Menopause goes mainstream

Menopause, long an underserved health topic, is moving out of the shadows and going mainstream – and Australia’s aesthetic practitioners have an important role to play.

Menopause has long been a taboo subject, often whispered about but rarely openly discussed; a biological stage experienced universally by middle-aged women, yet historically marginalised in both medical research and product development. For too long, menopause has been ignored and symptoms diminished.

Despite the public health importance of menopause, not to mention the economic and social cost, there are important gaps in our knowledge of the effects of menopause on numerous systems of the body.

However, the tide is turning. Menopause has become one of the most talked about health topics and is now being recognised as an urgent matter of public policy. In Australia, the recent Senate Inquiry into Issues related to menopause and perimenopause is setting the stage for a new era of care and understanding for women’s health.

For aesthetic medical practitioners, this overlooked corner of women’s health offers a ripe opportunity to support patients through menopause. As the aesthetics industry continues its shift from simply correcting the signs of ageing to seeking to address ageing at its source, aesthetic practitioners are well placed to play a pivotal role in a perimenopausal or menopausal woman’s care – going beyond skin-deep treatments to address some of the broader impacts of menopause.

Menopause: more than hot flashes

Menopause, a natural biological process, marks the end of a woman’s reproductive years. It is a transitional phase that typically occurs between the ages of 45 and 55, signalling the cessation of menstrual cycles.

During menopause, the ovaries gradually diminish their production of oestrogen and progesterone, the primary female hormones responsible for regulating various bodily functions.

This hormonal shift can trigger a wide range of symptoms, including hot flushes, night sweats, brain fog, mood changes, sleep disturbances, incontinence, vaginal atrophy, physical changes such as weight gain and body fat composition (especially central adiposity), and joint pain and muscle loss.

The menopausal transition extends well beyond these more commonly associated symptoms. Other symptoms include: heart palpitations; menorrhagia; genitourinary syndrome of menopause; oestrogen-deficient skin; dry eye syndrome; neuropathic pain or paraesthesia; snoring; tinnitus; hair loss; allergies; and temporomandibular disorder (TMD).

Menopause is not merely a change in hormones that needs temporary mollification – it is a complex interplay of a variety of factors affecting multiple systems of the female body.

Oestrogen, in particular, has far-reaching effects on the body. It influences how the body uses calcium, maintains cholesterol levels in the blood, and protects against cardiovascular diseases. The decline in oestrogen levels and its association with accelerated bone loss and decreased bone mineral density are well established. It has also been linked to increased risk of cardiovascular disease, diabetes and some cancers.¹

Genitourinary syndrome of menopause (GSM) affects 45 to 63 percent of postmenopausal women in Western populations.² It encompasses a range of symptoms affecting the genital and urinary systems and is characterised by vaginal dryness, irritation, burning and itching, decreased lubrication and discomfort during intercourse. Urinary symptoms, including urgency, dysuria and recurrent urinary tract infections, are also common.

Due to changing sex hormones in the brain, perimenopause symptoms can also be neuropsychiatric and include such symptoms as irritability, low mood, intrusive thoughts,
brain fog, fatigue, loss of joy and insomnia. As much as 45 to 68 percent of perimenopausal women develop depressive symptoms.³

Anxiety is another common psychological effect. There are few studies about anxiety and perimenopause, however some evidence⁴ finds the incidence of anxiety disorder in menopausal women is as high as 25 percent and its severity is related to the severity of the menopausal syndrome. Changes in physical health, such as thyroid issues or sleep disturbances due to night sweats, can also contribute to anxiety and depression.

HRT: Exploding the oestrogen myth

‘There are 3.28 million Australian women aged 40-59 years old today going through varying stages of perimenopause and menopause,’ says Dr Liz Golez, GP-obstetrician and principal cosmetic doctor at Lift Aesthetics in Sydney. ‘Twenty-eight percent of women will experience severe vasomotor symptoms such as hot flushes (the hallmark of menopausal transition/perimenopause and early postmenopause). Despite available safe treatments (menopausal hormonal therapy (MHT) or non- hormonal therapies), more than 85% of Australian women bothered by these symptoms fail to receive approved therapy.

‘Genitourinary syndrome of menopause (vaginal dryness, vulvovaginal atrophy, itching, laxity, and incontinence) affects 50% of post-menopausal women but only 7% get prescribed with oestrogen therapy.’

MHT, then known as hormone replacement therapy (HRT), was highly prevalent in the 1990s in the US, but a single flawed study in 2002 reporting elevated health risks drastically altered its course.

‘I think there are a couple of reasons we have got menopause so wrong,’ says Dr Ginni Mansberg, an Australian GP and television presenter with a special interest in menopause and women’s health. ‘For years menopause was perhaps overmanaged, at least in the US. Premarin – an old-school synthetic form of oestrogen – was the top- selling pharmaceutical in the US in the early 1990s! But a few things happened.

‘First, the 2002 Women’s Health Initiative (WHI) study was reported as showing a link between HRT and breast cancer. Sure, it did – for women with an average age of 63 when starting synthetic high-dose HRT. The quantum of risk? For every 10,000 women on a placebo, we saw 30 breast cancers, but we saw 38 in the takers of HRT. Not a big increase. If you took the group of women who started taking HRT before age 60, there was no increase in risk. But the finer details were just missed by reporters.

‘After this, journalist Barbara Seaman wrote The Greatest Experiment Ever Performed on Women: Exploding the Estrogen Myth. The prevailing view became that taking HRT is deadly and basically an indulgent beauty treatment, that to ask for it showed weakness. Women shut up. Doctors stopped learning about menopause and the whole thing fell under the cone of silence.’

Dr Judy Craig, medical director of Natural Looks Cosmetic Medicine in Perth, says this narrative continues to be perpetuated. ‘A large barrier to positive action to address the medical and economic consequences of oestrogen deficiency (menopause) is a reluctance of organisations, including medical advisory bodies and governments, to embrace the latest research data showing thepositive health benefits of MHT and new evidence in breast cancer risk with body-identical MHT over synthetic MHT,’ she says.

‘Until health professionals advising government accept data from recent studies that show that body-identical oestrogen alone reduces the risk of breast cancer, and combined with micronised progesterone has not been shown to increase the risk of breast cancer⁵, changes in the management of menopause will not occur, or will change very slowly as many doctors are reluctant to go against the recommendation of advisory bodies. Greater confidence in the safety of body-identical MHT will result from further studies if they confirm the findings in the study by Emilie Cordina-Duverger et al5.

‘Globally, MHT prescribing in women aged 45 to 64 averages only 5%, and in Australia, 14%. This is despite studies showing reductions in all-cause mortality and an increase in longevity for women on body-identical MHT.’

Dr Craig argues that only by improving awareness, increasing research funding and fostering open dialogue can we begin to address the gaps in menopause care and support. This shift is crucial not only for improving the quality of life for women but also acknowledging and addressing the broader economic and social costs associated with menopause.

‘For change to occur, I believe that we need more women in all aspects of management, government, research and education at an executive level and we need them to be informed on the issues facing menopausal women and be aware of the latest research and economic impact,’ she stresses. ‘Increasing public and government awareness may in time precipitate change.’

Medical misogyny & paucity of research

Appropriate care for menopausal women has been thwarted by various barriers, one of which is a paucity of research. Menopause has long been marginalised as a health concern, deemed insignificant when compared to other medical conditions. It can be argued this stems from societal tendencies to undervalue women’s health issues, particularly those related to ageing.

‘Historically, women’s health issues have been neglected, trivialised and underfunded,’ says Dr Craig. ‘While many are familiar with how the concept of “hysteria” was used to dismiss and pathologise women’s challenges in the 18th and 19th centuries, they may be shocked to realise that before 1993 women were rarely included in clinical trials, leading to a lack of proven data on the effects of many drugs and treatments on women.

‘In addition, there has been little investment in research into women’s health. A report from McKinsey and company stated that approximately one percent of healthcare research and innovation (2021) was invested in female-specific conditions beyond oncology.

‘This neglect of women’s health research has also led to an ignorance of the prevalence of the medical, psychological and economic impact of menopause on women. In 2017 a review of the literature found that there were few studies assessing the impact of menopause transition on women’s careers. Studies addressing the economic impact of menopause transition have predominantly been published since 2022.’

According to a 2023 perspective in Nature Ageing⁶, less than one percent of published studies of the biology of ageing considered menopause. This gap in research must certainly translate to gaps in women’s health care.

‘When we look at age-related diseases, over 75 percent of them are likely influenced by menopause in one way or another. But the great majority of preclinical biology research studies in ageing fail to consider menopause in their experimental setup,’ lead author Fabrisia Ambrosio, PhD, shared in an interview with Harvard Medical Magazine.⁷

‘Menopause is inextricably intertwined with ageing in female individuals. On average, females will live about a third of their lives postmenopausal. We lack data to understand how menopause affects ageing and how it might contribute to disease or age-related declines. In preclinical models, it’s something that we just haven’t effectively addressed, and so we haven’t been able to study it well.

‘The science has so much catching up to do. Hundreds of years of research studies have been dominated by male animal models and male humans.’

In February 2023 the Australian Government established a National Women’s Health Advisory Council to examine the systemic issues impacting gender inequities in health outcomes and improve Australia’s health system for women and girls.

The council will provide strategic advice to the government after looking at the healthcare offered in areas such as menstruation, reproductive healthcare, menopause, medical consent and pain management.

Dr Sarah White, CEO of Jean Hailes for Women’s Health and a member of the Women’s Health Council, wants the agency to address gendered gaps in research. ‘So much medical research has studied males and then generalised those findings to females,’ she told abc.net.au.⁸

‘The Therapeutic Goods Administration (TGA) should not approve medicines unless there is sufficient data around quality, safety and efficacy for males and females separately,’ Dr White says.

‘As a society, none of us seems to have a problem understanding that we need paediatric research and children’s hospitals. We intuitively understand that small boys are not the same as men, but for some reason, we treat women as if they’re small men.

‘We also need different treatment guidelines and public awareness campaigns. If you look at something like menopause, it affects 50 percent of the population and, of those, 10 percent will have symptoms that really impact their ability to work, live, study and play. But we still don’t have anywhere near enough research on it.

‘We need to make sure there is equality of funding for conditions like endometriosis and menopause, and perhaps even more funding, to make up for injustices in the past.’ Tricia Currie, head of the Victorian Women’s Health Council and CEO of Women’s Health Loddon Mallee, told abc.net.au8 that women’s voices are not being heard in the healthcare system.

‘When we do our work as women’s health services and ask women what’s missing from medical care, time and again they say ‘we’re not being heard’. They might be speaking, they might be telling their story, but they’re not actually being heard.

‘There’s unconscious bias within the health care system, which is why it is important that we have structures around decision-makers that ensure governments are hearing from women, and diverse women, about not only what the issues are but what some of the potential solutions are.’

Knowledge gap amongst HCPs

There remains a gap in knowledge of the complexities of menopause amongst healthcare practitioners, resulting in inadequate health care and/or a deficiency of care options for those who are menopausal or in the perimenopausal stage.

Dr Liz Golez says the menopause ‘knowledge gap’ started 20 years ago. ‘Research shows that GPs, gynaecologists and pharmacists mostly lack the skills and confidence in managing menopause,’ she says. ‘The medical knowledge gap began 20 years ago when the conflicting WHI study spread false and frightening information about HRT.

‘The knowledge gap trickles down to the consumer, the women who have been failed by the medical system, since they were never empowered by their women’s health provider to watch out for these symptoms of menopause or get started on MHT or non-hormonal treatments in a timely manner.’

‘We certainly have to acknowledge that treatment in this space is suboptimal,’ Dr Ginni Mansberg agrees. ‘It is not taught in medical school or even as part of GP, endocrinology or gynaecology training. For your doctor to be ‘up to date’, they need to invest a lot of time and money to join societies and upskill their knowledge on their own. That’s not to say that the experiences of serious medical gaslighting that I hear about every single day are okay; it’s just awful.’

In a 2023 perspective in the Medical Journal of Australia, the authors write that lack of clinician knowledge, poor access to services, negative attitudes and lagging research have led to substandard menopause‐related health care.⁹ ‘Irrespective of symptoms, menopause causes silent biological changes that may increase women’s risks of cardiovascular disease, diabetes, osteoporosis and some cancers. Consequently, it should be expected that health care providers, especially general practitioners, are equipped to provide evidence‐based menopause advice to the 3.28 million Australian women aged 40–59 years. Sadly, this is not the case.

The authors argue that first-line management of menopause‐ associated issues should be occurring at the level of primary care, yet GPs and specialists are not equipped to confidently manage menopause and frequently recommend unproven, and often ineffective, complementary therapies before prescribing MHT or effective non‐hormonal therapy.

‘Contributing to this health care knowledge gap are two decades of widespread dissemination of conflicting, and often frightening, information about menopause treatment, and omission of menopause from most undergraduate and post‐graduate medical and allied health training. Thus, state‐of‐the‐art menopause care is not available to most Australian women,’ the authors state.

Menopause and Public Policy

Governments across the world are beginning to recognise menopause as the urgent matter of public policy it is. The National Institute on Aging in the USA and the National Health Service (NHS) in the UK have introduced guidelines and resources specifically targeted at menopausal care.

In the UK, where menopausal women are believed to be the fastest-growing workplace demographic, more than 500 workplaces have been certified as ‘menopause-friendly’. Anti- discrimination laws that include menopausal status have also been bolstered, with employers now legally obliged to make ‘reasonable adjustments’ for women going through menopause.

In November 2023 the US government created a Women’s Health Research Initiative to determine gaps and infuse new funding, the first tranche of which is US$100 million. Further, a new bill, the Menopause Research and Equity Act of 2023, has been presented to Congress to ensure commitment to ongoing research related to menopause, perimenopause or mid-life women’s health.

In Australia, there is a push for menopause to be more widely recognised as a significant health issue – and the recent Senate Inquiry suggests the issue of menopause is finally beginning to receive some attention.

‘As the awareness of the economic impact is very recent, it will take time to translate into affirmative action in many nations,’ says Dr Judy Craig. ‘I believe that the UK has led the way in this regard. The UK government passed the Menopause and the Equality Act in 2010, which details how workers may be impacted by menopause and outlines the legal obligations that employers have under the Act. On 6 March 2023 the Minister appointed Helen Tomlinson as the Government’s DWP Menopause Employment Champion. Tomlinson’s aim is to educate women and encourage employers to sign the Menopause pledge. This is an important step in the process of raising awareness and supporting women in the workforce whilst they navigate the transition to menopause and then manage post- menopausal changes for life.

‘In contrast, the Australian government initiative, announced by the Albanese government, is to invest in digital tools to improve access to quality care for women. I could not find any workplace affirmative action.

‘A colleague of mine shared the experience of a woman she was treating for severe incontinence requiring full pads and frequent trips to the bathroom to change. She was perceived as inefficient by her supervisor and lacking dedication to her job and was fired. As a result of this, she became homeless. Her homelessness resulted from a combination of embarrassment, preventing her from seeking help earlier, little or no government funding to provide treatment for women with incontinence, and lack of workplace understanding and support. Employer awareness of menopausal issues and a supportive work environment could have resulted in help, rather than unemployment and homelessness.’

The role of Aesthetic Clinics

‘Menopause care aligns seamlessly with the mission of aesthetics and anti-ageing clinics, which focus on addressing the signs and effects of ageing,’ says Dr Judy Craig. ‘The hormonal changes associated with menopause, particularly oestrogen deficiency, contribute to accelerated skin ageing through collagen degradation. By offering treatments that address both the hormonal imbalances and their aesthetic consequences, clinics can provide more comprehensive care and significantly benefit their clients.

‘In addition to facial treatments, many devices used for addressing facial ageing, such as radiofrequency or laser therapies, have been adapted to treat vaginal changes associated with menopause. Both areas experience similar issues; loss of mucosal and skin elasticity and thickness, and collagen degradation, making it possible to use these technologies to address concerns in both domains. Electromagnetic stimulation (such as Emsella), electrical stimulation (such as EmpowerRF (VTone)), PRP and exosomes can also provide relief from many of the symptoms of GSM, all non-surgically and with a short recovery time.

‘Menopause can be a sensitive topic, and the environment of an aesthetic clinic – often characterised by its relaxed, private setting – can facilitate open conversations about these issues. The extended treatment times and personalised care offered by these clinics provide an ideal opportunity to discuss menopause, its symptoms and available treatments. This not only helps build trust and loyalty with clients but also allows practitioners to address incontinence and sexual health concerns in a supportive manner. Having advanced devices available can also serve as a practical tool to initiate discussions and explore treatment options for these often-overlooked aspects of menopausal health.’

Dr Ginni Mansberg believes arming yourself, as an aesthetic practitioner, with knowledge about menopause is vital. ‘The women in your clinics are very likely to be at this stage of life. Understanding the hormonal swings and their impacts allow you to not only connect better but to be her superhero,’ she attests.

‘In addition, both perimenopause and menopause have enormous impacts on the skin. Understanding the role of oestrogen in the skin and the impacts of losing it will alter at least the topicals you suggest for your patients.’

‘To be honest, I think every health care practitioner needs this understanding – from rheumatologists who assess women with aches and pains to cardiologists who see the women with palpitations to neurologists who see women with escalating migraines or feeling like they have dementia. And don’t get me started on psychiatrists who continue to prescribe anti-depressants that are notoriously unhelpful at this stage of life instead of hormone therapy!

‘In the UK, many practitioners practice both menopause care and aesthetics. They do seem to go hand in hand.’

Chiza Westcarr, a menopause wellness coach and aesthetics educator, says the bread and butter of modern aesthetic practices is perimenopausal and menopausal women with ageing concerns.

‘There are many of us in aesthetics that do not make the connection. Here are just some of the changes that result in women flocking to aesthetic practices, desperate for help: collagen and elastin decline rapidly in the first 5 years; bone resorption occurs; dehydration and dryness increase; the skin thins; pigmentary changes become more noticeable; and wound healing slows as do cytokine and growth factor signalling, driving inflammation and contributing to the common skin-associated symptoms of menopause,’ she says.

Westcarr, who is hosting the Australian aesthetics industry’s first menopause symposium, Thriving Through Menopause, in February 2025, stresses that upskilling is the first step. ‘As aesthetic practitioners, we most definitely need to revise our approach, and to learn about menopausal skin and menopause as a whole, as this is not taught in any formal curriculum.

‘There are so many opportunities for practices to diversify and adapt their service offerings. We owe it to ourselves and to our patients.

‘Patients’ concerns are so much more than facial lines and wrinkles,’ she continues. ‘Every organ system has receptors for oestrogen; the hormonal decline causes changes to all aspects of the menopausal woman’s life – from brain fog and increased dementia risk to GSM and libido loss. By understanding the changes going on, we can not only provide a treatment journey but also resources and referrals to help her make informed choices.’

Charlotte Body is the Founder of Menopause in Aesthetics, a UK-based conference focusing on the synergy between menopause and aesthetics. She says that with the large majority of the demographic for aesthetic clinics being peri- or post-menopausal, coupled with many women reporting difficulty accessing support through their GPs, more and more aesthetic clinics are expanding their services beyond merely treating the skin- related impact of menopause.

‘Many women feel let down by their GPs when it comes to menopause, and aesthetic clinics are increasingly becoming the place they turn to,’ she says.

‘With the majority of patients visiting aesthetics clinics being in their 40s and 50s, practitioners are well placed to take the services they offer these women to the next level beyond merely addressing their lost collagen, lines and wrinkles.

‘We believe the future of aesthetic medicine isn’t anti-ageing; it’s agelessness and longevity, a holistic and 360-degree approach to menopause.’

The intersection of menopause and medical aesthetics presents a unique opportunity to provide women with better menopause care. Aesthetic practitioners can play a pivotal role in offering more than just skin-deep solutions and provide a more comprehensive approach in managing some of the broader impacts of menopause. AMP