Women are in perimenopause or menopause while their child has an eating disorder
Let me tell you a story — the story that gave me my wake-up call.
I'd been supporting this brave couple for a while. They were both doctors, both working hard at caring for their teen daughter who was suffering from anorexia. Getting her to eat, enduring her meltdowns, her tears, her hateful resistance, her erratic love. Navigating the health service — the good and the bad. All the usual stuff.
Like so many parents, they reported exhaustion, tears, anger and fear. On our calls they looked strong, resilient, courageous, determined and capable.
And then on one of our calls the mother told me, with this massive smile, that she had started hormone replacement therapy (HRT) and felt soooooooo much better.
Next call, they're both beaming. The husband is squeezing her shoulder and saying how wonderful it is to see her playing tennis again.
Recently they sent me some news. Their daughter is recovered, enjoying a full life and…. the mother wrote how HRT had helped her… 'and I am still on it'. With an emoji.
So I've been asking myself: how come we don't guide all mothers of a child with an eating disorder to get help with perimenopause and menopause?
Mothers are at peri/menopause age when their teen gets an eating disorder
Women are commonly in perimenopause between the ages of 45 and 55. Then, menopause symptoms can go on for any length of time, but usually it's about 7 years. But these numbers are highly variable (much younger women may be in menopause), and so is the number and severity of symptoms women experience.
I'll do the maths for you.
Age 30, you give birth. Age 45, when perimenopause starts getting common, your child is 15 and at a peak age for an eating disorder. Or you have a child, as I did, age 37. When they're 17 and yelling how much they hate you, you're 54 years old and the effects of the menopause makes it all so much harder to shrug off.
Peri/menopause: diminishing women's strength just when they most need it
Caring for our teens through an eating disorder is extremely demanding and emotional. Family-based treatment (FBT) and similar approaches require parents to become skilled and resilient supports, 24/7 at home. Even if you are not so involved in the minutiae of your child's care, the demands are great.
My resources are all about making this as easy as possible.
“She carried me on her shoulders when it seemed anorexia would drown me.”
Maya’s tribute to her mother, at the All in the Mind Mental Health Awards, BBC Radio 4 (10 June 2014)
If a woman is suffering from the effects of peri/menopause, she's not just carrying her child on her shoulders. She's doing it while swimming through molasses.
She doesn't know there is medical help. Or she is poorly informed about the risks and benefits. "I might try some homeopathy," she stutters, rubbing the molasses out of her eyes.
Let's talk about perimenopause and menopause in family-based treatment (FBT)
It's not often I google something and nothing comes up. Today on 14 February 2023 I've googled 'menopause FBT' and 'menopause caring for child with eating disorder' and there's nothing. I hope this post changes that.
What an internet search will bring up, and that's important too, is that menopause can be a time when a woman's eating disorder appears or re-appears. Given that mothers of a teen with, say, anorexia, may have had anorexia in their own teen years, it's another reason to take care of the mother's peri/menopause.
"My main symptom was anxiety and feeling so low -which in view of the situation we were in, seemed appropriate. I had no real flushes. I went just to give it a try, otherwise I think I would have asked for antidepressants.
From a mother
HRT really did help me cope and feel better. I seemed to cry a lot less – always a good thing!"
So clinicians, may I suggest you point every mother towards perimenopause / menopause advice. Parents supporting other parents, charities, professional institutions, the same. I've given workshops and I've given talks to big parent audiences, all about self-care, and I may have urged people to get medical checks (having personally experienced the exhaustion of low thyroid, iron and B12) but I've not mentioned menopause (having experienced it as 'no big deal').
I now believe that no advice on self-care should omit physical wellbeing, including peri/menopause help.
Women: go ahead and consult a doctor
I have no idea if I could have cried less over my daughter's two periods of eating disorder if I'd had HRT during my perimenopause and later, menopause.
What I did do throughout my child's illness is research the many ways of making myself stronger and more resilient. You will find them in Chapter 15 of my book, in my Bitesize audio collection, and sometimes I run a workshop on this too.
Being as well as we can be through perimenopause and menopause isn't just about hormone replacement therapy (HRT) (some prefer to call it 'menopausal hormone therapy', MHT). A doctor may recommend other things, and in terms of self-care, there's:
- your lifestyle: sleep, exercise, nutrition, reduce smoking and alcohol
- good psychological management
But again, when we're swimming through treacle, we might not be able to apply this good advice. The lack of estrogen is affecting our sleep, our energy, our appetite and our emotions.
And it's a double-whammy: when our child has an eating disorder, we tend to have more anxiety, less sleep, we may use alcohol to self-soothe. And even if we have the energy to exercise, we don't dare to when our children have been told they must resist their exercise compulsion.
I did pretty well. I thought it was because menopause isn't really a big deal. And because I have a good lifestyle and good emotional tools and a lovely counsellor. Maybe you did pretty well too.
But maybe some of us have just been lucky. The reality is that some women — many women — have more severe effects and they need medical advice, whether it's about self-help, 'natural' remedies, or HRT.
I know many mothers who have started antidepressants while supporting their child through an eating disorder. If that's what you need, great. Bear in mind, though, that bringing your estrogen or testosterone levels back up might be part of the picture. And while you're at the doctor, get all the usual blood tests for fatigue.
It's not all hot flashes
In case you think this piece is not relevant to you or to the women you see, please know that if a woman doesn't have hot flashes, she could still be suffering from other debilitating effects of the perimenopause and menopause. And those could be making caring for her child extra hard.
For instance, women in perimenopause or menopause may be experiencing some of these, to a greater or lesser extent:
hot flushes; night sweats; poor sleep; fatigue; poor concentration; brain fog; poor memory; mood swings; depression; anxiety; irritability/raging; poor libido; pain with sex; pain wearing tight trousers; urinary symptoms; dry skin; itchy or crawly skin; dry eyes; sore mouth; restless legs; headaches; muscle pain; joint pain; heavy menstrual flow or worsening premenstrual syndrome (in perimenopause); restless legs; and even… eating disorders.
Our children need our calm, competent, confident support through their own journey through hell. To do the best job possible, we need to sleep well, feel good and have access to our compassion.
By the way, don't underestimate perimenopause. For me, I think it was the worse of the two periods. In perimenopause, ovaries are winding down the production of estrogen and testosterone, with erratic ups and downs. Both hormones affect many functions of our body.
It's not about pathologising women
When I told a friend that from now on, peri/menopause help is on my radar for all women I support, he was worried it could pathologise or belittle women's reality. Like, "Oh you're in a bad mood today! Are you hormonal by any chance?"
Let's be clear: all parents have every reason to suffer when their child has an eating disorder. Every parent needs compassion and help. There is no 'either/or'. Fathers cry and yell and feel hopeless too. Fathers ask me how to control their emotions just like mothers do.
Our child's eating disorder hits us when we are old enough to be — usually — pretty wise, pretty competent, with a reasonably stable life. Or not. Parents are amazing. Parents are heroic.
My point is this: what if a woman, who is highly likely to have the extra burden of peri/menopause, could have that load taken off her?
What if she could continue carrying her child through tranquil waters, not molasses?
HRT: risks versus benefits
I'm one of these people who heard, 20 years ago, that HRT presents disproportionately high risks. I even have the 2002 book from the Women's Health Initiative, heavily annotated. I never realised that meanwhile, studies were re-analysed, and more trials have been published. So get yourself some up to date information. Get it from a range of sources, because the field has its ups and downs — a new study comes along, the media shouts about it, a menopause society may change their risk-benefit advice… and then another paper comes out pointing out the first study's flaws.
When you read about risks, be on the alert for which type of HRT was used. Nowadays we know that estrogen given transdermally (patches, gels, sprays) does not present the risk of blood clots associated with tablets — yet many studies report on women whose estrogen came in tablets — indeed as I write it seems that, unexplicably, these are still commonly prescribed. Also micronised progesterone (like Utrogestan) presents a lower risk of breast cancer than the synthetic types used in older studies (mare's urine, anyone?)
Also, if you're researching vaginal inserts of estrogen (like Vagifem) to help with local symptoms, you will probably find that this is very low risk, as the dose is tiny and locally applied.
I know your time and energy are already short, given your child is your first priority. Hopefully you can just visit a knowledgeable doctor. Otherwise, here are some sources to get you started more easily:
In the UK, the National Institute for Health and Care Excellence (NICE) 2015 guideline 'Menopause: diagnosis and management' rest on a review of all the evidence. It is being reviewed in light of more recent evidence. For instance it's risk table included some concerning results from a 2019 study, which was then disputed by the British Menopause Society.
A more recent source in the UK: Joint position statement by the British Menopause Society, Royal College of Obstetricians and Gynaecologists and Society for Endocrinology on best practice recommendations for the care of women experiencing the menopause (2022)
Official guidance balances not just risks and benefits to a woman, but to society. In the UK there was a shortage of HRT around 2021-22. Partly due to coronavirus, partly because of two hugely influential TV documentaries by Davina McColl (here and here). So the 2022 position statement above is partly in response to those shortages: it's prioritising women with distressing symptoms over those wanting to prevent the longer term effects of low estrogen.
America: The 2022 hormone therapy position statement of The North American Menopause Society: abstract here and a more detailed write up from the Australasian Menopause Society here.
Australia: the Australian Menopause Society is made up of doctors and other clinicians: their site has many factsheets
Balance-menopause is a source of much information, in many languages. Dr Louise Newson is a passionate advocate of menopause health. I never trust just one source, but what she says matches much of the official sources listed above.
Onwards
For more help for you, the parent, see Chapter 15 of my book, listen to my Bitesize audio collection, and sometimes I run a workshop on this too. I'm a parent, not a clinician, so don't read what I say as advice. I can't comment on the latest HRT scare, whenever that happens next. What I do is collate information and prompt you to seek out what is right for you and your child.
