When Should Doctors Start Talking To Women About Menopause?

As I sit down to write this blog and try to organize all the information I want to relay without making it too overwhelming, I reflect on the title I chose for this blog and my personal experience with this, as a patient. Doctors are patients as well (duh, I know, but I thought worth pointing out nonetheless) and I realized that as a patient who goes in for my yearly physical and gyne appointments, I have yet to have a conversation with my doctors about menopause. I absolutely love my primary care doctor and my gynecologist and they are magnificent physicians. But the topic has not been brought up during any of my visits. There are many reasons why this may be the case - the realities of time constraints during medical check-ups, I haven’t brought it up myself, or because they know I am a doctor (and endocrinologist), so it may be assumed that the conversation would seem superfluous. And while any combination of these reasons may be true, I also know that nowhere in my medical training across 4 different academic institutions - as a medical student, internal medicine resident, or as an endocrine fellow, were we specifically taught about how to have conversations about menopause with our patients during clinic visits and that this likely holds true across many programs . That’s a problem. 

So when should this conversation ideally start to be part of the medical visit? As early as when a woman is in her mid-30s. That is the recommendation from the Stages of Reproductive Aging Workshop 10 which was made up of international medical experts within the field of female reproduction. In the United States, perimenopause typically occurs between the ages of 35-45 years old and menopause typically occurs between the ages of 45-55 years old, with the average age of menopause being 52 years old.

Here are some important facts related to the menopausal transition that are important to discuss:

Why It Happens

Here is a very condensed crash course in female menstrual reproduction! At the time of birth, a female has about 1-2 million ovarian follicles. The ovaries secrete various hormones, including estrogen and progesterone. In adolescence estrogen levels increase, marking the onset of reproductive years and is when periods start. From birth and over the reproductive years, this reserve of follicles declines and when this ovarian reserve follicle count reaches about 1,000 estrogen levels have drastically declined and  this is when menstruation stops. Unfortunately, menopause is a retrospective diagnosis, meaning, it is only established once there has not been a menstrual period for at least 12 months. 

There are several lifestyle factors or environmental exposures that have been shown to accelerate ovarian aging, leading to earlier menopause, something that is not desirable. These factors include cigarette smoking, endometriosis, industrial chemicals, and chemotherapeutic agents.

Health Implications

Bone: Estrogen is an essential hormone for bone density. After the menopausal transition, we see an immediate decrease in bone density that tends to continue to decline in the years following menopause. Decreased bone density increases the risk of osteoporosis, which itself increases the risk of bone fractures. 

Heart Disease: Menopause changes can increase a woman’s cardiovascular risk. While the increased risk is not something that is necessarily immediately observed at the time of menopausal transition, it is something that has been correlated with an increased risk of heart disease 10 years after the transition.

Body Composition: During the menopausal transition, women will tend to have increased abdominal fat mass and decline in lean muscle mass, decreased energy expenditure (meaning a decline in how many calories are burned), and daily caloric needs also decline. Once in the postmenopausal state, the increase in fat mass and decline in lean mass typically occurs for up to 2 years at which point it stabilizes. Unfavorable changes in body composition can lead to increase visceral adipose tissue, which not only increases heart disease risk, but also risk for insulin resistance and the medical conditions linked to insulin resistance, such as type 2 diabetes and metabolic dysfunction associated liver disease (formerly known as non-alcoholic fatty liver disease).

Symptoms

Whether a woman experiences symptoms and the intensity of symptoms is highly variable from one woman to the other. Also important to keep in mind is the fact that the transition from premenopause to menopause is not a simple “on-off” switch, nor is it a simple glide, rather, it is more like a rocky hike. This means that with the fluctuating estrogen levels that are a hallmark of the menopause transition, the experience of symptoms are bound to fluctuate and be erratic. 

Erratic Bleeding: This is directly due to the variable estrogen levels that impact uterine lining thickness. A woman can have several months of having a monthly period, skip two months, have a period, skip 3 months, have a period for two straight months, and then go several months without a period again. Even though menstrual periods are erratic, a woman CAN still get pregnant during this time!

Vasomotor Symptoms (VMS): These are the sudden hot flashes that can lead to sudden flushing, feeling uncomfortably hot, sweating, as well as night sweats that disrupt sleep. This is due to the rises in FSH levels from the pituitary gland.

Sleep: Declines in progesterone as well as the variable FSH levels that lead to night sweats can cause disruptions in sleep which include frequent night time awakenings or reduces deep sleep.

Musculoskeletal: As discussed above, the decline in estrogen directly impacts bone density leading to significant declines. Also, many women experience increased joint pains or arthritis, which may be due to declines in lean muscle mass leading to laxity in the ligaments and tendons around joints and predisposing a woman to increased pain in certain joints.

Cognition: Verbal learning and verbal memory are notable and reliable cognitive changes in the menopausal transition. 

Mood: While not every woman experiences mood changes, a frequent symptom reported is an increase in anxiety. For some women, the loss of progesterone can heighten anxiety.

Treatment Options

Erratic Bleeding: because this is due to the fluctuating estrogen levels produced by the ovaries, the best way to prevent the erratic bleeding is with oral contraceptive pills. The concentration in estrogen in pills is different than the estrogen in menopausal hormone replacement therapy. 

Vasomotor symptoms: The most effective ways to treat this is with hormonal treatment, both menopausal hormone replacement therapy as well as oral contraceptive pills. For individuals who cannot take hormones, there is a new FDA approved medicatio, fezolinetant, that can be used to help treat hot flashes. Studies have also shown that women who consume one cup of cooked soybeans daily have better controlled vasomotor symptoms.

Musculoskeletal: The best way to address the musculoskeletal changes in menopause is through prevention, meaning actively engaging in exercise and eating nutrient dense foods. More specifically, the best exercise for bone is resistance training (high weights low reps). When it comes to nutrition, making sure to eat calcium rich foods (my favorite plant-based sources are baby bok choy and tofu), and lean protein to help build lean muscle mass. It is important to keep vitamin D levels above 30ng/dL, so it may be important to take a vitamin D supplement. And finally, menopausal hormonal therapy (but not oral contraceptive hormonal therapy) is FDA approved for the prevention of bone loss. For those who have osteoporosis, it is recommended to take medicines to help prevent fracture.

Cognition: This is a very hot topic right now, specifically looking into the role of menopausal hormone therapy (MHT) and whether or not it can prevent dementia. There have been clinical trials that have indeed looked into this question and they show that there is no benefit of MHT preventing dementia. So while there are multiple beneficial uses for MHT, dementia prevention is not one of them. Some ways to prevent dementia include getting proper and sufficient sleep, avoiding alcohol and other risky substances, learning a new language, and even learning a new dance!

Resources

As you can see, there is so much information and what I have provided above is just a drop in the bucket. If you are interested in learning more about any of these recommendations and exploring other topics related to menopause, I highly recommend you check out the patient education resources from The Menopause Society

https://menopause.org/patient-education/menopause-topics

If you have menstrual periods, it is important to understand what the menopausal transition looks like and it is my hope that this is a conversation that becomes more mainstream and certainly more present during medical visits. It should not be up to the patient to bring up the conversation and is something that I also hope to see more colleagues of mine prompting during medical appointments. In the meantime, I will make sure to do my part in actively engaging my patients in these conversations at their appointments.