M., a 56-year-old National Defense employee, was referred to our memory clinic, a tertiary care center, for a second opinion. Her medical history included a minor stroke ten years previously, after which she had not experienced any residual symptoms. She came to our clinic because she had been suffering from increasing lapses in memory for approximately five years. She was also having trouble focusing, difficulty with performing multiple tasks and difficulty following and remembering conversations with close family. At the time of the appointment, she was unable to work because of these symptoms and she needed help to perform routine tasks at home such as cleaning and cooking. Neuropsychological evaluation showed impaired processing speed and impaired memory performance, and her brain MRI showed diffuse vascular damage with confluent white matter hyperintensities (Fazekas grade 2, global cortical atrophy grade 1, medial temporal lobe atrophy grade 1 bilaterally, and no microbleeds). M. was diagnosed with early-stage vascular dementia, and appropriate supporting care was initiated3. However, shortly after visiting our clinic, she initiated hormone replacement therapy (HRT) after her family had read about the menopause on the internet. Within six months after starting HRT, she noticed a major improvement in her symptoms: “After six months, I was a completely different person! […] I could function independently again […]. I could actually just do everything myself.” Clinical evaluation and Mini Mental State Examination (MMSE) confirmed her subjective improvement, slightly rising from 27 to 29 points. Due to her clinical improvement, she did not meet the criteria for vascular dementia, and her diagnosis was reversed. At present – a year later – M. has no cognitive complaints, she performs her tasks of daily living independently, and she has returned to work.
Menopause and cognitive function
Menopause is marked by fluctuations and an eventual drop in estrogen levels and is retrospectively determined after twelve months of amenorrhea. The period preceding menopause, in which changes in the menstrual cycle start to occur, is known as perimenopause and it normally lasts four to ten years1. Approximately two thirds of perimenopausal women1 experience cognitive symptoms such as memory problems, and attention or language deficits, alongside the more widely known vasomotor symptoms (VMS) such as hot flashes1 4. There are many subjective reports of memory loss, and several studies have also demonstrated objective cognitive impairment during perimenopause2 5. In addition, perimenopause is associated with symptoms of mood disorders, such as depression, which in itself may lead to cognitive complaints, and it is closely associated with memory and attention deficits6. HRT could help to relieve perimenopausal symptoms, to improve mood and sleeping patterns, thereby cognitive function7. The indications and precautions of HRT are outside the scope of this article and are clearly stated in the current NICE guidelines8. Finally, studies have shown that educating women about the effects of the perimenopause on cognition significantly improves quality of life during perimenopause9.
Patients and stigmatization
Although roughly half of the people in the world go through menopause, research shows that this is still a stigmatized subject. Not only sexist, but also ageist notions may constitute barriers to perimenopausal symptoms becoming visible in the public and medical domains. Health care is generally constructed around the perspective of non-elderly males. Women – and their bodies – are expected to fit into this male-oriented system, which is often seen as being as asexual or neutral. The female physiology, including menstruation, pregnancy, and menopause, is thought of as a complicating factor in health care and research, and is often set apart as belonging to a specific specialism such as gynecology. In clinical practice however, all specialisms work with female patients and many specialisms require a basic knowledge of the effects of menopause to provide good care. The compartmentalization of menopausal complaints and the corresponding lack of emphasis on these complaints in general medicine, may have adverse effects for patients when they present with symptoms which are not overtly linked to female physiology or anatomy – such as the cognitive impairment in M.’s story.
Cultural attitudes toward female-specific complaints may also play a role in the relative invisibility of perimenopausal symptoms. As with other attributes viewed as “women’s issues” such as menstruation, women who talk about menopausal symptoms are sometimes dismissed as behaving in exaggerated or even hysterical ways, and research has shown they may be perceived as less intelligent when mentioning these issues10. M. reported that she felt her complaints had not been taken seriously by her treating physician, in line with reports of stigmatization amongst healthcare professionals when considering menopause-related complaints11.
“Well look, if you talk to a female doctor, they can sometimes relate, or may have educated themselves. The male doctors have an attitude of, well, they think it’s really all bit of a fuss about nothing. Really far-fetched.”
Women may internalize this cultural attitude and report feeling ashamed about their symptoms, with low self-esteem and impaired quality of life as a result.
The link between menopause and ageing may also lead to feelings of shame and anxiety. This negative connotation reflects cultural ideologies about ageing, classifying older women as less worthy, relevant or intelligent. It is worthy of mention here that, in cultures where ageing is valued as a positive trait, women have a more positive attitude towards menopause, and even report less bothersome symptoms12. The combination of gender- and age-related stereotypes may challenge open dialogue of menopausal symptoms in daily life and between patients and clinicians. Furthermore, because of the associated lack of awareness and knowledge, women may not attribute any symptoms to perimenopause. M.’s experience opened this dialogue within her environment, revealing perimenopausal symptoms in friends and family that had not been discussed previously.
“Well, so that they did actually start to think about it a bit and they said, sort of, I’ve actually got […] those symptoms and I think I will […] go and talk to my doctor about them.”
Healthcare professionals and stigmatization
Negative views about ageing are not only present – and persistent – in patients but also in physicians. Physicians generally view older people and women as less intelligent and less competent, and this impedes an open patient-physician dialogue, possibly leading to ineffective communication about perimenopausal symptoms, and the incorrect interpretation of perimenopausal symptoms in women consulting their clinicians13. For example, because of a partial overlap in symptoms – fatigue, sleep problems, anxiety, mood disorder – a mistaken diagnosis of burn-out, or in this case even dementia, may be made, with the potential role of menopause not being considered. The presence of other social vulnerabilities may further exacerbate the risk of misdiagnosis. The concept of multiple jeopardy comes into play here: different social vulnerabilities found in conjunction, including female sex and gender, older age, and poor financial stability, cannot be viewed separately and, when combined, they may render patients especially susceptible to ineffective dialogue, misdiagnosis and adverse outcomes. Indeed, patients who deviate from the sociocultural normative image (e.g. middle-income or financially stable, white, and able-bodied), are less likely to have effective dialogue with their physician in which their complaints are heard and patient satisfaction is reached14. This may also be the case with perimenopausal symptoms. Studies show that menopause-related complaints are generally more severe in women with low education levels, women who live in rural settings or women with reduced financial stability15. To our knowledge, there are no studies looking at the prevalence of the misclassification of perimenopausal symptoms in groups with different sociocultural or socioeconomic backgrounds.
Social impact
The personal impact in M.’s case is clear. But the social impact of perimenopause is also evident in terms of women’s ability to work: over three-quarters of women report serious problems relating to the demands of their occupation12. Especially in women with severe perimenopausal symptoms, impaired employability is therefore a distinct possibility. For M., working in a male-centered environment such as National Defense may have had a further impact on her ability to discuss her symptoms and adapt her working environment to match her changing needs. Physicians working in those male dominated domains may be even less inclined to consider sex- and gender-specific health issues such as menopause. Research shows that, in most work settings, adaptions of this kind are not addressed or considered normal. More often, women overcompensate, aiming to disprove the presumption that they might be less productive when experiencing “women’s issues”16. This may further increase anxiety and impair quality of life as well as working performance.
Education and awareness
Physicians play an important role in the normalization of the discussion of perimenopause and may complement it with professional subject-specific knowledge. Unfortunately, however, M’.s experience may well be more than an isolated case. Lack of awareness amongst clinicians impairs the recognition and acknowledgement of the symptoms experienced during perimenopause17. Although gynecologists are often better informed about the effects of menopause, other medical professionals are much less aware of perimenopausal symptoms and treatment options, and therefore less likely to recognize and treat them18. Awareness in the public domain could facilitate the discussion of perimenopausal symptoms in daily life and in clinical practice. M is optimistic in this regard, having observed an increased awareness of perimenopause symptoms in younger generations.
“Look, with our generation […] you don’t talk about it of course […] you can just see that these are things that are talked about these days […] by younger people. Younger men and women.”
In addition to this heightened awareness in the public domain, clinicians could benefit from formal education about menopausal transition. At present, doctors report that they have not been trained in this area and they feel badly equipped to deal with menopause in clinical practice19. Furthermore, although there are guidelines that address menopause separately, menopause is not mentioned in general clinical guidelines – once again assigning female physiology to a separate domain without the much-needed integration in the domain of general medicine, geriatrics or neurology20. Since menopause is also often not recorded or mentioned in patients’ clinical files, physicians receive little systematic encouragement to consider the role played by menopause. In combination with the stigmatization of menopause that we have described among healthcare providers and patients, the potential role of menopause may therefore often be overlooked during the initial clinical assessment of patients.
Implications for practice and policy
In conclusion, perimenopausal symptoms – especially in the cognitive domain – continue to be underrecognized in clinical practice and clinical education, and they may therefore be undertreated as well. Growing awareness in the public domain about the impact of menopause may facilitate more openness about perimenopause among patients and physicians. Furthermore, better training for general physicians, occupational health physicians, internists, geriatricians, and neurologists, could lead to a better understanding and recognition among physicians of menopause-related cognitive problems. More knowledge will help to counter stereotypical thinking, facilitating better physician-patient dialogue and enhancing clinical awareness of the menopausal transition. We believe this is a prerequisite for the better recognition and counselling of perimenopausal women. In the case of M., a more structural change in the recognition of the role played by menopause in symptoms of the kind from which she suffered could possibly have been facilitated if physicians had been given more information about this subject in clinical guidelines for cognitive impairment. This could well have led to a much earlier improvement in her quality of life. Furthermore, in hospital care, awareness could be enhanced further by recording menopausal status in patient files. Breaking taboos and educating healthcare professionals about the menopausal transition and on how to discuss this with their patients will almost certainly lead to improvements in the care delivered. Furthermore, this information should be tailored to include women from a range of cultural, geographic and socioeconomic backgrounds so that they can obtain support and guidance during perimenopausal transition and embrace the next chapter in their lives with more confidence and a better quality of life.