Knowledge of menopause is undergoing a revolution. Research in this area has boomed in recent years, particularly since 2020, according to the U.S. National Library of Medicine database.
“It’s an exciting time for its study because there are many areas in which we can work,” rejoices the gynecologist. Maria Jesus Cancelo. Because about menopause “there have been a lot of taboos and ignorance. “It was a stage in the woman’s life that happened hidden, the symptoms couldn’t even be explained.”
This has changed and “women demand a state of health and quality of life similar to what they had before menopause,” explains Cancelo, spokesperson for the Spanish Society of Gynecology and Obstetrics (SEGO).
The taboo and the research which took man as a universal model, ignoring the particularities of the other half of humanity, caused knowledge of menopause to be relegated to the margins.
The recent appearance of a non-hormonal medication for hot flashes symbolizes this new stage. However, some questions regarding this stage of female life have only been half-answered.
Why do women go through menopause?
The answer seems obvious. With age, the egg reserve decreases and hormone production declines sharply. Menopause means the end of a woman’s fertile period.
“It’s a natural phenomenon,” he explains. Santiago Palaciosdirector of the Climate and Menopause Chair of the HM Hospitales Foundation. “It is possible that at the phylogenetic level, women died at menopause, which happened in the 15th century, but advances in science allowed them to live a long time.”
However, menopause is an exception in the animal world. Only a handful of mammal species have been observed in which females stop ovulating at a certain time. Four of them are cetaceans: the beluga, the narwhal, the killer whale and the short-finned pilot whale. The fifth is our closest relative, the chimpanzee.
The discovery of the latter has also called into question the theory which justified human menopause: the grandmother hypothesis or the adaptive value of a woman forgetting to have children to take care of her grandchildren. children.
Hot flashes and other symptoms of menopause
“The end of a woman’s fertile period begins between the ages of 45 and 55, the average age is 50,” he comments. Mariam de la Pozapresident of the Catalan Society of General and Family Physicians (SEMG Catalunya).
Hot flashes, sleep, skin or hair disorders are some of the symptoms they notice “and often they consider it normal and they put up with it”, he emphasizes, specifying that in each woman a different set of symptoms may manifest “and we must always approach them in a personalized way”.
The classic treatment consisted of providing the hormones whose decline caused them: mainly estradiol and progesterone. However, despite decades of use, the mechanism by which the absence of a hormone generates vasomotor symptoms, the famous hot flashes, has not been studied until now.
“We didn’t know what the mechanism of action was,” recognizes María Jesús Cancelo, from SEGO. The appearance of fezolinetant, a drug recently approved to treat hot flashes in women who have contraindicated hormones – due to thrombosis, heart attack or hormone-dependent cancer – has thrown a little light on this relationship.
“Through research into new drugs, we know that certain neural systems have an abnormal response linked to this lack of estrogen. New research is shedding light on the pathophysiology of hot flashes.”
Why do some women suffer from symptoms and others do not?
“It’s a very difficult question to answer,” recognizes Santiago Palacios. Why do some women see their quality of life greatly affected by hot flashes, sleep problems and even brain fog (not to mention symptoms that appear in the medium and long term, such as genitourinary atrophy or cardiovascular problems) and others barely concerned? is he aware of it?
“One of the reasons is genetics. If the mother has had many hot flashes during her life, the daughter is at greater risk“, emphasizes the gynecologist. “The type of life and the amount of estrogen in the body also influence: menopause is defined when it drops below 40 picograms per liter, but there are women who have 20 and others do not reach 5.”
María Jesús Cancelo also regrets this lack of knowledge. “We don’t have an answer to this question, but what we do know is that most women will experience some symptoms at some point.”
Why do menopausal symptoms last so long?
In some women, symptoms can appear years before the end of their fertile period, this is called perimenopause: they begin to experience hot flashes and discomfort from the age of 40-45.
“It is true that there is a percentage of women who do not have symptoms and do not need any treatment other than health care, the majority will experience this between three and five years and then l The intensity will decrease, but 5% of women will have symptoms and hot flashes throughout their life.
Again, the reason is unknown “and this implies a significant loss of quality of life. The lack of estrogen will have an impact in many areas, not only on the central nervous system but also on genitourinary symptoms, the bone density and even the cardiovascular system.
Why there are no more treatments for menopause
Hormone therapy has been the mainstay of menopausal symptom management for the past four decades, “but it has been like a pendulum,” comments Santiago Palacios.
The publication of Femenine Forever, a book by American gynecologist Robert Wilson, in the late 1960s caused an uproar around this treatment. “In the 1980s, a lot of hormones were prescribed, but then it was realized that giving just estrogen could increase endometrial cancer.“.
The prescription of hormones was then reduced, “until it was demonstrated that combining it with progesterone reduced the risk”: it increased again. Later, “it was found to increase the risk of breast cancer, then it was disproved, then it was found to increase cardiovascular risk.”
About six years ago, he emphasizes, bioidentical hormone therapy appeared, “which has succeeded in reducing cardiovascular risk. We are in a good period in terms of treatments.”
The use of hormonal therapy, however, left aside women for whom it was contraindicated: those who had suffered a heart attack or thromboembolism or who had suffered from a hormone-sensitive cancer, such as endometrial cancer. or breast.
The appearance of fezolinetant has reversed the situation, but that is not enough. “It doesn’t solve the whole problem either,” says María Jesús Cancelo. “It relieves some of the symptoms but does not act on other syndromes.”
One of the major challenges of its approach is therefore the search for new drugs, as well as the reformulation of current options. “The most important thing is to make the treatments comfortable, so that instead of one tablet per day, we can have one per month,” explains Santiago Palacios.
There is also a long way to go to minimize the risks associated with hormone therapy, such as venous thrombosis. “The ultimate goal is to ‘rejuvenate’, that is, to eliminate the symptoms of menopause.”
