Most of Jen Gessert's initial symptoms were relatively mild.
"It was mostly sleep disturbance, and I call it 'sweat the bed' when you just wake up in a drenched bed," Gessert said. "And I'm like, 'I don't know, I guess it just happens.'"
Gessert is in perimenopause, the period that leads up to menopause that can last from a few months to a decade. Common symptoms include hot flashes, night sweats, sleep issues and mood shifts, but the range of symptoms can be wide, from brain fog to panic attacks and rage.
Besides hot flashes, Gessert said she started having connective tissue problems.
"Bam, bam, bam, (I) started getting injuries when I've never had injuries in my life, and it was all tendons and ligaments," Gessert said. "I snapped my hamstring. I had tendonitis in my elbow. Then I had tendonitis in my shoulder. All that I was like, 'I guess that's just life.'"
She thought she was experiencing more injuries due to typical aging, but she said her final straw was an intense pain in her Achilles tendon that made it hard or impossible to walk sometimes for days at a time. So, she said she started tracking her symptoms and found they were happening on a 28-day cycle, just like a menstrual cycle. Gessert said her own research suggested it could be linked to perimenopause.
But finding adequate care did not come easily to Gessert. She said her primary care provider initially pushed back against prescribing hormone replacement therapy, a standard treatment for perimenopause symptoms. Finally, Gessert said her provider offered to prescribe an oral dose of estrogen, a pill, instead of a patch.
"I was like, 'Oh, I'd really prefer transdermal, because there's a separate metabolic pathway from oral versus transdermal that has reduced cardiovascular risks.'" Gessert said. "And she said 'no, they're exactly the same risk profile,' and that's when I knew she was fired."
Gaps in Care
Gessert was right, her provider was wrong and she's not the only patient to have a story like that. Studies show that there are large disparities in access to quality menopause care. Most practicing medical providers didn't get much training on menopause in school, if they got any at all. Research shows those education gaps can lead to women feeling dismissed and to delays in getting care, all for a major life change that impacts roughly half of the U.S, population.
Sabrina Yoder is a registered nurse in Ketchikan who specializes in perimenopause and menopause care.
"A lot of the women that are coming to me have already sought care elsewhere and been frustrated," she said.
Yoder said she talks to a lot of perimenopausal patients who say providers have told them to exercise more to address weight gain or prescribed an antidepressant for depression or anxiety. But she said when perimenopause is the cause, treating just the symptoms isn't as effective as prescribing hormone replacement therapy.
"If the cause is a low estrogen, low progesterone, (or) abnormal, imbalanced hormones, especially a change that's very drastic for that woman, although there might be some benefit of the antidepressant or sleeping medication, there won't be as much success," she said.
She said there's no one-size-fits-all treatment for someone in perimenopause or menopause, and studies show about one in five women transition to menopause without serious symptoms. But Yoder wants patients to know hormone treatment is an option. She said an interpretation of a study that circulated two decades ago misconstrued hormone replacement therapy as risky, but many studies show it’s safe and beneficial for most women. For some, such as those with a history of breast cancer or blood clots, the risks of the therapy may outweigh the benefits.
Barbara Norton, a nurse midwife and nurse practitioner, said the minimal education practitioners get on menopause is likely due to structural sexism, but she’s glad the treatment options for those approaching menopause are better than when she went through it herself about two decades ago.
"As a midwife, I thought, well, this is natural and normal, and I'm tough. I'm just going to tough it out. (I) never considered hormones. Really, nobody offered them," Norton said. "So it was just not talked about."
Finding providers with advanced training
She said patients seeking treatment should find practitioners with advanced training in menopause care and she recommends making sure a provider is certified by the Menopause Society, a gold standard in education on the topic.
"There are definitely people out there providing care and it's not really based on the best evidence," Norton said.
Norton said she sometimes sees red flags in a patient's history when they come to see her. She said those can include when a patient has previously received immediate prescriptions of testosterone, when they've only been prescribed progesterone or have been prescribed estrogen without progesterone. In women who still have a uterus, research shows including progesterone with estrogen prevents an increased risk of endometrial cancer.
Norton said patients can also ask their provider directly about their continuing education related to menopause, which can help practitioners stay up-to-date on new research.
'Oh, hallelujah!'
Jen Gessert, the patient in perimenopause, jumped through many hoops to get better care. At first, she used an online-only company. She said she was happy with the care she got there, but Norton recommends against using that model because patients can't talk to the provider.
Then Gessert found out Norton was providing care in Anchorage, where she lives.
"I was like, 'Oh hallelujah!' There's a real human who has real training in the flesh, who also provides primary care," she said, and said she already trusted Norton because she'd seen her for the birth of her first child.
Gessert said she now uses a patch for estrogen and takes progesterone pills. She recently started having hot flashes again, she said, so under Norton's care she's increasing her estrogen dose. She said she'll continue to work closely with Norton on her care as she approaches menopause.
