📚 Everything You Need to Know About the Menopause

There are some things that happen in life that people don’t talk about, despite the commonality of the experience. Recently, a group of my online friends started discussing their, and their partners’, experience of the menopause. One person shared with the group, and all of a sudden the stories came pouring out. I knew the basics, but I didn’t realise how much of a difficult — and sometimes devastating — experience it could be.

My wife and I are both 45 so it felt like a good time to learn a lot more about it. Kate Muir’s book, Everything You Need to Know About the Menopause (but were too afraid to ask) is an excellent place to start.

The key points I took from the book were:

Dealing with the effects of the menopause over a long period of time is a relatively recent phenomenon. In the Victorian era in the UK, people used to die at the average age of 59. With average life expectancy now extended by thirty years, women have to live in a post-menopausal state for much longer.
There is nowhere near enough education about the menopause. We learn about puberty at school but not about what happens to half of the population in later life. Given how reluctant people are to talk about it, access to information can be difficult.

The divide between those who have menopause support and knowledge and those left to suffer is massive.

More worryingly, the lack of education also extends to the medical profession. The book contains horrific stories of undiagnosed and misdiagnosed patients, including the case of one woman ultimately being given electroshock therapy after being diagnosed with ‘treatment-resistant depression’. It turned out that her symptoms were caused by hormone deficiency:

Although the menopause will happen to every woman in the world, and has massive health consequences, according to a Menopause Support investigation, 41 per cent of UK medical schools do not give mandatory menopause education.

… in one study of around 3,000 British menopausal women, after complaining of the onset of low mood or anxiety, 66 per cent were offered antidepressants by their doctor instead of hormones.

Some good news is that there is freely-accessible information out there for medical professionals, for example this 90-minute video from Dr Louise Newson on assessing perimenopausal and menopausal women, and safely prescribing HRT during remote consultations:

Menopause leads to other major health issues — osteoporosis (brittle and fragile bones), Alzheimer’s (dementia) and heart disease. There are some things you can do to combat a reduction in bone density, such as high-impact exercise, but on their own they are not as effective as when they are combined with Hormone Replacement Therapy (HRT). Using body-identical transdermal estrogen after the age of 50 halves a woman’s chances of breaking a hip and reduces her chances of having a heart attack.
A Women’s Health Initiative study in 2002 made people extremely wary of HRT. It turns out that there are different types of treatment; compounded ‘bioidentical’ tablets are awful as there is no reliable way to know what they contain, whereas body-identical hormone cream does not carry the same risks:

We need to question the conventional wisdom, which says that HRT causes breast cancer and that the risks of taking HRT outweigh the benefits. What most people – including me, until I began my investigation – think they know about HRT is wrong on two counts: every form of HRT is not the same, and the terrifying cancer-scare headlines which erupted with the Women’s Health Initiative Study back in 2002 refer to the older, synthetic forms of HRT that have now been superseded by a completely different products.

The bad news: In the general population, 23 cases of breast cancer will be diagnosed per 1,000 women. If women take the old, synthetic HRT, an additional 4 cases appear. If women drink a large glass of wine every day, an additional 5 cases appear. If women are obese (BMI over 30), an additional 24 cases appear. The good news: If women take 2.5 hours of moderate exercise per week, 7 cases disappear. If women take estrogen-only HRT, 4 cases disappear.

The experience of the menopause is yet another burden for women that can hold them back in their careers. It typically turns up at a time when they already have a lot on their plates, trying to sustain a career whilst dealing with moody teenagers and ageing parents. Hot flushes can be debilitating. Thanks to reports on COVID-19 we have heard a lot about ‘brain fog’; unfortunately this is another symptom of the menopause:

When scientists ask menopausal women about their symptoms, 80 per cent report hot flushes, 77 per cent report joint pain, and 60 per cent memory issues. Aside from these three, further plagues of the menopause include: heart palpitations, sleeplessness, anxiety, depression, headaches, panic attacks, exhaustion, irritability, muscle pain, night sweats, loss of libido, vaginal dryness, body odour, brittle nails, dry mouth, digestive problems, gum disease, dry skin, hair loss, poor concentration, weight gain, dizzy spells, stress incontinence – and last but not least, something that might be from a horror movie: formication, which means an itchy feeling under the skin, like ants. I had that. Quite simply, the majority of women battle through the menopause, and only a lucky few are symptom-free.

Suicide is at its highest for women aged 45–49, and at its second highest in the 50–54 age group.
Some women have to deal with menopause much earlier in their lives than they would otherwise expect. Early onset menopause, and medical menopause (i.e. following a medical procedure), can both be extremely traumatic. One in 40 women experience the menopause before they turn 40.
Women actually produce more testosterone than estrogen. According to menopause experts, testosterone is an essential hormone that should be replaced and yet it is not officially prescribed ‘on licence’ on the UK National Health Service as part of HRT. It shouldn’t be considered a ‘lifestyle drug’ just used to enhance a person’s libido, but “a life-saving hormone that will preserve [women’s] brains, bodies and long-term health.” It enhances “cognition, muscle, mode, bone density and energy.”
There is a ‘window of opportunity’ at the start of the menopause to begin estrogen replacement which reduces the chances of dementia and Alzheimer’s.
However, promising research is growing on older women starting HRT a decade or more after the menopause.
There is a small group of oncologists are looking at prescribing HRT to breast cancer survivors following a good recovery, used in conjunction with anti-cancer drugs such as tamoxifen. It may be that in some cases, the quality of a person’s life post-menopause outweighs the risks.

The book is a must-read. It has increased my knowledge from next-to-nothing to a broad, general understanding of something that half of the people around me will go through at some point in their lives. I’ve bought a second copy to be left in our book-swap rack at my office.

Exercise or sleep?

It was a struggle today. I only managed just over four hours’ sleep last night. I was up just very early this morning in order to fit my indoor bike trainer session in before an early work meeting.

I’m very surprised it was as high as 67%!

I had planned to go to bed earlier, but we have a young teenager who has just moved into the ‘not tired at night’ phase and it doesn’t yet feel right to leave him to shut down the house while we ascend the wooden hill.

Due to the lockdown I am missing the hour of walking that used to be part of my daily commute to and from the office, so since March I’ve been prioritising exercise on most days. I enjoy exercise for its own sake, but it’s also motivating that there are numerous articles about how desk-based jobs are literally killing us:

Both the total volume of sedentary time and its accrual in prolonged, uninterrupted bouts are associated with all-cause mortality, suggesting that physical activity guidelines should target reducing and interrupting sedentary time to reduce risk for death.

But…other research says that lack of sleep may lead to Alzheimer’s disease in later life. I remember hearing how Margaret Thatcher got by on four hours’ sleep a night, making her the “best informed person in the room” according to her biographer; she suffered from dementia in her final years.

A wise man that once worked with me said “you can’t cheat the body”, and he’s right. But given the choice between exercising and sleeping, what’s the right balance to strike?

Are you still not going out?

Friends and family think I’m at best over-cautious, or at worst ridiculous. They don’t say it to me directly, but I sense it.

Most people I know seem to have returned to some kind of normality. Getting together indoors, going to pubs and restaurants, eating out, sharing trips in cars. These things crept back in gradually. People are fed up with keeping away from others and so badly want it all to be over. We stopped hearing about the people catching it, going to hospital with it, dying from it. It feels like the risks abated, and behaviour changed day by day.

Because I am not joining in, and continue to avoid any unnecessary face-to-face contact, I’m now very much an outlier. “Are you still not going out, Andrew?” “Life has to go on.”

I question my attitude all the time. I get drawn in. Perhaps I am being over-cautious, and need to get back to being social again. I’m certainly missing human contact and having any kind of a social life. But then I read a horror story about the long-term problems that some COVID survivors are trying to cope with, and it just reinforces my desire to keep away from everyone. It’s as if there is one version of events out there in the real world, and then people I know are gaslighting me.

COVID-19 has not been with us for very long, and every day there seems to be new stories about possible impacts on the human body, or new developments such as being able to catch the virus more than once. Even if the long-term impacts are mild, I am happy to make sacrifices to avoid them. From the New York Times:

“In meetings, “I can’t find words,” said Mr. Reagan, who has now taken a leave. “I feel like I sound like an idiot.””

I remember one December where I had to run a workshop after a big night out of festive drinking. My hangover manifested itself in that I was unable to string sentences together properly. Something had altered in my brain, albeit temporarily, and it was torture. As I spoke, it was as though I had a separate inner dialogue that was asking me “Where is this sentence going?”, and I didn’t know. The thought of being stuck like that permanently fills me with dread.

The film Awakenings (1990) with Robert De Niro and Robin Williams has always fascinated me. Based on a book by neurologist Oliver Sacks, it depicts people who had become victims of the encephalitis lethargica epidemic of the 1920s. From Wikipedia:

The disease attacks the brain, leaving some victims in a statue-like condition, speechless and motionless. Between 1915 and 1926, an epidemic of encephalitis lethargica spread around the world. Nearly five million people were affected, a third of whom died in the acute stages. Many of those who survived never returned to their pre-morbid vigour.

The book and/or the film draws a link between the influenza pandemic of 1918 and the subsequent encephalitis lethargica pandemic that followed. My understanding is that there is no irrefutable evidence that the first pandemic caused the second one, but this continues to be the subject of scientific debate.

Curious, I searched the web for “encephalitis lethargica” and “COVID” and found that (of course) I am not the only one to be thinking about this. Some examples:

US National Library of Medicine: From encephalitis lethargica to COVID-19: Is there another epidemic ahead?

The above characteristics can be indicative of the ability of coronaviruses to produce persistent neurological lesions. Acute COVID-19-related encephalitis, along with the potentially long-term worrying consequences of the disease, underscore the need for clinicians to pay attention to the suspected cases of encephalitis in this regard.

The Lancet: COVID-19: can we learn from encephalitis lethargica?

We should take advantage of both historical and novel evidence. The prevalence of anosmia, combined with the neuroinvasive properties of coronaviruses, might support neuroinvasion by SARS-CoV-2. Whether the infection might trigger neurodegeneration, starting in the olfactory bulb, in predisposed patients is unknown. We should not underestimate the potential long-term neurological sequelae of this novel coronavirus.

NHS University College London Hospitals: Increase in delirium, rare brain inflammation and stroke linked to COVID-19

“We should be vigilant and look out for these complications in people who have had COVID-19. Whether we will see an epidemic on a large scale of brain damage linked to the pandemic – perhaps similar to the encephalitis lethargica outbreak in the 1920s and 1930s after the 1918 influenza pandemic – remains to be seen.”

The Conversation: How coronavirus affects the brain

Encephalitis and sleeping sickness had been linked to previous influenza outbreaks between the 1580s to 1890s. But the 20th-century epidemic of encephalitis lethargica started in 1915, before the influenza pandemic, and continued into the 1930s, so a direct link between the two has remained difficult to prove.

In those who died, postmortems revealed a pattern of inflammation in the seat of the brain (known as the brainstem). Some patients who had damage to areas of the brain involved in movement were locked in their bodies, unable to move for decades (post-encephalitic Parkinsonism), and were only “awakened” by treatment with L-Dopa (a chemical that naturally occurs in the body) by Oliver Sacks in the 1960s. It is too early to tell if we will see a similar outbreak associated with the COVID-19 pandemic, though early reports of encephalitis in COVID-19 have shown features similar to those in encephalitis lethargica.

The aftermath of this global event has many lessons for us now in the time of COVID-19. One, of course, is that we may see widespread brain damage following this viral pandemic.

I’m not sure when I’ll be at the stage where I feel comfortable visiting friends at their houses, sharing car journeys, or meeting up in pubs or restaurants. I doubt that there is a rigorous logical set of conditions that would need to be specifically met before I start doing those things again. I’ll know it when I feel it. Perhaps this stuff is just different for everyone based on their perception of risk versus their need to socialise to maintain a quality of life and good mental health. Perhaps part of it is that I am lucky to have a job that I can do from home so my need to venture out is minimal. Perhaps my interest in politics over the past few years has made me much more deeply distrustful of our government and their response to the pandemic than many other people. Eight months in, the novelty of being at home all the time has worn off, but I’m still ok to keep hunkering down for now.

It’s all relative

On my walk with the boys on Monday night we had a great ‘ramble chat’ that covered a vast range of topics. It was so lovely to hear them ask questions and respond to each other on how they interpreted the world. We got to talking about my work and I told them that my team had been tackling a problem of helping staff in different cities to have a faster connection to each other, but that there is a natural limit to how fast this can be. We talked about computer networks, the speed of light, and relativity. I gave them my understanding that time isn’t a thing that just exists on its own; it is related to space, and that time is perceived to be (or is?) slower for things that move faster. We watch a lot of Star Trek together and my youngest boy pointed out the connection where various fictional spaceships have ‘slingshotted’ around the Sun in order to gain enough speed to travel through time. I told them about the experiments where very accurate clocks were flown around in aircraft and got out of sync with the same clocks on the ground.

Back in the world of fact, it got me thinking about how much relativity really has an impact on everyday life. I wondered if going on lots of international business trips kept you younger, for example.

I had read before that GPS satellites have had to be designed to take relativity into account:

…the relativistic offset in the rates of the satellite clocks is so large that, if left uncompensated, it would cause navigational errors that accumulate faster than 10 km per day! GPS accounts for relativity by electronically adjusting the rates of the satellite clocks, and by building mathematical corrections into the computer chips which solve for the user’s location. Without the proper application of relativity, GPS would fail in its navigational functions within about 2 minutes.

So much for satellites that are moving at 14,000km/hr in orbits 20,000km above the Earth. What about people?

This article explains the impact on someone that travels around a lot at relatively high speed to the rest of us:

For this example we will look at an airline pilot. For simplicity let’s say that our pilot spends his or her whole career on the Atlantic route, flying (on average) 25 hours a week for 40 years at an average speed of 550 mph (880 km/h). This is undoubtedly a lot of “high” speed travelling but how much time will our pilot “save” due to time dilation?
…
… in a lifetime of flying our airline pilot saves a total of 0.000056 seconds as compared to an external observer.

Not much to be concerned about, but that number of 0.000056 seconds (56 microseconds) still seems big in that there are things in the real world that are that long. It’s roughly the same as the cycle time for the highest human-audible tone (20 kHz), or the read access latency for a modern solid-state computer drive which holds non-volatile computer data.