Menopause from 2 sides

I decided to become a certified menopause provider for my patients and for myself.

I have listened to patients describe physical and mental changes after treatment for breast or ovarian cancer with empathy, curiosity, and a toolbox of clinical skills for decades. Most of these women are experiencing “Menopause Extra”. Extra because they have additional estrogen depletion from hormone therapy, extra because they have gone from full on to none, extra because they are already at the end of months of dismantling from surgery, radiation and chemotherapy. Depleted as they are from everything else, every creek and bump is more intense, like an old car with no shock absorbers.

As I navigate my own midlife experience, including the rush of social media messages that validate menopause but also suggest that nearly every reason for discontent or discomfort could be traced to hormonal change, I took matters into my own hands to become a Menopause Society Certified Provider (MSCP).

The Menopause Society is not the end all, be all. Certification requires various fees for membership and passing a test. In order to prepare for the test, an outline of learning objectives and a book can be purchased through the membership but there is no formal course. The book has chapters separately written by different experts in the field which catalogue various studies and evidence. Subject matter review often concludes with vague statements and contradictions. Research that follows a consumer driven market that is off and running does not tend to answer questions or solve problems that are clinically relevant.

The test, including scoring and the badge received for passing, are separately managed by a testing center. A variety of newsletters, learning tools, and continuing medical education including an annual meeting are integrated into membership. My perception is this is a much-needed institution and the goal to train and educate is lofty and much needed. Still, I’m left with a feeling that various stakeholders are trying to make a buck off of the overall endeavor. I understand this to be true in almost all health care and health care adjacent businesses, and I say that with the least amount of cynicism and negativity that such a statement allows.

Once I was credentialed, I was able to access the full database of Menopause Society Providers and found that in my area and a 50-mile radius, I am the only oncologist and hematologist. I can use this to bring more expertise about menopause to patients with cancer and blood disease. This is most glaring in women who have hormone positive breast cancer. Young women are thrown into early menopause, and older women are often on hormone therapies that augment many of the most symptomatic elements of menopause like poor sleep, joint pain, hot flashes and irritability. Then, like a knife twist or salt on a wound, effective hormone therapies are typically contraindicated due to increased risk of cancer recurrence.

Beyond those more obvious cases, I have seen women who felt unheard in more of the in-between places. For example, women with history of blood clots, myeloproliferative disease, hormone negative breast cancer, endometrial cancer. What is lacking is guidance from someone with expertise not just in the data, which is limited, but in someone who can listen and personalize, listen and extrapolate, listen and understand uncertainty, listen, and make a plan.

I’ve concluded that helping women feel ease in this constellation of change and discomfort comes both from prescribing medications and from small changes and thoughtful tracking of interventions that predominantly focus on the basics- sleep, exercise, nutrition. Supporting and cheerleading the need for time and the acceptance of a new normal are helpful when the communication feels authentic and comes from a trusted provider. The needle moves when basic interventions are done with habit and consistency. Habit and consistency are easier when they come without obstacle or friction. This is boring but true.

For clinical situations that are grey, that sit in the beyond and between, I tend to start by unpacking the questions and goals the patient has. Together, we try to come up with a best- and worst-case scenario that calls out the uncertainty. I suggest we establish a baseline with whatever testing and data we use the concrete metrics in parallel with the trial intervention.

As an example, a patient had ductal carcinoma in situ, hormone receptor negative, with a 2 mm area of invasive breast cancer that was hormone positive. She underwent bilateral mastectomy. She had been on the cusp of perimenopause with sleep difficulty and irritability and had a short course of hormone therapy prior to her diagnosis which in her words “had lifted the fog and brightened her life.” She stopped this when diagnosed, completed surgery and then fell back into a symptomatic place with hot flashes, joint pain, insomnia, and severe anxiety.

After we tried the basics and made minimal progress, we created data points with a symptom tracker and a bone density baseline. She chose to work with a provider that compounded very small doses of hormone therapy and tracked her serum levels meticulously. We talked of the risk of hormone therapy given the small component of hormone positive breast cancer but put it in the context of complete mastectomy, making local recurrence nearly impossible. We talked of the unregulated compounded hormone therapy infrastructure but recognized that it allowed for the smallest dosing possible for symptom relief. We talked about the limit of serum levels of hormone levels but acknowledged that it provided real time trends. After several years of this, she tapered off of all hormones and now manages with a focus on diet, exercise, sleep and focused supplements. But she chose her values and her risk. That is patient centered care and I’m proud and excited to offer more of it in my practice.

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