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- The menopause transition has a profound impact on women's health, mental health, and healthcare needs.
- An estimated half of women Veterans served by VA may be affected by the menopause transition.
- The authors share findings and future directions from a Career Development Award designed to address knowledge gaps in our understanding of women Veterans' experience of menopause and menopause-related care.
Almost half of women* Veterans served by VA are aged 45-64,1 the age range typically affected by the menopause transition (perimenopause and early post menopause). This period is characterized by changes in reproductive hormones and symptoms that impact daily functioning and quality of life, including hot flashes and night sweats, sleep difficulty, genitourinary symptoms (e.g., urinary incontinence, vaginal irritation/dryness, pain with intercourse), and mood changes. Risk for depressive episodes is also two to five times higher during this period compared to other points in the lifespan. Hormone changes, menopause symptoms, and accumulating risk factors in the menopause transition influence risk for aging-related chronic health conditions such as cardiovascular disease, osteoporosis, and sexual dysfunction, which increases dramatically for postmenopausal women.
Women Veterans exhibit a high prevalence of risk factors (e.g., cigarette smoking, trauma exposures, life stressors, pre-existing conditions) and reproductive health concerns that may contribute to greater menopause symptom burden, as well as common health and mental health comorbidities.1 Unaddressed menopause symptoms can impact health, mental health, and daily functioning, and represent a missed opportunity to promote healthy lifestyle changes. However, there are no official guidelines for menopause management in VA, and current practices and preferences for menopause-related care are unknown. It is essential to understand the experiences, care needs, and care preferences of menopausal women Veterans so that VA providers can offer effective, gender-sensitive care. Further, we need to understand providers’ current practices and the challenges they face specific to menopause-related care in VA in order to offer resources for improved care. In this way, the menopause transition can shift from a period of vulnerability to an opportunity to improve whole health and healthy aging in the years that follow.
“Improving Women Veterans’ Health: Addressing Menopause and Mental Health” was designed to identify and address gaps in our knowledge of women Veterans’ experience of menopause and menopause-related care in VA. This study uses multiple approaches, including: 1) cross-sectional, national VA electronic health record data for all women Veterans aged 45-64 receiving VA care in FY2014-2015 (n= 200,901); 2) survey data collection in a sample of 232 women Veterans aged 45-64 enrolled in VA care in Northern California; and 3) qualitative interviews with women Veterans aged 45-64 (n=32) and VA primary care providers (n=13) from eight VA Women’s Health Practice-Based Research Network sites across the country.
We first used electronic health record (EHR) data to examine menopausal hormone therapy prescribing patterns and menopause symptom burden (menopausal hormone therapy and/or ICD codes indicating menopause symptoms) in relation to common comorbidities among midlife women Veterans. We found potential disparities in menopause symptom management, with Black women Veterans less likely than their non-Black peers to have documented menopause symptoms or be prescribed menopausal hormone therapy, despite ample evidence from observational studies in community samples supporting a higher frequency, more severity and bother, and longer duration of vasomotor symptoms among Black women compared to other racial/ethnic groups.2
We also found that a higher symptom burden may indicate underlying complex comorbidities and potential complications with treatment for comorbid conditions. Menopause symptom burden was associated with depression, anxiety, post-traumatic stress disorder, and chronic pain; among those women with chronic pain, menopause symptom burden was also associated with higher risk patterns of opioid receipt, including long-term, high-dose opioids and long-term opioids co-prescribed with other central nervous system depressants (e.g., sedative-hypnotics) despite the increased risk for misuse and overdose that these combinations bring.3
EHR data provides limited information on menopause symptom experience, highlighting the importance of primary data collection for additional insights. In our study, most survey respondents reported experience of common menopause symptoms within the past two weeks, including hot flashes and night sweats (54 percent), genitourinary symptoms (69 percent), and sleep difficulty at the level of moderate-severe clinical insomnia (based on Insomnia Severity Index scores; 36 percent). Manuscripts examining potential demographic and psychosocial risk factors for menopause symptom burden are currently in progress.
We also asked about current practices and preferences for menopause symptom management. Survey respondents reported lifestyle changes (e.g., physical activity, mind-body approaches, 44 percent), followed by pharmacological treatment (prescribed medications, 31 percent; menopausal hormone therapy, 19 percent). While little is known about the potential efficacy, harms, and/or benefits of cannabis use to manage menopause symptoms, almost 30 percent of women Veterans reported this approach. Survey responses highlighted opportunities for growth in the provision of menopause-related care in the VA setting. Only 22 percent of respondents reported currently or ever receiving menopause-related care from their VA providers, while 41 percent reported that they were not, but would like to.
The importance of menopause-related care in VA, as well as current gaps in availability, was also highlighted in qualitative interviews with midlife women Veterans and VA primary care providers across the country (manuscripts in progress). In brief, Veterans described feeling unprepared for the menopause transition and highlighted a desire for support and evidence-based, trustworthy information on menopause and menopause symptoms from their VA primary care providers. They also expressed interest in more peer support for menopause-related concerns, and a preference for non-pharmacological treatment options. Both Veterans and providers highlighted sexual dysfunction and urinary symptoms as an important but under-discussed issue for women in and after the menopause transition. Consistent with past research in community settings, providers cited a need for educational resources and a lack of formal training in menopause management.
Our work identifying menopause-related information in the EHR highlighted the need and opportunity to develop means of classifying menopause status within this resource. Working with partners at the VA Informatics and Computing Infrastructure (VINCI ), we developed a hybrid algorithm that classifies menopause status at a target date using structured (e.g., ICD codes) and unstructured (e.g., last menstrual period date documented in chart notes) electronic health record data. This algorithm is currently published in the VA Centralized Interactive Phenomics Resource (CIPHER ), and the resulting menopause status variable is now available in the COVID-19 Shared Data Resource for research and operations. We hope to build on this work, applying the algorithm on a larger scale to examine age at menopause, menopause-related health and healthcare changes, and menopause-related treatment decisions.
Using findings from the studies described above and a participatory research process with midlife women Veterans, we developed a Veteran-centered, menopause-focused psychoeducation and symptom tracking mobile application prototype. We are in the process of conducting a user study to assess the feasibility, usability, and relative validity of the tool, and will add updates and refinement for future efforts to promote collaborative self-management and/or ambulatory data collection. Findings about cannabis use for menopause management have also sparked new lines of research to investigate patterns of use as well as potential risks and benefits for these practices among midlife and older women. Finally, we are using the survey and qualitative data from this study to identify patient needs and preferences, gaps, and best practices, to develop and evaluate resources to advance gender-sensitive menopause-related care in the VA setting.
*Women” used for brevity; to include women and gender-diverse individuals.
- Frayne SM, et al. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4: Longitudinal Trends in Sociodemographics. Utilization, Health Profile, and Geographic Distribution. Washington, D.C.: Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration, Department of Veterans Affairs; February 2018.
- Blanken A, et al. “Racial/Ethnic Disparities in the Diagno-sis and Management of Menopause Symptoms among Midlife Women Veterans,” Menopause 2022; in press.
- Gibson CJ, Li Y, Huang AJ, Rife T, Seal KH. “Menopausal Symptoms and Higher Risk Opioid Prescribing in a National Sample of Women Veterans with Chronic Pain,” Journal of General Internal Medicine 2019; 34(10):2159-66.