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In today’s AMA Update, Madelyn E. Butler, MD, an obstetrician and gynecologist (OB/GYN), and member of the AMA Board of Trustees, covers all things menopause: from what patients need to know about symptoms, timing and preparing for perimenopause—to advice for physicians on menopausal research, training and hormone therapy. AMA Chief Experience Officer Todd Unger hosts.
- Madelyn E. Butler, MD, obstetrician and gynecologist (OB/GYN); AMA Board of Trustees
Unger: Hello, and welcome to the AMA Update video and podcast series. Today we're talking about women's health, specifically misconceptions about hormone therapy and menopause. I'm joined today by Dr. Madelyn Butler, a member of the AMA Board of Trustees and an OB/GYN in Tampa, Florida. I'm Todd Unger, AMA'S Chief Experience Officer in Chicago. Welcome, Dr. Butler.
Dr. Butler: Thanks, Todd, for giving me this opportunity to discuss something that is very important in women's health.
Unger: Well let's first talk about menopause or perimenopause, the time leading up to it. It's something that, of course, all women go through, and yet many end up talking about it with their friends and not with physicians. Can you give us a quick overview to start of what's happening during perimenopause, common or even uncommon symptoms?
Dr. Butler: Well, what's happening during perimenopause is it's a transition phase from your fertile years to your unfertile years. And it's not something that just kind of happens instantaneously. It happens gradually and it's a period of transition that can last three to eight years. And it's characterized by a decrease in estrogen.
And when you have a decrease in estrogen, you can have hot flashes, you can have night sweats, you can have anxiety, other emotional symptoms, insomnia, changes in your sex drive, and just a whole host of symptoms. And it's very individual to the patient. So it's a time of transition and it can last a lot longer than we think.
Unger: Dr. Butler, I'm curious if you find that your patients are unprepared for or surprised by what's happening to them?
Dr. Butler: Well, Todd, I think they're very unprepared in many ways because coalescing with that time of transition, many of them are taking care of elderly, ill parents, many of them are dealing with children leaving the home for the first time, career transitions that occur in life.
So in the middle of all these transitions and all these life challenges, they're experiencing the changes, the hot flashes, the inability to sleep, the emotional changes that occur. So they are unprepared because they don't know that the symptoms can last quite a long time and they don't know what's what.
Is it stress? Is it the things that I'm going through just in my life in general? But all of those things create the perfect storm. And sometimes patients overlook their need for help and they don't know how to differentiate what are symptoms of perimenopause and what are symptoms of the stresses that they're facing in their daily life.
They know that their cycles are going to stop, but they don't know what to expect leading up to that. And I think many times they think that it's just going to happen overnight and they don't understand that some of the symptoms can last for years.
And there are lots of things that we can do to treat those symptoms. But we, as physicians, have to take the time to listen to patients and see what symptoms they're experiencing, because every transition is unique to every patient.
Unger: We're seeing a lot of discussion in the media about just the lack of focus on this particular topic. And there was a recent article in The New York Times Magazine that suggested that we have a high cultural tolerance for women's suffering. Do you think this is gender bias or is there something more at play here?
Dr. Butler: I think that when you talk about suffering, that's a relative term. And I think that also perimenopause and menopause can vary so much from woman to woman because 85% of us will have minimal symptoms. But 15% of us will have rather severe symptoms that require treatment. And it can run the whole gamut from emotional symptoms to vasomotor symptoms, which are the hot flashes, the migraine headaches, the insomnia, all of those things.
So, I think that most of us, thankfully, don't have significant amounts of suffering. But the key here is how the symptoms affect your quality of life. And I think if the symptoms are affecting your quality of life, your ability to carry on your day-to-day routine, that's when we really need to discuss treatment.
Unger: Well, that same article talked about how when some women go to their doctors and they talk about symptoms like you've just talked about, that maybe they get kind of waved off or given remedies that don't work. What do you think is driving this?
Dr. Butler: Well, I think it depends on the physician. Certainly, I would hope that in the women's health care setting when you go see your gynecologist that would not be the case. But I think that other family doctors, perhaps internal medicine doctors, they have so many other problems to deal with that the issue of perimenopause and menopause really requires a knowledge of all of the treatments available. And it requires a lot of time drilling down to what the patient's most troublesome symptoms are and what sorts of things you can offer her to help her.
So I think it's a matter of time and familiarity with the transition and all of the treatments. The reason why a lot of people perceive the treatments don't work as we first try things that are perhaps not prescription, there are a lot of proprietary herbal remedies that don't totally take care of all the symptoms, but they can help with quite a few of the most troublesome symptoms, like hot flashes. Relizen would be a product that would come to mind.
And as long as the patients are informed that it's going to take the edge off but it's not going to totally treat the symptoms, I think that having knowledge of what to expect is very important. Hormonal therapy is the next line. And that is very individualized depending on the patient's personal history, her risk factors, her family history for cancer, et cetera.
Unger: Well, let's talk a little bit more in detail about hormone therapy. How does it work and what do physicians need to know about this?
Dr. Butler: Well, first of all, it starts with the different kinds of menopause. So if you have a patient that undergoes surgical menopause, when she has surgery and her ovaries are removed, she's going to have symptoms that are very abrupt. And those patients, if in the absence of contraindications, for example, you don't want to give a patient that has had breast cancer hormone replacement. But when you don't have ovaries, you can put that patient on an estrogen patch right after surgery.
That's someone that's going to have very abrupt, very significant symptoms. So that's one kind of menopause, surgical menopause. Then there's the physiologic menopause, which is more gradual and may start with hot flashes, insomnia. I usually try over-the-counter remedies for this kind of early perimenopause transition, like the raloxifene, which is a proprietary herbal blend.
And I also try over-the-counter sleep aids, like ZzzQuil, Alteril, tryptophan, valerian. Those kinds of things that are herbal and not prescription. Because I think that prescription meds have quite a few side effects.
So then there's the surgical, there's the physiologic, and then there's drug-induced menopause. For example, a woman gets diagnosed with breast cancer, she goes on chemotherapy, if chemotherapy is toxic to her ovaries, that woman may not be able to take estrogen.
But there are certainly other things that we can do to treat symptoms that really affect her quality of life, like vaginal dryness. If you have a patient that's dealing with cancer, she's had chemo and now she can't have intercourse with her partner, that is something that really affects relationships and quality of life and just satisfaction with life in general.
So I guess my point here is the treatment of menopause is very tailored to the individual patient and not two patients are the same and not two patients sometimes require the same treatment.
Unger: Now, Dr. Butler, there was a major study years ago that found elevated risks for some women who received hormone therapy, it caused a bit of a panic and a big drop in prescriptions. Can you talk to us a little bit about the risks of this particular type of therapy and how we put those risks in context for patients who are suffering?
Dr. Butler: And I still remember that day because in my practice, my phone would not stop ringing and everyone was calling. They were worried about their hormone replacement prescription. And at that time, with the research that we had, what we had at the time told us that every woman in menopause, most every woman with the exception of a few with cancer risk, should be on hormone replacement. Because what we were telling our patients then was that hormone replacement helped their cardiovascular system, helped prevent dementia, and just helped their bones and their quality of life in general.
Well, the Women's Health Initiative Study actually showed that, now granted this was medroxyprogesterone, which is a synthetic progesterone, and estrogen, which was conjugated estrogen developed from horses, so it was a little bit different formulation that's what's being used today. But what it found was it actually increased the risk of breast cancer after about five years and it increased cardiovascular disease and Alzheimer's, believe it or not, in some patients. And we were actually using that to prevent dementia.
So what we found since is that a lot of those patients probably already had some ongoing cardiovascular disease because in the cohort of people studied, they were a little bit older. So yes, I remember that day, and certainly now everything has changed to a more individualized approach.
For example, that surgical patient that I mentioned, that chemotherapy patient that may need her vaginal dryness treated. So the frail woman of slight build that may be predisposed to osteoporosis, that may be someone that we may use estrogen to treat her post-menopausal symptoms because it will also strengthen her bones.
So again, we are back to that individualized approach, taking that patient's personal medical history and her family history and devising a treatment plan that suits her best.
Unger: Dr. Butler, some physicians have said that women in menopause are underserved and that we lack the understanding that we really need for these patients. Are physicians trained in this therapy in med school? And what do we need to know to bring them up to speed?
Dr. Butler: So the training of women's health and the perimenopause and menopause transition is something that occurs in an OB/GYN training program. It also occurs in internal medicine and family medicine, it's a primary care track. Certainly we touch upon it in medical school. But as you know, medical school trains you with all of the general information that you need to know. But then specific treatment protocols and paradigms are really what is stressed in the residency program.
So I think that when you talk about training, we do get trained. But then there's the whole discussion of research. And I think there's a big gap in women's health research. It's only been in the last about 30 years that any significant attention has been placed on women's participation in clinical trials, for example. And a real emphasis now that we have women in places of power, they are expecting that we tend to their health care needs and that we address their health conditions in research studies.
So, I think that in the past, we didn't have a lot of the information that we needed. We're only beginning to get it. It's still a big gap in women's health care research. So hopefully, in the future that research will be done and we will have more answers and we'll be able to understand the transition even better. Because women are living longer than ever before, so it used to be in the year 1900 a woman's life expectancy was about 49 years.
Now, women are living well into their 90s, sometimes up to 100. And so we're living about half of our life in menopause. So I'm excited to know what the research is going to show in this last most important part, I think, of our lives.
Unger: As you look at the landscape out there, are there any new studies, research or treatments on the horizon that you're excited about?
Dr. Butler: Well, I'm hoping that someone does a study to the breadth of the Women's Health Initiative. I think it's time to take a second look and do some head-to-head studies on different modes of delivery. Now we have gels that we can use on the skin to deliver hormone therapy, we have patches, there are pellets. And I think we need to have some head-to-head studies on how those hormones are absorbed.
I don't know if that particular study is being done, but that is an example of a study that needs to be done. We also need a closer look at more of the holistic remedies because our patients are asking for more holistic remedies. And I think it's a time to look at the melding of maybe Eastern medicine and Western medicine, looking at acupuncture and looking at some other holistic options that might be good alternatives for patients to treat their symptoms.
Unger: Well Dr. Butler, so interesting, especially you point out the issue around life expectancy and the changes there and the portion of lifetime that we're really talking about here. And again, the emphasis that you've made here on the individualized approach, certainly huge needs as we go forward in terms of research and treatments.
Dr. Butler: Absolutely.
Unger: Thank you so much for being here today. It was really interesting. We'll be back soon with another episode. In the meantime, you can find all our videos and podcasts at ama/assn.org/podcasts. Everybody out there, thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.