According to the International Menopause Society, “The purpose of the day is to raise awareness of menopause and the support options available for improving health and well-being.” While we have come a long way in bringing this issue into the spotlight, I still encounter patients on a daily basis who are unaware of what this transition can mean to their long-term health and quality of life. Some do not discuss their symptoms with their physician, and others, despite sharing their symptoms with their doctor, often leave the visit with “just live with it” as the recommended course of care due to fear of breast cancer (Barber and Charles 2023).

I have been teaching my menopause course, Menopause Transitions and Pelvic Rehab, for almost three years. A common question raised by participants during the course is whether discussing hormonal treatment options is outside the scope of pelvic rehabilitation. While I understand the concern, I do have some thoughts I would like you to consider. To elaborate, let me share a recent clinical experience I had when evaluating a patient for an orthopedic pathology.

This patient was a cis-female patient in her late 40s who presented to the clinic for mid-back pain. She had an extensive medical history of auto-immune conditions and work-related injury. She had been hospitalized due to her diagnosis and had lost a substantial amount of weight. As with any therapy evaluation, I asked how she was sleeping.

What she reported isn’t atypical for many of my patients. She was having pain that was disrupting her sleep patterns. She also reported hot flashes that were waking her up frequently in the night. She would go on walks occasionally but was not exercising regularly due to fatigue. Her food intake consisted of several servings of vegetables and fruit but was lacking in protein. On further discussion, she reported not having a period for a little over a year. She had misgivings about hormones due to breast cancer risk and wasn’t sure it was an option for her.

I was able to explain the background behind the Women’s Health Initiative and how this research was misinterpreted in the media and among many in the healthcare community regarding the safety of hormone therapy (Bluming and Tavris 2018). I explained estrogen is approved for the treatment of hot flashes and prevention of osteoporosis by The Menopause Society (position statement 2022). I also discussed the current recommendations of weight training from the Center for Disease Control of two days a week. We strategized goals for implementing this into her plan as she progressed in her exercise ability. I highlighted how the ability to process protein diminishes as she ages (Bauer et. al, 2013) requiring diligence to ensure adequate amounts in her diet.

On her next visit, she reported meeting with her obstetrics and gynecology doctor. She was given the option of hormone therapy and had started on a daily regimen. Her sleeping had improved, and she was feeling more like herself. She was making an effort to get protein at every meal, and while she was still not exercising consistently, she was hoping to start soon.

This patient was at high risk for osteoporosis due to her substantial weight loss and low BMI (Xiang et. al, 2017). Her sleep was being impacted by her hot flashes. Lack of sleep has been shown to increase the risk of cancer, heart disease, and neurodegenerative disease (Garborino et.al, 2021). It can also affect our patient’s ability to cope with stress and pain. How is someone supposed to heal if they can’t sleep? If I had not known about approved hormonal medications for the symptoms the patient was experiencing – I would not have been able to explain this option to the patient.

As pelvic health therapists, prescribing medications is certainly outside our scope. However, if we aren’t aware of their indications, how are our patients supposed to know their options? We are often the health care provider in whom they spend the most time and thus our patients often report symptoms to us that they haven’t shared with their doctor.

That is not to say that patients do not talk to their doctors about menopause. Many patients do actually report their symptoms to their physician; however, studies have found that these physicians often have not received the proper education on the menopause transition and are not always aware of when to prescribe hormone therapy (Kling et. al, 2019). We can provide referrals to specialists who DO have that knowledge so patients can know their options and make decisions together with an informed provider.

We can help to bridge the knowledge gap by knowing risks, benefits, and treatment options, not for prescription of medication, but as a conduit of information to give our patients options to discuss with their providers. This can allow for symptom management, improving quality of life, and in some instances prevention of fracture.

The more healthcare clinicians that have a basic understanding of menopausal symptoms and treatments, the more patients can be made aware of the options available to them. This allows for a dialogue to occur between physician and patient. Certainly, this is only a small piece of the treatment puzzle. There are many more important aspects of treatment including building muscle, sleep hygiene, stress management, and nutrition, which do fall within our scope.

In honor of World Menopause Day, let’s celebrate by raising awareness for our patients in regard to this change, and what can be done as they navigate through this transitional time. Join me on November 2-3, 2024 in Menopause Transitions and Pelvic Rehab to be a part of the conversation. 

References:

1. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 2022. 29(7): p. 767-794.
2. Barber, K. and A. Charles, Barriers to Accessing Effective Treatment and Support for Menopausal Symptoms: A Qualitative Study Capturing the Behaviors, Beliefs and Experiences of Key Stakeholders. Patient Prefer Adherence, 2023. 17: p. 2971-2980.
3. Bauer, J., et al., Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc, 2013. 14(8): p. 542-59.
4. Bluming, A.Z.T.C., Estrogen Matters. 2018, 1290 Avenue of the Americans, New York, NY 10104: Little, Brown Spark. 310.
5. Garbarino, S., et al., Role of sleep deprivation in immune-related disease risk and outcomes. Commun Biol, 2021. 4(1): p. 1304.
6. Kling, J.M., et al., Menopause Management Knowledge in Postgraduate Family Medicine, Internal Medicine, and Obstetrics and Gynecology Residents: A Cross-Sectional Survey. Mayo Clin Proc, 2019. 94(2): p. 242-253.
7. Xiang, B.Y., et al., Body mass index and the risk of low bone mass-related fractures in women compared with men: A PRISMA-compliant meta-analysis of prospective cohort studies. Medicine (Baltimore), 2017. 96(12): p. e5290.

AUTHOR BIO
Christine Stewart, PT, CMPT

Christine Stewart, PT, CMPT (she/her) graduated from Kansas State University in 1992 and pursued her master’s degree in physical therapy from the University of Kansas Medical Center graduating in 1994. She began her career specializing in orthopedics and manual therapy then became interested in women’s health after the birth of her second child.

Christine developed her pelvic health practice in a local hospital with a focus on urinary incontinence and prolapse. She left the practice in 2010 to work at Olathe Health to further focus on pelvic rehabilitation for all genders and obtain her CMPT from the North American Institute of Manual Therapy. She completed Diane Lee’s Integrated Systems Model education series in 2018. Her passion is empowering patients through education and treatment options for the betterment of their health throughout their lifespan. She enjoys speaking to physicians and to community-based organizations on pelvic health physical therapy.