A menopause center: bridging the midlife gap.

As women 40-60 years of age become the fastest growing segment of the population, it is time for women's health care providers to identify the health care needs of these women and provide the appropriate services. In 1985, Northwestern Memorial Hospital developed the Menopause Center to address these concerns. The objectives of the Menopause Center are to inform women of the natural bodily changes menopause creates, dispel common myths about the menopause, identify risk factors for osteoporosis and heart disease, provide information regarding hormone replacement therapy, and provide a forum for women experiencing the menopause to share information.     

The readability of printed education materials regarding hormone replacement therapy

In summary, HRT is a preventative medication that has been shown to decrease the incidence of heart disease and osteoporosis. It also has been shown to reduce symptoms of menopause and to increase the quality of life of users. Choosing to begin and maintain HRT is a personal and complicated decision. In evaluating the risks and benefits of HRT for any one woman, that woman and her primary care provider must individualize her past and current medical history, her family history, and her lifestyle. Together they must come to a decision that best represents the health, social needs, and desires of the patient. Individualizing HRT is difficult for a woman to do on her own, and it is time-consuming for a practitioner. Using PEMs to clarify the benefits and risks of HRT can be very beneficial to a woman considering such therapy. PEMs, however, are not a substitute for one-on-one education, and especially are not appropriate for teaching if their level of technical difficulty is beyond the scope of a patient's comprehension. This study suggests that many of the PEM's provided to women on the subject of HRT are failing to reach their target audiences because of their level of reading difficulty. A stated objective identified in the national initiative Healthy People 2000 (U.S. Department of Health and Human Services, 1997) is to "Increase to at least 90% the proportion of perimenopausal women who have been counseled about the benefits and risks of hormone replacement therapy for the prevention of osteoporosis." PEMs are one way to reach this objective, provided they are understandable to the clientele of focus.     

Health professionals' knowledge of women's health care

Until 1986, the only issues in women's health which received direct attention were those related to childbearing. At that time the National Institutes of Health made inclusion of women in research a criteria for funding. Since then, the knowledge base to guide disease prevention and treatment of women has grown dramatically. Unfortunately, the incorporation of these data into clinical practice has been much slower. The purpose of this needs assessment was to establish a comprehensive data base on which future programming decisions could be based. Areas of interest identified by health care providers included stress reduction, breast health, prevention of heart disease, and osteoporosis. Other topics that emerged were menopause and reproduction issues, cancer prevention, domestic violence, substance abuse, nutrition, and weight control. These data suggest topics for future programming.     

Sexually transmitted diseases in men

Sexually transmitted diseases are the most common infectious diseases in the United States. Physicians, nurses, and other health care providers are uncomfortable discussing sexual issues with their clients. Therefore many health care needs are not addressed, and many opportunities for education aimed at preventing STDs are missed. In the periodic health history, the health care provider must elicit information about sexual practices (vaginal,oral, or anal intercourse), sexual orientation (heterosexual, homosexual, or bisexual), sexual risk behaviors (ie, unprotected intercourse with multiple partners), contraceptive use (particularly condoms), and prior STDs. Based on this information, the health care practitioner moves to more specific questions regarding sexual health. The health care practitioner asks about sores on the penis, dripping or discharge from the penis, staining of the underwear, testicular pain, and scrotal swelling. For the client who engages in oral sex, the health care practitioner asks about sore throat. For the client who engages in anal intercourse ask about diarrhea, rectal bleeding, anal itching, and pain. Probe the desire phase, the arousal phase (erection), and the ejaculation phase. Ask about the desire for fatherhood and concerns about fatherhood. An important part of health care is prevention. Culturally specific and sensitive information should be available for patients. Patient education should not consist of simply handing a brochure to a man. Using the brochure as a guide for including all the necessary information and ascertaining the man's understanding may be a very effective method of patient education. For men who are at increased risk for STDs or who present with symptoms of STDs, offering diagnostic testing is necessary. Men who have multiple sexual partners especially need diagnostic testing and prevention counseling. The CDC recommends annual HIV and hepatitis C testing for men who have sex with men and other men who have increased risk for contracting HIV. Another important consideration at the periodic screening examination is the vaccinations that are to be recommended. Men who have sex with men should receive hepatitis A and hepatitis B vaccine. Additionally, it is recommended that all adolescents should receive hepatitis B vaccine.     

Preventive care for the menopausal woman

In summary, menopause represents a stage in a woman's life for the primary care physician to have an important impact on health [43]. Decision-making must weigh individual risk factors for health disease, osteoporosis and breast cancer. Hormone replacement therapy remains an important issue for the postmenopausal woman [44]. More evidence is needed to define the specific health benefits and risks of HRT, particularly as it relates to the prevention of CHD. A patient centered approach using a shared decision making model is most likely to result in improved patient satisfaction and desired health outcome.     

Assessment and prevention of osteoporosis through use of a client self-reporting tool

Osteoporosis is an age-related process that affects one out of every four women above 65 years of age. This article focuses on the assessment of osteoporosis through use of an osteoporosis assessment tool that is filled out by the client. The tool requests information about the woman's demographic profile, chief complaint, related symptoms, pain profile, risk profile, past medical history, nutritional history, fitness profile, menopausal history and self-care practices. The tool also includes information for the health care provider to complete about the client's lab analysis. Assessment needs to be extensive in order to uncover the specific factors that place an individual at risk for the silent changes of osteoporosis. The health care provider can elicit the aid of the client in securing such a comprehensive assessment.     

Benefits of hormone replacement therapy in postmenopausal women

PURPOSE: To provide an overview of current research regarding hormone replacement therapy (HRT) and to assist healthcare providers to better educate patients about potential benefits of this therapy. DATA SOURCES: A systematic review of healthcare literature was conducted with 602 articles selected from CINAHL, Medscape, Pubmed, and Medline databases. Keywords directing the search included hormone replacement therapy, benefits of hormone replacement therapy and trends, hormone replacement therapy and osteoporosis, hormone replacement, and menopause symptoms. CONCLUSIONS: According to the literature, HRT can assist women with postmenopausal symptoms. In addition, research shows that HRT can help some postmenopausal women with selected comorbid conditions such as osteoporosis, type II diabetes, certain cardiovascular pathologies, and colorectal cancer. The decision as to who should use any form of HRT needs to be based on the individual woman's needs, quality of life, and potential risks versus benefits. IMPLICATIONS FOR PRACTICE: HRT has been a benefit to many women in the treatment of postmenopausal symptoms. Recent studies have shown that HRT, whether it is combined estrogen and progestin therapy, or estrogen-only therapy, can help postmenopausal women with osteoporosis and some selected comorbid conditions. Recent research indicates that some women are dying from comorbid conditions rather than breast cancer. Although the research regarding HRT in some areas may be limited, further research adds to existing knowledge and offers new ideas and possibilities in the treatment of postmenopausal symptoms and selected comorbid conditions. Certainly HRT can improve quality of life and possibly longevity for selected women. Ongoing research is needed to further validate such benefits, as well as to further explore the risks and benefits of long-term HRT. Increased knowledge about HRT will help healthcare providers better educate patients about the potential benefits of HRT, while providing documentation about who should take selected types of HRT or whether alternative treatment is preferred.     

Managing menopause

Many women will spend one third of their lifetime after menopause. A growing number of options are available for the treatment of menopausal symptoms like vasomotor instability and vaginal atrophy, as well as the long-term health risks such as cardiovascular disease and osteoporosis that are associated with menopause. Currently, hormone replacement therapy (estrogen with or without progestin) is the primary treatment for the symptoms and long-term risks associated with menopause. However, recent evidence calls into question the protective effect of estrogen on cardiovascular disease risk. The association of risk for breast cancer with estrogen replacement therapy also has not been fully clarified. In addition, many women cannot or choose not to take hormones. For treatment of osteoporosis and heart disease, pharmacologic choices include antiresorptive agents such as bisphosphonates and calcitonin, and estrogens or selective estrogen receptor modulators such as raloxifene. In addition, complementary options that include vitamins, herbal treatments, exercise and other lifestyle adaptations are gaining increased interest. The growing number of choices and questions in this area emphasizes the need to individualize a treatment plan for each woman to meet her specific needs.     

Diagnosis and Treatment of Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM), formerly referred to as vulvovaginal atrophy or atrophic vaginitis, is a common chronic condition that requires a collaborative treatment plan between a health care provider and a woman to relieve symptoms and improve quality of life. Many women are not aware that symptoms can be controlled with treatment. Current treatment options approved for GSM include vaginal moisturizers, lubricants, and hormones. For women with GSM symptoms that are unresponsive to nonhormonal therapy, low-dose vaginal estrogen therapy is the preferred pharmacologic treatment. Clinicians should be trained to routinely ask appropriate questions during the history to elicit sufficient information to assess for GSM. Physical examination findings may further confirm suspicion of GSM.     

The decision to take hormone replacement therapy among women with disabilities

Whereas making decisions during menopause can be challenging for all women, those with physical impairments face special issues with respect to menopause in general and hormone replacement therapy (HRT) in particular. In this correlational study the authors explored the factors such women consider when making decisions about HRT One hundred sixty-seven women with physical impairments throughout the United States completed surveys concerning their attitudes and knowledge about HRT Approximately half the menopausal women were currently taking HRT The strongest predictor of HRT use was women's perceptions of their health care providers opinions about their taking HRT, combined with their motivation to comply with the provider's recommendation. Thisfinding points to the significant role that nurses and other health care providers play in assisting women to make informed health care choices during menopause.     

Ethnicity and prenatal health promotion content

Prenatal care health promotion education is an important strategy for reducing perinatal health disparities. The purposes of this study were to (a) identify differences between the health promotion content women wanted to discuss and the content women reported discussing and (b) determine whether ethnicity was related to health promotion content. A cross-sectional study used face-to-face interviews to obtain data about 159 Mexican American and African American pregnant women's prenatal experience. Women wanted more health promotion content than they discussed. Despite wanting information about more health promotion topics than African American women. Mexican American women discussed fewer topics. Ethnicity, number of topics women wanted to discuss, whether a woman had a primary provider, and type of prenatal provider model were also related to content.     

I PREPARE: development and clinical utility of an environmental exposure history mnemonic.

The I PREPARE environmental exposure history mnemonic is a quick reference tool created for primary care providers. Health care providers (N = 159) were asked to evaluate a prototype mnemonic, to suggest new health history questions, and to propose the deletion of less relevant questions. The goal of this evaluation was to create a practical and clinically relevant mnemonic, rather than to obtain quantitative estimates of validity. The final I PREPARE mnemonic cues the provider to "Investigate potential exposures;" ask questions related to "Present work," "Residence," "Environmental concerns," "Past work," and "Activities;" provide "Referrals and resources;" and "Educate" the patient by reviewing a checklist of strategies to prevent or minimize exposures. The sequence of I PREPARE makes intuitive sense by cueing the provider to ask specific questions and provide educational materials to the patient. National improvements in the quality of environmental exposure history data are predicated in part on the creation of simple and convenient tools for use in clinical practice.     

An educational intervention as decision support for menopausal women

The purpose of this study was to develop and test a decision support intervention (DSI) to assist women to make and act on informed decisions that are consistent with their values in the area of menopause and hormone replacement therapy (HRT). Mode and intensity of intervention were tested in midlife women (N 5 248), randomly assigned to one of three intervention formats: written information only, guided discussion, or personalized decision exercise. Data were collected over 12 months. Knowledge, decisional conflict, satisfaction with health care provider, and self-efficacy improved following intervention and were maintained for 12 months for all groups. Women's adherence to their own plans over 12 months was 59% (exercise), 76% (calcium intake), and 89% (HRT). Carefully written information is effective in promoting knowledge, adherence, and satisfaction among well-educated, interested women. It was concluded that women can understand complex information, including tradeoffs regarding treatment options. Women will adhere to their own plans, suggesting that consumer rather than provider plans may be the more appropriate gold standard for measuring adherence. © 1997 John Wiley & Sons, Inc. Res Nurs Health 20: 377–387, 1997     

What women wish they knew before prophylactic mastectomy

Although prophylactic mastectomy significantly reduces the incidence and recurrence of breast cancer, little is known about women's information needs before the procedure. We surveyed 967 women, from 6 healthcare systems, with bilateral or contralateral prophylactic mastectomy performed between 1979 and 1999. There were 2 open-ended questions: "What one thing do you wish you had known before your prophylactic mastectomy" and "Is there anything else you would like to share with us?" Three researchers categorized responses, and informational needs were ascertained. Seventy-one percent (684 women) responded, of which 81% answered one or both open-ended questions. There were 386 comments (made by 293 women) that related to information needs; 79% of women had bilateral prophylactic mastectomy and 58% had contralateral prophylactic mastectomy. Most concerns (69%) were related to reconstruction: the longevity; look and feel of implants, pain, numbness, scarring, and reconstruction options. Many women wished they had seen photographs to better prepare them for the final result. Our findings suggest that information needs of many women undergoing prophylactic mastectomy, particularly those selecting bilateral prophylactic mastectomy, have not been sufficiently addressed. Clinicians and health educators should be aware of patient needs and must counsel women accordingly.     

Estrogen, SERM

Osteoporosis is uncommon before menopause and dramatically increases in prevalence thereafter. That is why estrogens provide protection against osteoporosis. Studies of women receiving estrogen replacement have demonstrated improvements in bone mineral density (BMD) as well as endothelial function. Recent randomized trials, however, have produced equivocal results and raised questions about whether combined hormonal replacement therapy (HRT) prevents later cardiovascular events. Investigations of alternatives to HRT have suggested that selective estrogen receptor modulators (SERMs) may confer cardiovascular and osteoporosis protection. Raloxifene is a second-generation SERM used for the prevention and treatment of postmenopausal osteoporosis. Raloxifene decreases the incidence of vertebral fractures by 30-50% in postmenopausal women with osteoporosis. We also studied its effect on postmenopausal elderly women with osteoporosis.     

Documentation of preventive education and screening for osteoporosis

The purpose of this study was to identify provider documentation practices related to osteoporosis prevention and screening for women aged 40 to 65 years and to determine whether documentation practices differ by type of provider. The setting was an obstetric/gynecologic clinic of a large metropolitan health maintenance organization in Minnesota. One hundred fifty medical records were reviewed for documentation addressing calcium intake, vitamin D intake, exercise, hormone replacement therapy (HRT), and bone mineral densitometry. A statistically significant difference was found between physicians and advanced practice nurses in the documentation of vitamin D and HRT as osteoporosis prevention strategies. The results of this study suggest a need for increased awareness on the part of providers about the importance of their comprehensive documentation of counseling and education interventions as one strategy to promote positive outcomes such as osteoporosis prevention.     

Risk of hormone replacement therapy in stroke patients

Hormone replacement therapy (HRT) (oestrogen with or without progestin) is often initiated with the onset of menopause to decrease symptoms of oestrogen deficiency, such as vasomotor instability (hot flashes) and urogenital effects ( 1 2 3 ). HRT can also prevent long‐term consequences of oestrogen deficiency, such as osteoporosis and cardiovascular disease ( 1 2 3 ). The decision to start HRT in peri‐ and postmenopausal women is complicated by concerns of increased risk for thromboembolic events, uterine cancer and breast cancer ( 2 3 4 ). Thromboembolic stroke is a particular concern due to its association with the use of oral contraceptives with high oestrogen content ( 3 , 4 ). However, for older women it has been suggested that HRT use decreases or has no effect on stroke risk ( 5 6 7 8 9 ). Should these findings apply to a women with a history of thromboembolism, in this case ischemic stroke?     

Indications for hormone replacement therapy

Postmenopausal primary ovarian insufficiency may lead to the clinical picture of the climacteric syndrome and to metabolic changes inducing specific diseases due to oestrogen deficiency. In symptomatic states of oestrogen deficiency, Hormone Replacement Therapy (HRT) is indicated for therapeutic reasons. If there is an increased risk for osteoporosis, for cardiovascular diseases or for Alzheimer's Disease, the preventive administration of HRT has to be discussed. In the combined presence of an increased metabolic risk and of subjective symptoms, HRT is still the best choice. Recent alternatives to classical HRT are Tibolone and, in the later postmenopause, Raloxifene. Incorrect media reports lead to insecurity and to concerns about the use of sexual steroids after menopause. HRT can be accompanied by a small weight increase of 200-500 g. However, more important in most women is the normal trend to weight gain in the 40s and 50s. HRT does not increase blood pressure. If there are some hints for an abnormal coagulation system in the personal or family history of a patient, thrombophilia should be excluded before the begin of HRT. The risk to have an endometrial carcinoma during HRT is not increased, but endometrial cancers are more frequent with unopposed estrogen administration. The incidence of breast cancer increases continuously with ageing. If 1000 women start HRT at the age of 50 and continue for five years, two more cases of breast cancer are diagnosed within the next 20 years. This small increase of morbidity is not accompanied by an increased mortality due to breast cancer: mortality does not change. The data available today show a clear decrease of total mortality up to the age of 75 years in women using oestrogens and speak in favour of HRT. If HRT is used for less than five years, cancer risk is not increased. The gain in Life Quality primes significantly. For the indication of long term HRT, the risks and benefits have to be evaluated individually.     

Menopause medicine: current treatment options and trends.

Demographic trends and increasing demand, as well as the intricacy of the emerging field of menopause medicine, dictates the need for a multidisciplinary approach for the care of the peri- and postmenopausal patient. A menopausal program benefits the individual patient by obviating the acute symptoms and by preventing long-term consequences. As morbidity and mortality rates associated with the long-term implications are reduced, substantial public health aspects are also beneficially affected. Cost effectiveness of a menopause program and routine HRT should be calculated as the net present value (NPV) for the health care financing program, and should prove to be greater than the NPV of future costs anticipated without an investment in primary preventive menopause program. We believe that the educated use of a menopause counseling program will yield an increasing benefit for the individual patient and the community. Should menopause be regarded as an endocrinopathy, thus justifying routine HRT, or are we engaged in the "medicalization" of a physiologic process? Bearing in mind the data reviewed above, it seems to us that ample reason exists to make every woman aware of the opportunity to receive long-term HRT. The decision to use it depends heavily on the patient's own informed assessment of her particular benefit-risk equation. Combined-continuous estrogen-gestagen replacement seems to provide the desired multisystem beneficial effects, and at the same time be the most convenient and associated with the least short-term side effects. Although emerging trends regarding the long-term risks associated with the use of such regimes are reassuring, more information needs to be elaborated before final conclusions can be offered.     

Designer estrogen vs. hormone replacement therapy: the menopausal woman's dilemma

Although hormone replacement therapy (HRT) has many proven health benefits for postmenopausal women, relatively few women are taking advantage of this option. A major reason for this is lack of understanding by women of the benefits and risks of using HRT. Additionally, many women are uninformed about "designer estrogens," more correctly known as Selective Estrogen Receptor Modulators (SERMs), as an alternative approach to the use of esrogen. One of the major challenges of contemporary nursing is to help women maintain optimum health and enjoy a high quality of life after menopause. One aspect of managing menopausal health is an understanding of the hormonal options available to women. The purpose of this article is to present a synthesis of information comparing HRT and SERMs so that the reader can help his/her clients make informed choices about replacement therapy.