THERE IS STILL “a long way to go” to remove the stigma around menopause in Ireland, according to the clinical lead of the Rotunda Hospital’s menopause clinic.
Dr Caoimhe Hartley told The Journal that while progress has been made in providing better treatment options for women experiencing menopause, we are “not where we need to be” with women’s health in Ireland and the existing misinformation surrounding healthcare for women needs to be tackled.
“If you compare the options for women at the moment who are experiencing menopause symptoms or have concerns or want to talk to someone, to what would have been available to the same women five years ago, we’re definitely improved,” she said.
The Rotunda Hospital’s menopause clinic was opened by Health Minister Stephen Donnelly in October last year. Five similar clinics have also been established around the country, including in Galway and Limerick.
The clinic runs a morning and afternoon clinic every week and has been very busy since it opened, Dr Hartley said.
As well as being the clinical lead of the Rotunda’s menopause clinic, Dr Hartley also has her own menopause clinic in Dalkey.
She has a background in general practice but worked extensively in women’s health training in Canada, where she became accredited by the North American Menopause Society.
She is also accredited by the British Menopause Society, where she is a trainer, and tutors with the Royal College of Surgeons.
Complex patients
She told The Journal that the Rotunda’s clinic treats women of all ages who are both symptomatic or just wanting to become more informed about menopause.
She said the clinic also sees more “high risk” patients who have more complex medical conditions or have a history of illness, such as breast cancer or cardiovascular disease.
“Their GP may not be comfortable managing that or managing their menopause symptoms in the context of that medical condition, and they get referred to us. We see a lot of complex patients and patients who have a medical history of something, and really the age is anything from younger than 40 to all the way up into their 60s, 70s even. There’s no age limit.
“What we do is we talk to them about lifestyle options. We talk about things like cognitive behavioural therapy, which is CBT, we talk about reducing smoking and alcohol, increasing exercise all the lifestyle interventions that people are already familiar with by the time they come in. Then we speak to them about non-hormonal medications, so medications that don’t contain hormones. There will be a list of those options and it really depends on what you’re treating.”
Hot flashes, night sweats, low mood, sleep disturbances, joint pain and urinary tract infections are just some of the symptoms associated with menopause, but Dr Hartley said affects every woman differently.
“It’s very wide-reaching. Every patient that comes in is completely different and how it impacts them is completely different,” she said.
“Anything from mild symptoms they can manage, all the way up to the maybe 20% of women who have symptoms that are severe enough to really impact their quality of life. That can be anything from it’s impacting on their relationships with their partners, it’s impacting their relationships with their family.
I have women who cannot work, where their night sweats are so severe that they can’t sleep.
“They have cognitive changes, that they totally lose their confidence and feel they can’t function properly at work.
“I have women who can’t drive because their anxiety is so severe. I have women who report mood symptoms that are bad enough that they don’t enjoy doing anything anymore. They don’t enjoy spending time with their family or friends and they feel hopeless, and that can be really distressing.”
But she said it’s important to stress that symptoms are different for all women and will not impact everyone in the same way.
“For some women, these symptoms can be severe, but that won’t be true for others,” she said.
But she added that she didn’t “want to terrify women into thinking that they’re going to get to menopause and that everybody feels dreadful. That’s not true either.”
“It is a spectrum and everybody is different. The point is, if you are impacted in any way, you should go and talk to someone because there’s always really good options. Even just to get the support and education is important.”
Treatment for menopause has improved and become more modern, which Hartley says is down to increased research and the revaluation of the Women’s Health Initiative (WHI).
Following the first clinical HRT trials in the 1990s, findings were published by the WHI in 2002 which said there was an increased risk of breast cancer, heart disease, stroke and blood clots related to taking the drugs.
The results caused panic and caused many doctors to stop prescribing HRT. But further analysis published in 2014 found that some of the risks were overestimated.
The results also showed additional benefits of HRT use for women in their 50s.
“If you went to 2003, 2004, 2005, what was the point really in talking to someone about their menopausal symptoms when a lot of doctors didn’t feel they had any options, or that they could prescribe HRT? From 2013 onwards, we started to have really safe options again and that probably took five or six years to actually seep into clinical practice and to see GPs and doctors being more comfortable and confident prescribing for menopause.”
There has been a gradual momentum in dismantling the taboo of menopause in recent years, which Dr Hartley puts down to more women speaking about their experiences.
“I think we’ve seen a slow change that’s happened from maybe 2019 onwards, and people’s attitude to this. It’s probably part due to a social movement and women of this age and women with these symptoms becoming more vocal and that causing a bit of momentum.
The more people we hear talking about it, the more comfortable we’re talking about it and it just gained momentum over a few years.
She also credits Joe Duffy and RTÉ’s Liveline with helping the conversation around menopause.
In May 2021, Liveline had so many calls from women sharing their experiences of menopause that the topic was covered for five days straight.
“It allowed those women to have a huge platform for that voice, and I think that was really good for other women to hear all of those stories being told on the national broadcaster.”
However, while Dr Hartley feels the stigma around discussing menopause has lessened in recent years, she said there is “still a way to go”.
“I think a lot of that is because we associate menopause with ageing and we have this youth-obsessed culture and society where people don’t want to talk about ageing and don’t want to be seen as ageing,” she said.
“It’s seen as a really negative thing, when if you look at the really interesting international research that would suggest in cultures where they see ageing as a much more positive thing, and they view menopause as a more positive thing in general, that actually women tend to report fewer menopausal symptoms and they’re less stressed by going through menopause a lot of the time.”
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She said some of the stigma also relates to the culture in Ireland of not speaking about private matters.
“We wouldn’t have been traditionally great at talking about women’s health and talking about periods and talking about things that are maybe a bit more private, which is fine, but I think that maybe prevents people from sharing information and it can make people feel very lonely if they’re symptomatic.
She added that Ireland is slowly starting to see better education and better options being available to women, but we’re not where we should be with women’s health.
Dr Hartley said there is “still a lot of gaslighting” that goes on, where women being made feel that their symptoms are “not legitimate”.
There’s a lot of misinformation in women’s health and not knowing what source to trust for information.
“They get told 10 different things and they don’t know who to believe.”
She said that more than half of patients that come in relay information about menopause that is inaccurate or relevant to their own health which they have received from either friends and family, the internet or a medical practitioner. She added that it’s not the women’s fault this happens.
“It is such an individual process. If we talk about HRT, for example, HRT is just an umbrella term for lots of different medications. So if somebody says ‘I’m on HRT’, you don’t really know what they mean.
“Women might say: ‘I’ve heard there’s an increased risk of blood clots or stroke with HRT.’ That’s technically true, but only if you’re talking about oestrogen as a tablet, but not if you’re talking about oestrogen as patch. There’s a lot of nuance.”
She said women getting their information from other women who have experienced menopause can be helpful if it’s accurate and relevant – but sometimes it can be inaccurate.
“I have plenty of patients who say ‘God, my mum went through menopause without any difficulty and didn’t really have symptoms and felt really well’ and they then think ‘what am I doing wrong that I am so symptomatic?’. But they’re not doing anything wrong. It’s just the luck of the draw.”
According to Dr Hartley, education is key in improving how menopause is seen and treated, for both women and their doctors.
Last October, the Minister for Health launched a menopause awareness campaign to encourage conversation around the topic.
The Department said the campaign was a “direct response to the demand from Irish women for greater knowledge and understanding of menopause as well as better access to accurate information and supports so that they can proactively manage their experience”.
From a medical perspective, Dr Hartley said she has seen an increasing interest in the field.
“I do a lot of teaching through the Irish College of General Practice. I was involved in writing one of the modules for their community gynecology course, and it’s something that we’ve seen increasing support for and increasing interest in from general practice and community based healthcare providers,” she said.
“Those GPs have gone through the course will hopefully be better equipped to manage and counsel their menopausal patients.”
She said it is “hugely positive” that the amount of books and online resources available, as well as both public and private clinics have increased in number, but that more needs to be done.
“It has to change at a social level. I think how we view women in society, how we view women who are older in both a social setting and in a workplace, how we value them, is really important and probably has to change,” she said.
“I think we have to encourage people to value this and see it as a priority to be informed on contraception, menopause, endometriosis, polycystic ovarian syndrome.
You can’t know there’s an option if you don’t know there’s an option. That starts with the medics.
She said medics have to “be better, take responsibility and ask the question”.
“Painful sex, for example. A lot of women that I see will not volunteer this information, and they don’t have to, it’s their private information, but if you don’t open the conversation, sometimes they won’t even feel like they’re allowed to talk about it or that it’s an option to discuss it or that it’s not taboo and off the table.”
She said that while more research and data is needed, it’s all about educating women, something many of her patients are already being proactive with. Some of her patients are not very symptomatic, but want to educate themselves.
“It’s really heartening to see women talking about long-term health and empowering themselves. They’re being proactive, which is excellent.”
Asked if the Government could do more, she said: “Of course they could do more, I think we could say that about any aspect of healthcare in Ireland. There’s always room to improve. Hopefully these clinics, the more successful they are, the more well supported they are, the bigger they will get and the more access we’ll be able to provide for women in the community.”
Dr Hartley will be one of a number of experts from both medical and corporate backgrounds speaking at the National Menopause Summit at the Mansion House in Dublin next month.
The summit, the first of its kind in Ireland, aims to provide factual information to women about menopause as well as to debunk some of the myths surrounding it and call for a greater understanding of it in the workplace and in society.
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