Doctors’ training on menopause is minimal and women’s ‘change of life’ phase can often be sidelined, but it is time for a dedicated clinic and the “HRT discussion”, gynaecologists have acknowledged.

Often shrugged off by doctors and patients themselves, menopause and its challenges merit a healthy debate, they said.

In light of a lack of support and awareness, myths about hormone replacement therapy (HRT), often still shrouded in taboo, gynaecologists said women should be empowered to ask questions, seek alternatives – even through a dedicated menopause clinic.

They should know they could do better, rather than just grin and bear debilitating symptoms and “struggle for nothing”.

Gynaecologists Chiara Frendo Balzan and Olivia Ann Cassar, both with 20 years of experience in the field, pointed to a ‘just get on with it’ approach, maintaining menopause could be dismissed to focus on more serious women’s health issues.

But patients did not necessarily have to deal with the hot flushes, brain fog, lack of sleep and libido, as well as weight gain and mood swings – just some of the symptoms they will face when menopause hits between 45 and 55. 

Although a natural part of life, menopause can cause severe problems as oestrogen production slows down and stops.

Doctors are not taught about menopause, and some are scared to tackle the subject, Frendo Balzan admitted, adding it was “literally two pages long” in medical school.

Even when she was teaching medical students in Wales, the focus was on fertility.

What she learnt around 20 years ago was now also outdated and many women were denied treatment due to a “completely flawed” Women’s Health Initiative study that shed a bad light on oestrogen replacement and its connection to breast cancer that still has repercussions today. 

The now-debunked bad publicity about the ‘danger’ of HRT led to resistance to treatment, and though the study was reviewed and retracted, it instilled fear in both doctors and patients.

Researching HRT on the internet can still offer misleading information and patients should have a “good discussion” with their doctors on this, Frendo Balzan said.

“It is quite ironic what we were doing just a few years ago,” she said about HRT, which replaces missing hormones. “You cannot deny treatment you know will work when someone is struggling.”

At her clinic, Frendo Balzan, who has a special interest in functional medicine and hormones, encounters frustration and fear because the scaremongering effects are still lingering.

Armed with incorrect information, doctors do not have time to talk their patients out it.

“They do not need to suffer in silence and can be supported physiologically to have a good menopause.”

No dedicated clinic

Cassar, an obstetrician and gynaecologist, who heads Mater Dei Hospital’s fertility clinic, also acknowledges the way hormonal issues can often be downplayed.

Gynaecologists may not give menopause much importance because they are dealing with so many other – even life-threatening – issues.

Cassar pointed out that while the hospital had clinics for anything from adolescent gynae to perinatal mental health, there was nothing for menopause.

Patients should be referred directly to the right clinic, skipping gynae outpatients, which sees 200 patients a day, she said.

“How much time can a doctor dedicate? Patients would be asked to do a hormone profile, which, basically, tells them they are menopausal – and that is about it. See you in six months!”

“In Malta, we are both obstetricians and gynaecologists, so none of us just focus on one or the other,” she highlighted.

Training is much more on the obstetrics than on the gynae side. Young trainees at hospital, starting on gynae, are trained mostly on pregnancy-related issues and gynaecological theatre. 

“It is difficult to prescribe HRT because it is not something we were trained much on,” Cassar said about the need for curriculum changes both at undergraduate and sub-specialist levels, when the trainee doctors come into the gynaecology department.

Realistically, if gynaecologists started seeing a pregnant patient, they are likely to be taking care of her mostly in her menopause.

“We should, therefore, be more aware of what is going on in this phase. But even when it comes to research, we tend to look more for pregnancy-related studies,” she said.

Patient resistance

However, it is not just doctors. From Cassar’s experience of an ageing patient population she has been following from when they had children, they too resist treatment. 

“My patients are growing older – a quarter on my daily list will be menopausal. And of these, maybe one will be on HRT.

“I am in favour of prescribing medication that helps. Why should I resist giving it and why should they resist taking it?”

Putting it down to “a cultural mindset”, Cassar witnesses a big difference between Maltese and foreigners in her private practice. 

“With Maltese patients, I have to bring up the subject. There is a lot of resistance, but they should not be putting up with this. They may complain about weight gain and other symptoms but have not considered treatment, failing to understand that HRT also improves heart and bone health.” 

Without HRT, even if a woman is sailing through menopause, bones get brittle and the risk of heart disease increases, she pointed out.

On the other hand, foreigners will just ask specifically for HRT.

“They will come to me at 60 plus saying they are feeling so well that they do not want to come off the treatment even after 15 years.”

Cassar is, however, noticing a slow shift. Twenty years ago, women simply refused HRT. 

“Back then, they were OK with having make-up melting down their face. Today, they have such busy lives they cannot imagine doing what they do while having a hot flush every 10 minutes,” Cassar said.

“Our lifestyle is such that we cannot afford not to sleep at night and to feel down all the time.”

Cassar believes that in the next 10 years, more women will request treatment and not stick out the symptoms, aware they can do better. 

“Once they start, feel well and look younger, they will not want to stop.” 

This is not about giving it some time, and it will pass, she said. 

“It will not. And you cannot spend 10 years of your life not sleeping at night.

“It is a big thing if quality life at home is suffering, and marriages can break up as a result.” 

While pharmaceutical companies were pumping big money into rejuvenation and fertility treatments, menopause products were limited, particularly testosterone, and women were not tackling age internally, Cassar said.

Something else is going on

Menopause is the rest of your life after one year of no periods. But there is also perimenopause, which is a very confusing time that Frendo Balzan describes as “a second puberty”.

Characterised by hormonal chaos and instability, it can take up to 10 years of irregular cycles, fatigue, palpitations, unexplainable anxiety, an irritable bladder, and painful joints.

“When you go to a doctor and you say you are tired and you cannot cope at a time when your kids are usually teens and are draining you, you are prescribed anti-depressants.

“With some insight, that woman would know she is not depressed but that there is something else going on.”

Age on its own is diagnostic and hormonal tests are unnecessary at that point, Frendo Balzan said.

If women do not know much, let alone men, she pointed out. 

Both gynaecologists believe gender may also come into play, with symptoms being downplayed by doctors, including younger ones, who have not experienced them.

‘We think we can do better’

Pharmacist Daniela Magro, who heads the Women’s Health Unit at a local wellness company, also believes women need to be more open about menopause and that doctors are not challenged enough. 

“Women should know their options and be able to demand products; not be at the mercy of dismissive gynaecologists… They can start to enjoy life again.”

A workshop to tackle hormones and menopause is being organised by Pink, together with Niumee, in the wake of World Menopause Day.The Pink Women’s Wellbeing Brunch, a Times of Malta event at The Phoenicia Malta on October 23, will host functional medicine and hormonal health expert Dr Irina Matveikova, who will unveil the “hidden truths” behind menopause.She will shed light on powerful solutions to help balance hormones and create optimal health and vitality.

Tickets are available from www.ticketline.com.mt