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Lifting the Fog
Date: October 1, 2013
After Wen Shen finished her residency in obstetrics and gynecology at Hopkins in 1987, she jumped straight into private practice in the resort town of Southampton, N.Y. She quickly found that her Hopkins training hadn’t prepared her for the problems many of her new patients were facing.
These women were in their 50s, and they were complaining of the hot flashes, night sweats, moodiness, memory lapses, vaginal irritation, and other symptoms that can accompany the onset of menopause. The severity of their problems was all over the map, with relatively minor annoyances on one end of the spectrum and full-scale life crises on the other—serious enough to put careers and marriages at risk.
“In my residency at Hopkins, the patients we saw in the clinics were mostly young women, so we were dealing with pregnancies, birth control, and sexually transmitted diseases,” Shen says. “Now all of a sudden I found myself seeing patients who wanted me to do something about these menopause symptoms, and I just didn’t know what to do. It was a helpless feeling.”
So Shen set out to find answers that would help her avoid unnecessary delays and potential missteps in helping her new patients. Without the Internet back then to guide her, she scrounged around for textbooks and journal articles in bookstores and libraries.
What she found astonished her: “The reference materials out there had very little information about the things my patients were struggling with, and very little information about how I might help them,” she says.
Flash-forward 18 years to 2005, when Shen took a new career turn. With her three children now headed into young adulthood, she decided to return to academia and mix more research and teaching into her clinical work. She came back to Hopkins as an assistant professor of gynecology and obstetrics.
“Right away I found out that we still weren’t teaching residents at Hopkins about menopause,” she says. “It was almost funny, how right away I became the menopause queen around here. Whenever residents found themselves with a menopausal patient in our clinics, they’d page me.”
They were full of questions: What tests should we order? Are there other possible causes for these symptoms? If a patient complains of “mental fog” and memory lapses, can that be due to menopause—or is it just aging … or something else? When is hormone therapy recommended? What other treatments are out there, and which should we try first?
The opportunities for OB/GYN residents to see menopausal patients were still as rare as they had been during Shen’s time in the program. Mindy Christianson, who completed her residency in 2010, chalks that up to the demographics and health needs of the community in and around the East Baltimore campus.
“I didn’t have much exposure to menopause patients, and so coming out of my residency here, I just didn’t feel comfortable taking care of them,” says Christianson, who recently joined the OB/GYN faculty after completing a clinical fellowship in the department in Reproductive Endocrinology and Infertility. “The more I thought about it, the more I found myself wondering, ‘If I’m training at Hopkins and I feel uncomfortable in this area, what’s it like for residents in the rest of the country?’”
In short order, Shen ran out of patience with the situation. “It became more and more obvious that this was no way to teach our residents,” she says. “That’s how I got the idea in my head: ‘Somebody’s got to do something about this, and I guess that somebody is going to be me.’”
Viewed over the course of a woman’s lifetime, menopause is more of a gradual transition than a discrete event. It can start anytime between 40 and 60, with the average age of onset being 51, and it unfolds over the course of a four- to five-year stretch as a woman’s ovaries slowly but surely stop producing eggs.
Once menopause ends—the official definition is 12 months after a woman’s final menses—the body will produce lower levels of estrogen and progesterone, a development that over the long haul can have a wide range of health effects on bone metabolism, cardiovascular functioning, breast health, and more.
During menopause, however, the levels of those hormones actually go both up and down, following something of a roller-coaster pattern. These fluctuations help spark the most common symptoms of menopause, which vary wildly in number and intensity among different individuals.
“Patients in menopause have unique complaints and issues,” Christianson says, “and the doctors we’re training here really need to be ready for that when they step out into their own practices. The size of the population of people living through menopause and then in their post-menopause years is huge right now. And with the baby boom generation getting older, it’s getting huger every year.”
The U.S. Census Bureau estimates that there will be between 50 and 60 million menopausal and post-menopausal women in the country by the year 2020—an increase of between 5 and 15 million since 2000. With the average life expectancy of these women now up to 85 years, a sizable number will be spending fully one-third of their lives during or after menopause.
Both Christianson and Shen stress early on in conversations about the topic that menopause is both a perfectly natural process and one that many women go through without suffering significant health issues. Shen points to a 1998 Gallup poll that asked postmenopausal women to choose the point in life when they felt happiest and most fulfilled.
“More than half (51 percent) chose the years between 50 and 65, the ages that include menopause,” Shen says. By comparison, just 10 percent of the women surveyed chose their 20s, 17 percent chose their 30s, and 16 percent chose their 40s.
But somewhere between 10 and 15 percent of women endure menopause-related symptoms that Shen rates as “severe.” These are the patients who can arrive at their doctor’s office in desperate straits. They can’t get any sleep, their mood is always sour, their workplace performance is slipping, and their relationships are going south.
“By the time they show up, they’re feeling scared and desperate,” Shen says. “They’re saying, ‘Look, I just screamed at my boss.’ Or, “My husband is going to leave me if I don’t stop behaving like this.’ They know what’s happening, they can see it clearly, but they can’t seem to stop it on their own.”
Such extreme moodiness can also be accompanied by the somewhat mysterious phenomenon known as “mental fog.”
“For highly functioning professionals, that’s actually one of their major issues,” Shen says. “In the middle of giving a high-powered presentation, they find themselves”—here she snaps her fingers, then slaps her forehead—‘Wait, I was going to say something, but it just slipped my mind.’
“Things like that are happening more often than these women are comfortable with,” Shen continues. “They’re not coming up with numbers and names, and this is happening at an age when people are at the peak of their careers. They just can’t afford to seem less than totally sharp.”
Once she decided to remake menopause education in residency, Shen signed on for the nine-month-long curriculum development course offered each year by the School of Medicine. It meets once a week on the Bayview campus, guiding participants step by step through the creation of their curricula.
“What that did was give me a firm foundation not just in establishing a curriculum, but establishing it in a way where you can measure things and show that it makes a significant difference,” Shen says. “It was a fabulous experience, actually.”
She also stopped in at about this time to see Jessica Bienstock, the residency program director in the Department of Gynecology and Obstetrics. Shen wanted to understand how difficult it might be to add new material in an era of tightened work-hour restrictions for residents.
Bienstock offered nothing but encouragement. Not only was she looking at the demographic trends showing more and more women headed into menopause, she was also looking at results of the annual in-training exams residents take through the Council on Resident Education in Obstetrics and Gynecology (CREOG).
“Our residents were not doing particularly well on the menopause questions,” Bienstock says. “So we’d already been thinking about that, and we’d been thinking as well about the fact that our residents don’t see a lot of menopause patients. I was very happy to hear about Dr. Shen’s plans.”
“The Gang of Four” is Shen’s playful name for the team she assembled to get the ball rolling. Wanting input from colleagues who understand the lifestyles and learning preferences of contemporary residents, she recruited two young physicians—Christianson and Jennifer Ducie—who were either still in the residency program or just finished with it. Shen’s faculty colleague Kristiina Altman helped lead the project as well.
Their first step was to gain a better understanding of the lay of the land nationwide. They sent Web-based surveys to the 258 residency-training directors listed in the CREOG database, asking them to share the survey with residents. Eventually, they received 510 responses from residents.
“We expected to find that there would be a huge need for teaching residents around the country more about menopause, and that’s what we found,” Christianson says. “In fact, it was a little worse than we expected.”
Survey results were published this past spring in the online journal Menopause. Overall, the study indicated that fewer than one in five residents receives any formal training in menopause, while seven in 10 residents say they would like to receive such training.
“The residents who responded basically admit that their knowledge and clinical management skills of menopause medicine are inadequate,” says Christianson, the study’s lead author.
Today, menopause medicine is a more nuanced and cautious affair than it used to be. Early on in her practice in New York, Shen found her way to the North American Menopause Society (NAMS), which was then a fledgling professional society just getting started on the work of helping physicians deliver better information and improved care to their menopausal patients. (The society will celebrate its 25th birthday next year.)
“The first thing I learned from NAMS was that there was a real need for research in this area,” Shen says. “But physicians at the time were basically handing out hormone therapy like candy to every menopausal and postmenopausal woman who walked through the door.”
Gynecology was still dominated by male physicians then, and that may have contributed to some level of disconnect between doctors and patients when it comes to understanding just how much the effects of menopause can vary from individual to individual.
“They tended to send a whole lot of women home with Valium and Xanax back then, too,” Shen adds. “And so we ended up with a lot of women being drug dependent in their later lives.”
Shen links the evolution of the field in no small part to broader changes in American society. By the time the baby boomer generation started to arrive at middle age, many social taboos around the topic of menopause had disappeared.
“People my age, we have moms who just didn’t talk about menopause,” Shen says. “It was regarded as an embarrassing subject. Also, more of our moms tended to not work outside the home, and that meant issues surrounding workplace functioning weren’t as important.”
Modern-day clinical treatments for menopause symptoms generally fall into one of three broad categories, with “common sense” being the first line of defense.
Consider the example of a menopausal patient who’s having trouble sleeping. Her physician might first test out some simple “sleep hygiene” improvements—avoiding caffeine and alcohol in the evenings, darkening the room, and having a warm drink before turning in. Basic lifestyle changes can also help, especially regular, weight-bearing exercises.
These first steps are unlikely to solve the most serious cases. “Night sweats can have women up and down over and over again during the night,” Shen says. “I’ve had patients who are changing the sheets on their bed three or four times a night, and it’s like that night after night after night.”
Next, the physician might try a pharmacological solution. Antidepressants can help reduce night sweats, with Paroxetine (65 percent reduction) and Venlafaxine (57 percent) performing best. But the choice of which antidepressant can be complicated, with the mix of side effects varying quite a bit from drug to drug.
The last treatment to consider is hormone therapy, which seeks to stabilize hormone levels in the patient’s body. This remains the most effective treatment for hot flashes, night sweats, and vaginal atrophy, but its use necessitates a careful, case-by-case balancing of risks and benefits (see below).
In Christianson’s experience, as physicians get deeper into the treatment options, they need to sort through increasingly complex issues with their patients.
“This topic of hormone therapy especially can be overwhelming and daunting at first,” Christianson says. “I don’t see how residents who don’t have any experience with it or training in it could possibly feel comfortable in this area.”
Another challenge for young physicians is recognizing when and how the physiological changes of menopause can have long-term implications for patients. Estrogen deficiency due to menopause can contribute to the risk of osteoporosis, for example, especially in women who go through the transition early, starting before age 45. Similar complexities can arise during and after menopause in the areas of cardiovascular disease and breast health.
Sexual activity is something else physicians should discuss with menopausal patients, especially those who are divorced, separated, or single. As the vaginal walls get thinner during menopause, it makes it easier for sexually transmitted diseases to take hold. In fact, menopausal and postmenopausal women now rank as the fastest growing population of new HIV infections.
“The most important thing we’ve learned in this field is that we need to evaluate every individual case in particular,” Shen says. “There is no single answer out there that can apply to every woman who’s going through menopause.”
The menopause curriculum made its debut two years ago as a series of four lectures. It has grown step by step since then, and this year’s new residents will have eight lectures. For the first time, they’ll also travel out to Green Spring Station in north suburban Baltimore to see patients at Shen’s menopause clinic.
This gradual rollout enabled Shen and her colleagues to pay attention to the goal of creating a program in which senior residents become an integral part of the teaching process, serving as mentors and even delivering some lectures.
While it’s still too early to come to any firm conclusions about the success of the curriculum, Christianson describes the early results as “very promising.” On pre- and post-curriculum tests, the residents’ scores have jumped from 57 percent before the lectures to 80 percent after.
In surveys prior to the curriculum, nearly 85 percent of residents said they felt either “barely comfortable” or “not at all comfortable” about caring for menopausal patients. After the lectures, 71 percent of residents described themselves as either “comfortable” or “very comfortable.”
Shen has also been active on other fronts in promoting menopause education. In recent years she served first as vice chair and then chair of the professional education committee at the North American Menopause Society.
“I made a lot of noise during a lot of meetings,” she says with a laugh. “I thought it was just ridiculous that as the professional group for menopause, we didn’t have a curriculum to teach residents.”
Her push succeeded. NAMS worked with the Association of Professors of Gynecology and Obstetrics (APGO) to create a Web-based curriculum that’s available for a fee. However, the Hopkins researchers’ survey data indicate that today’s residents much prefer training delivered in supervised clinics, lectures, and case presentations to Web-based independent study.
And that bit of frustration is how Shen found herself talking now and again with patients about her goal of expanding access to the new Hopkins curriculum to residents around the country. “Then this wonderful patient of mine decided to give me this wonderful check,” she says. “It was just fabulous of her, and she has continued every year since then to support this effort.”
The surprise donation helped finance a program to videotape the curriculum lectures and offer them on CDs. Off to the corner of Shen’s office are two large oblong cardboard boxes full of the disks.
“There used to be four of those boxes,” she says. “I took the other two to the most recent APGO meeting, and 500 people came up to take a CD.”
Shen says she has come away from the project deeply impressed with the commitment and capabilities of today’s residents. “They are so facile at navigating the new world of information,” she says. “If we can just pose the right questions and point them in the right directions, they’re off and running, and that’s all they need.”