Menopause’s impact on women’s lives and adherence to treatment during the peri- and post-menopausal period
- When symptomatic, menopause can have a profound impact on multiple aspects of a woman’s life, including work3, family life, and sex life4, among others.
- Adherence to treatments for menopausal syndrome and other diseases during the peri- and post-menopausal period is crucial to women’s health outcomes.11-14
Menopause syndrome can impact quality of life
All women experience menopause. While the age that menopause occurs can vary significantly from one person to the next, in most women menopause occurs between 45-52 years1. Symptoms typically last 10 years or more.19 This topic is often considered a taboo7 and is seldom discussed openly, but the impact of menopause on both individuals and society is significant. While some women experience minimal changes during this phase, one study found that up to 90% suffer symptoms at some point during the menopausal transition, and approximately half of this percentage consider their symptoms to be bothersome.2 Post-menopausal syndrome has significant implications for women’s quality of life and productivity.20
Post-menopausal symptoms can vary both in duration19 and intensity20. The most common physical symptoms—such as sudden hot flushes, headaches, and sweating—may be accompanied by psychological effects, such as depression, anxiety, sleep deprivation (and, consequently, longer-term fatigue), and cognitive impairment20. Symptoms and medication side effects5 can have a significant effect on various domains of the woman’s life: work3, family, sex life4, and medication adherence.5
Menopause and work
Menopause symptoms can be distressing as they occur at a time when women have important roles in society and at the workplace.20 But the taboo7 surrounding the subject and the isolation that menopausal women might feel as they experience bothersome symptoms may put a hard end to their career and other aspirations. Studies show that specific symptoms, such as hot flushes, may push women to consider leaving the labor force.3 This not only keeps women from advancing in their careers, but it also exacerbates the negative thoughts that women can have about themselves during menopause transition, which can further contribute to depression and anxiety. A former c-level executive who experienced severe symptoms of menopause said, “Moderating that high-profile panel, in front of 200 industry experts, should have been a career highlight. It was a disaster.”6 Another woman testified about menopausal syndrome impact on her career, “Those years of confusion, self-doubt, and severe anxiety practically killed my entire career.”6
For many women, pursuing a career is extremely important; beyond a salary, it provides a sense of fulfillment and self-esteem and may also help prevent depression. Organizations can support their female employees’ careers by promoting dialogue regarding menopause symptoms. As one woman stated, “When I went through this, my initial fear of embarrassment stopped me from getting the support I needed. Finally, when it was too hard to continue pretending that nothing was amiss, I said in a 12- person meeting, ‘I’ll have to excuse myself for a few minutes. I’m having a hot flush and need a break.’ In that moment, I felt powerful, self-assured, and relieved.”6
Aside from the workplace, menopause can affect a woman’s family life. Increased anxiety and fatigue due to menopause can make women more irritable, which can in turn affect their behavior and relationships with close family members during a crucial life phase. Women in their 50s often have to deal with parents’ ill-health or passing, children leaving (or not leaving) home8, etc. As in the workplace, discussing and helping family members and friends to understand women’s menopausal experiences is key to healthy family relationships.
A woman’s sex life can also be affected by menopause. Hormonal changes may lead to sexual dysfunction and a decrease in sexual desire. Furthermore, sleep deprivation and emotional changes may lead to stress and irritability, which can further influence sexual behavior.9
Several types of treatment to relieve post-menopausal symptoms exist, but they must be prescribed, and most importantly, adhered to. For example, the previous article in this series describes cognitive behavioral therapy (CBT), a method that can relieve menopause symptoms. Care management plans that involve CBT may be helpful for many women.21
Menopause’s impact on medication adherence
Medication adherence is defined as “the degree to which the person’s behavior corresponds with the agreed recommendations from a health care provider.” Medication adherence has three components, commonly referred to as fulfilment, persistence, and compliance:
- Fulfilment10,17 means that the patient has received the medicines prescribed by the doctor.
- Persistence10,18 means that the patient has consumed the medicines over the initially intended duration.
- Compliance10,18 means that the patient follows the intended timing, dosage and indications for the medication.
In the case of menopause, medication adherence can be considered from two different angles:
- Adherence to treatments for other diseases during menopause transition and the postmenopausal period
- Adherence to medications for symptoms during menopause transition and in the postmenopausal period Research on post-menopausal women suggests that they are likely not to be adherent to treatment.
- One study found that severity of post-menopausal symptoms makes women less likely to adhere to highly active antiretroviral therapy (HAART).11, 12 Another study concluded that post-menopausal symptoms also negatively impacted medication adherence among breast cancer survivors.13 These higher rates of non-adherence for women experiencing post-menopausal symptoms can be explained by several factors. As stated earlier, post-menopause symptoms can lead, among other outcomes, to psychological disorders such as depression, which in turn negatively affect adherence.14 Therefore, dealing with the psychological health of women suffering from menopausal symptoms is crucial to preserving women’s health. Due to the aforementioned social taboo against discussing menopause, women often hesitate to seek treatment for their symptoms, which presents the first challenge to medication adherence. According to a survey in 5 European countries of postmenopausal women, up to 90% reported having experienced symptoms at some point during the menopausal transition, with approximately half of them considering their symptoms bothersome2. The proportion of women discontinuing the originally prescribed hormone regimen at 1 year was (31, 45,6% depending on the regimen).*5 Therefore, educating women on menopause therapy is the first major step toward better adherence and health outcomes. Doctors play a crucial role in this, as they are often the only people with whom women are comfortable talking about menopausal symptoms. Extended medical consultation promotes better compliance by addressing patients’ fears15 in other words, the more time a doctor spends with a patient, the better her or his medication adherence. Given the general tendency to overestimate their patients’ adherence16, physicians can assist their patients with the menopause transition by promoting discussion around treatment adherence. Different methods for assessing patient adherence is the topic for future articles in this series. Doctors should take a more active role in influencing their patients’ behavior and helping them to overcome the fear, anxiety, and depression that can result from menopausal symptoms. Aside from doctors, co-workers and family are equally important in providing support to menopausal women by encouraging them to talk about their symptoms, seeking medical advice and potentially beginning a therapy. Upcoming articles take a behavioral science perspective to analyze menopausal women’s behaviors and review frameworks that can help understand and improve treatment adherence.
* Based on an indirect calculation where proportion of adherence to continuous combined therapy users was (68.9%, 62/90) and sequential therapy users was (54.4%, 62/114)
A holistic perspective on the menopause transition to improve the patients’ experience
To systems of thinking: Why do rational people make irrational choices, and how can the answer help us better understand menopause?
- Johnson A, Roberts L, Elkins G. Complementary and alternative medicine for menopause. Journal of Evidence-Based Integrative Medicine; 2019;24:2515690X19829380.
- Constantine GD et al. Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries. Post Reprod Health, 2016; 22(3):112-122.
- Hardy C, Thorne E, Griffiths A, & Hunter M. Work outcomes in midlife women: The impact of menopause, work stress and working environment. Women’s Midlife Health; 2018; 4.
- Nappi RE, Nijland EA. Women’s perception of sexuality around the menopause: outcomes of a European telephone survey. Eur J Obstet Gynecol Reprod Biol. 2008;137(1):10-16.
- Hill DA, Weiss NS, LaCroix AZ. Adherence to postmenopausal hormone therapy during the year after the initial prescription: A population-based study. Am J Obstet Gynecol. 2000;182(2):270-276.
- Patterson J. It’s time to start talking about menopause at work. February 2020. Accessed August 19, 2020. https://hbr.org/2020/02/its-time-to-start-talking-about-menopause-at- work
- British Medical Association, Challenging the culture on menopause for working doctors, https://www.bma.org.uk/media/2913/bma-challenging-the-culture-on-menopause-for- working-doctors-reportaug-2020.pdf, Published on August 5, 2020, Accessed August 25, 2020.
- Hunter M, Smith M, in collaboration with the British Menopause Society. Cognitive behaviour therapy (CBT) for menopausal symptoms: Information for GPs and health professionals. Post Reprod Health. 2017;23(2):83–84.
- U.S. Department of Health and Human Services. Menopause and sexuality Women’s Health website. https://www.womenshealth.gov/menopause/menopause-and-sexuality, Accessed August 19, 2020.
- Jimmy B, & Jimmy J. Patient medication adherence: Measures in daily practice. Oman Medical Journal; 2011; 26(3): 155-9.
- Cutimanco-Pacheco V, Arriola-Montenegro J, Mezones-Holguin E, Niño-Garcia R, Bonifacio- Morales N, Lucchetti-Rodríguez A, Ticona-Chávez E, Blümel JE, Pérez-López FR, & Chedraui, P. Menopausal symptoms are associated with non-adherence to highly active antiretroviral therapy in human immunodeficiency virus-infected middle-aged women. Climacteric; 2020; 23(3): 229-236.
- DuffPK,MoneyDM,OgilvieGS,etal.Severemenopausalsymptomsassociatedwithreduced adherence to antiretroviral therapy among perimenopausal and menopausal women living with HIV in Metro Vancouver. Menopause; 2018; 25(5): 531-537.
- MillerL.Menopausesymptomsaffecttreatmentadherenceinbreastcancersurvivors.Cure Today website. https://www.curetoday.com/articles/menopause-symptoms-affect-treatment- adherence-in-breast-cancer-survivors, December 10, 2016, Accessed August 19, 2020.
- DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med; 2000; 160(14): 2101-2107.
- FistonicI,FranicD,PopicJ,etal.Adherencewithhormonereplacementtherapyin menopause. Climacteric; 2010; 13(6): 570-577.
- Heeb RM, Kreuzberg V and Grossmann V et al. Physicians’ assessment of medication adherence: A systematic review. J Pharma Care Health Sys; 2019; 6(1).
- AbhijitS.Gadkari&ColleenA.McHorney(2010)Medicationnonfulfillmentratesand reasons: narrative systematic review, Current Medical Research and Opinion, 26:3, 683-705
- Cramer JA, Roy A, Burrell A, et al. Medication compliance and persistence: terminology and definitions. Value Health. 2008;11(1):44-47.
- DalalPK,AgarwalM.Postmenopausalsyndrome.IndianJPsychiatry.2015;57(Suppl2):S222- S232.
- Monteleone P, Mascagni G, Giannini A, Genazzani AR, Simoncini T. Symptoms of menopause—global prevalence, physiology and implications. Nature Reviews Endocrinology. 2018 14(4):199 -215.
- Hunter M, Rendall M. Bio-psycho-socio-cultural perspectives on menopause. Best Pract Res Clin Obstet Gynaecol. 2007;21(2): 261–274.