Key Takeaways:
- Patients experiencing menopause are at risk for misdiagnosis-related harm.
- Patient harm is primarily due to the complexity of symptoms and the stigma that often surrounds discussions of menopause.
- Effective and equitable menopause care is an integral part of becoming an age-friendly health system and advancing patient safety.
Introduction
Menopause is a condition that is often unrecognized and misdiagnosed. Hospitals and the safety strategies they employ can play a key role in preventing harm to these patients. In this article, we share the common reasons for misdiagnosis and resulting risks to the patient, along with recommendations for patient safety professionals to address the unique needs of the growing menopausal patient population.
Menopause is a condition that is often unrecognized and misdiagnosed due to its wide range of symptoms, the extended amount of time it impacts health and, in part, by the fact that many clinicians are uncomfortable discussing the condition openly. With the collective mindfulness required of hospitals to become highly reliable organizations, we can eliminate the harm caused by misdiagnosis by ensuring our patient’s symptoms are adequately explained and not dismissed.
What is Menopause?
Menopause is a normal physiological stage in middle-aged women where a woman’s reproduction system no longer produces a menstruation cycle. Although it is diagnosed when a woman has not experienced menstruation for 12 months, there are phases before (perimenopause) and after (post-menopause) that involve complex hormone fluctuations that impact the entire body. The symptoms can be cognitive, such as trouble concentrating, memory lapses, and mood disturbances. The symptoms can also be physical such as joint pain, appetite changes, and fatigue. Hormone disruptions have such a broad influence on the body that they can mimic other conditions. In one example, a woman suffering from progressive cognitive decline was diagnosed with vascular dementia—confirmed by MRI—however her symptoms did not vanish until she was treated for menopause.
Prevalence
Menopause affects over a million women every year. In California, the number of menopause healthcare encounters is rising. See Figures 1 & 2. As our aging patient population increases, so does the number of patients in our care experiencing menopause. Symptoms of menopause can begin in the 30s and persist for up to 10 years after onset. Since the average age of onset is approximately 48 years of age, when combined with the perimenopause and post-menopause phases, this means half of the population may spend half their life subject to employment – disrupting symptoms such as cognitive changes, mood disorders and bone disease. For many of these patients, providers misattribute symptoms to other conditions or side effects of prescribed medications. With misdiagnosis rates estimated at up to 15%, menopause could be a significant contributing factor, potentially leading to inaccurate diagnoses.
Health Equity
Addressing the unique needs of a growing menopausal patient population is not only essential patient safety work, it is also essential health equity work. Studies consistently show that women are misdiagnosed more often than men. These gender biases contribute to health care disparities and negative outcomes in conditions such as heart disease, stroke, and pneumonia. Approximately one-third of women diagnosed with menopause are also diagnosed with hypertension. See Figure 3. Given that hypertension is a major risk factor for heart disease and stroke, and it is also associated with menopause, this raises the possibility that these related conditions are not being adequately recognized in women. There may also be racial and ethnic disparities among diagnosis. Although Hispanics and Caucasians represent similar portions of California’s population, the number of Caucasians diagnosed with menopause is nearly twice as high. See Figure 4.
Difficulties with Diagnosis
Misdiagnosis does not always result in patient harm. For example, if a patient receives seizure medication following a traumatic brain injury, they may not be harmed by the medication even if the seizures are later found to be caused by alcohol withdrawal. The goal of preventing misdiagnosis-related harm is to prevent harm associated with intervening based on the wrong condition, or harm from a condition ineffectively treated (due to being inaccurately diagnosed). For many women, this harm is significant. Women experience frustration, psychological distress, injury, or even death when their concerns are ignored, when there is a lack of awareness about gender differences in symptom presentation, or when they are released from care without proper testing. Despite the proven effectiveness of incentive spirometry in diagnosing COPD, for example, studies show that this test is more frequently used on men than on women. Missed opportunities to screen or dismissal of the patients’ symptoms can lead to a decrease in health-seeking behaviors, which in turn can result in further condition-related harm.
Two cognitive biases have been proposed as key contributors to misdiagnosis: the bias to overlook alternative possibilities, and the preference to believe initial thoughts. In fast-paced clinical settings, it is easy for well-meaning clinicians to rely on rapid decision-making, which can inadvertently lead to overlooking broader considerations.
Patient-Centered Harm Prevention
Women experiencing menopause are at significant risk of misdiagnosis-related harm. If the hormonal changes associated with menopause are not accurately recognized, the treatments recommended may be ineffective or inappropriate. Menopause affects health for more than half the adult lifespan, increasing the likelihood that symptoms are misattributed to other conditions or dismissed as baseline. This is an important front for patient safety work because patients with symptomatic menopause are at higher risk for comorbidities such as osteoporosis and insomnia. They are more likely to use antidepressants—a factor that can further obscure diagnosis due to the overlapping side effects; have increased primary care and gynecological visits; and face a greater likelihood of surgical trauma (hysterectomy).
The common treatment for menopause is hormone replacement therapy, although there are alternatives that are less researched. There are serious risks associated with hormone replacement therapy, such as elevated risks of cancer and cardiovascular disease: the decision to recommend treatment must be carefully balanced. While the potential benefits of reducing health risks should be considered, a critical factor should be the patient’s preference. Individualized care that fully informs the patient of risks, yet prioritizes their choice, is vital.
A patient-centered approach to safety means enacting system-level practices that foster a work culture continuously attentive to individualized risk. Managing the diverse needs of an aging population requires staff to be continually aware of the unexpected ways harm can occur. This means safe, equitable menopause care is only possible when health care teams work collaboratively to understand their patients and are supported by technical systems that seamlessly share clinical findings across encounters.
Recommended Actions
Education
- Incorporate menopause education into implicit bias training
- Ensure communication training for direct care staff includes methods specifically aimed at overcoming stigma and discomfort in discussing menopause
Clinical Practice
- When performing medication reconciliation, clinicians should carefully consider the more than 30 symptoms of menopause and differentiate them from medication side effects
- Use reflective statements to ensure care concerns are acknowledged
- Patient: “My brain fog lasts all day. I can’t read reports without coffee.”
- Caregiver: “It sounds like the brain fog is interfering with your work.”
Systems
- Optimize electronic health records so notes about the patient’s complaints are easily located
- Audit preoperative practices for obtaining informed consent. Ensure only appropriately licensed personnel are obtaining consent before a hysterectomy without exception
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