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  • Kaylee Zimmerman

Nobody Cares about Menopause: Sex-based Medical Disparities in the United States

October 30, 2023


[Image credit: Adobe Stock]

Menopause is a natural process during which women’s ovaries cease estrogen production, causing a range of symptoms that last for an average of 7 years but sometimes as many as 14 (What is Menopause? 2021). Some symptoms, such as increased bone fragility and vaginal atrophy, often continue after the menopausal transition. Systemic issues involving miseducation, a lack of research, and insurance coverage have resulted in menopause being more uncomfortable for women than necessary. Moreover, women aren’t being protected from predictable menopause-induced ailments. For these reasons, the medical disparities between female and male healthcare are a human rights violation.


A survey of 738 women under the age of 40 showed that 80% had limited or no knowledge about menopause. Across all age groups, women tended to seek information regarding menopause from family and friends rather than consulting health professionals and scientific literature (Munn 2022). All in all, much of the education that women under 40 have regarding menopause is either nonexistent or from nonmedical sources. Menopause begins between ages 45 and 55 (What is Menopause? 2021), so many women don’t understand the symptoms that they should be watching out for until they’re already in menopause or perimenopause. For example, arousal has been shown to be significantly higher in postmenopausal women who receive formal sexual education or do kegel exercises compared to postmenopausal women who do not (Nazarpour 2017). Thus, we can conclude that the widespread lack of menopausal education is, at the very least, decreasing sexual satisfaction in postmenopausal women. The less sexual intercourse menopausal women engage in, the more vaginal atrophy will occur. Vaginal atrophy leads to pain during intercourse and a slew of urinary symptoms. We can but don’t use widespread sexual education to improve these symptoms.


Hormone Replacement Therapy (HRT) is a commonly used means of managing menopausal symptoms and preventing dementia, cardiovascular disease, and osteoporosis. Marjoribanks (2017) conducted a meta-analysis of 22 studies involving 43,637 women. The analysis revealed that the only statistically significant benefit of HRT is decreased fracture incidence, while the only statistically significant risk is an increase of venous thromboembolisms in women with cardiovascular disease. Bone density screenings begin at age 65 when insurance is likely to cover it. Although HRT can therapeutically prevent bone density loss, many women don’t know there’s an issue until their first scan, which averages 10-15 years after menopause.


HRT was first used in the 1960s, and widespread use began in the 1990s (Cagnacci and Venier 2019). Contemporarily, there are many gaps in menopausal treatment, including treatment for women with cardiovascular disease. HRT has been shown to increase mortality from coronary heart disease from 20% to 40% and the reason for this remains unknown (Nachtigall and Nachtigall 1992). HRT has also been shown to be particularly helpful in women with a high risk of developing heart disease (Rozenberg 1998). When HRT is started in women under 60 years old and/or less than 10 years postmenopausal, it is more likely to decrease coronary heart disease than to increase it (Hodis and Mack 2014). The confusing nature of conflicting literature around HRT being used to prevent heart disease leads to a tentativeness of physicians to prescribe it in postmenopausal and menopausal women.


Despite HRT being a primary treatment for menopause, there is a significant lack of research on these medications. The role of estrogen and progesterone, including their optimal dosages in relation to heart disease, remains largely unknown. Considering that these medications have been in use for over 60 years, we should have a deeper understanding of their impact on heart disease, which is the leading cause of death in the United States. Heart disease causes one-third of the deaths in the United States, with a majority of these deaths being women (Lee and Foody 2015). We know that physiological differences between the sexes exist and that women have historically been excluded from many heart disease-related research studies (Westerman and Wenger 2016). These physiological differences could very well be estrogen and progesterone related, as HRT has been shown to significantly affect heart disease incidence in menopausal and postmenopausal women. Further research to determine these relationships is long overdue.


SSRIs and SNRIs, commonly prescribed antidepressants, have shown a 65% reduction in hot flashes (Handley and Williams 2015). However, they can also lead to decreased libido (Rosen 2019) in menopausal women who already suffer from vaginal atrophy, often resulting in painful sex. Physicians use diagnosis codes to determine medication coverage by insurance companies. While HRT is commonly used to treat vaginal atrophy, insurance companies, particularly Medicare, are less likely to cover it if the diagnosis code indicates it's for sex-related issues (Andrews 2019). A similar issue exists for male sex-related medications like Viagra (Andrews 2019). However, HRT is also prescribed for preventing things like osteoporosis, dementia, and heart disease, in addition to said sex-related problems. Yet HRT and Viagra are treated similarly by insurance companies. This can make treating uncomfortable menopausal symptoms, such as vaginal atrophy, prohibitively expensive, including when it’s being used preventatively for other symptoms.


Insurance companies often do not cover novel treatment options, causing providers to hesitate in prescribing them. Consequently, HRT, SSRIs, and SNRIs are frequently prescribed, even when other treatments may be a better fit for the patient. For instance, Veozah is a novel hormone-free treatment for hot flashes in women with coronary heart disease. Physicians are reluctant to prescribe such novel treatments because of insurance coverage issues. To seek insurance coverage, patients may need to try three other medications to demonstrate that the new medication is irreplaceable with a cheaper alternative. Among these trial medications, HRT, which is not indicated for women with coronary heart disease, may be included.


Many issues exist in the treatment of menopause. Better education related to menopause is likely to make the menopausal transition more comfortable for women and help them manage their symptoms better, especially since going on something like HRT is time-sensitive. HRT has been around for a long time, and there needs to be further research on this treatment option. Understanding its mechanism of action is important for many reasons, such as understanding its link to heart disease. New treatment options should be a priority, but even when they are made, insurance isn’t likely to cover these medications. The way that the United States treats education, research and healthcare around menopause is a huge issue, and the quality of life of menopausal and postmenopausal women is suffering. Menopausal healthcare, as it currently stands, is a human rights violation. There are sex-based differences in research and insurance coverage that make morbidity and symptom prevention unnecessarily insufficient. The United States has the resources to improve this healthcare inequality but chooses not to.


 

Glossary

  1. Disparities: Unjust differences in treatment of different individuals or groups.

  2. Estrogen: A hormone that develops and maintains female reproductive systems.

  3. Kegel exercises: Exercises to strengthen pelvic floor muscles.

  4. Meta-analysis: A research study pools information from many independent studies into one

  5. Libido: Sexual drive and desire.

  6. Perimenopause: The point in time where menopausal symptoms are beginning.

  7. Progesterone: Reproductive hormone involved in pregnancy and menstruation.

  8. SSRI / SNRI: Medications that affect serotonin and norepinephrine quantity, leading to decreased depression and anxiety.

  9. Vaginal atrophy: Thinning and increased dryness of the vagina due to a lack of estrogen.

  10. Venous Thromboembolism: Blood clots in veins that can lead to death.

 

Sources


  1. Andrews, M. The High Cost Of Sex: Insurers Often Don’t Pay For Drugs To Treat Problems. KFF Health News. 2019, Feb 19. https://kffhealthnews.org/news/the-high-cost-of-sex-insurers-often-dont-pay-for-drugs-to-treat-problems/

  2. Cagnacci A, Venier M. The Controversial History of Hormone Replacement Therapy. Medicina (Kaunas). 2019 Sep 18;55(9):602. doi: 10.3390/medicina55090602. PMID: 31540401; PMCID: PMC6780820. https://pubmed.ncbi.nlm.nih.gov/31540401/

  3. Handley AP, Williams M. The efficacy and tolerability of SSRI/SNRIs in the treatment of vasomotor symptoms in menopausal women: a systematic review. J Am Assoc Nurse Pract. 2015 Jan;27(1):54-61. doi: 10.1002/2327-6924.12137. Epub 2014 Jun 19. PMID: 24944075. https://pubmed.ncbi.nlm.nih.gov/24944075/

  4. Hodis HN, Mack WJ. Hormone replacement therapy and the association with coronary heart disease and overall mortality: clinical application of the timing hypothesis. J Steroid Biochem Mol Biol. 2014 Jul;142:68-75. doi: 10.1016/j.jsbmb.2013.06.011. Epub 2013 Jul 9. PMID: 23851166. https://pubmed.ncbi.nlm.nih.gov/23851166/

  5. Lee LV, Foody JM. Women and heart disease. Cardiol Clin. 2011 Feb;29(1):35-45. doi: 10.1016/j.ccl.2010.11.002. Epub 2010 Dec 17. PMID: 21257099. Pract. 2015 Jan;27(1):54-61. doi: 10.1002/2327-6924.12137. Epub 2014 Jun 19. PMID: 24944075.

  6. Marjoribanks J, Farquhar C, Roberts H, Lethaby A, Lee J. Long-term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2017 Jan 17;1(1):CD004143. doi: 10.1002/14651858.CD004143.pub5. PMID: 28093732; PMCID: PMC6465148. https://pubmed.ncbi.nlm.nih.gov/28093732/

  7. Munn C, Vaughan L, Talaulikar V, Davies MC, Harper JC. Menopause knowledge and education in women under 40: Results from an online survey. Womens Health (Lond). 2022 Jan-Dec;18:17455057221139660. doi: 10.1177/17455057221139660. PMID: 36533635; PMCID: PMC9772977. https://pubmed.ncbi.nlm.nih.gov/36533635/

  8. Nachtigall LE, Nachtigall MJ. Hormone replacement therapy. Curr Opin Obstet Gynecol. 1992 Dec;4(6):907-13. PMID: 1450357. https://pubmed.ncbi.nlm.nih.gov/1450357/

  9. Nazarpour S, Simbar M, Ramezani Tehrani F, Alavi Majd H. Effects of Sex Education and Kegel Exercises on the Sexual Function of Postmenopausal Women: A Randomized Clinical Trial. J Sex Med. 2017 Jul;14(7):959-967. doi: 10.1016/j.jsxm.2017.05.006. Epub 2017 Jun 7. PMID: 28601506. https://pubmed.ncbi.nlm.nih.gov/28601506/

  10. Rosen RC, Lane RM, Menza M. Effects of SSRIs on sexual function: a critical review. J Clin Psychopharmacol. 1999 Feb;19(1):67-85. doi: 10.1097/00004714-199902000-00013. PMID: 9934946. https://pubmed.ncbi.nlm.nih.gov/9934946/

  11. Rozenberg S, Vasquez JB, Vandromme J, Kroll M. Educating patients about the benefits and drawbacks of hormone replacement therapy. Drugs Aging. 1998 Jul;13(1):33-41. doi: 10.2165/00002512-199813010-00004. PMID: 9679207. https://pubmed.ncbi.nlm.nih.gov/9679207/

  12. Westerman S, Wenger NK. Women and heart disease, the underrecognized burden: sex differences, biases, and unmet clinical and research challenges. Clin Sci (Lond). 2016 Apr;130(8):551-63. doi: 10.1042/CS20150586. PMID: 26957643. https://pubmed.ncbi.nlm.nih.gov/26957643/

  13. What is Menopause? National Institute of Aging. 2021 Sept 30. https://www.nia.nih.gov/health/what-menopause#:~:text=Menopause%20is%20a%20point%20in,between%20ages%2045%20and%2055


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