Undated file photo of Oregon Health & Science University.
Courtesy of Michael McDermott / OHSU
Menopause can present a wide range of symptoms, from hot flashes and sleep disturbances to brain fog and loss of bone density. Though several safe and effective therapies are available, many patients still aren’t receiving the help they need. A new study from Oregon Health & Science University found that more than 60% of respondents with moderate to severe menopause symptoms weren’t receiving any treatment. The primary reason they reported not engaging in treatment was that their clinician hadn’t recommended it to them.
Maria Rodriguez is a professor of obstetrics and gynecology at OHSU and the director of the university’s Center for Reproductive Health Equity. Sara Cichowski is the university’s vice chair of gynecology and an assistant professor of obstetrics and gynecology. They both join us to talk more about the barriers to accessing menopause care in Oregon.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. Menopause can present a wide range of symptoms, from hot flashes and sleep disturbances to brain fog and loss of bone density. But a new study from Oregon Health and Science University found that more than 60% of respondents with moderate to severe symptoms were not receiving any treatment. The primary reason for this is that their doctors had not recommended it.
Maria Rodriguez is a professor of obstetrics and gynecology at OHSU, and the director of the University’s Center for Reproductive Health Equity. Sara Cichowski is an associate professor of obstetrics and gynecology, and the vice chair of gynecology at OHSU. It’s great to have both of you on the show.
Sara Cichowski: Thanks for having us.
Miller: Doctor Rodriguez, first – Why did you embark on this study?
Maria Rodriguez: Yeah. So as an OB/GYN and leader in women’s health, I’m really passionate about identifying some of the structural causes that lead to the inequities we see in women’s health care every day. And by structural causes, I typically focus on things like policy, our neighborhoods, the way health care is delivered, education and training. And for me, when I think about reproductive health, I think about it across a person’s lifespan. So from adolescence, at the time of onset of periods, all the way through menopause. And an area that’s really been neglected, even in progressive Oregon, has been perimenopause and menopausal care.
Miller: When you say it’s been ignored, what do you mean? What are examples of that, where you can just see the lack of attention that’s been paid to something that affects 50% of humans?
Rodriguez: Absolutely. Well, here’s one example. When you look at women’s healthcare and what we invest in, in terms of like our public health agencies or the types of policies that we pass, it all has to do around pregnancy and reproduction. So, we have expanded Medicaid coverage for people who are pregnant. We have contraceptive coverage at a higher match rate from the federal government. We’ve done all sorts of things to protect and respect the reproductive health of people capable of pregnancy.
But where we really lose sight of sexual and reproductive health comes when people transition out of bearing children and into a different stage of their life. And so, for example, at the Oregon Health Authority, we have a Maternal Child Health Division. We have a reproductive health program, but there’s nothing that centers around menopause, even though as you pointed out, about 50% of people are going to experience it. But 100% of women and others will experience it, too.
Miller: What about just the level of attention to menopause, in terms of study? I mean, how well studied in this country or around the world is menopause as a medical phenomenon?
Rodriguez: Yeah, and it’s not just menopause, it’s women’s health across the board. And the role that sex and gender can play in affecting disease has been remarkably understudied. We just haven’t invested in it as a country and there are so many basic things about biological health that we just don’t know – whether it is, for example, menstrual cycle details, the impact of the hormonal transition that occurs during menopause when estrogen levels decrease and how that impacts bone health, cognition, metabolism, cardiovascular health, really every aspect of our body is affected by that transition. And we have very little information on what those longer term effects are.
Miller: What do you see as the most important findings from this current study?
Rodriguez: I think a couple of things. One, it speaks to the fact that there’s a really high unmet need for perimenopausal and menopausal care in Oregon. And yes, this is a natural condition, but that doesn’t mean that there aren’t devastating side effects or consequences for people that are going through this without the support they need. It causes missed days from work, it affects mood, it affects relationships, all sorts of things about the way that half the population is functioning in society.
The second thing is, I think it kind of underscores what we already knew, which is that we in the medical and health care community have really let women down. We have some data that came out in the early 2000s that was misinterpreted and sort of suggested there was a much higher risk of use of hormone therapy, like estrogen, for people going through the menopausal transition. And that scared away a whole generation of doctors and other health care providers from offering it. And it also alarmed women because it made incorrect assumptions about the risk hormones would confer on developing breast cancer and other conditions.
So now we have a generation of providers that really haven’t been trained in how to take very good care of women going through menopause. And so I think it’s kind of a calling out to myself and other health care providers that we need to step up and figure out a better way to support people going through this transition.
Miller: I want to hear more about the key lessons that you both have drawn from that 2002 study, and the ramifications that has had for, now, more than two decades.
But Dr. Cichowski, to turn to you … and Dr. Rodriguez mentioned this briefly, and I gave just I think four symptoms in my intro. Can you give us a broader sense of the various ways that menopause, and perimenopause more broadly, can affect a body?
Cichowski: Sure. And I thank you for pointing out that … we identify menopause, but really these symptoms start up to eight to 10 years prior to the actual cessation of menses. And so there’s this critical time point where women are experiencing new things with their bodies, like hot flashes, vaginal dryness, sexual dysfunction, urinary incontinence symptoms, recurrent UTIs. There’s cardiovascular effects during this time, brain fog. It’s pretty much every system in the body … joint pain. And as the data and research grows, increasing awareness that many of these things that were individually treated may be attributable to a single cause, namely that of loss of estrogen as people go through perimenopause and menopause.
Miller: In addition to the pain, or really serious physical or mental challenges that might go along with not having these symptoms be treated, are there also potentially longer term health effects that stem from not having these symptoms treated? I’m asking this because that overall number that’s from the study – 60% of women who are even experiencing severe symptoms, not getting treated – I’m wondering what the potential repercussions of that are on health?
Cichowski: I think that’s why it’s important to look at menopause as not just the year where there’s been no periods, but the perimenopause, which is the 10 years before. And the reality is that many women experience menopausal symptoms, particularly hot flashes, sleep disturbances and mood changes for up to a decade after that transition into menopause. And so we’re looking at almost two decades of a woman’s life that there is a severe impact into quality of life, leading to things like depression, difficulty with relationships, difficulty with sexual function, difficulty with work. There’s some data on lost hours during this time period for women. And while we don’t have the data yet to say completely what happens to women who are better cared for during this transition, I think we, on a clinician level, experience that patients are suffering and it’s needless suffering because there’s very good therapies available.
Miller: What are those therapies?
Cichowski: Yeah. So some of the therapies are simple behavioral changes, cognitive behavioral therapy, sleep schedules, layered clothing, but there are good medical therapies available as well. And it really needs to be individualized depending on what symptoms, specifically, an individual is encountering. The most kind of staple or backbone of the therapy is estrogen replacement therapy or menopause hormonal therapy. And that needs to be tailored based on other medical history and also based on the presence or absence of a uterus.
Miller: Well, this is a good time then to dig a little bit more deeply into what Dr. Rodriguez was talking about first. Can you tell us what the public was told in 2002 about the risks of estrogen and maybe progesterone as well? Actually, now, I don’t remember if it was both of them, but the connection between that hormone therapy and cancer. What were we told 22 years ago?
Cichowski: Yeah, I think this is interesting because both Maria and I were training during this time period and there was this abrupt shift when WHI came out. And what occurred was a change to, there is an increase now in the risk of breast cancer if you’re on either estrogen or combined estrogen progesterone therapy. And that small increase from 1 in 1,000 to 1.4 in 1,000 just completely altered the landscape of how the therapy was viewed. And the study was not actually designed to look at that as the outcome. It was designed to look at cardiovascular effects of estrogen as a primary outcome. And in that study, there were not improved cardiovascular effects with estrogen when it was prescribed remote from menopause. So the data that came out of that was that it was neither beneficial but that it was potentially harmful as well.
Miller: And the results were really striking in terms of the decisions that doctors and patients were making. The numbers I’ve seen are that something like 40% of menopausal women had been taking these hormones before that slight increase in cancer risk was identified, was announced. And then four years later, it was down to 5%. And from what I’ve seen, the percentage now is even slightly below that. Was that reaction an overreaction?
Cichowski: I mean, hindsight certainly would imply that it was. I think there were still many providers who disagreed, and who had read through the data and read through the study, but the push back was strong. There were headlines that providers are harming, and potentially killing women, and increases in breast cancer. And I think the lay public message got strongly based on fear for women who were still benefiting from hormone replacement therapy.
Miller: I imagine that you could spend hours answering this question, so maybe it’s unfair to ask it. But how are experts thinking about the relative risks of taking these hormones now for people who are experiencing moderate or even severe symptoms, versus the potential risks of increased cancer … how do you think about the balance in 2024?
Cichowski: I think we really try to emphasize patient autonomy and have a shared decision making model of what symptoms are most bothersome. So for example, for a patient with recurrent UTIs as the main symptom, we would recommend topical estrogen, which has almost no systemic effect or risk of increase in breast cancer, and is well supported by both gynecology literature and other cancer society literature. In a woman who is 47, who’s having debilitating hot flashes, and mood disturbances, and sleep disturbances, we may talk more about systemic therapy and the risks and benefits of that, knowing that we have other non-hormonal options such as SSRIs or other mood medications that can often offset some of the effects that they’re experiencing through the menopausal transition.
Miller: Dr. Rodriguez, to go back to you – I’m stuck on one of the lines you said earlier that we have let women down, is essentially what you said, that the medical community has let women down. The lack of treatment that patients are being given right now, how much of that is due to a holdover from these cancer fears from more than two decades ago now, and how much is due to a sense that, well, this is just something that women go through and it stinks, but this is the way it is?
Rodriguez: Yeah, I think it’s multifactorial. We have kind of a long history in this country of gaslighting women and minimizing their concerns about their health. And I think that’s really well shown here in the field of menopausal care, where all these symptoms that we talked about have been sort of just blown off: “that’s natural, that’s normal.” And for me, it is of course natural. And for many women, they can transition through menopause without having too many symptoms that require medical attention. And so that’s where some of the lifestyle or other therapies that Sara talked about might make sense.
But I think we really have some important work to do to dispel not just misunderstandings but disinformation about effective therapies for menopause, both amongst women themselves, but also among the medical community. And so that’s where we’re doing some work to try to improve training and education for providers. OHSU, in partnership with the Oregon ECHO Network, launched last year, one of the first ever cohort study groups focusing on menopausal care across the state. And we’re gonna be offering that again in the spring as a way to try to reach out to primary care providers, particularly in rural settings. But this is a statewide need to try to improve provider knowledge of what are the best strategies and how to help. You share decision making with a patient about different therapies for menopausal care.
Miller: I want to turn to the availability of care. The New York Times reported yesterday that only 31% of OB/GYN residencies offer a menopause curriculum and that there are only about 2,300 providers who are certified in the U.S. right now in menopause care, even though 6,000 women reach menopause in the U.S. every day. Are we just facing an enormous shortage of healthcare professionals who are truly prepared to offer appropriate treatment?
Rodriguez: When I heard that, being of course an academic, I had multiple questions about, how did they define that? What does that mean? The menopause certification is an extra step that people from all different clinical backgrounds can go through. It’s offered through a professional society. But the reality is, menopausal care should be something that we’re learning about in medical school, and in both primary care and OB/GYN residencies. You really shouldn’t need an extra level of certification to do that.
And what’s the best way to train providers? I think a formal curriculum is certainly one option. Some of our colleagues here at Kaiser Permanente in Portland came up with a really great podcast as a way that they could deliver targeted information on menopausal education for residents. That can be effective as well. So we need to think about a lot of different ways to improve education and resources for all sorts of different types of providers that care for women in the midlife.
Miller: Dr. Cichowski, what recommendation do you have for menopausal or perimenopausal patients who feel like their doctors are not taking their concerns seriously?
Cichowski: I think it is important to advocate for your own health and your health care needs. And so sometimes requesting a referral to a specialist, sometimes seeking another provider in the practice or asking the question, “Is there another provider who might be more comfortable working with me on menopause hormone therapy?” I think the job that we have as clinicians is to educate other clinicians, and then help provide more pathways and access for patients. We know that a lot of this work can be done virtually. And so that helps eliminate some of the disparity that we saw for rural women trying to access care.
I think the important message for women though, is to reiterate, similar to what Maria said, that they’re not crazy, what they’re experiencing is very real, and deserves validation, affirmation and care.
Miller: Dr. Rodriguez, to drill down a little bit more in some of your findings, you did find that patients who are on public insurance – I’m imagining, in particular, something like the Oregon Health Plan, Medicaid – were even less likely than others to get menopause care. What do you think, whether it’s, say, the Oregon Health Plan or the V.A., leaders there [should] do with the information from your study?
Rodriguez: I think there’s lots of different steps that we could take. I mean, I think one of the first things that we could do is, Oregon has progressive policies around reproductive health and menopause falls under that definition, but we don’t have guidance from the Oregon Health Authority or others on, what does that mean for providers in the clinic? There’s not a newsletter, there’s not training resources, that’s something that we could build up.
But I think there’s a lot to be done within the health system too. So thinking about the Oregon Health Plan, we should look at what utilization controls are in place for hormone therapy medications. And that’s a fancy way to say, does your managed care plan require that you try several therapies before you can then have one that’s proven to be effective? Do you need to go through a lot of different paperwork or letters from your clinician in order to be able to try a medication? And we know that that’s pretty common, especially for medications that are newer, such as the newest FDA-approved therapy for hot flashes that’s non-hormonal. Cost is a really big barrier for people on that.
Then I think the other thing to think about is just again, our provider networks. Oregon’s a really well insured state, thanks to all the work people have done on expanding Medicaid and coverage. But if you don’t have a provider you can see without that training, you don’t have coverage at all. So I think insurance plans can and should look at different networks that they’re contracted with, making sure that they have an adequate number of people who are able to provide every level of women’s healthcare needed.
Miller: And finally, Dr. Rodriguez, you mentioned misinformation or disinformation is one of the things that you need to counter right now with patients. What exactly were you referring to?
Rodriguez: Well, I think two things. One is that we really haven’t done enough research on menopause in identifying effective therapies to be able to always answer the questions people have. And secondly, part of that has to do with, in the absence of … after the Women’s Health Initiative study, with sort of the health care community stepping back and away from estrogen, kind of a whole market industry sprung up with people that were desperate; trying other therapies, whether it was anything from a crystal to botanicals to compounded things, lots of different things have been tried. And we don’t always have great data on what works. That’s where it gets challenging for us to then have to try to talk to women who are desperately looking for something to ease their symptoms, but are also still concerned about the side effects or use of hormone therapy.
Miller: Maria Rodriguez and Sara Cichowski, thanks very much.
Rodriguez: Thank you so much.
Miller: Maria Rodriguez and Sara Cichowski are OB/GYNs at Oregon Health and Science University.
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