in her words

Why Modern Medicine Keeps Overlooking Menopause

Brain fog, brittle nails, allergies, hair loss: There are at least 34 symptoms of perimenopause. Still, medical providers keep missing them.

Credit...Juliette Borda

— Dr. Stephanie S. Faubion, medical director for the North American Menopause Society

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Sometime around age 40, the changes begin.

Maybe hair frizzes. Perhaps nails become brittle. The tummy might sprout an additional layer of fat. Periods may get shorter, or longer, or heavier, or lighter, or could become wildly unpredictable. There could be vaginal dryness. Or brain fog. Moodiness. Anxiety.

Some chalk the changes up to aging — which they are, in a way. Others focus on the individual symptoms, not realizing they could all be connected. Still others fear the worst.

But in most cases, it’s something as ordinary as can be: perimenopause, or the onset of menopause.

“Women are coming to the Mayo Clinic and saying: ‘Dear God, something is horribly wrong. I’ve put on 30 pounds, I’m losing my hair, I’m anxious. I’m a mess. I have palpitations,’” said Dr. Stephanie S. Faubion, director of Mayo Clinic’s Center for Women’s Health and medical director for the North American Menopause Society. “Literally, they think they’re dying.”

There are at least 34 symptoms of perimenopause — a stretch of time that can last anywhere from a couple of months to 14 years, when the body transitions toward menopause. (Menopause — literally: the ceasing of menstruation — occurs when it has been one year since the last period.) Those symptoms include hair loss, allergies or even a burning mouth.

But the medical industry hasn’t figured out how to provide proper care during or after this transition, or even which kind of doctor should do so, Dr. Faubion says. The North American Menopause Society, or NAMS, has certified 1,025 clinicians in the United States as menopause specialists, from pharmacists to midwives, who take training courses through the society in menopause medicine; 720 of them are physicians of different specialties.

“If you’re not even looking at the 55-year-old woman in front of you as being menopausal, then you’re missing a whole part of who she is,” Dr. Faubion said. “It’s not a disease; it’s a natural process, but we need to make sure that women aren’t incapacitated by the symptoms.”

How did this phase of life become so overlooked?

In Her Words asked Dr. Faubion to explain. Our conversation has been lightly edited and condensed for clarity.

Let’s start at the beginning. What’s the current state of perimenopause and menopause medicine?

I have to laugh because my answer is: What state? There is no state. There is a huge gap in terms of both provider and patient education about perimenopause and menopause.

We get “the talk” before we start our periods around the end of grade school, but nobody gives you “the talk” when you’re about to enter perimenopause.

Why not?

There are a number of reasons. Providers don’t have the information to give, but women also enter menopause at different times. Anything after 45 is considered normal, but some women might not enter until 55. And 7 percent of women enter it before age 45.

When do you catch everyone to give them this basic information that they need? And what do you cover? There are so many topics: changes in weight and changes in skin and hair and heart risks and bone health and sexual health. It’s not a simple thing.

You’ve referred to a “menopause management vacuum” in the past. Can you explain?

When you say “menopause management,” no one in the medical field really owns that space. It used to fall squarely in the realm of a gynecologist, but now gynecology is really subspecializing more into procedural-based areas like infertility or fibroid treatment, because that’s how they can support themselves, and the procedures are needed. There’s just less emphasis on the woman who’s coming into the office to report vaginal dryness or hot flashes.

I think it belongs in the realm of family medicine and internal medicine because it covers so many different areas of health. But those areas don’t own it either.

Is that also because there aren’t moneymaking procedures associated with menopause medicine?

Not really. The barrier is they’ve never been in this space and they don’t know how to be in the space. There’s a little bit of provider discomfort about the periods and uncomfortable sex and hot flashes.

Until internists and family medicine doctors see menopause as a threat to health in general, they’re not going to take it seriously. They’re going to say, “This is one of those female things that will go away.” That’s contributed to this gap in knowledge in terms of physicians and other practitioners and this “menopause management vacuum.”

What do medical students learn about menopause in school and residency?

It might be covered in an hour in medical school.

When we surveyed residency programs, across internal medicine, family medicine and gynecology residents, they had maybe one or two total hours of education about menopause. About 20 percent said they’d had no menopause education, and only about 7 percent said they felt prepared to treat menopausal women.

Are there health risks associated with menopause?

Everybody thinks that hot flashes are benign. We now understand that hot flashes may be associated with heart disease risk in some women. And menopause itself increases the risk of heart disease, which is the No. 1 killer of women.

It’s also an economic issue. There’s lost work productivity. There are women who drop out of the work force or cut back on work hours because of menopause symptoms like hot flashes. On average, women spend over $2,000 per year of excess health care expenditures related to symptoms.

If we could just acknowledge that, then we take this from being, “Oh, it’s nothing. Don’t worry about it. It’ll pass,” to “How can we use this time in a woman’s life to optimize her health so she lives a better life?” I just don’t think we’ve made that leap yet.

What will it take to make that leap?

It’s about awareness. A lot of the internal medicine and family medicine residents we polled said that they didn’t take care of menopausal women, which absolutely is not true. Over half of their patients are going to be women and the majority of them are going to be menopausal, because we have an aging population. That just tells you that these residents didn’t even see the women in front of them as being menopausal, which is part of the problem.

I think women as consumers will help push this along. Pressure from the menopausal woman to get something better out there has done more in the last couple of years than anything else.

There are a lot of small, menopause telehealth companies popping up to try to manage it, some better than others.

But the ideal situation would be every woman has a provider who is knowledgeable and can talk about the menopause transition, and you have educated patients and everybody works together.

I know we can do it better. It’s just a matter of getting our systems to work.

The Mayo Clinic has information about menopause and perimenopause. The Office on Women’s Health also has information on the basics of menopause. Or read the National Institute on Aging’s guide: What Is Menopause? The American College of Obstetricians and Gynecologists has a page about menopause and managing symptoms.

Women Living Better is an education and support group for perimenopausal women.

And this search tool from the North American Menopause Society can help you find a menopause practitioner near you.

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