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Chapter 5: Clinical Evaluation and Counseling

HISTORY AND PHYSICAL EXAM

Key Points

  1. The health evaluation at the time of the menopause transition should be tailored to the individual woman based on her medical, social, and family history, as well as on her symptoms and quality-of-life goals.
  2. Sexual and psychological histories are an important part of the assessment of women during the menopause transition.
  3. The evidence supporting various aspects of the physical exam, including the clinical breast exam and bimanual pelvic exam, is limited and contradictory.

Recommendations for Clinical Care

  1. A thorough history and focused physical exam can guide clinicians and their patients in managing the symptoms of the menopause transition and providing guidance to support enhanced health for women as they age. (Level II)
  2. The evaluation and counseling of a midlife woman should be individualized based on her underlying health, risk factors, and symptoms. (Level II)

DIAGNOSTIC AND SCREENING TESTS

Key Points

  1. The focus of healthcare visits for midlife women is to promote a healthy lifestyle while addressing symptoms and screening for cancer, cardiovascular disease, and other diseases associated with aging.

Recommendations for Clinical Care

  1. Although routine screening guidelines are available, screening should be individualized, based on a woman’s personal and family history, physical examination findings, lifestyle choices, genetics, and other specific risk factors. (Level II)
  2. Hormone measurements to determine menopause status are not routinely indicated  as menstrual cycle changes are generally the best predictor of menopause stage. Follicle stimulating hormone (FSH) and antimüllerian hormone (AMH) levels reflect ovarian reserve and may be indicated if menopause symptoms are atypical or occur at an early age. Salivary hormone testing of reproductive hormones is inaccurate and never indicated. (Level II)
  3. Abnormal bleeding requires evaluation, and multiple methods are available, including transvaginal ultrasound, endometrial biopsy, saline infusion sonography, hysteroscopy, and dilation and curettage. Assessing endometrial thickness by transvaginal ultrasound is an appropriate initial step, with endometrial biopsy and further evaluation indicated for a thickened endometrium (> 5 mm) or persistent bleeding regardless of endometrial thickness. (Level I)
  4. Cardiovascular screening should include a history and physical examination with measurement of height, weight, waist circumference, and blood pressure. A fasting lipid profile and chemistry panel may be indicated. An electrocardiogram is not recommended for routine screening but may be indicated on the basis of history and physical examination findings. (Level II)
  5. Routine screening for thyroid disease is not indicated; however, midlife women with symptoms, including hot flashes, irregular menses, weight gain, or depression, should be screened for thyroid disease with a thyroid-stimulating hormone level. (Level II)
  6. Testing for sexually transmitted infections should be performed on the basis of history and level of risk. (Level II)
  7. Routine screening for cancer of the breast, cervix, and colon is indicated for midlife women. There is considerable controversy regarding the age at which breast cancer screening should begin and end and the frequency of screening. Current guidelines generally include mammograms every 1 to 2 years, starting at age 40 to 50 years until age 70; Pap smears every 3 years or every 5 years with human papillomavirus co-testing until age 65; and colonoscopy every 10 years, starting at age 50 until age 75. (Level II)
  8. Routine screening for ovarian cancer is not indicated. (Level I)

COUNSELING ISSUES

Key Points

  1. Social, cultural, racial, and ethnic differences affect the way women experience the menopause transition, the frequency and severity of menopause-related symptoms, attitudes toward menopause, and use of available therapies.
  2. Lesbian women often have special health concerns, and healthcare providers should know a woman’s sexual orientation to provide optimal care.
  3. Violence toward women is a serious public health concern. Studies confirm that women are often not asked about intimate partner violence (IPV) by clinicians. Women who are victims of IPV and sexual violence are at increased risk for serious acute and chronic health problems.
  4. Although each woman’s experience of menopause is different, the menopause transition and postmenopause are important periods for all women to implement behavioral changes to ensure healthy aging.

Recommendations for Clinical Care

  1. Delivery of healthcare at midlife must respect each woman as a unique individual. Although some women view menopause as a natural phase of life, others may see their symptoms as a medical condition requiring treatment. Clinicians should ask women directly about their view of menopause, as a woman’s beliefs will impact the effectiveness of counseling. (Level III)
  2. When counseling a woman regarding treatment for menopause-related symptoms, the clinician should review all available options and encourage the woman to take an active role in the decision-making process. (Level II)
  3. Women generally appreciate language free of heterosexual assumptions. Asking all patients the open-ended question, “Do you have sex with men, women, or both?” provides an open, nonjudgmental environment for women to discuss their sexuality. (Level III)
  4. Healthcare providers should screen for IPV and sexual violence. An environment of openness, safety, and trust will help facilitate disclosure. Displaying posters and print materials about IPV and sexual violence in public and private areas in the office educates women about options and available resources. Many women are not aware of community outreach groups, safe shelters, or the full range of services available. (Level II)
  5. Effective counseling requires that the clinician
    • Develop satisfactory relationships through communication and listening
    • Provide all information necessary for an informed decision
    • Provide unbiased, factual, and comprehensive information on the risks and benefits of any therapeutic initiative
    • Elicit and include the woman’s preferences in any recommendations
    • Understand the woman’s comprehension of instructions and ability to follow them
    • Periodically evaluate treatment continuance and adjust regimens as needed (Level III) 

QUALITY-OF-LIFE ASSESSMENT TOOLS

Key Points

  1. A midlife woman’s quality of life (QOL) is not determined solely by her general health and menopause-related symptoms. Quality of life includes a woman’s perception of her life status within her culture and value system and is influenced by her goals, expectations, and concerns.
  2. Quality-of-life scales are important additions to research in the field of menopause.
  3. Quality-of-life scales can be categorized as general (Short Form-36, EuroQOL), menopause specific (Greene Climacteric Scale, Women’s Health Questionnaire, Menopause Symptom List, Menopause Rating Scale), or combined (UQOL, MENQOL).
  4. Assessment of a woman’s perceived QOL is valued as a therapeutic outcome and may be a determinant of her adherence to a recommended plan of care.

Recommendation for Clinical Care

  1. Quality-of-life scales are not only useful research tools but also may be used to assess a midlife woman in the clinical setting. (Level II)
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