Menopause & perimenopause

Talking to your doctor about menopause

by Dixie Mills, MD

Menopause is now a household word. We find the term in jokes, on the news, and it’s now even easily discussed with our girlfriends. But how often do we bring menopause up with our healthcare providers? Or how often do they talk to us about it?

In the past, menopause was just accepted as a fact of life. Not much attention was given to it in medical school, but in recent years, with the growing number of proactive baby-boomer women, it is definitely receiving more attention. Unfortunately, all this news brings with it a negative side in that menopause is now seen as a disease that doctors need to manage, fix and treat.

While we might want the easy fix, many women are not happy with these ideas, and are resisting them and asking for more. We applaud you for this. And much of our website is devoted to meeting those needs. However, we understand that a woman just can’t do everything, and she occasionally would like some assistance from the medical profession.

Here are some scenarios of the patient–doctor relationship to give you ideas for how this topic can be broached, and how to get the help you want and deserve during menopause and perimenopause. We’ll refer to your healthcare provider as a doctor, while recognizing that many of you see nurse practitioners, nurse midwives, or physician’s assistants and feel that this is great — sometimes even better!

Beginning the process

Our goal, at Women to Women, is for you to find a health provider who will work with you as a partner. This way you can collaborate on finding your best options during this often challenging period in your life. Most women have a primary care doctor or gynecologist whom they see for regular Pap tests. This is a great place to start. Explain to the front office staff that you would like some time — at least 15 minutes — to ask your doctor some questions about menopause, and you would like a separate appointment for this. If your doctor is in a group practice, ask if there is someone in the group who specializes in menopause.

Office practices vary widely when it comes to menopause. Some have a menopause library with books to check out; others have hand-outs to read; others offer show-and-tell sessions. If not, you can ask for a referral to a practice that does offer something like this. If you can’t get a referral or you’re a newcomer to the area, you may need to do some research on your own. Start by asking friends and acquaintances for recommendations. You may need to be a detective and do a little research. Thankfully, research is getting easier these days with internet connections.

Whatever you decide to do, try to make it enjoyable. If you have a couple of friends going through the same issues, bring them along to your appointment, then go out for coffee or whatever your favorite treat is afterwards to digest! It is always good to have an extra set of ears and eyes, and they can benefit also.

But before you begin any of this, we suggest getting a few things straight.

Know yourself

It is essential that you believe in your own knowledge of your body, and that you understand that you are the best source of what has worked, and what hasn’t, with your health. You indeed have lived in your body for many years now, and have that unique experience that your doctor does not. Only you have a gauge on the times in your life when you have felt the best. Think about these times, and try to recall what else was going on that contributed to your well-being.

In addition to knowing what has worked, you also probably know by now what kind of a decision-maker and what type of risk-taker you are. Some people recognize instantly what they want; others prefer sleeping on a decision overnight; and others like getting everyone’s opinion before saying yes or no. Some women are willing to go out on a limb and try something new; others need a stamp of approval. Many women are very intuitive; others may not trust or recognize that side yet. Most everyone also has some deep-seated fears, often related to trauma — and while some women are more conscious of these and have faced them, others are just starting to look. All of these styles are just part of what makes us each a unique human! None is essentially right all the time, or wrong all the time either.

While these styles are not commonly asked as a part of a health questionnaire, perhaps in the future they will be. Those questions that are commonly asked by health practitioners, about the basic facts of your health history, can be helpful to record ahead of time. Here are a few for you to think about:

What are the details on your periods?
This includes the age you started them, what adolescence was like with your periods, how many days in your average cycle, how long and heavily you bleed, whether you spot in-between, and the date of your most recent period, as well as your contraception and child-bearing history.

What is your past medical history?
Include anything medical that seems relevant, such as hospitalizations, surgeries, and acute or chronic illnesses and conditions.

What is your family history?
Menopause is a good time to take the long view of your health. Think about illnesses that run in your family — heart disease, cancers, or other significant health problems. By writing this down, you can often see family patterns that might not have been as obvious otherwise. If you know when your mother went through menopause and how it was for her, take note. You are obviously not your mother, but she was and may still be an important person in your life in more ways than one. You should also include your parents’ and other family members’ current health status. And if there are no health issues, that is also important and should be noted.

What medications and supplements are you on?
List every medication you take (if any), as well as what you’ve used in the past. You should also list any vitamins or supplements you take on a regular basis. Be sure to include any adverse reactions or known allergies.

How much do you drink and/or smoke?
Note how much caffeine and alcohol you drink per day, and if you smoke now or ever have, you should fess up.

How much exercise do you get?
Be realistic about this. And be sure to note what kind of exercise you’re getting. Does it include daily chores and activities, or daily visits to a gym?

What is your sexual history?
Include the past and present — how often and how enjoyable it is/was, whether you’ve noticed any changes in your sexual desire lately. Obviously some of this may be more private, and not part of a standard health history, but it should be included in a menopause health history.

What are your strengths and weaknesses?
To make this more personal, you can add what you feel are your strengths and weaknesses. This may help when thinking about your path through menopause, and what kinds of changes you are willing to make in your life.

You may already have this information on your computer, and can bring in a copy when you visit your doctor. If not, think about recording it — it is something we may not get around to doing, but once started, it’s easy to keep up. Some doctors’ offices have a form that they give you to fill out. You might keep a copy for yourself, and add your own categories.

Know your desires

We recommend that you be very clear about what you desire from your doctor. Different desires may require different providers, or different approaches. We think it’s wise to have a clear idea or intention regarding what you want to know — because then you are more likely to find it. We certainly realize that there is a rapidly changing volume of information out there, and it can be confusing and challenging for consumers and healthcare providers alike. But if you can see this state as a positive one — a learning one — it certainly helps.

Here are some ideas to help you focus your intentions. Do you want or need:

• Information about menopause before you are there? Check your knowledge of menopause.
• Information about what you are going through now, e.g. skipping periods or other symptoms of hormonal imbalance?
• Information about choices or options?
• Confirmation that what you are doing is safe?
• Answers to a question about something you read in a book or on the internet?
• Permission to try something?
• Support for what you are doing?
• Treatment for a particular symptom of menopause or perimenopause you are experiencing, e.g., vaginal dryness?

If you can be clear on one to three points or questions you want to get information or answers about, it will help immensely. Doctors — mostly men, who tend to be more solution-based in their thinking — need to know specifically what we want. They cannot read our minds (but that is another topic). And in a short period of time it is best to get right to the crux of the matter. It will also help to explain to your provider why you want to know. Many things may seem obvious to you but perhaps not to the doctor.

Oftentimes we become frustrated when our doctors don’t understand what we need, so it’s important to understand where they are coming from as well.

Know where your doctor is coming from

All health providers — doctors, nurse practitioners, physicians’ assistants, etc. — are human. They have spent many years learning to be experts in their fields, and even more years applying their expertise. Like all of us, they like to feel that they are good at what they do. Most doctors went into medicine to help people, but unfortunately we are currently overstressed by managed care, financial considerations, and having to work in factory-like conditions.

This is why doctors are trained to focus on a patient’s chief complaint, meaning the problem or symptom. We are not really taught to ask our patients if they have any questions. Many doctors find out why their patients are there from their nurses and never ask the patient themselves. They are often in the room and out again before you fully realize they were there, leaving you no time to ask your questions. This is why we recommend that you first try to arrange an appointment for a consultation about menopause if you do have questions about it.

Keep in mind that many doctors base their treatment of menopausal women on what they read in their scientific journals or from conferences they attend or from consensus statements from the North American Menopause Society. This organization takes a drug-based approach to menopause, which isn’t surprising because most of the studies they endorse are funded by pharmaceutical companies. But it is also in part because most doctors don’t think their patients are willing to undertake lifestyle and dietary changes, and in part because holistic methods aren’t as adaptable to the double–blind placebo–controlled trial that is the “gold standard” in conventional medicine.

In fact, most instruction in medical school and afterwards is informed by large studies, and guidelines are based upon what seems right for the population (often men). This gets translated into a one-size-fits-all approach that is difficult to apply in caring for the individual (especially a woman). It’s not that these methods are malicious in their intent; it’s just the way science has been taught in the West. Doctors are not really familiar with individualizing treatment, although this is becoming the latest thing. The curriculum in medical school was heavily geared toward fixing symptoms and managing diseases. We (at least when I was in medical school) did not get much exposure to what “healthy” looked like. Nor were we trained in the concept of wellness, and how to obtain it. So it’s no surprise that many doctors find it difficult to teach patients these concepts.

While one aspect of being a doctor is to be a teacher, some of us are just better at it than others. We did not get any training in education skills, and certainly not adult education. Instead, I’m afraid, we were unconsciously taught to treat our patients as children. For example, bringing in or mentioning information you’ve researched on the internet may be viewed as a threat or a waste of time by some doctors because they don’t think women have the training to understand what they’re reading. How information is exchanged between you and your doctor may be the test that tells you whether it’s a relationship you will find helpful. If the doctor wants to hold all of the information and power, and is not interested in discussing or listening to your ideas or in creating a partnership, it may be time to find another doctor.

The good news is that more information and instruction in customizing treatment plans is becoming available in continuing education programs for doctors and in medical schools, with more courses being offered on tailoring health care. Now that individualized care is being recognized as a viable approach, we may find doctor–patient relationships becoming more like partnerships. After all, we are all different and have unique perspectives to share.

Remembering that doctors are as unique as patients can also help!

Know who your doctor is

Choosing a healthcare provider to work with you during menopause is a highly individual decision. The doctor who delivered your babies and routinely performs your Pap smears may or may not be well equipped to discuss your menopausal transition. She or he may not be that interested in, or “up” on menopause, and prefer dealing with women of a different age. Certain doctors may be stuck in their ways for treating complaints and completely lack interest in customized treatments.

Since it is not a focus in medical school, many doctors haven’t learned much about hormonal imbalance. They might simply look at the numbers and say that you’re too young for menopause, or if you’re still having periods, ignore the idea altogether. This kind of dismissal can be frustrating, to say the least, especially since we know that menopause is a transition and that it can happen over a period of years while we are still getting periods. As individuals, some doctors know more about this topic than others.

We might presume that an older woman doctor would be more empathetic than a young male. Like judging a book from its cover, this can be misleading. In the past, women — being in the minority in medical school — had to incorporate many of the masculine features of a male doctor to earn respect, and perhaps did not become the most compassionate health providers.

On the other side of the coin, perhaps the young male doctor has seen his mother going through menopause, and hers was a positive experience. As with our homes (I just sold my house, and understand that there is a house for everyone), there is a good doctor for everyone. Some may be very popular, and you will hear about him or her from everyone you ask, but someone else may simply click with you. It just takes a bit of searching.

The rules of engagement

Once you’ve chosen your doctor, as with any interaction, there are certain rules of engagement and unspoken themes in the doctor–patient relationship. The doctor is traditionally seen as the person with the power and knowledge; they wear the white coats; they can be late. The patient is the one in need.

At Women to Women, we propose that this relationship be looked at more like a partnership, where one person has one body of knowledge and the other has another, and the combination of the information can take the experience to a new level. A woman knows her own body more specifically than the doctor, who has spent a lot of years reading books about diseases and taking care of women with problems. All of this reading and knowledge doesn’t guarantee that the doctor knows what is most critical about the woman in front of him.

Unfortunately, the archetype of the menopausal woman is that of a “complainer.” This can start things off negatively before you even say a word. By using certain techniques and common courtesy, you can stay within the parameters of the doctor–patient relationship and get what you want from your doctor.

We feel strongly about your power as an individual. From the moment you begin talking with your doctor, try to send the message that you are willing to take an active part in helping yourself get better. One of a healthcare provider’s worst nightmares is an overly “needy” patient who can’t be helped. Sending a message of excessive neediness feeds the negative menopause stereotype and, as with any relationship, can lead to poor interactions.

Show your doctor this willingness by doing your homework. By this I mean do some research, think about where you stand and what you want to get out of the relationship. However, it’s important to always acknowledge and respect the perspective of your doctor, just as you would hope to have him or her respect and acknowledge yours.

How to start the interaction

We would recommend that when you first enter the office, you find some way to connect with the staff and then with doctor when he or she enters the room — even if it’s something like the ease of parking or the signage for the practice. Starting out with a simple, positive conversation can coax doctors from those “factory-like conditions” they’re up against and set a welcoming tone to the encounter.

If this is a new provider you are seeing and you have a limited amount of time (try to confirm how much time you have beforehand), you might begin by introducing yourself and summarizing your main symptoms:

Hello — I’m Jane Smith. I’m 50 years old, and here is my medical history (provide your written copy). I’m basically a very healthy, active busy professional, but I’m concerned about some symptoms I’ve been experiencing lately. I’ve been reading about menopause and have tried some over-the-counter remedies, which seemed to work well at first, but now my hot flashes and lack of sleep are interfering with my lifestyle.

This opens the door for you to bring in a few articles you’ve found in the future to see if your doctor is aware of the information or interested in reading about it. Maybe something to save for the second date! You could then express the kind of patient–physician relationship you’re looking for and get down to specifics:

I had a doctor prescribe a pill but it didn’t agree with me, and I would like to partner with someone who could work more closely with me and my symptoms, which I realize will change over time. I know our time is limited today, but I am interested in knowing about….

You can insert whatever information you desire. Perhaps you’ve read about HRT and are interested in some alternatives and nonprescription supplements for menopause. Or you can say:

I am just having so much difficulty with understanding... (whatever it is) ...why my sex life has changed, or why I can’t remember things as well.

Then you can share what you’ve learned from your research, or heard while talking with your girlfriends, or wherever. Once the doctor replies and gives you some information, it is important to clarify your understanding. They need to know if it wasn’t clear, and you can always say so:

Oh, thank you so much. I got most of that, especially... (be specific so the doctor knows you’re listening), but I still don’t understand… (such and such).

It is very important for you to get the information you need, and you may need to guide your doctor a bit in that direction. Or, if a word is used that you don’t understand, don’t hesitate to stop and ask for a definition. Remember, you can always ask for clarification:

I’m sorry, I didn’t get all that. Could you please repeat that?

There may be moments in your interaction when the doctor says something that you don’t believe, or maybe you’ve read differing opinions that make more sense to you. Here you might say:

I respect where you are coming from, Dr. Smith, but my experience and research have been different, and I’d like to know what my options are and how, or if, we can work together.

Toward the end of the consultation, if the doctor has been helpful, express your thanks. Try to be specific about what was particularly helpful — the information, the ideas, the referral, the prescription, and so forth. Everyone likes to be appreciated (especially men).

If you invited a girlfriend, male or female partner to join you, you can always ask this person to bring up questions and help you keep track of the doctor’s answers.

As with so many things in life, try not to take it personally if your doctor is short with you, wants to pat you on the back, or doesn’t take you seriously. He or she is probably just not that interested in menopause, and perhaps it would be better if you tried someone else. And if you are repeatedly told to live with your symptoms, just grin and bear it, or if it takes more time for your body to adjust and it’s been longer than you can remember, then it’s definitely time to seek another opinion. Likewise, if the doctor does not appear to respect your individual priorities and concerns, it is probably not a good match. Many women are worried about offending their doctors, yet most doctors do not actually seem to take it this way. So we encourage women to put their health first, and not to worry about their doctor’s feelings.

Three questions about menopause you don’t need to ask

Though there are tons of questions about menopause to ask your doctor, choose carefully. You may think you want to ask the doctor one or all of following questions. But these are areas where I think women know more than they realize. I’d like to go over these in some detail.

Am I in menopause?
If you ask a question like this, you may get a dead-end answer like, “Oh, that’s easy. Let’s do a blood test.” I am assuming you are asking this question to validate the changes you are undergoing. A blood test may or may not answer your question, and deciding to do the blood test ends the conversation. (Take a look at our article on FSH testing to learn more about their limitations.)

Most women have so much more that they are curious about. And we probably would rather have time and space to discuss and digest our experiences than to obtain a one-word answer. So perhaps it would be wiser to explore your symptoms beforehand. You can do this with friends over coffee, or take our survey on the internet, or attend a seminar, and then see a doctor with a more detailed question, like:

I’ve missed a period. My last period was quite heavy. I think I’ve been getting hot spells at night. I’m curious about whether I might be in menopause and wondering if I should be doing anything to prepare?

How long are these symptoms going to last?
This is harder because there really isn’t a good answer — and be wary of anyone who tells you they know. Our bodies are much more complex than that, and how long your symptoms last may ultimately depend more on the lifestyle changes you make, or don’t make, than what a doctor can predict.

Am I ever going to be the same again?
Again, this question would require your doctor to get out the crystal ball! In truth, every woman knows the answer to this intuitively. We, along with our bodies, change every day, and it is a fact of life that we are never going to be the same again moment to moment! What this question is really getting at is our fear of the unknown, and we can learn to frame it around a more positive focus. (For more about embracing change, see our article on the joys of menopause.)

The more we talk

For women who have tried several doctors for help with menopause and still feel they’re not getting anywhere, it may be time to see a specialist in menopause. You may want to visit the website of the Institute of Functional Medicine, American College for Advancement in Medicine, or Natural Woman Institute to look for a practitioner willing to work with you on an integrative approach to menopause and perimenopause.

Menopause has not been given the attention it deserves in the conventional medical world, but things are changing. The North American Menopause Society recently held a symposium on bioidentical hormones for which doctors could receive credit for attending. While most of the information was fairly biased, leaders from compounding pharmacies, as well as doctors who prescribe bioidentical hormones, were able to present and share information. (For more information on this, see all our articles on bioidentical hormones.) This is a huge leap from where we were even ten years ago.

The fact is, menopause is becoming more popular! And the more we prepare ourselves to talk seriously about it, the more women will transition through it with greater health and happiness. If you feel stuck with your current doctor, don’t be afraid to explore other options. And remember that laying the foundation for good health by enhancing your nutrition and making healthy changes in your daily life can lead to great improvements during your transition through menopause, no matter who your doctor is.

 

Original Publication Date: 06/13/2007
Last Modified: 02/16/2010
Principal Author: Dixie Mills, MD