Why So Many Doctors Fail Women With Menopause Care

Each year when I visit my primary care physician for my annual physical, the first stop is his office, where we sit opposite one another for a few minutes. We begin with some small talk, which eases us into the next phase of the visit, which I dub “the reading of the questions." It’s a thorough list covering everything from head to toe.

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“How’s your eyesight? Your hearing? How’s your taste, smell, digestion? Your balance, appetite?” There’s much more, but I don’t remember all of the questions. Oh, yeah: "How’s your memory?”

From there, we move into the exam room and roughly an hour later, I’m heading home.

Yet, for me and scores of other women, rarely are we questioned about symptoms of menopause, which can be severe for some and last as long as 11 years. Hot flashes, night sweats, vaginal dryness, mood swings, sleep problems and weight gain are common, yet many physicians are not asking, and many women are not telling — too embarrassed or uncomfortable to bring it up.

Despite the fact that menopause and estrogen deprivation “can be debilitating, life-altering and even life-threatening, only about 6% of women receive counseling and treatment for the consequences of menopause,” wrote Dr. Lauren Streicher, a clinical professor of obstetrics and gynecology at the Feinberg School of Medicine at Northwestern University, in a letter to The New York Times in response to the Times’ recent article, “What if We Didn’t Dread Menopause?”

Lately, it seems that every time I come in contact with another female around my age —  a friend, acquaintance or stranger — the topic of menopause enters the conversation:

A 50-something woman is blow-drying her massive mane of blonde hair in the locker room of the gym. “Ugh, I can’t stand this heat another minute!” she says, as she abruptly shuts off her dryer and rests it on the counter. “These hot flashes! They make drying my hair even more challenging!” She madly reaches for a towel to mop the sweat that drips down her red face. I smile in commiseration.

A 40-something woman sitting next to me at a conference picks up her notepad and furiously fans her face. I look sideways in her direction, in commiseration. Perimenopause, clearly.

“Did I ever tell you about the time I visited my doctor with intestinal problems after a trip to the tropics? He diagnosed food poisoning,” my friend Linda told me at dinner recently. After completing a course of antibiotics, but still weak with exhaustion and appetite loss, she returned to her doctor. After listening to her complaints, he dismissively delivered his diagnosis: “Must be menopause.” I inhaled sharply, feeling resentful and angry for her.

And that’s how a lot of menopausal women are feeling these days: angry and resentful. Why? Because they’re not getting the guidance and help they need from their doctors.

A Yale University study of insurance claims revealed that although 60% of women suffering with significant symptoms of menopause seek medical attention, three-quarters of them are not being treated.

The menopause transition — and accompanying symptoms — can begin as early as a woman’s 30s and continue beyond her last menstrual period (usually around age 51), when she is officially in the post-menopause phase. At that stage, although some symptoms ease off, the risk for a number of health conditions, like osteoporosis and heart disease, rises, due to decreased levels of estrogen.

So why are so many physicians asleep at the wheel?

The stark reality is that fewer than one in five U.S. obstetrics and gynecology residents receives formal training in menopause medicine, cites an article in a 2013 issue of Johns Hopkins Magazine. In the article, Wen Shen, an assistant professor of gynecology and obstetrics at the Johns Hopkins University School of Medicine and the senior investigator of the survey conducted by Johns Hopkins said, “Our results suggest that to serve a fast-growing population of aging women in the boomer generation and beyond, OB/GYN (obstetrics/gynecology) residency programs need to address this training gap.”

Yet, the lack of information and unpreparedness is not for lack of wanting. The same study found that 70% of the residents were well aware of this gap and were hungry for menopause knowledge and proficiency.

Part of the knowledge gap can be traced back to 2002, notes Dr. Stephanie Faubion, medical director of the North American Menopause Society (NAMS) and a practicing clinician in the Woman’s Health Clinic at the Mayo Clinic in Rochester, Minn. That’s when hormone therapy, then a gold standard for treating menopause, was abandoned en masse after the release of a Women’s Health Initiative (WHI) study linking it to an increased risk of breast cancer, heart disease and stroke.

Not only did women forsake this treatment for their menopause symptoms, their physicians often followed suit. The doctors simply didn’t know — or never learned — any other way to treat them.

The issue only snowballed because these physicians were the very same ones in charge of teaching the medical students, says Dr. Mary Jane Minkin, clinical professor in the Department of Obstetrics, Gynecology and Reproductive Services at Yale University School of Medicine.

Rarely do physicians discuss menopause, unless the patient brings it up first. Studies of primary care physicians and gynecologists found that the discussion of menopause is initiated by the patient 91% of the time, and that the most challenging aspects of treating those patients were due to confusion and controversies in treatment options. There doesn't appear to be evidence  in existing research showing that this is any different whether the physician is male or female.

Primary physicians, too, should be involved in treating menopausal issues. That’s because once women are past childbearing age, many don’t necessarily continue to see their OB/GYN, notes Dr. Holly Thacker, professor and chair of the Center for Specialized Health at the Cleveland Clinic Lerner College of Medicine in Ohio, in an article for ACP Internist.

Thacker said this should begin as early as perimenopause — those years leading up to menopause — because women in this stage often have more symptoms (like sleep disturbances, mood swings and hot flashes) than during menopause.

There’s also evidence that treating symptoms early on can lead to better health outcomes. A 2018 study found a correlation between a risk of developing type 2 diabetes and the severity and duration of hot flashes and night sweats. Other studies demonstrate a slowing progression of osteoporosis if women are treated at the start of menopause.

Depending on their training, background or medical specialty, it’s clear that some health care providers might not feel comfortable treating menopausal symptoms, notes Dr. Nita Landry, a co-host on the television talk show The Doctors and a board-certified OB/GYN. That’s why it’s incumbent upon patients to open up the conversation. Here are some tips for how to do that:

• If you have an issue that is impairing your physical or emotional well-being, don’t allow your complaints to be dismissed. If your doctor isn’t comfortable discussing the issue(s) with you, ask for a referral to a health care provider who can help you.
• Be straightforward; ask your question. “I understand that many patients are uncomfortable speaking about certain female topics. But I assure you that we know lots of other women experiencing the same issues,” says Landry.
• In general, find a doctor with whom you feel comfortable talking. Word of mouth is invaluable: Ask friends, family or co-workers for recommendations.
• Keep a list of your symptoms — when they began, what triggers them, how they make you feel and things you’ve tried to relieve them. This will help provide the necessary information your doctor needs to help you.

“So many women have this concept that it’s all over with menopause,” says Faubion. “But it’s not! It’s the start of a new act; your third act, which can be liberating and an opportunity to make so many positive changes,” she says.

But to feel your best and take advantage of this third act, we must take an active part in our menopause care and hone our communication skills. After all, even the doctors need a little hand-holding, it seems.