Chapter 27 – Menopause in Primary Care




Abstract




The other chapters of this book cover the diagnosis and management of menopause-related problems, the science behind them and the risks and benefits of the various interventions available. ‘Doing nothing’ will result in the physiological and psychological sequelae of the loss of ovarian function.





Chapter 27 Menopause in Primary Care



Sarah Gray


The other chapters of this book cover the diagnosis and management of menopause-related problems, the science behind them and the risks and benefits of the various interventions available. ‘Doing nothing’ will result in the physiological and psychological sequelae of the loss of ovarian function.


How ‘doing something’ happens will vary according to the prevalent health system.


When a woman has recognized what is happening to her mind and body and decides that she wishes to discuss this further, she may then make an appointment with a recognized expert in the field of menopause. In most countries this will require personal resources or insurance.


If a recognized expert or the funding to see them is not available, general gynecology tends to be next line of approach. Dependent upon the training, updating, experience and approach of the individual clinician this may be entirely appropriate.


However, the holistic approach of primary care provides a very credible alternative. Menopause is often emotive and the emphasis on consultation skills within primary care in conjunction with experience of multisystem medical problems and risk assessment means that menopause sits well within this setting. The argument of this chapter is that managing the menopause should be an extended primary care role particularly in health systems where gynecology is primarily seen as surgical.


Primary care is the point of access for women with undifferentiated symptoms and to a variable degree according to the health system will assess, make a diagnosis and manage the problem presented. The cessation of reproductive function is universal and there is a strong case to be made that training should be available such that menopause is recognized, and initial support provided within the primary care sector wherever in the world that may be.



Role


The role of primary care within the field of menopause can be broken down as follows




  1. 1. To act as the first point of contact for a woman with symptoms that are affecting her and provide a diagnosis.



  2. 2. Once menopause has been recognized by the woman and her health care professional to provide




    1. a. Discussion, risk assessment and first-line management options.



    2. b. Onward referral to a clinician with greater expertise if necessary.




Diagnosis


Primary care sifts undifferentiated symptoms. Its strength is an ability to manage uncertainty but generally there is an attempt to understand what is happening. This may take several visits and often a symptom diary. A clear presentation may enable diagnosis at first consultation. As this book illustrates there are many symptoms that can arise as a result of the decline in ovarian function. Historically, trials of menopause treatments have been required to look at individual symptoms – usually numbers of flushes as their primary end point. There is more to menopause than flushing and this simple message needs to be promulgated both to clinicians and women.


When I teach menopause at is most basic to primary care clinicians, I talk about




  1. 1. Brain-mediated symptoms – such as temperature regulation, sleep regulation, mood, memory and ability to cope



  2. 2. ‘Below the waist’ symptoms – vaginal dryness, bladder irritability, sexual difficulty



  3. 3. Structural symptoms – joints, muscle, skin and energy


I emphasize that any one woman may have none, some or all, but if she has a variety of these and is in the 45–55 age group and there has been a change to her bleeding pattern, then menopause should be at the top of the list of differential diagnoses.


This may be simplistic, but a simplistic approach may be needed to move some colleagues on from the attitude of ‘What do you expect at your age? Put up with it …’ Recognition of menopause and an understanding of its impact may provide the answer the patient was looking for and may satisfy her.



Investigation


Menopause was stated by NICE [1] to be a clinical diagnosis. Holistic assessment is required, and this is the strength of primary care. The various symptoms and observations across a variety of body systems will build a picture rather like a jigsaw. It would be unlikely that a diagnosis made on the grounds of bleeding pattern, symptom profile and impact would be overturned by either blood tests or imaging and can be proposed at a first consultation. We should aim for the primary care clinician to have enough knowledge, along with an ability to listen and to integrate information, to be able to do this.


Investigation may have a role in evaluating risk. There are a variety of validated risk assessment tools and primary care will be particularly familiar with those looking at cardiovascular disease, fracture risk and may have experience in memory assessment, breast risk and others. Haematological and biochemical tests taken for other conditions may well be available and interpretation of these is an everyday activity. Access to imaging and more specialized investigation will vary with the health system but they are often available and can be appropriately selected either to enable the management decision in primary care or to assist the assessment of a more specialist clinician.

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Sep 9, 2020 | Posted by in GYNECOLOGY | Comments Off on Chapter 27 – Menopause in Primary Care
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