Working with your Doctor

This helpsheet is part of a series on getting the best possible health care to cope with your early menopause. The first installment: Finding The Right Doctor.

Working with your doctor — as a partner  in your healthcare is a crucial aspect of coping with early menopause or premature ovarian failure (POF).

Since there are so many things that are confusing, so many options open to you in terms of treatment, and so many changes going on with you both physically and emotionally, it’s important that you develop a strong doctor-patient relationship to ensure that you’re getting the quality care you deserve.

And you have it in your power to get just that!  It’s a matter of knowing what to expect from your doctor — from the first visit on — and knowing how best to work hand-in-hand with your doctor.

This way, you can rest assured that your questions will be answered, your needs carefully discussed, your options clearly explained to you, and your concerns addressed.

So following is an explanation of the different aspects of an examination, the tests you will get, and tips on how to get the most out of your healthcare provider.

Your First Office Visit: What to Expect

When you first see a doctor as a patient to discuss your premature menopause, you’ll go through both a medical history interview and a physical exam. Both are vital components of the office visit — each supplying different information to the doctor.

It is also likely that you will undergo certain tests if you haven’t had any done recently. All of this will enable your doctor to get a picture of your current menopausal status and to begin evaluating what form of hormone replacement therapy or other menopausal management therapy would work best for you.

The Consultation

This is essentially the “get-acquainted” portion of your visit — in a number of ways. Your doctor will begin getting acquainted with you, your medical history and your symptoms, and you’ll begin getting an idea of how your doctor will be handling your menopause.

Because your doctor needs to know just what you’ve been experiencing and other important facts about your past health and your family’s medical history, it’s important to be prepared with all necessary information… and extremely important to be as explicit and forthright as possible when answering questions.

You should be prepared to tell your doctor about:

•    Your family medical history — when your mother entered menopause, any diseases that run in your family — including breast cancer, osteoporosis, cardiovascular disease. This will help your doctor evaluate whether or not hormone replacement therapy (HRT) is a good choice for you… and the form of HRT that may work best.

•    Your own medical history — Again, this is important, especially when it comes to prescribing HRT. If you’ve had a history of blood clots, for example, this will affect the form of therapy the doctor recommends.

If you’re in premature menopause due to breast cancer or other cancer treatments, your doctor will need to know the type of treatment you had, the duration, and so forth. And if you’re in surgical menopause, again, your doctor will need to know the specifics about your disease and the treatment you followed.

•    Your lifestyle — general information on your habits, including exercise, diet, smoking, and drinking. And be completely truthful! All too often, women feel uncomfortable admitting to bad habits to a doctor — for example, if they smoke, they don’t want to mention it because they know it’s bad.

But this isn’t the time to make yourself out to be a saint! All of this information is important — in terms of evaluating the HRT option and possible long term risks from premature menopause.. Unless you’re honest, you won’t get the help you need.

•    Your menstrual cycle over the past few months — frequency of periods, any skipped periods, duration, flow, etc. As mentioned earlier, it’s a good idea to have this all jotted down to be sure you don’t make any mistakes.

•    Physical symptoms — what symptoms you’ve been experiencing, how often you get them, severity of the symptoms. And tell the doctor about them in order of importance — this will enable her to understand what your priorities are.

•    Emotional symptoms — something that often isn’t a factor in regular gynecological exams, but one that does play a part in premature menopause. Because of the emotional toll that premature menopause causes — not to mention the very real mood swings and depression brought on by depleted hormone levels, it’s important to discuss emotional symptoms you’ve been going through.

This will help the doctor determine whether to put you on an anti-depressant or another medication or herbal supplement (like St. John’s Wort).

•    Your sex life — not the most fun topic to chat about with someone you’ve only just met, but a necessary one. For example, if you’ve been experiencing pain during sex, you may already be suffering from vaginal atrophy; or if you’ve lost interest in sex, you may have low testosterone levels. Again, be as frank as you possibly can.

•    Your future plans where pregnancy is concerned — another topic that is specific to women in premature menopause. If you’re considering pursuing donor eggs or other more experimental treatment for premature menopause, let your doctor know.

This may affect the type of therapy you can get — or she may be able to tell you about infertility clinics or reproductive endocrinologists. In fact, even if you’re considering adoption, it’s a good idea to mention this. She may have information on adoption agencies or private adoption lawyers that can help you.

If possible, it’s an excellent idea to bring copies of any pertinent medical records — blood tests you’ve recently had (not only follicle stimulating hormone (FSH) or estrogen levels, but also cholesterol tests, or general blood chemistries). Your doctor may want to retest you, but even in this case, it’s helpful for her to have a record of your past tests.

It’s tough to say exactly how long you can expect this initial consultation to last because it can and does vary according to your specific situation, what you need to cover and so forth. But, all in all, expect to spend from 15 minutes to as much as 30 to 40 minutes just talking. If the doctor talks to you for less than fifteen minutes or if you haven’t covered the points listed above, don’t hesitate to offer subjects up yourself… and think about looking for a new doctor!

The Physical Exam

Once your doctor has gotten a chance to talk with you and learn about your case, it’s off to the examination room for your check-up.

Even though you’re seeing the doctor specifically because of early or premature menopause, the physical exam itself is pretty much the typical gynecological exam you’ve been through dozens of time before.

Expect the doctor to check your weight, pulse, blood pressure, and heart; feel your thyroid — the gland in your throat — to check for swelling or abnormalities; give you a breast examination, and palpate your abdomen.

Then it’s on to the pelvic exam — in which your doctor will be checking for vaginal atrophy (a sign of low estrogen), give you a Pap smear, and view your vaginal walls and cervix.

Unless you’ve had more than one recent blood test to check your hormone levels, you will probably get a blood taken at this time as well — to run hormone level tests and, possibly, other blood tests such as thyroid antigen.

Typical Components of an Examination

Here’s a list of the procedures and tests you can generally receive when seeing a doctor — as well as what the doctor is checking for and why these procedures are important.

Physical Exam:

•    Cardiovascular check-up (blood pressure measurement, listening to heart, etc): check for signs of cardiovascular disease, high blood pressure, varicose veins — which helps the doctor determine whether you’re a good candidate for HRT

•    Pap Smear: part of your usual gynecological exam, checks for possible cancerous or precancerous cells in your vagina, cervix and uterine lining. If a pap test comes back positive, your doctor will probably order other tests.

•    Thyroid: checks for enlargement or lumps. If there appear to be abnormalities, you’ll probably also get a thyroid blood test (see below).

•    Breasts: checks for lumps, thickening, cysts, nipple or skin changes.

•    Abdomen: checks for swelling and tenderness.

•    Pelvic exam: checks for cancer of the vulva, size and condition of your reproductive organs; strength of your pelvic muscles, uterine cancer signs; vaginal dryness and atrophy, uterine or bladder prolapse.

Blood tests:

Blood tests are done to determine the levels of different hormones you are producing (which is used to diagnose menopause), and to measure other components such as cholesterol and thyroid hormone. Most common is testing of:

•    Follicle Stimulating Hormone (FSH): usually drawn on the first, second or third day of your cycle; usually tested for at least two successive months; high FSH (over 30) is considered a signal of menopause or ovarian failure.

•    Estradiol: also usually tested more than once. Low levels (less than 36) is usually considered a sign of menopause or ovarian failure.

Depending on your symptoms and health history, the doctor may also check your:

•    Testosterone: typically measured if you’re complaining of symptoms such as very low libido, fatigue, etc. Levels less than 30 nanograms/ml typically considered low.

•    Progesterone: Levels greater that 5 milligrams/ml on day 20 of your cycle indicate that you are still ovulating.

•    Luteinizing Hormone (LH): high LH to FSH levels can signal polycystic ovarian disease (PCOD) — which can cause stopped periods without menopause.

•    Prolactin: often measured if you have stopped having periods, but aren’t experiencing menopausal symptoms — and/or if your FSH and estradiol levels are normal.

•    Lipid profile (blood cholesterol and triglyceride levels): measures your LDL and HDL cholesterol as well as your triglycerides. Given to determine your cardiovascular risk — which often increases with low estrogen levels. Often if you have high levels before going on HRT, your doctor will want to check it a few months after taking HRT, to determine if the HRT has had a positive impact.

•    Thyroid: measures the levels of thyroxine (T4) and T3; often tested because premature ovarian failure is often linked with autoimmune disorders and because many thyroid disease symptoms mimic menopausal ones.

(If you haven’t had a recent physical or blood chemistry test, your doctor may also test your blood sugar levels, liver function, and blood count — all to help determine your overall health and condition.)

For a detailed helpsheet explaining these tests, the units of measurement, and the meaning of the results, see: Hormone Level Tests

Special Tests

Given for specific circumstances (which generally aren’t used immediately, but may be scheduled for a later visit):

•    Bone mineral density test (BMD): checks for signs of osteoporosis or osteopenia.

•    Vaginal sonogram (also called a pelvic ultrasound): measures the thickness of your uterine lining, shows if you have uterine or ovarian cysts, endometrial hyperplasia, fibroid tumors, uterine or ovarian cancer, sometimes even endometriosis. Typically given if you have unexplained or excessive bleeding — especially if you are on HRT.

•    Endometrial biopsy: small scraping of tissue taken from your uterine lining; typically given if you have unexplained bleeding and if your sonogram showed possible abnormalities.

Follow-Up Visits: How Often, When and Why

As you’d expect, you’ll go back to see your doctor once the results from your blood tests are in. At this point, you and your doctor will discuss the results and come up with a course of action. Usually you will be given a prescription for HRT and begin taking it immediately.  You may also get sent for a bone mineral density test, since premature menopause puts you at such a high risk for osteoporosis.

Your doctor probably will recommend that you schedule a follow-up visit in two to three months to see how the HRT is working. This gives your body time to adjust to the hormones, and allows you to see if your symptoms subside and if you have any difficulty with the HRT.

Again, it’s a good idea to be prepared when you go in for the follow-up, armed with information about how you’ve adjusted to the HRT.

Be prepared to explain when and if you are bleeding and any symptoms or side effects you’ve noticed. And don’t ignore emotional symptoms. Some women experience PMS-like symptoms from HRT, including depression and moodiness. It’s important for you to let your doctor know what is happening to you, so she can evaluate your treatment.

If the HRT doesn’t seem to be doing its job, you may go through another blood test to see where your hormone levels are and try another form, until you end up with a therapy that works well for you. Often your doctor will recommend that, during your first year on HRT, you go in for follow-up exams every three months.

Your doctor may suggest that you get your bone density checked after a few months of taking HRT if you showed bone loss in your first scan. This will show how well the HRT is working in combating osteoporosis and signal if you need any further intervention, such as increasing your calcium intake or even taking Fosomax or another bone-builder. More recently studies have indicated possible side effects related to Fosomax and it tends to be prescribed only for the highest risk groups.

Usually, once it appears that you have adjusted to HRT, your doctor will tell you to come in for a checkup every six months. You should have a pelvic exam, a breast exam and any blood or urine tests necessary depending upon your symptoms — and once a year, you should have a Pap test.

When Should You Call Your Doctor In Between Visits?

While you may have no trouble at all adjusting to HRT and will only see your doctor during appointments, there are certain times when you should always call your doctor to check in and possibly arrange an interim check-up. These are:

•    You are on HRT, have an intact uterus and experience any unusual bleeding — including extremely heavy bleeding, bleeding when it isn’t expected (after six months of continuous HRT, for example), breakthrough bleeding, etc.

This may signal fibroids, endometriosis, polyps or something more serious like endometrial hyperplasia or uterine cancer. In this case, your doctor should order a pelvic ultrasound and/or an endometrial biopsy.

•    You notice changes in your symptoms — perhaps you had stopped getting hot flashes and are getting them again; are noticing a change in your periods or are experiencing strong cramping. Your doctor needs to know about these changes and may want to change your HRT.

•    You develop uncomfortable side effects from HRT — such as migraines, allergic reactions, pains in your legs, etc.

Finally, if you have any questions at all — about treatment options, new prescriptions that have been introduced and that interest you, minor side effects, anything that affects your quality of life — you should feel free to call your doctor and ask. If you’re with the right doctor, you should be secure in the knowledge that she will answer your questions and take interest in your menopause management.

The 10 Rules of Being a Good Patient

Having a good doctor-patient relationship is a two-way street. To get the best care possible, you have to be a good patient.

Being a good patient doesn’t mean accepting the doctor’s word blindly or staying completely quiet throughout an examination. It does mean being involved, interested and informed.   So here are ten simple rules that will help you get the care you deserve:

#1   Be prepared. The old Boy Scout motto applies just as well to medical patients. When you see your doctor for a regular appointment, call with a question, or come in for a special problem, you should always be ready to explain exactly what your complaints are, what symptoms you’ve been having, and so on.

As I’ve mentioned before, it’s often a good idea to keep notes on symptoms (consider using our symptom tracker), or jot down questions you have. This way, when you speak to your doctor, you’ll have the pertinent information at hand. It’s also helpful to list your complaints or questions in order of importance — so you’ll be sure to get the most important points covered if you run out of time.

#2   Be organized. When you call for appointments, let the receptionist know why you need to see the doctor — and be as specific as possible. This will help her schedule enough time for you. And be sure you know what you need to bring with you for insurance purposes.

#3   Be prompt. Don’t show up late for appointments. It sounds simple, but many people do this… and it doesn’t make for the best doctor-patient relationship! If you’re worried that you’ll be stuck reading magazines in the waiting room for a long time, call before your appointment and ask the receptionist if the doctor is running behind schedule — and if you should arrive later.

#4   Just as you expect your doctor to be professional yet friendly, be the same. A good doctor-patient relationship is a professional one — so you should be professional yourself. Don’t overdo the small talk, little niceties and jokes. A little of this goes a long way.

Yes, it’s good to feel at ease and to chat a bit. But you don’t want to waste the doctor’s time on subjects that don’t relate to your medical situation, nor do you want to detract from the real business of your appointment… your health.

#5   Don’t underplay any symptoms or physical complaints you may have. All too often, when you’re sitting in a doctor’s office, you get an attack of the “it’s not really that bad” syndrome — and either don’t mention problems you’ve been having or mention them as an afterthought, as if it’s really not a big deal.

Well, when it comes to premature menopause — or anything about your health, actually — it is a big deal! Some symptoms can mean you’re adjusting poorly to HRT, or, worse, that you’ve developed complications, like fibroids, or even cancer. Your doctor won’t be able to help you if you don’t clearly and honestly present any physical complaints to her.

Do her — and you — a favor by speaking up. A confident patient who is forthright about her problems gets the best care.

#6   Ask questions. This is one of the toughest areas for many women… including me. While I’m a forthright person in general, put me in a doctor’s office and suddenly I find myself keeping my mouth shut, listening, and nodding my head — even if I have a million questions. But it’s important to ask questions of your doctor — questions about treatments, prescriptions, tests, and so on.

Again, being a good patient means keeping yourself informed and understanding what is going on in your body. If you don’t ask questions, you won’t be able to get a clear picture of your medical situation.

#7   In a similar vein, be sure you understand the doctor’s answers — and don’t be frightened to ask for further explanations. Just because your doctor thinks she’s answered your questions doesn’t necessarily mean she has where you’re concerned. If your doctor explains something to you, but you’re still unclear about it, simply say so — and ask for further explanation at that time. Don’t go home and wonder — or call later. Asking follow-up questions at the right time saves time for both you and the doctor.

#8   If you’re confused, ask for information in plain English, not medical-ese. Often a doctor will tell you about procedures or treatments using technical language… and you have only the vaguest idea of what she’s talking about. Speak up! Ask for a translation in simple, layperson’s terms. If you don’t understand what is being said, you can’t make an educated decision… which, in the long run, won’t help the doctor or you.

#9   Before you leave, be sure you understand the possible side effects of any tests or medication the doctor recommends. Again, it’s a matter of speaking up and asking questions. Before you leave your doctor’s office, before you fill that prescription or schedule a test, make sure you know what to expect, what the test entails and why it’s being recommended — or what the prescription is for, why you need it, and whether you can expect any side effects. This way you’ll know what you’re in for — and won’t need to call the doctor later with questions.

#10   Finally, if you’re dissatisfied with the care you’re getting, speak up! Your doctor won’t know that you have a problem with her care unless you point it out. So let her know diplomatically. Be clear, honest, and explicit. Then, if the problem isn’t rectified, start looking for a new doctor.