Intended for healthcare professionals

Rapid response to:

Analysis

Normalising menopause

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj-2021-069369 (Published 15 June 2022) Cite this as: BMJ 2022;377:e069369

Rapid Response:

Let’s be inclusive about other global ways of managing the menopause to improve the lives of women not just centre the conversation around the biomedical paradigm

Dear Editor

I used to run a holistic gynaecology clinic and make many women aware of more options to handle menopause than just HRT. I find the current dialogue about just HRT as the solution a very narrow one. Though HRT is one very valuable intervention for some women. Also, menopause strife is more noticeable amongst western based women than, for instance, other parts of the world.... so, there are cultural, sociological, environmental, dietary even 'spiritual outlook' factors at play in the experience of menopause. I notice this especially positioned as a South Asian woman brought up in the UK noticing a contrast in the way menopause is viewed across cultures I belong to. It's a transition in life that requires personalized care and discussion of a woman's particular circumstances; there may be lifestyle interventions that work or there may be need for HRT. Or maybe a mixture of that could possibly vary from time to time. It also depends on whether the woman is perimenopausal or past the menopause.

Other interventions may be: increasing dietary phytoestrogens (Soya, tofu, red clover or supplements with them); acupuncture and mindfulness have some RCT evidence to support their use for hot flushes; yoga and tai chi also help the body - kundalini yoga may help a woman’s sexuality; attending supportive groups or circles of women may help. This can increase oxytocin levels and decrease stress (see Taylor's work at UCLA on the 'tend and befriend' physiology).[1] Safe space groups can be away of releasing anger and a life time’s worth of unaddressed pent up emotions; periodic bursts of herbal supplements, so from my own Asian culture, Ayruvedic herbs such as Ashwagandha and adaptogen which may help in areas where Testosterone HRT is considered or Shatavari (which can be used as a phytoestrogen). There are also western herbal options too. There are further non evidence based but historically empirically based ecological interventions too. It is wise to reflect that much of obstetrics and gynaecology guidelines have low levels of good quality evidence. [2,3,4]

HRT (with its vested interests of the pharmaceutical industry) is not the only intervention of significance, rather one angle of many possibilities that women could explore around the menopause. What is important is personalised care, that women should be listened to about what they want as there are so many narratives on social media of women being gaslighted either by being prevented from obtaining HRT or being coerced into accepting HRT spun as the only option when it is not wanted. I liken the situation to the polarity in the birth world where there are current clashes between those who want the choice for birth to be medicalised versus those who would like birth to be as ecological and physiological, and hence it is good to reflect on UK Montgomery v Lanarkshire [2015] Supreme Court ruling where healthcare professionals need to centre their advice around what the woman wants and what she holds as valuable. Herein lies female empowerment. Having written on decolonising ideas of healing in medical education [5] and the exclusion of ideas of healing that are not aligned with western biomedicine, at this point in time, let’s be inclusive about other global ways of managing the menopause to improve the lives of women.

References
1. Taylor SE. Tend and Befriend: Biobehavioral Bases of Affiliation Under Stress. Current Directions in Psychological Science. 2006;15(6):273-277. doi:10.1111/j.1467-8721.2006.00451.x
2. Prusova, K., Churcher, L., Tyler, A. & Lokugamage, A. U. Royal College of Obstetricians and Gynaecologists guidelines: how evidence-based are they? J. Obstet. Gynaecol. 34, 706–11 (2014).
3. Ghui, R., Bansal, J. K., McLaughlin, C., Kotaska, A. & Lokugamage, A. An evaluation of the guidelines of the Society of Obstetricians and Gynaecologists of Canada. J. Obstet. Gynaecol. (Lahore). 36, 658–662 (2016).
4. Howick, J. We don’t know whether most medical treatments work, and we know even less about whether they cause harm – new study. The Conversation. June 17 2022
5. Lokugamage AU, Ahillan T, Pathberiya SDC. Decolonising ideas of healing in medical education. Journal of Medical Ethics 2020;46:265-272.

Competing interests: I ran an NHS holistic gynaecology clinic and a maternity acupuncture service between 2005-2020

21 June 2022
Amali. U Lokugamage
Consultant Obstetrician and Gynaecologist and Honorary Associate Professor; Medical Educationalist
University College London
London, UK.