US Pharm. 2007;1:73-76.

Many women are uncomfortable discussing menopause, which involves a variety of sensitive issues. During early menopause, women may experience anxiety, depression, weight gain, sexual dysfunction, and stress incontinence, all of which can be difficult to discuss. Women often refer to this stage in life as "the change," because they associate it with a loss of fertility and youth. Many women have difficulty sharing their concerns with and seeking advice from a health care professional. This article provides pharmacists with strategies for engaging women in conversations about menopause and for addressing women's concerns regarding this transition. 

Symptoms of Menopause
Menopause is defined as the absence of menstruation for 12 consecutive months with no underlying secondary cause of amenorrhea. In the United States, the average age at menopause is 51.4; however, many women begin experiencing hormone fluctuations in their early 40s. During this transition, referred to as perimenopause, women often observe changes in their menstrual pattern. They might notice that their menstrual flow lasts longer than usual, sometimes exceeding seven days and resulting in a shortened length of time between periods. At other times, they might skip one or more menstrual periods and experience amenorrhea for 60 days or longer before their cycle resumes. This often continues until the patient has her final menstrual period (FMP).^1,2

Menopause is associated with a drop in estrogen production. Because estrogen receptors are located throughout the body, women can develop a number of different symptoms during menopause ( Table 1).^3,4 The pattern of symptoms varies from woman to woman.

The most common complaint is vasomotor symptoms, which include hot flashes and night sweats. Vasomotor symptoms are estimated to occur in 68% to 93% of menopausal women and are often most severe in the first five years after the FMP. Hot flashes and night sweats can cause disrupted sleep, daytime sedation, chronic fatigue, and decreased quality of life. More than 50% of women who seek medical care for menopause do so because of the severity of vasomotor symptoms. Therefore, this symptom appears to be the one that patients find easiest to discuss.

Another symptom of menopause that significantly impacts quality of life is physical changes in the urogenital system. Decreased estrogen concentrations result in a thinning of the epithelial lining of the urethra and vagina, with a corresponding reduction of collagen and adipose tissue in the vulvar region. These changes cause many women to experience urinary frequency, urgency, and stress incontinence. Some women might have an increased propensity for urinary tract infections. Vaginal atrophy also can result in vaginal burning, itching, and discomfort. Other symptoms associated with these changes include less vaginal lubrication, decreased libido, dyspareunia, vaginal tears, and postcoital bleeding, which can lead to sexual dysfunction (e.g., difficulty with arousal and/or responsiveness during sexual intercourse). Sexual dysfunction can negatively impact personal relationships and lead to discord, anxiety, de­pression, and decreased quality of life.³ Urogenital symptoms (especially sexual dysfunction) are probably the most sensitive topic of conversation for menopausal women. Many find it embarrassing to talk about these problems even with their spouse, and without such dialogue, either partner can end up feeling unattractive or undesirable.

During menopause, women might also present with an alteration in mood. Affective symptoms include sadness, irritability, crying spells, and feelings of despair, loneliness, isolation, and worthlessness, as well as decreased interest in daily activities. Some women might also experience somatic symptoms such as altered sleep patterns (i.e., either insomnia or hypersomnolence), changes in appetite that result in either weight gain or loss, or increased fatigue and lethargy, while other women might report impaired concentration, memory, and cognition.⁴ All of these symptoms can interfere with relationships and lead to decreased quality of life. Many women do not associate these problems with meno­ pause or recognize that hormone fluctuations might be the culprit for these problems. As women might not initiate a dialogue about these changes in mood with a health care professional, it is important for health care providers to initiate conversations about menopause-associated mood alterations with women.

As a result of alterations in hormone levels following meno­ pause, women may also experience cosmetic changes such as loss of collagen in the skin and less skin elasticity. Women may notice a visible change in skin thickness, and the skin might appear more thin and transparent. They may also notice an increase in keratosis (age spots), especially on skin surfaces that are frequently exposed to sunlight. Many women notice a change in hair growth and develop hirsutism, perhaps on the lip, chin, or cheeks, as well as on other ana­ tomical regions. Due to decreased skin elasticity, some women develop breast atrophy and drooping. In addition, some women experience weight gain, loss of muscle mass, and alterations in body fat distribution.³ Women can find these cosmetic changes distressing and become self-conscious about their bodies. Some women may develop body dysmorphic disorder, depression, or anxiety.

In addition to the above mentioned acute symptoms, menopausal women also face health risks associated with estrogen deficiency. Menopause can increase the risk of osteoporosis and heart disease. Following menopause, women are more likely to develop age-related diseases. Many women will realize they have passed the youthful stage of being relatively "bullet proof" when it comes to their health, and some might require their first prescription medication for a chronic health condition. All of these changes can be very stressful.

As demonstrated, menopause can negatively impact a patient's quality of life. Women are often self-conscious about the changes occurring within their body. They might be shy or embarrassed about talking about their health concerns. Therefore, it is important for the pharmacist to be sensitive, responsive, attentive, and professional when communicating with women who are experiencing menopausal symptoms.

The Patient Interview
Pharmacists should seek opportunities to engage women who may be experiencing perimenopause or menopause in a dialogue concerning  symptoms. They can watch for cues; for instance, some women will make subtle comments about hot flashes. Others might approach a pharmacist for recommendations concerning vaginal lubricants, herbal supplements, or multivitamin formulas to help manage menopausal symptoms. Some women might seek information concerning the pros and cons of hormone replacement therapy (HRT). Pharmacists providing medication therapy management services have the opportunity to explore the reproductive status of the female patient and to screen for any symptoms of menopause when collecting her medical history, performing laboratory tests (e.g., blood pressure, lipids, bone minderal density), and conducting a review of systems.

When initiating dialogue about menopause with a female patient, it is important to consider the setting of the interview. As with all sensitive health topics, it is imperative to identify a private counseling area where the patient will feel comfortable discussing personal health issues. This helps promote open communication. The patient should feel that she has the pharmacist's full attention and be confident that she will not be overheard, judged, or interrupted during the exchange.

Next, the pharmacist should be aware of his or her body language when discussing sensitive health topics with a patient. He or she should project confidence and competence by being clinically well prepared to provide pharmaceutical care to the patient. A lapse in knowledge can cause a dip in confidence, which may cause the patient to be reluctant to communicate. Additionally, pausing, stuttering, looking away, or flushing because of an inability to think of what to ask or say next can leave the patient with the impression that the pharmacist is uncomfortable with the topic. Therefore, mental or written outlines can be useful tools for guiding discussion.

During the interview, the pharmacist should maintain eye contact with the patient. Leaning slightly toward the patient will let her know that you are listening closely and are interested in what she is saying. Notes should be taken during pauses in the interview but not while the patient is talking. The pharmacist should let the patient know up front that he or she intends to take some notes but should also keep in mind that because it can be difficult for the patient to be open and honest about her concerns, writing while she is talking may make her feel that her concerns are not being heard or taken seriously. The pharmacist should ask open-ended questions, encourage thoughtful responses by asking probing follow-up inquiries, and make reflective, nonjudgmental statements (e.g., "You have found many of these changes to be distressing").

One of the first factors that should be addressed is the woman's reproductive stage. Is she premeno­ pausal or postmenopausal? If the woman's age or menopausal status is unknown, asking if she has experienced menopause can lead to awkwardness and embarrassment for both parties if she merely appears older than her actual age. Therefore, it is better to ask, "Are you having menstrual periods every month?" Posing the question this way as­ sumes the patient is having normal menstruation and allows the patient to elaborate on her menstrual cycle. If the patient says no, follow up with probing questions such as:

• How often do you menstruate?
• How many days does each period last?
• How many days lapse from the start of one period to the start of the next?
• Do you experience heavy or light flow?
• When was your last menstrual period?
• Is there any likelihood that you are pregnant?
• Have you had a hysterectomy? If so, was one or both ovaries removed? Was the cervix removed? How long ago was the procedure?

The patient's responses to these questions will help guide follow-up questions and establish her reproductive history. If a woman has recently developed amenorrhea, the pharmacist should recommend an appointment with the woman's doctor for further evaluation. She might need testing to rule out pregnancy, hypothyroidism, hyperprolactinemia, or other endocrine disorders. In addition, a follicle-stimulating hormone test may be needed to evaluate reproductive status.

If it is confirmed that a woman is experiencing menopause, the pharmacist should explore the pattern of her symptoms and evaluate how they impact her quality of life. Since vasomotor symptoms may be a less sensitive topic than some other menopausal symptoms, it might be advisable to begin by saying, "Many women who experience hormone fluctuations complain of hot flashes and night sweats. Have you noticed any problems with temperature control?" Follow-up questions might include:

• Have you noticed any waves of heat that begin in your scalp and move across your torso?
• Have you experienced any feelings of being hot even when other members of your family are comfortable?
• Have you been adjusting the thermostat to a cooler temperature at home, even though others in your household are cool or cold?
• Have you been wearing lighter clothing while at home because you are often hot and
uncomfortable?
• Have you been awakened at night due to hot flashes and sweating?
• Have you changed the type of covering that you use at night or started kicking off the covers during the night due to sweating?
• Are you sleeping through the night?
• Are you experiencing any daytime fatigue due to sleep disruption?

An open-ended probe such as "describe those symptoms for me" or "describe your sleeping pattern" should follow these questions.

Once a history of vasomotor symptoms has been collected, a treatment plan can be developed. This might include recommending nonpharmacologic interventions such as avoiding hot environments (e.g., whirlpools, saunas), eliminating hot beverages, and avoiding spicy foods. You might also identify a nonprescription alternative for management such as black cohosh or soy isoflavones, or you might refer the patient to a physician for prescription therapy such as HRT, venlafaxine, or clonidine.

Once a rapport has been developed with the patient, more sensitive topics such as urogenital symptoms should be discussed. The pharmacist can ask a number of questions to explore the patient's pattern of symptoms:

• Have you passed urine when you did not intend to, such as when you have coughed, laughed, or sneezed?
• Are you experiencing any vaginal dryness or discomfort?
• Have you noticed any change in your desire for intercourse?
• Are you experiencing intimacy problems with your partner?
• Do you have difficulty with vaginal lubrication?
• Do you have problems reaching climax?
• Do you experience any vaginal bleeding after intercourse?
• Do you experience anxiety when thinking about intercourse?
• Are you experiencing any depression?
• Do you feel sad, blue, or down in the dumps?
• Have you noticed a decreased pleasure in life?
• Are you happy with your sexual partner?
• Do you have a good relationship with your sexual partner?
• When did you first notice sexual dysfunction? Did this problem develop abruptly or gradually?
• Describe the emotions you have felt since your problems with sexual function developed. For instance, do you or your partner have anger about this problem?

It is important to ask the patient to provide descriptive responses to each question. Because many women are hesitant to discuss their sexuality, the pharmacist should observe the patient, try to gauge her comfort level, and paraphrase inquiries as necessary to keep her at ease.

Again, once the pharmacist has collected a history of symptoms, he or she can discuss treatment options with the patient. These might in­ clude Kegel exercises, vaginal lubricants, or other interventions. In ad­ dition, the pharmacist may decide that the patient requires referral to a physician for evaluation and management with systemic HRT or vaginal HRT. If the woman is experiencing intimacy problems, she might benefit from professional counseling. A pharmacist may not be able to address all of the patient's health concerns regarding meno­ pausal symptoms, but he or she can refer the patient to specialists who can properly assist her.

Conclusion
This article provides information that allows pharmacists to initiate dialogues with female patients about a sensitive topic of conversation--menopause. Using the suggested communication strategies, the pharmacist will be able to identify the pattern of a particular patient's symptoms and develop a management plan for that patient.

REFERENCES
1. Menopause Practice: A Clinician's Guide. North American Menopause Society Web site. Available at: www.menopause.org/edumaterials/cliniciansguide/cliniciansguidetoc.htm. Accessed July 12, 2006.
2. Soares CN, Joffe H, Steiner M. Menopause and mood. Clin Obstet Gynecol. 2004;47:576-591.
3. Nachtigall LE, Nachtigall MJ. Menopausal changes, quality of life, and hormone therapy. Clin Obstet Gynecol. 2004;47:485-488.
4. Spinelli MG. Depression and hormone therapy. Clin Obstet Gynecol. 2004;47:428-436.

To comment on this article, contact [email protected].