Tara Iyer, MD, is passionate about dispelling common myths about menopause.
Treatment for menopause became the subject of debate in the early 2000s when the Women’s Health Initiative (WHI) concluded that hormone therapies widely prescribed for menopausal symptoms came with an increased risk for blood clots, stroke and cancers based on a randomized control trial with post-menopausal volunteers aged 50 to 79 across the United States.
After news about the dangers of hormone therapies spread, many patients did not seek care for the symptoms that accompany and precede the end of menstrual cycles. However, reanalysis and follow-up studies repeatedly found that hormone therapy is actually very beneficial for those under the age of 60 and within 10 years of menopause — the majority of the post-menopausal population. The findings from the WHI have since been critiqued and updated.
“There is a lot of stigma, misunderstanding and misinterpretation of menopause that persists today as a result of the one-size-fits-all approach to how the WHI trial findings for older women were publicized and discussed,” says Tara Iyer, MD, of the Division of Women’s Health. “Over the last two decades, physicians have worked hard to not only clarify the benefits of hormone therapy, but also to reshape the entire narrative surrounding menopause and its treatable symptoms.”
Iyer is board certified in family medicine and obesity medicine. However, neither area of study provided training about what happens after the reproductive years for women. While she recalls a curriculum that was devoted to topics like adolescent medicine, complex contraception and geriatrics, midlife care and menopause were notably absent.
“As a family medicine physician, I felt like I was doing my patients a disservice by not being able to adequately answer a lot of their questions about perimenopause or menopause,” Iyer explains. “Symptoms of both are often misunderstood or misattributed to stress and aging.”
During menopause, the ovaries stop releasing eggs and making two female hormones: estrogen and progesterone. These hormone levels fluctuate during a period known as perimenopause before steadily decreasing during menopause. Common symptoms include irregular periods, hot flashes and night sweats. Patients can also experience a constellation of possible symptoms known as the genitourinary syndrome of menopause that includes pelvic pain, vaginal dryness, painful intercourse, urinary symptoms and more. More severe symptoms might include significant mood changes or bone loss (such us osteopenia or osteoporosis) after menopause.
To help raise awareness about menopause, Iyer gives lectures to internal medicine residents and has been part of seminars on sex and gender at Harvard Medical School (HMS). As part of a women’s health elective or rotation both HMS students and medicine residents spend clinical time with Iyer as part of a larger curricula.
“One of my goals is to ensure menopause isn’t glossed over in medical education,” Iyer says.
Though there are around 30 to 35 classic symptoms, many more likely exist. And although menopause typically begins when a woman is in her 40s or 50s, it can begin prematurely because of surgery, chemotherapy or an underlying medical condition. Even after symptoms subside, low estrogen levels can affect long-term bone or heart health.
“Menopause is not a singular event that everyone goes through in the same way,” Iyer explains. “There’s also a misconception that menopause is restricted to a finite period of your midlife. In reality, once you have your last period, menopause will be an important, lifelong consideration.”
Iyer now leads the Brigham’s Menopause and Midlife Program in the Fish Center for Women’s Health. It is one of the few clinics of its kind in the country, and she works to address the gaps in clinical care for menopause she had noticed throughout her training.
“A lot of the time, we have to start from the basics because about half the patients who have come into my office have no idea what to expect from perimenopause or menopause,” Iyer explains. “Many people don’t talk about it and assume it’s a natural process that one must undergo without treatment. Every woman who lives long enough will undergo menopause, but that does not mean they need to suffer through without treatment should they have bothersome symptoms
When patients have never been taught to expect to manage menopause symptoms, their quality of life can suffer. They may struggle with more irritability, anxiety and depression in their personal lives. They may face sexual dysfunction, weight gain and intimacy issues that make sustaining relationships difficult. They may experience brain fog or hot flashes that make them feel embarrassed at work.
“I have patients who feel like they are on the verge of divorce and others who want to scale back on work or retire early,” Iyer says. “When I tell them that there is finally something that can explain and safely address most of their symptoms, the relief can be very emotional.”
Since joining the Brigham in January, Iyer has seen patients from their 20s to 80s. Through each encounter, her job is to explain how menopause can come with painful — but treatable — symptoms.
During Iyer’s women’s health fellowship at Cleveland Clinic, she also noticed that weight management was a common concern that coincided with menopause. Soon after, she became certified in obesity medicine. At the Brigham, she holds dual appointments at the Menopause and Midlife Health Clinic and the Center for Wellness and Weight Management, where she sees patients once a week.
While her clinical practice is keeping her busy for now, Iyer hopes to conduct clinical research to investigate how the hormonal changes associated with menopause affect weight management in the near future. She’s especially interested in focused on perimenopause, which is understudied, and the long-term effects of hormone therapies.
Such research has the potential to inform important clinical care for patients today and in the future.
“The treatments that work during menopause might require modifications for perimenopausal patients,” Iyer says. “Perimenopause can be more complex and severe because the hormones are fluctuating much more than in menopause. We have so much less information about how to address and improve symptoms during perimenopause.”