Better Training for Menopausal Management Urgently Needed

Tara Haelle

March 04, 2016

The newest generation of medical graduates and primary care providers lack the training to manage the menopausal symptoms that an increasing number of women will experience during the next decade, argues a new perspective article published in the March 3 issue of the New England Journal of Medicine.

"Reluctance to treat menopausal symptoms has derailed and fragmented the clinical care of midlife women, creating a large and unnecessary burden of suffering," write JoAnn E. Manson, MD, DrPH, from Brigham and Women's Hospital at Harvard Medical School in Boston, Massachusetts, and Andrew M. Kaunitz, MD, from the University of Florida College of Medicine in Jacksonville.

"Clinicians who stay current regarding hormonal and nonhormonal treatments can put menopause management back on track by helping women make informed treatment choices," they add.

By 2020, more than 50 million women will be older than 51 years, the average age of menopause, Dr Manson and Dr Kaunitz report. Close to three quarters of women experience menopausal symptoms such as hot flashes and night sweats, and the subsequent mood changes, sleep problems, difficulty concentrating, short-term memory lapses, and loss of productivity that accompany these vasomotor symptoms can significantly decrease women's quality of life and lead to higher healthcare costs. Yet many women go unevaluated and untreated, even when a plethora of hormonal and nonhormonal treatments exists to treat these symptoms, Dr Manson and Dr Kaunitz argue.

 
If you're going to care for women beyond a certain age and stay current, what you learned in residency about menopause is unlikely to be true. Dr Owen Montgomery
 

Owen Montgomery, MD, chairman of the Department of Obstetrics & Gynecology at Drexel University in Philadelphia, Pennsylvania, told Medscape Medical News he agrees with the authors that improved training for clinicians regarding menopause management is essential.

"The needs for women's health services continues to increase because of the growing population, the aging population, and the percentage of women who are living longer," Dr Montgomery said. "There is an increasing demand for care of women past their reproductive life."

Dr Montgomery said he tells residents in his grand rounds that what they will see in their practice is "not your grandmother's menopause."

"When I thought about menopause, I thought about my grandmother, who lived in the Midwest and went prematurely gray, but that's not what the care of postmenopausal women is about in 2016," Dr Montgomery told Medscape Medical News. "I think for a medical provider, if you're going to care for women beyond a certain age and stay current, what you learned in residency about menopause is unlikely to be true."

He also pointed out that the future of US healthcare will include team-based care, in which every clinician needs to practice to the top of their scope of practice. Because midwives tend not to treat women older than 50 years, obstetrician-gynecologists will become the specialists to which postmenopausal women will most often turn.

Misunderstanding of Women's Health Initiative Results

One stumbling block to quality care of perimenopausal women, write Dr Manson and Dr Kaunitz, is the misuse of the initial findings of the Women's Health Initiative (WHI) trial, which has led to "anxiety and confusion" in women who now fear hormone therapy. In fact, hormone therapy use has declined by 80% among US women since the study's publication in 2002, yet as many as 20% of women in early menopause could benefit from hormone therapy because they experience moderate to severe vasomotor symptoms and lack contraindications to therapy, the authors say.

"The gap in provision of appropriate treatment has left an opening for a burgeoning market for untested and unregulated alternative treatments, including custom-compounded hormone products that are not regulated by the Food and Drug Administration...which have raised concerns about dose consistency, product contamination, and unsubstantiated safety and efficacy claims," the authors write.

They point to a recent survey of 3725 postmenopausal women, conducted by the North American Menopause Society, that found that 35% of women currently taking hormone therapy are taking a compounded hormone product.

Dr Montgomery agrees that the WHI findings have not been appropriately communicated to providers and women.

"Medical educators have remained fixed in time since the WHI came out saying estrogen kills, but if they kept up with the literature, estrogen keeps women alive longer," Dr Montgomery said. "Young doctors are being told hormones are terrible and don't prescribe them, but if you look at the data, they actually save lives."

The concern about an increased risk for breast cancer associated with hormone therapy has led women to miss the benefit of reduced risk for heart disease and osteoporosis, Dr Montgomery said. Even among women with breast cancer, those who suffer from vaginal dryness, painful sex, and related urinary symptoms can use vaginal estrogen, he added.

The American College of Obstetricians and Gynecologists published an updated committee opinion this month addressing this issue.

"Among women with a history of estrogen-dependent breast cancer who are experiencing urogenital symptoms, vaginal estrogen should be reserved for those patients who are unresponsive to nonhormonal remedies," the American College of Obstetricians and Gynecologists committee writes. "Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms."

Dr Manson and Dr Kaunitz also point out that too few women receive treatment such as low-dose vaginal estrogen for vulvovaginal atrophy, or genitourinary syndrome of menopause. Nearly half of women in midlife or older experience these conditions, which can reduce women's physical and sexual health and quality of life.

Paula Amato, MD, an associate professor of obstetrics and gynecology at Oregon Health & Science University in Portland, also told Medscape Medical News that no findings from WHI should preclude short-term use of hormone therapy for menopausal symptoms, especially closer to the time of transition.

"Unfortunately, it has been interpreted in such a way that exaggerates the risks for the average woman without contraindications or a high baseline risk for breast cancer or heart disease, and downplays the benefits," Dr Amato said. "Every treatment carries risk. The question is whether the benefits outweigh the potential risks. I think that in the case of [hormone therapy], the pendulum has swung too far in the direction of risks over benefits."

Even for women who cannot or choose not to use hormone therapy for various menopausal symptoms, a wide range of nonhormonal treatment options are available as well, such as selective serotonin-reuptake inhibitors, norepinephrine-reuptake inhibitors, and gabapentinoids, the authors write.

"Women's symptoms are too often dismissed by providers and patients themselves as something inevitable that they should be able to deal with," in part because of inadequate training and competing demands on curricula for residents, Dr Amato said. "In addition, I think menopause is often given short shrift because it is not a procedure-heavy discipline, but instead requires lots of time counseling, and thus reimbursement is much lower." She also recommended cross-training among disciplines to counter natural biases that arise in practice.

Insufficient Training

The biggest barrier to treatment is insufficient training for clinicians, Dr Manson and Dr Kaunitz note. They point to a 2009 survey of 100 internal medicine physicians that found that the majority of them regarded care of menopausal women to be "very important," but only half felt comfortable managing menopausal symptoms. More than a third had not clinically treated menopausal symptoms in the previous 6 months.

"[M]ost primary care residency programs in the United States don't provide adequate education in women's health in general or in menopause management in particular," Dr Manson and Dr Kaunitz write.

"[W]e must train and equip the next generation of health care providers with the skills to address the current and future needs of this patient population."

Dr Kaunitz has received grant funding from Bayer, Teva, TherapeuticsMD, and Endoceutics and personal fees from Bayer and Teva. Dr Kaunitz served on the North American Menopause Society Board of Trustees from 2011 to 2016, and Dr Manson served from 2009 to 2014. Both served on the advisory board for the North American Menopause Society's Position Statement on Menopausal Hormone Therapy in 2012. Dr Montgomery is a member of the North American Menopause Society and has designed curricula to teach obstetrician-gynecologist residents about menopause.

N Engl J Med. 374;9:803-806. Abstract

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