Perimenopause and Menopause: Challenges and Solutions

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% 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:

• Lack of Knowledge and Awareness: Beyond hot flashes and irregular periods, symptoms like memory/concentration issues, mood changes, brain fog, and vaginal dryness are less known, preventing women from recognizing them as menopause-related.

• Normalization of Symptoms: Women tend to normalize their symptoms or wrongly attribute them to other causes like stress, other existing conditions, or simply aging, not realizing their symptoms warrant medical attention.

• Embarrassment: Discussing personal issues like sexual dysfunction or vaginal problems can be embarrassing.

• Perception of Menopause as Natural: Some women believe menopause is a natural process that doesn’t require treatment or that doctors cannot do much to help.

• Lack of Confidence in Healthcare Providers: Many women lack confidence in their healthcare providers’ knowledge about menopause and treatment options like hormone replacement therapy (HRT).

• Concerns About HRT: Misconceptions and concerns about the risks of HRT deter women from seeking treatment.

What Do Doctors Know About Perimenopause and Menopause?

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

How Did the 2002 “Women’s Health Initiative” (WHI) Findings Influence Practitioner and Patient Attitudes About HRT?

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 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. These findings led to a sharp decline in HRT use. However, 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. For younger women in perimenopause, HRT could provide relief from menopausal symptoms, and the benefits outweighed the risks of HRT.

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 make perimenopause and menopause care more challenging:

• Variability in Symptoms: The symptoms can vary greatly between women, making it difficult to diagnose based solely on symptoms.

• Gradual Onset: Perimenopause is a transitional phase that can last for several years, making 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.

• Overlapping Conditions: Symptoms like mood changes, sleep disturbances, and fatigue can also be caused by other medical conditions or medications.

• Age Variability: The onset of perimenopause can vary significantly between women, making it difficult to diagnose based on age alone.

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.

• Continuing Medical Education (CME): Providing CME opportunities focused on menopause can help current practitioners update their knowledge and skills.

• Patient Education and Advocacy: Empowering women with accurate information about menopause and available treatments is crucial.

• Research and Policy Support: Continued research into menopause and its treatments can help clarify the risks and benefits of various therapies.

• Interdisciplinary Collaboration: A collaborative approach involving gynecologists, primary care physicians, endocrinologists, and mental health professionals can provide more comprehensive care.

A Note

There’s no question that getting care for perimenopause and menopause can be a challenge. 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.

The transition through perimenopause and menopause is a critical period that warrants knowledgeable and compassionate medical care.