Furaha Bishota: My battle with menopause, the silent storm

This is the first of a four-part series on menopause that we shall run for the next four weeks.

When we meet Furaha Bishota at the Barista in Nairobi's Riverside, she exudes calm and composure. However, the last five years of her life have been anything but serene. The post-menopause phase nearly turned her world upside down.

For a 55-year-old, she appears fit, stylish, and petite, belying the struggles she recounts.

"In Africa, we say, 'Aging is not lost youth but a new stage of opportunity and strength,' yet for many women, menopause turns this opportunity into a challenging ordeal," begins Furaha, a mother of three.

Menstrual flow

"I was looking forward to the menopause and post-menopause phases of my life. I was excited and ecstatic because for me, this would mark the end of my monthly menstrual flow and I thought nothing would be more liberating. Nothing prepared me for what was to come," says the certified accountant, internal auditor, and development professional.

At 49, she noticed a shift in her personality.

"I am extroverted and an extremely happy person but I suddenly became quieter and loved keeping to myself more. I, however, did not have major mood swings. A short while later, I started experiencing the hot flashes."

She describes the intensity of these episodes: "While these would not last long — about two minutes — my whole body would feel like it was in flames. Just as I was trying to navigate these, the night sweats set-in. This was in 2020 and it coincided with the Covid-19 era, so at first I thought it had something to do with the pandemic. I would wake up with my sheets completely drenched. This phase lasted a few months, then went away."

Read also: The emotional roller coaster of transitioning to menopause 

Initially, Furaha didn't seek medical attention, unaware of the hormonal connection. Insomnia soon followed.

"This was a bit confusing as it happened at a time when I had a full-time consultancy, was running a business and was taking some professional courses. So at first, I just thought it was burnout and that my body was just acting up."

The resulting fatigue was overwhelming.

"Looking back, of all the menopause symptoms I have had to deal with, insomnia has been the most difficult. This is because at work, you are still expected to show up and be productive. This is also one symptom that has refused to go away. I just manage to keep up and live with it to-date. What I have realised is that working out in the morning helps me kick-start my day energetically."

Fatigued and detached

"In addition to insomnia, another difficult symptom to manage has been brain fog and memory loss. I have lost concentration, it is difficult to focus, and I have become very easily distracted. I misplace literally everything and remembering appointments and even names has become a nightmare," she notes remorsefully.

Furaha reflects on the potential impact on her parenting: "My eldest is 21, the second is 16 and the last is 14. They are currently all in the United States of America for their studies. When the menopausal symptoms set in, they were still around and very much needed my care and attention but I was always fatigued and detached. I would get home and all I wanted was to lie down and not have a conversation with anyone. By then, I did not know what I was dealing with and I can only hope that I didn't deny them my motherly attention and love."

Read also : Breakthrough as FDA approves non-hormonal menopause pill

The most alarming symptoms emerged in 2021. She was diagnosed with a thyroid problem in January — a condition she'd never experienced before.

"In July of the same year, I was hospitalised at MP Shah Hospital with a heart condition. Feeling your heart racing or heart palpitations, as well as aches and pains, including in the chest area are common symptoms of the menopause in many women. It was just one diagnosis after the other and this got me super worried. I had always been a fitness junkie and now I was having to deal with one extreme condition after the other."

Towards the end of 2021, she decided to dye her hair.

"I think I was going through a mid-life crisis because I suddenly wanted to rock mild-blonde hair," she says with a hearty laugh.

"Previously, I had never thought of colouring my hair. So, I went and got it mildly done but a few days down the line, my hair started falling off in patches. Of course, my first thought was that the dye had been too harsh on me or maybe the colour used wasn't right. I went to see a trichologist, and they recommended a treatment that involved getting injections on my scalp. It was too painful and I ditched it all together."

She resorted to wigs to conceal her balding but found them unbearable due to heat.

"Overtime, I have embraced my hair-loss and started sporting a bald look. The hair has started slowly growing back but there are still a few patches that are visible where the balding was most severe."

Before she could celebrate hair regrowth, Furaha developed what her dermatologist diagnosed as 'extreme menopausal eczema' on her legs.

"My legs just started scarring." This was puzzling, as she'd never had eczema before.

"All this while, I had not linked all or any of these symptoms to menopause. And so, I was seeing different specialists for different conditions. During menopause, the skin is greatly impaired due to the change in oestrogen levels as these levels decline. Oestrogen is essential for healthy skin."

Read also: Menopause: Body changes to expect

"Even before the eczema could be treated, I was diagnosed with vitamin D deficiency. I remember this time that I had gone to drop my kids off at school in the US and coming back to my hotel room, I was just in excruciating pain. My joints were literally on fire, and I sobbed uncontrollably in that hotel room. I couldn't understand what was happening to me.

“I even started thinking that maybe I was suffering from a terminal illness. On my flight back to Nairobi, I depended on strangers to help me get around throughout my journey. Immediately after I landed, I went to see my doctor and told her I was not going to leave the hospital until the problem with my body was detected and treated."

Around this time, she began researching her symptoms, discovering their connection to menopause.

"It all made sense. By listening to the likes of Oprah Winfrey and Michelle Obama share their lived experiences, I felt that I was not alone, and I accepted that I needed to make some life changes, especially in my workout routine and diet."

Furaha's experience is not isolated. Research shows that approximately 1.2 billion women are either dealing with peri-menopausal or postmenopausal symptoms. This is about a third of the world's female population.

According to a University College London (UCL) study published in April 2023, more than 90 per cent of postmenopausal women were never taught about menopause at school (this translates to nine in ten women) and over 60 per cent only started looking for information about it once their symptoms had started.

Joint pain

Dr Mary Claire Haver, a US-based certified obstetrician gynaecologist and one of the leading menopause specialists globally, admits that menopause as a condition is not given enough attention in medical schools.

"We'd been taught that women tend to complain and somaticize symptoms because of dissatisfaction with life circumstances and stress. The 'it's all in her head' medical mantra was very much alive and well. If anything, we had a code for that, WW for Whiny Woman, and it was pretty much the acronym for patients who came in complaining of a cluster of symptoms; weight gain, brain fog, irritability, joint pain, decreased sex drive, poor sleep, and fatigue." she says this in one of her interviews with Steven Bartlett of the Diary of a CEO YouTube channel.

According to a 2022 survey by Biote, nearly two out of every five women reported experiencing menopause symptoms that interfered with their work performance or productivity each week and contributed to burnout.

Almost one in five had quit a job or considered quitting because of their symptoms, underscoring the reality that menopause is not an emotional issue that employers can simply wave off, but a serious medical condition that threatens workplace operations.

Unfortunately, the negative societal perceptions of menopause, the stigma that comes with this topic, especially in an African setting and the failure of the medical community to prioritise the health of this group have resulted in a knowledge gap among women entering this phase of their lives. This could have a substantial negative influence on their overall quality of life.

Dr Haver's own personal journey, which presented the same life-disrupting symptoms my many patients have long complained of, piqued her curiosity on how menopausal symptoms are handled globally and she started reading and researching on the same.

"When I turned to social media to discuss my own menopause journey, the conversation exploded into two million TikTok followers eager to participate, share their stories, and ask for advice," she notes in yet another interview.

So what exactly is menopause and why are its symptoms so disruptive?

According to Dr Grace Kanyi, a consultant obstetrician and gynaecologist based in Meru County, natural menopause is defined as the permanent cessation of the monthly menstrual periods. This is determined when a woman has experienced 12 months of amenorrhoea, or, simply put, 12 months of not having periods without any underlying pathological or physiological conditions. "On average, this occurs at the age of 52."

"When menopause occurs, it reflects a complete or near-complete ovarian follicular depletion, which then results in hypoestrogenism, or oestrogen deficiency, which refers to a lower than normal level of oestrogen," she explains.

She notes that, that oestrogen, and therefore the lack thereof of the same, impacts every tissue and organ system in the body of a woman.

To put it in simpler terms, "When a girl is born, she is born with all her follicles present. This is unlike in men or boys, where there's continuous production of their sperm. For the girls, they have a permanent number of eggs that they are born with and these are all the eggs they can have in their lifetime."

"So, when girls start to get their monthly menstrual cycle, there is a specific number of oocytes that are going to be recruited and this means that, as time goes on, the girls are depleting their egg count with each menstrual cycle.”

Studies show that by the time a majority of women are getting to 30 years of age, they have depleted 90 per cent of their egg stock and by the time they hit 40, they only have about three per cent of their eggs left.

Read also: Scientists reprograming ovarian cells in bid to eliminate menopause

"So, this depletion goes on and on until approximately age 52, when the eggs are completely exhausted. Menopause, therefore, occurs as a result of the depletion of those active oocytes, from which women develop the bulk of their oestrogen for normal functionality. Therefore, we can confidently say that menopause is genetically predetermined."

"When this natural phenomenon occurs, then the menopausal symptoms start to manifest. The most popular are usually the hot flashes, which start as a wave of heat on the upper chest that quickly spreads to the face before breaking into a sweat. They mostly occur at night and they can be so intense."

"Another way hypoestrogenism affects women of this age is through insomnia. They start having very irregular sleep patterns and this, in the long run, results in irritability. There is also a mental health effect to this, as there has been a rise in depression cases among women in menopausal transition and this calls for mental health assessment care for women in this age group."

Another key manifestation of low oestrogen levels in women is depreciated bone health. Women in their menopausal era have very brittle bones and this is why it is very common for women in their 60s to suffer a mild fall and end up with a fracture.

This is a very important discussion to have because oestrogen is very important in the maintenance of bone health. This loss of bone health is called osteoporosis.

It is important to note that menopausal symptoms manifest differently for different women. Some people may have intense symptoms of menopause, while others have mild symptoms."

There are over 60 symptoms that manifest with menopause, ranging from vaginal dryness to mood swings, brain fog, weight gain, hair loss, anxiety, depression, cardiovascular diseases, and changes in libido. This is why it is important to have regular check-ins with your obstetrician/gynaecologist when you get to this age.

Dr Kanyi says she has observed that women are aware of this phase of their lives and are constantly seeking professional help at least in the last couple of years.

"The majority of the women who are consulting on this are those who occupy spaces in boardrooms. This is because, ironically, peri-menopausal and post-menopausal symptoms start manifesting at the time when women are at their career peak. As such, they are self-aware and do not want all these changes in their bodies to affect their functionality and career trajectory."

On how best to manage or deal with the symptoms, Hormone Replacement Therapy (HRT) is highly rated by the specialists. This refers to exogenous reproductive hormones given to replace the naturally produced oestrogen when its levels decline in menopause. This form of therapy may be made up of oestrogen only or a combination oestrogen and progesterone.

"HRT is a game-changer when it comes to softening the effects of menopause. However, having said that, HRT is not to be administered liberally," quips Dr Kanyi.

"This is because it comes with certain inputs and side effects. As a result, gynaecologists must thoroughly assess patients who are seeking this treatment while taking into account their prior medical history. For instance, if we have a patient who has had previous Deep Vein Thrombosis (DVT), a heart disease, or a history of breast cancer in their lineage, HRT will not be ideal for them. For this group of patients, we tend to use other natural methods such as supplements with phyto oestrogens. We also encourage the intake of foods rich in phytoestrogens, such as soy, grapes, apples, kidney beans, cabbage, and spinach.

"Another consideration in administering HRT is whether the patient has a uterus or not. If the patient had their uterus removed at some point earlier in life, due to other gynae-related issues, it becomes quite simple to give them oestrogen. This can be administered for about five years, according to previous literature. Recent studies, however, indicate that this should be done for two to three years."

If a patient has a uterus, then caution is advised because if you give oestrogen, which is unopposed, the results will be thickening of the inner lining of the uterus, which is called endometrial hyperplasia, and this becomes an important risk factor.

It is important for patients and their doctors to discuss formulations that have both oestrogen and progesterone to protect the inner lining of the uterus. This is the reason why a licenced gynaecologist should be the only one to administer HRT.

For bone-health, oestrogen administration does not exactly have a direct impact, as earlier literature indicated. More refined and advanced data shows that a particular group of drugs called bisphosphonates are helping reduce osteoporosis. Another recommendation for women to maintain their bone health is to literally and intentionally soak-up in the sun so as to adequately take up Vitamin D directly from the source. We also encourage them to consume foods that are rich in calcium.

In terms of the availability of medications to slow down the impact of menopause, Dr Kanyi says these are available in public hospitals though not as readily as in private hospitals.

On affordability, however, she says this is kind of an out-of-pocket sort of expenditure, which is not affordable for most patients.

"A lot of times, even patients with private health insurances have to pay from their pockets as treatment for menopausal symptoms is not covered by these insurances."

"For us in the profession, we have learned that telling a woman in her menopausal era that this is the available treatment that will significantly improve the quality of your life helps them decide whether they want to spend money on the same."

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