Menopause: a turning point for women’s health

Rising demand for menopausal hormone therapy (MHT) in the UK has resulted in shortages of some products, as suppliers struggle to keep up with demand. A consequence of increasing awareness of menopause symptoms and treatment options among women, prescriptions for MHT in England have doubled in the past 5 years to more than 500,000 a month. Used to alleviate distressing vasomotor symptoms, genitourinary syndrome of menopause, and postmenopausal osteoporosis, MHT can also help minimize disruptions to work and quality of life. In response to an outpouring of anger from women affected by the MHT shortages, on April 29, the UK Government announced the formation of a new taskforce to address the supply chain issues.
Although a natural part of reproductive aging, menopause does not affect all women the same. Duration of the menopause transition, age at onset of natural menopause, and menopausal symptoms—type, severity, and duration—all vary and can be affected by both modifiable (eg, obesity, smoking) and non-modifiable (eg, race, ethnicity , socioeconomic status) factors. In the Study of Women’s Health Across the Nation (SWAN)—a multiethnic cohort of 3302 women in midlife in the USA—80% of women reported vasomotor symptoms, which persisted for a median of 7·4 years. Race and ethnicity strongly influenced the duration of vasomotor symptoms, with Black women reporting the longest duration (10 1 years) compared with Hispanic women (8 9 years), non-Hispanic White women (6 5 years), Japanese-American women (4 8 years), and Chinese-American women (5 4 years). Black women were also more likely to start menopause at a younger age, have a longer transition, and have more severe symptoms than other racial groups.
Yet beyond the reproductive transition, menopause is also a biopsychosocial turning point in cardiometabolic disease risk for women. Increases in insulin resistance, fat mass, dyslipidaemia, and endothelial dysfunction occur at the menopause transition, contributing to a worsened cardiometabolic profile independent of chronological aging. Vasomotor symptoms, sleep disorders, and mood changes associated with menopause can also increase cardiometabolic risk. Additionally, a history of some reproductive and gynaecological conditions such as gestational hypertension or diabetes, premature ovarian insufficiency, and functional hypothalamic amenorrhoea can worsen the cardiometabolic profile. As a result, the menopause transition is associated with an increased risk of cardiometabolic diseases such as obesity, diabetes, cardiovascular disease, osteoporosis, dementia, and cancer that can emerge 10–15 years after the onset of menopause. In 2020, a scientific statement on behalf of the American Heart Association included the menopause transition for the first time as a sex-specific event that can profoundly affect future cardiometabolic health in women.
In the June issue of The Lancet Diabetes & Endocrinology, we publish a two-paper series on menopause. The papers discuss the cardiometabolic changes that occur during the menopause transition and management approaches for menopause with a view to preventing cardiometabolic diseases. The overarching theme of the series is that the menopause transition is a time of accelerating cardiometabolic disease risk. As such, it presents an important opportunity to raise awareness of the symptoms and downstream health consequences, adopt healthy behaviors and institute early management of traditional cardiovascular disease risk factors, and implement screening and preventive strategies to reduce the risk of chronic cardiometabolic diseases that can occur in later life.

For too long, women’s health-care needs at menopause have been under-recognized and underserved by the health-care profession. Writing in the second Series paper, Roger A Lobo and Anne Gompel concur: “menopause management is poorly practiced and has not been an adequate part of graduate or postgraduate education for health-care providers”. These deficiencies need to be remedied—health care for women approaching menopause, at menopause, and after menopause must be improved. With a demographic of half the world’s population, who spend around a third of their lives after menopause, the unmet need could not be larger. Education, support, and access to treatments for menopausal symptom relief and prevention of later-life chronic diseases must be available to all women regardless of race, ethnicity, socioeconomic status, or geographical location. With such a foundation in place, women will be able to go through the menopause with confidence, embrace the next chapter of their lives, and lead longer and healthier lives.

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