Reverse puberty. Ovarian retirement. The change. It’s shrouded by secrecy and thought of as women’s business. But with more than half the population impacted at some point in their lives, it’s something we all need to know about. Kath Kovac is smashing the taboo on menopause. This article first appeared in Cosmos Print Magazine, March 2025.
Imagine a disease that affected 51% of the world’s population. Of those affected, a lucky 20% may barely notice, while around 60% may experience mild to moderate symptoms.
The unlucky remainder can lose all motivation, might quit their jobs, and can suffer extreme depression and anxiety to the point of becoming suicidal.
Imagine this insidious disease was also one of society’s biggest taboos, shrouded in secrecy and shame.
What if this disease was not a disease at all, but a completely natural phenomenon? Like death and taxes, there’s no way out – it’s a certainty for half of the world’s people.
Its name? Menopause.
Stages of menopause.
Secret women’s business?
The menopausal transition is a unique experience for every human born with ovaries. This includes cisgender women, transgender+, non-binary and gender fluid people (see ‘Trans+ and non-binary experiences’).
The individuality of menopause is one reason why it is so hard for doctors and specialists to treat patients and for work colleagues, relatives and friends to understand the changes that occur at this time.
Of course, it is easy to think that if cis men experienced menopause, it would have been addressed and solutions found many years ago. But like most other areas of women’s health, unless the issue also directly affects men, very little is known about it.
The result is 1.1 billion people worldwide with a unique combination of symptoms that are variously ignored, rebutted or misdiagnosed – and only occasionally properly treated.
Signs of menopause
Let’s start with some definitions. The word ‘menopause’ technically refers to a person’s final menstrual period. For most women, this happens slowly and naturally, while for others, it can be caused suddenly by surgical removal of the ovaries or by cancer treatments.
From the very day of our last menstrual bleed, the medical system describes us as ‘postmenopausal’ – although we don’t know it’s happened until a year later (see diagram below). The many years after puberty and before sex hormone levels start fluctuating is called ‘premenopause’. And the time in between is called ‘perimenopause’, and is usually when most people experience the worst symptoms of all.
The most common signs are the ones most people know about – erratic bleeding, hot flushes and night sweats. Erratic bleeding means that the regular menstrual cycle becomes unpredictable, in both timing and amount of bleeding. Hot flushes and night sweats are pretty much what they sound like – an intense experience of heat or sweating that not only makes people feel distressed, but also impacts cognition and confidence (see ‘Making menopause real for men’).
At least 32 further symptoms are known, according to a US Medical News Today review of scientific articles. In alphabetical order, these are: acne, anxiety, brain fog, brittle nails, depression, dizziness, dry and itchy skin, fatigue, hair loss, headaches and migraines, heart palpitations, insomnia, joint and muscle pain, low libido, memory lapses, osteoporosis, panic attacks, tingling and electric shock, tinnitus, urinary stress incontinence and infections, vulval and vaginal dryness, and weight gain.
This impressively awful list is pretty much all thanks to the fluctuations and eventual decline in 2 hormones: estrogen and progesterone.
Trans+ and non-binary experiences
Endocrinologist Dr Ada Cheung leads a trans health research group at the University of Melbourne. She says that menopause is only relevant for older trans people presumed female at birth who do not use gender affirming hormone therapy (i.e. testosterone).
Of those using testosterone, most don’t generally want to stop using it, says Cheung. “It’s almost like they’re having ongoing menopause hormone therapy, so they don’t really experience menopausal symptoms.”
With around 1.5% of the Australian population identifying as trans+ or gender diverse, Cheung says education is really needed among health professionals.
Changing perspectives
A 2022 article published in Climacteric, the journal of the International Menopause Society, looked into women’s perspectives of erratic bleeding – the kind where you might go for many months without a period, and then have what feels like buckets of blood come flooding out all at once. The authors concluded that the experience “is fraught with ambiguity [and] feelings of uncertainty about how to make sense of symptoms, and inevitably begins with a period of self-appraisal”.
The ‘self-appraisal’ is important, and points to another less-discussed aspect of menopause – the intense psychological journey from who a person was in their menstrual cycling years to who they become in the post-bleeding phase of life.
Neuroscientist Dr Lisa Mosconi explains that like a teenager’s brain going through puberty, a menopausal brain “basically gets rid of some neurons that you no longer need and makes room for neurons that you will need in the next phase of your life.”
Sociologically speaking, this makes sense. As Mosconi says, “older women have always been the cornerstones of society… becoming the support for children and grandchildren. The rewiring and remodelling potentiates the brain structures responsible for empathy, emotional control, [even] peace of mind.”
This might provide a measure of comfort for those in the grip of physical menopausal symptoms – which can last for more than a decade, and even the rest of a person’s life. And it also provides a biological reason for why we can survive beyond our reproductive years, unlike most of the animal world.
One exception to that rule is the killer whale. While male killer whales typically live to around 30 or 40, the grandmothers often pass 80, playing important leadership roles and identifying where to hunt prey. Belugas, narwhals, short-finned pilot whales and chimpanzees go through menopause, too.
Science speak
Estrogen and progesterone are neurotransmitters – molecules that carry signals from one brain cell to another. Every type of brain cell, as well as every mitochondrion, has receptor molecules that receive these chemical messengers. Mitochondria are the energy powerhouses of our bodies, converting the chemical energy in the food we eat to energy we can use.
“Menopausal women wonder, ‘Why is every single part of my body falling apart? Why am I so tired all the time?’,” says menopause specialist Dr Sunita Chelva. “Well, it’s because of these hormones, against a backdrop of multiple other life challenges.”
Hot flushes and night sweats
In the medical lingo, hot flushes and night sweats are called vasomotor symptoms, which also include heart palpitations and changes in blood pressure. Endured by around 80% of women, the symptoms are caused by fluctuating estrogen levels. Apart from the physical discomfort of burning up from the inside or waking up drenched, vasomotor symptoms can affect cognition, making it harder to concentrate and retain information.
Data from 2023 study in the journal Maturitas has implicated a signalling molecule called neurokinin-3, or NK3, in hot flushes. Declining estrogen triggers the release of NK3, which interacts with NK3 receptors in a part of the brain’s hypothalamus. This organ controls body temperature, hunger, thirst, sleep and more. And the more NK3 that interacts with NK3 receptors, the hotter things get.
Changes in thinking
Clinical neuropsychologist and Associate Professor Caroline Gurvich of Monash University explains that estrogen and progesterone are also ‘neuroprotective’.
“Estrogen in particular helps protect our neurons. So when estrogen levels fluctuate and decline, our memory, our ability to retrieve information, our high-level executive thinking skills can also fluctuate and decline during menopause.”
Gurvich stresses that this isn’t permanent, and nor is it early onset dementia, as many perimenopausal people imagine.
“Most menopausal symptoms can impact cognition. But when we measure people’s thinking skills, the speed of processing information doesn’t change. It’s people’s efficiency in learning that seems to be key. It’s a subtle change, but for some people, it has a huge impact on their life and their confidence.”
The evidence for treatment
While this subject is worthy of an entire Cosmos article alone, the essence is that replacing the body’s premenopausal levels of estrogen and progesterone through menopausal hormone treatment (MHT) is the most effective treatment of all.
Unfortunately for a generation of menopausal women, a single flawed research article that incorrectly linked MHT to breast cancer in 2002 caused GPs worldwide to instantly stop prescribing MHT.
“In the 1990s, about 40% of menopausal Australian women were on hormone therapy,” says Professor Susan Davis AO, Director of the Women’s Health Program at Monash University. She says that MHT not only safely improves menopausal symptoms, but can also benefit cardiovascular health and prevent osteoporosis and fractures.
Davis believes women should not be denied treatment simply based on age or years since menopause.
“In an almost panicked response to the drop in prescribing MHT, US doctors put out a statement, based on the same data, that the benefits outweighed the risks of hormone therapy if you were aged less than 60 or within 10 years of menopause. Many women in their 60s are still getting severe symptoms, and are asking for MHT. And unfortunately, most GP’s and gynaecologists are saying no.”
Professor Susan Davis, Director of the Monash Women’s Health Program. Credit: Courtesy of Professor Susan Davis.
Davis and her colleague critically reviewed the evidence, and showed in the Lancet Diabetes Endocrinol medical journal that there were no more adverse outcomes for being on MHT aged 60–69 compared with a placebo treatment.
“All the guidelines that are dogmatically saying you can’t start MHT after the age of 60 or more than 10 years from menopause are flawed and should be reviewed,” Davis insists.
Menopause at work: an equality issue
With menopausal women being the world’s fastest growing workforce demographic, the realities of working through menopause are starting to hit hard.
Dr Linda Dear, a GP from New Zealand, ran an online survey of 5,000 women in 2024. According to Dear, more than 50% of Australian women find it harder to do their job, and 1 in 9 consider leaving the workforce because of symptoms and lack of support.
Workplace wellbeing adviser and TEDx speaker Thea O’Connor, who presented at the 2024 Australian Government Senate Inquiry into issues related to menopause and perimenopause, says that not talking about it makes things worse.
“Isolation and secrecy probably have the worst possible impact on wellbeing that you can imagine,” she says. “We need to name it and claim it, and ask for the support we need.”
However, despite reams of anecdotal evidence and countless self-reported surveys, Davis says that the data about menopause at work is effectively inconclusive.
“The samples are biased, because if you tell people you are doing a survey of menopause at work, the most likely people who are going to complete it are those who are bothered by menopause.”
“The medical workforce are saying that if we’re going to have policies, let’s make sure they are correct, and if they’re going to be correct, let’s get the data.”
To address this issue, Davis has just recruited 8,000 women across Australia to a national health study in which questions about work are carefully hidden to avoid bias.
Where to from here?
Scientific experts and wellness advocates all agree that the most-needed action by far is education. And not just of the general population and workplace managers, but more importantly, of GPs and other health professionals.
With GPs receiving on average only 1–2 hours of menopause-specific information
during their medical degrees, Chelva says things must change.
“Part of the Senate Inquiry was trying to get the education bodies to be on board with the fact that everybody needs to be trained – not just gynos, endos and GPs, but every specialty in medicine and every allied health professional,” Chelva stresses.
Of the inquiry’s 25 recommendations, 8 were related to awareness raising and education. Thea O’Connor says some of the easiest ones to implement should be “the general awareness campaigns, including menopause in secondary school sex education.”
“I also like their recommendations around work. Some will need more investigation, such as whether the Fair Work Act can be tweaked to include menopause as a reason to request flexible working conditions.”
We can now only play wait-and-see to discover the value that the Australian Government puts on health during menopause.