Is Singapore ready for the menopause wave from a super ageing society?
Ms Chen Xujin, 63, sought treatment for her perimenopausal symptoms early and now enjoys a range of sports as well as dancing. ST PHOTO: JASON QUAH
SINGAPORE – Ms A was a high-achieving teacher in a tuition centre when she started experiencing hot flushes and night sweats in her late 40s.
It affected her sleep and concentration and she started making mistakes at work, which led to negative feedback from students and parents.
After a poor work appraisal, her self-identity crumbled and she entertained thoughts of suicide. She quit her job.
During mental health counselling, she was advised to seek a medical assessment at KK Women’s and Children’s Hospital (KKH), says Associate Professor Rukshini Puvanendran, co-director of the KK Menopause Centre.
That was when Ms A found out she was in perimenopause.
This transition period before a woman’s last period is a time when hormones fluctuate wildly and periods may become irregular.
Symptoms, which may seem unrelated, can range from the irritating (itchy skin, dry mouth) to the embarrassing (incontinence, the urge to pee often) to the debilitating (anxiety and depression).
Perimenopause symptoms can last up to 10 years before a woman hits menopause, which is defined as 12 months without a period.
In Singapore, menopause typically occurs from ages 45 to 55. The average age of menopause here is 49, earlier than the Western society average of 51.
While menopause has always been a part of a woman’s life cycle, its social and economic repercussions are growing, thanks to rapidly ageing societies like Singapore and more women entering the workforce.
By 2025, an estimated 1.1 billion women worldwide will be postmenopausal, according to The Menopause Society (formerly known as The North American Menopause Society), a non-profit organisation of leading clinicians and other experts. That is about one in eight people in the world.
A staggering US$25 billion (S$33.3 billion) can be attributed to menopause-related medical costs in the United States alone, according to a study published in April 2023 in the journal Mayo Clinic Proceedings.
Lost work productivity linked to menopause symptoms is estimated to cost about US$1.8 billion a year in the US, the researchers said.
That figure does not include the cost of women scaling down their working hours, losing their jobs, retiring early or changing jobs because of symptoms, said the study, which surveyed some 5,000 women aged 45 to 60 who were patients at the Mayo Clinic.
Six in 10 have moderate to severe symptoms
Menopause awareness has skyrocketed in Western countries since around 2019, thanks to celebrity advocates, including talk-show hosts Oprah Winfrey and Drew Barrymore, former US first lady Michelle Obama and British television presenter Davina McCall.
Some of it has trickled down to Singapore as well.
Professor Tan Hak Koon, chairman of the division of obstetrics and gynaecology at KKH, notes: “While the number of women with perimenopausal and menopausal symptoms seen at KKH has almost tripled from 2009 to 2023, it is still a small proportion, given that Singapore is an ageing population. By 2030, one in four citizens will be aged 65 and above and women tend to outlive men.”
Professor Tan Hak Koon, chairman of the division of obstetrics and gynaecology at KK Women’s and Children’s Hospital. PHOTO: KKH
The hospital expanded its menopause service into a multidisciplinary KK Menopause Centre in October 2023 to cater to the anticipated demand.
Professor Yong Eu Leong, emeritus consultant in the department of obstetrics and gynaecology at the National University Hospital (NUH), has seen “a significant increase” in the number of women requesting menopausal consultations in recent years, although absolute figures are not available.
Since menopause is a stage of life and does not usually require hospitalisation, there is scant data to show the true extent of its effects on Singapore women.
Not every woman will seek treatment for her symptoms, which can vary over time, and not every doctor will link the wide-ranging symptoms to the menopause transition.
“Many women may manage menopausal symptoms at home or through primary-care physicians rather than seek hospital treatment. Consequently, it is challenging for hospitals to routinely record or track menopause cases,” Prof Yong says.
He adds: “Women will be living more than a third of their lives after menopause due to increasing lifespans. The problems with undiagnosed menopausal symptoms would correspondingly increase.”
NUH’s ongoing Integrated Women’s Health Programme (IWHP) gives a glimpse into the possible scale of the issue.
Started in 2014, this cohort study of 1,200 women aged 45 to 69 aims to holistically identify symptoms of menopause and its associated medical conditions. It has generated over 15 publications to date.
A study published in October 2023 found that over six in 10 of the women reported at least one moderate to extremely severe symptom, which is consistent with figures from other developed countries, Prof Yong says.
Interestingly, the No. 1 symptom here is muscular and joint discomfort (arthralgia), whereas hot flushes are the most common symptom in Western countries.
The IWHP’s latest study published in December found that three out of four of the women studied had arthralgia. Prof Yong says the reason is unclear.
Rounding up the top five symptoms among women in Singapore are, in descending order, sleep problems, vaginal dryness, physical and mental exhaustion, and hot flushes.
Those suffering from severe symptoms were more likely to suffer from moderate disability and weaker lower-body strength. They also rated their health status as poorer compared with others.
Despite their symptoms, only 21 out of the 1,200 women in the cohort study were taking menopausal hormone therapy (MHT). This typically involves taking oestrogen and progesterone in the form of gels, patches and/or oral preparations under a doctor’s guidance.
Civil servant Susheela, 57, started experiencing joint pain about six months after surgery to remove a fibroid that covered one of her ovaries and her womb.
The operation, done eight years ago to remove her uterus, induced surgical menopause, but she did not follow up with a gynaecologist after she was discharged.
Madam Susheela, who declined to reveal her full name, thought she was having cramps at first, but the continuous pain in her elbows, hips and knees persisted, gradually increasing in intensity. She rates the pain as eight on a scale of one to 10, and has also been diagnosed with osteoporosis.
Because she has had to slow down her movements to avoid pain, it takes her twice as long to cook and clean at home, where she lives with her husband and two adult sons.
“I now take the pain as part of my life because I don’t want to go to see the doctor and then have to see a physiotherapist. It’s very time-consuming and I can’t keep taking time off from work,” says Madam Susheela, who is a participant in NUH’s cohort study.
Suffering in silence
Perimenopause can be a confusing time for women, who may not think they are entering the menopause transition as they still have their periods, says Prof Rukshini, who is also head and senior consultant of KKH’s Family Medicine Service.
Associate Professor Rukshini Puvanendran (right), co-director of the KK Menopause Centre, with a patient. The centre was launched in October 2023. PHOTO: KKH
Dr Chua Yang, a gynaecologist and obstetrician who runs private practice A Clinic For Women, adds: “Singapore women experience more aches and pains and sleep disturbances than the typical hot flushes and mood swings. The symptoms are therefore less specific and not immediately thought of as menopause-related. Women may suffer lethargy and tiredness from the symptoms and not realise it is due to menopause.”
Dr Chua is a past president of the Asia Pacific Menopause Federation and the Menopause Research Society (Singapore).
Besides the lack of knowledge, Asian women tend to have “neutral attitudes” towards menopause, says Prof Rukshini. Many believe they should endure it, as compared with Caucasian women, who proactively seek out ways to manage it.
“Several studies have shown that Asian women lack knowledge on menopause and are unprepared for this transition in their lives. They also have several misconceptions and there is a demand for more trustworthy sources of information,” she says.
Among their fears is an unfounded belief that MHT’s risks outweigh the benefits, a legacy of a flawed Women’s Health Initiative study in the US in 2002 that was subsequently misrepresented in media reports. That led women and even doctors to stay clear of MHT in droves for almost two decades.
Dr Chua says: “It is important to put the risk of breast cancer associated with MHT into clinical context. The risk associated with long-term oestrogen use is much lower than the risk conferred by obesity, inactivity and alcohol use.
“If women have reduced their own risks of breast cancer by not smoking, drinking excessively, not becoming obese or sedentary, they would have very little fear about the very marginal increased risks added if they need to consider using MHT for improved quality of life.”
Prof Rukshini says subsequent research has shown that women in their 50s who use MHT experience a lower risk of heart disease, fractures and “all-cause mortality”, including for cancer.
“MHT has been shown to be safe and effective in most women under the age of 60 with bothersome menopausal symptoms who are not at risk of breast cancer or blood clots,” she says.
In fact, letting perimenopausal symptoms fester and suffering in silence may lead to bigger problems down the line.
For instance, urinary urgency or the need to pee often is a common symptom as decreasing oestrogen levels cause the bladder lining to be very sensitive.
Says Prof Wong: “The need to look for restrooms frequently can really affect their social lives and mental health. On numerous occasions, women share that they do not go out so often because of the fear of troubling their friends and companions by the constant need to look for toilet facilities.
“As a result, they tend to remain at home, with resultant social isolation.” Prof Rukshini also recounts the case of a patient, Mrs B, whose hot flushes and night sweats led to poor sleep and irritability, while vaginal dryness made her fearful of sex with her spouse.
The 47-year-old stay-at-home mother with two teenagers lashed out at her family, and her husband moved out. Her younger son also developed depression after feeling guilty about his parents’ separation.
She realised what was happening to her only when her sister took her to KKH for a consultation. MHT alleviated her symptoms and she is seeing a counsellor to improve her relationships.
Life after menopause
Ms Leeanne Beveridge, 58, felt she did not know herself any more after she started experiencing perimenopausal symptoms such as extreme mood swings. PHOTO: COURTESY OF LEEANNE BEVERIDGE
Ms Leeanne Beveridge, 58, developed irregular periods in her 50s which she thought could be fibroids. She also had hot flushes, insomnia and weight gain, as well as aches and pains.
“When you put them all together, it’s like you don’t know yourself any more,” says the former draughtsman who is an Australian citizen and a permanent resident here.
But it was when she became a “little volcano of rage” around her husband and daughter, who started to avoid her, that she knew she needed help.
“The mood swings and anger were my biggest problem. Things would come out of my mouth before they even crossed my mind. I would feel really bad and almost want to cry,” says Ms Beveridge, who is a patient at the KK Menopause Centre.
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Activities she used to enjoy, such as riding her motorbike, also became painful as her hands became inflamed, making it difficult for her to hold onto the clutch at traffic lights.
“Taking MHT helped to reduce those symptoms and enabled me to keep enjoying life the same way as before,” says the keen outrigger ocean paddling enthusiast.
Ms Chen Xujin, 63, took a more proactive stance after seeing how her mother suffered from bone loss and “emotional issues” following the menopause transition. The latter developed a hunchback and was eventually bedridden.
“I was deeply affected and told myself that I needed to do something about it when I faced menopause, so that I don’t follow in her footsteps. I want to lead a good-quality and healthy life and don’t want to burden my loved ones,” says Ms Chen, who used to work as a gynaecologist and obstetrician in China before moving to Singapore, where she is now a citizen.
So, when she started having irregular periods, heart palpitations and hot flushes so intense her T-shirt would be wet in seconds, she sought medical help.
Then 47, the single mother was having a particularly hard time juggling studying for a bachelor’s degree and looking after her teenage daughter. She declined to reveal her occupation or degree details.
A patient of KKH, she was put on MHT, which relieved her symptoms.
Fast-forward 16 years later, Ms Chen now enjoys an active lifestyle that includes swimming, jogging, cycling, table tennis and dancing.
“It is important to be open to your loved ones and educate them on menopause and how it will affect them. We cannot assume and expect that they will understand what we are going through, but we still need to communicate with them,” she says.
“When my daughter was in primary school, I went through the female reproductive system with her, from the first menses to menopause. When she saw me taking MHT, I explained it to her. She now helps support me by driving me to work or for my studies and is always the calm one.”
Prof Rukshini adds that menopause is not a disease that women should be afraid or ashamed of.
“It marks the end of their reproductive phase, but is also a new beginning for them to take charge of their life – emotionally, mentally and physically,” she says.
Dr Chua adds: “I would love to see Singaporeans understand and be responsible for their health even more. They are the demand. If they need all our cost-effective food to be less sugary and less oily, then the supply will naturally move in that direction. “Similarly, if women need to talk about their menopause and their symptoms or their mental health, then healthcare providers will need to get updated with these management options and counsel their patients accordingly.”