcare professionals and health systems. more effective and efficient in the longterm, as well as empowering women, to deal with their own sin. 

Gita: I think that, look, the way I would like to see is that we can use it as really an opportunity to check on our health and get, communicate with our health professionals and really prepare for the next, 30, 40 years ahead of us post menopause, so being proactive and, doing all the lifestyle interventions is very important. 

Gavin: You mentioned in your paper, people with early menopause falling through a gap in care. Perhaps you could tell us a little bit about why that happens, what some of the outcomes from that are and why it's important.

Gita: I think where there is gap in care is that they've been not been diagnosed correctly. If they, between the ages of 40, 44, they may go to the doctors and all that and they might say, Oh no, you're perimenopause or, somehow they don't think that the women could be postmenopausal.

Yes, and by the time you do all the diagnostics and the symptoms and all that, you might actually move into average age. The diagnosis happened a lot later than, and they would have gone through the early menopause transition. So I think it is just, making sure that the women are identified accurately and a lot earlier on.

And we've in our frame, clinical framework given. A sort of a checklist to identify, that can be used to identify women going through menopause, early menopause. 

Gavin: Do the misdiagnoses have a kind of lot of knock on effects? I guess they miss these lifestyle interventions you were talking about.

Gita: Yeah, exactly. And also monitoring, that if they know they're at risk of these chronic conditions later on, then they can be doing something and start a lot earlier on in life. I think that's very important. And also like their care, they might feel really what's wrong with me, no one is really taking me seriously.

I think it's very important for women to be engaged and involved at the outset when they have these symptoms. to their GPO clinicians and get that kind of two way conversation happening. So part of the article here is also to empower women to let them know what they can expect as they're going through early menopause.

Gavin: Do you think that these gaps in care are exacerbated by the difference in resources in high income countries and low middle income countries? 

Gita: I think so. I also think that the gaps might be To be honest with you I still think that we don't know a lot about the experience of early menopause in women from low middle income countries.

We actually don't, they might be going through early menopause for them, might be in their early, late 30s. We don't know that. Do you know what I mean? Because they, overall, the whole distribution has shifted left, so they're experiencing these symptoms a lot earlier. So one of the things what we have done is to estimate age of menopause for women going through menopause earlier is to actually get a family history.

So we do know that if the mothers have gone through early menopause sisters have gone through early menopause, chances are quite high that she will go through early menopause. The other predictors you can use is smokers. Smokers tend to go through early menopause as well. So that's the the thing women with no children also tend to go through, have early menopause.

So you can see that, these factors do contribute to our age at menopause. And early menopause happens to women who, have that history family history of early menopause. If they're smokers, if they don't have children. These old things tend to lead to earlier menopause. 

Gavin: We've talked quite a lot, or at least touched on, gaps in the data.

Are, are there major gaps in the data on women going through early menopause? And what do we still need to find out? What do we need better data on? 

Gita: Look I do think that we need to, first of all To actually find out more detailed experience of a woman going through her symptoms as she's going through the menopause.

More detailed. Is it longer? Is it more severe? Does she get any other type of symptoms? So that's important, number one. The other thing also is future health. From the data sets that we have, we can look at cardiovascular disease and osteoporosis. But what about other conditions, for instance mental health?

We don't really have good evidence whether women are more likely to experience depression during early menopause, so that's a gap there in terms of that. And similarly, whether she's at higher risk of cognitive decline, we don't know that, I think those future health implications still lacking.

The ones that I mentioned with CBD and both have that very clear cut. Now, having said all of these things, I must also say a positive thing about menopause if I may. And they're at lower risk of breast cancer. Okay, so I think, when you look at the whole spectrum, there are increases of cardiovascular and all that, but they are lower risk of breast cancer is because they're less likely to be exposed to longer duration of estrogen, which tank, so that, that is one thing that is known. Really getting more information on people from low middle income countries is, it's important understanding the experience of menopause. It's crucial. Yeah, I keep in mind that, these women are young women, they still have jobs and, the economic consequences of early menopause, I think it's huge, if we don't manage it or deal with it, hopefully.

Gavin: Yeah, so what are some of the economic consequences of early menopause? Maybe we could talk about how it actually affects the economy and also does it affect the earning power of women who are going through early menopause? 

Gita: What I like to think about is again, it's their management.

So if they have, debilitating symptoms like hot flushes and night sweats. Then, she might not be able to go to work, right? I think that's important to realize. And that this is where I think workplace has to be a bit more supportive. In the sense of being more flexible, making sure that, the work environment is conducive for women going through menopause.

The other thing also is I think it's important to talk about it. It's a natural process. All women will go through it. metaphors, it's just different timing. So again, making it more normalized is a good thing to do. 

Jessamy: I would, I think it would be, I think it's important that we slightly address the elephant in the room in the, in how the series landed and some of the issues around that.

A major message of the series, it's a fantastic series, is about empowerment of women. But one of the papers talks a bit about menopause being over medicalized. And obviously on the one hand it's easy, there, there's a group of people that. That that, so that, that's true, because we're actually trying to medicalize a normal period of life.

And it's more that society has made it very difficult for women to go through this period. On the other hand, there's a group of people saying, wait a minute, there hasn't been any research into menopause. We don't have any treatments. We've completely neglected this group of women. How can it be over medicalized when we can't even treat it properly?

And I say treat in inverted commas because again, that depends on whether you're viewing it as a sort of pathology or not. I just wanted to hear, your thoughts on. On the, on this sort of line between the two, because it's been so interesting to see the response to the series and to see some of these issues come up and I'm really pleased that it has actually, because I think, these are really important topics and issues that we need to discuss and we need to address in a very clear, https: otter.

ai and science based way, but also in a social way, understanding the social context in which we're all living. 

Gita: Good questions and comments. Desmé what I Personally for me, I think it's a natural part of Asian, the culture that I come from, Indian culture and all that. It's, women going through menopause.

It's seen you've reached a high status, your matriarch, and everybody respects you, calls you g all of a sudden. So to me it's. It's, so it's very cultural based, right? And so I, I don't see that negative connotation. Now, women do go through symptoms and it can be very debilitating.

And I think for them, whatever we can find management, there might be medication that they can take to manage it. It's available, if they want lifestyle intervention, we all know that it's available, non hormonal. So there's all kinds of options that are available for women. But for me personally, I believe that menopause is natural part of aging, just like how we have menarche.

We have periods. And I know some cultures celebrate that, celebrate, absolutely right. We have menarche, we have pregnancy, people celebrate. So let's enjoy menopause as well, another stage of our life and then we can fall. So that's how I say, see that, rather than thinking about medicalizing or not.

I said, yeah, such a natural. phase of our life, let's embrace it and deal with whatever we need to. Yeah, some cultures like, even Japanese culture, like we do know that they report less symptoms, right? And of course, but we don't know whether they experience less symptoms, but they do report it.

But, you get to see, they have this, all of a sudden this extra respect they've gained just because they're in that. Menopause stage. So I see in a very positive light, I say, yeah, that's good. Next, next lot, yeah. I think , yes. I that's why I think it's important as well to understand different cultures Yes.

And how they deal with menopause. COVID once, not everybody will have this. Yeah. I love that, as menopause across cultures. Yeah. It, that to me is something that we all can learn about. It reminds us back to, you know, draw a little bit insights from ancient times. Absolutely. I think that's certainly.

I'm trying to understand 

Gavin: what other support might be helpful for those with early menopause. 

Gita: I think that first of all definitely the many psychological support, counseling, because if they're feeling distressed and they're getting all this. experiencing menopause a lot earlier. I think that's important psychological support.

And also I like to think about, helping them with a strategy to manage or even, strategies to maintain or improve their both bone health, cardiovascular health, generally this is going to make a woman feel much better about themselves. So I think that kind of advice is important.

The other thing also is monitor them, over time in terms of get their blood pressure done, check their lipids level because these are all markers of, cardiovascular disease, get DEXA's work done, so more get all those statistics, collect them and monitor how they're progressing because we can do something about it.

The good news is, for instance, if cardiovascular disease, we know that they're high risk for cataracts, depending on their. Blood, they can take things to reduce their blood pressure if they can't do it through lifestyle intervention. We know that they can reduce their lipids profile, like that, and so there are medication, proven medication, that safe medication that women can take to deal with it, to manage their cardiovascular risk.

I think that's really, get them to do that a lot earlier in life before they experience these events. 

Gavin: I would imagine availability of these kind of interventions and helpful things varies across countries, right? 

Gita: Absolutely. So some, the best thing, of course, is the lifestyle interventions, for instance, again, exercising, eating healthily, not smoking, not boring.

Drinking excessively. These are things that will keep women healthy. At least try and put their cardiovascular disease at bay or monitor it because some of them might be already at high risk due to genetics, right? At least we can, they know that, I have a much higher risk of getting cardiovascular disease down the track if they've had early menopause.

Let's monitor. Let's look at my lipid, the cardiovascular risk. How are they doing? What can I do to reduce it? And that could be medication, through medication or through lifestyle. 

Gavin: What for you are the immediate next steps that are really important in early menopause research? 

Gita: I really think for me, it's really getting data from low income, low and medium income countries.

Just to look at their distribution of age and menopause and how would we define early menopause in this group? I don't think it'll be 40 to 44. It might even be earlier, but also then how do they manage? So people in China or in India or in low middle income, how do they manage their symptoms, it would be nice to hear from the women themselves as well.

So my first thing I like to do is obviously, get that data because we have sparse data on low middle income countries on menopause, experience of menopause in this group. And I have to admit that some of the work that we've published and referenced in terms of the long term impact of early or premature menopause actually came from.

The consortia that we are leading, we have about 800, 000 women from different parts of the world. And because you have such large numbers, you can actually look and see, study early menopause in detail. So we want to be able to do similar sort of things. With data from low middle income countries, but that's important.

Gavin: Thanks so much for listening to this episode of The Lancet Voice. Remember, you can subscribe wherever you usually get your podcasts and we'll see you again next time.