76 Addressing Vasomotor Symptoms Experienced by Peri- And Postmenopausal Women With MENOGAP

Faculty Mentor: Lisa Taylor-Swanson (Nursing, University of Utah)

Introduction

Menopause, or the cessation of menses, is a life transition that occurs at some point in every woman’s life. Menopause is not an event, rather a transitional period typically lasts several years – the exception being a surgically or medication-induced menopause. This period is an indication of a woman’s shift past childbearing age. Women may experience physical or emotional symptoms during peri- or post menopause well as early post menopause. In addition to emotional changes, such as anxiety and depression, (Bromberger, et. al, 2013), vasomotor symptoms are among one of the most reported indications of menopause (Paramsothy, et. al, 2017). These symptoms occur when the body’s vessels constrict or dilate to regulate body temperature. Vasomotor symptoms include a range of experiences, such as hot flashes, night sweats, a sense of anxiety, and/or heart palpitations (McKimlay, Brambilla, & Posner, 1992). These symptoms frequently lead to decreased quality of life for many women. In fact, women who experience vasomotor symptoms have an increased rate of health care visits, decreased productivity (Whiteley, et. al, 2013), and overall cost the US healthcare system billions of dollars per year (Faubion, et. al, 2023).

In addition to dealing with these unpleasant facets of growing older, many women feel unequipped to handle this major transitional period (Harper, et. al, 2022). In fact, 73% of women in one survey did not receive care for these symptoms during medical visits, rendering many women unable to manage this transition (Allen, et. al, 2023). In addition to many midlife women being unprepared for menopause, many healthcare providers are likewise unprepared. In fact, only a third of surveyed OB-GYN residents receive menopause-based training and are properly equipped to provide adequate care (Allen, et. al, 2023). The lack of informed medical care along with the lack of patient education has created a gap in which women are without the proper care and knowledge to cope with the peri- or postmenopausal transition.

Beyond conventional medical care, 25% of women have reported seeking integrative medicine to relieve their menopausal symptoms, including acupuncture therapy (Gentry- Marahaj, et. al, 2017). Acupuncture has showed promise in reducing symptoms in menopausal women, but it does come with certain barriers (Vanden-Noven, et. al, 2023). In fact, peri- or postmenopausal women are a socioeconomically vulnerable group, and given that acupuncture is not covered by some health insurance policies, there is a significant barrier in receiving this treatment and therefore relieving symptoms of peri- or post menopause (Taylor-Swanson, et al., 2014). This points to a much larger, systemic issue, where a majority of middle-aged women are unequipped to acquire the resources needed to manage this physical and emotional transition. Studies show that medical care and patient education (Afshari, et. al, 2020) provided in a group format is far more effective compared to a standard one-on-one care structure (Cunningham, et. al, 2021). MENOGAP is a program which aims to provide evidence-based medical and integrative medical care, as well as patient education in order to increase community access as well as the self-management of symptoms. MENOGAP curriculum includes four weekly group sessions of medical care, as well as social support, prescription management, integrative medicine education, group acupuncture, and self-care education. Women are able to share their experiences and ask questions not only to the care providers, but also to each other. A major aim of this program is to increase the self-management of symptoms and thus decrease vasomotor symptoms experienced by peri- and postmenopausal women.

MENOGAP was created to combat the lack of knowledge surrounding the menopausal transition and educate peri- and postmenopausal women about symptom management. This program integrates conventional and integrative medicine to create a multifaceted approach for these women to handle this transitional period. MENOGAP sessions involve three components: facilitated discussion, didactics, and experientials. These components are designed to improve the cognitive, behavioral, and health outcomes for the women participating. The MENOGAP program is comprised of four weekly group health meetings lasting 2.5 hours each week. Each MENOGAP session takes place in a large conference room, where the majority of the care takes place, along with individual clinical rooms available if needed (e.g., for Pap test). Evidence- based health content prepared by two licensed clinicians is printed out and provided to participants prior to the start of each meeting. Each meeting consists of two “doc talks” completed by these two clinicians. The first part of these meetings is led by a menopause- certified physician, whose role is to provide medical management of symptoms brought up by the patients. The physician also leads a discussion about symptom management, answers any questions, and may lead one-on-one consultations requested by any of the MENOGAP participants. The physician assists in requesting prescription refills, suggesting treatments, and discussing symptom management with each of the participants. The second aspect of a MENOGAP meeting consists of acupuncture therapy completed by a licensed acupuncturist and education on self-health management through evidence-based integrative health techniques, including herbal supplements, massage, breath work, and self-acupressure. During the session, each patient receives acupuncture therapy with the MENOGAP acupuncture protocol, taking into account their symptoms and resulting in a traditional Chinese medicine treatment plan. The participants are then monitored as they rest with the needles in place for approximately 30 minutes, after which time the acupuncture needles are removed. The last part of the session is dedicated to any additional questions or concerns the participants may have. Each session focuses on a different topic, including vasomotor symptoms, sleep, stress management, nutrition, bone health, sexual health, mental health, and more, resulting in a comprehensive plan of care for patients suffering from peri- or postmenopausal symptoms and leaving them better equipped to handle their care.

This thesis addresses the feasibility and acceptability of MENOGAP in delivering high quality patient care and decreasing vasomotor symptoms in menopausal women. In comparing self-reported vasomotor symptom rates in women before and after participating in MENOGAP, we were able to analyze the value of this program and its function in decreasing vasomotor symptoms experienced by women through the peri- or post- menopausal transition.

Methods

Participant Recruitment

The purpose of the study from which this thesis was derived was to determine the feasibility and acceptability of MENOGAP in delivering high quality patient care and increasing health literacy for women experiencing peri- or post menopause. Participants in this study were recruited through physician referrals, as well as flyer postings throughout the University of Utah Health system. Participants were required to be 35 years of age or older and to have/have previously had a uterus, and were excluded if they were pregnant. At least one week before the first MENOGAP session, participants in the study were screened for eligibility and completed the informed consent process, which included risks/benefits, what participation involves, and their questions were answered. Any questions or concerns were addressed before a signature was obtained. No randomization was used in this study.

Patient Screening

Before the first session of MENOGAP, participants filled out surveys to collect baseline data. Table 1 includes the survey presented to participants. They also were asked to disclose their last health screenings, e.g., colonoscopies, mammograms, Pap smears, thyroid levels, DEXA bone density scans, fasting glucose/A1Cs, and cholesterol levels. After the completion of the final session of MENOGAP, participants were asked to complete the same questionnaire, with questions regarding demographics, satisfaction with the program, screening rates for chronic illnesses like diabetes, colorectal cancers, etc., adherence to self-care at home, and outcome measurements to be used in a future study (mood, sleep, etc.).

Table 1: Pre-Participation Survey

Menopause Rating Scale

Vasomotor symptoms were measured with four items that comprise the somatovegetative subscale of the validated scale, the Menopause Rating Scale (MRS). The scale is a 5-point Likert-type scale, and items are rated on a scale from 0 to 4, from none (0) to very severe (4). The MRS questionnaire used in this study included questions regarding urogenital, psychological, and somatovegetative symptoms, but for the purpose of this thesis, only the somatovegetative subscale items were analyzed. The four items measuring vasomotor and somatic symptoms read: “Hot flushes, sweating (episodes of sweating), Heart discomfort (unusual awareness of heartbeat, heart skipping, heart racing, tightness, Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early, and Joint and muscular discomfort (pain in the joints, rheumatoid complaints).” The total scores were determined by summing the individual item scores and dividing by 4. Figure 1 is a depiction of the MRS provided to participants in the MENOGAP program. This questionnaire was completed before the first session and after the final session of MENOGAP, and results were compared to analyze the efficacy of the program in decreasing vasomotor symptoms.

Results

Study Characteristics

This study was approved by the Institutional Review Board (IRB #00168678). The sample size of women participating in this program was 29. Descriptive statistics were used to determine levels of feasibility and accessibility, including race, age, and ethnicity. The average age in the group was 50.38, with a standard deviation of 4.93 years. The majority (82%) of participants were white, non-Hispanic, while 18% were Hispanic. All four sessions were attended by 68% of participants.

Data Analysis

All analyses were performed with a two-tailed paired t-test. Statistical significance was set at p<0.05. Table 1 shows the MRS scale data, ranging from 0 (no symptoms) to 4 (very severe symptoms) for the somatovegetative subscale.

The somatovegetative subscale, which includes vasomotor symptoms, the mean MRS score before MENOGAP was 1.440 with a standard deviation of 0.666, which falls between the mild to moderate scores. After MENOGAP, the mean MRS score for somatovegetative symptoms was 1.115 with a standard deviation of 0.581, which falls closer to the mild score. The mean difference in scores before and after MENOGAP for this category was 0.300 (p = 0.026), which is statistically significant.

Discussion

MENOGAP, which integrates both conventional and integrative medical approaches, is associated with a statistically significant reduction in self-reported vasomotor scores among menopausal women. Specifically, the mean MRS score for somatovegetative symptoms, which includes vasomotor symptoms, decreased from 1.440 at baseline to 1.155 following the completion of the program (p = 0.026).

This change is meaningful, especially considering the short intervention period and the limited scope of measurement using the Menopause Rating Scale. The clinical importance of this finding points to the idea that even a brief, integrative intervention like MENOGAP can lead to measurable improvements in vasomotor symptoms. These findings suggest that group health visits, particularly those that combine conventional and integrative approaches, may be an effective and supportive option for managing vasomotor symptoms in peri- and post-menopausal women. This aligns with evidence from other studies, which support the use of group-based interventions for symptom management during menopause (Cunningham et. al, 2021). Beyond symptom reduction, the structure of MENOGAP allows women to share experiences, normalize their experiences, and build a community, all of which may contribute to self-efficacy and overall wellness. In this way, MENOGAP addresses the physiological and psychosocial aspects of peri- and post-menopause, a multifaceted transition that seems to be often underserved and unaddressed.

The statistically significant improvement in vasomotor symptoms also raises larger questions about the role of patient education and the integration of evidence-based integrative and conventional care. Despite the many symptoms reported among peri- and postmenopausal women, many report feeling underprepared and unsupported during this life stage (Harper, et. al, 2022). There remains a significant gap in both health education for women as well as training for healthcare providers on menopause management (Allen, et. al, 2023). This lack of knowledge can lead to underdiagnosis, mismanagement, and an overall diminished quality of life for many women navigating this difficult transition. There is a clear necessity for more education, resources, and interventions to equip women to handle this transition.

This study, although limited in size, contributes to a growing field of evidence that suggest that accessible interventions like group medical visits can be highly effective. In addition to this, by incorporating elements like mindfulness, nutrition, exercise, and peer support, programs like MENOGAP empower women to take a more active role in their health.

Limitations and Future Improvements

While the results of this study are promising, there are a few limitations to consider. The small sample size (n=29) limits generalizability, and the use of the MRS, although a validated tool, does not capture the full scope of peri- or postmenopausal symptoms. In addition, the lack of randomization and a control group could introduce the possibility of bias, including placebo effects.

To further enhance the MENOGAP program and its results, there are a few improvements that could be considered for the future studies. For one, a randomized controlled trial design would strengthen the validity of the findings by controlling for placebo effects and bias. A larger sample size could also allow reduce the margin of error and increase the statistical power of the study. Long-term follow up assessments could also be considered, as they would help determine the sustainability of symptom improvement and whether ongoing support is needed. Lastly, a more diverse population in terms of race, ethnicity, and socioeconomic status could allow for a broader scope of understanding as to how the program can help a wider range of women.

Conclusion

Despite its limitations, this study provides compelling preliminary evidence that group medical programs like MENOGAP may offer meaningful relief for peri- or post- menopausal women struggling with vasomotor symptoms. More importantly, it sheds light on a broader systemic issue: the need for improved menopause education and resources for treatment. As the population of midlife women continues to grow, innovative programs like MENOGAP may serve as a model for future care, ensuring that all women have access to responsive, inclusive, and empowering care.

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