August 2020, Volume XXXIV, Number 5
A multidisciplinary approach
By Rachel S. Cady, MD, FACOG
omen 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 guidance from questionable sources about their midlife/postmenopausal care. They are longing for avenues to address what is often an array of new and seemingly “strange” symptoms. They are busy women, a “sandwich generation” who do not want to travel far and wide for fragmented care. Cuyuna Regional Medical Center’s general OB-GYN department wondered if we could help fill the void in menopause medicine—and, if so, how to identify the “what, why, and how”?
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.
Menopause care is a subspecialty that requires a unique skillset.
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.
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 menopause-related symptoms are left disappointed, confused, and misinformed. While this statistic seems shocking, the root of the problem lies in the simple fact that many clinicians have not been properly trained in menopause care. The vast majority of physicians and residents report feeling at a loss when trying to address, counsel, and treat even the most basic symptoms associated with menopause. As a society, we have placed emphasis on contraception, prenatal care, and pap smears, but very little on perimenopause, menopause, and sexual concerns. Women are too often left to navigate their journey independently via web searches, headlines, and unregulated online supplements.
For clinicians, menopause care is a subspecialty that requires a unique skillset and knowledge base. Comprehensive care for women experiencing menopause requires a collaborative group of specialists in multiple fields who are well trained in the unique nuances that are part of menopause.
A multidisciplinary approach
Cuyuna Regional Medical Center’s Menopause and Healthy Aging program began in January 2019 to meet the needs of aging women as they transition through both perimenopause and menopause. The goal is healthy aging utilizing evidence-based medicine. The program provides personalized, interdisciplinary care for health issues specifically related to perimenopause, menopause, and sexual health.
Our group is comprised of OB-GYNs and nurse practitioners who are menopause practitioners certified through the North American Menopause Society (NAMS). With the help of a registered nurse and LPNs, team members work together to develop clinic procedures, patient education, and individualized treatment plans. We also serve patients at the Riverwood Health Care Center in Aitkin.
We work with certified pelvic floor physical therapists, pharmacists, dietitians, sex therapists, pain specialists, psychotherapists, primary care specialists, and other professionals who have expertise in midlife women’s health. The goal is to provide comprehensive, evidence-based consultative care and education under one roof in collaboration with the patient’s primary care clinician.
Our group offers multiple educational activities throughout the year for the community at large about issues specific to perimenopause and menopause. A website for patient education with current write-ups, videos, and blogs serves to inform both patients and the general public. An annual continuing medical education program on the most updated information in this field is offered to colleagues. Since the COVID-19 pandemic, monthly Facebook Live talks have been the primary modality for community education. Being a rural area, many of our patients prefer 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 topic, and there is little information about proven solutions. Optimizing telemedicine to reservation clinics, as well as education for clinicians, are two concrete measures to bridge the gap. The Cuyuna website features blog posts and videos to educate both the general population and clinicians.
The spectrum of concerns ... with this natural phase of life varies dramatically.
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 (Menopause-specific 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.
The North American Menopause Society (NAMS) provides a standardized questionnaire for menopause patients that highlights many symptoms and conditions unique to menopause—sexual issues, mood problems, hot flashes, hormone replacement therapy, sleep concerns, and many more—to help focus individualized care in an efficient, effective manner.
The organization offers online education videos for patients, a free app for clinicians called MenoPro for clinical guidelines, updated clinical publications, and patient handouts 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 menopause-specific health concerns and problems and determine insances that warrant referrals to a specialist, the NAMS health questionnaire can provide useful guidance.
The International Society of the Study of Women’s Health (ISSWSH) is an equally valuable, multidisciplinary professional organization that carries out many essential purposes, including education and support for clinicians treating women’s sexual health.
The International Menopause Society and National Vulvodynia Association are two additional resources for patients and clinicians.
The author acknowledges the contributions of the following menopause specialists and colleagues at the Menopause and Healthy Aging program: Michael Cady, MD, FACOG, NCMP; Melissa Goble, WHNP, NCMP; and Donna Claypool, WHNP.
© Minnesota Physician Publishing · All Rights Reserved. 2019
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.