When Doctors Disagree About Menopause

I wasn't having some dramatic medical emergency. I was spotting.

It wasn't particularly heavy or alarming, but it was irregular for me, even by perimenopause standards. And because apparently annual Pap smears aren't recommended anymore, it had been a while since anyone had actually gone under the hood to make sure everything was okay. I just wanted to make sure.

I already had a Primary Care Physician and a telehealth menopause provider who prescribed my HRT, an estradiol patch and progesterone. My PCP had initially raised an eyebrow because HRT wouldn't have been her first line of treatment for perimenopause. But my symptoms had improved so drastically that she ultimately decided it was working and was fine with me continuing.

Still, I thought, I'm taking hormones. I'm having some irregular bleeding. I'm 49. Maybe I should have an actual OB-GYN on my team, preferably one who specializes in menopause, to help me navigate whatever these remaining years decide to throw at me.

Simple, right? Absolutely not.

The different meanings of "menopause specialist"

I've discovered that "menopause specialist" can mean very different things. There seem to be a few different camps:

• The old-school doctors: Birth control tends to be the go-to during perimenopause.
• The newer-school doctors: More comfortable prescribing estradiol patches, gels and progesterone.
• The test-everything doctors: They want to see your hormone levels before deciding what to do.
• The treat-the-symptoms doctors: Hormones fluctuate during perimenopause, so symptoms guide treatment more than bloodwork.
• The look-at-everything doctors: Symptoms, medical history and testing are all considered, but many of the ones I've found charge an additional concierge fee for that level of care.

Same woman. Same symptoms. Completely different philosophies.

Ultimately, my hormones are out of whack, and I'm just looking for the most effective, accessible way to balance it all without losing my mind in the process. Who knew Hormone Replacement Therapy would become such a point of contention among healthcare providers?

I'm just trying to feel better

I wasn't trying to join a side in the Great Hormone Debate. I was just trying to feel better. Unfortunately, the OB-GYN I found fell into the first camp - an old-school doctor. I explained that I was taking an estradiol patch and progesterone. She was immediately against it.

Not, "Here's why I would have chosen something different."
Not, "Let's talk about the risks and benefits."
It felt like: You absolutely should not be doing this.

She told me the patch wasn't for perimenopause. She told me it wasn't bioidentical. She told me it could be responsible for my irregular periods. She was so combative about it that I actually felt like she was mad at me.

I remember sitting there thinking, "But another doctor prescribed this." I'm not buying hormones from somebody in the parking lot behind CVS. A licensed medical professional evaluated me and prescribed them. My PCP knows I'm taking them. Yet I'm sitting in another medical professional's office feeling like I've somehow made a reckless medical decision.

I came in wanting a Pap smear. I left questioning my entire existence.

Later that month, I told my telehealth menopause provider what happened. Completely different reaction. She calmed my nerves and explained why, based on my history and the amount and type of bleeding I described, she wasn't immediately concerned and didn't think I automatically needed imaging at that point.

So now what?

One medical professional has me leaving the office wondering whether my HRT is causing a problem and whether I need an ultrasound. Another hears the same story and essentially says, "This can happen. Here's what we're watching for."

How is the patient supposed to reconcile that?

Maybe that's the part of "advocating for yourself" we don't talk about enough. We constantly tell women to ask questions. Get a second opinion. Find a specialist. Do your research. Know your body. But what happens when you do all of that and the experts still disagree?

I don't expect medicine to be completely black and white. Two doctors can look at the same information and reasonably choose different approaches. But I do expect someone to explain the gray.

Don't just tell me another form of treatment is wrong. Tell me why you disagree. Tell me what evidence you're relying on. Tell me the benefits and risks of your recommendation versus theirs. Tell me what would make you change your mind.

Otherwise, you're not helping me make an informed decision. You're asking me to choose which philosophy or methodology I believe.

So, what do you do when your doctors disagree?

1. Ask why, not just what. "I wouldn't prescribe that" isn't enough. Ask why they recommend something different for you and whether your current treatment is actually harmful.
2. Ask what they're watching for. "Is this normal?" isn't always the most useful question. Ask: What would make this not normal? What means call you? What means go to urgent care?
3. Remember that a second opinion is another opinion, not necessarily the final answer. Sometimes it gives you clarity. Sometimes it gives you another decision to make.
4. I went looking for another expert on my team. Instead, I learned that "specialist" doesn't necessarily mean "consensus."

Informed consent can't simply be about finding the one doctor who has all the answers. It's about finding doctors willing to explain why their answers are different.