Pay More Attention to Menopause

Here's what doctors need to know about this condition that affects all women 

                                                     by Diana L. Bitner MD

There is a health condition that all women experience and is the single most dramatic risk factor for heart disease, stroke, diabetes, obesity, and osteoporosis. This health condition is well understood and can be managed with evidence-based treatments.
However, this condition is rarely discussed, adequately screened, or sufficiently treated. Women feel confused, ignored, and minimized when they complain of symptoms leading up to and during the most burdensome years. Many women are told "it is just a phase, (essentially) deal with it" and even the most ardent brain thermostat gives up over time, and hot flashes go away. Vasomotor symptoms act as alarm bells telling us that cholesterol levels, blood sugars, and inflammatory markers are rising, bone is wasting, and the corpus colosseum is shrinking.
But since menopause might seem too murky and confusing, hormone treatment too confusing and scary, and women being only 50% of the population, it is often dismissed as something to be accepted like Tom Cruise telling Brooke Shields on National TV that postpartum depression was in her mind and she should exercise more.
Menopause needs to be seen for what it is -- the cessation of ovarian function. Loss of estrogen causes metabolic derangement. There's no controversy about that.
Menopause is an opportunity for the healthcare system to do the right thing -- whether for a 16-year-old after life-saving chemotherapy, a 35-year-old after an unexpected BSO, or a 51-year-old experiencing natural menopause and told her rising waistline, sleeplessness, and pain with sex is natural and to "watch her diet."
The effects of loss of estrogen are lifelong. As healthcare providers, I believe we are obligated to inform women of life-altering irreversible changes, and best practices to alter their diet, exercise, and other habits as well as perhaps consider hormone medication options to mitigate physiologic changes.
A study that stands out in my mind showed that peritoneal fat cells change their phenotype in menopausal women. With loss of estrogen, the cells produce significant amounts of inflammatory agents such as CRP and IL-6 versus the pre-menopause state. The KEEPS trial showed women taking transdermal estrogen have less insulin resistance, and JoAnn Manson at Harvard showed that women undergoing a BSO before age 45 had a significant increase in risk for cardiovascular disease if not given hormone replacement. These are just a few examples of the width and breadth of data demonstrating how hot flashes are alarm bells for what is happening under the surface.
In the years of my uphill battle to develop a whole service line for midlife and menopause in a large healthcare system, I have gained a thorough understanding that even if a clinical program is a good idea, buckets of money do not exist for implementation. I have learned that clinical programs require strategy, planning, and a positive business proforma. And, many champions must speak loudly for coveted dollars to be invested.
In the process to help my healthcare system understand the opportunity of menopause, I strategized for and got a meeting in the C Suite with several system business leaders. In this meeting, a very well respected executive, near retirement, leaned back in his chair, steepled his fingers, asked me the question that had been a consistent barrier for leadership: "Menopause Clinic? Isn't menopause just something women have to deal with?"
Thank goodness he wanted open discussion of that question and I was able to present the solutions we would be solving and the clinical as well as business case for the program. The result of that meeting was health system support, and I am forever grateful he listened and that our Midlife and Menopause Health Services Clinic now exists.
Take Marcie (not her real name) as an example. She waited 3 months to see me. Her chief complaint in EPIC was "menopause symptoms" and as I reviewed her history, I saw she was 54, had never been pregnant, was 16 months from her last period, and had gained 12 pounds in the last 8 months.
Her prior physical with her PCP covered all the screening basics, but the standardized form did not allude to menopause status or treatment options. In the annual visit HPI there was mention of night sweats, and in the plan was "refer to Midlife and Menopause." Victory No. 1, high referral rate from our PCPs as a result of many "lunch-n-learns," and happy patients.
I walked in the room, laptop in hand, and sat down across from her. I shook her hand, closed my computer, and asked, "what is hard?" She quickly answered, "the fatigue, the fatigue is really hard." Her night sweats started 1 year prior to her LMP and ever since, she had been waking up tired and she felt moody. She also talked about how sex hurt, and was no longer enjoyable. She used to initiate sex with her husband, but now neither did because fear outweighed desire.
Over time as she felt worse, she exercised less, and ate more simple carbs. Because of the weight gain, she felt unattractive to her husband, and was frustrated every morning because her clothes did not fit. Victory No. 2, she was sharing personal details, which would lay the foundation for a trusting doctor-patient relationship.
I then took the driver's seat, opened my computer, and walked her through a symptom inventory, including questions about sexual health as well as lifestyle habits. I asked what she took in for each meal and snack, and how much alcohol she consumed. I gained many data points, which would allow for risk stratification, and help me understand opportunity for risk-reducing change. We reviewed her medical history, including potential risk factors such as DVT, which could preclude safe use of hormone therapy. We discussed the components of sex drive, and why her libido had changed. She visibly perked up and was involved. Victory No. 3, potential partner in preventing her premature heart attack.
After a pelvic exam that revealed low estrogen demonstrated by flat rugae and a pH of 7.0, and tight tender pelvic floor muscles, she got dressed, and we talked. I explained how her ovaries had stopped producing estrogen, progesterone, and testosterone, and loss of these hormones caused many of her symptoms. While she had minimal healthcare knowledge and only a high school education, I saw a light bulb turn on as I explained the physiology of where the hormones work on the brain, skin, vagina, uterus, breast, and bones. I explained how triggers such as sleep deprivation, weight gain, and a diet high in sugar could also trigger symptoms. A tear rolled down her face as she said, "I am not crazy?" Victory No. 4, the tear. Now, opportunity was palpable.
Next we discussed options for treatment, starting with lifestyle. I have created a list of seven habits I call the SEEDS, or "Seven Essential Elements of Daily Success" including water, vitamins, food groups, fiber, exercise, sleep, and gratitude. We put together how the habits could help, leading to a discussion of her barriers. Victory No. 5, starting her process to healthy change.
The discussion about hormone replacement therapy ensued, and I informed her of the basic findings of studies such as ELITE, WHI, KEEPS, NHS, and Vital. I explained the likely benefits of HRT, how to take it, and guidelines, giving the menopause.org website. She was a perfect candidate to trial HRT, and chose to accept a prescription. Victory No.6, a balanced discussion leaving her knowing there were hormone medication options.
I then asked her to follow up in 3 months, and to have blood work done, including an HbA1c and a DEXA bone density test. Because of her not having children and a history of dense breasts, I offered her an appointment at the high-risk breast clinic for advanced screening. Also, because of her fatigue, I sent her to the preventive cardiologist, and for her tight pelvic floor, to the Pelvic Floor Physical Therapist. Victory No. 7. Total health understood, valuable healthcare resources being utilized.
After 8 months, Marcie lost and kept off 20 pounds, worked to drop her HbA1c from 6.1 to 5.5, and lowed her blood pressure and cholesterol. She is happy on her 0.05 mg estrogen patch and micronized progesterone. Her stress echo was negative, and she had only mild osteopenia. Her fatigue was gone, her moods happy and coping skills improved, her exercise regular, and she felt normal. Victory No. 8. Heart attack prevented until age of 106 (dramatized, but you get my point).
Yes, menopause visits can be lengthy, and not well reimbursed. In a Work Relative Value Unit (WRVU) based system, moving from an ob/gyn salary to that of a card-carrying NAMS Certified Menopause Practitioner is not the best personal financial move. However, the results of such work is priceless. If more healthcare systems were to embrace mid-life and menopause health as the front-line of wellness care for women, engaged patients would flood the gates to join and everyone wins.
Menopause is an opportunity, not a just a condition or group of symptoms to be tolerated. Menopause needs to be embraced for the gift it gives us, a chance to save lives and reduce preventable illness