Coordinated Management

Introduction

In this section, we provide a brief overview of coordinated (i.e., multidisciplinary and interprofessional) management of menopause. The first section explains why a coordinated effort of different physician specialists and other healthcare professionals (HCPs) is sometimes the necessary and often the optimal approach. In the second section, we briefly survey the most pertinent topics in patient-HCP communication, including cultural sensitivity and patient-centeredness.

Interprofessional Care in Menopause Management

The symptoms experienced during peri- and postmenopause can be both bothersome and varied, including vasomotor symptoms (VMS), genitourinary syndrome of menopause (GSM), psychological problems, sexual dysfunction and sleep disturbance (see Presentation). Sequelae like osteoporosis or cardiovascular disease (CVD) may also develop. These symptoms and conditions can have a serious impact on the patient’s quality of life, and may require assessment, diagnosis and treatment by a panel of diverse specialists, including gynecologists, endocrinologists, fertility specialists, psychiatrists, osteoporosis specialists, cardiologists, oncologists and others, ideally in conference with each other.^2,3 Supporting medical professionals with important roles in menopause management include nurses and nurse specialists, psychologists, social workers, nutritionists and pharmacists. A properly constituted multidisciplinary team of physicians and other HCPs can evaluate and treat each patient in an individualized manner, addressing each of the partially overlapping biopsychosocial issues that may arise during the menopausal transition (Figure 5-1).

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Multidisciplinary care is particularly important in cases of premature and early menopause, with the trifold aim of morbidity prevention, reproductive planning and supportive and emotional care. In an ideal situation, such patients should be attended to in dedicated clinics with a multidisciplinary team available on site or referred to a clinician with expertise in menopausal care. Menopause after cancer is another time when a multidisciplinary approach involving coordinated efforts from gynecologists, oncologists and psychologists, is essential.

Primary care practitioners (PCPs) represent the first point of contact for a woman with bothersome menopausal or menopause-associated symptoms. As such, they play a key role in the diagnosis of menopause. Furthermore, PCPs are typically also the main initial source of support and information, and can provide both risk assessment and prescribe, if needed and always in accord with the patient, the first-line therapy for symptom management. If bothersome symptoms continue despite this initial effort, the PCP should refer the patient to a specialist.

Nurses play an indispensable role in all aspects of menopause management. In addition to assisting physicians in the evaluation and treatment of patients (e.g., history-taking, assessing vitals, sleep patterns and mood), they can act as patient educators, encouraging exercise, healthy eating habits, proper hydration, calcium and vitamin D supplementation (if appropriate) and teaching stress-relief methods. Nurses who specialize in menopause may have broader duties, coordinating multidisciplinary management, formulating a treatment plan in collaboration with the patient, and periodically reviewing the effects of therapy.

Menopause is best considered from a holistic, biopsychosocial perspective. As such, psychologists can provide crucial support women undergoing menopausal transition, helping them navigate the meanings of menopause, maintain a positive outlook and prevent cognitive, emotional and behavioral symptoms before they arise. Psychologists may also provide cognitive behavioral therapy (CBT) as treatment for common menopause-associated symptoms, including depression, anxiety, sleep disturbance and VMS. In addition to one-on-one work, psychologists may also work with small groups of women, or guide patients to self-help materials, whether in a physical format or online.

Nutritionists, dietitians, and exercise specialists can help ensure that the patient is maintaining a healthy diet and staying physically active during the menopausal transition. Women who seek out the help of these professionals often have concerns about increased body weight and altered fat distribution. It is important to tread carefully around issues of weight, asking for permission before starting a discussion. Recommended physical activity includes at least 150 minutes per week of endurance exercise and regular resistance training (daily, if possible). Dietary changes should focus on achieving a caloric deficit of 500 Kcals per week; patients should receive education and support to limit snacking, alcohol intake and to reduce portion size during regular meals. Although no particular diet is recommended to achieve these goals, the Mediterranean diet has demonstrated a potential benefit in preventing bone loss. Indeed, the benefits of exercise and improved diet in general translate not only to weight loss, but also better cardiovascular and bone health.

Pharmacists can play an important role in interdisciplinary menopause care by helping patients navigate the available pharmacotherapeutic options, discussing the risks and benefits of each drug, and addressing concerns about long-term medication use. In addition to educating patients, pharmacists can collaborate with the other members of the care team to develop an individualized care plan and help ensure patient compliance. Addressing and alleviating fears surrounding MHT (Assessment and Treatment) is a task that pharmacists are ideally positioned to implement. However, the emphasis should be on empowering patients to make their own decisions.

In a holistic care model of menopause management, the emphasis should always be on empowering patients to make their own decisions. Some suggested ways of empowerment are schematically shown in Figure 5-2. Healthcare practitioners can support empowerment starting in the premenopause stages by providing evidence-based information on menopause and challenging entrenched negative perceptions. During the perimenopause and early postmenopause, HCPs can provide accurate and realistic information on treatment (including access to self-learning tools), offer reassurance about symptom severity and duration and treatment side effects, advise patients about other effective approaches to symptom management and encourage widening their support network, among other strategies (Figure 5-2).

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Communication Strategies for Discussing Menopause with Patients

Because discussion of menopause and its symptoms touches on potentially sensitive topics, including sex, sexuality and vaginal health, patient-HCP communication about menopause presents a set of challenges not usually present in other patient-HCP interactions. Because these topics are cross-culturally sensitive and because each culture has a different conceptualization of menopause and menopausal symptoms (see Assessment and Treatment for a brief overview), it is important that all patient-HCP discussion takes place in a patient-centric manner, with the HCP displaying both cultural humility and cultural competence.

Patient-centeredness describes an attitude to medicine that stresses a view of the patient as a unique individual who must be approached holistically, with care taken to respect their values, preferences and needs. Both the physician’s and the patient’s agenda are taken into consideration, optimizing patient care outcomes. In the context of menopause, this means going beyond the biomedical model, which prioritizes objective symptoms and finding the optimal treatment for those symptoms, and applying instead the biopsychosocial model, which incorporates the individual patient’s experiences and expressed needs.

Cultural humility represents an attitude that recognizes that our own culture shapes our worldview and that it is not possible to know everything there is to know about the world’s diverse cultures. It is important to note that the word “culture” used in this sense should be understood to signify not only race or ethnicity, but can and should be applied to other categories which may influence a person’s worldview and life experience, including socioeconomic status, sexual orientation, educational attainment, etc. Cultural humility means adopting a proactive approach to engagement with other cultures and self-evaluation of our own biases, counteracting the tendency to prioritize our own values and understanding of the world. Applied to the patient-HCP interaction, cultural humility requires recognizing that the patient is the expert in her own culture. Interpersonal cultural humility consists of openness and desire to learn about other people’s cultures.

Cultural competence means obtaining a deeper understanding of the experiences and practices of a particular culture. Undertaken with intra- and interpersonal cultural humility, the attainment of an adequate level of cultural competence can enrich the patient-HCP interaction. Two important pitfalls must be avoided in the pursuit of cultural competence, however. First, it is important to recognize that this is a lifelong process that, given the enormous cultural diversity in the world, is difficult to complete even for just one foreign culture; thus, cultural humility should never be abandoned. Second, it is just as important not to stereotype people from any given culture; intra-cultural diversity may sometimes be as broad as inter-cultural differences and people should always be assessed holistically. The challenge is to understand the influence of cultural background without assigning it a deterministic causative power.

Specific communications strategies that may be useful to improve patient-HCP communication include:

• Providing evidence-based information through both direct conversation and through the use of educational materials, including pamphlets and videos
• Normalizing common menopausal symptoms and reassuring patients that their experiences are normal and expected
• Addressing and acknowledging the emotional impact of menopause, including mood changes and anxiety and offering coping strategies
• Follow-up communication, either in person or via telephone, email, or teleconference
• Using plain, easy-to-understand language rather than medical jargon
• Encouraging questions and creating opportunities for clarification
• Empathizing, to the extent possible, with the patient in their experience of menopause.