#93 What They Don’t Teach in Med School About Menopause
Almost Everything
This article first appeared in the Medium.com publication: Menopause Matters: Empowering Women’s Health
They can’t diagnose what they don’t know.
By Joan Naidorf DO
When my friend Linda started having symptoms of peri-menopause around age 50, she spoke to her general internist about it . Her physician offered medication to address anxiety. After discussing some of the same problems with her regular gynecologist, she was told extensively about peri-menopause with advice on what to expect and some options on what she might do to address the issues.
Why such a difference in the diagnosis and approach? One likely explanation is the spectacular lack of menopause-related education offered during medical school. Medical school curriculum is generally divided into two years of basic sciences, followed by two years of moving through hospital based clinical rotations. Deep within the curriculum subject of obstetrics and gynecology, after the lessons on pregnancy, eclampsia, ectopic pregnancy, pelvic infections, and contraception, might be a lecture or two on menopause.
During most clinical rotations, students and residents become part of a team with an attending physician, taking care of hospitalized patients. Menopause and peri-menopausal problems are generally not seen in patients who are hospitalized. Students and residents do participate in outpatient clinics where peri-menopausal patients may or might not present for care. Most of the outpatient OB-GYN care I recall from my own training centered on monthly obstetric visits and contraceptive treatments.
As a physician trained in emergency medicine, I routinely saw women with gynecologic and obstetrical problems that prompted them to seek treatment in the emergency department. I even delivered one baby in the back seat of her father’s car. There was no emphasis or education regarding menopause or peri-menopause.
The author on duty in the emergency department
Internal medicine physicians rotate through its subspecialties of internal medicine–cardiology, pulmonology, gastroenterology, rheumatology, endocrinology, nephrology, hematology-oncology and infectious disease. A 2019 Mayo Clinic survey of medical residents found that 58% had received one lecture on menopause in their training and 20% had received no menopause training whatsoever. Family medicine physicians, who complete residency training, gain more experience diagnosing and treating women's health issues in the office setting. With the firehose of information presented during training, menopause education becomes a minute component.
Even physicians entering the field of obstetrics and gynecology get quite limited training in menopause matters because of the relative weighting of inpatient care and the higher population of younger women in the outpatient clinics. Teaching programs generally serve more low income and under-insured patients who tend to present as younger women who are still in their child-bearing years.
After years practicing obstetrics and gynecology in Napa, Calif., Dr Rebecca Levy-Gantt has chosen to specialize in peri-menopause care. She remembers, “when I was a resident (a million years ago) all of our information about menopause and hormone therapy actually came from lectures that were sponsored by drug companies, especially Pfizer, the maker of Premarin and PremPro. This was before the Women’s Health Initiative, and Pfizer was the sponsor of ‘a big new study’ that was going to be designed to show that estrogen helped prevent cardiovascular disease.
It certainly sounded feasible, as younger women didn't have heart attacks, but menopausal women did. “We thought it must be because women in menopause are missing their estrogen, and replacing it would help prevent heart attacks,” Levy-Gantt says.
The Women’s Health Imitative (WHI) was a huge, prospective study begun in the early 1990’s to look at the effect of hormone replacement therapy on the incidence of chronic disease in menopausal women. The design and effect of that study has been complicated, with one group taking Premarin (estrogen only) and another taking Prempro (estrogen plus progesterone).
When the women in the Prempro part of the study were documented to have a higher incidence of invasive breast cancer, that portion was stopped. Panicked women taking hormone replacements abruptly stopped them.The media pounced on the news story, and unhelpful fears and conclusions about menopausal hormone replacement took hold.
In the years following, randomized controlled studies – prospective studies that measure the effectiveness of a new intervention or treatment designed to reduce bias and provide a rigorous way to examine cause-effect relationships between an intervention and outcome – were conducted, in addition to deeper dives into the WHI data.
Dr Heather Hirsch, a certified internist specializing in midlife and menopause, works to help increase education on the safe use of hormones to treat peri-menopause and menopause symptoms.She has posted a clear and informative video on the topic that is quite helpful. The Women's Health Initiative (WHI) Study Explained... And its not what you thought! - Bing video
Hirsh notes that the women who started an estrogen-only medication actually did well and saw many benefits from starting hormone replacement therapy earlier. She also concludes that the formulation of medication matters and several more options exist for physicians to prescribe for their patients.
WHI Study had flaws
Another flaw in the construction of the WHI study was the advanced average age of the participants and the fact that they began hormone replacement well after the onset of menopause. We now know that peri-menopause symptoms in women of color begin much earlier and go largely unaddressed. How Menopause Affects Women of Color - The New York Times (nytimes.com) Data now suggests that beginning treatment earlier can be beneficial.
“There's so much nuance to treating women in perimenopause and menopause, that we should have thought about that before. But PremPro was all we had at the time, so it was that or nothing. I'm so glad that there are so many safe choices now and so much good information out there that we can use to treat our patients going through their menopausal transition and into their menopause years.” Levy-Gantt notes. Her book, ,Perimenopause For Dummies, (Wiley Press) will be available in November of 2023.
Additional education is crucial
Physicians, nurses, and nurse practitioners interested in advanced training and learning best practices for treating peri-menopause, can opt for ongoing education through the North American Menopause Society (NAMS), one of the largest U.S. nonprofits focused on this time in a woman’s life. . It should be noted though, “NAMS also accepts charitable contributions from corporations, foundations, and individuals (members and nonmembers) to support the educational programs, research, and other activities of the Society.”
NAMS sponsors yearly educational meetings, posts educational videos and articles for professionals and for women in the public, and has a certification program for medical professionals. The organization developed a competency examination program in 2002 to “set the standards for menopause practice and to assist women in locating clinicians who could provide optimal menopause-related healthcare. More than 1,000 professionals carry the additional certification of a NAMS Certified Menopause Practitioner (NCMP).
Women experiencing symptoms of peri-menopause must feel comfortable talking about them with their physicians and those symptoms must be diagnosed accurately for effective treatment to be prescribed. Problems not reported to the physician, nurse-practitioner or physician assistant will certainly not be addressed. Due to modesty or embarrassment, some women may be reluctant to discuss their symptoms with male physicians. If you think that your symptoms are being dismissed or ignored, you can try again with your current practitioner or find another who is both receptive to hearing your issues and willing to work with you to treat them effectively.
Joan Naidorf is a physician, author, and speaker based in Alexandria, VA.
https://www.drjoannaidorf.com/ @joannaidorf
