The Doctor Will (Maybe) See You Now

by WV Marshall

Some women celebrate perimenopause. Others bemoan it.

No matter how you choose to recognize (or not) this milestone of womanhood, you need to know that the onset of perimenopause means an increase in some health risks, such as changes in LDL cholesterol (the “bad” cholesterol).

Or possibly increasing the likelihood of heart disease. Or how about changes in bone density, a problem for both men and women, brought on by a reduction in estrogen?

These very real health risks skulk about, hidden by any of a number of distracting – sometimes debilitating – physical complaints such as hot flashes, night sweats, weight gain and brain fog.

While menopause treatments that help ease discomfort or manage the onset of chronic conditions, the fact remains, according to research, only a small minority of menopausal women are receiving the medical care they deserve.

AARP magazine cited a Yale University review of insurance claims from more than 500,000 women in various stages of menopause.

The study indicated that while 60 percent of women with significant menopausal symptoms sought medical assistance, nearly three-quarters – 75 percent – of them were left untreated.

“Doctors are not helpful,” says Philip M. Sarrel, professor emeritus of obstetrics, gynecology and reproductive services, and psychiatry, at the Yale School of Medicine. “They haven’t had training, and they’re not up to date.”

“Nearly one-third of this country’s women are postmenopausal,” gynecologist Wen Shen, assistant professor in the Johns Hopkins School of Medicine Department of Gynecology and Obstetrics, told AARP. “Many of them are needlessly suffering.”

Doctors treat symptoms, helping women achieve better sleep, reduce anxiety and enjoy a better sex life. But it’s beyond that, doctors say.

When perimenopause is properly managed, particularly early on, women could lower their risk for many common, life-threatening diseases that they are susceptible to for the next 25 years.

As an example, AARP noted a 2017 study that found that when hot flashes and night sweats lasted longer and were more severe, a woman was at risk for developing type 2 diabetes. Other studies have indicated that treatment at the onset of menopause could slow the progression of osteoporosis, the magazine said.

“When we talk about menopause, we’re not just talking about hot flashes and night sweats and dry vaginas,” Shen told AARP. **“We’re talking about what happens after the ovarian hormones go away and women become at increased risk for osteoporosis, heart disease, cognitive decline.” **

AARP cited a 2013 study that indicated menopause was a risk factor for developing cardiovascular disease.

What’s more, **perimenopause “means the loss of a key neuroprotective element in the female brain and a higher vulnerability to brain aging and Alzheimer’s disease,” ** said Lisa Mosconi, a professor of neurology at Weill Cornell Medicine and lead author of a study on menopause and dementia in the PLOS One.

It wasn’t all that long ago – sometime around 1908 – that an American woman’s life expectancy finally crossed the 51-year mark. (Stages of perimenopause typically begin between the ages of 45 and 55; notice how age 51 is smack in the middle?).

Women in America nowadays could spend about a third of their lives in a stage of menopause. About 6,000 women in the United States reach menopause a day. By 2020, AARP reported, 50 million women will be postmenopausal.

AARP surveyed more than 400 women between the ages of 50 and 59 about their experiences with, and attitudes toward, menopause. One result was sobering. Forty-two percent of respondents said they never discussed menopause with their healthcare providers. When they did, only one in five said they were referred to a menopause specialist.

The fact is, most medical schools and residency programs don’t include perimenopause in their core curricula – courses on this phase of a woman’s life tend to be electives. AARP said a survey indicated just 20 percent of ob-gyn residency programs provide any kind of menopause training – and the vast majority medical residents said they feel “barely comfortable” discussing or treating perimenopause.

“We spend a lot of time in the health care profession teaching women how not to get pregnant,” said New York City gynecologist Tara Allmen, author of “Menopause Confidential.” “Then we teach them how to have babies, and possibly we teach them how to breastfeed. But that is where the lectures end.”

“Menopause is as different from obstetrics as surgery is from pediatrics,” James Woods, a professor of obstetrics and gynecology at the University of Rochester School of Medicine in New York, said in the AARP article. Formerly an obstetrician, Woods now specializes in menopause.

“Every woman’s ovaries will age and then stop producing estradiol, the body’s most important estrogen. But each person will be different in how she reacts to that loss,” said Woods, who writes a blog called menoPAUSE. “Menopause management requires a lot of listening. There are no ‘packages’ that can be given to all women.”

Slowly, however, doctors are realizing the need to rethink how they work with women throughout the stages of menopause, AARP said.

After meeting pushback initially, Chicago’s Northwestern Memorial Hospital opened a Center for Sexual Medicine and Menopause. Gynecologist Lauren Streicher said the clinic, which opened in October 2017, isn’t just about treating menopause. It also is about rethinking the midlife woman’s entire health profile.

Because menopause affects all aspects of a woman’s overall health, Streicher developed a network of subspecialists in fields from cardiology to neurology – all knowledgeable in the nuances of menopause.

She’s not resting on her laurels, though. Next on Streicher’s to-do list is making menopause education a requirement in the ob-gyn residency at Northwestern. Starting in 2019, menopause education was elective, but she wants to change that, adding that she aims to make menopause management a course available to residents of every subspecialty.

“Menopause management needs to be comprehensively integrated into medical curricula and residency training across primary care as well as a number of subspecialties,” said internist JoAnn Manson, chief of the Division of Preventive Medicine at Brigham and Women’s Hospital in Boston.“The fragmentation of women’s healthcare has led to untreated symptoms and a serious impact on women’s health. Many women who would have benefited from hormone therapy may have suffered needlessly.”

To help fill in the gaps in physicians’ knowledge about menopause management, the North American Menopause Society offers physicians continuing education courses on menopause and certifications in the field of midlife medicine, AARP reported.

NAMS has certified more than 1,100 doctors in menopause management, meaning the doctors passed a test that indicates a working knowledge of hormonal and non-hormonal therapies to treat menopause symptoms and are up on current research.

“It can be hard enough to be menopausal,” NAMS Executive Director JoAnn Pinkerton said. “Women deserve to have a provider who understands menopause and can guide them through it.”