A recent study by researchers at La Trobe University and Monash University in Melbourne, Australia, suggests that working women “need more managerial support [while] going through menopause.” This “Women at Work” study explored the health and wellbeing of working women and women’s satisfaction at work, yet focused on working experiences in or around menopause. The lead researcher, Professor Gavin Jack, reports that “menstrual status did not affect work outcomes” but that “if a woman had one of the major symptoms associated with the menopause — for example weakness or fatigue, disturbed sleep or anxiety, then this did influence how they regarded work.” Jack is further quoted as saying: “What is really important is not the fact of going through the menopause in itself, but the frequency and severity of symptoms which women experience, and how these factors affect their work.”
This study has been described in several news sources over the past few weeks, such as the International Menopause Society, Science Daily, and IrishHealth.com. I have many reactions to this research, both positive and negative.
I’ll present my positive feelings first: I appreciate the fact that researchers are talking about the fact that menopausal women are a large part of the workforce and that menopausal experiences matter for individual women. I also applaud the attention given to the fact that workers are human beings with bodies, and that bodies matter. The idea that employers should recognize that paid workers have bodies and that paid workers may be affected by their bodies is an excellent one. I agree that employers should be educated to be more sensitive to menopause and other bodily experiences that their paid workers might have, and simple adjustments in work policies and work environments can go a long way in making employees happier and more productive (plenty of research has already shown this). Finally, and maybe most importantly, as one article in Science Daily notes, “Not enough attention is paid to the experiences which people go through at different stages of life — the workplace treats this very unevenly.” I couldn’t agree more. Especially when it comes to midlife and aging, we forget that paid workers are still dealing with bodily transitions. We forget the range of chronic illnesses that paid workers might have at midlife and beyond, as well as the many normal health transitions that any midlife or aging individual deals with. Anything from the acquisition of bifocals (and learning to see differently through bifocal lenses) to the hassles of dealing with back pain, neck pain, arthritis, hearing impairments, insomnia, etc., can affect one’s work. Not to mention menopause, prostate conditions, and other aging health concerns that can involve a range of different signs, symptoms, and stages. Starting at midlife, it is also much more common to deal with caregiving for elderly parents, divorces and remarriages, putting kids through college (or putting up with adult kids living at home), deaths of parents and spouses/partners, and other social transitions, and all of these things will impact how a paid worker feels and acts on the job. There is much to pay attention to about paid workers in their 40s, 50s, 60s, and beyond, and I believe that this research is a good start on that. Middle-aged paid workers may be reaching the peaks of their careers and may be excellent at their jobs, but they’re still dealing with a multitude of other life circumstances at the same time. And if they’re not performing well on the job, it may well be because of these very same issues. Paid workers are people, with full lives and physical bodies that they can’t leave at home (no matter how much they try).
I’ve been thinking a lot about the messages that women do or don’t get at menopause.
Because of this, I decided to come up with a list of things that women would love to hear at menopause (or perimenopause, if we are talking about when women experience the majority of their signs and symptoms).
I’ve divided my list into things that they might want to hear that are true, and things that they might want to hear but might not be true yet (but should be). I’d love to hear reader comments on this division and any ideas about what I’ve forgotten that should be on my lists!
Things Menopausal Women Would Love to Hear That ARE True:
1. It’s okay to be glad to be done with menstruation, the threat of pregnancy, the burdens of contraception, etc. It’s also okay to use the menopausal transition to question whether you really wanted kids, whether you had the number of kids you wanted, and whether you’ve been satisfied with your reproductive life in general. It’s normal to have all of these thoughts and feelings.
2. You’re entering the best, most free part of your life! But, it’s okay if it doesn’t feel like that yet.
3. Menopause does not mean you are old. In fact, potentially you are only half way through your life.
4. You are not alone. Lots of people have the experiences you do. You are normal!
5. I understand what you’re going through. (Or, alternatively, I don’t completely understand what you’re going through but I’m willing to listen.)
6. It’s okay to be confused and frustrated at this time of life, or in any other time of life!
7. You’ve had an entire lifetime of reproductive experiences, and this is simply one more. How you feel about menopause is probably related to how you’ve felt about other reproductive experiences over time, however. It might be helpful to reflect back on all of the reproductive experiences you’ve had to sort out how you feel about menopause.
8. Talk to other women you know. Talking about menopause helps everybody.
9. Menopause and midlife can be as significant or insignificant as you’d like them to be. For some women, these transitions mean very important things but, for others, they mean little. Whatever it means to you is okay.
10. Researchers are working hard to understand this reproductive transition more fully.
Things Menopausal Women Would Love to Hear But Might NOT Be True:
1. This is guaranteed to be your last menstrual period. You are done! (Or, a related one: You’ve already had the worst signs and symptoms. It gets better from here on out!
2. Signs and symptoms of menopause will be predictable and will not interrupt your life.
3. No one will think negatively of you or differently about you if you tell them you’re menopausal.
4. There are no major side effects to hormone therapies or any other medical treatments you might be considering.
5. Doctors will be able to help you, and will understand your signs and symptoms, if you need relief.
6. Leaky bodies are no problem! No one will care if your body does what it wants whenever it wants.
7. Partners, children, coworkers, and others will completely understand what you’re going through.
8. Middle-aged women are respected in this society, and it is truly a benefit to be at this life stage.
9. There is a clear beginning and a clear end to this transition.
10. Clinical researchers are researching the parts of menopause that you care about.
In my opinion, things that menopausal women would love to hear but might not be true speak to many of our societal norms and biases. Menopausal women are in a tough spot when it comes to norms about bodies, aging, gender, etc. Items on this second list also speak to menopausal women’s difficulties in accessing quality health care or getting safe relief from symptoms when needed. The latter list also notes the potential disconnects between research findings and women’s true needs during this transition. The first list represents what we should probably tell women and represents the kinds of supportive comments they might want to hear while going through perimenopause in particular.
Anyone who has ever loved anyone and existed in any kind of intimate relationship, or raised a kid, or negotiated with their parent as their parent ages knows that you can both love someone and also be very frustrated — even feel like hating them — at the very same time. You can love someone while simultaneously being extremely frustrated by her or him.
These same complicated love-hate emotions seem very present at perimenopause and menopause. The more I listen to middle-aged women talk and the more I see the media around menopause, the more I realize this. Feminist scholars have often stressed that menopause is not solely a negative transition and that women can find the transition positive at times. At the very least we’ve found that women feel indifferent or mixed about menopause, even if they don’t feel positive about the transition. BUT feeling positive or indifferent about reaching menopause (i.e., being happy to reach a certain period of life) is completely different from living with perimenopause. The signs and symptoms of perimenopause and menopause (e.g., hot flashes, night sweats, insomnia, irregular bleeding, etc.) can be grueling, and to discount that means telling women that their everyday feelings are not real. Especially when one thinks about the uncertainty women feel when they don’t know how long perimenopause will last (and when menopause will finally arrive), it is important to think about the very real and very negative feelings women might have even if they are happy overall about making this reproductive transition. Feelings of negativity might also come from women’s thoughts about what menopause means for their fertility if they’ve had trouble conceiving (“After all I’ve been through, now I have to go through this?”) or what menopause means about aging (“Should I worry about aging now? What is coming next for me?”). Even if women are glad to be done with monthly periods, they might still be fearful of aging or mourn their fertility in some way. Women who have decided not to have kids might feel that it’s unfair to have to go through menopause when they didn’t even use their reproductive capacities, even if they are glad to finally be rid of periods. To not acknowledge these complicated emotions is to discount the complicated life courses that women lead. At any life stage we think about what has happened before and what will happen next, and our thoughts about both the past and the future affect how positive we can be about the present. Automatically this means we will have complicated emotions as we make life stage transitions.
Thinking about the road ahead, I know that I’m going to be like every other middle-aged woman. I’m going to love and hate perimenopause and menopause. Just like I’ve loved and hated all other reproductive events in my life. It’s too bad we don’t talk about this stuff more openly, because complicated emotions are actually fairly commonplace. At home. At work. In all of the arenas of everyday life. If we acknowledged this more fully ahead of time, we might be better off as we go through our life stage transitions. Transitions might still be rocky and rough, but at least we’d know it’s normal to have these emotions.
This name for peri/menopause has appeared in many cultures and has been passed down through the eons, generation to generation. I, myself, really like calling it The Change, as it describes the awe and magnitude of peri/menopause. The Change honors the call to attention, the rupture from the known, the reflective incubation, the life choices and the leap of faith that a conscious, mindful passage through peri/menopause requires. The Change encapsulates the seismic shifts, the unexpected turns, the disturbing reorientations, the annoying distractions, the unsummoned losses, and the depth of self-discovery that is available to every woman willing to answer the call and step into the initiatory potential of this passage to Eldership.
As I prepare my workshop (The Chrysalis and the Crone: A Conscious Menopause) to bring to the SMCR Conference next week, I find myself deeper and deeper in the reality of our contemporary, global culture and the crisis of the absence of rites and initiations. Specifically, how does it affect each and every one of us, that our experience is being defined only by our ‘symptoms’? What does it mean for us and our planet if we pay attention to the attempts of the psyche to guide us out of our work-a-day-lives and into discovering what else might be possible? What if we choose not to be thwarted by the unimaginative beliefs that the soul’s needs are unquantifiable and thus unimportant?
Marion Woodman describes this vacuum:
“The doors that were once opened through initiation rites are still crucial thresholds in the human psyche, and when those doors do not open, or when they are not recognized for what they are, life shrinks into a series of rejections. Torschlusspanik [a German word connoting the terror of disconnection] is now part of our culture because there are so few rites to which individuals will submit in order to transcend their own selfish drives. Without the broader perspective, they see no meaning in rejection. The door thuds, leaving them bitter or resigned. If, instead, they could temper themselves to a point of total concentration, a bursting point where they could either pass over or fall back as in a rite of passage, then they could test who they are. Their passion would be spent in an all-out positive effort, instead of deteriorating into disillusionment and despair“. (from Richard A. Heckler’s Crossing: Everyday People, Unexpected Events and Life Affirming Change, p. 134)
If this is true, then instead of suffering ‘symptoms’ and struggling, each of us, to suppress or get rid of these symptoms, we might consider peri/menopause as a collective imperative to initiate and embody change – in ourselves and our society. Peri/menopause might be the catalyst to shake us awake from our collective trance, to step away from our habituated notions of who we are and how our world is supposed to work.
Here’s the rub: change is pain. We are, for the most part, creatures of comfort. We like, for the most part, to be lulled. But our souls long for more, and at peri/menopause we can no longer ignore the small whisper, deep in our psyches, asking: “Is this it? Is this all there is?”
Change is afoot …
My kids and I read a book about “the last snowflake” a few years ago. The book was a story about how the last snowflake felt as it hit the ground each winter – lonely because his friends were ahead of him and probably melted already, or maybe carefree and floating on the wind to say the last goodbye to winter. This year my kids and I keep trying to wonder when that last snowflake would fall. Was it a few weeks ago? No. Was it last weekend? No. Well, here it is snowing again today so will I see the last snowflake tonight? At some point this snow has to end – it’s late April! When WILL that last flake fall?
Plenty of people have written and sang about the “last snowflake” (do a web search and you’ll see). It’s a great thing to philosophize about: when will it come, what will it look like, will I miss it, am I ready for what comes after it, and, in general, how do I feel about the transition it represents? Am I glad to see that last snowflake of the season, or am I melancholy about it? Am I ready for the warmer weather, or did I like wearing warm sweaters and fleece pajamas? Do I like winter after all, even though it’s hard and long and seemingly never-ending, until it’s over? I like spring a lot but it’s always so short in Michigan and we head right into hot weather, there’s really not much in-between. Plus spring and summer mean the ramping up of activities and a busier schedule – am I ready for that? A part of me is already missing that last snowflake even though I don’t know if I have seen it yet….but then again, I’m pretty ready for winter to be over. Can I feel two things at once? Can I be sad and glad to see that last snowflake?
Why am I writing about snowflakes? Because I read a piece on the Red Hot Mamas website the other day about a menopausal woman’s last period that reminded me that of my thoughts about last snowflakes. In “A Gentle Good-bye,” Christine Merser talks about how she did not get to say goodbye to her last period at age 42, that it came too fast and she mourns (at least in part) the idea that she’ll never menstruate again. She acknowledges the hardships menstruation sometimes caused and the hassles that were part and parcel of it, but also reminisces in its life-giving qualities and feels a sense of loss. She feels her last period was a “benchmark moment” and suggests that in not knowing that her last period was indeed her last, she did not get to say that “gentle goodbye” that she wanted to say. She also talks about menopause as representing the “October” of her life, signifying ends rather than beginnings, but at the same time wants it to mean new and better things. The idea that the last period cannot be predicted but is hoped for, but then may be bittersweet when it’s finally reached is something that I’ve heard from so many women. Menstruation is hard, especially when it is unpredictable in perimenopause or before, but a part of it is also safe and representative of a kind of stability and identity that is hard to give up. Merser proposes that cessation of menstruation is the “first thing she can’t fix” about her body. Regardless of the freedoms that you might get when it’s over for good or the things about it that you will gladly give up, women aren’t always quite sure they really want to be done with menstruation forever once they sit back and think about its meanings. So they ask, Am I glad to see that last period, or am I melancholy about its passing? Am I ready for the midlife and beyond, or did I like being younger? Am I ready to give up my monthly reminders of womanhood? Do I like menstruation after all, even though it’s hard and long and seemingly never-ending until it’s over? I might like midlife a lot but it seems like it might be short and it might head me right into aging for real, so how long will I really be in this good midlife stage? Does a part of me miss my period before I’ve seen my last one?
Like snow, menstruation can be unpredictable, uncertain, burdensome, and a hassle, and we might all be very happy to say goodbye. BUT, for those of accustomed to the seasons and the good parts of each season, we might also be somewhat sad to see snow and menstruation leave us. Especially if we don’t get to say a chance to say goodbye.
Disclaimer: This analogy probably only works for those who live in Northern climates and are used to the good and bad things that come with snow. And yes, I’m sort of making light of menstruation here, but my feelings about the last snowflake this year are noticeable to me and I thought it might be fun to play with this analogy.
In Heather Dillaway’s re:Cycling post of March 28, “The Physical Body and the Lived Body”, she invited a conversation about the importance of understanding the “lived bodily experience” when we examine menstruation. She suggests that “we cannot comprehend menstruation until we separate the physical body from the lived body”. Her inquiry reflects the dilemma many of us face when we attempt to enter the female experience through our cognition. Inevitably we rely on what we’ve heard repetitively and from many sources; what we’ve been taught, cajoled, shamed, brainwashed, and had whispered to us. In this way our experience has been formed from the outside in. This is what Dillaway delightfully (albeit cognitively) calls the “governmentality” of (our) bodies – that is, all the rules that surround bodies, all the norms that suggest exactly how our bodies should be and behave”.
If we agree reframing and embodying our own experience is called for, the logical question is no longer WHAT is our lived experience (that would still keep us in our heads) but HOW do we experience our bodies to discover our experience from the inside out? What are we called to do, or perhaps more relevantly, to BE, to develop the ability to fine-tune our inner attention, to deepen our listening and to familiarize ourselves with the terrain of our interiority?
How we chose to do this — how we each bypass the machinations, the loops, the highly developed editing abilities of our minds, the habituation of needing more, more, more information — is as personal and varied as the individuality of each inner landscape. However, I would like to suggest the following three components as a place to start:
“Going inward” only can happen when we slow down. This is a timeless realm, where attention will only settle on our experience, like a butterfly on a flower, when the air is still.
We also need to bring our curiosity to the unknown. We won’t free ourselves from the tyranny of imposed meaning until we are willing to enter into our experience and be willing to not know what we will find. Not even think we might know. Simply not expect to know.
We also need to build up the courage, the resources, the terra firma, the self-esteem, nay, the self-respect to go in and gently, lovingly touch those uncomfortable, painful, and often vulnerable parts of ourselves. These wary parts might even back away from us at first, but in truth, have been waiting for us to arrive for a long time. As the poet Mary Oliver says, “you only have to let the soft animal of your body love what it loves”.
These three mindfulness-based practices are at the foundation of a conscious embodiment of our menstruation, hormones and peri/menopause. They offer a way into our experience that allows understanding to bubble up from the experience itself. If we can BE in our bodies, if we can sit quietly and notice who we are when we menstruate, when we ovulate, and the tempo of our own monthly cycle, in this way we permit ourselves the experience of knowing ourselves from the inside out.
Who knows, something unexpected and remarkable might happen. By bringing consciousness into our experience, it might shift the experience itself…
The premises of the much-discussed new series House of Cards hosted on Netflix, are that no one in the world of politics can be trusted, that alliances are fragile, and that disaster looms at every moment. Beneath the surface of beautiful buildings, attractive people, glamorous receptions, and rousing rhetoric lie depths of deception and betrayal.
At the heart of the intrigue are the central power couple, US Congressman Frank Underwood and his wife, Claire, who heads a non-profit NGO dedicated to providing clean water to impoverished African villages. They appear to be well matched and unified in their ambitions for both personal power and their pet projects while expressing benign neglect toward each other’s outside sexual pursuits.
All is well in the Underwood cacoon until perimenopause makes its destabilizing entrance. There’s a concept that’s sometimes referred to as “Chekhof’s Gun” that goes something like this, “If you show a shotgun on the wall in an early scene, someone better use it before the play is over.” Well, the menstrual shotgun first appears in an early episode when Claire is seen standing before an open refrigerator door and she’s not looking for a quart of milk. Frank notices, says little, and the moment passes. Four or five episodes later Claire makes a deal to accomplish one of her goals, knowing it will undercut a grand scheme he is working on. When he learns of the betrayal, he employs the deadly menstrual shotgun, “Is it the hot flashes?” Whereupon she throws him out of her office and departs for New York to be with a long-time lover.
But this is only the first season of what promises to be an ongoing saga, so following yet another political crisis, she returns to Washington. But something has changed. She has been having dreams about saving a child who is being choked by vines and, in a final scene, visits an ob/gyn to discuss having a baby, despite the fact that she has had three prior abortions. Perimenopause has suddenly altered her perspective. As viewers have already learned that her husband hates children, the set up for next season’s drama is well established.
No question – Poise’s Second Talk Campaign is undeniably courageous, taking on Menopause, the Previously Unmentionable. Call me impatient and unappreciative, but I just can’t help mourning the missed opportunity to REALLY empower women, instead of aligning with those unrelenting forces bent on squeezing the Mojo from the second half of our lives.
Seeped as I am in the journey of menopause, (my own, and as co-creator of the Menopausal Mojo Teleseminar program), my curiosity was cautiously piqued when I opened the Poise link in this blog post last month. (Cautious because, after all, Poise is an incontinence product and the association is not only anxiety provoking but inadvertently quantizes my experience into a demeaning and unimaginative metaphor — something like shame meets discouragement meets insult. Sorry, that’s just how it feels to me. Let it be known, I am not in denial here – it has been a while since I could safely jump on a trampoline with anything in my bladder.)
Nevertheless — someone is talking publicly about menopause. And I am certainly curious to see what aspect of this rich, challenging and potentially transformative experience they are choosing to highlight.
The first thing we see: “8 in 10 women agree, it’s time to change the way we think about menopause”.
YES!!! What we’ve been saying all along, my wonderful co-conspirator, Karen Clothier (creator of the body-mind-spirit focused and unexpectedly successful Menopause the Magical Telesummit) and me. We find ourselves coming back again and again to feeling the urgent need to rebrand menopause. We clearly do want another way to understand peri/menopause. After hundreds of years of agents of the male paradigm systematically dismantling our authority of our experience, using shame to silence our inherent collaborative tendencies, we have lost the language to talk about the transformative experience of our 40’s and 50’s – as we move from fertile women to mature women, from “child bearer’s to bearers of wisdom” (Kristi Meisenbach Boylan The Seven Sacred Rites of Menopause).
Clearly the difficulty begins with the term “menopause” itself. The term was coined in 1812 by the French physician de Gardanne and is defined as (a moment in time) 12 months after the last menstrual period. A little hard to acknowledge a rite of passage when its beginning, middle and end are as elusive, instantaneous and vague as that. But that’s not all, that’s simply the scientific use of the word. Our everyday use of it also describes perimenopause (the 5-10 year period before the Moment-In-Time) as well as post-menopause (an unspecified period after the Moment-In-Time). Confused yet?
Small wonder that we need new, updated language, imagery, descriptions, mythology and role-models — a full-spectrum, holographic map to describe the physical, emotional and spiritual terrain of our midlife experience.
Wait, I’m getting a little ahead of myself. Back to the Poise menopause page, and how it misleads women by reducing this remarkable transition into … yes, you got it … SYMPTOMS. As if symptoms are the menopausal experience. And the successful management of said symptoms is all there is to this phase of our life cycle. Tragically reductionist, when seen from the perspective of how insidiously the media molds our reality. This is brilliantly elucidated in Jennifer Siebel Newsom’s movie Miss Representation, which shows “the media’s limited and often disparaging portrayals of women and girls, which make it difficult for women … to feel powerful.”
“Disparaging”. Hold that thought while we listen to Dr. Jennifer Berman, Poise’s menopause and intimacy expert, describing mood swings. In the clip “What’s the DEAL with my moodswings”*, does she validate our experience and perhaps suggest that our emotions might be valuable indicators of our experience? Does she acknowledge the virtually universal need of women at this stage to retreat (I would venture to say the developmental milestone in the female psyche to withdraw and self-reflect), and then acknowledge how at odds with our externally driven, production oriented culture this urge is? Perhaps she suggests that THAT might be the reason WHY our moods are swinging – that our emotions are accurately reflecting the environmental imbalance of the whole paradigm? Wouldn’t it be the moment for Poise, and all those interested in empowering women, to ask this crucial question: why are we making menopause all about what’s wrong with us?
Here’s what the good doctor says: “Moodswings are very common during the perimenopause and menopause. Women will describe symptoms of feeling more irritable and short fused, more weepy and depressed, more (uh) anxious and sort of, (uh) difficulty concentrating …and that’s very common during perimenopause, and it tends to level out, to some degree, as women approach menopause.”
Firstly, is it just me or is her tone patronizing? Is she explaining anything new here and offering solutions as promised? Is she even answering the question: “What’s the DEAL with my moodswings”?!
Now of course I see what a masterful campaign Poise have created here. They’ve captured an untapped market, have obviously paid close attention to the terms used by women in their focus group and have echoed the aspirations of menopausal women to save us from our Symptoms.
How much more interesting would it be if they used the global reach and collective power of the internet to invite us to create new language and ways to define our midlife experience that go beyond complaining about hot flashes (see “personal stories” on the site)? Ladies, instead of letting them reduce our experience to managing our symptoms, let’s demand inspiring stories about how we are stepping into the second half of our lives with the Mojo that comes from accessing our collective wisdom, our wizened humor and our well-earned self-respect. Now that’s a branding campaign worth following.
The other day a Huffington Post article crossed my desk, titled, “Gift Guide 2012: What To Get The Menopausal Women In Your Life.” According to this article, here are some of the things menopausal women (read: perimenopausal women) might want this December:
- Coldfront cooling palm packs (to relieve sweaty palms)
- A personal desk fan (for those hot flashes at work)
- A “menopause gift basket” filled with healthy treats and goodies, maybe also including vitamins, and alternative remedies for relief, “to stabilize mood and help the body adjust to hormonal changes.”
- A Feel Cooler Cooling Mattress Pad or Cooling Pillow that interacts with your nightly body temperatures to cool you down (for night sweats)
- Cool Sensations Moisture Wicking Bed Sheets (reportedly for those floods of night sweats you might get)
- Hot Girls Pearls – cooling beads to wear around your neck (for hot flashes) – apparently these have even made it onto Oprah’s Show
- Tickets to Menopause the Musical
- Sweat-wicking pajamas (there are lots of different brands, again to deal with night sweats)
Clearly the theme here is that menopausal women get hot and need relief. Fair enough, for many menopausal women this would be true. But this list got me thinking: what might I add to this list? Here are some I thought of:
- Humorous gifts, such as books of jokes about menopause and aging?
- Books about menopause
- Cookbooks that specialize in natural eating?
- A yoga gift certificate? Or other exercise certificate?
I’d love to hear from readers about other ideas for menopause-related holiday gifts.
Then I got to thinking again: If my daughter had reached menarche already, what kinds of holiday gifts could I get her that relate to her life stage? Here are some of the ideas I thought of, and I definitely need help from readers to expand this list:
- Pretty reusable (washable) maxi pads (e.g., Lunapads)
- A cool bag to carry maxi-pads around in
- A cool tampon case (like the ones that Uncommon Goods sells)
- Cool new (extra) underwear
- A special calendar for her to use to track her periods
- New Moon Girls’ magazine (or just an online membership to New Moon Girls)
- The book, Our Bodies Ourselves, or other books on puberty and menstruation
So, readers, what else belongs on this list? Those of you already buying for Hannukah and Christmas might have some great ideas…..please chime in!
The highlight of last week’s meeting of the North American Menopause Society (NAMS) meeting was a presentation of the primary results of the KEEPS study (Kronos Early Estrogen Prevention Study). A press release describing the findings, along with a list of FAQ (frequently asked questions), is available on the Kronos website. KEEPS was designed to confirm the critical timing hypothesis by looking at the use of menopausal hormone therapy in healthy women who were 6-36 months from their last menstrual period. Primary outcomes were progression of two atherosclerosis markers: carotid artery wall thickness (cIMT) and coronary artery calcification (CAC). In both cases, there were no statistically significant differences among the three groups (two hormone therapy formulations and a placebo group). The study failed to meet the stated goals by the stated criteria. Medical and popular coverage of these preliminary, non-peer-reviewed results have been almost uniformly positive, advocating renewed use of estrogen as menopausal therapy to women, provided they are young and healthy.
The timing hypothesis1 was born out of the collective cognitive dissonance following the unexpected findings of the Women’s Health Initiative, which failed to confirm the widespread belief that menopausal hormone therapy (specifically, estrogen) would protect menopausal women from cardiovascular disease.
The birth of KEEPS
Soon after the results of the Women’s Health Initiative were published, the discredited idea of menopausal hormone therapy for the prevention of cardiovascular disease was resurrected in the form of the critical timing hypothesis. In 2005, the KEEPS study was launched with much fanfare in the popular press and the medical literature. The lead editorial2 in the journal Climacteric heralded it as a move “[t]owards safer women, safer doses, safer routes and safer timing of administration of safer menopausal therapies,” and the journal invited an article describing the study design3.
KEEPS is a “prospective, randomized, controlled trial designed, using findings from basic science studies, to test the hypothesis that MHT when initiated early in menopause reduces progression of atherosclerosis. KEEPS participants are younger, healthier, and within 3 years of menopause thus matching more closely demographics of women in prior observational and epidemiological studies than women in the Women’s Health Initiative hormone trials. KEEPS will provide information relevant to the critical timing hypothesis for MHT use in reducing risk for CVD.”4 The target sample size was 450 women completing the study, with a goal of at least 150 women in each arm. The recruitment goal was 720 women.
Rather than using the synthetic hormones (conjugated equine estrogen, CEE and medroxyprogesterone acetate, MPA) from the WHI, KEEPS included more “natural” hormonal products, comparing oral conjugated equine estrogen (o-CEE, derived from pregnant mares’ urine, and taken as a pill – Premarin, 0.45 mg) with transdermal estradiol (t-E2, taken by patch – Climara, 50 mcg). Estrogen taken alone causes endometrial cancer; KEEPS added oral micronized progesterone (OMP, 200 mg for 12 days per month), which is identical to the human hormone molecule.
The three arms were:
- PLACEBO – placebo pill, placebo patch, placebo OMP
- o-CEE + OMP – active pill, placebo patch, active OMP
- t-E2 + OMP – placebo pill, active patch, active OMP
The purpose of KEEPS was to test the critical timing hypothesis, that is, to answer the question:
Does estrogen therapy, when administered during the critical timing period, protect women from cardiovascular decline?
A study of this size and duration in healthy young(er) women cannot hope to address clinical outcomes, such as stroke, heart attack and the like. Therefore the study had two surrogate markers of atherosclerosis (a part of cardiovascular health) as primary outcomes:
- Rate of change in the thickness of the wall of the carotid artery (CIMT)
- Amount of arterial calcification of the coronary artery (CAC)
Both measures have strong evidence linking them to future cardiovascular disease.
Recruitment and Retention 4, 5
KEEPS met recruitment targets (727 randomized women at 8 centres) and exceeded retention targets (466 women completed all 4 years of the trial, and an additional 118 women discontinued study medication but continued to be followed for 4 years).
Hallmark greeting cards and related trinkets have long exemplified wholesome, up-tempo, Norman Rockwell-styled sentimentality, often packaged in clichéd verses and trite images of puppies, kittens, flowers, babies, sunsets and other references guaranteed to elicit a smile, a tear, or a warm glow. However, as rude humor has spread its influence, expressed most vividly and viciously in celebrity roasts and the Comedy Central show, Tosh .0, Hallmark was not to be left behind. A visit to the racks of cards, books, and novelties at your local card shop reveals a wide variety of snarky items offering cheap shots at a wide variety of groups, hobbies, and practices.
Among them are several items that attempt to poke fun at what are thought to be characteristics of women in some stage of the menstrual cycle, notably PMS or menopause. Setting aside the fact that the items perpetuate the common misuse of the term menopause when what is meant is perimenopause, consider a small book presently on sale titled, Not Guilty by Reason of Menopause.
It is comprised of more than 50 pages, organized in double-page spreads, each of which offers a completion to the phrase, “You might be menopausal if. . .”
A few examples will suffice:
“. . . you think about the ‘til death do us part line in your wedding vows a little too often.”
“. . . you tell all your children they’re not your favorite.”
“. . . when your husband proposes a romantic vacation, you suggest ice fishing.”
Collectively, it amounts to an anthology of mean-spirited nastiness with little redeeming humor. Women are depicted as crazy, stupid, vicious, obese, and every other negative stereotype imaginable.
And with each insult women are expected to smile sweetly at being the butt of a bad joke. Of course, to express outrage or even mild annoyance with these sorts of put-downs is to risk of being accused of lacking a sense of humor or, worse yet, of being “politically correct,” the favored dismissive term of those who demand that their repugnant values are somehow benign or lacking in impact or intent.
We’ve come a long way from the days of 1910 when Hallmark was founded and especially from 1944 when the company adopted the slogan that is still theirs today, “When you care enough to send the very best.” In this case one might ask, “The very best of what?”