Clinical Innovations

Menopause Health Program

Mapping the inevitable and inescapable middle-age female journey from internal body bonfire to out-of-the woods climacteric clearing

An interview with Kathryn Macaulay, MD, Director of the UC San Diego Menopause Health Program and Clinical Professor of Obstetrics and Gynecology at the University of California San Diego, sheds light on the evolving phases of menopause, myths, trends, and expectations. Dr. Macaulay is well versed in advising on woman wellness practices traversing perimenopause through the maelstrom to post-menopause. In the same vein as the “So long, farewell, Auf Wiedersehen” song from the classic film “The Sound of Music,” menopausal women wave goodbye to their periods, period products, and monthly mood swings as they prepare for the bleed-less calm ahead. Navigating this personal journey is best done with the guidance of an Obstetrics and Gynecology Clinician and not alone due to the variable and unique individual experiences associated with this natural aging process.

Tell us about your background and how you came to specialize in menopause

Public cry origins

Spurred by the JAMA July 2002 publication “Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women” and subsequent heavily broadcasted trial results in the Women’s Health Initiative Randomized Controlled Trial which concluded “overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 5.2-year follow-up among healthy postmenopausal women.” Increased risks of coronary heart disease, breast cancer, stroke and pulmonary embolism, were now associated with using hormone therapy, causing an uproar of worry about disease prevention. Dr. Macaulay described the widespread implication of this news and social climate as her impetus to action:

“thousands of women stopped using hormone therapy and health care providers became risk adverse to prescribing hormones – women were left with an unmet need to handle their menopause symptoms.” – K. Macaulay, MD

Before this point, hormone therapy was the standard treatment of menopause care. To address the needs of her patients, Dr. Macaulay rocket-launched the Menopause Health Program at UC San Diego in 2004 and it is going stronger than ever today with a large volume of new and returning patients.

In 2013, JAMA published a sequel study “The Women’s Health Initiative Hormone Therapy Trials: Update and Overview of Health Outcomes During the Intervention and Post-Stopping Phases” which walked-back some of the early hormone therapy findings to re-assess quality of life measures, primary efficacy, and safety. Fence-straddled providers and patients were once again weighing hormone therapy risks and benefits.

The bridleway path to clinic

When Dr. Macaulay was junior faculty, the idea for a menopause program originated as her clinical project for the National Center of Academic Leadership in Medicine (NCLAM) career development. Her professional goal was to start a menopause program and she came up with a brilliant clinical model that involved expansion with interdisciplinary providers. This program is dedicated to helping women sort out the pros and cons of using hormone therapy and is structured to spend more time with women consulting on menopause care. Dr. Macaulay and her clinic partner at the time, a now retired Nurse Practitioner, acquired esteemed knowledge on the ins and out of managing menopause, completing training through the North American Menopause Society (NAMS or new moniker The Menopause Society) and receiving menopause certification. This society is the authority writing menopause guidelines for providers. Credibility and reputation generated soaring demand as the extra certification designated the Menopause Health Program as a menopause specialty clinic listed on The Menopause Society’s website. 

What and When is menopause with expert clinician Dr. Macaulay

Perimenopause Prep

Perimenopause is the stage leading up to menopause and begins in a women’s late 40’s – average age is around age 47 with an anticipated duration of transition to menopause of ~3 to 4 years. Signs of perimenopause:

• Irregular menstrual cycles
• Vasomotor symptoms (hot flashes and night sweats)
• Mood changes, irritability, worsening depression or anxiety
• Cognitive changes, impaired concentration and focus
• Decline in libido (sexual desire)
• Genitourinary symptoms, vaginal dryness

Menopause Milestone

Around 51-52 years of age, menopause arrives and is officially reached after 12 consecutive months of amenorrhea.  (Though younger women can experience menopause if undergoing surgery to remove ovaries or due to chemo or radiation therapy).  While not all women are bothered by menopause symptoms, common complaints associated with menopause include:

• Vasomotor symptoms (75-85% of women)
• Cognitive disruptions
• Irritability
• Weight gain
• Difficulty sleeping (insomnia, night sweats)
• Pain during intercourse, vaginal dryness, irritation
• Low libido
• Bone health concerns, osteoporosis

Postmenopause

Periods stop and many discomforting symptoms, like jumbled brain fog, abate. Risk for osteoporosis increases after estrogen levels decline permanently so women who have risk factors for osteoporosis should consider early screening (or if average risk, usual screening at age 65). Vaginal bleeding is not expected after menopause, so any postmenopausal bleeding should be evaluated by an Ob/Gyn.

Modern program momentum

Today, Dr. Macaulay is the primary provider seeing patients in the menopausal program and is searching for a Nurse Practitioner to join the program. She frequently collaborates with an Internal Medicine provider who is also trained in menopause when needed for management of medically complex menopausal patients.  Her consultation practice is based in La Jolla and Encinitas, CA. The specialty program trains 3^rd year Ob/Gyn residents, Internal Medicine interns rotating through Women’s Health, and covers didactics for OBGYN 3^rd year medical students and residents in Primary Care, Ob/Gyn and Psychiatry. Patients travel mostly from Southern California, Nevada, and Arizona for menopause treatment at UC San Diego.

Trends

“In the past year, we have seen renewed interest, an uptick in women in general – and in the media – discussing menopause out in the forefront.” – K. Macaulay, MD

Menopause is having a big moment and generational shift thanks to increased media coverage and celebrity highlights. Previously, the topic was taboo and women suffered silently. With newer research studies and a reversal of the hormones-as-harm messaging – more women than ever are coming in to see Dr. Macaulay to manage their symptoms, even women over 60.  She notes, “While menopause is not reversible, it is a time for women to look at their overall health and make a plan for healthy aging moving forward."  Menopause comes, it conquers, and life sails on.  She directs to a fresh take in the wake of the initial hormone study with New York Times stories “5 Things to Know About Menopause and Hormone Therapy” article (Feb. 2023) and “Women have been Misled About Menopause” article (Feb. 2023). Turns out, risks aren’t as high as initially publicized in healthy women within 10 years of menopause and under the age of 60.  Many women in their 40s and 50s who are healthy and early in the menopause transition are candidates for hormone therapy.  Consulting with an Ob/Gyn or menopause practitioner is recommended to discuss treatment options. Women over 60, while typically not candidates to start hormone therapy for the first time due to increased cardiovascular risks, can consider non-hormonal treatment options and targeted low dose hormonal therapies for vaginal symptoms.

“While the media has been helpful in promoting the safety of hormone therapy, it is important for women who are years past the transition to menopause to understand that hormones may not be safe but other treatment options exist.”– K. Macaulay, MD

Insights from our expert clinician, Dr. Macaulay. There are a large portion of women who are really symptomatic who can benefit from hormone therapy. Last year, viewership and publicity from media publications, including one by a journalist who gave the keynote address at the annual meeting of The Menopause Society in 2023, educated the lay public about where we are with hormone therapy and who is a safe candidate for using it. More providers are asking about using hormone therapies and want to talk about menopause and concerns about the risk. The general public has a better understanding, and there is less use of unapproved compounded hormones. There are safe FDA-approved “bioidentical” hormones and therefore, typically no need to prescribe/use unapproved hormone products from compounding pharmacies.  A deleterious trend was seen where women were going to alternative providers –who weren’t giving the safest forms of hormone therapies – and then facing potential risks. Interest in treating menopausal women grew after a study looked for other ways to treat symptoms.

Treatments

Dr. Macaulay discusses treatments for menopause. Since the 2002 study in hormone therapy, subsequent studies have shown safer routes for using estrogen such as transdermal preparations rather than oral estrogens. The safety profile for certain types of progestogens is also better understood, with micronized progesterone likely to be safer for breast and metabolic health compared to synthetic progestins. Bioidential, not synthetic, progesterone, lower doses for different estrogen gels and patches are used to customize treatment for menopause symptoms. There have been a lot of improvements and several studies looking at non-hormonal new products such as Fezolinetant (VEOZOAH brand name), a novel Neurokin 3 (NK3) receptor antagonist for treating menopausal vasomotor symptoms. The medication works in the thermoregulatory zone in the hypothalamus and was shown in clinical trials to be an effective treatment for hot flashes and night sweats. This provides an alternative for women who can’t use hormone therapy such as women with estrogen sensitive breast cancer or history of deep vein thrombosis.  Other non-hormonal alternatives include SSRI or SNRIs, a class of anti-depressant. Gabapentin and oxybutynin are other non-hormonal options used off label to treat vasomotor symptoms.

In sum, quality of life during menopause is best treated with the mantra of medicine for woman wellness – rest, healthy diet, and exercise. When these behaviors are not enough to reign in health concerns, a visit to the clinic could help create a custom treatment plan to lessen the burdens of menopause. Dr. Macaulay also educates her patients on preserving bone and cardiovascular health after menopause and encourages regular screenings for breast, cervical and colorectal cancers. After a longer initial consult and curated treatment plan which may involve prescribing medication, a follow-up visit takes place in 3-4 months, and then annually as needed. Patients are also encouraged to have a primary care doctor for other health issues that may arise during the postmenopausal years.  Dr. Macaulay helps primary care doctors within the UC San Diego Health system manage their menopausal patients by providing electronic consults for appropriate patients.  The growing clinic is seeking a new nurse practitioner with menopause certification. Discover more about menopause treatment and clinical studies at UC San Diego Health. Lastly, don’t worry – it’s not a midlife crisis, it’s just menopause and a new biological age!