Empowering Primary Care Providers in Menopausal Management
Jeffrey Levine, MD, MPH, professor and director of Reproductive and Gender Health Programs in the Department of Family Medicine and Community Health at Rutgers Robert Wood Johnson Medical School, shares insights from his 2025 Practical Updates in Primary Care presentation, The Menopausal Journey – Essential Care for Every Stage. Dr. Levine outlines the evolving understanding of menopause’s clinical impact and emphasizes the importance of proactive primary care management.
Reference:
- Levine J. Digging deeper series: The menopausal journey – Essential care for every stage. Presented at: Practical Updates in Primary Care Conference; May 8, 2025; Virtual. Accessed May 5, 2025. https://www.hmpglobalevents.com/pupc
TRANSCIPTION
Jeffrey Levine, MD, MPH: Hi, I'm Dr. Jeffrey Levine, I'm Professor and Director of Reproductive and Gender Health Programs in the Department of Family Medicine and Community Health at Rutgers Robert Wood Johnson Medical School here in New Brunswick, New Jersey.
Consultant360: What are the main topics you'll be reviewing in your presentation, "The Menopausal Journey – Essential Care for Every Stage," at PUPC?
Dr Levine: I think the main thing, number one, is to make primary care providers aware that with the aging of the baby boomer population and other patients, that unless they're going to be retiring anytime soon, they're going to be taking care of many patients who are either postmenopausal or going through the menopausal transition. And that the current lifespan of a woman in the United States is about 80 to 82. So women can expect to spend about 40% of their lifespan in the postmenopausal period.
So issues that are going to impact quality of life are going to be important to them, and because so many of those patients are going to be in their practices, it should be important to primary care providers.
C360: Why is this topic particularly relevant right now?
Dr Levine: Sure. Again, these symptoms can dramatically impact patients' quality of life. As many as, you know, 80% of women when they go through the menopause transition will suffer with vasomotor symptoms. And the number of women who will eventually have genitourinary syndrome of menopause, because that tends to take years to develop, is variable because of the way it's been evaluated and defined in the past. But again, as many as 84% of women will suffer with that in their lifespan. So that certainly impacts, again, overall quality of life.
The other area of concern that we're becoming more aware of recently is that at no time in a woman's lifespan do we see more prevalence of depression than during the menopause transition. And we now have strong evidence that a significant number of those women — it's due to the impact of those hormonal changes that occur during the menopausal transition and its impact on resilience. So stressors that usually a woman would be able to handle at other parts during their lifespan, because of those hormonal changes, they may not be able to handle those stressors as well, and result in depressive symptoms or even overt depression.
And again, during that menopausal transition, you have more life changes — work changes, relationship changes, kids moving out of the house. And so you have increases in stressors and, again, reduced ability to deal with them.
C360: What are the most important takeaways from this presentation for clinicians in practice?
Dr Levine: I think, one—that it's important for primary care providers to proactively ask their patients, especially a woman over 40, if they're having any symptoms. Because a lot of patients think that, “Oh, this is just part of aging,” and they suffer in silence. So being proactive about inquiring about these symptoms, and then also keeping up to date about how to objectively discuss management options of the most bothersome symptom that the patient has.
There's a lot out there—misinformation about safety and effectiveness of hormonal therapy—so a lot of patients who might benefit are not even discussed that option or don't realize that it is safe and effective for them to use. And that there are a lot of non-hormonal options either for patients who can't or don't want to use hormonal therapy that can still help dramatically improve their symptoms.
So getting providers, one, comfortable asking about these symptoms, and then using same strategies we do with other behavioral change about shared decision-making, listening to the patient's concerns, what are their most bothersome symptoms, what are their fears or beliefs about some of the treatment options, what have they heard about with other treatments—and then together arriving at a decision of what to try to help them manage their symptoms, and then agree to have a follow-up plan.
You want to give them realistic expectations. Some of these therapies can take a month. Some—especially for genitourinary syndrome—can take 3 to 4 months before they achieve significant effectiveness. And so having a follow-up plan, and knowing that there are many treatment options, so if one doesn't work, they can try something else.
And the last thing is being aware of new therapies that are on the horizon. There’s a new therapy, fezolinetant, or Veozah, which is a neurokinin-3 inhibitor. The hypothalamus is sort of the thermostat of the body, and it gets dysregulated or goes haywire when there are estrogen fluctuations because there are a lot of estrogen receptors on the hypothalamus.
So that's why women develop those vasomotor symptoms even before menopause and often worse during menopause when estrogen levels dramatically plummet. And so there are treatment options for women—let’s say breast cancer patients who cannot use systemic estrogen, or women for other reasons who cannot or do not want to use estrogen—that may help alleviate these symptoms. And there are other ones on the horizon that we should keep up to date on so that we can give patients the full spectrum of options when we counsel them about how to best treat their symptoms.
C360: What gaps in knowledge or areas for future research would you like to see further explored around this topic?
Dr Levine: I think there's an unclear understanding of the role that estradiol or estrogen therapy or estrogen-progestin therapy play in terms of risk of breast cancer, or whether early on they are protective against heart disease or other conditions. So is it when you use these hormonal therapies in a woman's lifespan can they possibly be actually protective early on? And then maybe—we do know that later in life they can accelerate things like coronary artery disease.
So I think getting a better understanding of which patients may benefit the most and when. We do know that women under 60 and women who are less than 10 years postmenopausal tend to have far more benefit than risk when using those therapies. But finding out whether transdermal application of estrogen may actually be safer—there’s some evidence that that may be true, but we don’t have hard evidence about that.
And also about other therapies, again, on the horizon that may add to the options that patients may have, as opposed to compounded therapies that a lot of patients spend a lot of money on, that are not FDA approved, may vary dramatically in their dosages, may have components in them that are not safe, or use things like salivary hormone testing, which has been debunked and yet still pushed a lot in social media for patients to use.
And how do we help patients understand what are really safe and effective versus ones that are not only expensive but might be harmful—and also very expensive because they're not covered by insurance.
Yeah, I think the other thing that I think one provider should be aware of is that there are certain risk factors that will make menopausal symptoms worse in patients.
One is Latino or African American patients tend to have more severe symptoms. So again, identifying those patients earlier. Obesity—often patients with obesity tend to have far worse symptoms and the symptoms last longer. And smoking—smoking does so many bad things, but what it often does is lead to earlier onset of severe vasomotor symptoms and also worse symptoms.
So another reason to hopefully encourage patients to stop smoking.
And also if you do identify a patient who has symptoms of depression, but on their PHQ-9 they don't have major depression—in other words, their PHQ-9 is less than 15—they don't have a history of depression and they have associated other perimenopausal symptoms like hot flushes or night sweats, you actually may be able to manage those depressive symptoms with estrogen therapy — either in combined hormonal contraception if they're perimenopausal, or using menopausal doses of therapy in postmenopausal patients — not only manage their vasomotor symptoms but also improve their depressive symptoms.
But it’s important to understand that if you have patients who have a history of depression, patients who have major depression, then you want to start with SSRIs or SNRIs, because not only will those probably better manage their depressive symptoms but may actually improve their vasomotor symptoms as well.