Jessica Erlendson woke up in the middle of night feeling anxious and like bugs were crawling under her skin. Both sensations are common symptoms of menopause.
She took a walk and bath to ease her discomfort, but to no avail.
“I started crying, and my husband came in at that point. It’s probably five o’clock in the morning, and he said ‘Who died?’” said Erlendson, who is 53. “And I said ‘I don’t know, I guess I have.’”
Menopause, the transitory phase where a woman stops getting her period, can be debilitating for some women. Yet menopause is little understood by most people and one of the best treatment options for it is not generally prescribed, says Dr. Alison Shea, an obstetrician, gynecologist, menopause and reproductive health specialist at St. Joseph’s Healthcare in Hamilton, Ont.
Women’s hormone levels fall drastically during menopause, which generally lasts six to eight years. These hormonal changes affect every part of their bodies, from cognitive functioning, bone and heart health to overall well-being.
Three out of four people who go through menopause have symptoms that interfere with their daily lives, according to The Menopause Foundation of Canada, a non-profit that advocates for better menopausal care. One out of four of those women have menopausal symptoms so severe they can no longer work.
Hormone therapy — a treatment that involves replacing women’s depleted hormones — is the best treatment option for menopausal women, says Shea, who is chair of the Canadian Menopause Society, a multidisciplinary group of health-care professionals focused on menopausal health.
But most doctors do not prescribe hormone therapy for menopause and some even discourage it, she says. Often, this is because doctors are not current on best treatment practices.
“We need to do a better job educating the doctors from the ground up.”
‘Looking for relief’
Hormone therapy was widely prescribed to help women manage menopausal symptoms from the 1960s until the early 2000s, when a study by the Women’s Health Initiative drastically changed this practice.
The initiative, which ran a series of clinical studies of post-menopausal women beginning in 1991, examined the effects of hormone therapy on women. In 2002, the trial was cancelled after hormones were found to increase women’s risk of various diseases, like cardiovascular or cancer.
Fueled by media hysteria, medical institutions responded by advising all medical practitioners to discourage the use of hormone therapy, says Dr. Sofia Ahmed, a professor in the faculty of medicine and dentistry at the University of Alberta.
“Those who did not have stats background or numeral literacy … made it [sound] quite scary,” said Shea. “Overall, most of the risks were about eight more cases in 10,000 women … That’s a very low absolute number.”
The use of hormone therapy to treat menopause fell by 28 per cent in Canada and 46 per cent in the United States and in many European countries as well.
But the initiative’s study was flawed, says Ahmed. The women in the trial were in their 60s — more than a decade older than the average age of menopause in Canada, which is 51. Side effects from hormones differ between age groups, with younger menopausal women being the least likely to suffer health effects from hormone treatment.
The type of hormones, and how they are ingested, also factor into the potency of their side effects. In 2023, Ahmed published a study that found consuming estrogen orally, as opposed to with a topical patch, increased the risk of hypertension by 14 per cent in study participants.
Estrogen derived from an animal — in this case, female horses — was more likely to result in hypertension, whereas participants who took a synthetic replica of estrogen found in humans were less affected.
Hypertension, or high blood pressure, is one of the leading causes of cardiovascular disease globally. Lowering the risk of hypertension from estrogen hormone therapy greatly reduces the chances of women developing other diseases from the treatment.
Since the Women’s Health Initiative study was cancelled, many other studies like Ahmed’s have shown there are safe ways to take hormone therapy for menopause. These hormones can significantly improve women’s ability to live normal lives while they go through menopause.
“Women … are taking hormone therapy because they have such bad symptoms,” said Ahmed. “They’re looking for relief.”
‘Repeat yourself’
To this day, doctors in Canada continue to cite the Women’s Health Initiative study when discouraging women from using hormone therapy, says Shea.
In 2021, the Canadian Menopause Society released a guideline on safe hormone therapy prescriptions for women in menopause to help inform the public.
Erlendson cites the guideline in a Facebook group she founded that helps women advocate for themselves during doctors’ visits. The group counts more than 8,000 members.
“In order to get good care during perimenopause and menopause, you have to come into the doctor’s office and say, ‘I found out this information. I want to try this drug,’” she said. “And then they say all the reasons why you shouldn’t have that drug. And then you have to gently, insistently, repeat yourself until they say, ‘fine, if you want to get cancer’.”
Many doctors do not have time to update their menopausal care recommendations because they are overworked and underpaid, says Shea. Discussing menopausal care options with patients can also take time — something some doctors cannot spare with full waiting rooms.
The Canadian Menopause Society made a submission earlier this year to the House of Commons Standing Commission on Health that included advocating for a billing code for “menopause care” to enable doctors to charge for providing menopause counselling. Without a billing code, doctors are not paid for offering this service.
Many doctors also lack the time to get re-educated on effective menopausal care.
“It’s a bigger system problem, and a fee-for-service problem — which puts patients at a disservice,” said Shea. “And it’s really not up to the family doctors to decide … This needs to come from higher up from the government.”
Menopausal specialists often have long waitlists. Shea, who is based in Hamilton, has a 14 month-long waitlist.
Dr. Angela Hunt, a naturopathic doctor specializing in menopausal care in Kingston, Ont., says many women come to her seeking care that is longer than the 15-minute appointment they can get with a family doctor. Many others do not have a family doctor at all.
“The first visit I spend with someone is 90 minutes,” said Hunt. “The conversations around menopausal care take time and a lot of traditional medical appointments don’t have time.”
The Canadian Menopause Society is creating short courses with menopausal care guidelines for doctors to get up-to-date care information quickly. Shea says the society is also organizing talks in medical schools to teach students about menopausal care.
“Except for pediatrics, everybody needs to know about menopause,” she said.
For now, many women resort to doing their own research or asking each other for help on menopausal care, said Erlendson.
“I wish that we didn’t really need to be having these conversations. But we absolutely do because someone right now is in a Walmart parking lot bleeding profusely and has been told that she’s fine and has no idea what to do next, because the doctor isn’t helping her,” Erlendson said, referring to prolonged periods, which are a lesser known symptom of pre-menopause.
“We’re struggling,” she said. “And we need to be taken seriously.”
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