The big M, the change, second spring, nightcrawlers, internal furnace – the nicknames and slang for menopause and perimenopause are endless. As a society, we’ve made jokes about menopausal symptoms and downplayed the impact it has on women's health and well-being. As a result, far too many women have suffered in silence, believing that their symptoms were “normal” or too taboo to discuss. Today, only 41 per cent of women in Canada seek medical advice to treat their menopausal symptoms.

“My menopause symptoms interrupted my day-to-day life,” shares Laura, a Women’s College Hospital (WCH) patient. “I started developing night sweats, nausea, itchiness and with the sleeplessness, it just became too much. I was irritable during the day, and as a full-time working parent with aging parents I help support, my plate is just too full to feel that awful all the time.”

Laura’s experience is all too common. “We need to normalize menopause,” says Dr. Michelle Jacobson, gynecologist and menopause specialist at WCH. “Recently, there has been an uptick in media coverage and conversation around menopause. This is such an important step forward. Women are beginning to realize that they aren’t alone in their experience, that treatment options do exist and that there is nothing embarrassing about going through menopause.”

Despite growing public awareness, menopause remains undertreated. “Women are going to their care providers to address their symptoms only to be told that there’s nothing they can do, or that treatment options are too risky,” shares Jacobson.

“The reality is that there is a significant gap in provider training and education around menopause and perimenopause. As a result, physicians don’t feel confident providing care. In some instances, this lack of knowledge even leads to misdiagnosis and patients taking medications that don’t actually address their underlying health issue.”

Much of the hesitation and fear surrounding menopause treatment stems from a study released in the early 2000s, which found that women randomized to hormone therapy had a higher risk of breast cancer, stroke and heart disease. We now know that there were significant flaws with the way the study was interpreted, most importantly, that age matters and that there is a window of opportunity where the benefits of starting hormone therapy greatly outweigh the risks.

“Reanalysis of the initial study data, as well as newer studies, have continually shown that hormone therapy is not associated with an increased risk of heart disease in women aged 50 to 60, and in fact, it might even be protective. The absolute risk of stroke in younger menopausal women is also very low, as is the risk of breast cancer,” explains Dr. Iliana Lega, scientist and medical lead of reproductive endocrinology at WCH. “Unfortunately, the study’s initial findings were so widely accepted that there are still many physicians and patients who believe hormone therapy is dangerous.”

That was the case for Laura when hormone therapy was first presented as an option. “In an early appointment, Dr. Jacobson brought up hormone therapy as a possible option should I need it. But I resisted,” says Laura. “I was under the assumption that there could be extremely negative side effects, and I thought that I was “ok to do it alone, just like my mom and grandmother did.”

To address this knowledge gap, Dr. Lega and Dr. Jacobson collaborate to advance menopause education and care from a cross-disciplinary perspective. In 2023, they co-wrote a review for healthcare providers on menopause treatment in the Canadian Medical Association Journal. The review was the second-most-read article in the journal that year.

“The review provided physicians with straightforward evidence-based guidance on treatment for menopause, notably hormone therapy,” adds Lega. “The popularity of the article and the feedback we received showed us that there's strong interest in this topic. Providers want to address the gap in menopause care; they just need the resources and knowledge to do it.”

Within medical education, Lega and Jacobson are supporting and training the next generation of menopause specialists, working to advance the skills and knowledge of residents and fellows. In endocrinology and gynecology at the University of Toronto, they have set up dedicated fellowships in menopause and women’s health. “Trainees are interested in this field of medicine and are looking for these learning opportunities. Ultimately, having more physicians with a focus or interest in menopause will help to improve access,” says Lega.

While more menopause specialists will be helpful, it will not fully address the gap in care. Existing providers also need education in menopause care. “Women undergoing menopause without complex medical needs and who are otherwise healthy, could be treated by their primary care team. They do not necessarily need to see a specialist,” says Jacobson.

“With this in mind, we both regularly take part in peer-to-peer education – providing lectures and talks to our fellow physicians across a range of specialties, including primary care, gynecology, endocrinology and oncology. We want to collaborate with our colleagues so that treatments for menopause are more widely available. Our hope is that with greater understanding and confidence, more providers will initiate conversations with their patients about menopause and perimenopause.”

For patients with more complex health needs undergoing menopause, Dr. Lega and Dr. Jacobson have developed a series of specialty clinics at WCH that take a comprehensive and multi-disciplinary approach. Women living with conditions like Turner’s Syndrome or those who have undergone cancer treatment, for example, require a more holistic approach that recognizes their specific needs, as well as heightened risks. “These types of specialized menopause clinics simply don’t exist elsewhere in Canada,” adds Jacobson. “We are addressing the health needs of a patient population that wouldn’t be able to receive this type of treatment elsewhere.”

“I am really grateful that hormone therapy was available to me,” Laura shares. "I know experiences vary, but if there’s treatment for symptoms interrupting your daily life, then it just makes sense.   With greater education, information and access to care, menopause could actually be a positive chapter in a woman’s life,” she notes.