Improvements needed in the care of women diagnosed with early menopause

So because I’ve been working in this area for about 30 years I have to say overall I’m still disappointed. I don’t think the job’s been done yet. Women’s health is not as regarded or given the resourcing that I think it should be, and women’s mental health is nowhere on anyone’s radar. Menopause, and education about menopause I think is still an issue we need to do more in, and I’m really concerned that even in our own medical student populations it’s not well known. And so even, I teach I lot of medical students so I keep banging that drum, but I’m always astounded by the final year medical students when I ask them what do they know about menopause. I think the last group I had a boy he put his hand up he said, “My mum went through it I think.” These were final year medical students, they’re about to become interns, so it is an issue. And I think the problem is it’s not – it’s not a condition that is owned by any specialty, and that’s part of the problem. It isn’t fitting neatly anywhere.

So tied up in this whole thing is I think the role of women, and of course there’s a conflict there because back in the 70s we were very grateful to the feminists of that generation who made it easier for women to be regarded as professionals in the workplace. We’ve still got work to do, but that was an important movement forward, and in that movement forward was a kind of, to make it you have to almost ignore any of those women issues that would be then used to hang you and say “You’re just not as good,” – all that stuff about, “We can’t have women pilots because, oh my goodness, once a month they’re just going to go off, they just can’t make decisions, and my goodness, what if you had a menopausal woman pilot, she’ll crash the plane for sure.” All that sort of mythology.

So we’re sort of in a bind, because if we say “Look, hormones have an impact on mental state, hormones have an impact on cognition,” then the other side of that is, “See we told you, women are just unreliable.” What we have to be able to say though is everybody, male and female, have an impact of gonadal steroids on their brains, and that message hasn’t got out there yet. And actually women have an advantage because we actually have a whole bunch of hormone treatments that we can use as therapies to actually improve quality of life and improve mental state for women who have a dramatic change that is observable, and have body markers that are observable. I hope that we’re in a better place now than maybe when I started my career.

Really as we all live longer it’s really important that our mental state and sense of happiness and wellbeing is as good as we can get it, because to be miserable with depression and have that awful sense of not being fulfilled for another 30, 40 years is just terrible. That’s why I’m just – we’ve got to get the message out there, and I’m thrilled about this project for that reason.

It starts with, you know, GP awareness and diagnosis, so supporting GPs. I mean, it’s hard because GPs get bombarded with a lot of things. There are a lot of things we could be more aware about. So we don’t specialise in early menopause. [laughs] So we have to specialise in everything. So that in itself is tricky. But perhaps that might mean, you know, having some more awareness amongst women in general to say, “Well, you know, if this is happening to you, think about, ask your GP, be that prompt.” So it’s quite all right for a woman to go to a good GP and say, “Do you think it could be early menopause? Can we test for it?”

So I think the two could go hand-in-hand and then after that having, you know, clear guidelines about management and then having, you know, access to that team so a specialist and the allied health and obviously what would help for the woman is if she could access that on, you know, schemes like the Enhanced Primary Care and so on so that she can go and have some of those allied health visits and get a rebate for it and so on.

So I think access to a specialist, so either an endocrinologist or a gynaecologist. A psychologist who’s got a little bit of experience in the area as well. I would really like access to some – like an exercise physiologist to help with osteoporosis management. Because you tell them to go away and do weight-bearing exercise, then I often wonder about their sort of – the glibness of my recommendation to go away and exercise, I always think it should actually be a little bit more specific but I don’t have the expertise to say, you know, specifically what sort of exercise they should be doing. So I think access to that would be really important. It might only be a few sessions to learn what they need to do and then they can keep going with it, yeah.

So someone like a dietician or a health coach as well, yeah. Just a general sort of chronic disease prevention service would be great. It doesn’t have to be run by a doctor. It can be a very experienced nurse practitioner, for example, you know, working together with a dietician.

In terms of services or resources that you would like to see for health professionals treating women with early menopause?

Yeah, look, more education generally. So it would be nice to have it as more routinely part of training for, you know, specialist junior doctors and GPs. Part of the lack of that is because there’s a lack of services in in the public system and junior doctors are trained through the public system. So if they’re not there they’re not going to get exposure. So you might not get exposure until you’re actually fully qualified. So that would be nice.

Probably some online resources for people as well and just some general advocacy and promotion. It would be nice if, for women, they could access, you know, that you could give them a pack or they could access some services where, you know, they can get access to a psychologist who’s appropriately trained if they need it. Or they can access an exercise physiologist or a physio if they need for that sort of thing, you know. Sort of a multidisciplinary approach would be helpful. Yeah.

I think the barriers to better management of POI are – they are multiple. One is, it’s still regarded as a rare condition. So unless we bring it to the attention of doctors, then it won’t be picked up, and we know that it is often neglected for not just months, but years, before a proper diagnosis is made.

So I think education is very important, we need to educate family doctors in particular, but certainly specialties such as endocrinology and gynaecology, so that they’re more aware. I think women are reluctant to discuss this because they often also don’t believe it could be happening to them. Secondly, they’re frightened about what is happening, and are reluctant. Thirdly, they’re rebuffed often on their first consultation by the doctor who says, “There’s nothing wrong with you.” I worry sometimes that there’s a gender difference, and I’m not sure if that’s true.

If it is true it will change because we’re training more female medical students than male medical students, and we’re certainly training more female gynaecology trainees than male gynaecology trainees, so I not only look like a dinosaur but I will be a dinosaur before too long. [Laughs]. So I think if there’s a gender problem it will be resolved. We try very hard with our trainees to make them understand that every consultation they have with any woman is a sensitive one and needs to be approached in that manner.

What are your reflections on barriers to management, to kind of improve the care of women? What are some of the things that you think are lacking, or should be…

I think knowledge, yeah? Understanding what it is. I think when I look into the things, is you need to tell them, and explain to them. I don’t know. Because I suppose the actual frequency, or prevalence of premature menopause is not so high, that’s why it’s not a public issue, yeah? That’s one of the things.

The two… I think we need to understand first of all the background of the person, and what it is they believe in their culture. Because Australian is a very, you know, mixed ethnic groups. So there is the need of that. We need to get rid of the stigma that the hormone replacement is actually bad, rather than good.

That you know, stigma to the medication that they need to take, and a stigma to themselves, that they are not… You know, not good, not able, not whatever else, sort of things. And I think group support. I was trying to look at group support; there’s only one in Australia. I don’t know you know, the support is basically online kind of things, so you know, it might not be a bad idea to… you know, look into it, and see.

The other thing is language barrier. If you’re trying to explain to English-speaking, and take you, you know, many hours, just imagine to the one you have to talk to, which no knowledge of the language. If we use the phone interpreter, sometimes my problem is, I say three words, it… That person will talk a lot, and I don’t know if that’s what it’s meant to be. So you know, there’s always the uncertainty in mine, if that’s exactly what I want them to answer, you know? So there is the difficulty.

So the first thing about early menopause is awareness that it exists. So education that this can happen and – and I think there are community health resources about that. Normally if a person presents to the GP because in a little country town we’re slightly under resourced it often take a while to get in. They’ve normally got symptoms. So there’s normally something already going on. But for community health groups, that’s what I was saying before, education in community health groups.

So I think that we’re – in the rural areas we have less resources and people expect to have to pay. So we’re a little bit under resourced. I think the amount of money that’s spent on health and preventative health and education in rural areas is far less than it is in the cities on a one to one basis. So we’re – as I say we take on many hats and so we use resources, I mean, you can’t be an expert in everything and most of our specialist colleagues are very good at providing information over the phone that might help in a one on one situation.

Yeah I think the, I think the isolation is an issue, it’s improving all of the time, like we’ve recently got radiotherapy services here and wow, what a coup that was, but I think if we need things we have the ability to tap into other services and the beauty of being in a regional centre like this is that we have a really great interdisciplinary team. So say for example a patient came into chemotherapy and they needed my support, day oncology staff can just ring up and say, “[participant name] can you, can you come over and, and meet up with this patient?” and that’s great because we know the who’s who of what and who to go to about you know making it happen.

So I think that’s conducive to a really good multidisciplinary close knit team really and we do have multidisciplinary teams and health care professionals from other agencies, other metropolitan centres link in so from that perspective we’re not at a disadvantage at all because there’s ways and means around it and it’s just about being a little bit more, using a little bit more initiative I think. Yeah.

We’re currently working on that here in this regional setting and that is a young women’s support group, we have two, we do have two breast cancer support groups in town and they would undoubtedly welcome young women with open arms however I think the issues that an older woman experiences when we, compared to those of a younger woman are very different and I think younger women need to be in a group where they can discuss the fertility issues, early menopause issues, raising small children, work, financial constraints, all of those things because they are very different to those of older women. So yes a younger women’s support group is on the cards and that’s what we’re working in but it’s not something that happens overnight and I think it will be well received, when it gets up running.

I think because it’s such a challenging area I think it would be really good, I mean I think that if you created a resource, a website or something like that, as well as just having the latest recommendations about the particular areas of help that menopause affects, a list of people that actually treat it so practitioners would know, I know a lot of GPs that struggle with patients. Even that aren’t on cancer treatment with menopausal symptoms and so from that point of view like I say in our, in my experience there’s not a huge number of people that specialise in this area.

I think the uptake of the allied health services, particularly the importance of diet, the importance of exercise, probably not quite as much the psycho-oncology which I think has been around a bit longer is incredibly variable in terms of one practitioner to another. Some people will think that it overloads women to talk to them about diet and when they’re 15 kilograms heavier than they were when they finished their chemotherapy that’s the time you should talk to them.

I think you probably just need a – I think the things that, and I think there’s probably resources for it, the things that they need to know are the things that are likely to occur. The question is whether they want those to occur so do they want the cancer treatment and so that’s another whole vexed issues of you know, ‘Is it worth having the treatment despite the fact that you’ve ruined my life?’ type thing so, but most will go ahead with it because they want to live, you know, they see it, they want to live.

So I think there needs to be an education resource where they get the breadth of what potentially can occur. They get some sort of multidisciplinary approach and you involve the primary care giver, the GP so that the GP can hopefully can fill in the holes that don’t occur whatever system they’re getting treated through because there will be holes in whatever system that they get treated through.

They may not have an exercise physiologist, they may not have this, that may not have that, so there are ways and means of being able to instigate all of those things but at the end of the day you kind of need someone who might be able to sit there and look at the whole lot and go, “Okay, there’s three things here that I think you really need that you haven’t had. You haven’t seen an endocrinologist or you haven’t seen a cardiovascular specialist because you’ve had 10 people in your family die of a heart disease and we think that you might be at much higher risk now than you were,” so I would think pri- a model that involved primary care significantly would be really important.

I think that dogma in medicine needs to change in many areas and we can be very dogmatic about how every patient must be on ZOLADEX [goserelin] and exemestane or ZOLADEX [goserelin] and tamoxifen because that is what the literature shows. I don’t think that dogma helps patients and for the small additional benefit of putting them on ZOLADEX [goserelin] for some women, for many women they don’t think it’s worth it. But if you are a dogmatic provider, a doctor especially, you have great influence and great power, so people will listen to you and people will undertake all sorts of toxicities because the doctor said so. I think that the thing that most needs changing is the area of doctor patient communication about one’s choices.

That maybe we listen to the patients more when they say it’s a problem. Sometimes the patients will say “No, I’m really struggling with this, but the doctor says I’ve got to take the tablet.” And I think maybe we need to be a little more open to the fact that there are pros and cons, and for the patient… The pros for us is we are going to stop the breast cancer coming back and yes, that’s a pro for the patient. The cons for us, they got hot flushes but that might be a big problem for the patient and we need to recognise that and to try and help the patients deal with that. Rather than saying, “Well if you stop your tablet the cancer might come back.” I think we need to see it as their problem needs to be looked at with them to see how it can be resolved as much as you possibly can.

And to be aware that when we push these young women into early menopause, it’s really quite a harsh thing. And it’s not surprising some of them take a little while to adjust. And that we should just be aware that it is hard for them. We are doing the best we can, we are trying to stop the cancer coming back, but for them it’s very difficult.