Menopause: Help your patients make the change

As a family planning clinician, you are accustomed to helping women choose the method of contraception that is right for them. As your patients move toward menopause, you face the challenge of helping them make appropriate health decisions as they approach this new stage of life.

About 24.5 million women worldwide during the 1990s will reach menopause each year, and by the year 2030, 1.2 billion are expected to be age 50 and older, according to the North American Menopause Society in Cleveland.

The Menopause Society's 1997 menopause survey shows that 52% of American women ages 45 to 60 view menopause as the beginning of a new and fulfilling stage of life. The majority of peri- and postmenopausal women surveyed said they would advise other women to approach men opause with a positive attitude. How can you prepare patients for positive health experiences during this time of life?

While 49% of American women receive information about menopause from health care providers, they also are reading books, magazine articles, and even articles posted on the Internet to become more educated on the subject, according to the Menopause Society survey findings.

"I think it is important to provide as much information as possible," says Robert Rebar, MD, professor and chairman of the department of OB/GYN at the University of Cincinnati College of Medicine. "That takes time, and in today's world, that's a difficult venture."

Rebar's office maintains a library of books for patients to borrow, as well as a number of bro chures. (The Menopause Society offers a series of 10 easy-to-read booklets covering topics including menopause basics, treatments, abnormal uterine bleeding, and cancer. See resources, p. 61.)

As the number of women moving toward menopause grows, so do the options available for treatment of hot flashes, vaginal dryness, and prevention of osteoporosis. Whether those options are drug-related or complementary therapies or simply lifestyle changes, it is important that clinicians seek the approach that works best for each patient.

Perimenopause challenges

Perhaps your patients are now hitting perimenopause, entering the six or so years immediately before menopause in which they experience fluctuations in levels of hormone produced by aging ovaries. Irregular bleeding patterns and hot flashes are indicators of this state.

"Perimenopause causes consternation for many women and clinicians because things change each month, and one month doesn't predict the next," says Andrew Kaunitz, MD, professor and assistant chair of the department of OB/GYN at the University of Florida Health Sciences Center in Jacksonville. "This can be a frustrating time."

Estrogen levels may be lower than they were in reproductive years, and there is an increased risk of loss of bone mineral density, Kaunitz says. Increasing emotional changes may accompany this time, with women reporting mood swings.

As one way to address this issue, family planners may find that low-dose oral contraceptives (OCs) are indicated for healthy, non-smoking women, he says. Low-dose OCs will help regulate periods, address bone density issues, and provide effective contraception if needed.

For perimenopausal women for whom combination OCs are contraindicated, including smokers, diabetics, and hypertensives, oral progestins given cyclically will regulate menses, Kaunitz says. He also reports good success using DMPA in contraceptive doses combined with supplemental estrogen therapy to cause amenorrhea, suppress vasomotor symptoms, and improve bone mineral density.

Decision: Hormone therapy?

While the short-term effects of lower estrogen functions, such as hot flashes, night sweats, insomnia, and mood swings, bring women to the clinician's office, the long-term consequences, such as increased risk of heart disease and osteoporosis, often lead them and their providers to choose estrogen or combination hormone therapy during the midlife passage.

Patients should be informed partners in the decision to use hormone therapy, Rebar stresses. In a study of 2,106 women who had received a prescription for hormones, nearly 40% quit taking them altogether after one year, while another 35% cut back on the prescribed dosage.1

"It is important to emphasize that it is not a panacea, and it is not a fountain of youth," Rebar says. "You need to look for absolute contraindications, of which there are few."

According to the Menopause Society, contraindications for estro gen therapy include the presence of breast cancer, abnormal uterine bleeding of an unknown cause, a high level of triglycerides, history of blood clotting disorders, and liver disease.2 While cigarette smoking isn't a contraindication, smokers considering hormone therapy should stop smoking because it alone increases cardiovascular risks.

Be sure your patient understands and supports use of hormone therapy before it is prescribed, Rebar says. For patients who are considering such therapy, Rebar suggests they go home, read about the method, write down their questions, and return in a couple of weeks to discuss their concerns before any prescription is written.

Kaunitz supports this approach and notes that U.K. and U.S. studies have found that female physicians are more likely to personally use hormone therapy than other women, underscoring that well-informed women are more likely to take advantage of the benefits offered by hormone therapy.3,4

(Editor's note: See story on choices in prescription hormone therapy, at right. Contraceptive Technology Update will include information on complementary therapies in an upcoming issue.)

References

1. Carroll L. Many menopausal women do not take HRT consistently. Medical Tribune Aug. 15, 1996.

2. North American Menopause Society. Menopause Treatments. Cleveland: 1997.

3. McNagny SE, Wenger NK, Frank E. Personal use of postmenopausal hormone replacement therapy by women physicians in the United States. Ann Intern Med 1997; 127:1,093-1,096.

4. Isaacs AJ, Britton AR, McPherson K. Why do women doctors in the UK take hormone replacement therapy? J Epidemiol Community Health 1997; 51:373-377.