Counseling perimenopausal women

Key points 

Counseling midlife women about the safety of long-term hormone therapy (HT) changed dramatically with the release of the results of the Women's Health Initiative (WHI) on July 9, 2002. A flurry of media and public attention had an impact on both women and their health care providers. In a recent poll 70% of obstetrician-gynecologists reported that they were spending more time at office visits explaining the pros and cons of HT (1).

Health care providers are now counseling about menopause, HT, and nonprescription remedies to perimenopausal women as well as postmenopausal women who are reevaluating the appropriateness of their initial decision to receive HT. To assist women with making this decision, it is important to understand how women make health decisions during the menopausal transition. It is also important to understand women's counseling needs from their perspective.

The decision-making process 

Both the menopausal transition and women's decision-making about HT and alternatives are an ongoing process. A decision made by a woman at one time could change several times, based on changes in her personal or environmental situation. Women's decision-making is a nonlinear, multistage process (2). The stages are: precontemplating, contemplating, committing, critically evaluating, and continuance.

During precontemplation, women are not actively thinking about using HT. During contemplation, women determine their menopausal status and begin to think about using or not using HT or alternative therapies. During commitment, a woman makes a decision to either use or not use HT. During the critical evaluation stage, women reevaluate their prior decisions. Following the evaluation, a decision is made whether to continue with their decision, based on experience.

The outcomes of the process could be the decision to use HT, alternative therapies, or lifestyle changes.

Support should match each of the stages of the process. In half of qualitative studies about women's decision-making and HT, women rationally weighed benefits and risks to determine whether they would use or discontinue HT. But because of conflicting and incomplete information some women felt ambivalent, frustrated, and confused. Different women preferred to assume different roles in the decision process. Some relied on their provider, others decided together with their provider, while others took control and made the decision themselves (Table 1) (3).

Table 1. Influences on Women's Decision-Making

	Internal
	Personal considerations:
	• Needs
	• Benefits and risks of HT and nonprescription remedies
	Attitudes and beliefs:
	• About menopause
	• About HT and nonprescription remedies
	Values:
	• About being in control of the decision
	• Desired menopausal experience
	Context:
	• Personal life situation
	• Amount of knowledge about menopause and management
	• Degree of exposure to media reports about research findings about HT
	External:
	Interactions with:
	• Friends, family, co-workers
	• Health care providers
	• Cultural groups
	• Information sources

Problems reported by women 

Major complaints reported by women have included a lack of information about menopause, poor communication with physicians, and a lack of time to discuss menopause management at clinical encounters. A major problem identified by all the participants was a lack of reliable, accessible, and understandable information about menopause and HT. Some felt pressured to take HT or noted a lack of interest, knowledge, or willingness by their physicians to discuss nonprescription remedies. Many women turned to informal, accessible information sources such as lay publications, family, and friends. The impact of the media was very influential on women's decisions about HT and their perceptions of risk factors.

Sources of information also varied between cultural groups. While Caucasian women preferred written sources of information, such as newspapers and magazines, African-Americans preferred information from friends and family (3). Of women aged 47 to 75 who were members of health maintenance organizations, 75% reported exposure to counseling, but only 33.2% felt that they had received high-quality information (4) Fig 1).

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Figure 1.

Women's perceptions of their needs 

Women value communication with their health care providers, being treated as partners in their care, and being respectfully listened to. They want information about both HT and alternatives, as well as guidance about possible side effects, and assistance with weighing benefits and risks for all therapies (2). A 2003 study by the National Consumers League found that two thirds of women reported that their physicians left treatment decisions up to them, while the majority felt that menopause treatment decisions should be a collaborative effort (5).

Decision-making and counseling guidelines and supports 

The National Committee for Quality Assurance has developed standards and a method of measurement of the quality of menopausal counseling (5).

Counseling guidelines developed by several other organizations focus on collaborative and informed decision-making, personalization of information, weighing of risks and benefits of HT and alternatives, assessment of needs and goals, and clarification of values and priorities (Table 2).

Table 2. Counseling Resources for Clinicians

	National Association of Nurse Practitioners in Women's Health: www.npwh.org
	Menopause & and Hormone Replacement Therapy: Collaborative Decision-Making and Management
	Institute for Clinical Systems Improvement: www.icsi.org

Tools that help patients make choices include booklets, audiotapes, computer interactive formats, and internet web pages. Evaluation of these indicates that they enhance participation and improve the quality of the decision (6).

Conclusions 

Research about women's decision-making about HT was conducted prior to the release of the findings of the WHI and may not apply to the current situation. New research will need to be conducted.

Decision-making about HT and alternatives is a process with ongoing reevaluation and revision. Some women proceed through the process quickly, while others may take a prolonged time and cycle through phases several times.

Counseling methods can consist of one-on-one discussions with physicians or nurse practitioners, supplemented with written materials, audio and videotapes, workbooks, or computer programs.

Both before and after the release of the WHI results, there has been a lack of quality information about menopause and management options. There is a gap between what women desire and what is currently available. Innovative solutions delivered outside the traditional office visit in a variety of formats will need to be designed by health care providers. It is important that these are culturally relevant and responsive to the needs expressed by women.

Prior to counseling a woman, the caregiver should (1) assess the amount of knowledge the woman has; (2) determine the stage of decision-making the woman is in; and (3) clarify the role the woman wants to take in the decision.

When counseling a woman, explore her beliefs about menopause, HT, and nonprescription remedies, and her needs, values, preferences, and goals. Provide information about benefits and risks of all options. Help the woman explore pros and cons of each decision by clarifying current research findings and personalizing them to her health history.