As I walked into the exam room, Carol’s smile quickly turned to tears.
“What is going on?” I asked, sitting down on a stool.
She let out a big sigh. “My life is great, I mean, really great. I’ve been dating a man for almost a year and he is terrific. Work is great too — I made partner.” She looked away for a moment, then back at me, her eyes brimming with tears. “See this,” pointing at her eyes, “this happens all the time now.”
I’ve known Carol for years as a patient. I was always impressed, and a little envious, of her nonstop energy. Driven to be at the top of her field, she gave everything she had to her career — motherhood, even finding a significant other, were never a high priority. She embraced the challenges, thriving in her male-dominated work world, and found rich rewards professionally.
“I cry at everything these days. I’m in the middle of a meeting, then someone pushes my buttons, which I normally can handle easily, and suddenly tears are welling up in my eyes. My boyfriend asks a simple question and I want to scream at him.”
She went on to tell me her periods were erratic, she was irritable and moody, and she wasn’t sleeping well, waking up drenched in sweat throughout the night. “It’s so embarrassing! The worst part is that I feel like I can’t control it. You have got to help me.”
“It’s like you are going through a second puberty,” I told her with a smile.
“Exactly! I’m 52 and acting like a teenager! But how do I explain that to a bunch of men?”
After 25 years in practice, I hear this scenario frequently when my patients are transitioning into menopause. So what options are there to help with their symptoms?
When determining a treatment plan for patients like Carol, there are many factors to consider. First, what symptoms are most bothersome to the patient? Usually, some combination of: hot flashes, night sweats, insomnia, mood swings, anxiety, depression, vaginal dryness, dyspareunia, decreased libido, weight gain. Second, does the patient have any health issues and what medications is she taking? If I find out she has liver disease or a history of blood clots, that impacts her options moving forward. The same is true of family history or personal history of cancer, especially breast, ovarian, or uterine. Finally, I try to understand what my patient’s expectations are — what quality of life improvements is she hoping to achieve? For example, maybe the hot flushes aren’t so bad but the insomnia is impacting her work and family life.
Right now, the gold standard in menopause treatment is hormone replacement therapy (HRT), the benefits of which include elimination of hot flashes and night sweats; improved mood and feelings of well being; and improved vaginal atrophy. HRT was a popular treatment method for many years but in 2002 a Women’s Health Initiative study claimed it was associated with an increased risk of breast cancer (it also suggested that the protective effects believed to be associated with HRT were not substantiated). Over the years, though, many of the study’s claims have been refuted — but the stigma persists. In recognition of the controversy, Dr. Avrum Bluming and Carol Tavris discussed the benefits of HRT in a recent LA Times article titled “Once and for all: Hormone replacement is good for women.”
In my armamentarium, HRT is definitely high on the list, and I offer my patients various options for taking it including tablets, patches, creams, and gels. If I want something more individualized for the patient’s particular symptoms, I will use a compounding pharmacy (with PCAB accreditation). Sometimes I only use HRT during the harrowing roller coaster of hormonal changes, each year re-evaluating if the patient needs to continue at the current dosage. For others, the quality of life is so vastly improved on HRT, indefinite continuation is desirable. And, if HRT is contraindicated for a patient and/or the patient prefers not to use it, I try to tease apart what symptoms are most problematic. So, if it is insomnia, I suggest alternative methods to help manage the patient’s sleep (e.g., warm baths, Sleepytime tea, decreasing caffeine intake, possibly prescription sleep aids). If it is hot flashes, I might ask the patient to consider a low-dose antidepressant. There are similar alternative treatment options for vaginal atrophy (which I discussed in a recent Op-Med). Most importantly, I tailor my management according to each patient’s needs. This includes acknowledging that there will be some trial and error in finding what works best. It is also requires recognizing that the treatment plan may change year-to-year, depending on the patient’s evolving needs.
During Carol’s appointment, we discussed options to help her feel more in control of her body and hormones. For someone who thrives on being in control, as Carol does, the unpredictability of menopause was scary. For her, acknowledging the changes she was experiencing and respecting her body was empowering. In the end, we decided to try HRT to ease some of the physical changes she was experiencing. In her follow up appointment three months later, her smile was back.
Andrea Eisenberg has been an ob/gyn in the Metro Detroit area for nearly 25 years. Through her many years in women’s health, she has shared countless intimate moments with her patients, and shared in their joys, heartaches, secrets, losses, and victories. In her writing, she captures the human side of medicine and what doctors think and feel in caring for patients. She has documented these stories on her blog. She has been a contributor to Intima, A Journal of Narrative Medicine and Pulse, Voices From the Heart of Medicine. Andrea is also a contributing author at BBN Times and a guest rotating blogger on KevinMD and Doximity. She is currently in Doximity’s 2018-2019 Authors Program.