Why this book?
I have been a gynecologist for almost forty years, and in my professional career I have had occasion to speak with many women about their health; as one may imagine, menopause has often been a major subject of these conversations. Over the years, I have found myself dealing more and more with this subject, partly because my patients and I simply happen to have grown older together, and partly because this biological process of menopause combines hormonal (endocrine) aspects with aspects to do with emotions and relationships, which I deal with as part of my second professional identity, as a qualified sexologist and sex therapist.
So I was the last person likely to be indifferent to the changes that the aging process brings about in a couple’s sex life!
The unmistakable sign of menopause is the cessation of menstruation, caused by metabolic phenomena affecting the body (biological aspects) and one’s emotions (psychological aspects), and it is accompanied by aging processes that follow independent biological mechanisms. Together, they are responsible for all those changes occurring in maturity that are not exactly “welcome.” The way a person behaves, accepting these rather unwanted events, and taking the best from them, represents the key to aging in a positive way, while a slight vein of anxiety, or depression, is the mirror of one’s reaction as one adjusts to the new situation.
In any transition phase, when life inevitably leads towards something that has to happen, and that may not always be pleasant, one needs a safe environment in which to voice one’s doubts and - why not? - also one’s fears. Generally, women do not seem to have a clear idea of what to expect in this phase of life, perhaps because the experience has not been passed on from one generation to the next; might it be possible that mothers have not wanted to worry their daughters prior to the event? This is likely. In any event, many women are in the dark as regards what lies beyond menstrual irregularities, and unfortunately they are also the target of information in the media which, by its popular nature, cannot be exhaustive, and cannot respond to the doubts of an individual person.
Many women express the need to know whether what they are going through is normal, what the limits of this normality are, how to combat a normality that worsens the quality of life, and especially how it is possible to realize whether a symptom is being transformed into an illness. Others ask whether the right thing to do is to treat minor complaints, with the certainty that medication will not cause worse damage. If we remember the controversy over hormone treatment for menopause that sprang up more than 10 years ago, and that has not yet been completely resolved, the dilemma is not as off-the-wall as it may seem. In this connection, I recall a former school friend of mine, just over 40 at the time, who came to see me at the first symptoms of menopause. I spoke to her as delicately as I could about possible hormone therapy. In response, she showed me a page from a fashion magazine, and told me flatly that that regime was the cause of breast tumors, and was therefore to be rejected outright. By contrast, another friend regarded menopause as the most wonderful time of life for her, because it coincided with falling in love and marrying for the second time. Her happiness over her personal situation meant that she did not even notice the physical inconveniences!
A gynecologist is that doctor who is always sought when a patient has a complaint involving the genitals, or one of the functions exercised by that part of the body: reproduction/contraception, the urinary tract, and the sexual function. As such, a variety of requests are made to gynecologists, but not all of these fall within her or his field of expertise. As a result, the gynecologist acquires considerable experience and knowledge of these requests, as well as women’s expectations and their difficulties.
I feel particularly caught up in this mechanism, because, in my dual specialty of gynecologist and doctor of sexual medicine, I also treat men, and I have learnt to understand their emotions and their expectations regarding sexual health and relationships. I thus have the privilege of noting the joys and tribulations of the human spirit from a dual perspective.
After many years, I am still enthusiastic about my work, which I find highly interesting, creative, and always new. From the hours I have spent with my female patients came the idea for this book, that offers an overview of the issues associated with the two faces of the menopause: the normal (physiological) face, that only requires awareness and a little patience, and the more problematic face, for which medical intervention may be necessary.
I thank all of my patients for the trust they have shown me, and for having taught me the ability to listen, without which no diagnosis is possible, and no suitable intervention can be devised. Accordingly, this book is dedicated to them, and to whoever wants to get to know the myriad aspects of menopause as a physiological phenomenon, albeit a rather challenging one.
The issue of aging is more important now than in the past, given that the average lifespan has gotten longer. I believe that addressing menopause in a positive way, understanding its mechanisms and taking action against its negative effects, or, better still, preventing those negative effects, can be a wonderful way to tackle aging with determination: vitality, awareness, emotional balance and good health are the best ingredients for a journey that is set to remain a long one.
This volume is written in a good-natured way, to help women to understand somewhat better an event which affects them closely, in the hope that they may get useful information from it, as well as personal benefit. It is written also for those who, working in the health profession as care workers and therapists, want a few extra pointers for advising their patients as well as possible.
What is Menopause?
Only recently has menopause become a subject of interest in itself, also to researchers. However, this should be no surprise. Indeed, at the start of the 20th century women in Europe had a life expectancy of just 48 years. This has gradually increased, thanks to progressive improvements in social and economic conditions in European countries. Today, unless one has a major metabolic disease, the average lifespan is 80 years; it is predicted that, in 2020, in the United States alone, there will be 46 million women over the age of 50 who could live another thirty years or so, namely a third of their lives, in menopause; according to UN projections, this figure is set to rise. In the year 2050, women aged 60 or over will make up 40% of the female population in Europe, and 23% of the global population, thanks to better and better living conditions. It is clear that in the Western world an ever higher number of older seniors, men and women, who have surpassed the age of 85, will maintain their intellectual vivacity, the product of a wellbeing that is more than just the absence of illness. By comparison, at the end of the second millennium, life expectancy in sub-Saharan Africa was just 52, and in many African nations it actually fell by three years, owing to the AIDS epidemic.
In the Western world, the average age of menopause is 51 or 52, a figure that has remained unchanged in the last few decades. However, the age is lower in women who have a poor socio-economic level.
Menopause as a biological phenomenon remains the same, but as a subjective experience it is today very different from the past, thanks to the fact that living conditions in Western countries have greatly improved compared to the early 1900s. Continual social progress affords us a level of wellbeing never seen before, with good quality food, comfortable housing, and the possibility of accessing increasingly effective medical care. The peak of sophistication in the medical field, the miracle which tends to go unnoticed, is the possibility of early diagnosis and, in some cases, even prevention. This is not the best of all possible worlds, as I am well aware, but the well-being that Western society has achieved was unthinkable up until just a few decades ago.
The first manifestations of menopause (usually a major delay in the cycle, or a series of hot flashes) always arrive unexpectedly. I don’t know a single woman who has not said, somewhat agitatedly: “No, it’s not possible, it’s too soon! Doctor, what can it be?”
Many of these women, namely today’s 50-somethings, are in an active phase of their lives, or even “super-active”, because neither their working life nor their role in looking after the family has come to an end. There was a time when it was said that the years of menopause were emotionally difficult because they coincided with other important changes: children leaving home and leaving the world of work; there was talk of the “empty nest syndrome” to describe a family and social situation in which, after having been busy at home and outside the home for years, the woman found herself “unemployed.” After a life spent juggling two full-time jobs, it suddenly seemed that nobody needed her any more, and it was supposed that this sense of not being needed might explain the mood swings and dissatisfaction that many women complained of. Today we are seeing that the social situation is completely different (the exact opposite of the “empty nest”!), because reproductive trends have changed, and many women have their first child around the age of 40. The life cycle remains the same, but the phases that comprise it have become longer: one enters the world of the workplace, and one thinks about a family later; of course, a woman in her 40s today no longer resembles the 40-somethings of 20 years ago, and, in terms of her life phases, this is the right time to think about a child.
Because one enters the world of work, and only thinks about starting a family at an older age, the nest of a woman who has just entered menopause, and who had a pregnancy around the age of 40, is populated by one or more lively adolescents who keep their mum constantly on the go.
In this respect, I see menopause as a new territory, whose essence is social rather than medical. Indeed, women in their 50s and 60s are the ones who have shown how many wonderful and gratifying things the years of one’s “young old age” might still offer. They are women who, in growing older, have continued to remain naturally attractive, to work with creativity, to make room for interests that they were unable to pursue in their years of full-time employment, and who have enriched their emotional life by looking after grandchildren and the extended family. Credit for this lies not just with them; it also lies in the social development in which they have been fortunate enough to live, and to grow old. I can’t help thinking that what we today regard as “normality” has been achieved thanks to the generations of women who, together with their men, paved the way for these privileges to become real.
Women entering menopause today belong to the generation of Baby Boomers, born in the prosperity of the post-war years, for whom parity of rights between the sexes and widespread access to education have been acquired rights to be fought for. Thus, the Baby Boomers were the trailblazers for the generations that followed, and they very much continue to be pioneers in this phase of their life, too. Arriving at menopause after having been privileged by culture and social well-being, this generation has basically established new models of behavior also in the medical field, because it was the first to become aware of the importance of replacement therapy, of prevention, and of early diagnosis of illnesses such as cancer of the uterus and breast cancer, as well as the first to decide to maintain professional and personal interests, and to choose an active lifestyle that fulfilled the biological needs of the elderly.
Kandinskij gives a wonderful image of the person who is the first to bring about a change, and describes this person as the tip of the iceberg, one that, on emerging, pulls along all the rest, who are still underwater. Similarly, women going through menopause today are paving the way for new behavioral models, and show how growing old today is an adventure that is yet to be written, owing to the infinite possibilities we have for maintaining a state of extended physical and emotional well-being, and also for attenuating its more disagreeable physical aspects.
Naturally, there are patients who present with purely medical ailments, such as uterine fibroids and heavy menstrual bleeding, and the problems of older women who have been problem-free in the initial phases, but, in the longer term, have developed ailments mainly linked to tissue atrophy. A less numerous group, but one no less important, comes to talk about sexuality, which has started to become problematic: sometimes because there is a loss of desire, sometimes owing to a physical difficulty, and other times owing to a difficulty on the part of their husband.
But why is it so important to get ready and enjoy life in the post-menopause years? The answer’s simple! If menopause occurs shortly after turning 50, and women are living into their 80s on average, it follows that we will have more years to live after menopause than the whole duration of fertility. What’s more, even the most glamorous 50-somethings eventually hit menopause: All women experience alterations of sleeping patterns, mood swings, changes in circulation (the notorious hot flashes!), and vaginal function (dryness that makes sexual relations difficult). While these are inevitable, one way or another - just like wrinkles! - they can, however, be considerably reduced in their seriousness by careful prevention.
We know that growing older is inevitable, and that one day we will be forced to reckon with a string of physical and mental limitations, but we also know that many resources are available in the West to enjoy life to the full, even in this phase of life. Qualitative improvements in lifestyle, and modern medical tools, afford opportunities that were previously unthinkable, and so looking backward at our grandmothers and mothers shaking their heads and refusing help, because “as they managed, so we will manage, too”, is not the right attitude. Previous generations had a life expectancy that was around 10 years less than ours, and, for this simple reason, they were less exposed to the functional limitations of a debilitating and progressive illness such as osteoporosis and bone deformations. Certainly, to get results in the field of prevention it’s not enough for the patient to have theoretical information: consultation with a doctor is needed to help people achieve this awareness.
Debunking myths and legitimate expectations
The task of a woman in her 50s is not to stay young forever; it’s to build a future for herself in which her previous life represents her inheritance, and her future life represents opportunity. The future depends on expectations that a person has, and in some sense on their dreams.
The most absurd myth, or counter-myth, that needs to be debunked right from the start is that good looks don’t matter!
Anyone who says this is a liar, and a shameless liar. Good looks are important in every aspect of life, including the professional aspect. But while the beauty of adolescent models with perfect make-up who we admire in fashion magazines is beyond reach, the personal style of a real, fulfilled woman, who is happy with the way she is, and who takes good care of herself, is unbeatable. What does it mean to take good care of oneself? Well, it certainly consists in looking after one’s physical well-being, which comes from exercise and a healthy diet. There is a wide choice of ways to maintain muscle tone and burn off a few calories along the way: one could go back to practicing a sport played in one’s youth, which one perhaps was later forced to drop, or else try a completely new exercise with gentle physical activity that does not involve any danger of injury. These include yoga, Nordic walking and acquagym, or one could even simply start the habit of going to work on foot, or parking the car a few blocks further away. Actually, three or four hours a week of brisk walking are enough to lend our metabolism a hand, so… no excuses!
As regards diet, the same applies, to some extent: There is no need for heroism (what would the world be like without Nutella?); a little commonsense is all it takes. Just organize your meals so you can relax and enjoy them with friends and family, and make sure that your lunch break is actually a real break from work, possibly with one or two co-workers (why not?). A moment of socialization improves one’s mood and helps to keep the amount of food under control.
After all, healthy eating in Italy is easy; for years our diet has been recognized as the most balanced, including seasonal products rich in fibers, vitamins and salts that are cooked without too many fats. Of course, there is no such thing as a miracle menu (the most popular are based on boiled fish and fresh vegetables) but, apart from the dominant factor of genetic predisposition, a healthy diet has the most important role in safeguarding health. The benefits are seen in a lower incidence of diabetes, hypertension and cardiocirculatory disease, and that is why it is absolutely necessary to be careful and aware.
The human body is a collection of organs that work in close contact with each other, and it is inconceivable that the health (or otherwise) of each does not influence the next. This goes beyond the physiological aspect, and also includes the domain of feelings and emotions, in which there are many more variables.
Well-being is often also down to interpersonal relations, built up over the years. This gives rise to a way of living that includes a range of attachments, such as old and new friends, pastimes and interests that help to develop a network of social relations, and obviously the family ties that time consolidates, smoothes, and makes more mellow.
While we’re at it, let’s debunk another stereotype: women of a certain age no longer progress in their careers… Says who? With the benefit of her accumulated experience and self-assurance, a motivated woman can achieve any goal without needing to compete against younger women, or she can also decide to make a radical new departure in her working life. In this, women are freer than men, partly because by nature they are more aware of their needs, and partly because society puts them under less pressure. A woman aged 50, the age when menopause reigns supreme, can freely choose to dedicate her time to more gratifying activities, and not consider the deadlock in her career as a failure: there are one’s loved ones, her long-term companion and her personal interests, from which up until now she has stolen time. Are we certain that this decision is less commendable?