Media coverage and changing attitudes are breaking down the taboo around menopause and perimenopause, allowing women to be more open about the struggles they face. But the decline in hormones behind menopause can trigger a whole constellation of health problems which vary from woman to woman. The symptoms of these health problems often overlap with yet other, separate conditions common around mid-life. As a result, women with menopausal symptoms are often left floundering: suffering ill health and trying to get the right treatment by trial and error.
Many people aren’t fully aware how this affects women’s lives and impacts their healthcare, and diagnostics developers could do more. We are a group of women who work within TTP’s diagnostics team – offering unique insight into the ways scientific innovation can address women’s health challenges – and we believe that it is time for broader recognition that more effective diagnostics could massively aid in improving the lives of menopausal women, making this time less burdensome, alienating and difficult.
What is menopause?
Menopause is strictly defined as the permanent cessation of menstruation, after 12 consecutive months without a menstrual period, marking the end of a woman’s reproductive phase. Perimenopause, the transitional period preceding menopause, can span a number of years of a woman’s life, often starting in the late 30s or early 40s, but can continue into the late 50s.
Clinical definitions aside, many women in mid-life experience changes and symptoms – what we call “menopausal symptoms” – that could be the beginning of menopause. This transition often coincides with a double burden of peak career and caregiving demands for both children and/or aging parents. This confluence of biological transition and social responsibilities presents unique challenges for well-being, workplace productivity and homelife.
While vasomotor symptoms such as hot flushes and night sweats are commonly recognised as manifestations of menopause, the symptom profile is far broader and multifaceted. Common menopausal symptoms include psychological effects (e.g. mood swings, anxiety, depression), cognitive changes (e.g. memory lapses, difficulty concentrating), musculoskeletal discomfort (e.g. joint pain), urogenital symptoms (e.g. vaginal dryness, urinary incontinence), and metabolic shifts (e.g. weight gain, altered lipid profiles).
Not all women experience menopause with significant symptoms. Some report minimal or no disruptive effects, illustrating the biological and genetic diversity underlying hormonal changes. Understanding these differences is critical for healthcare approaches and for avoiding one-size-fits-all assumptions in treatment – and better diagnostics can be part of this.
Diagnosis, recognition and tracking of menopause
The highly variable age of onset of menopausal symptoms, coupled with overlapping symptoms due to other conditions, can mean that women experience symptoms for years before menopause is confirmed and lead to under-recognition or misattribution to lifestyle or mental health factors.
The main diagnostic approaches rely on single-time-point hormone measurements (e.g. follicle-stimulating hormone, luteinizing hormone and oestradiol). But this “snapshot” approach fails to reflect the dynamic and cyclical nature of the endocrine system and in particular the high intra- and inter-day variation of hormone levels during perimenopause. Because of this, many health systems recommend the diagnosis of menopause based on symptoms alone.
This diagnostic ambiguity often leads to delays or barriers in accessing the most appropriate care, such as the most suitable types of hormone replacement therapy (HRT).
The ambiguity cuts two ways. HRT has been a subject of much controversy over the years and has been associated with an elevated risk of some types of cancer and stroke. The risks and benefits are now better understood, but HRT usage is still associated with small but real risks. Despite this, many women continue to be offered HRT without a clear diagnosis.
Technologies enabling continuous or high-frequency measurement of key biomarkers (e.g. oestradiol, progesterone, luteinizing hormone) can provide a more complete picture of hormonal rhythms over time. This opens the door for more personalised and proactive management of perimenopause and menopause.
A number of companies now offer multi-day testing strategies often via a urine dipstick coupled with a smart phone app. For example, ClearBlue, an established player in the Women’s Health market, is now offering such a test.
Similarly, emerging saliva-based platforms may enable high‐frequency snapshots leading to hormone insights at home. Eli Health is one of the companies piloting such approaches. Clinical data and healthcare professional acceptance for continuous or high-frequency hormone monitoring are lagging behind, but such tests may offer a valuable tool.
But for the time being the basic difficulty is that menopause symptoms can be easily mistaken for conditions that present similarly. Equally, other conditions can be mistaken for the menopause and left untreated.
Hypothyroidism
Hypothyroidism (underactive thyroid) and hyperthyroidism (overactive thyroid) are two other conditions that are difficult to distinguish from perimenopause, due to similar symptoms. Like menopause, hypothyroidism can cause weight gain, fatigue, brain fog and mood changes, while hyperthyroidism presents with hot flushes, fatigue, and heart palpitations.
Both can occur spontaneously, are more common in females than males, and occur later in life, making them prime candidates for being mistaken for perimenopause. Use of an appropriate diagnostic test is important to ascertain whether symptoms are due to menopause or an indication of another underlying condition, such as a thyroid issue.
The cornerstone of hypothyroidism diagnosis is TSH level measurement. TSH is generated by the pituitary gland to stimulate the thyroid gland; in hypothyroidism, this level is elevated to compensate for the underactive thyroid.
A healthcare provider would normally send for a blood test when presented with symptoms matching hypothyroidism, but this adds time to the diagnostic journey and a pre-screening test could be useful for someone suffering with symptoms to rule in or out the condition. Having a diagnostic test for TSH at the point of care would allow the right treatment to be prescribed right away or at least allow the healthcare provider to move onto other possibilities efficiently.
Anaemia
Anaemia is another persistent women’s health issue that intersects with menopausal symptoms. Due to menstruation, women easily become anaemic when they don’t eat enough of iron-rich foods. The effect can be exacerbated by heavy periods, which become more common as women move into the perimenopausal years and can further accelerate iron loss.
Iron deficiency is cumulative, and the effects can be difficult to recognise in the early stages. Common symptoms include tiredness, feeling faint or dizzy, palpitations and shortness of breath. Many of the symptoms of anaemia are similar to those encountered in menopause and may be easily confused.
If iron deficiency is identified properly, however, it can be rectified with iron supplements. Conversely, if anaemia is ruled out other treatments such as HRT may be more confidently considered.
The use of appropriate diagnostic tests can ensure that the right treatment is started promptly. As with the other conditions described above, a rapid and accessible test for iron deficiency performed at the physician’s office would be hugely beneficial.
Genitourinary syndrome of the menopause (GSM)
Genitourinary syndrome of the menopause, or GSM, is a rarely discussed aspect of the menopause, perhaps because of stigma or a feeling that it shouldn’t be part of ‘polite discussion’.
Nevertheless, GSM may affect as many women as the more widely known symptoms such as hot flushes. Estimates vary depending on the precise symptoms, but GSM affects around half of all postmenopausal women and can also affect around 15% percent of pre-menopausal women1. Symptoms can begin in the early forties and come as a complete surprise to those encountering them.
The onset of symptoms can be quite sudden and often confused with other conditions, particularly in younger women. Essentially, declining oestrogen levels affect tissues where oestrogen receptors are present, in particular in vaginal, vulval, and bladder tissue, and can cause these tissues to weaken, leading to a variety of problems collectively known as GSM.
The symptoms of GSM can include more frequent urinary tract infections, which can usually be treated with a course of antibiotics. However, UTI diagnostics have some well-known weaknesses, as we have discussed before. For example, commonly used UTI detection dipsticks have very limited sensitivity – they may miss an infection – and culture-based methods take several days and only detect a small range of bacteria and only when present at high levels.
This lack of reliable diagnostic testing for UTIs often leads to clinicians prescribing antibiotics without a positive test result. However, GSM can also lead to people feeling like they have a UTI when they actually don’t have an infection, which is thought to be caused by lack of oestrogen making the bladder walls more sensitive and prone to inflammation.
The upshot is that women may be prescribed several rounds of antibiotics before it is realised that the problem is actually GSM rather than infection. When women are treated with topical oestrogen, the UTI-like symptoms often resolve. The lack of a reliable UTI diagnostic test means that women can be caught in a bewildering cycle of antibiotic use for apparent UTIs that never resolve.
In a similarly confusing clinical situation, lack of oestrogen can make vulval and vaginal tissues sore and inflamed and this can feel like the symptoms of candidiasis (thrush). It is not unusual for women to be treated for candidiasis multiple times before it is realised that the true root of the problem is GSM.
Existing diagnostics for candidiasis are rarely used, and patients are often just treated based on their symptoms. In menopausal women, this can mean receiving an ineffective treatment for fungal infections with poor side effect profile. With accurate diagnostics for candidiasis, this painful and disheartening quandary could be avoided.
So, what is needed?
With appropriate diagnosis, GSM, UTIs, and candidiasis can each be treated simply and effectively. But without an appropriate diagnostic, getting to the right treatment can take many appointments and much guesswork, leaving women suffering unnecessarily. Diagnostics companies could help by considering a panel test focussed on the symptom groupings often encountered by menopausal women.
Danger of ignoring more serious conditions
At the same time, there is a real risk that menopause is over-relied on as an explanation for a multitude of ailments, meaning that potentially more serious diagnoses are overlooked.
For example, many women report drenching night sweats and fatigue as symptoms of the menopause. These prominent symptoms overlap with those of lymphoma, a form of blood cancer; almost a third of lymphoma diagnoses occur in women aged 45-64, which is the age likely to overlap with the menopause. Other serious conditions also occur in this age range. For example, endometrial cancer or its precursors are often associated with irregular menstrual bleeding which is also common in the perimenopause years.
Similarly, low mood and anxiety are frequently part of perimenopause and HRT can be hugely beneficial in treating these symptoms. However, there is also a danger of dismissing women with legitimate mental health concerns as simply being a little down because of their time of life.
It is known that women are diagnosed later than men for a variety of conditions though the reasons are unclear and potentially multifactorial. However, misattribution to the menopause could be a factor in this problem2,3. There is a growing understanding that sex differences can lead to women being underserved in healthcare.
The intersection between menopause and these other conditions underscores the critical need for clinicians to investigate symptoms thoroughly, rather than defaulting to a diagnosis of “menopause”. Diagnostic tools would be hugely valuable in assisting clinicians to thoroughly investigate patient symptoms.
Could better diagnostics offer a guide to the best treatment?
Menopausal symptoms intersect with a number of other health issues that may occur at a time when women are handling multiple pressures in addition to their biological transition. Instead of forcing women to try various, often inappropriate treatments to alleviate their symptoms, or go on (non-tailored) HRT without proper diagnosis of menopause, better diagnostics would provide a much-needed guide so women can get the best treatment quickly. At the same time, better diagnostics could reduce serious conditions going untreated as a result of menopause being used as a catch-all explanation.
Menopause and perimenopause are rightly discussed more and more as society is becoming more aware of women’s health. However, diagnostic tools are still lagging behind. If we believe that women should be supported to live well through these years, we should back this up with widespread access to sound and evidence-based diagnostic tools.
To summarise, we believe that peri(menopause) diagnostics should:
- Be able to quickly rule out conditions that have symptoms which overlap with menopause.
- Be available in healthcare settings so that one appointment can thoroughly investigate the issue and provide a well-informed treatment plan.
- Be able to prevent the unnecessary and potentially harmful use of ineffective treatments.
- Be able to aid in the accurate and targeted use of HRT (when women wish to go down this route).
- Allow women to be more in control of their health and avoid bewildering and confusing heath quandaries.
- Not be used to invalidate or dismiss the symptoms or concerns of women.
As an independent technology and product development consultancy, TTP helps clients to solve complex challenges and deliver commercially grounded solutions. TTP’s Diagnostics team specialises in distributed and point-of-care solutions in all areas of diagnostics.
Reference:
- https://www.cureus.com/articles/29859-the-genitourinary-syndrome-of-menopause-an-overview-of-the-recent-data#!/
- https://www.nature.com/articles/s41467-019-08475-9
- https://www.reuters.com/article/business/healthcare-pharmaceuticals/women-diagnosed-years-later-than-men-for-same-diseases-idUSKCN1R62II/
