‘Good marketing, not good biology’: The myth of the ‘menopause cliff’

I feel it coming. The slow transition towards the day it – my period, that is – eventually stops.

There’s the unpredictable menstrual cycle that initially made me dig out a pregnancy test from the bowels of the medicine cabinet, the only blood rushing was away from my head as I awaited the negative result. And I’m occasionally woken in the middle of the night by a hot flush, which reminds me that my body has become less tolerant of wine.

But generally, in my mid-40s, the path towards menopause – the permanent end of menstruation – has been gently winding. I still feel strong and sleep well. It has not felt like I’m hurtling towards a “physiological cliff” that is going to result in my destruction as a woman – as a human.

Yet, this is precisely how a new study, published in the journal Nature Medicine, characterises it.

The population average from the lab tests of more than 1 million women revealed a “physiological cliff” at the final menstrual period – including hormone, skeletal, liver, kidney and lipid systems – the study’s authors wrote.

There was also a “transient rise” in average depression scale ratings and sleep issues.

Women can have vastly different experiences of perimenopause (the time when periods start changing, typically four to six years before menopause) and menopause.

About one in four women will have no menopausal symptoms. A similar proportion will have severe symptoms, while the rest will experience manageable, albeit annoying symptoms.

On The Imperfects podcast this week, author and entrepreneur Zoë Foster Blake shared that she began perimenopause in her late 30s.

“So anxiety ramped up to an 11,” says the 46-year-old. “And sleep was terrible: waking up all through the night and never feeling rested. [I was] irritable: fury, rage over things that shouldn’t have been inciting that level of rage.”

The symptoms of many women can feel abrupt, says Stuart Phillips, a professor and chairman of the Department of Kinesiology at McMaster University in Canada. “So ‘cliff’ matches lived experience.”

But, saying it’s a “physiological cliff” is both incorrect and untrue.

“It’s not a thing,” says Professor Martha Hickey, a professor of obstetrics and gynaecology at the University of Melbourne.

If the ‘cliff’ isn’t real, why is it being talked about?

The new Nature study is not the first to refer to menopause as a “cliff”.

A study published in February corrected years of framing menopause as a muscle “cliff”. Menopausal women do not suddenly start wasting away, they found.

“Women lose muscle with age much the way men do,” Phillips says.

The new study found that hormone levels starting to change 12 to 15 years before menopause and many of those changes were microscopic.

“Nobody needed Nature Medicine to tell them estrogen falls when the ovaries stop,” says Phillips.

“The shifts in everything else – liver enzymes, lipids, kidney markers – are mostly a tenth to four tenths of a standard deviation, at the population level. Probably real. Invisible in any one woman’s blood work.”

But by marking the point of sharpest change across hundreds of millions of blood tests, they make it appear more dramatic than it is.

The one exception is bone loss, which does accelerate in that decade before a woman’s final period. And there’s a cheap fix for that, he adds: lift weights.

“Why do we keep hearing it’s all a cliff?” I ask Dr Fatima Khan, menopause doctor and author of Hormone Health is Mental Health.

“One dramatic moment is an easier story to tell than a 10-year one,” says Khan. “Most women I see think of menopause as something that happens at 51, like a switch. It really doesn’t work like that.”

The “cliff” story is easier to tell. It’s also easier to sell.

“Watch the menoposse jump on this,” Phillips says. “Calling it a cliff is good marketing, not good biology.”

Menopause has become “weaponised”, agrees Hickey, who heads menopause services at The Women’s Hospital in Melbourne. “There’s a huge amount of money to be made in remedies and treatments and prevention.”

About $US15 billion ($21.4 billion) globally to be precise.

A study published in September analysing #womenshealth posts on social media found that most were related to hormones and reproductive health, including menopause and perimenopause and either sold an intervention or had a financial interest.

“A common trend in these health posts is sensationalised language that’s being used to market an intervention to women,” says Dr Brooke Nickel of the School of Public Health at the University of Sydney.

Should menopausal women do anything different?

“Menopause is a normal and inevitable life stage for all those born with functioning ovaries,” Hickey says. “Describing this as a ‘physiological cliff’ is potentially alarming for women and implies a dramatic physical and mental decline, which this study does not demonstrate.”

She adds that there is no good evidence that women in perimenopause or menopause should be doing anything different from anyone else.

“The basics are the same for everyone: sleep, stress, nutrition, movement,” Khan says.

Though it’s nothing different in kind, it’s a time to be more deliberate in how we care for our health.

“Lift something a couple of times a week, mostly for [your] bones, and because strength is what keeps you independent at 80,” Phillips says. “Eat enough protein; the number doesn’t change at menopause. Guard your sleep because that’s where the symptoms do their damage to everything else.”

If symptoms are causing distress and interfering with your life, then see your doctor about menopausal hormone therapy (MHT).

“It is a legitimate treatment for symptoms, and it helps your bones,” Phillips says. “It won’t build muscle. Training does that, at any age, with or without oestrogen. But I fully acknowledge that less symptoms can equal better sleep, better sleep equals better everything … ”

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