‘I’m menopausal, having great sex with my ex-husband – and confused’

The dilemma I have been having a dreadful time with the menopause for the past two years and a mental health team is now involved with my care. My husband and I split up seven years ago, but we remained close and see each other often. My husband has stayed the past couple of nights as I’m in quite a scary place, but we ended up having sex, and lots of it. I have not had sex for a long time and our sex life when we were married was never good, it was a real chore for me. We talked so much and have felt totally relaxed around each other. Please tell me what’s happening to me as I am meant to be having a breakdown, but I am having the most wonderful time with my husband. I had not slept for three nights before that when the psychiatric nurse prescribed me sleeping tablets. My mood swings are horrendous, yet I feel I have fallen in love with the man who has always been my rock. It’s like I am seeing him for the first time.

Mariella replies Perhaps you are! Thank you for providing a sliver of tangible proof to back up my specious theory that the devil you know can occasionally reinvent himself. What a relief to the many frustrated couples out there despairing of ever rekindling passion. That’s the good news!

You are in the throes of a particularly malevolent menopausal period, in the care of mental health experts and on medication, the side effects of which I am entirely unaware. It’s fair to say there are a lot of potential disrupters to your state of mind. Before you rush to your wardrobe to dust off your wedding dress, I suggest you share this latest development, not only with me, but with those professionals who are charged with your welfare.

It may be bizarre, but it’s certainly not shameful that you and your ex have rediscovered your mojo. But just as antidepressants can curtail your sexual appetite, so other forms of medication can heighten and exaggerate your physical and emotional responses. When the meds wear off you don’t want to find yourselves facing each other across the kitchen table and wondering what on earth it was that propelled you back under the same roof.

Hot flushes are not the only symptoms. Perhaps a voracious sexual appetite can be thrown into the pot

It’s early days, of course, but it has always struck me as odd that we have no expectation of passion resurfacing. In life we enjoy repetition in so many areas, and plenty of them are sensual – food, massage, scents to name a few – so why do we think that once an attraction fades, it will never take on a new form and appeal again?

There’s another reason I welcome your letter and that’s because it mentions the menopause. Generally the only news we’re given on that front is bad – most recently the connection between HRT and the increased risk of breast cancer a further addition to the grim tidings. Clearly the hormonal disruption that has affected your mental health so badly is nothing to go whoop about, but your reawakened sexuality definitely is.

There is an unfathomable mystery to this hormonal readjustment, despite being experienced by 50% of the world’s population. Much of it is down to the shroud of shame too often draped over the workings of women’s bodies. The trickle-down effect of titbits of information from those brave enough to acknowledge the “M” word has led us to realise that hot flushes and flaring tempers are not the only symptoms. Anxiety, sleeplessness, mania, out-of-character behaviour and, perhaps, judging by your experience, a renewed and voracious sexual appetite, can all be thrown into the pot labelled “natural” symptoms. Surely it’s time for a serious investigation into the scientific truth and cultural taboos around the menopause – a condition we understand so little about that it’s burdened with the same level of stigma as a terminal illness.

I’m delighted that, in this dark passage of your life, light has poured in with the presence of your ex. He’s certainly worthy of reconsideration for being at your side during troubled times and in your bed these last few days. That said, the fact that you haven’t slept for three nights makes me worry about your capacity to make rational judgments. I suggest you continue to enjoy the pleasure of his company, but wait until the mist of medicine clears before you leap to any long-term conclusions. Also, be honest with the professionals helping you, because their ability to support you depends on understanding what you are feeling. And enjoy this gift of life-affirming passion and companionship from what seems an unlikely quarter.

I’m not so sure our relentless march forward is in our best interests as a species. Relationships can be victims of bad timing or immaturity, compelling alternative distractions and many other changing priorities. So when we walk away from a person with whom we’ve shared chemistry, who’s to say that a future spark can’t reignite that inferno?

If you have a dilemma, send a brief email to mariella.frostrup@observer.co.uk. Follow her on Twitter @mariellaf1

‘I’m menopausal, having great sex with my ex-husband – and confused’

When it comes to menopausal hormone therapy, women are left guessing at the risks | Margaret McCartney

As a freshly minted doctor in the early 1990s, I attended lectures describing hormone replacement therapy – which is now known, in this context, as MHT, menopausal hormone therapy – as close to a miracle cure-all. Women shouldn’t worry their pretty little heads, it was implied at the time, because doctors knew best – and this treatment would not only make them feel fantastically sexy, but prevent cardiovascular disease and strokes. Promotion, back then, went beyond recommending it for menopausal symptoms. It was the elixir of life, preventing future illness and making women look younger.

Let’s sidestep the sexist and ageist undertones of that era, and fast forward to the publication of the Women’s Health Initiative study in 2002, which found that the treatment increased the risk of breast cancer. For every 10,000 person-years of combination menopausal hormone therapy use (oestrogen plus progesterone), there were seven more heart attacks, eight more strokes, eight more blood clots on the lungs, and eight more invasive breast cancers. In the ensuing years, the amount of menopausal hormone replacement being prescribed fell by half.

In November 2015, the National Institute for Health and Care Excellence (Nice) published new guidance on treating the menopause. In a press release, it suggested that menopausal hormonal treatment was being underprescribed, and GPs needed to prescribe it more. “For the last decade, some GPs have been worried about prescribing HRT, and women worried about taking it …” it wrote. “For health professionals, the guideline should boost their confidence in prescribing HRT, having fully discussed the woman’s individual circumstances with her.”

That seemed pretty clear, but now a new UK study apparently shows that the risks of breast cancer have been underestimated and “nearly tripled” when women were taking hormone treatment for menopause.

So should I still feel confident about prescribing it? Is this a high or a low risk? Is it a risk worth taking? Well, that depends on the patient. There will be women who regard the risks as reasonable because they experience such enormous benefits. Then there are other women who would consider a much smaller risk of serious harm unacceptable. Autonomy rules, and there is no “correct” answer (although I suspect the General Medical Council would be quick to hold doctors to account for what was viewed as reckless prescribing). But to make that autonomy meaningful, we have to be able to make a rational, informed choice. That needs quality data. So what does the latest study tell us?

It’s a prospective, cohort study, which specifically looked for hormone use and age at menopause, which many other studies have not. Just over 39,000 women had their age at menopause documented, and 775 of these developed breast cancer. They found that the women who used combination MHT were more likely to develop breast cancer by a factor of 2.7; this risk dissipated when the women stopped the MHT, but rose the longer it continued.

The NHS offers detailed decision aids for treatments for everything from arthritis to angina – but none on the menopause

We need to put this into context: 2.7 times a small number is still a small number, so you need to know what your risk was to start with. For a woman aged between 50-70, the risk of breast cancer is about 5%. Is an increase to about 13% for the years a woman is taking the hormones worth it? I don’t know. But I am also concerned as to whether this cohort are truly representative of the population at large, because the women who volunteered for this study were not asked to participate randomly, but were recruited through newsletters sent out by a breast cancer charity. They may, therefore, have been more likely to have a family member with breast cancer, or share the same environmental risks as friends with breast cancer, and so faced a higher risk to start with.

I also don’t reliably know how much the change in breast cancer risk is per woman: as one of the authors, Dr Michael Jones, told me: “Our results are internally consistent and we can talk about relative changes, but we cannot make external extrapolations in absolute risk to the whole UK.” In other words, care is needed – and we will need this data to be replicated in other data sets before we can be confident that it applies equally to other women.

Uncertainty is a hallmark of medical decision making. If a woman develops breast cancer while taking MHT, no one can be sure whether it would have happened in any case. We need context. We can’t control our genes, but what other risk factors can we at least partially control? Cancer Research UK says that 9% of breast cancers are linked to obesity, 6% to excess alcohol, and 3% to insufficient physical activity. In context, MHT is linked to 3% of all breast cancers. If this has been underestimated, as the new study claims, by up to 60%, that means that up to 5% of all breast cancers could be linked to MHT. But there are so many ongoing uncertainties that I think pinning it down to the last percentage point makes this look more accurate than it is.

So what do we do in the meantime? GPs are under enormous pressure anyway – each of our appointments is just 10-12 minutes long, with an average of 2.5 problems being discussed, so there’s barely time to make a safe diagnosis, never mind discuss most of the side effects for each possible treatment. There has been a quiet revolution in medicine in the last decade, a realisation that making choices is often hard to do well. There are now a wealth of “shared decision aids” online, based on high-quality evidence and with the emphasis on assisting patients, not dictating “choice”. They work in different ways; some are online or DVD-based, and they usually try and lay out the pros and cons of treatments in a logical way, giving the person enough time and information to make high-quality decsions.

These have been shown to help people make better decisions about treatment choices – and using them before or after GP appointments is a useful way of making oneself surer of healthcare choices.

The NHS has a website devoted to detailed decision aids for treatments for everything from arthritis to angina – but none, so far, on the menopause. Nice does have an information section on its website about the pros and cons of hormone treatment for menopause, but doesn’t provide any numbers about the risks – or define what they mean by “low-risk”, in common with other US decision aids – and while that might be enough information for some women, it’s unlikely to be detailed enough for others.

We need better quality information that doesn’t offer more certainty than we actually have: we are in a new era of medicine, and honesty about the knowns and unknowns, and the limitations of our knowledge is essential. I will continue to prescribe MHT, but when it comes to discussing risks and benefits, I suspect I will be answering many questions with an honest “I don’t know”.

When it comes to menopausal hormone therapy, women are left guessing at the risks | Margaret McCartney

NUT: menopausal ladies "being forced out of teaching"

“High workplace temperatures, bad ventilation, bad or non-existent rest or toilet amenities, or a lack of entry to cold consuming water at operate can make all these symptoms worse…

“Employers have a responsibility to take into account the troubles that women may experience in the course of the menopause and that female employees ought to be ready to expect assistance and help in the course of what is, for many, a extremely hard time.”

The NUT stated the union had heard “anecdotally” that a lot more teachers more than the age of 50 are getting subjected to formal disciplinary procedures than younger colleagues.

Speaking on Thursday, Christine Blower, common secretary, said: “We typically find that the approach in colleges now is that by some means or other, if you have been doing it for a extended time, you should be stale and not fairly the ticket that you would get with a younger instructor.

“We reject that. We consider it is essential you have a stability in the occupation of youth and age. And which is as correct for males as it is for girls.”

She added: “I think it is not just the menopause we have acquired experience of older girls finding that their abilities are not imagined of as becoming as very good as these of younger teachers.”

A resolution to be debated by the conference in excess of Easter weekend calls for the creation of an urgent advice document to allow colleges to take the situation a lot more critical.

NUT members are also calling for the union to take “strike action if schools refuse to make ideal changes to accommodate the needs of ladies experiencing symptoms that affect their capacity to educate during the menopause”.

NUT: menopausal ladies "being forced out of teaching"