September 1, 2023 — An alarming divide is giving birth to the devils menopause care in the United States – thanks to persistent myths about hormone replacement therapy and shortcomings in the way new doctors are trained. The result: countless women are struggling with the physical and emotional toll of this life transition.
These shortcomings have led to an influx of doctors who have switched from traditional practice to virtual startups that focus on women’s health problems and treat patients who come to them desperate and frustrated after years of unresolved problems.
The solution is often so simple as to be almost maddening, say specialists: vaginal creams containing low doses of estrogen, which can address the symptoms of menopause, from vaginal dryness to recurring urinary tract infections.
“This is without a doubt one of the most meaningful interventions I have ever offered to a patient, and yet it is underutilized,” said Ashley Winter, MD, chief physician and urologist at Odela Health, a digital health clinic for women. “Many businesses are thriving in this area of menopause because it is underserved by traditional healthcare – your gynecologist usually deals with reproduction, and when women finish having children, they are usually released from their care. gynaecologist. .”
More than 1 million women in the United States go through menopause every year. According to a 2022 study, 4in ten women report menopausal symptoms that are so disruptive that they hinder their work performance at least weekly.
And yet many women do not receive appropriate treatment.
In part, this is due to the damaging legacy of faulty data, doctors say. Early results from the federally funded Women’s Health Initiative (WHI), published in 2002, showed that hormone replacement therapy led to increased risks of heart attacks, strokes and breast cancer. But further analysis showed the opposite: Hormonal therapies have a beneficial effect on cardiovascular and bone health and generally reduce the risk of death in younger or early postmenopausal women.
Hormone replacement therapy (HRT) delivers estrogen, sometimes with progesterone, to the body through gels, creams, patches, pills, suppositories, or a device placed in the uterus. Systemic HRT sends hormones into the bloodstream, while topical HRT – like vaginal estrogen cream – specifically treats vaginal symptoms of menopause.
Myths about the health risks associated with systemic and topical HRT have long been debunked, and research on topical HRT in particular shows that it carries no risk for cancer or other chronic diseases.
But even though twenty years have passed since the misinformation first began to spread, people remain woefully uninformed about hormone treatments.
The FDA still requires estrogen products to include a black-box warning on the initial data, even though it has now been proven to be false.
“This, in my opinion, is one of the most damaging PR setbacks of modern medicine,” Winter said. “It literally killed women. And it has made them unhappy.”
The public has a dire lack of knowledge about menopause management, says Stephanie Faubion, MD, medical director of The North American Menopause Society and director of Mayo Clinic’s Center for Women’s Health.
Treatment with low dose estrogen is not a radical approach; In fact, it’s the standard treatment for women experiencing many menopausal symptoms, Faubion said. But the topic has nuance and some people get lost in the details.
“I don’t think there’s a lot of knowledge about the risks and benefits of hormone therapy in general,” Faubion said. “New information comes out so often that it is difficult to keep track of everything. The answer is complicated and depends on the dose, duration of treatment and the formulation you use. It is difficult for many people to understand.”
But Winter said the lack of public knowledge reflects a larger problem: Knowledge gaps also exist among doctors, due to insufficient training on menopause-related issues.
During her six-year residency in urology, she never learned the role of vaginal estrogen in urinary problems, Winter said. It wasn’t until a 1-year fellowship on sexual dysfunction that she learned about the treatment.
“Despite dealing with urinary problems, incontinence, blood in the urine – training to deal with all these concerns – the role of local hormones in the vagina to deal with it was never taught and never discussed,” Winter said. “I never prescribed any of it.”
A year ago, Winter left her job at Kaiser Permanente to join Odela. After years of prescribing medications for overactive bladder with little to no results, she says, she is now using the knowledge she gained during her fellowship to help women who have battled debilitating symptoms for years.
Urologists aren’t the only doctors who don’t have the proper training. Obstetrics and gynecology residencies provide little knowledge about treatments for menopause, she said Ghazaleh Moayedi, DO, a gynecologist and complex family planning specialist for the Texas-based Pegasus Health Justice Center.
The problem is partly system-based, she said. Training programs often direct patients who are uninsured or covered by public insurance to medical assistants. Patients who qualify for Medicaid or Medicare are often pregnant or over 65, Moayedi said, so women who are actively transitioning can slip through the cracks.
“What that means in a state like Texas where I live, where it’s difficult to qualify for Medicaid, is that the people we see who do qualify are pregnant,” she said. “And you don’t use Medicare until you’re 65. So most gynecologists don’t graduate with extensive experience in menopause.”
According to Medicaid.gov, 80% of the national population covered by Medicaid is age 45 and younger.
When doctors have proper training and prescribe topical hormones, patients don’t always follow the treatment plan, says Andrea Rapkin, MD, professor of obstetrics and gynecology at the David Geffen School of Medicine at UCLA.
That failure to pursue treatment is another example of the remaining doubts caused by the misinformation spread through early research, Rapkin said.
“I’ll prescribe an estrogen product and I’ll find out they haven’t taken it, even though I’ll reassure them,” she said. “I think there are still some concerns, but I’m glad to see that there is a growing interest in vaginal hormones.”