(Re)framing menopause: a comprehensive public health approach

Over half of the world’s population will experience menopause, the point in time 12 months after a woman’s final menstrual period (World Health Organization, 2022). Most women experience menopause between 45 and 54 years of age (Namazi et al., 2019). Perimenopause, the period leading up to and one year after menopause, is characterized by the fluctuation and decline of key hormones, which cause menopausal symptoms in most—but not all—women (World Health Organization, 2022). The most common symptoms include irregular periods, vasomotor symptoms (commonly known as ‘hot flushes’ and ‘night sweats’), and genito-urinary symptoms, as well as mental fatigue, ‘brain fog’, joint pain and insomnia which can negatively impact women’s wellbeing and quality of life (Panay et al., 2021). Most menopause research to date has focused on the medicalized symptoms and management of menopause (Nappi et al., 2021; Crandall et al., 2023). While these studies are important, describing menopause purely in terms of physiology and symptomology misses a broader range of socio-cultural, environmental, commercial and political determinants that are instrumental in developing comprehensive responses which promote the health and wellbeing of populations. A range of socio-cultural factors influence how women experience and respond to menopause (Ilankoon et al., 2021; Li et al., 2023; Lycke and Brorsson, 2023; Matina et al., 2024), including those who experience menopause but do not identify as female (Hickey et al., 2022). Research demonstrates that the problematization of menopause may contribute to experiences of stigma and shame, which may prevent women from speaking openly about their symptoms (de Salis et al., 2018; Dahlgren et al., 2023; Whiley et al., 2023). This, in turn, enables dismissive narratives about menopause to persist (Sergeant and Rizq, 2017). Experiences of menopause also intersect with other issues that may impact women’s health and social equity. Menopause typically occurs at a time in midlife when women may also be experiencing a range of economic and social stressors, including those related to secure employment, and access to affordable housing and health care. They may also be experiencing changes relating to their social identity, cultural expectations relating to the end of fertility, caring responsibilities (including for older family members), as well as the structural inequities associated with gendered ageism. Women also report negative experiences in the workplace (Jack et al., 2016; Faubion et al., 2023), however, such experiences might not be solely attributable to menopausal symptoms. Rather there may be a range of structural and situational factors that marginalize and silence older women’s voices and experiences (Beck et al., 2019; Steffan, 2021; Whiley et al., 2023), with many workplaces ill-equipped (or unwilling) to support women during their transition to midlife (Verburgh et al., 2020). Discursive representations of menopause may also influence women’s subjective experiences of menopause and have a significant impact on their quality of life (Atkinson et al., 2021; Li et al., 2023). One of the challenges for public health is that menopause is framed as a women’s health issue that is both ‘exceptionalized’ and ‘unexceptional’ (Cahn et al., 2022, p. 79). For example, some construct menopause as a period of ‘irrationality’ and ‘instability’ for women who are no longer useful to society (Rowson et al., 2023, p. 1918), but others view menopause as a natural, normal and inevitable part of the ageing process (Hickey et al., 2022, 2024). Researchers have identified that competing and conflicting framings about menopause include: a ‘negative symbol of age’ and a ‘crippling disease that can be cured by hormone replacement’; a commercial issue in which menopause ‘treatment and disease prevention become consumer goods’; a ‘natural part of aging’ that may provide opportunities for personal growth and development; and an issue that is ‘taboo’ or sensitive for women to openly discuss (Krajewski, 2019, p. 138). Framings about menopause are constructed by a range of powerful groups and institutions; including health and medical groups and professionals, commercial entities seeking to profit from menopause (not only the pharmaceutical industry but also the wellness and ‘workplace’ industries), the media, and governments (Padamsee, 2011; Krajewski, 2019; Women and Equalities Committee, 2022; Rowson et al., 2023). These groups shape socio-cultural narratives about women’s bodies, including how menopause should be treated, experienced and talked about. For example, researchers have demonstrated that while there is increasing visibility in the media about menopause, media reporting has mainly focused on individual determinants and ‘debilitating symptoms’ which may ultimately reinforce and exacerbate the stigma that women experience (Rowson et al., 2023, p. 1912). Even the most well-intentioned celebrity ambassador or social media influencer might do more harm than good by foregrounding individual experiences and the consumption of wellness products and medicines, rather than focusing attention on the need to address the structural, social and cultural issues faced by women in midlife (Orgad and Rottenberg, 2023). Public health researchers have also demonstrated the importance of mapping and monitoring how commercial interests contribute to framing women’s health issues (McCarthy et al., 2023), including how they co-opt feminist narratives (Copp et al., 2024), commercialize women’s health concerns (Mishra et al., 2023) and provide ‘solutions’ that respond to women’s fears and anxieties (Pitt et al., 2023). While studies exposing predatory commercial tactics have been an important part of responses to complex public health issues, there is still limited understanding of how commercial interests ‘catastrophize’ menopause as a strategy to stimulate and drive (arguably unnecessary) product purchases (Davey, 2023). This includes understanding the innovative marketing strategies that those with vested interests may use to frame solutions for menopause (Krajewski, 2019), such as the impacts of ‘menopause influencers’ (Lewis, 2023), and ‘menowashing’ strategies that reinforce harmful tropes and gendered ideologies, particularly relating to ageing (Bettany, 2024). It also includes how the absence of strong government policies and regulations may contribute to commercial responses to menopause (for example, in the workplace) that are not based on robust independent evidence or women’s experiences (May and Davey, 2024). Until recently, menopause has been largely absent from government policies and discussions. However, there are signs that that is beginning to change. A current Australian parliamentary inquiry is looking broadly at the range of factors that may shape women’s experiences of menopause, including their economic participation and healthcare experiences, and the socio-cultural factors that may drive community attitudes (Senate Standing Committees on Community Affairs, 2023). In Ireland, the Women’s Health Action Plan (2024–2025) includes investments in specialist menopause clinics (Department of Health, 2024). A government committee in the United Kingdom (UK) in 2022 focused specifically on the inequities associated with menopause in the workplace, highlighting a range of systemic and structural factors that influence experiences: ....for too long, too many people experiencing menopause have struggled with societal stigma, inadequate diagnosis and treatment, workplace detriment and discrimination. This is not normal, nor should we see it as inevitable. (Women and Equalities Committee, 2022, p. 3) This new policy interest in menopause provides opportunities for the public health community to collaborate with women to shape discussion of and responses to menopause, including advocating for healthy public policies, and strength-based approaches which empower women to ‘increase control over, and to improve, their health’ (World Health Organization, 1986). This includes reframing medicalized models of menopause towards comprehensive public health approaches which take into consideration the range of determinants and policy responses (including regulation) that may either promote women’s health and wellbeing and lead to positive experiences, or may (un)intentionally exacerbate inequalities for different population sub-groups. Transformative approaches will contribute to shaping new meanings and expectations of menopause, reducing negative stereotypes and stigma, challenging inequalities and providing trustworthy and tailored information to different sub-groups of women (Jean Hailes for Women’s Health, 2024). At Health Promotion International we welcome interdisciplinary empirical, review, perspective and policy contributions that progress conversations about experiences of menopause and the range of comprehensive public health and health promotion strategies that may be developed to respond. Five areas of particular interest for the journal include: The lived experiences of menopause in a range of social and health contexts, with an emphasis on the factors that may exacerbate health inequities. These studies should recognize the diverse range of experiences with, and attitudes towards menopause. The discursive representations of menopause, including dis/misinformation. This includes studies which seek to understand how menopause is framed by different stakeholders and the impact of this framing on attitudes and experiences. The intersection of menopause with the other health, economic and social stressors during midlife, including the impacts of gendered ageism on overall health and social equity. The commercial determinants of menopause, including the impacts of novel products and promotions—such as social media influencer and celebrity endorsements. Researchers should also consider a broader range of corporate political activity from those with vested interests in menopause, the impacts of conflicts of interest, and the role of regulation. The role of public health advocacy and strengths-based approaches in protecting and promoting health and wellbeing in the transition to menopause. Rather than a primary focus on individualized behavioural interventions, we encourage articles that consider ‘upstream’ approaches that respond to gendered ageism, the power structures that may influence the responses to menopause, and the points of leverage to create change. An increased focus on the experiences of menopause is overdue and welcome. However, we need to understand which stakeholders are driving this increased focus and for what purpose. This understanding will help to identify and avert any potential unintended consequences. The public health community has an important role to play in disrupting destructive and potentially harmful framings which seek to problematize and medicalize menopause, and detach women’s experiences from broader socio-cultural, commercial and political contexts. At the same time, we must be careful not to dismiss the experiences of those who are significantly impacted by menopause. (Re)framing menopause to acknowledge a diversity of experiences will help to avoid damaging narratives and stimulate new ways of thinking that improve policies and practices and ultimately benefit the health and equity of women through the menopause transition and beyond. Jean Hailes for Women’s Health receives funding from the Australian Government to produce consumer health information, conduct research and deliver health professional education for women’s health issues, including menopause.