WOMEN’S HEALTH Menopause

Menopause A multidisciplinary approach

BY RACHEL S. CADY, MD, FACOG

Women over the age of 50 represent the nation’s fastest-growing population segment, according to recent Census Bureau data. This group—currently 64 million, or one-third of all American women— is expected to continue to rise rapidly as women live longer. The average woman lives one-third to one-half of her life in postmenopause, and 75% experience significant menopausal symptoms.

Unfortunately, the small number of menopause specialists across the nation does not meet the demand, and Minnesota is no exception. The state’s menopause specialists are clustered mostly in metropolitan areas. Access to care for patients in rural areas presents both a challenge and a unique opportunity for new models of care.

One region’s story

Throughout my years of OB-GYN practice in multi-specialty clinics in Crosby, Aitkin, and Mora, the change in demographics and needs of our patients has become more apparent. The population is aging in our area. Women desire a better quality of life but are bombarded with weak

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The “what” was the manageable part: the growing number of retirees to our Brainerd Lakes area. Many of my OB/GYN colleagues were not trained in menopause medicine or women’s sexual dysfunction treatment, nor in the unique needs of this aging population—but we wanted to learn.

The “why” was that this is a dynamic area of medicine that is rapidly evolving. As a group, and as a hospital, we resolved to do better. The interest was there, along with the ever-growing need.

The “how” was going to be through hospital support, careful planning, and continued learning.

For a couple of years, we took stock of our local resources, did our prep work, and learned from others. To have a treatment center, we would need a team: dietitians with specialty training in menopause weight management, pain specialists, easy access to pharmacists for medication review, pelvic floor physical therapists, mental health providers with an interest and understanding of midlife, and many other components and involvement from primary care and other specialists. And above all, the mutual desire to do a good job, to fill a need, and to provide local care to patients. Throughout the course of attending live and virtual conferences from menopause and sexual medicine societies, hitting the books, networking with more seasoned practitioners in the arena, and becoming certified through the North American Menopause Society (NAMS), we were finally able to start our program.

Assessing needs

The menopause transition (perimenopause) and menopause comprise a time of opportunity to make overall health assessments, plan for the future, and address the unique set of accompanying symptoms. This can be incredibly challenging for women to navigate on their own.

The spectrum of concerns, questions, and bothersome symptoms associated with this natural phase of life varies dramatically. Bleeding concerns, low libido, painful sex, vulvar pain, hot flashes, weight gain, sleep disturbances, anxiety/mood changes, and hot flashes are just part of the vast array of common symptoms. Addressing health care maintenance guidelines, hormone replacement therapy (HRT), bone health, cancer risk assessment, and cardiac health is equally important for comprehensive care. All are paramount to healthy aging.

Tragically, three out of four women who seek medical help for menopauserelated symptoms are left disappointed, confused, and misinformed. While

3 Menopause from page 24 Our group is comprised of OB-GYNs and nurse practitioners who are menopause practitioners certified through the North American Menopause this statistic seems shocking, the root of the problem lies in the simple fact Society (NAMS). With the help of a registered nurse and LPNs, team that many clinicians have not been properly trained in menopause care. The members work together to develop clinic procedures, patient education, vast majority of physicians and residents report and individualized treatment plans. We also serve feeling at a loss when trying to address, counsel, and patients at the Riverwood Health Care Center in treat even the most basic symptoms associated with Aitkin. menopause. As a society, we have placed emphasis We work with certified pelvic floor physical on contraception, prenatal care, and pap smears, but therapists, pharmacists, dietitians, sex therapists, very little on perimenopause, menopause, and sexual Menopause care is a subspecialty pain specialists, psychotherapists, primary care concerns. Women are too often left to navigate their that requires a unique skillset. specialists, and other professionals who have journey independently via web searches, headlines, expertise in midlife women’s health. The goal and unregulated online supplements. is to provide comprehensive, evidence-based

For clinicians, menopause care is a subspecialty consultative care and education under one roof that requires a unique skillset and knowledge in collaboration with the patient’s primary care base. Comprehensive care for women experiencing clinician. menopause requires a collaborative group of specialists in multiple fields Our group offers multiple educational activities throughout the who are well trained in the unique nuances that are part of menopause. year for the community at large about issues specific to perimenopause A multidisciplinary approach and menopause. A website for patient education with current write-ups, Cuyuna Regional Medical Center’s Menopause and Healthy Aging program videos, and blogs serves to inform both patients and the general public. began in January 2019 to meet the needs of aging women as they transition An annual continuing medical education program on the most updated through both perimenopause and menopause. The goal is healthy aging information in this field is offered to colleagues. Since the COVID-19 utilizing evidence-based medicine. The program provides personalized, pandemic, monthly Facebook Live talks have been the primary modality interdisciplinary care for health issues specifically related to perimenopause, for community education. Being a rural area, many of our patients prefer menopause, and sexual health. local access to care. Unfortunately, for Native Americans and other minorities, awareness about perimenopause and menopause, what to expect, and related health conditions is disproportionally lacking. Few studies exist about this

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When a patient schedules a consult with our program, a member of the team calls the patient to preplan the visit, optimizing time and, ideally, minimizing unnecessary return trips to the clinic. Patients appreciate this extra effort, as it demonstrates both a respect for their time and a willingness to reduce onsite clinic visits during the COVID-19 pandemic.

Patients are given options for phone, Zoom, or in-person consults. We utilize menopause-specific intake forms such as MENQOL (Menopausespecific Quality of Life), as well as problem-specific intake forms, particularly for individuals with libido/orgasm/vulvar pain-specific concerns.

While consulting via phone visits, our team provides patients a recommended set of services, including labs work. Opportunities for streamlined services, if desired from the patient, also include imaging, vaccines, other specialty visits coordinated for patient convenience, “streamlined” care, improved compliance, and fewer unnecessary logistical frustration.

During site visits, patients are made comfortable with warm blankets, iPads for education, and comfortable exam rooms. At the conclusion of the consult, each patient is given a Menopause and Healthy Aging packet with a care plan carefully outlined, along with evidence-based problem-specific information, a follow-up care plan, an explanation of personal expectations, and contact information for follow-up questions.

Additional resources The International Society of the Study of Women’s Health (ISSWSH) is The North American Menopause Society (NAMS) provides a an equally valuable, multidisciplinary professional organization that carries standardized questionnaire for menopause patients that highlights many out many essential purposes, including education and support for clinicians symptoms and conditions unique to menopause—sexual issues, mood treating women’s sexual health. problems, hot flashes, hormone replacement The International Menopause Society therapy, sleep concerns, and many more—to and National Vulvodynia Association are two help focus individualized care in an efficient, additional resources for patients and clinicians. effective manner.

The organization offers online education The spectrum of concerns ... following menopause specialists and colleagues at the videos for patients, a free app for clinicians with this natural phase of Menopause and Healthy Aging program: Michael called MenoPro for clinical guidelines, updated life varies dramatically. Cady, MD, FACOG, NCMP; Melissa Goble, clinical publications, and patient handouts WHNP, NCMP; and Donna Claypool, WHNP. called “Menonotes.”

NAMS also provides a platform for clinicians interested in certifying in midlife care. Nationwide, there are approximately 1,100 NAMS-certified practitioners. NAMS is an excellent resource for ongoing educational opportunities and collaboration with other expert clinicians to receive help with challenging patient scenarios.

The International Menopause Society offers additional training and medical education as well. For physicians who don’t want to become a certified practitioner but would like to screen women for menopausespecific health concerns and problems and determine insances that warrant referrals to a specialist, the NAMS health questionnaire can provide useful guidance. The author acknowledges the contributions of the Rachel S. Cady, MD, FACOG, is the director of Cuyuna Regional Medical Center’s Menopause and Healthy Aging program. She is a fellow of the American College of Obstetricians and Gynecologists and a certified menopause practitioner through the North American Menopause Society (NCMP). She is a member of the International Society for the Study of Women’s Sexual Health, the International Menopause Society, National Vulvodynia Association, AAGL, and AUGS.

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