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Why do some women have severe symptoms during their menopause transition while others do not?
The answer may be in the past
There is a vast range of menopausal experiences. It seems that for every woman who tells me that she is struggling, I hear from another whose only symptom was her period stopped. We see this in other areas of ovarian and uterine health. For example, some women have heavy periods and/or bad menstrual cramps and others do not. Some people have easy pregnancies, with short labors and others have the opposite. We don’t always have answers for these differences, but there is emerging research that tells us for women and menopause some of the answers may lie in the past.
A variety of factors influence the frequency and severity of symptoms in menopause (meaning from the menopause transition, also known as premenopause, to beyond the final menstrual period), such as genetics, whether someone smokes, or if they have surgical menopause (their ovaries removed). There is also a growing body of research that tells us that Adverse Childhood Experiences or ACEs may play a role. ACEs are potentially traumatic events that happen during childhood, such as parental divorce, parental alcoholism, or witnessing violence in the home. This kind of trauma is unfortunately common—according to the Centers for Disease Control and Prevent (CDC) 61% of adults are exposed to at least one adverse childhood experience. ACEs are also additive, so the more that are experienced, the greater the risk of consequences. One in six Americans have experienced four or more ACEs.
And there is emerging data that specifically links some symptoms of menopause as well as depression that develops during the menopause transition with ACES.
One study, published in 2017, enrolled women while they were still having regular menstrual cycles and then the women were followed for 16 years. Among the participants, 39.5% experienced no ACEs (so in keeping with other data), 22.2% had experienced one ACEs, and 38.3% had experienced two or more. Almost 21% of women developed a new diagnosis of depression during their menopause transition. Those women who had experienced two or more ACEs were twice as likely to develop depression during this time. As these women did not have depression previously, the menopause transition may unmask a vulnerability for depression for some.
Another more recent study from 2020 shows similar findings. The study design was a little different. It was a cross-sectional study that looked at women at one point in time and documented whether they had experienced ACEs or not and also screened these women for depression and anxiety. Women with 4 or more ACEs were more likely to experience depression during their menopause transition or after their final period. This study also looked at menopause related symptoms, such as hot flushes, sleep disturbance, mental exhaustion, joint discomfort, bladder issues, and vaginal discomfort. Women with 4 or more ACEs were much more likely to have severe menopausal symptoms, be they related to the whole body (such as hot flushes or joint pain), or specific to the reproductive tract (bladder or vagina). Other studies have also picked up on this connection between ACEs and hot flushes, but this more recent study expands the symptoms linked with ACEs to beyond hot flushes. One study has even linked one ACE, parental divorce, with a lower age of menopause. This is important as the younger a woman is when she experiences menopause, the greater her risk of cardiovascular disease, dementia, and osteoporosis.
What is the mechanism? The toxic stress from ACEs may impact the development of the nervous system and possibly also the endocrine system (specifically how the brain, ovary, and adrenal gland work together to produce hormones) with long lasting consequences—even as long lasting as menopause. While ACEs may be linked with other factors that increase symptoms in menopause, such as smoking, when researchers controlled for these other variables they found that the ACEs themselves were an independent risk factor.
So how does knowing this help? After all, it’s not like we can go back and undo the trauma.
When we know about trauma, we can acknowledge it. Bearing witness to someone’s past trauma and understanding that this connection may exist between childhood trauma and health can itself be helpful. For physicians, we can also make sure our patients receive trauma informed care.
Screening women for ACEs before they start their menopause transition may help identify women at higher risk for depression and physical symptoms, which may be helpful medically. In addition, it is another piece of the menopausal puzzle and some women may be helped by knowing the factors that may be contributing to their menopause experience. Also, as we learn more perhaps we may discover ways to help mitigate the effects of ACEs, or we may find that women who have ACEs and symptoms in menopause may do better with one form of medical therapy versus another.
A history of ACEs doesn’t mean that any person is guaranteed to have consequences, but ACEs appear to be a risk factor. And the more we learn, the more we can find ways to help.