With the advent of unprecedented numbers of women baby boomers now entering the perimenopausal and menopausal years, family physicians will increasingly be called on to discuss options and issues concerning menopause. Information that is widely available in the popular press, women's magazines, the Internet and even television commercials makes the physician's role as “information interpreter” especially crucial.
More patients than ever are armed with books, articles and computer printouts about menopause options when they visit their family physicians. Patients have many questions about the risks and benefits of hormone replacement therapy (HRT) and increasingly ask about nonpharmacologic treatment possibilities. What was once a fairly straightforward discussion about the benefits of HRT for most women has become a lengthy visit in my practice. Women want to live as long and healthy a life as possible. They want to introduce minimal health risks into their lives and feel great. They want energy, clear thinking, a vigorous sex life, a stable mood and a good night's sleep.
I enjoy discussing menopause with patients. This is an area with few absolutes and many controversies. It is a grand opportunity to explore a woman's personal health goals and beliefs, her fears and hopes. It is a chance to review individual risk factors and lifestyle choices and practices. A woman experiencing life and physical changes provides physicians an excellent opportunity to help her prepare for the future, with optimal health as an attainable goal.
As Cutson and Meuleman1 point out, not all women wish to “medicalize” a normal physiologic process. And, many women fear the potential risks of conventional HRT. Increasing numbers of patients are seeking “natural” alternatives—be that through phytoestrogens, herbal supplements or compounded isomolecular hormone formulations by physician prescription.2–4 Because patients are asking about these approaches, more physicians are seeking to become educated about such options.
Controversy abounds in the medical literature about the possible risks of breast cancer in women taking HRT. Now, the possibility that HRT may actually promote cardiovascular disease in some women—as reported in the recent Heart and Estrogen/progestin Replacement Study (HERS)5—confounds not only patients but physicians as well. No wonder women are seeking advice and treatment from a variety of nonconventional practitioners.
I believe that what patients want is advice from their family physician. This includes an individualized discussion of risks and benefits with an emphasis on the challenges of compliance, side effects and their management. Different preparations and methods of delivery should be offered, especially in conjunction with the mention of new products (e.g., vaginal capsules, combination patches and progesterone delivery through intrauterine devices).6 If a patient opts against HRT or “natural” alternatives, a careful plan should be constructed to ensure adequate weight-bearing exercise, calcium supplementation, cholesterol-lowering and other preventive measures. Patients want the ability to arrive at a reasonable decision for themselves, with the help of a caring and informed physician.
We do need to learn more about herbal approaches, phytoestrogens and so-called “natural” or isomolecular HRT. Much more research in women's health is imperative. We need good studies that are not funded by commercial interests and that compare various treatment options across a broad spectrum of women. Our patients deserve no less.