Do You Need a Menopause Gynecologist?

It used to be referred to in hushed tones as “the change of life,” and for the most part, women just had to grin and bear it. 

Over the past decade, though, perimenopause and menopause have been recognized as real issues that can seriously affect the lives and long-term health of many women.

Suddenly, perimenopause and menopause seem to be everywhere — celebrities have companies aimed at treating common symptoms, they’re featured in plot lines of TV shows and movies, and what the New York Times has called “the first great perimenopause novel” has been published.

At the University of Miami Health System, the new Menopause Clinical Program takes a multidisciplinary approach to caring for patients experiencing symptoms related to perimenopause and menopause.

Starting in August, the program has attracted more than 200 patients who were referred by gynecologists, psychologists, and other care providers. 

“There are no specific requirements for being a menopause gynecologist — we only need to be interested and listen to the patients and offer them exactly what they need,” said Flavia Fairbanks Lima de Oliveira, M.D., Ph.D, the founding director of the program.

Dr. Fairbanks came to UM three years ago from the University of Sao Paolo in Brazil.

Would you agree that perimenopause and menopause are having a cultural moment right now?

Yes. Around 10 to 15 years ago, everyone was talking about pregnancies and natural deliveries and not being too invasive. Now, it seems that as this group of women has gotten older, the talk is shifting to perimenopause. 

Menopause is a certain thing for every woman who’s alive. Just as everyone had a first menstrual period and went through puberty, everyone will be having or facing the last one in menopause.

Back in Brazil, we have a well-known journalist, a man, who said, ‘If menopause occurred in men, it would be solved forever.’ No one accepts anymore that this is just aging, that everything is in your mind. No, we are looking for solutions.

Apart from physical symptoms, what are some of the most significant issues people have with perimenopause and menopause? 

You cannot imagine how many marriages are affected and how many divorces are due to menopause. It’s often because people lose their sexual drive, they’re not feeling well, or they have low self-esteem. And sometimes, the partners are not that present anymore, and then the relationships are affected.

Nowadays, women are more productive.

They’re a part of the market. They need to be useful. They need to think; they need to rest and be productive. No one is okay who doesn’t sleep, who feels completely weak and fatigued, etc. It’s not fair, right? A study performed at the Mayo Clinic by Dr. Stephanie Faubion found that the market is losing $1.8 billion/year due to menopause.

Women at that age have important roles — many of them are CEOs, directors and many other things. If they are not feeling well, they can’t produce. Many of them are spending their work hours going to doctors and trying to find solutions and taking medications and antidepressants, and they are always facing hormonal changes. It was established that if we treat these women appropriately, they will be more productive, and the financial impact will be much better.

Why was the Menopause Clinical Program established?

We established the menopause clinical program because patients were getting sent from the PCP [primary care physician] to the psychiatrist, the psychiatrist to the PCP. Sometimes, a gynecologist would identify an issue as hormonal, but nobody was taking on organizing a program for holistic patient care. So that’s what we are doing now.

What can patients expect when they visit the Menopause Clinical Program?

When a patient arrives, we first interview them about symptoms and what treatments, if any, they’ve tried. Depending on need, patients may undergo a hormone panel via blood draw, a mammogram and an ultrasound. If patients are deemed good candidates for hormone replacement therapy (HRT), they’ll get a customized treatment program. During the first year, they’ll have check-ins every three months to adjust medications and see how they’re feeling. 

We also include physical therapists in the program because many of these diseases affect the pelvic floor, and patients can have not only sexual dysfunction but also genitourinary problems like urinary leakage and pain during intercourse, which affects the quality of life. Psychologists are also included because of the emotional issues associated with menopause, like anxiety and depression. We also have a very close interaction with the endocrinology department, because some patients also suffer from thyroid dysfunction, adrenal dysfunction, and other issues like diabetes and hypertension. 

For many years, thinking about hormone replacement therapy was influenced by a now-discredited study linking HRT to health risks for women.

How has that thinking changed in the medical community?

Since that 2002 study, many other research papers have been published showing that HRT can be safe and a good choice for patients if the guidelines are followed. And that’s exactly what we’re trying to do here, just to put things in the correct place. You know, hormones are not for everyone and are not forever. But there is a specific place and time during a woman’s lifetime when many women can benefit from HRT. We know that menopause symptoms affect 60-70% of women and that they can impair the quality of life. 

Everything we do nowadays is to bring patients and the community a good quality of life. We want our patients to be healthy and to be safe. And why would we deny something we know can be safe if it’s correctly and appropriately used?

When is HRT appropriate for patients?

Suppose a patient starts presenting with any symptoms like menstrual irregularities, hot flashes, vaginal dryness, insomnia, or lack of sexual desire. If we document that these symptoms are related to the lack of diminishing hormones, we can start thinking about whether hormone replacement is appropriate. We need to get the patient’s permission, after excluding all major contraindications and possible side effects.

We have a term that’s very old and not totally correct or appropriate anymore, but it’s called ‘the window of opportunity.’ It’s generally defined as the 10 years around the age of menopause. Here in the US, that’s around 52; in Brazil, it’s a little earlier, around 48-50, given nutrition, genetics, and other factors. 

Why this window of 10 years? This would be when your cardiovascular system would benefit from receiving hormones. It doesn’t have time to block arteries or have major risks for cardiovascular and thromboembolic events. Nowadays, we know that people are entirely different. So if we have a patient who is completely healthy, who doesn’t present any kind of cardiovascular problem, has normal blood pressure, no risk of diabetes, regular BMI, and exercises, then she’s a good candidate. Maybe she can keep using hormones for a long time if she’s feeling well. 

On the other hand, if we have a patient who’s within the window of opportunity but has other medical problems, maybe she’s not a good candidate, and we need to avoid hormones.

So that’s why the concept of ‘window of opportunity’ is not necessarily abandoned these days, but it’s a simple way to explain to patients when hormone therapy is beneficial. 

Jodie Nicotra is a contributor for UHealth and the Miller School of Medicine.

Tags: Dr. Flavia Fairbanks Lima de Oliveira, Hormone replacement therapy (HRT), Menopause and mental health, Menopause and productivity, menopause treatment