Let's talk about menopause

The knowledge gap on menopause in South Africa is immense. Many women, men and GPs are uninformed about the physical and psychosocial fallout of peri-menopause and menopause in a country where an estimated 14% of women are older than 45.

Emotional volatility and sleep disturbances were among the common symptoms 40 women shared in an in-depth survey on menopause in South Africa: “Something is off, I can’t sleep, can’t concentrate and I want to kill my kids,” a 45-year-old woman said; “My mind goes blank” (age 54); “I thought I had early onset Alzheimer’s” (age 46).

More than 60% of women who participated in the Embrace survey in 2023 were experiencing symptoms, yet most of them did not initially attribute their distress to menopause.

Women lack information about perimenopause and menopause said Lauren Fisher, the founder and CEO of Embrace — a company launched to offer access to affordable, effective and empathetic menopausal care among women in Africa — which released the survey of women from 37 to 62 years old.

“In my dipstick analysis, the GPs lacked knowledge and confidence

—  Dr Brenda Kubheka, Health IQ CEO

But women are not the only ones lacking in education on menopause. Two-thirds of GPs who responded to an online survey about menopause by Dr Brenda Kubheka — a speaker at the South African Menopause Society 2025 Congress last month — said they were not knowledgeable about the latest guidelines for the “medical management of menopause”.

Nearly half of the doctors said they were not confident in “prescribing hormonal treatment when appropriate”, the survey found, despite more than half of them having over 15 years of clinical experience.

“In my dipstick analysis, they lacked knowledge and confidence ... these alarming statistics showed a gap in knowledge when they are the ones supposed to be providing care,” said Kubheka. More than half of the 59 GPs who responded to her on closed Facebook and WhatsApp groups worked in private practice, three-quarters of them were female and most were based in Gauteng, followed by the Eastern Cape.

No dedicated midlife women’s clinics exist in the public health sector, which has a high disease burden, said Dr Trudy Smith, a gynaecologist and oncologist at Wits Donald Gordon Medical Centre. Medical students probably get, at most, two lectures on menopause she said, suggesting “we could better”.

DOCTORS PRACTISING ‘BY BODY PARTS’

“Medical practitioners may be treating menopause by body parts,” said Kubheka, referring, as an example, to a woman being sent to a psychiatrist for increasing anxiety, an optometrist for dry eyes and a neurologist for forgetfulness. “When put together these are all symptoms of menopause.”

For a woman with these symptoms, appropriate hormone therapy to replace falling levels in menopause is recommended, studies show. 

Dr Tobie de Villiers, who specialises in hormonal issues and bone health, said about 70% of patients who consult him have symptoms of menopause and about a quarter of these are troubling and need treatment. “The rest have varying intensity of symptoms and the risk of osteoporosis and fractures,” he said, adding that about a third of women seem to transition through menopause smoothly.

Women consulting doctors about distressing symptoms are often told “there is nothing wrong with them”, doctors and advocates in the field said.

Menopause coach Karen Nebe said: “They are being gaslit and given the wrong information and not being offered the information and choices they need.” Younger women tipped into early menopause, by surgery or medical treatments, also struggle to get the right diagnosis, said Nebe.

Women living with HIV experience a higher prevalence of symptoms and greater bone loss during menopause, a longitudinal study in South Africa (lead author Nisha Andany) found.

PERIMENOPAUSE: A HOT TOPIC

Perimenopause has recently grabbed attention on social media platforms, such as TikTok. This stage of a woman’s transition to menopause, typically from about 35 to 45 years old, is more difficult to identify and treat than menopause because of fluctuating hormone levels.

“In perimenopause the symptoms are not constant. Oestrogen levels are generally lower but the values spike up and down, which can be an emotional rollercoaster,” said De Villiers. However, treatments such as a low-dose oral contraceptive are an option for women with intense symptoms.

Gynaecologist Dr Elmarie Basson, who has a private practice in Cape Town, is alert to the complexity of both perimenopausal and menopausal symptoms. “[This transition] is multidimensional and we are just scratching the surface,” said Basson, who sees women struggling with symptoms that disrupt their relationships, families and careers.

Women should learn about menopause and check the credentials of those whose tips they follow, she said. “Lots of people are jumping on the menopause bandwagon and women should make sure they are not taking false advice.”

Hormonal therapies have been proven in studies to dramatically alleviate symptoms in perimenopause and menopause, while making healthy changes to lifestyle, such as being active, benefits people at any stage of life.

STARTLING STAT: 35% Of women told the Embrace survey that they did not know about perimenopause

 

COMMON MENOPAUSAL SYMPTOMS: Vasomotor symptoms like hot flushes and night sweats, sleep disturbances, the loss of bone density, joint pains, brain fog, the loss of libido and dryness of vagina, mood fluctuations including increased anxiety, and the increased risk of heart disease, are among the symptoms that erode menopausal women’s quality of life.

THREE MENOPAUSE MYTHS

1. HRT causes breast cancer: False. 

Many women are scared to take hormone replacement therapy because the results of a study, released in 2002, were misinterpreted to wrongly warn of an increased risk of breast cancer for all menopausal women taking combined (oestrogen and progesterone) hormone replacement therapy.

Further analysis of the Women’s Health Initiative trial results revealed not only that the breast cancer warning was inaccurate for all women, but also that women who started HRT soon after menopause had a reduced risk of heart disease and osteoporosis.

2. ‘It’s all in your head’: False

Yes, menopause affects your brain but falling levels of the hormones oestrogen and progesterone also affect your reproductive, vasomotor (hot flashes, night sweats), skeletal (loss of bone density, increased risk of osteoporosis), cardiovascular (can impact blood pressure, cholesterol levels and heart health), metabolic (changes in weight and fat distribution), urinary (urination frequency/urgency) and nervous systems (mood swings, anxiety and sleep disruptions).

3. Menopause starts after 50: False

Perimenopause typically begins about four years before a woman's last period in her 40s but it can start earlier. Usually this lasts several years and menopause is reached between 45 and 55 years old, with 51 being the average age of onset. But genetics, lifestyle, health, disease, medical treatment and surgery influence the timing. The cessation of menstrual cycles for 12 consecutive months signals the start of menopause.

LIGHTS SWITCHED ON AGAIN

Fears about hormone replacement therapy are common, however, after a single flawed study in 2002 raised a false alarm that all women were at elevated risk of breast cancer if they took combined HRT. For healthy women under 60 the benefits outweigh the risks, many studies since then have found.

A Cape Town professional wanting to follow a “natural, healthy path” during her menopause transition went without hormones for eight years, but she endured such severe insomnia, fatigue and inflammation that ultimately she started having suicidal thoughts.

“I had hit rock bottom and decided to go on HRT. I had side effects because I had not had hormones in my body for years, but after three months I started to feel a bit better.”

Her experience of HRT was “like the lights had been switched on again, like night and day”, with the restoration of her sleep, particularly after she switched from oral HRT to a transdermal estrodial gel and micronised progesterone she said.

Yet in South Africa most women have limited access to menopausal hormonal treatment in the public sector, said Smith. “There is unfortunately very little for women in the government sector. The medications on the essential drug list are old and outdated and often not available.”

UCT head of reproductive medicine, gynaecologist Dr Malika Patel, said menopausal hormonal therapy (MHT) was available in the public health system but preparations were limited.

“Not everyone requires or wants to take medication,” said Patel. “The current evidence suggests that MHT — which is not safe for everybody — should be used early in the menopause, either until age 60 or for 10 years.”

Women should be educated about menopause and empowered to make their own choices together with their health practitioner, she said, also advising lifestyle modification, eating more healthily and regular check-ups to review blood pressure, blood sugar and other indicators.

A new treatment option in South Africa is a testosterone gel, recently approved for use by women in menopause with a low libido. “We have been waiting for the gel intended to increase sexual desire,” said Basson. 

De Villiers cautioned that the testosterone treatment for women has been registered strictly for “underactive sexual desire” and not for other potential benefits, like building muscle mass.

BREAKING TABOOS & SHIFTING WORKPLACES

Cultural beliefs and experiences influence the attitude of African women to menopause, a qualitative study in South Africa led by Gloria Makuwa at the University of Pretoria showed.

Initiating conversations about menopause should take African cultures into context, said Kubheka, the CEO of Health IQ Consulting: “Menopause is a taboo subject: we are not talking about it."

The recent release of the US documentary The M Factor: Shredding the Silence on Menopause intensified the worldwide spotlight on menopause. Both Cape Town screenings of the film were sold out said Nebe, who brought the trailblazing documentary to South Africa. In Hermanus, about 180 women, and a few men, attended the screening last weekend and the film may go to Joburg she said.

At the end of the screening, many women were asking: “Where do we find the doctors [to help us]?”. But Nebe, who left the corporate world to coach on menopause, said: “It is not just about finding doctors. We want women to educate themselves ... to advocate for themselves.”

Raising awareness, linking women to practitioners and advocating for the destigmatisation of menopause in the workplace are priorities, say women working in this field. Fisher said that one in 10 women consider leaving their jobs because of menopausal symptoms.

Rising activism around women’s rights in menopause, particularly in the US, UK and Australia, is gaining ground in the fight to end discrimination. The UK, for example, recently updated its guidelines under the Equality Act to address menopause in the workplace. The update legally requires employers “to make reasonable adjustments for employees experiencing significant menopausal symptoms” — for example, flexible working arrangements.

Fisher said they have started talking to South African employers about training and the impacts on them. “We have done talks at corporates which have been well received, but few men attended. I hope this can change.”

MEN CAN HELP

Men who care about women can find ways to support them during this transition.

Supporting women through menopause mirrors the basics of a good relationship. First, said Basson, women must feel free to talk openly. “Menopause is so stigmatised that women won’t talk about it. They will talk to me but not to their partners.”

Men experience their own changes with ageing, when testosterone levels and libidos tend to decline, she said. Sharing and talking about experiences is important. Men also need to ask questions and listen attentively to the answers, said Basson.

She said it can be difficult to support women overwhelmed by symptoms and men need to ask their partners: “How can I support you?” Hugging your partner who is sweating out a hot flash may not be welcome, for instance. Nothing irritates a woman more than a man saying to her ‘it’s just your hormones’,” she said.

In a F’acebook post one man called menopause “a biological coup, where hormones go on strike ... a full-blown, body-snatching, hormone-obliterating, emotional rollercoaster from hell. If you’re lucky enough to be standing beside a woman going through it, buckle the fuck up!” he wrote of the hormonal hurricane with which women wrestle while men stand around clueless.

“Menopause isn’t her problem — it’s your test,” he wrote, urging men to step up with patience, compassion and empathy. “Support her like the Khalisi she is. Menopause isn’t some tragic downfall- it’s a transformation. She’s stepping into a new version of herself, one that doesn’t have time for bullshit or people-pleasing... Respect it.”

ASK ABOUT HRT

Embrace, which works with top doctors in the field of menopause, has a friendly AI chatbot called Lindi (in the testing phase) who has been trained on menopause. “What is HRT?” I asked Lindi. Lindi replied: “Hi there! Hormone replacement therapy, often referred to as HRT, is a treatment used to relieve symptoms of menopause by replenishing hormones that the body no longer produces after menopause. It can be particularly effective for managing symptoms like hot flashes and vaginal dryness. Hormone therapy can come in various forms, such as tablets, patches, gels, or creams. It's important to discuss with a health-care provider to see if it's suitable for you, as it may not be recommended for everyone.”

• For more information visit the South African Menopause Society: menopause.co.za