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Obstacles to Perimenopause and Menopause Care

A look at the reasons why millions of women navigating perimenopause and menopause face challenges in getting effective care.
Obstacles to Perimenopause and Menopause Care
Last updated:
6/28/2024
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Currently, 75 million women are in perimenopause, menopause, or post-menopause in the U.S. And, it’s estimated that almost 22 million American women will enter perimenopause over the next ten years! What can these women expect when they seek diagnosis and treatment for perimenopausal and menopausal symptoms? Is the American medical system prepared to help these women navigate the hormonal roller coaster of perimenopause and menopause? Ahead, a look at the challenges facing women in the U.S.

How are perimenopause and menopause defined?

First, let’s define perimenopause and menopause, because many people are still confused about these terms. Perimenopause refers to the transitional period before menopause, when a woman’s ovaries produce less estrogen. This hormonal change can lead to perimenopausal symptoms, including irregular menstrual cycles, hot flashes (also known as hot flushes), night sweats, mood swings, and vaginal dryness. While many people believe these are symptoms of menopause, these symptoms are actually related to perimenopause and usually start much earlier in a woman’s mid-40s, and can last 4 to 8 years.

Menopause is defined as the point at which menstrual periods have stopped for 12 consecutive months, marking the end of a woman’s reproductive years. It occurs when the ovaries stop releasing eggs, around age 51, on average. The majority of women experience a reduction in symptoms within a few years after menopause, but a significant minority – around one-third – of women continue to experience menopause symptoms.

Why are women reluctant to ask for perimenopausal and menopausal care?

Many American women will spend at least a third of their lives in perimenopause and post-menopause, and the majority of them receive no treatment. One of the reasons is the reluctance to raise the topic of perimenopausal and menopausal symptoms with healthcare providers.

In an eye-opening 2018 article published in AARP The Magazine, writer Jennifer Wolff wrote that only 50% percent of women with significant symptoms even seek medical attention for perimenopausal and menopausal symptoms. Nearly three-quarters of these women are left untreated.

Why aren’t more women raising the subject of perimenopause and menopause with their healthcare providers? There are a number of key reasons.

  • There’s a general lack of knowledge and awareness about the range of symptoms beyond hot flashes and irregular periods, such as memory/concentration issues, mood changes, brain fog, and vaginal dryness, among others. This lack of knowledge prevents women from recognizing their symptoms as menopause-related.
  • Women tend to normalize their symptoms or wrongly attribute them to other causes like stress, other existing conditions, or simply aging. Many women don’t realize their symptoms warrant medical attention.
  • Some women are embarrassed to discuss personal issues like sexual dysfunction or vaginal problems with doctors. The menopausal transition is still a taboo topic for many women.
  • Some women have the perception that menopause is a natural process that doesn’t require treatment or that doctors cannot do much to help. Some women think their symptoms are inevitable and not worth “wasting a doctor’s time.”
  • Many women lack confidence in their healthcare providers’ knowledge about menopause and treatment options like hormone replacement therapy (HRT).
  • Many women have concerns about the risks of -- and misconceptions surrounding – HRT.

What do doctors know about perimenopause and menopause?

As noted, some women are reluctant to seek care because they lack confidence in their healthcare providers’ knowledge about perimenopause and menopause. Their lack of confidence is backed up by the fact that doctors – even obstetricians/gynecologists (O.B./GYNs) – receive limited education on menopause during their medical training and residency programs.

A survey of 145 OB/GYN residency program directors across the U.S. found that only 31% of programs reported having any menopause curriculum at all. Nearly 20% of the directors surveyed stated that their program’s menopause curriculum was limited to just a rotation block. The survey also found that 84% of program directors believed more menopause educational resources were needed in their program.

Another survey reported that more than half (58%) of fourth-year OB/GYN residents surveyed felt they needed more education about menopause medicine, including hormonal/non-hormonal therapy, bone health, heart disease, and metabolic syndrome.

Medical textbooks provide scant or inaccurate information on menopause, with 58% having no reference to it at all. Around 12% of textbooks dedicated less than a page to the topic.

A 2019 study found that nearly two-thirds of resident physicians in family medicine, internal medicine, and obstetrics/gynecology provided incorrect answers about menopausal treatment, and one in five reported receiving no lectures on menopause during their residency.[4]

According to a 2022 survey of almost 100 ob-gyn program directors, about 70% of their programs have no menopause-related curriculum. Among the programs with a menopause curriculum, 71% reported having two or fewer lectures per year.

It’s clear that the lack of structured menopause education in medical training is leaving many doctors ill-equipped to properly counsel and treat perimenopausal and menopausal patients.

This lack of training also poses another challenge for patients. Many women report feeling dismissed or misunderstood by their healthcare providers. In a 2020 survey conducted by AARP, 45% of women aged 45 to 60 reported that their healthcare provider did not take their perimenopausal or menopausal symptoms seriously. Women report having to rely on non-medical sources like websites and friends for menopause information due to their healthcare providers’ lack of knowledge. This increases the risk of receiving inaccurate or incomplete information.

The good news is that, with the growth in numbers of perimenopausal and menopausal women, more efforts are underway to improve the situation, including increasing and even mandating menopause curricula in medical school.

The AARP article referenced earlier quotes internist JoAnn Manson, MD, chief of the Division of Preventive Medicine at Brigham and Women’s Hospital in Boston. According to Dr. Manson: “Menopause management needs to be comprehensively integrated into medical curricula and residency training across primary care as well as a number of subspecialties. The fragmentation of women’s health care has led to untreated symptoms and a serious impact on women’s health. Many women who would have benefited from hormone therapy may have suffered needlessly...There are estrogen receptors on every single organ in the body. We can’t just ignore menopause and say, ‘There, there, sweetie. Just buck up and deal with it.’”

This concern was also reflected in a 2022 article in Current Opinion in Endocrine and Metabolic Research journal. According to the authors, “...training on menopause management is profoundly inadequate even nowadays. Menopause management requires theoretical education and clinical experience for the optimal management of menopause-related issues. Although menopause education is included in some medical and specialty training curricula, physicians are not adequately trained to provide the standard of care to women transitioning to menopause.”

How did the 2002 “Women’s Health Initiative” (WHI) findings influence practitioner and patient attitudes about HRT?

As noted earlier, many women are confused about the risks and benefits of HRT or believe that there aren’t any safe or effective treatments for menopause. These misconceptions can be traced back largely to the 2002 release of the findings of the Women’s Health Initiative (WHI) trials. The implications of the WHI report have continued to affect perimenopause and menopause care – and the attitudes of both patients and practitioners – more than 20 years later.

At that time of the initial report, the WHI reported that the combined use of estrogen and progestin in postmenopausal women increased the risks of invasive breast cancer, coronary heart disease, stroke, and pulmonary embolism. Experts concluded that the risks of HRT treatment far outweighed the potential benefits. These findings contradicted the prevailing belief at the time that HRT protected against chronic diseases.

The WHI findings caused significant upheaval and led to a sharp decline in overall HRT use. In fact, the percentage of women aged 50 to 74 years taking HRT, which peaked at 42% in 2001, declined by 70% between 2001 and 2008.

Subsequent analyses revealed that the risks and benefits of HRT varied significantly based on a woman’s age and the time since the onset of menopause. Basically, for younger women in perimenopause, HRT could provide relief from menopausal symptoms, and the benefits outweighed the risks of HRT. On the other hand, initiating HRT years after menopause posed much higher risks with far fewer benefits.

The latest comprehensive report from the WHI in 2013 reinforced these findings. It concluded that HRT remains an appropriate treatment option for younger women experiencing moderate to severe menopausal symptoms.

More than 20 years after the initial WHI bombshell, some doctors and patients mistakenly still believe that all HRT is dangerous. This misconception is reflected in the fact that less than 7% of women are currently on HRT.

A 2021 study published in the journal Menopause found that a significant number of healthcare providers lack comprehensive knowledge about hormone replacement therapy (HRT). The study reported that 60% of surveyed primary care physicians had misconceptions about the risks and benefits associated with HRT, which is a critical aspect of menopause management.

A 2021 survey by the American College of Obstetricians and Gynecologists (ACOG) found that only 25% of women who could benefit from HRT are currently using it. This underutilization is often due to a lack of physician confidence in prescribing HRT, compounded by insufficient patient education about the therapy’s benefits and risks.

What other challenges make the diagnosis and treatment of perimenopause and menopause more difficult?

Apart from patient reluctance to seek care, a lack of menopause education for practitioners, and confusion about the risks and benefits of HRT, other factors can make perimenopause and menopause care more challenging. These factors include the following.

Variability in symptoms

The symptoms of perimenopause and menopause can vary greatly between women, ranging from irregular periods, hot flashes, mood changes, vaginal dryness, and sleep disturbances to changes in sexual function. Some women may experience minimal symptoms, while others may have severe symptoms. This variability makes it difficult to diagnose based solely on symptoms.

Gradual onset

Perimenopause is a transitional phase that can last for several years before reaching menopause. The gradual onset and fluctuating hormone levels during this time can make it challenging to pinpoint the exact stage a woman is in.

Lack of definitive tests

There is no single definitive test to diagnose perimenopause or menopause. Diagnosis is primarily based on a woman’s menstrual history and symptoms. Blood tests to measure hormone levels – including estrogen, progesterone, like luteinizing hormone (L.H.) or follicle-stimulating hormone (FSH) – can be helpful but may not provide a precise diagnosis due to fluctuating levels during perimenopause.

Overlapping conditions

Some symptoms of perimenopause, such as mood changes, sleep disturbances, fatigue, and irregular periods, can also be caused by other medical conditions or medications, including hypothyroidism. The risk of developing an underactive thyroid increases in women who are 40 and above. This can make it challenging to attribute the symptoms solely to perimenopause.

Age variability

While the average age of menopause is 51, the onset of perimenopause can vary significantly between women, occurring as early as the late 30s or as late as the early 60s. This age variability can make it difficult to diagnose based on age alone.

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What can improve the situation?

Improving the management of perimenopause and menopause requires a multifaceted approach:

Enhanced medical education

Medical schools and residency programs need to incorporate comprehensive training on menopause management into their curricula. This includes up-to-date information on the risks and benefits of various treatment options, including HRT.

Continuing medical education (CME)

Providing CME opportunities focused on menopause can help current practitioners update their knowledge and skills. Professional organizations like the North American Menopause Society (NAMS) and the American College of Obstetricians and Gynecologists (ACOG) offer valuable resources and certification programs that can help bridge knowledge gaps.

Patient education and advocacy

Empowering women with accurate information about menopause and available treatments is crucial. Healthcare providers should engage in open, empathetic discussions with their patients, addressing misconceptions and providing evidence-based guidance.

Research and policy support

Continued research into menopause and its treatments can help clarify the risks and benefits of various therapies, leading to more nuanced and individualized care. Policymakers can support this by funding menopause research and promoting public health campaigns to raise awareness.

Interdisciplinary collaboration

A collaborative approach involving gynecologists, primary care physicians, endocrinologists, and mental health professionals can provide more comprehensive care for perimenopausal and menopausal women. Such teamwork can help address the multifaceted nature of menopause and ensure that all aspects of a woman’s health are considered.

A note from Paloma

There’s no question that getting care for perimenopause and menopause can be a challenge. Unfortunately, significant gaps still exist in patient awareness – and the education and training of physicians – regarding menopause management. While there is an increasing focus on improving medical education, these gaps continue to contribute to difficulties in diagnosis and treatment, leading to patient frustration and unmet healthcare needs.

As a patient, you can start by learning as much as possible about perimenopause and menopause. Become familiar with the signs and symptoms, and be willing to openly discuss your symptoms and concerns with your healthcare provider.

When you are looking for help with the diagnosis and treatment of perimenopause and menopause, one option is to choose a healthcare professional associated with the Menopause Society. Practitioners who demonstrate their expertise in menopause are awarded the credential of NAMS Certified Menopause Practitioner (NCMP).

The transition through perimenopause and menopause is a critical period that warrants knowledgeable and compassionate medical care. One simple solution is to choose Paloma for your hormonal healthcare. Paloma Health’s practitioners have extensive experience working with women going through hormonal transitions, including perimenopause, menopause, and hypothyroidism. Your Paloma care team can provide treatment to optimize your hormonal balance with medical treatment, as well as lifestyle recommendations and nutritional guidance to improve your quality of life. Consider scheduling a call with a Paloma care manager to explore whether Paloma Health is right for you.

References:

Senator Baldwin Leads Bipartisan Bill to Boost Menopause Research, Expand Training and Awareness Around Menopause | U.S. Senator Tammy Baldwin of Wisconsin. www.baldwin.senate.gov. Published May 3, 2024. Accessed June 11, 2024. https://www.baldwin.senate.gov/news/press-releases/senator-baldwin-leads-bipartisan-bill-to-boost-menopause-research-expand-training-and-awareness-around-menopause

Wolff, Jennifer. “What Doctors Don’t Know Aout Menopause.” AARP The Magazine. August/September 2018. https://www.hopkinsmedicine.org/-/media/womens-wellness-program/what_doctors_dont_know_about_menopause-aarp.pdf

Alsugeir D, Wei L, Adesuyan M, Cook S, Panay N, Brauer R. Hormone replacement therapy prescribing in menopausal women in the U.K.: a descriptive study. BJGP Open. 2022 Dec 20;6(4):BJGPO.2022.0126. doi: 10.3399/BJGPO.2022.0126. Erratum in: BJGP Open. 2023 Mar 21;7(1):BJGPO.2022.0126.C1. doi: 10.3399/BJGPO.2022.0126.C1. PMID: 36216368; PMCID: PMC9904798. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9904798

Welsh, Erin. Most OB/GYN residency programs in U.S. lack dedicated menopause curriculum. Healio. July 11, 2023 https://www.healio.com/news/womens-health-ob-gyn/20230810/most-obgyn-residency-programs-in-us-lack-dedicated-menopause-curriculum

Tariq B, Phillips S, Biswakarma R, Talaulikar V, Harper JC. Women’s knowledge and attitudes to the menopause: a comparison of women over 40 who were in the perimenopause, post menopause and those not in the peri or post menopause. BMC Womens Health. 2023 Aug 30;23(1):460. doi: 10.1186/s12905-023-02424-x. PMID: 37648988; PMCID: PMC10469514. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10469514/

Kim N, Gross C, Curtis J, Stettin G, Wogen S, Choe N, Krumholz HM. The impact of clinical trials on the use of hormone replacement therapy. A population-based study. J Gen Intern Med. 2005 Nov;20(11):1026-31. doi: 10.1111/j.1525-1497.2005.0221.x. PMID: 16307628; PMCID: PMC1490267.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490267/

Hess, Rachel, MD, MSc et al. Understanding physicians’ attitudes towards hormone therapy. Vol. 15, Issue 1, January 2005. DOI:https://doi.org/10.1016/j.whi.2004.10.002 https://www.whijournal.com/article/S1049-3867(04)00103-3/abstract

Barber K, Charles A. Barriers to Accessing Effective Treatment and Support for Menopausal Symptoms: A Qualitative Study Capturing the Behaviours, Beliefs and Experiences of Key Stakeholders. Patient Prefer Adherence. 2023 Nov 15;17:2971-2980. doi: 10.2147/PPA.S430203. PMID: 38027078; PMCID: PMC10657761.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10657761/

Allen, Jennifer T. MD, NCMP, et al. Needs assessment of menopause education in United States obstetrics and gynecology residency training programs. Menopause 30(10):p 1002-1005, October 2023. https://journals.lww.com/menopausejournal/abstract/2023/10000/needs_assessment_of_menopause_education_in_united.4.aspx

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Mary Shomon

Patient Advocate

Mary Shomon is an internationally-recognized writer, award-winning patient advocate, health coach, and activist, and the New York Times bestselling author of 15 books on health and wellness, including the Thyroid Diet Revolution and Living Well With Hypothyroidism. On social media, Mary empowers and informs a community of more than a quarter million patients who have thyroid and hormonal health challenges.

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