Collaborative Approach to Women’s Health: Menopause and Beyond

Natural menopause is a spontaneous permanent ending of menstruation, occurring in the United States between ages 40 and 58, with an average of 51 years. Two hundred years ago, menopausal medicine was not on the radar screen. In 1800, only five percent of women in the United States lived past age 50. A century later, with advances in public sanitation and better nutrition, women’s average life expectancy rose to 49 years, with a baby girl born today looking at an average 84-year life span.

With this increase in life expectancy, it is important to address the larger issues of healthy aging. Adding 30+ years of post-menopausal life, with its social, biologic and physical consequences, poses a new series of challenges. Providers caring for menopausal women today are the first professionals to view this changing demographic with a more holistic and integrative perspective. These women are also more educated, discerning and involved consumers who turn to their providers for guidance and comprehensive, integrated care. Consumers and providers are aligned on the major goals of health care for menopausal women: optimizing quality of life, minimizing risks for disease and supporting the demanding years of midlife and beyond with vigor and vitality. The baby boomer generation is the first group of women to enter menopause with a sense of group identity, with clear expectations for a longer and more engaged life than they observed in their own mothers. Yet the basic biologic plan has not evolved to keep pace with these goals without the active energetic investment of each woman in her own best interest.

Optimal menopause management may involve the skills of many health care providers, from western medical traditions (internal medicine, gynecology, psychology, orthopedics and dermatology, to name a few) to the larger spectrum of complementary therapies and modalities. The table below lists some of the major categories used in integrated menopausal care:

Table 1. Some Major Categories of Collaborative Health Care in Menopause
Nutritionally focused educators: bone health, heart disease prevention, cancer risk- reducing and weight management diets
Functional medicine evaluations: gastrointestinal health and balance, adrenal function
Body workers of many backgrounds: physical therapy, chiropractic, massage therapies, subtle movement awareness practices, Pilates, yoga, aerobic exercise teachers, personal trainers
Hormone specialists: reproductive funstion-related, thyroid and adrenal hormones
Standard western medical: evaluations of heart disease risk, viral disease-exposure, organ health, bone density, breast cancer screening, pap tests for early detection of gynecologic abnormalities, skin cancer detection/prevention and colon cancer screening.
Psychological evaluation: counseling services, mood and sleep hygiene, intimate relationships and community support systems assessments

As opposed to natural menopause, women who have entered menopause abruptly through medical treatment (such as chemotherapy) or surgical treatment ( removal of the ovaries due to presence of tumors or other disease) often experience more severe symptoms; are younger than women who experience natural menopause [Hysterectomy Surveillance—United States, 1994-1999. Surveillance Summaries. 2002;51(SS05): 1-8. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a1.htm. Accessed: 6/29/04.] and require more supportive care from a greater diversity of allied professionals [North American Menopause Society. Menopause Core Curriculum Study Guide. 2003]. Advancements in understanding the mechanisms of disease, along western models of pathophysiology and energy medicine–the interplay of stress and disease states (psychoneuroimmunology), nutrition and functional medicine, body mechanics and energetics–all contribute to the burgeoning of new approaches to optimizing health and wellness and lowering risks for diseases. New data from the study of genomics present additional opportunities to health care providers and consumers to actively prevent disease by finding who may be genetically predisposed to a certain condition.

First Things First
The timing and experience of women entering into full menopause varies widely. Sleep disorders, hot flashes, night sweats, headaches, changes in memory, loss of sexual desire, urinary concerns, mood alterations and dryness of skin and vaginal tissues represent the symptoms most commonly reported by menopausal women. Symptoms and their intensity may vary among different ethnic groups, Body Mass Index ratios (BMI, the measure of lean to fatty tissue weight) and activity levels (more exercise correlates with milder symptoms overall).

The goal of menopause care is first to listen carefully to appreciate the individual experience, values and goals of every client/patient.

  • Assemble a priority list of symptoms, from most troubling to least annoying.
  • Obtain baseline laboratory evaluations (see Appendix A)
  • Perform a comprehensive physical examination, including the thyroid, breasts, heart/lungs, abdomen, pelvic reproductive organs, skin and neurologic status.
  • Discuss options for addressing each symptom or problem.
  • Compile a series of objective measurements to assess relief of symptoms and/or to mitigate laboratory abnormalities.
  • Establish a schedule for routine follow-up and periodic reassessment to ensure relief of symptoms and goal fulfillment.

A combination of prescription medications or therapies with complementary and alternative modalities (CAM) results in a judicious blend of wisdom practices to optimize a woman’s health on a daily basis and lower her long-term risk for serious diseases. Appropriate nutritional habits and beneficial dietary preferences, which can affect long-term balance, vitality and disease prevention, along with pulse diagnosis/chiropractic assessment, are other important elements to address.

Baseline Assessments to Prevent Disease and Dependency

Bone Density
A steady loss of bone mineral density is the norm in low-estrogen, biologic states, such as early post-partum lactation and typical menopause in women. Menopause results in blood levels of estrogen hormone that are lower than those measured in healthy men up to age 70. DEXA scan technology or heel ultrasound exams can predict the strength of the bones and risk for hip or spine fractures, the major cause of loss of independence with aging.

Heart Disease
It is well known that heart disease is the most common cause of death in women, with significant increase in risks for women with advancing age and disadvantageous changes in blood lipids over time. Blood pressure tends to rise with age, especially in sedentary populations. Fitness practices, yoga, movement and self-defense modalities all contribute positively to better short- and long-term health. Many natural products, such as red rice extracts and niacin, have proved to reduce “bad” cholesterol [Prescriptions for Nutritional Healing, in Part Two,Cardiovascular Disease, p270, Balch and Balch, Penguin, 2000.], as do diets low in saturated fats and high in omega-3 fats–whole grains and legumes.

Electrocardiograms, stress testing and heart scans for calcium can also be performed for a more accurate medical assessment of baseline cardiovascular health. While it is not the standard of care for the majority of women to have energy pulse diagnosis [such as is done in Traditional Chinese Medicine, TCM, or Jin Shin Jyutsu] to evaluate the “circulation-sex” [as described in 5-element TCM texts] flows of the five element systems, increasing numbers of consumers seek the integration of the wisdom traditions of the East along with western medical scientific studies.

Cancer
Family history contributes significantly to an individual’s risk for disease. The earlier one pays attention to these historical facts, the more opportunity to gear lifestyle and health care towards prevention and reducing the incidence of disease. Breast cancer is the number one fear of many women, yet it is a relatively rare cause of death. Mammograms are still the best early detection modality to reduce the risk of an invasive tumor, with ultrasound and MRI providing additional imaging modalities that may be of clinical value in particular situations. Clinical breast exams, combined with breast self-exams and periodic mammograms, are the standard of western breast care as set forth by the U.S. Primary Care Task Force [www.nih.gov].

Estrogen supplementation in menopause has been shown to be a neutral factor relative to being diagnosed with breast cancer in the largest randomized controlled trial (RCT) study [WHI part II, May, 2004, http://www.nhlbi.nih.gov/health/women/index.htm] with a solid body of data supporting better survival from breast cancer in those diagnosed in women on estrogen as compared to those who do not take it after menopause [Bush T, Whiteman M, Flaws J. Hormone Replacement Therapy and Breast Cancer: A Qualitative Review. The American College of Obstetricians and Gynecologists 2001: 98(3): 498-508.

Early detection colon cancer screening, occult blood testing of stool and colonoscopy, have reduced the incidence of this malignancy for all midlife adults, and should be performed according to guidelines developed by U.S. Primary Care Task Force. High-fiber diets without saturated fats, which help reduce oxidative stress and prevent constipation, along with estrogen replacement after menopause, also reduce colon cancer risk.

Although many CAM therapies, such as chiropratic, acupuncture, physical therapy techniques and herbal remedies, are becoming more mainstream, they should still be considered with the same caution as other therapies. CAM treatments may not be safer than conventional ones and may even pose more risks, especially for some of the vitamins and herbs, which are not required to be manufactured according to strict pharmaceutical guidelines or receive FDA approval. At the present time, CAM therapies are not proven for prevention of serious diseases such as osteoporosis.

Conclusion
Combining the best practices of the Western medical knowledge base with sensitive individualized collaborative health care results in optimal short and long term health and wellness for women. As we negotiate the diverse paths of menopause and beyond, more and better information becomes available to diverse practitioners. We are at a cross roads with regard to both the paradigm in which collaborative care is possible and the technologies that support it.

Appendix A
Heart disease: Cholesterol fractionation, complete blood count are the principal tests in generally healthy women.
Other metabolic diseases: Evaluate baseline liver function tests and consider thyroid disorders as well as aberrant glucose metabolism, as well as other less common endocrinopathies
Osteoporosis: Bone mineral density, hip and spine, guide us with individual risk assessment for osteoporosis. Heel ultrasound may also be used to avoid the cost of a Dexa scan but is not as reliable.
Breast Cancer: Family history (first degree relatives are most important), annual screening mammogram and clinical breast exam help to reassure the patient that she is free of abnormalities as best we can determine with clinical breast examination and current imaging technology. A past history of benign breast disease and positive family history are not a contraindications for supportive hormone supplementation.
Uterine pathology: Endometrial sampling to evaluate abnormal bleeding and/or transvaginal sonogram may help to assess the uterine anatomy, endometrial thickness and possible intracavitary polyps and myomata uteri (fibroids) if present.
Life Style: Emphasis on personal practice (smoking cessation, exercise, nutritional enhancement) is crucial.

Ricki Pollycove, MD, MHS, is a board certified ObGyn, specializing in collaborative comprehensive women’s health, menopause, breast health, disease prevention and risk reduction for over 25 years.