While I was at the North American Menopause Society (NAMS) conference last month I had the opportunity to have a conversation with Pauline Maki Ph.D.
Dr. Maki is the past-president of NAMS and this year’s Chair of the Scientific Program Committee for NAMS. She is Senior Director of Research, University of Illinois at Chicago Center for Research on Women and Gender as well as a Professor of Psychiatry and Psychology, University of Illinois at Chicago.
Madeleine Burnside: I would like to ask you first about NAMS.
Pauline Maki: The North American Menopause Society is the place where practitioners, physicians, nurses and physician’s assistants go for evidence-based information about how to keep women healthy and maintain their quality of life at midlife and beyond. NAMS is known for having a program that certifies healthcare providers in menopause medicine, and that means they have studied the evidence base and demonstrated their proficiency in it in the exam and they’re ready to practice, and this gives people the opportunity to enter their Zip code onto a webpage and be able to find someone who is certified in menopause medicine. For women that’s probably our biggest service, because there is a lot of evidence that women—particularly symptomatic women who have hot flashes—find that there is a real reluctance and lack of training among healthcare providers in how to treat them either hormonally or non-hormonally and which therapies to recommend, or even to counsel them on what to expect in the course of the natural history of their experience. And so NAMS is the go-to place to help women find providers who can help them navigate this transition, at least for those who need it.
MB I think that’s so important. I had a sort of outlying and negative experience myself, and I spoke with someone along the way who told me that I should really write a book, and so I got serious about it. And then a friend of a friend is Dr Lynnette Leidy Sievert, who is a great advocate for NAMS who’s also broadly culturally based, and that was an interesting way in. How important are other kinds of studies, such as ones that are anthropological?
PM NAMS is unique in its interdisciplinary nature. Of course Lynnette was here, and she talked about cross-cultural differences in women’s experiences of hot flashes. We had an evolutionary psychologist as our keynote speaker today who talked about the evolution of desire. And Dr Ellen B. Gold, from the Study of Women’s Health Across the Nation, is here to discuss the history of menopausal symptoms in women living in the United States. I’m a cognitive neuroscientist and past President of NAMS and I don’t even practice, and was brought in by a veterinarian who did the first monkey studies to try and understand for whom hormone therapy might be beneficial in terms of cardiovascular health. So we have a wide range of members here—researchers, OB/GYNs, practitioners, a wonderful representation of nurses who practice very well because they have the ear and the time to listen to their patients. This kind of interdisciplinary nature is also reflected in our flagship publication called Menopause, which still ranks as the highest journal that focuses on menopause, and it’s one of the top ten journals in OB/GYN. We have articles by anthropologists, basic scientists, people who do clinical trials on hormonal and non-hormonal interventions, so you can even see it in the range of material we publish.
MB How do you attract people to that training?
PM That’s a great question. People following the Women’s Health Initiative not only stopped prescribing hormone therapy, but really stopped talking to women about their symptoms because they didn’t know what to do about them—they didn’t know the information, there were some concerns from a legal standpoint, and they didn’t have a sound understanding of the evidence base for non-hormonal interventions. What happened in training, particularly in medical schools, is that there was simply no curriculum about the menopausal transition, which has led to a fundamental gap in this generation of physicians who were trained between 2002 and now. One way that NAMS has tried to fill in that gap is to at least provide an evidence base to guide those women who want to seek therapy for moderate to severe vasomotor symptoms through the downloadable app called MenoPro, which has a feature for women to help them understand their treatment options, and also gives providers access that helps them guide their talk with patients in making decisions about what treatments might be best for them.
MB And NAMS has trained over a thousand practitioners, is that right?
PM Yes, we currently have a thousand certified NAMS menopause practitioners—isn’t that astounding? That’s a milestone!
MB Do you think that as your folks go out and practice successfully that alone will serve as a public-relations tool?
PM Part of it is the recent history of concerns about what could be offered to women, and a lack of knowledge about the good evidence base, so they don’t know what they don’t know. There’s also, to be perfectly frank, not a great deal of money in practicing menopause medicine. You don’t do procedures, it’s a discussion about something as controversial as hormone therapy, or even an alternative non-hormonal therapy for hot flashes, and that takes time. Office visits now are fifteen minutes, and you almost need to schedule the annual exam separate from the menopause consultation visit because there’s just not enough time, and many providers are reluctant because they can’t bill very much. Maybe with this revolution in medicine and the idea that we’re going to reward healthcare systems for providing quality care will change that dynamic. The field of psychiatry suffers from the same thing—we have a difficult time maintaining our budget because what do psychiatrists do—they talk, they talk about people’s problems and try to understand. In those areas of medical care that are not procedure-based—where it’s not a simple decision but rather a discussion and a close interaction with patients— it’s a circumstance where when there isn’t a lot of money there isn’t a lot of draw. So since we know the data that women have these concerns and are bothered by them, we encourage practitioners to start up a menopause clinic every-other Wednesday, and only see your menopause patients on that day; basically, get known for devoting a certain amount of your time to addressing women’s concerns. That’s a concept that Dr Peter Schnatz, who is now the NAMS President, is trying to model through their Clinician Mentorship Committee. He’s going to teach people how to build a menopause practice in ways that are financially feasible for clinicians while offering women the kinds of help that they need.
MB Folks have talked to me about support groups or even finding ways to become aware of their existence. Sanity Papers is, in its own way, a kind of disjointed support group. I have close to fifty stories, and though I realize that’s not a clinical study, as one of my subscribers told me she reads every one faithfully because she’s looking for herself. That’s the point of doing it, because some of my symptoms I didn’t see anywhere until they turned up as a footnote in one of the biggest bestselling menopause books out there, and I thought this author wrote all these pages and my symptoms end up as a footnote? I think we’re all looking for that, because you don’t want to make it all sound so scary and bad. And it’s been interesting to interview nurses, because they not only have more data but a dual viewpoint—they see patients and then when they go through it themselves realize what all of them were talking about, and that’s also because they didn’t get the training. I believe your program could short circuit a whole bunch of that.
PM It could, and we are disseminating it and offering it at other meetings, including those in Canada, which should help the spread of that information. I think what you said earlier about support groups underscores the need to normalize these experiences for women, and that’s probably the greatest gift we can give them. In my non-professional life, when I tell women that I study the mood and cognitive changes, and also alternative treatment for vasomotor symptoms, they will say—so reliably it’s uncanny—that’s a menopause symptom? And I say yes, the irritability and the inability to emotionally regulate optimally in a way that makes you feel good about yourself—sure, that’s a menopausal symptom. And it doesn’t start when you begin skipping your period, it starts in the late transition when your cycles are changing just a little bit. I find that many women are attributing those factors to relationships—I hear a lot of husbands saying you need to talk to my wife about this—but when I say to women, oh no, no, this is normal, it’s okay, and your memory—yes, your mom and grandmother had Alzheimer’s, but what you’re experiencing right now is what sixty-two percent of women experience, and we think it comes back after menopause. And that’s relief, because what you do not want people to do when they can’t remember the name of that movie they watched only last night is panic. It’s anxiety and stress and depression, and few people understand that forty percent of women during the transition have elevated depressive symptoms, and particularly among women with a history of major depression the transition is a very, very critical window of vulnerability. So medically, how come we as psychiatrists aren’t treating women prophylactically, by talking to them about their periods and peri-menopause and what can happen and adjusting doses and what they’re going to do if this worsens. That’s the type of ideal future we would have, but even if women with predisposing factors for a variety of different menopausal symptoms had the information they could at least say it’s not all in my head, it’s normal, other women experience it. Part of that information about what’s normal comes from friends, and it’s such a relief to hear oh, so you’re feeling really irritable and yelling at your husband or partner—oh, me too! For example, we’re partnering with the National Network of Depression Centers to do the first guidelines on the identification and treatment of peri-menopausal depression. It’s a wonderful partnership, and we have this dream team of experts, so we need to work on a patient guide that’s equivalent to that—just what to expect in terms of your mood.
MB That would be so great, because I’ve interviewed people who were suicidal. I’ve interviewed people who said if it weren’t for the drugs I would have killed myself. I myself have a history of depression, but actually it stopped when I was around 40 for various reasons, and I was extremely fortunate in that I didn’t go back there. What I had instead was irritation and anger and other issues, and I knew that the irritation was part of menopause, but I thought the rest of it was that I’d gone nuts. After all those years of thinking I was nuts because I was so depressed I thought I’d finally actually gone nuts and jumped over the cliff and hadn’t even seen the lemmings!
PM In telling women there’s this window of vulnerability, that there’s a transition—even having that knowledge that generally things get much better and are confined to this period of hormonal flux, that in and of itself can be reassuring. We talk about suicidality, which is a key component of severe major depressive disorder, but women aren’t told, for example when they undergo fertility treatments, that certain drugs are going to really mess their moods up. It’s not even written on the package insert, and there are a certain percentage of women for whom undergoing fertility treatments with certain compounds are going to make them not themselves and give them very dark thoughts. We think it has to do with how our brains process serotonin and estrogen and the interaction between those two. Particularly for women’s health, with the exception of postpartum depression where there’s increasing knowledge, there’s a real fundamental lack of understanding about how hormonal transitions influence cognition and brain functioning. And it’s a huge disservice to women, because it shouldn’t surprise us that hormonal factors play a role, since women are twice as likely as men to get depressive disorders and anxiety. The good news is that there’s phenomenal work being done by people like Dr Claudio Soares who spoke yesterday about the neurobiology of this—we’re beginning to get bio markers that show us this, and the role of inflammatory processes and how those interact with what menopausal stage you’re in. It’s exciting, but the word needs to get out, which is why it’s good to have places where women can go online.
MB Well, I don’t have a giant following, but I’m shocked that there aren’t more people here at the NAMS conference. It’s such an important thing that needs to be popularized. It’s great if your doctor knows, but as you said you get a quarter of an hour. You might go back, but I’ve had people say to me they were totally satisfied with their doctor’s response but that their cousin pulled them back from trying to kill themselves. That’s a giant miss there.
PM NAMS is entering into a partnership with the Red Hot Mamas, and that’s how we’re going to try to spread the evidence base that we have in the knowledge NAMS collectively puts together through its programs and web materials using the Red Hot Mamas reach, which is immense, and through that partnership help to transfer information to women. That’s exciting and starting this year.
MB I’m assuming you’ve gone through menopause yourself.
PM Not yet!
MB Oh, really! May I ask what your age is?
PM I’m 50.
MB Oh well, then you’re right on that edge, and it’s all to be discovered! But I’m interested in how practitioners, particularly those who are as involved as your participants, have had ideas change as a result.
PM I can give you one example. I’ve studied cognitive aspects, and I do brain-imaging studies, so I actually look to see how estrogens and hot flashes influence the brain. We know the cognitive changes begin to start when women are in the late reproductive period, and then as soon as they get into the early menopausal period they become statistically significant, and I can tell you it’s mostly a prefrontal problem, from my own subjective experience with not being able to remember things, not keeping track as well. So my ideas of what it would be, which would be more like a straightforward memory problem—I can’t learn my way from my hotel room to the conference center– that’s one example of what I thought. And though my experience has some of that, a lot of it is having something right on the tip of my tongue that I can’t get at, which tells me it’s prefrontal. So there’s a good one from me, and I’m having plenty of cognitive lapses.
MB That did start to interest me to the point where originally I thought I was only going to interview people who were going through the process or immediately afterwards, and now I’ve started to interview older people and see where their heads are at. I had a few people laugh and say oh, I’ll never get that back, but what it seems to me in talking to them is that they’ve actually compensated, particularly in the case of one who was a stock broker—super high pressure and super smart. Well, now she’s just as smart but she’s different. Then I’ve had other people—and this has been a bit my experience—who say that once it all passed they got a degree of clarity back they probably had at 12 but didn’t have for all those years in between. These people did okay, but there’s a sense of cutting to the chase, which in my case had to do also with being irritated for several years—now I’ve sort of integrated that and it’s been an interesting process and very positive as far as I’m concerned.
PM After the window of vulnerability closes how do women reflect back on their transitions, that’s a fascinating area, because it gives other women hope about what they can expect.
MB Exactly, and that is part of the point. I want to give people hope. I want to say congratulations you’ve got no symptoms, or if you do you’re not alone, and then say when all of this passes you actually get something at the end that you didn’t have before.