Highlights
- •The conceptual framework of the Healthy Menopause and Ageing is a holistic model of care incorporating disease and disability.
- •Healthcare model’s core: lead clinician, specialist nurse, patient, interdisciplinary network of health and allied health professionals.
- •Provision of specialist teams in Europe needs to be expanded, as the number of women (“baby-boomers”) currently reaching menopause is increasing.
- •Accreditation of the subspecialty Women’s Health should be actively promoted.
Abstract
Worldwide, the number of menopausal women is increasing. They present with complex medical issues that lie beyond the traditional scope of gynaecologists and general practitioners (GPs). The European Menopause and Andropause Society (EMAS) therefore provides a holistic model of care for healthy menopause (HM). The HM healthcare model’s core consists of a lead clinician, specialist nurse(s) and the woman herself, supported by an interdisciplinary network of medical experts and providers of alternative/complementary medicine. As HM specialist teams are scarce in Europe, they are also responsible for structuring and optimizing processes in primary care (general gynaecologists and GPs) and secondary care (HM specialists). Activities for accreditation of the subspecialty Women’s Health are encouraged.
Keywords
1. Introduction
The menopause can now be considered to be a mid-life event as the lifespan of women continues to increase in developed countries [
[1]
]. By the year 2025, the number of postmenopausal women is expected to rise to 1.1 billion worldwide. Although not all women will experience short- or long-term problems of menopause, the high prevalence of hot flushes [World Health Organization. http://www.who.int/whr/1998/media_centre/press_release/en/index3.html. (accessed 05.06.16).
2
, 3
] and vaginal atrophy [2
, 4
], which can last for many years, as well as osteoporosis (1 in 3 women are at risk of an osteoporotic fracture) [[5]
], makes caring for ageing women a key issue for health professionals.International Osteoporosis Foundation. http://www.iofbonehealth.org/facts-statistics-category-22 (accessed 05.06.16).
The European Menopause and Andropause Society (EMAS) aims to provide holistic consensus advice on the management of menopausal women through its position statements and clinical guides [
[6]
]. This position statement intends to provide a model of care for (healthy) ageing menopausal women.2. Concept of healthy ageing and healthy menopause
Health and disease can be conceptualized as a continuum, reflected by a dynamic balance between faced demands and an individual’s capacity to adapt physiologically, psychologically and socially. That concept incorporates physical, mental and social functioning, which differs between individuals and changes due to ageing [
[7]
]. Healthy ageing includes survival to old age, delay in the onset of non-communicable diseases (NCDs) and optimal functioning for a maximal period at individual levels of body systems and cells. The conceptual framework of Active and Healthy Ageing (AHA) [[8]
] incorporates items such as functioning (individual capability and underlying body systems), wellbeing, activities and participation, and diseases, including NCDs. Signs of impaired function may act as markers of failure to reach developmental potential (“health resources”), accelerated ageing or underlying disease processes, and offer opportunities for early intervention [[9]
]. Furthermore, markers of function and wellbeing above average (“health strengths”) may act as guidance for successful and sustainable interventions to reach best age- and lifestyle-related health status in an individual or epidemiological approach.The conceptual framework of the Healthy Menopause (HM) [
[7]
] breaks the AHA concept down to menopause regardless of when and why menopause occurs. Herein, HM is defined as a dynamic state, following the permanent loss of ovarian function, characterized by self-perceived satisfactory physical, psychological and social functioning, incorporating disease and disability as well as a woman’s desired ability to adapt and capacity to self-manage. Thus, HM incorporates both obtained and developed resources aiming to maintain, revisit, adjust, recover and improve that dynamic balance. Most importantly, the conceptual HM framework encompasses women as a whole, beyond their hormonal, reproductive and physiological health.3. Evidence of what women want
Women’s conceptions of the menopausal transition are individual and incorporate both physical and psychological symptoms. However, the menopausal transition has also been described, in a more holistic view, as a natural process affected by endocrine and lifestyle factors, the psychological situation and ageing per se [
[10]
]. Ethnic and sociodemographic differences in menopausal symptom management have been observed. A US study [[11]
] found that white women tended to focus on specific symptoms by seeking help through formal healthcare systems, but ethnic minorities approached their symptoms more holistically, by seeking help through their family members and friends. Thus, medication for menopausal symptom relief was a first step for white women and a final step for ethnic minorities. Moreover, attitudes towards the menopausal transition may differ between women and their physicians [[12]
]. Thus, awareness and identification of women’s different perspectives are crucial for healthcare professionals, as consultations regarding menopause-related matters constitute a significant part of the workload [[13]
].Despite the omnipresence of all kinds of media, there is a lack of knowledge among women regarding menopause, treatment options and possible risks associated with menopausal hormone therapy (MHT) [
14
, 15
, 16
], making informed decisions difficult for individual women. Furthermore, some women may feel completely ignored by their healthcare providers [[17]
]. Thus, first of all, women want their healthcare providers to start listening to what they report [[17]
]. Secondly, women want clear, evidence-based information about the various hormonal and non-hormonal treatment options [16
, 18
, 19
, 20
, 21
]. In addition, they want to discuss and seek help for non-vasomotor menopause-related symptoms, such as weight gain, sleep disturbance, tiredness, moodiness, low sexual desire and dyspareunia [[22]
].4. Current healthcare provision for menopausal women
Although in women aged 45–64 years, the prevalence and incidence of at least once menopause-related consultation has been reported to have fallen from 18.1% in 1996 to 10.4% in 2005 [
[13]
], menopause remains an important part of general practice work, especially when facing the increasing number of women (“baby-boomers”) currently reaching menopause. This is in stark contrast to the poor specialized training most GPs and gynaecologists receive in post-reproductive healthcare. For them (and others), international scientific societies have provided numerous clinical standards and guidelines on treatment of menopausal symptoms, including the International Menopause Society (IMS) [[23]
], EMAS [24
, 25
, 26
, 27
], Endocrine Society [19
, 28
], North American Menopause Society (NAMS) [29
, 30
, 31
, 32
] and NICE [[33]
]. EMAS has also provided recommendations on the management of menopausal women with comorbidities such as cardiovascular disease [National Institute for Health and Care Excellence (NICE). Menopause: diagnosis and management (NG23). November 2015. https://www.nice.org.uk/guidance/ng23/resources/menopause-diagnosis-and-management-1837330217413. (accessed 12.05.16).
34
, 35
], osteoporosis [36
, 37
, 38
, 39
], obesity [40
, 41
], endometriosis [[42]
], lichen sclerosus [[43]
] and epilepsy [[44]
]. Despite the many recommendations available, an electronic survey of UK GPs found that the majority lacked confidence in effectively managing peri- and postmenopausal women [[45]
]. Similarly, trainees in obstetrics and gynaecology have been shown to be insufficiently qualified for post-reproductive bone healthcare (Switzerland) [- Wilkinson J.F.
- Short H.L.
- Wilkinson S.
- Mander A.
Commissioning for menopause specialist services: a local perspective: an internet-based survey to assess the potential demand for menopause care in West Cheshire and the skills of local primary care clinicians in this field, with a view to informing future commissioning locally.
Post Reprod. Health. 2015; 21: 98-104
[46]
], sexual healthcare (UK) [[47]
] and core menopause topics (USA) [- Gleser H.
Sex women and the menopause: are specialist trainee doctors up for it? A survey of views and attitudes of specialist trainee doctors in community sexual & reproductive health and obstetrics & gynaecology around sexuality and sexual healthcare in the (peri)menopause.
Post Reprod. Health. 2015; 21: 26-33
[48]
]. These findings are not surprising given the rapid changes in opinion on the benefits and risks of MHT during the past decade, which has caused confusion among healthcare providers and women. To counter this deficit in knowledge, a 2-year formal menopause medicine curriculum introduced to trainees in obstetrics and gynaecology in the USA has been shown to significantly improve their knowledge and self-assessed competency in core menopause topics [[48]
].5. Healthcare model for a healthy menopause
The conceptual HM framework [
[7]
] is a holistic model of care covering physical, psychological and social functioning. It also reflects the need of midlife women to at least maintain if not improve their (health-related) quality of life (QoL), which is now an integral component of contemporary healthcare [[49]
].The HM concept incorporates disease and disability, thereby targeting a healthy menopause for every woman regardless of her comorbidities. The latter is of tremendous significance, as the prevalence of (multiple) chronic medical conditions has been shown to increase dramatically in midlife women within a short period of time. Thus, the more conditions a woman develops, the greater reduction in health-related QoL will she experience [
[50]
].Obviously, this holistic approach in the management of menopausal women, also recommended by the FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health [
[51]
], requires a less traditional model of healthcare provision.Here we provide an integrated healthcare model for HM. The main goals are healthcare and health promotion for midlife women and empowerment of women to make positive choices for their post-reproductive health and wellbeing. The HM healthcare model’s core is the triangle consisting of: 1) a lead clinician (gynaecologist, sexual and reproductive health specialist or GP with special interest) who holds appropriate national qualifications or other recognized certificates, with support from other appropriately qualified clinicians to cover for training, leave and other absences; 2) (a) specialist nurse(s) who can run independent clinics supported by the clinicians; and 3) the woman herself. The triangle’s objective is to set up a personalized care plan for a woman’s short-, mid- and long-term goals in the context of physical, psychological and social functioning, incorporating the woman’s perception of her life status within her culture and value system, expectations, concerns and opinions about endocrine and age-related physical and psychological changes related to midlife. Lead clinicians should provide specialist expertise that is both comprehensive and integrated for the care of the midlife female, as detailed in Table 1 [
52
, 53
].FMH Swiss Medical Association. http://www.fmh.ch/files/pdf17/reproduktionsmedizin_version_internet_d.pdf (accessed 05.06.16).
Table 1Overview of healthcare provider skills., adapted from the HM healthcare model
[52]
.| Clinical skills | Procedural skills |
|---|---|
|
|
|
|
|
|
|
|
|
|
| |
| |
| |
| |
| |
| |
| |
| |
| |
|
The specialist nurse(s) should provide and/or support strategies for empowerment in relation to educational interventions, physical activity/exercise, healthy diet, stress management, healthy lifestyle, and prevention of (non-)communicable diseases [
[54]
].Beyond the HM healthcare model’s core, the triangle, there is an interdisciplinary network providing backup medical expertise for the most frequent medical conditions and disabling diseases in developed countries [
[55]
] (Table 2). Referral pathways should be short, transparent and well structured.Table 2Network of medical disciplines supporting the HM healthcare model.
| Most frequent non-communicable diseases/conditions in midlife women (modified according to [55] ) | Network of medical disciplines |
|---|---|
| Ischaemic heart disease | Cardiology |
| Chronic low back pain, neck pain | Orthopaedics, anaesthesiology |
| Stroke | Neurology |
| Musculoskeletal diseases | Rheumatology, orthopaedics, physiotherapy |
| Cancer | Oncology, surgery |
| Depression | Psychiatry, psychology |
| Diabetes mellitus | Endocrinology, nutrition medicine |
| Chronic respiratory disease | Respiratory medicine |
| Dementia | Radiology |
| Laboratory medicine | |
| Pathology, microbiology |
This interdisciplinary network of medical specialists may be complemented by additional healthcare providers from the alternative/complementary medicine field, such as physiotherapy, osteopathy, chiropractic, naturopathic treatment, homeopathy and traditional Chinese medicine. A medical specialist team dedicated to the HM healthcare model should follow standard quality criteria and receive internationally acknowledged quality management certification from bodies such as the International Organization for Standardization (www.iso.org) or the European Foundation for Quality Management (www.efqm.org).
6. Translating the HM healthcare model into practice
In most European countries, post-reproductive gynaecological care is delivered either by GPs or by general gynaecologists. Only women with complex issues or who fail to respond to treatment are referred to specialist services (secondary care). However, across Europe dedicated specialist health service provision is scant. Until women’s healthcare (including menopause healthcare) is accredited as a medical subspecialty it will not receive sufficient support from healthcare authorities and governments. Thus the proposed multifaceted HM healthcare model will remain split into primary and secondary care (Fig. 1).
Fig. 1Healthcare model for Healthy Menopause (HM).
The HM healthcare model’s core consists of a lead clinician, specialist nurse(s) and the woman herself, supported by an interdisciplinary network of medical experts and providers of alternative/complementary medicine (secondary care). The HM specialist team is responsible for structuring and optimizing processes in primary HM care (GPs and general gynaecologists) and for education (including web-based interventions such as the Webinars provided by EMAS) of primary care physicians and laypersons, and should play an active role in scientific societies and during negotiations with healthcare authorities.
The HM specialist team is also responsible for structuring and optimizing processes in primary and secondary HM care. Each health authority/region should have a dedicated HM medical specialist team. Therefore the major resource implication is in funding and supporting a specific clinical team outside routine gynaecological services. Patient flow needs to be regularly mapped so that bottlenecks can be identified and dealt with within established referral timescales. Time needs to be made available in job plans so that members of the HM medical specialist team can regularly undertake teaching in primary care. In that way, rather than services being provided by unregulated non-medical professional groups, evidence-based care can be provided by trained health and allied health professionals [
[56]
]. Thus, accreditation of the subspecialty Women’s Health should be a political goal, as it will create national academic leaders qualified to run interdisciplinary Women’s Health Centres, improving holistic clinical care [51
, 52
].7. Conclusions and recommendations
- •The conceptual framework of the Healthy Menopause (HM) is a holistic model of care covering physical, psychological and social functioning and incorporating disease and disability. It encompasses women as a whole, beyond their hormonal, reproductive and physiological health.
- •The HM healthcare model aims to translate the HM framework into practice.
- •The HM healthcare model’s core consists of a lead clinician, specialist nurse(s) and the woman herself, supported by an interdisciplinary network of medical experts and providers of alternative/complementary medicine.
- •Provision of HM specialist teams in Europe is scant and needs to be expanded, as the number of postmenopausal women is increasing.
- •HM medical specialist teams should follow standard quality criteria and receive internationally acknowledged quality management certification.
- •Accreditation of the subspecialty Women’s Health should be actively promoted.
Conflict of interest
P. Stute: In the past year Dr. Petra Stute has received grants/research support from Medinova AG and Dr. Kade/Besins Pharma GmbH, consulting fees from Max Zeller Söhne AG, Madaus GmbH, and speakers honoraria from MSD Merck Sharp & Dohme AG, Dr. Kade/Besins Pharma GmbH and Max Zeller Söhne AG.
I. Ceausu: None declared.
H. Depypere: None declared.
I. Lambrinoudaki: None declared.
A. Mueck: None declared.
F. R. Perez-Lopez: None declared.
Y. T. van der Schouw: None declared.
L. M. Senturk: None declared.
T. Simoncini: None declared.
J. C. Stevenson: In the past year Dr John C. Stevenson has received grants/research support from Abbott, consulting fees from Abbott and Mylan, and speakers honoraria from Abbott, Bayer and Mylan.
M. Rees: In the past year Dr Margaret Rees has received consulting fees from Metagenics.
Contributors
Petra Stute prepared the initial draft, which was circulated to EMAS board members for comment and approval; production was coordinated by Irene Lambrinoudaki and Margaret Rees.
Funding
No funding was received for the preparation of this position statement.
Provenance and peer review
This article is an EMAS position statement and was not externally peer reviewed.
References
World Health Organization. http://www.who.int/whr/1998/media_centre/press_release/en/index3.html. (accessed 05.06.16).
- The impact and management of symptoms experienced at midlife: a community-based study of women in northeast Scotland.BJOG. 2012; 119: 554-564
- Duration of menopausal vasomotor symptoms over the menopause transition.JAMA Intern. Med. 2015; 175: 531-539
- Writing group of as: vaginal atrophy of women in postmenopause. Results from a multicentric observational study: the AGATA study.Maturitas. 2016; 83: 40-44
International Osteoporosis Foundation. http://www.iofbonehealth.org/facts-statistics-category-22 (accessed 05.06.16).
- EMAS position statements and clinical guides.Maturitas. 2014; 77: 303-304
- Health in middle-aged and elderly women: a conceptual framework for healthy menopause.Maturitas. 2015; 81: 93-98
- A life course approach to healthy ageing.Oxford, 2014
- The european innovation partnership on active and healthy ageing: the european geriatric medicine introduces the EIP on AHA column.Eur. Geriatr. Med. 2014; 5: 361-362
- Women's conception of the menopausal transition–a qualitative study.J. Clin. Nurs. 2007; 16: 509-517
- Symptom-specific or holistic: menopausal symptom management.Health Care Women Int. 2012; 33: 575-592
- Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries.Post Reprod. Health. 2016; (pii: 2053369116632439. [Epub ahead of print])
- Menopause-related workload in general practice 1996–2005: a retrospective study in the UK.Fam. Pract. 2010; 27: 499-506
- Menopause: knowledge, attitude and practice among Italian women.Maturitas. 2009; 63: 246-252
- The Asian menopause survey: knowledge, perceptions, hormone treatment and sexual function.Maturitas. 2010; 65: 276-283
- Women's attitudes to hormone replacement therapy, alternative therapy and sexual health: a web-based survey.Menopause Int. 2007; 13: 79-83
- Menopausal symptom experience: an online forum study.J. Adv. Nurs. 2008; 62: 541-550
- Healthcare seeking and treatment for menopausal symptoms in the United States.Maturitas. 2007; 58: 348-358
- Treatment of symptoms of the menopause: an endocrine society clinical practice guideline.J. Clin. Endocrinol. Metab. 2015; 100: 3975-4011
- Hormone therapy dose, formulation, route of delivery, and risk of cardiovascular events in women: findings from the Women's Health Initiative observational study.Menopause. 2014; 21: 260-266
- Menopause management–getting clinical care back on track.N. Engl. J. Med. 2016; 374: 803-806
- What midlife women want from gynecologists: a survey of patients in specialty and private practices.J. Womens Health (Larchmt). 2014; 23: 513-518
- IMS Recommendations on women's midlife health and menopause hormone therapy.Climacteric. 2016; 2016: 109-150
- EMAS position statement: the ten point guide to the integral management of menopausal health.Maturitas. 2015; 81: 88-92
- EMAS position statement: non-hormonal management of menopausal vasomotor symptoms.Maturitas. 2015; 81: 410-413
- EMAS clinical guide: low-dose vaginal estrogens for postmenopausal vaginal atrophy.Maturitas. 2012; 73: 171-174
- Maintaining postreproductive health: a care pathway from the European Menopause and Andropause Society (EMAS).Maturitas. 2016; 89: 63-72
- Androgen therapy in women: a reappraisal: an Endocrine Society clinical practice guideline.J. Clin. Endocrinol. Metab. 2014; 99: 3489-3510
- The 2012 hormone therapy position statement of: the north american menopause society.Menopause. 2012; 19: 257-271
- The North American Menopause Society statement on continuing use of systemic hormone therapy after age 65.Menopause. 2015; 22: 693
- Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society.Menopause. 2015; 22: 1155-1174
- The North American Menopause Society recommendations for clinical care of midlife women.Menopause. 2014; 21: 1038-1062
National Institute for Health and Care Excellence (NICE). Menopause: diagnosis and management (NG23). November 2015. https://www.nice.org.uk/guidance/ng23/resources/menopause-diagnosis-and-management-1837330217413. (accessed 12.05.16).
- EMAS position statement: managing menopausal women with a personal or family history of VTE.Maturitas. 2011; 69: 195-198
- EMAS position statement: managing the menopause in the context of coronary heart disease.Maturitas. 2011; 68: 94-97
- EMAS position statement: vitamin D and postmenopausal health.Maturitas. 2012; 71: 83-88
- EMAS position statement: bone densitometry screening for osteoporosis.Maturitas. 2011; 68: 98-101
- EMAS position statement: the management of postmenopausal women with vertebral osteoporotic fracture.Maturitas. 2014; 78: 131-137
- EMAS clinical guide: selective estrogen receptor modulators for postmenopausal osteoporosis.Maturitas. 2012; 71: 194-198
- EMAS position statement: managing obese postmenopausal women.Maturitas. 2010; 66: 323-326
- EMAS position statement: diet and health in midlife and beyond.Maturitas. 2013; 74: 99-104
- EMAS position statement: managing the menopause in women with a past history of endometriosis.Maturitas. 2010; 67: 94-97
- EMAS clinical guide: vulvar lichen sclerosus in peri and postmenopausal women.Maturitas. 2013; 74: 279-282
- EMAS position statement: managing the menopause in women with epilepsy.Maturitas. 2010; 66: 327-328
- Commissioning for menopause specialist services: a local perspective: an internet-based survey to assess the potential demand for menopause care in West Cheshire and the skills of local primary care clinicians in this field, with a view to informing future commissioning locally.Post Reprod. Health. 2015; 21: 98-104
- Gynaecologists' awareness of bone healthcare in Switzerland.Swiss Med. Wkly. 2014; 144: w13931
- Sex women and the menopause: are specialist trainee doctors up for it? A survey of views and attitudes of specialist trainee doctors in community sexual & reproductive health and obstetrics & gynaecology around sexuality and sexual healthcare in the (peri)menopause.Post Reprod. Health. 2015; 21: 26-33
- Effectiveness of a 2-year menopause medicine curriculum for obstetrics and gynecology residents.Menopause. 2016; 23: 275-279
- Impact of hormone therapy on quality of life after menopause.Menopause. 2013; 20: 1098-1105
- Newly developed chronic conditions and changes in health-related quality of life in postmenopausal women.J. Am. Geriatr. Soc. 2015; 63: 2349-2357
- FIGO committee for ethical aspects of human reproduction and women's health. Ethical issues in women's post-reproductive lives.Int. J. Gynaecol. Obstet. 2015; 128: 189-190
- Update: a review of women's health fellowships, their role in interdisciplinary health care, and the need for accreditation.J. Womens Health (Larchmt). 2015; 24: 336-340
FMH Swiss Medical Association. http://www.fmh.ch/files/pdf17/reproduktionsmedizin_version_internet_d.pdf (accessed 05.06.16).
- Empowerment and coping strategies in menopause women: a review.Iran. Red Crescent. Med. J. 2015; 17: e18944
- Health issues for menopausal women: the top 11 conditions have common solutions.Maturitas. 2015; 80: 24-30
- Niche markets: filling gaps with expertise, ingenuity.Consult. Pharm. 2015; 30: 434-442
Article Info
Publication History
Published online: July 08, 2016
Identification
Copyright
© 2016 Elsevier Ireland Ltd. All rights reserved.
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