Education of Community and Health-Care Providers JANINE O’LEARY COBB A Friend Indeed Publications Box 515, Place du Parc Station Montreal, Canada H2 W 2PI Although it is generally agreed that information is the first requirement for women approaching menopause, most studies suggest that women don’t know an awful lot about what is happening to them. In a lengthy and comprehensive study of menopausal women in the province of Manitoba, Dr. Patricia Kaufert established that a substantial number of women do not discuss menstrual status with their doctors.’ A more recent study from Philadelphia indicates that even welleducated, upper-income women look to popular women’s magazines for their basic information.* What we have is a situation where some women get their information from magazines (undoubtedly a minority since the public is not generally a “reading public”), some women augment this with information from the doctor, and others rely on information from friends and family. This would not be so distressing if all three sources were purveying the same general sorts of information, but this is not the case. Most women end up very confused. Let’s look first at the kinds of articles about menopause presented in magazines. Most are written by premenopausal journalists whose primary objective is to provide assurance-for themselves as much as for their readers. These articles rely heavily on the idea that “no one will ever guess,” and are replete with anecdotal evidence of women who are youthful, full of vitality, and attract younger lovers. The writers are so anxious to reassure that they gloss over the very real discomfort suffered by some women. To them, menopause, like aging, is to be avoided and, if possible, eliminated. I have been interviewed for many such articles. When I say that graying hair and slight weight gain are not so bad, that hot flashes are uncomfortable but not the end of the world, I find myself slotted into the category of “good old sport.” The problem is not menopause but the interviewer who is frightened of growing old. Occasionally we also see articles written by doctors. Doctors tend to use information garnered from a clinical population, or from studies published in medical journals. This is perfectly understandable, but it hardly contributes to a well-rounded picture of the menopausal woman. Moreover, a recent study tells us that women’s perceptions of menopause strongly affect decisions about whether or not to accept estrogen replacement therapy (ERT) and that women who accept a prescription are already more likely than most to define menopause as d i ~ e a s eWomen .~ who accept ERT are usually seen at 6-month intervals. This means that these women will return, as will those who are followed prior to or after hysterectomy, to make up the bulk of the average gynecologist’s menopause practice. Is it any wonder that doctors’ accounts of menopause almost always picture it as a malady? But the doctors who write, whether for women’s magazines o r for medical journals, and the doctors women consult are not always the same people. It is no 221

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secret that there is enormous discrepancy in the advice given to menopausal women, and that they get conflicting advice from their health care providers. Many women are being counselled by older doctors (who have developed some cynicism about miracle drugs), by family physicians (who appear more likely to take into account factors other than menstrual status before prescribing), by practitioners in other fields (nursing, nutrition, and even alternative medicines such as naturopathy and homeopathy), and by an expanding network of women’s health workers-all of whom have in common a healthy (and I use the word advisedly) respect for potential long-term and side-effects of powerful hormones. Then, in addition to these experts, we have the lore of other women: the stories of the “change of life” baby, the miseries of Marge and her night sweats, the day that dear Auntie Bea went ‘round the bend. It is not only a lack of information that makes education about menopause difficult, but the sorting out of what is authentic and what is not. Given the contradictory nature of all this information, it’s no wonder that women distrust most of what they hear. And distrust, in turn, leads to apprehension. The result is the “noncompliant patient.” Women are not normally uncooperative, but the confusion surrounding menopause makes it easier to do nothingat least until our health care providers get their act together. Five years ago, when I first recognized the signs of my own “change of life,” I started digging around for reliable guidelines to menopause. Intrigued by what I found, I began a support network for menopausal women-through the mail. From an initial group of 25, it has grown to more than 3,000. Women who participate receive a monthly bulletin covering developments in research about menopause, discussions of life events often felt to be a problem at midlife, and explanations of how to take better care of themselves. We’ve had issues on heart care, breast health, arthritis, migraines, nutrition, exercise, anxiety, depression, and among other topics. A very popular part of the newsletter is the letters section. Here is a place where women can share their experiences and enlist the sympathy and support of others who understand. Women who are coping with menopausal ailments write in with suggestions about remedies that have worked for them, or with queries about the experiences of other women. So far, so good. Now this newsletter was not taken very seriously by the medical profession for some time. A couple of medical journals mentioned it, but always felt compelled to add that the editor had no medical background. It reminded me of the time I found myself on an open-line radio show with a doctor, and someone called in to ask if there was any way of knowing when menopause would occur. The doctor responded by saying that, other than familial tendency, there was no way of knowing. When the caller said, ‘‘I don’t understand,” the doctor said, “FA-MI-LI-AL TEN-DEN-CY!” After a long pause, I jumped in and said, “It tends to run in the family.” “Oh,” she said, “thank you.” Sometimes it’s better not to speak “medicalese.” After the newsletter had been in circulation for two or three years, two things started to happen. First, women’s health centers in Canada and the United States began to subscribe in increasing numbers. Then we started getting letters from women telling us they had found copies in their doctors’ waiting rooms. Since I had very few doctors on my computer lists, I assume that the doctors’ wives or receptionists had subscribed. (Doctors are notorious for expecting free subscriptions to everything!) However, there was no real acknowledgment of the newsletter and, since I was still donating my time to the enterprise, I was getting discouraged. Then, in

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the spring of 1987, I went to a conference in the Netherlands and stayed for a few days with one of the officers of a group called VIDO (Vrouwen in de Overgang), which has been instrumental in educating the Dutch about menopause. VIDO was started by one woman who formed a small support group of women in menopause; it has expanded to cover every city and town in the Netherlands. With a government grant, VIDO rents and staffs a coordinating office and also maintains a house in the country (left to them by a rich widow) where midlife women can go to spend quiet weekends away from the stress of family or work. But what really impressed me was the fact that VIDO members were routinely asked to come and talk about menopause to medical students at the University of Leiden. That gave me heart. I knew that a coordinated network of groups and federal government-funded offices were just not feasible in the sprawling countries of North America, but the prospect of establishing enough credibility to influence medical training was a challenge. Last year, I spoke at menopause seminars sponsored by hospitals in various cities across Canada and a symposium sponsored by Health & Welfare Canada (our equivalent to your NIH), and I was asked to meet with the Women’s Health Issues Committee of the Ontario Medical Association, an association that represents almost 19,000 doctors in the province of Ontario. The purpose was to consult with the Committee regarding a possible physician education program to sensitize doctors to the concerns of menopausal women. Because our first meeting was to establish whether such a program was needed, I took with me excerpts from letters from readers, excerpts that described meetings with the doctor. I could have taken excerpts from 500, but I only took excerpts from 30, about 5 pages in all. With this evidence, the committee quickly decided that there was a need for this kind of program. There is no doubt that physicians need help if they are to be more sensitive to the needs of menopausal women, and I mention this initiative of the Ontario Medical Association (even though we haven’t yet decided on the final product, an article or a position paper) because I believe it is a promising first step. But it is only a first step. (Incidentally, one of the committee members has asked me to speak to medical students at the University of Toronto this year. So I feel that I’m making progress!) One of the problems we didn’t tackle was the everlasting confusion, in the minds of physicians as well as in “folklore,” between naturally menopausal women and menopause that is surgically induced. To avoid this confusion, it was decided that the OMA program would be targeted to natural menopause only. Unfortunately, this ignores a large proportion of women who probably need even more help and information. We also didn’t look at ways in which a woman can obtain reliable information about menopause before she gets to the doctor’s office. We all know that it is unrealistic to expect doctors to devote 30 minutes to a detailed discussion about menopause. And yet women desperately need information b&re they see the doctor. If we are to get on with a viable education program for both the community and health care providers, we need to arrive at some understanding about what menopause means. We need a viewpoint that knits together the requirements of all those now called upon to talk to or to treat menopausal women. If we had some kind of coherent perspective on menopause, I don’t think it would be that difficult to mobilize informed and interested persons as educators: nurse-practitioners, dietitians, physiotherapists, women’s health center workers, members of groups such as the Boston Women’s Health Book Collective, or the National Women’s

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Health Network. These educators could sit down with small groups of menopausal women to explain the options about what could and should be treated, and what could be alleviated by changes in diet or regular exercise. But this kind of educational program can be implemented only if there is some sort of consensus about the broad outlines of appropriate menopause education, including endorsement by physicians, who are often reluctant to relinquish control of their patients. I believe the community and health-care providers can work together in the best interests of the menopausal woman, and I would like to suggest three basic assumptions to underpin such an educational program: FIRST PREMISE Menopause is not a pleasant prospect: Not because a woman will necessarily feel unwell, but because it requires her to confront her own aging. And aging is not a pleasant prospect for a woman in this society. More often than not, it is the specter of old age, and not the presence of menopausal ailments, which is the more worrisome. Theoretically, menopause and aging are separate concepts. But as we live through menopause, we encounter many situations which unite them. And one situation is often the visit to the doctor. Doctors themselves not only share in the general contempt for aging women, but, according to some studies, acquired these negative attitudes towards older women during medical trair~ing.~ Many of us have abandoned the kindly obstetrician who delivered our babies because of his undisguised distaste for our change in status. He, in turn, is undoubtedly influenced by medical terminology which insists on viewing readiness for pregnancy as the absolute standard of femininity. Any deviation is not viewed as change, but rather as decline. Medical descriptions of menopause, typically, are governed by words such as “failure,” “depletion,” “loss,” “shrink,” “atrophy,” “decline,” “deteriorate,” “wither,” and, of course, “senile.” These words have enormous power-power to rob women of their essential woman lines^.^ Education about menopause must take into account the cultural factors which shape (and distort) so-called scientific or medical descriptions. A ten-year-old girl is not seen as less than the person she will be. And the postmenopausal women is not less than that which she once was, only different. The view of the menopausal woman in medical training and medical texts is both sexist and ageist. This should be acknowledged and changed. SECOND PREMISE Menopause is not a disease. If this concept of menopause were acceptable, surely it would be culturally universal, both in time and space. I can’t count the number of presentations I’ve attended where we are told that this is one of the first generations of women to live past menopause. This is simply not true. The life expectancy of a woman in past centuries may have been less than 50, but this is only an average, and an average which reflects the vast numbers of young women who used to die in childbirth, not the absence of a postmenopausal period. It is true that more women live past menopause now than ever before, but there have always been women past the age of 60-we have only to think of our own grandmothers and great-grandmothers.

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Moreover, there appears to be a number of present-day cultures where the menopausal ailments of Western society are simply not recognized.”8 Women stop menstruating and have virtually no other indication of menstrual status: no hot flashes, no broken bones, no problem with dry vagina. If menopause is a true deficiency condition, the deficiency should be applicable to all women past childbearing age. Pathologizing menopause may make it more credible when seeking research funds or getting sponsorship for a clinic (and sometimes it may be iatrogenic disease induced by removal of the uterus and/or ovaries), but women should not have to be diseased to be interesting to health care providers. This is not to say that women do not experience discomfort at menopause. As I have suggested, women whose menopause has been surgically induced may experience very severe effects; they constitute a separate group. Among naturally menopausal women, a small minority also experiences intolerable symptoms. We are not yet sure why this is, but examination of diet, exercise patterns, and familial tendencies would probably give us a clue. For the vast majority of naturally menopausal women, the transition from reproductive to nonreproductive status entails some kind of discomfort or even turbulence-but no more than the turbulence of any other major life change, whether that change is purely physiological (as from the nonreproductive child to the reproductive adolescent), purely social (like the change in status from married to divorced, or a geographic move to a new community), or a combination of physiological and social, like the birth of the first child. In fact, menopause often arrives at a time of great social change-job responsibilities, aging or unwell parents, and departing children. As with any other upheaval, the body is under stress and outside sources of stress are poorly tolerated. But, again like any other period of change, there are compensations. The discomforts of menopause lead many women to examine their daily habits, their roles and relationships. This self-awareness can lead to positive change such as giving up smoking, taking up regular exercise, adjusting the diet, spending more time with female friends, changing jobs. When energy levels fluctuate, women may refuse customary chores, forcing others to make the meals or do the laundry. This is when a woman may find herself coerced into visiting the doctor because she’s not being “herself.” But some women don’t want to be their old “selves” any longer, and menopause provides an impetus to make the change. Being irritable and anxious is characteristic of a person under stress. Menopause is often stressful. But this does not make it a disease. LAST PREMISE

Women have the right to be informed and to choose. There are still women around who prefer to put their trust in the doctor and let him choose for them. The good doctor would, of course, explore options with the patient and encourage bilateral decision-making, but our medical systems do not encourage this type of discussion. Most women take their prescription and quietly leave, but their frustration is reflected in the high degree of noncompliance, and the tendency to seek out another doctor. This kind of passive obstruction is characteristic of women over 50 but, more and more, younger women are confronting the situation, asking pertinent questions, and treating the doctor as a collaborator rather than an authority.

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There are risks in permitting women to choose. Women will become privy to the controversial aspects of menopausal treatment. Is porous bone necessarily fragile bone? What are the risk factors for osteoporosis and how should they be weighed? Can the doctor judge when a vagina is “nonfunctional” or is this a judgment to be made only by the patient? Which is more “natural,” conjugated equine estrogen, 17-beta estradiol, or estradiol valerate? They will have to become familiar with the progestogens and with the potential of natural progesterone. They will discuss whether it is appropriate to take only one hormone or to take both hormones together, or to cycle a progestin for 5 days or for 11 or more. They will discuss possible side effects and potential long-term effects. And they will be told that the adjustment of a proper prescription requires tailoring the therapy to a woman’s unique biology. In fact, the most convincing accounts about the need for estrogen replacement or hormone replacement therapy stress individual evaluation and prescription. And there’s the rub. By and large, menopause clinics are set up to study particular forms and dosages of hormones: if you attend them, you are likely to get the product provided by one or two pharmaceutical companies. Women should know this before they attend. Similarly, physicians tend to rely on particular combinations of products, prescriptions that seem to work for most of their patients. If menopause clinics are guided by economics, then many gynecologists are guided by beliefs. While it’s true that medicine is as much art as science, many women may well choose, as I have, to do without hormones and to wait until the situation is a little more stable, just a little more scientific. Informed consumers may well decide to remain untreated, or, more accurately, to self-treat, paying increased attention to nutrition, to regular exercise, and to screening tests. If you invest in education, this is part of the deal. But consider the sense of control engendered by this increased knowledge of one’s own physiology, a sense of control that does much to correct for the out-ofcontrol sensations typical of the perimenopause. I would think that an informed consumer would be a much more interesting patient to most health-care providers.

SUMMARY I submit that education about menopause should rest on three basic assumptions: (1) that menopause requires us to confront the stigma of aging; (2) that menopause is not a disease, but a challenge; and (3) that optimal treatment of the menopausal woman needs the informed and educated participation of the patient. If we can agree on this, whether as medical consumers or health-care providers, I think that we can do much to alleviate the present state of confusion. NOTES AND REFERENCES I.

KAUFERT,P. A. & P. GILBERT.1987. Medicalization and the menopause. In Health and Canadian Society: Sociological Perspectives. Coburn et al., Eds. Fitzhenry & Whiteside. Toronto.

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2. MANSFIELD, P. K. & B. BOYER.Midlife women and menopause: Experiences, concerns and health care needs. Paper presented at the 8th Conference of the Society for Menstrual Cycle Research, Salt Lake City, June 1-3, 1989. 3. LOGOTHETIS, M. L. Women's decisions about ERT: The relationship between attitude and use. Paper presented at the 8th Conference of the Society for Menstrual Cycle Research, Salt Lake City, June 1-3, 1989. 4. SPENCE, D. L. ef a / . 1968. Medical student attitudes toward the geriatric patient. J. Am. Geriatr. SOC.16: 976-983. 5. For a more detailed argument, see MARTIN,E. 1987. Medical metaphors of women's bodies: Menstruation and menopause. I n The Woman in the Body. Beacon Press. Boston. 6. KAUFERT,P. A. et a / . 1986. Menopause research: The Korpilampi Workshop. SOC.Sci. Med. 2 2 1285-1289; Culture, Medicine & Society 1U: 23-71. 7. WRIGHT,A. L. 1983. A cross-cultural comparison of menopause symptoms. Med. Anthropol. 7: 20-35. 8. BROWN,J. K. & V. KERNS.1985. In Her Prime. Bergin & Garvey. South Hadley, MA.

Education of community and health-care providers.

I submit that education about menopause should rest on three basic assumptions: (1) that menopause requires us to confront the stigma of aging; (2) th...
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