2005

Women's Health Clinic: Multidisciplinary Team Advances Care for Women With Menopausal and Sexual Health Concerns

Points to Remember

• Conflicting evidence exists regarding the risks and benefits of hormone therapy.
• Decisions about hormone therapy require consideration of multiple medical and gynecologic factors and can benefit from coordination of care among clinical specialties.
• Sexual concerns are highly prevalent in women as well as men, but most physicians do not receive training in — or are uncomfortable — discussing sexual concerns with their female patients.
• Mayo Clinic's newly opened Women's Health Clinic addresses these emerging needs in clinical care. Comprising a multidisciplinary team from internal medicine, gynecology, and psychology, the team provides integrated care for women with menopausal concerns, questions about hormone therapy, and sexual health concerns.

Scope of Problem

Nearly three-quarters of women experience hot flashes as they pass through menopause. For some of these women, hot flashes and other menopausal symptoms can last for years and be quite troublesome. Yet when estrogen therapy is indicated, the clinician has many issues to consider, and recommendations need to be individualized for each woman. When estrogen therapy is contraindicated or declined by the patient, alternative approaches need to be considered.

Sexual concerns become increasingly frequent as women pass through the menopausal transition and in women with chronic conditions such as cancer, diabetes, and cardiovascular disease. Community studies indicate that the prevalence of female sexual dysfunction ranges from 25% to 63%. Yet traditional models of care do not prepare clinicians to address these concerns. In addition, women are often reluctant to bring up sexual concerns at medical visits because they fear their concerns may be dismissed, they think the clinician's reaction may make them uncomfortable, or they believe treatment options are lacking.

Standard Treatment

Estrogen therapy is the most effective treatment for hot flashes and other menopausal symptoms. But many women cannot or choose not to take estrogen therapy, and physicians are increasingly reluctant to prescribe it. Women who may benefit from estrogen therapy are experiencing difficulty finding providers to prescribe it and are unable to get relief from troublesome symptoms. Women with breast cancer and other hormonally sensitive cancers search for safe, effective alternative therapies to estrogen therapy for menopausal symptoms and may have difficulty identifying an approach that works for them.

Few physicians bring up the topic of sexual concerns with their female patients because of time constraints, feeling uncomfortable discussing the topic, or lack of knowledge. Treatment options, when initiated in the primary care setting, tend to be limited to recommending reading material or prescribing medications.

A New Approach: Women's Health Clinic Consultation

The integrated team of internal medicine, gynecology, and psychology specialists at the newly opened Mayo Clinic Women's Health Clinic is uniquely prepared and qualified to meet these emerging patient needs. By providing comprehensive assessment and treatment of sexual health concerns, as well as focused consultation regarding menopausal concerns and hormone therapy questions, the team offers indepth consultations that benefit from expertise in multiple specialty areas.

For women with menopausal concerns or hormone therapy questions, the physician reviews and assesses relevant past and current medical and gynecologic conditions, past experiences with hormone therapy, and each patient's health goals and preventive health strategies and helps formulate an individualized treatment plan. Education regarding menopausal health and wellness is provided, and nutritional approaches are reviewed. Collaboration and communication with each woman's primary care provider are emphasized.

For women with sexual concerns, the initial evaluation is provided by an internist or gynecologist and usually includes assessment by a sex therapist. A private, confidential, and comfortable setting for candid discussion of issues and solutions is provided. Evaluation and treatment for conditions relating to sexual interest or desire, problems with arousal or orgasm, painful intercourse, and other sexual concerns are provided by a team with expertise in assessing the medical, gynecologic, emotional, and lifestyle factors intertwined with sexual concerns.

With the 1998 introduction of the drug sildenafil (Viagra) to address an aspect of men's sexual performance, there is growing interest and confusion among women and their physicians about what pharmacologic treatments are available for women and when or if they are necessary. Currently, about 12 companies are developing products to treat female sexual dysfunction. Sorting out the emotional and relationship issues from medical issues involved in sexual concerns is challenging. Through consultation with the Women's Health Clinic team of experts, optimal treatment for sexual disorders is provided, based on the latest medical information as well as expertise in sex therapy, integrating mind-body medicine into the plan of care.

• Menopausal symptoms such as hot flashes, vaginal dryness, and sleep problems
• History of breast, ovarian, or uterine cancer
• Questions about conventional hormone therapy
• Questions about so-called natural or bioidentical hormones and alternatives to hormone therapy for menopausal symptoms
• Sexual health concerns
  • Decreased sexual desire or interest
  • Problems with arousal or orgasm
  • Limited sensation or pain
  • Discomfort with intercourse

• Chronic pelvic pain: refer directly to gynecology
• Chronic vulvar pain: refer directly to gynecology
• Unexplained vaginal bleeding: refer directly to gynecology
• Depression or anxiety, not on stable treatment course: refer to psychiatry