Menofuzzies in Perimenopause

Occasionally, the attempt to empathize with someone during a visit falls flat. She knows it, I know it, and the therapeutic encounter is anything but. Since I am around the same age as many of my female patients, when a woman comes in with perimenopausal symptoms I am quick to understand. It's common for women to complain of sleep disorder, mood swings, weight gain, fatigue, irritability, muscle aches and memory issues on top of the daytime hot flashes and night sweats. A couple of years ago, at my husband's 35th high school reunion, one of his former classmates was almost frantic because she thought she had early onset Alzheimer's disease. As she spoke of her word-finding difficulty, walking into rooms and forgetting what she went there for and awakening every 45 minutes, all the women surrounding her were sagely nodding their heads. Nope, we told her, you aren't crazy or paranoid, you are experiencing the "Menofuzzies".

In order of magnitude what women most hate is:

1. Weight gain.
2. Mood swings.
3. Weight gain.
4. Insomnia
5. Weight gain.
6. Memory issues.
7. Yep--Weight gain. It's a big issue.
8. Hot flashes and night sweats.

Even though I struggle with the fifteen pounds I have gained over the last 17 years, I am 5'10' so the weight distributes well and I don't look like I'm at the top of the acceptable BMI (Body Mass Index). Having never had any issues at all losing weight until I hit 40, I understand how frustrating it is to walk over fifteen miles a week (often more than that), eat far less than at any other period of my life and still have difficulty with the zipper. The mood swings I can deal with, the insomnia gets better with the exercise, the memory issues fluctuate but my older colleagues and friends (female) tell me that it will improve and the light at the end of the tunnel no longer appears to be a train. Except for the weight. Some of my patients have gained 20 to 50 pounds or more during this time of life and they are frustrated and angry. And they do not need me to empathize with them. Or tell them that other women are having the same problem. What they care about is THEIR weight gain and how to deal with it.

Unfortunately there are no easy answers to mid-life weight gain. It's still a calories in/calories used kind of equation. I recommend Weight Watchers and these already time-stressed patients are frequently not interested in finding yet another meeting to attend. I suggest using the on-line and app versions of Weight Watchers and they promise to look into it. I encourage exercise and talk about the fact that it is the closest thing yet to a Magic Pill but they are already exhausted and look at me in disbelief when I tell them that one has to invest energy to make energy. I recommend apps like LoseIt to use self monitoring as a technique for weight loss. I advise them that there are no good pharmacologic solutions and rarely recommend lap-band surgeries or other similar procedures except in extreme cases.

I try to steer them away from hormones except when their insomnia from night sweats and persistent awakenings is intolerable. Generally patients don't find much relief with over-the-counter preparations (OTC) but they seem generally safe to try. Many patients come in requesting anti-depressants but these often worsen their weight issues. Again, that Magic Pill of exercise can make a difference if an individual will stick with it. There's no down side to exercise (unless you run in front of a truck) and a safe thing to try for many of the issues arriving in peri-menopause and beyond.

The bottom line is, like many health issues, there are no easy answers and certainly no ONE pill is going to make this transition and its difficult aspects all go away. Staying physically fit, maintaining or developing good dietary habits, having a fulfilling home life and a satisfying life outside of one's home seems to be the best medicine for navigating this time of life. But not everyone has the supports in place to make the kind of lifestyle changes necessary to achieve these goals--their jobs exhaust them, their kids are in trouble, their husbands are unsupportive or absent, there is no flexibility in their schedules, their is no flexibility in their thinking and any number of other difficult circumstances. And when they are frustrated with little or no time to develop these kinds of lifestyle changes, they may find my advice lacking.

The Lurking Physician

In addition to reading a number of medical bloggers, I "lurk" on twitter chats and try to watch twitter updates from the 88 people I am currently following. The majority of the people I follow are doctors who are interested in how social media can help patients, plus a few "learning" entities like Brainscape just to improve my language studying skills (which I highly recommend). I am just a neophyte to Social Media but am excited by its potential for my patients.

Brainscape

Suddenly the ability to followup with patients directly without a medical assistant playing messenger in between seems more attainable. Communications would be cleaner and both physicians and patients would be better served. Right now I do this on a small scale by using email but this is fraught with difficulty. Patients send me their information and sometimes they cannot open my email response because it is encrypted (per HIPPA requirements). Other times their emails are caught by my spam filter and I never see them! As I've written about in previous posts, there are recommendations by august bodies like the AMA on how to use email professionally but frankly, they are both out-of-date and a little out-of-touch with their recommendations. However, having said that, HIPPA fines are substantive so no one wants to be caught in the wrong while communicating with patients.

In the meantime, patients are becoming more web and social media savvy. It is exciting to have a patient come in who has been on the Mayo clinic website and is asking about what preventive steps they should be taking instead of me initiating the discussion. It makes me feel like a partner in their care instead of a mother giving advice. I am a mother and I enjoy that role. Nurturing is part of healthcare but when I feel more like the disciplinarian then an advisor, neither I nor the patient are likely to benefit.

The "early adopter" physicians and e-patients on Twitter, Facebook, Google+ and LinkedIn, among others, are working hard to improve the lines of communication so that patient care is better. It's an exciting time to be involved and I am looking forward to learning more and sharing a lot.

What's my Worry Today in Primary Care?

Worrying about patients is part of my job. In these last couple of weeks it's been a long-time patient with a life-threatening illness, a pregnant woman who didn't want to be pregnant, and a young person who thinks that a pill will fix her out-of-control life. (I get a lot of older folks who are looking for that magic pill as well but they don't worry me as much). Mostly I leave those thoughts at the office but sometimes they come  home with me. Lately what's followed me home are patients who are avoiding treatment or visits because they have a high deductible or no insurance at all. Last week was a middle-aged woman who just got insurance after being without for several years. She had several concerning issues but the most worrisome to me was the thickened area in her breast. She didn't tell me about it but on physical exam there it was--it felt wrong. It didn't belong there. It was a little hard, a little irregular. Classic sensation for a cancer.. She hadn't had a mammogram or a physical in years because of the cost. Would it have made a difference if she'd had one last year? I don't know. Maybe. And maybe this "area" will prove to be nothing, though I doubt it. 

The number of uninsured Americans has gone up a few percentage points in the last ten years. What I am seeing more of are underinsured individuals--people with high deductibles and high premiums. These are the people who skip needed care because they can't afford it OR they have the perception that they cannot afford it. They are "non-adherent" with medications because they fear the cost of followup lab tests even when their medicines are on the $4 Kroger list. They don't come see me because they don't know we offer a 35% price cut for cash paying patients. They equate health care with health insurance. They are aware of the skyrocketing costs of hospitals, medicines and doctors and fear that if anything is found on exam that they'll never get insurance (a reasonable fear to have these days since many people are outright rejected and others are quoted outrageous premiums based on what are often minor problems). Or the patient may obtain insurance without coverage for a pre-existing condition.

I await the mammogram report with trepidation and hope she doesn't skip it. She was concerned about missing a couple of hours at her new job. God forbid she lose the job that is supplying her with health insurance. I am sure she can't afford COBRA. And if the worst occurs will she lose her job anyway because she can no longer work while going through surgery, chemotherapy and radiation? And then what?