Why Is Menopause Management Not Better Understood By OB/GYN Care Providers?
Today, menopause management as a finite field of medicine is a product of many laboratory and clinical studies targeted at understanding the biology of menopause and the impact of hormonal and non-hormonal treatments. Why, then, do women in the menopausal transition or in menopause itself often confront a medical community that is either not aware of or is even indifferent to the challenges they face?
The concept of menopause is not new. Symptoms of menopause in midlife were observed in women as far back as the time of Aristotle. By 1921, the term “menopause” gave this time of life a name. However, women’s psychosocial issues were slow to gain recognition, perhaps because gynecologic care was provided by mostly male physicians in an era of paternalistic medicine. Evidence the debate in the 1970s as to whether premenstrual dysphoria actually existed. The concept that symptoms of menopause might begin months or years before that one year without a menstrual period (officially called menopause) or that the symptoms for some women might last well into their 70s was not discussed.
In 1968, Robert Wilson, a gynecologist in New York City, published “Feminine Forever” advocating that menopause was a discrete time of life and was treatable. In his own words, “The often-severe suffering of my menopausal patients made me regard menopause as a serious medical condition endangering the health and happiness of any woman…In the vast majority of cases the distressing bodily changes following menopause are reversible through estrogen treatment.” Unfortunately, by portraying menopause as a “disease to be treated,” he inflamed the feminist movement, which at that time was advocating menopause as a natural transition in life to be tolerated and even embraced. It was out of that debate that in 1992 the Women's Health Initiative was funded by the National Institutes of Health (NIH) to study hormone replacement and its potential preventive actions. Those results and subsequent study-analyses, fueled by the pharmaceutical industry, spawned a wide range of treatments for menopause. Around that same time, in 1989, the North American Menopause Society was formed, bringing together scientists and physicians in OB/GYN and general medicine with a goal to “promote the health and quality of life of all women during midlife and beyond through an understanding of menopause and healthy aging.“
Even with these efforts, why do women patients still ask, "Why is menopause not better understood by care providers?” Here are four possible answers. 1. Formal training in OB/GYN is usually clinic based, involving younger patients with a focus on obstetrics, contraception, and sexually transmitted infections. 2. The practice of OB/GYN demands that the practitioner acquires a wide range of surgical skills for managing obstetric care and gynecologic surgery. Menopause management is not dominated by the requirement of manual surgical skills. 3. Menopause management in the office is time-intensive in an era when insurance reimbursement rewards procedures and shorter visits with higher numbers of patients seen. 4. Menopause management requires more individualization of education and treatment, which is, by itself, a higher level skill in medicine. This form of practice is more trial and error than much of medicine and requires patience by clinician and patient, an emotion which is often in short supply in our world of short attention spans.
Is there a brighter future for menopause care? Efforts are underway to improve research, therapeutics, and gynecologic care to address the needs of educated menopausal women. As more women care providers age and become more interested in menopause medicine, patients will benefit. In addition, women themselves will bring about change as they become better educated about menopause management. Menopause is a time of life, NOT a disease. Distressing symptoms can be eased with a variety of modalities for interested and educated patients guided by knowledgeable care providers.
By James Woods, M.D. and Elizabeth Warner, M.D.
Dr. Woods treats patients for menopause at the Hess/Woods Gynecology Practice.
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James Woods | 5/2/2016
