Having suffered for ten years with agonising pain caused by polycystic ovaries, Karen Bowen was delighted when her doctors suggested a full hysterectomy.
But while the operation was a success, the surgery threw her straight into menopause, which triggered yet another problem: severe asthma.
Within months Karen developed attacks that had her fighting for breath and needing emergency hospital treatment.
‘It felt like someone was sitting on my chest,’ she recalls. ‘I couldn’t walk or talk in sentences as I was taking gulps of air.
‘At the same time, my blood pressure and heart rate went through the roof because my heart was desperately trying to get me to breathe,’ says Karen, 58, a skin clinic owner and mother of twin girls.
‘On around nine occasions they were so bad that I thought I was going to die – it was terrifying.’
It was initially put down to a recurrence of the childhood asthma she briefly had and she was given standard inhalers, but they did little to help.
It was only in 2021, 15 years after her surgery, that she was finally diagnosed with severe asthma, which requires different treatment, brought on by the rapid switch into menopause.
Most people think of asthma as a condition that comes on in childhood. But new research confirms menopause can trigger asthma in women who have never suffered from it before.
But experts fear that women may not realise they’re affected by it or that they won’t receive the necessary medication – which is worrying. Especially as asthma that comes on in adulthood is often harder to treat.
Even some health professionals seem unaware of the link between asthma and hormones, says Erika Kennington, head of research and innovation at the charity Asthma & Lung UK.
She said: ‘It is therefore possible that this delays diagnosis in older women, leaving their symptoms untreated. There is definitely a need to raise awareness of hormones as an asthma trigger.’
Research, published in the journal Menopause, showed the peak age for adult-onset asthma was between the ages of 50 to 54.
It was based on ten years of data involving more than 14,000 postmenopausal women who did not have asthma before the menopause, and mirrors what doctors see with their patients.
‘I see a peak in adult-onset asthma in women in their 40s and 50s every week,’ says Dr Pujan Patel, a consultant respiratory clinician at Royal Brompton Hospital in London, adding that it can be triggered by both natural menopause and surgical menopause brought on by a hysterectomy.
Asthma, which is when the airways become inflamed if in contact with a trigger, affects 7.2 million people in the UK. A further 200,000 have severe asthma and cannot manage their symptoms with standard medication.
While childhood asthma predominantly involves allergic triggers such as dust mites and pollen, adult-onset asthma is more likely to be triggered by viruses, stress and other non-allergic triggers. But why would menopause trigger asthma?
Previous studies blamed low levels of the hormone oestrogen for promoting inflammation, says Dr Viki Male, a senior lecturer in reproductive immunology at Imperial College London. Oestrogen is produced mostly by the ovaries, which can be removed in a hysterectomy.
She says: ‘Increased inflammation raises the risk of the non-atopic asthma [asthma not caused by an allergic trigger].’
That being said, high levels of synthetic oestrogen — found in certain forms of hormone replacement therapy (HRT) — seem to have the same effect, she says.
A 2021 paper in the journal Chest found that women on HRT had a 63 per cent increased risk of asthma, while women who stopped treatment were twice as likely to stop needing to use asthma treatment.
The scientists from Denmark decided that women prescribed HRT should be told they could develop asthma symptoms.
But Dr Male says: ‘If you take the right amount of oestrogen – but not too much – then increased inflammation should not be a risk.’
Researchers are investigating whether ‘male hormones’ such as testosterone – also present in women in small quantities – could be key ‘in the development of asthma around menopause’ too, explains Dr Patel.
In men, testosterone and other androgens (hormones that mainly trigger male traits) are associated with less inflammation.
So, male hormones may exert more influence in menopausal women, who have less oestrogen to balance it out with, and this may increase inflammation in the airways rather than reduce it (as it does in men).
‘We don’t understand exactly what’s happening, but the one thing that shouldn’t be ignored is that there is a hormonal influence on asthma, and that GPs and specialists should be aware that the risk is higher in women,’ says Dr Patel.
Some women who develop asthma around menopause may need injections of lab-created proteins (biologic treatment), to target specific parts of the immune response and control their symptoms.
‘Yet a lot of asthma medication is focused on the allergic pathway, so we see a lot of older women with asthma who don’t respond to asthma drugs,’ says Erika Kennington.
This is what happened to Karen, as doctors treated her symptoms as a recurrence of her childhood asthma, rather than adult-onset asthma.
After her hysterectomy, she started taking HRT and the asthma kicked in within months.
‘I started to catch chest infections and I’d find myself fighting for breath,’ says Karen, who lives with her husband Paul, 69, in Stone, Staffordshire. ‘But I didn’t put the two things together then.’
She was given a standard low dose steroid inhaler to reduce inflammation, as well as a reliever inhaler which contains fast-acting medicines to relax the airways. But she still often needed extra help with her breathing at hospital.
‘But each time I went to hospital I felt like it wasn’t taken seriously,’ says Karen. She’d had mild asthma until the age of eight and her doctors told her this was a recurrence.
Finally, in 2021, Karen was referred to a specialist centre where she was diagnosed with severe asthma instead, and then started on different treatments.
In February last year she started a biologic treatment called tezepelumab – an injection that blocks a chemical messenger thought to play a key role in irritating and inflaming the airways.
It has helped reduce the severity of her attacks but in August last year she was hospitalised again, so she may soon be switched to a different drug.
Dr Male suggests women keep a symptom diary about their ‘asthma and hormone situation you’re in at different times’.
‘Given the evidence showing HRT can increase the rate of adult-onset asthma, it’s sensible to keep an eye on any respiratory symptoms if you’ve recently started taking it, and GPs shouldn’t dismiss those who have noticed changes with HRT or the menopause,’ she says.
Karen is incredulous that it took so long to identify her severe asthma and its cause.
She says: ‘It’s so important that there’s more awareness of this connection – there could be women out there who have respiratory symptoms and might not even know it’s asthma.’ asthmaandlung.org.uk
