The truth about 10 common menopause misconceptions

ASEBP sat down with Dr. Angela Ochs to talk about the most common misconceptions about perimenopause and menopause and what the facts are.  

Misconception #1: I am too young for menopause

The facts: This is the most common misconception I hear from patients! The average age of menopause is 51 or 52.  Remember, menopause is reached after one full year of no periods. Some people are 46 and have already had a full menopause. That also means some people are 56 and are still having periods. About five to eight per cent of the population can have menopause between 40 and 45. This would be considered an early menopause. About one per cent are even younger than age 40, and that is what we call premature ovarian insufficiency (POI).  

Misconception #2: Menopause is an instant change

The facts: Most people do not just suddenly stop having periods. Your hormones wax and wane over time, and there are typically years of changes that happen before you before you reach your last menstrual period. Some women are more irritable. Some (lots!) have trouble falling or staying asleep. Some women have hot flashes or night sweats. This time of change is really called perimenopause, whereby the periods start to change. They may be more or less frequent or more irregular, and eventually you start to skip periods. Patients are typically struggling with some kind of symptoms for three to five years before their last period.  

Once you have had your final menstrual period, the literature suggests you may have two or three years of symptoms after. However, I have several 80-year-olds still on hormone therapy, because when they try to stop it, their symptoms return. It is really not the same for everyone, and this is where it is important to have a good relationship with your primary care provider to find the right treatment for you. 

Misconception #3: Menopause hormone therapy is dangerous

The facts: Unfortunately, this myth came from older studies where women already in their sixties were put on menopause hormone therapy (MHT). They did see more breast cancer and cardiovascular disease in these women. It is not that hormone therapy is suddenly bad for you at age 60. It is just that breast cancer is more common, heart disease is more common, and strokes are more common too, and hormone therapy can exacerbate all these conditions. What we know now about MHT, due to new studies, and looking at the older ones again, is that hormone therapy is safe when we start it within 10 years of your last menstrual period.  

Usually, MHT is given through transdermal estrogens, patches or gels, that are absorbed through the skin directly into the bloodstream and deliver continuous, steady-state hormone levels. They completely avoid the liver, and because of that, there is amarked reduction in clotting. Even if someone had a previous history of blood clotting, that does not mean they cannot necessarily have hormone therapy. That is a discussion to have with your physician to see if it is safe for you or not. To prevent thickening in the endometrial lining of the uterus (which can lead to precancerous changes or even endometrial cancer), we balance out the estrogen with progesterone. We have several ways of doing this including an oral progesterone, a progesterone only birth control pill, or inserting a Mirena intrauterine-uterine device. 

Most times, you can still have hormone therapy if you have a family history of breast cancer. If a patient has or had breast cancer, that is different. I will always try to find a non-hormonal treatment option to help patients in this case. If we have tried everything and they are suffering, I might still discuss hormone therapy, but this is never my first option in this scenario.  I may even look at prescribing hormone therapy if a patient is older than 60. It is about looking at a patient’s overall health and quality of life and deciding together what the best options are. Remember that hormone therapy is safe (for most) when prescribed within 10 years of the last menstrual period and for some, that may be age 55 or later. 

The other misconception out there is regarding the safety of vaginal estrogens in patients with a history of breast cancer or blood clots  Vaginal estrogens are local therapy. They are a lower dose, and they only work directly where you use them. This is such a simple therapy that makes a huge difference in quality of life. 

Misconception #4: Menopause Hormone Therapy will solve all your menopause symptoms

The facts: MHT is great at treating some symptoms, and many symptoms are interconnected. It is like a cycle. For example, vasomotor symptoms (hot flashes and night sweats) can disrupt our day, and particularly when they disrupt our night, then we do not sleep. When we do not sleep, our mood is impacted. When our mood goes down,, multiple facets in our life are impacted.  We can get irritable with our families, be unproductive at work, be too tired to exercise, the list goes on and on. Hormone therapy is good for these symptoms because it breaks the cycle by treating the vasomotor symptoms.  

Local hormone therapy, especially through vaginal estrogen, can also improve the vaginal environment, to help with vaginal dryness, itching, burning, and painful intercourse.  

Testosterone is not a standard part of menopause hormone therapy, but it is a hormone that can be prescribed for low libido. There is no evidence, however, to support prescribing testosterone for issues with low energy, muscle mass, or cognition. In Canada, if you are already menopausal, you must be on hormone therapy already in order to have testosterone supplementation. If you are perimenopausal, it is different, because you are already making estrogen and progesterone, so then we just add some testosterone. There can be unwanted side effects with having too much testosterone, so we prescribe a dose that is much lower than what we would give men.   

There are many symptoms that MHT may not be helpful with. The evidence we have available says that hormone therapy does not help with aches and pains. Anecdotally in practice, I do feel some patients may experience a change. But it either does or does not. It is not dose dependent. Some patients may see improvement because it helps with their sleep, or it helps them cope better overall.  

The other thing that hormone therapy does not improve is brain fog. This is a period of time, three to five years usually, where our brain is adjusting to our new low or changing estrogen environment. People may see an improvement because their sleep has improved with hormone therapy. When you sleep better, your brain works better. But if we just have someone experiencing brain fog, but no hot flashes, and they are sleeping well, brain fog is not going to get better with hormone therapy.  

There is also no evidence to support the use of hormone therapy as a preventative treatment for cardiovascular disease, osteoporosis, or dementia. 

Misconception #5: The only treatment for perimenopause and menopause symptoms is menopause hormone therapy

The facts: There are a lot of other non-hormone treatments for symptoms of perimenopause and menopause. Some women may not be able to take hormone therapy due to other health problems and sometimes women do not want hormone therapy.  

For mood symptoms, we can try various antidepressants. They can also help with hot flashes and night sweats, decreasing the frequency and severity sometimes in half.
A common side effect from those treatments is sleepiness, so they might also help with sleep.   

Another class is Gabapentin, which is a medication that we use for sciatica and nerve pain. It can also be used for arthritic pain. Gabapentin can reduce the frequency and severity of hot flashes by half as well. 

Another medication is Oxybutynin. It is used to treat symptoms of an overactive bladder, such as frequent urination, urinary urgency, and incontinence, and it also significantly reduces the frequency and severity of hot flashes.  

There is also a new class of medication that works on the receptors in our brain that are responsible for body temperature regulation. When estrogen starts to drop, we need to regulate these receptors more. This medication binds to these receptors to dial them down. There are two types of this medication now: Veozah (Fezolinetant) and Lynkuet (Elinzanetant). With these medications, there is only one dose, which is easy, and they can deliver a 70 per cent reduction in vasomotor symptoms and even help with sleep. 

Sex therapy can help with changes in libido, which often occur after menopause, because external factors can be a major contributor. There is also a medication, Addyi, that is used to treat low or absent sexual arousal in women, but it is a pill that has to be taken every day, it is expensive, and it can also have side effects.  

There are also a lot of different lifestyle choices that have an impact. How much alcohol you have, the amount and type of exercise you do, how you sleep, and what you eat can all make a difference.  

Misconception #6: Brain fog is a sign of dementia

The facts: People experiencing brain fog may worry that they are going to get dementia. This is not the case. This is an example I share with them. When you have brain fog, you have a pen, and you put the pen down, and you cannot remember where you put it. When you have dementia, you say, “what is that?” as you do not know what the pen is. Brain fog usually lifts within three to five years, but it can be very stressful and scary for those who suffer from it. 

Misconception #7: You cannot get pregnant when going through perimenopause

The facts: If you are having periods, you can get pregnant. The likelihood may decrease the longer you are in perimenopause, but it is not zero until you are menopausal.  

The hormone therapy used to address contraceptive needs (i.e. birth control pill) is very different from Menopause Hormone Therapy. If you are on MHT you still need contraception.  

Misconception #8: Solutions are one size fits all

The facts: There are lots of options, and everyone’s experience and symptoms are different. Some people have a lot of symptoms, and some do not have many symptoms at all. Everyone’s ability to cope with the symptoms is also very different. It is important for patients to have a discussion with their health care providers to determine what their quality of life is, what could work best for them, and what they are comfortable with.   

Misconception #9: Hormonal blood tests are an accurate way to determine whether you are in perimenopause

The facts: Your hormones change every day, so the symptoms you are experiencing and how you are feeling are a better indicator than blood tests in this case. I typically only order blood tests if a patient is experiencing premature ovarian insufficiency (POI), or if a patient is already on transdermal hormone therapy and they are not getting better. I might order hormone levels then to ensure they are absorbing properly through the skin. I do not routinely do blood tests though. It is more important to treat patients with symptoms versus lab tests.  

The true indication that you are in perimenopause is a change in your periods. For instance, if you have a cycle every 28 days, then suddenly they are 40 days apart or even 21 days. In early perimenopause you would see a difference around seven days, one side or the other. Once you hit late perimenopause, you are skipping periods. Once someone has skipped one period,  95 per cent of people will have their last period within the next three to four years.   

Misconception #10: It is normal and inevitable to suffer through perimenopause and menopause symptoms

The facts: Perimenopause and menopause symptoms can be seriously debilitating. For anyone who is going through the menopause transition, it is important to remember that you have estrogen receptors head to toe, so changes in our endogenous estrogen production can affect many different organ systems. Our skin has estrogen receptors so our skin can become dry and itchy. Our brains are affected by changing estrogen leading to brain fog, forgetfulness, and poor sleep. Our hearts have estrogen receptors and low levels of estrogen produce palpitations. Our joints have estrogen receptors and estrogen changes can lead to joint aches and pain. The vagina is full of estrogen receptors and during this time you may experience dryness, itching, and painful intercourse, resulting in low libido. Everything has estrogen receptors! When estrogen declines, it can cause a lot of symptoms and can impact your daily living. While this is a normal change, it is also a medical issue, and you do not and should not have to suffer with symptoms.  

It is different for everyone, but the best advice I can give is to advocate for yourself. There are treatment options available, and there is always someone who can help you.   

How ASEBP supports you

ASEBP is here to support you on your health and wellness journey.  

• Prescriptions ASEBP covers all prescription medications for menopause that are licensed by Health Canada and have an approved indication. Coverage for newly approved medications may be added following appropriate national and provincial reviews.   

• Employee and Family Assistance Program (EFAP) ASEBP covered members and their dependents each have access to free yearly hours to access a range of supportive resources that can help you manage menopause-related changes. Connect with mental health counsellors, registered dieticians, fitness instructors, sleep consultants, and many other health practitioners who have experience supporting individuals through menopause to help support your health goals.   

• Health Spending Accounts (HSAs) that may be used to reduce eligible out-of-pocket medical expenses, after your ASEBP benefit plan, other benefit plan (if applicable), and provincial health care coverage have been exhausted.   

• Wellness Spending Accounts (WSAs) that may be used toward eligible wellness-related products, services, and activities that support your wellness, fitness, and personal growth.   

• Wellness Website Trusted wellness information and tools through ASEBP’s Wellness Hub, including resources on menopause, healthy living, and overall well-being. 

Coverage can vary by plan, so be sure to review your benefit details by logging in to My ASEBP or contacting a benefit specialist for assistance if you have questions or are unsure about your specific coverage.  

The information provided in this article is for personal use, reference, and education only. ASEBP does not provide medical advice. Before starting any medication, product, or treatment, you should always consult with your pharmacist, health care provider, or call Alberta Health Link at 811.