Menopause

Menopause is the point in time exactly twelve months after a female has had her last menstrual period, or shedding of the lining of the uterus. As a female ages, the hormone levels that drive menstruation decrease, beginning the process of perimenopause, which eventually leads to menopause and can result in various symptoms including depression, difficulty sleeping, and hot flashes, or abrupt feelings of heat typically in the upper body. Once a female reaches menopause, those symptoms typically subside, but after menopause, the risk of other health conditions such as osteoporosis, or brittle bones, increases. At least since the fourth century BCE, researchers understood that menopause occurred in females but held many negative ideas and misconceptions about the process, which resulted in stigma that left females uninformed about what happened to their bodies as they aged. Research on and perceptions towards menopause evolved over the twentieth century, and as of 2024, researchers understand it as a typical part of aging and development in females, marking the end of their reproductive years.

1. Historical Perceptions of Menopause
2. Developing Hormone Treatments for Menopause
3. Stigma Regarding Menopause
4. Modern Understandings of Menopause
5. Impacts and Controversy Regarding Menopause

Historical Perceptions of Menopause

Colloquially, people use the term menopause to refer to the process or period of time when a female is reaching the last menstrual period of their life. However, the National Institute on Aging defines menopause as the moment in a female’s life twelve months after she has had her last menstrual period. This article will use the definition of menopause that the National Institute on Aging provides.

The general understanding of menopause as the ceasing of a female’s menstrual period dates back to the fourth century BCE, though people disagreed about the age at which it occurred. Aristotle, a philosopher and scientist from ancient Greece, acknowledged that menstruation ceased around the age of forty, and he associated that cessation with the end of fertility. From the fourth century BCE to the seventh century CE, various other philosophers and scientists noted the fluctuating age of females who experience menopause, which was typically between thirty-five to sixty years of age. However, other philosophers, such as Diocles, who studied medicine in Greece, claimed that all females experience menopause at age sixty.

From the fourth century BCE into the early mid-nineteenth century CE, physicians subscribed to the idea of the four humors and the importance of maintaining balanced body fluids, which eventually influenced their treatments for menopause. In the fifth to fourth century BCE, Hippocrates, a philosopher and physician on the island of Kos, Greece, developed the theory of the four humors, which aimed to explain disease. Essentially, according to Hippocrates, there are four humors in the body, blood, phlegm, black bile, and yellow bile, which related to the four elements of air, water, earth, and fire, respectively. Each humor correlated with an organ, such as the brain, lung, spleen, and gall bladder. Hippocrates thought that illness indicated an imbalance in one of the four humors and argued that physicians could only relieve illnesses by restoring the balance through methods such as bloodletting. Therefore, bloodletting became a prevalent treatment method that aimed to get rid of fluids that physicians perceived were causing illness.

In the sixteenth century, the idea of purging bodily fluids largely influenced physicians’ understanding of menopause, and they began writing about their understanding of the process in more detail. For example, in 1563, Giovanni Marinello, a physician from Italy, released a book claiming that as soon as a female stopped menstruating, they immediately fell ill with various symptoms, such as vomiting, frequent nose bleeds, or eye disorders. According to Marinello and other physicians and writers at the time, all females accumulated diseased blood in their bodies that was so dangerous that the body needed to purge it through menstruation to survive. Consequently, researchers thought the idea of menopause and the resulting accumulation of diseased blood was detrimental for females. However, in 1582, Jean Liébault, a researcher who studied ideas of female health in France, argued that blood during menstruation was simply pure, natural blood, and that the blood itself did not result in harm. Around the late sixteenth century, most physicians began rejecting the idea that blood during menstruation was poisonous and needed purging.

In the eighteenth and nineteenth centuries, medical and biological investigation increased as researchers began to ask more questions about how the body works, leading to new hypotheses regarding the causes of menopause, such as insufficient blood flow. In 1777, John Leake, a physician from England, published a book titled Chronic or Slow Diseases Peculiar to Women that had a section attempting to explain the reason menstruation stops as females age. In it, Leake states that menopause occurs because when females age, the blood vessels in their uterus, the organ where a fetus develops, no longer have enough force to pump out blood, permanently halting their ability to menstruate. As of 2024, researchers recognize that menstruation occurs when the lining of the uterus sheds, causing an expulsion of blood and tissue. However, Leake and other researchers in the eighteenth and nineteenth centuries may have understood menstruation as a part of the body’s circulatory process, ultimately impacting their perceptions of the causes of menopause. In 1628, William Harvey, a physician who studied anatomy from England, became one of the first to explain that blood moves throughout the entire body in one direction and returns to the heart, an idea that researchers still understand to be true as of 2024. According to Wulf H. Utian, a physician who researches female health and menopause, Leake used ideas from Harvey’s research on blood circulation to inform his hypothesis about the causes of menopause. Despite researchers’ inaccurate understanding of menstruation and menopause at the time, observations on the symptoms of menopause continued into the nineteenth century.

In the early nineteenth century, Charles-Pierre-Louis de Gardanne, a physician from France, gave menopause its name, unifying the language researchers used when discussing and studying the topic. In 1821, de Gardanne wrote a book titled De la ménopause, ou de l’âge critique des femmes (On Menopause, or the Critical Age of Women). In it, he coined the term menopause, which is, as of 2024, what researchers and physicians refer to the permanent cessation of menstrual periods. Menopause comes from the Greek words men (month) and pausis (cessation). Gardanne explains in his book that he coined the term menopause to unify the language that writers have used to describe it, and to prevent confusion among physicians and their patients. He justifies his actions by stating that researchers and physicians throughout time referred to menopause using many different names, such as the critical age, women’s inferno, and the middle age decline. According to Christine Théré, a researcher from France who studies gender and sexuality, many of the names used in history applied to both sexes, rather than being specific to females, and Gardanne was likely aware of that. Having a common name to refer to menopause allowed researchers to become more unified in their studies of menopause in the years that followed.

Developing Hormone Treatments for Menopause

Once researchers better understood the symptoms and had a more unified idea of menopause, they began investigating hormone therapies as treatments for it in the late nineteenth century, and one of those first therapies involved the ingestion of cow ovarian tissue. The ovaries are part of the female reproductive system and produce egg cells and hormones called estrogen and progesterone. During menopause, females’ estrogen levels drop, resulting in various menopausal symptoms. Estrogen is the sex hormone in female bodies that maintains the menstrual cycle and prepares the body for menstruation. One of the first instances of using estrogen to treat menopause occurred around 1886, by researcher Ferdinand Mainzer from Germany. He prescribed oral therapy of bovine ovarian tissue to treat females experiencing menopausal symptoms, such as the symptom of sexual dysfunction, which is when one is unable to experience satisfaction from sexual activity. The treatment method that Mainzer used decreased sexual dysfunction. Other researchers conducted similar treatments with the ovarian tissues of animals, and found that when females ingested those tissues, they also saw a reduction in sexual dysfunction. By 1890, pharmaceutical companies, such as Merck & Company, started selling powdered and pill forms of cow ovaries as an oral treatment for menopausal symptoms. As of 2024, researchers understand that ovarian tissues contain estrogen, which likely resulted in the ease of menopausal symptoms upon ingestion.

In the twentieth century, researchers learned to purify estrogen and develop synthetic forms of the hormone to treat menopausal symptoms. In 1923, Edgar Allen and Edward Doisey, researchers from St. Louis, Missouri, became two of the first to locate estrogen in the body, as well as isolate and purify it. Allen and Doisey’s work propelled research into hormone-based treatments. For example, in 1946, Hans Wiesbader and William Filler, physicians from New York City, New York, used lab-made, or synthetic, estradiol, a type of estrogen hormone, to treat menopausal females and found that it was successful in reducing various symptoms of menopause, such as hot flashes.

The development of estrogen-based treatments for menopausal symptoms increased rapidly in the mid-twentieth century and the late-twentieth century, largely because many physicians advocated for their use, including physician and author of Feminine Forever Robert A. Wilson. In 1966, Wilson published his book Feminine Forever, which advocated for the idea that menopause is a disease, or more specifically a deficiency disease, and that estrogen-based treatment could fix it. Wilson emphasized that estrogen treatment would get rid of all symptoms of menopause and prevent symptoms of aging, which increased the use of estrogen therapy amongst females. By the late twentieth century, Premarin, which was an estrogen treatment derived from the urine of pregnant horses, was one of the most prescribed treatments for menopausal symptoms.

Stigma Regarding Menopause

Despite developments in understandings of and treatments for menopause over time, there has been much stigma surrounding menopause, leaving aging females unsure about what was happening in their bodies and what they could do to help themselves through it. According to Michael Stolberg, a researcher from Germany who studies the history of medicine, one instance of such historical stigma is present in the 1776 edition of Aristotle’s Book of Problems, a text that Aristotle and other scientists, philosophers, and physicians wrote and compiled between the third century BCE and sixth century CE. Stolberg explains that in their book, Aristotle and his coauthors claim that females experiencing menopause are full of filth, and males should refrain from what they call using, or engaging in intercourse with, menopausal women. Consistently, opinions towards menstruation and menopause remained negative, and according to Stolberg, researchers in the sixteenth century even regarded it as dangerous. Some researchers and physicians during the sixteenth century claimed that menstrual blood could kill plants and insects and even cause rabies.

According to Utian, from the nineteenth to the twentieth centuries, researchers continued to connect menopause to females’ roles in society and described it as a negative event in their lives. Early researchers such as Marc Colombat de L’lsere, a physician from France, claimed in his 1845 article that because they can no longer reproduce, females in menopause no longer live for the human species, but instead live for themselves. Additionally, according to Utian, in the early 1900s, many people regarded menopause as a tragedy and thought that females experiencing it would have difficulty enjoying life and making a living. Stigma increased even further in the late 1900s, which caused menopausal females to pursue treatment, especially as Wilson spread strong support for hormone treatments. In his advocations, Wilson argued that hormone therapies made females experiencing menopause easier to live with and helped them make their partners happier. According to Marcianna Nosek and colleagues, a group of researchers and professors studying nursing and family and female health, the stigma that accumulated over the years made many females feel shameful about menopause, which resulted in a lack of knowledge regarding it.

Modern Understandings of Menopause

As of 2024, researchers and physicians separate menopause into three stages, which are perimenopause, menopause, and postmenopause. Perimenopause is the time of transition into menopause, typically during a women’s forties. Perimenopause typically results in fluctuating menstrual periods and often the start of perimenopausal symptoms, and it lasts between two and eight years. Twelve months after a female’s last menstrual period, they reach menopause. The average age of females experiencing menopause is fifty years old, however, that age varies from person to person and can even depend on genetic factors. Finally, once a female reaches menopause, researchers consider the time thereafter as postmenopause, which lasts for the rest of their lifetime.

Every person’s experience with menopause is different, which often results in a wide variety of symptoms and risks at differing times. The most common symptom, which can occur anytime from perimenopause to postmenopause, is hot flashes. Hot flashes can be either frequent and intense or occasional and mild. Thus, depending on their severity, they can interfere with day-to-day activities. There are many other symptoms that commonly occur during perimenopause, including sleep disturbances, mood changes, and weight gain, but those vary from person to person. During postmenopause, the risk of heart disease increases, along with the chance of osteoporosis, which typically occurs when the mineral levels in a person’s bones decreases. There are also higher chances of cancer in the ovaries, breasts, and uterus, as well as Alzheimer’s disease, which occurs when the connections in the brain regarding memory start to degrade, during postmenopause. Menopausal females can also experience vaginal atrophy, which is when the tissues of the vagina and urethra begin to dry and thin. Vaginal atrophy typically occurs during postmenopause, and it often causes general discomfort but can sometimes lead to other health issues, such as infections. In a study from 2005, researchers estimated that about eighty-five percent of postmenopausal females have had some symptoms associated with menopause. 

Menopause can occur naturally due to aging, but sometimes, various medical procedures and treatments, such as surgeries or anticancer treatments, can induce menopause. For example, if a person has a particular condition, such as ovarian cancer or ovarian cysts, physicians may surgically remove their ovaries. Ovaries produce estrogen, so removing them can trigger menopause in females. Surgically induced menopause can sometimes result in more severe symptoms or risks of menopause than in non-induced menopausal women. Females with surgically induced menopause can have higher risks of cancer, sexual dysfunction, and psychiatric disorders. Anticancer treatments can also induce menopause. For example, when an individual receives chemotherapy, which uses strong chemicals to prevent the spread of cancer, the medications and chemicals can attack the ovaries, which can cease menstruation for an extended period, resulting in temporary menopause. However, once someone stops chemotherapy, menstruation may begin again between eight months and two years later. Physicians have noted that females who underwent chemotherapy and continued to menstruate after completing treatment typically experienced complete menopause at a younger age than females that did not undergo anticancer treatments.

Depending on the type and frequency of symptoms that menopausal females experience, physicians can prescribe them hormone replacement therapy, or HRT. The symptoms that HRT typically treats are hot flashes and vaginal discomfort or dryness, but physicians also often prescribe it to reduce the risk of health conditions such as bone loss. The goal of HRT is to replenish the low levels of hormones in menopausal females that cause many of their symptoms. One type of HRT is the estrogen-only treatment. Estrogen alone is effective at treating symptoms of menopause, however, the risk of developing cancer in the lining of the uterus goes up when individuals take estrogen-only treatments. So, physicians typically only give the estrogen-only treatment to females who no longer have their uterus. An alternative form of hormone therapy is a combined treatment containing both estrogen and progestin. Progestin is the synthetic form of another female sex hormone called progesterone, which maintains the menstrual cycle and pregnancy. Including progestin in hormone treatments lowers patients’ chances of getting cancer of the lining of the uterus compared to the estrogen-only treatment, so physicians can give the combined treatment to females that still have their uterus. There are many ways females can take HRT to treat symptoms of menopause, including tablets, skin patches, implants, gels, and sprays. Treatments for symptoms of induced menopause are similar to females experiencing natural menopause. However, physicians typically avoid prescribing HRT if the hormones in the treatment could worsen the patient’s cancer.

For those who cannot take estrogen or progestin-based hormone treatments, alternative forms of treatment exist, such as medications used to treat depression, seizures, and high blood pressure. Physicians can use a low dose of antidepressants to lessen the frequency of hot flashes or, depending on the patient’s symptoms, depression itself. Other forms of medication, including gabapentin, typically used to treat seizures, and clonidine, typically used to treat high blood pressure, can also reduce the frequency of hot flashes.  Furthermore, physicians may use supplements such as vitamin D to build up bone strength in menopausal females with osteoporosis. Thus, there are many forms of medication that a female experiencing menopause can take instead of hormone treatments to help ease symptoms. As of 2024, physicians prescribe treatments based on the symptoms and preexisting health conditions of the patients, as well as their preferences.

Impacts and Controversy Regarding Menopause

Researchers have debated the potential risks, including cancer, associated with HRT since its creation in the mid-twentieth century, and debate about HRT as a treatment for menopause persists, as of 2024. In the 1960s, Wilson’s book Feminine Forever reinforced the use of HRT. However, people found many decades later that the company that distributed Premarin was paying him, and that may have motivated his strong support for the treatment. In the 1970s, researchers started to publish studies on the correlation between HRT and various forms of cancer. For example, in 1975, physician Harry K. Zeil and researcher William D. Finkle from California published a paper demonstrating that estrogen treatments directly correlate with cancer of the uterine lining. Soon after, many physicians and researchers adjusted the dosages of estrogen treatment to minimize risk, and they also began prescribing it with progestin, which reduced the risk of cancer in the uterine lining. However, those reductions did not resolve all concerns about the medical implications of HRT.

In 2002, scientific and public debates regarding HRT increased after the Women’s Health Initiative, or WHI, an organization that aims to expand research in menopause and women’s health, published a study claiming that even though HRT had some benefits, they were minimal compared to the drawbacks. According to writer Susan Dominus from the New York Times, the WHI’s study caused widespread panic amongst the public, and the use of HRT drastically dropped. After the WHI’s publication, researchers and writers published various papers criticizing the design of the study, adding to the complexity of knowledge surrounding HRT. For example, Angelo Cagnacci and Martina Venier, both physicians who work with and research female health, claimed that the 2002 WHI study had limitations because the subjects of the study had their last menstrual period a decade prior to participating, which means that the study did not consider younger females experiencing menopause. According to the pair, later research suggests that HRT might be most beneficial to females who are reaching or have just experienced menopause because older females typically have more health risks. Thus, not including younger menopausal females in their study may have skewed the WHI’s results. As of 2024, researchers continue to explore the cautions and dosages to optimize HRT to better treat menopausal symptoms, but physicians are still looking for new alternatives for females who cannot take HRT as well. 

Frequently, females experiencing menopause are uninformed or misinformed about what is happening to their bodies. For example, in 2022, according to a research poll by Preeti Malani and colleagues, a group of researchers and physicians from University of Michigan in Ann Arbor, Michigan, only forty-four percent of females experiencing menopause talked about their symptoms with their physician. Furthermore, according to Rachel Rubin, a physician practicing urology and sexual medicine from Washington, D.C., some menopausal females report that they do not experience the common symptoms of hot flashes or night sweats but do experience other symptoms such as depression and painful sex, and they do not realize those symptoms are a result of menopause.

To combat the stigma surrounding menopause and inform women on the changes occurring during menopause, many forms of media, such as the podcast “menopause: unmuted,” attempt to spread accurate, complete information about menopause to help others become better informed. The podcast “menopause: unmuted,” produced by the pharmaceutical company Pfizer, is about females’ firsthand experiences with menopause, and it provides advice and information to its audience on how to deal with symptoms and understand the stages of menopause in attempt to combat the lack of knowledge surrounding the topic. In 2021 a group of researchers from New York City, London, England, and Chicago, Illinois, conducted a study to examine the effects of “menopause: unmuted” on a group of menopausal women. The researchers found that the podcast increased knowledge on menopause in that group of women, which allowed them to better manage and treat their symptoms. They also found that the podcast normalizes menopause itself, helping women to feel more comfortable talking to family and friends about their experiences to gain a support group. With the amount of misinformation that has accumulated from years of stigma, media like “menopause: unmuted” can help others have a more accurate perception on menopause.

Menopause is a natural occurrence that affects more than one million females every year in the United States. Viewpoints on menopause have evolved over time. First, researchers simply had a basic understanding of menopause as the cessation of menstruation, then they argued it was a dangerous or disease-ridden process. Today, as of 2024, they recognize it as an event that is a natural milestone of life. Every female’s experience with menopause varies. However, there are sources of support and treatment methods that make the process easier, and individuals continue to develop more of those resources to better support menopausal females.