Management of menopause and midlife health issues: what do midlife women want from primary care clinicians?

By Tracy Flanagan, MD Carl A Serrato, PhD Andrea Altschuler, PhD Karen Tallman, PhD Elizabeth Thomas, MD Introduction As the Baby Boomers move into their 50s and 60s, a larger proportion of Kaiser Permanente (KP) members will be menopausal women. Menopause and midlife have many potential short-term and long-term health consequences, including heart disease, osteoporosis, and physical and emotional symptoms of low estrogen levels. Even if menopause and midlife do not have dramatic health consequences for individual women, many women at this stage of life are looking for strategies to stay healthy or to become healthier. How well KP meets these health care needs has implications for how KP is viewed by its members and by the community at large. KP’s new “Thrive!” marketing strategy focuses on wellness and total health and dovetails with the needs of many midlife women. Wellness is a focus that includes a broad range of issues of concern to patients but not necessarily physicians: physicians are expert in acute care but not necessarily expert in preventive care. In short, our future success depends on KP’s ability to address wellness issues—such as menopause and midlife health— with our current and prospective patients. For example, women want to learn about menopause and their health care options but are not receiving the information and consultation they need. Of 665 women in a recent survey, more than half left their medical appointments with unanswered questions about menopause and hormone therapy (HT). Women understood the symptoms of menopause but not its long-term health risks. KP members also want more information than they have been receiving from clinicians. Women reported fears about aging and illness; wondered whether to seek care for vague symptoms; and were displeased that clinicians tended to trivialize symptoms. The researchers concluded that the women lacked understanding of normal menopause and did not know what to expect. Most women were interested in relieving symptoms and in preventing future illness and wanted individualized treatment based on their personalized risk assessment. Recent KP efforts to inform women about menopause have included use of individualized appointments with a Menopause Nurse Practitioner; development and distribution of the Menopause Guidebook; availability of menopause classes and group appointments; and mass mailings of a one-page information pamphlet. These programs were somewhat successful but either showed limited scope or engendered only partial recall in female readers because the written information was not reinforced or personalized by a clinician’s endorsement. This KP experience shows that to be successful an intervention must be focused, personalized, and reach a high percentage of perimenopausal and menopausal women. Such an intervention can take place only during an office visit—the only strategy that can 1) improve women’s understanding of menopause, 2) provide personalized information and care, and 3) reach a high percentage of women in the targeted age group. Although menopause is widely considered to be best addressed in the Gynecology Department, this approach misses many women in the targeted age group. In the KP Northern California (KPNC) Region, a two-year study of utilization patterns of female Kaiser Foundation Health Plan members aged 45 to 57 years showed that of 6000 women, about 6% were seen only in the Gynecology Department, 60% were seen in both the Gynecology and Internal Medicine Departments, and 25% were seen only in the Internal Medicine Department. In a one-year period, 34% of the same women visited the Internal Medicine but not the Gynecology Department,