NURSING PRACTICE AND HEALTH CARE

Importance and objective: Women have an unmet need for support during the emotionally and physically challenging phase of menopause transition. This calls for an ideal virtual and/or physical group for community building, education, and formal peer support. The objective of this review was to examine the groundwork conducted to establish a multidisciplinary menopause support group in the Mid-South region. We describe various elements for implementation of provider-supervised strategies in other healthcare settings.

Methods: We describe the steps taken to establish a provider-led peer support group while reviewing the relevant literature to generate a detailed assessment of practical steps and practices for menopause support groups.

Discussion and conclusion: Despite the low health literacy rates in the greater Mid-South area, the support group discussed reached women from diverse backgrounds and provided an interdisciplinary array of information. Surveys completed by support group participants are used to assess the quality of this provider-led peer support initiative. Future surveys assessing prior knowledge of the condition, acceptance of interventions, and compliance with therapy may guide the topics covered in the support group. This is turn may have potential to improve long-term health concerns, as menopause remains an ever-evolving field.

Menopause transition, Menopause, Support group, Community outreach, Health literacy, Mid-South

Menopause support groups are essential for building bridges between health care providers and patients while facilitating a space for communication and education to increase patient self-advocacy and health literacy. In this review, we address the need for support groups among vulnerable populations with low health literacy rates and discuss specific strategies to implement among such support groups.

Health literacy rates in most locations surrounding the health care system in the greater Mid-South area are in the lowest quartile nationwide. In some locations, 67% of the population is at or below basic health literacy scores [1], presenting an urgent, unmet need for accessible health education. Further, support groups provide ideal spaces to address issues occurring not only in the greater Mid-South area but across North America.

Menopausal transition can be an intense time of change for many women; thus, a space for emotional and educational support is essential [2]. Additionally, for perimenopausal women, education in anticipation of post menopause is important so that women are prepared for what is ahead, can coordinate options for managing these changes, and can initiate behaviors leading to healthy aging [3].Support groups provide an ideal space for education in a more casual setting and can serve as a forum to increase patient volume for women’s services. Women in similar physiological periods can collaborate on shared experiences and emotions while being supported by health care professionals within a clinical setting. The ‘Transition to Menopause’ support group at Regional One Health aims to meet those needs and provide such care.

In 2018, through collaborative efforts of the Colleges of Medicine and Nursing, women’s health providers with faculty practices collaborating with a local hospital/healthcare practices began discussions on effectively providing menopausal transition education to women in communities with low health literacy rates. Throughout three years of continuous evaluation, introspection, and working with the system’s marketing department, the menopause support group has employed many methods and modalities to disseminate support group information and provide effective resources that meet community needs. Marketing strategies relied upon word of mouth, social media, and brochures. Moreover, strong calls to action were emphasized in promotional materials to encourage participation. These strong calls to action were implemented by considering the target audience and providing them with a clear, direct means of learning about menopause services. The audience was encouraged to attend meetings and make appointments with menopause care providers.

Support group participants were enrolled from the community and associated hospital primary care clinics through outreach by marketing personnel. Promotional materials were distributed among surrounding communities using social media platforms, webpages, blogs, and other virtual-based promotion techniques to attract participants. The promotional materials addressed topics to be covered; emphasized the importance of such resources; and highlighted credentials of the health care professionals leading the support group, including the NAMS-Certified Menopause Practitioners credentialing for two lead providers in the support group. The materials contained information about the meeting location and time as well as contact information for the health care professionals organizing the events. Meetings occurred in person upon initial establishment of the support group and continued into the COVID-19 pandemic, whereupon it was then adapted to a virtual platform. With the increased availability of the COVID-19 vaccine and changes in CDC recommendations, the support group was held in a hybrid manner – both in person and via virtual platform. The number of participants fluctuated monthly but typically included less than a dozen women.

Analytical formal measures and surveys were implemented to gauge participant satisfaction and future desires in addition to informal conversations with participants during group gatherings. 

The ‘Why’

Menopause is defined as the cessation of the menstrual cycle and is diagnosed retrospectively after 12 months of amenorrhea [4]. Physiologic cessation of ovarian function is characterized by decreased production of ovarian follicular estrogen [5]. Dysregulation of the hypothalamic-pituitary-ovarian axis during menopause results from decreased ovarian feedback of Inhibin and estradiol (E2). The declining concentrations of Inhibin stimulate an increase in follicle-stimulating hormone (FSH), which downregulates E2 [6]. While this is typically a normal physiological change for many women and is accompanied by the cardinal symptoms of vasomotor “hot flashes,” the physical and hormonal changes may stimulate other symptoms such as irregular menses, mood changes, and sleep disturbances [7]. Support groups specifically work to target these emotional, physical, and relational needs while providing peer-based and professional healthcare support even before symptom onset.

Many women experience a range of physical, emotional, and sexual changes that present during menopause, [8] with some common physical symptoms of menopause including hot flashes and night sweats [9]. Evidence suggests a strong association between a woman’s age at menopause and biological aging, and symptoms of menopause may accelerate the aging process [10,11].

Decreased estrogen stimulates bone remodeling, which results in bone loss and microstructural deterioration [12]. Declining levels of estrogen and testosterone by the ovaries and adrenals contribute to sexual symptoms such as a lower sexual drive and poor lubrication [13]. Mood and behavioral changes such as depression are typical clinical presentations as well as changing perceptions of body image [14].

At high concentrations in vivo, estrogen exerts a beneficial antioxidant effect by inhibiting the 8-hydroxylation of Guanine DNA bases; however, estrogen levels decrease during menopause and pro-oxidant effects predominate [15,16]. This oxidative stress can result in disruptions to the circadian rhythm, which can affect the quality and amount of sleep that women receive [15,17].

The ‘How’ of a provider-led peer support group

Support groups are an ideal space for patients to confidentially share information and firsthand experiences related to menopause transition and for medical experts within a community to connect with patients. Thus, the need for support groups and education is widely present, especially in urban locations such as the greater Mid-South area. Our support group engages women from a diverse array of medical, socioeconomic, and ethnic backgrounds.

Provider-led peer support groups such as ours provide a collaborative space for women to engage with trained menopause care specialists who can provide evidence-based, real-time responses to their questions. Additionally, such support groups, when hosted in a socially distant indoor space like a conference center, serves well as a casual environment with temperature control in times of the pandemic.

Nuts and bolts

Providing accessible and convenient education is essential; thus, our support group implements various strategies to facilitate attendance. For instance, the support group is strategically scheduled in a hybrid manner, with in-person and virtual meetings being available around lunch time so that women could participate during their lunch breaks. Additionally, food and beverages were provided at in-person meetings to incentivize attendance and ensure that participants’ dietary needs were met. Support group sessions were hosted at health care facilities if participants intended to schedule appointments to consult providers. (Tables 1 and 2) provide our framework for establishing our menopause support group.

Menopause support group sessions began with an educational presentation by a health care provider, with opportunities for open and honest dialogue and to question the provider during the presentation being made readily available. This was followed by a discussion forum to continue the conversation and elicit opportunities for support group members to share individual experiences and bond over shared emotions and concerns.

Through the casual dialogue initiated by participants and healthcare professionals alike, support group participants shared their questions with healthcare professionals, providing insight into participants’ concerns and various modalities to control and mediate their concerns. Additionally, participants were encouraged to seek out their health care providers when specific concerns arose as well as seek a diagnosis by a health care provider in a clinical setting if needed.

Our menopause support groups provide educational treatment primarily through oral lectures with an accompanying visual presentation. The presentation was delivered by a health care provider and included citations from peer-reviewed scientific literature to support the presented material. Participants were encouraged to engage in question-and-answer dialogue during and after the educational aspect of the support group. In the virtual platform, participants were encouraged to use the chat box function provided by the video conferencing platform to share thoughts or questions about the material. This chat box function allows participants to express their thoughts publicly to the whole group or privately to the lecturer. The lecturer is alerted of the message and can quickly address the concern(s) without auditory input from participants.

Participants asked a wide range of questions including the following inquiries: “I am 57 and haven’t gone through menopause. Why is taking so long to happen?” “How does a hysterectomy or oophorectomy affect menopause?” “What natural remedies help with the side effects of menopause?” and ‘’Does marijuana provide relief from menopause?”

Since academic support is delivered through the healthcare provider, open dialogue is also encouraged, as the healthcare provider can step back and provide space for peers to express their concerns. These concerns, when expressed by peers in the menopause support group as the health care provider transitions from continuous conversation to curtailed comments, facilitates a safe space for participants to express their honest concerns. Healthcare providers intervene, at appropriate times, to contribute current medical advice to participants’ concerns and fears.

The focus of the support group centers on menopause’s impact on quality of life, the effect social determinants of health contribute, and women being the best advocates for their health in this phase of life. Health education has been a proven technique to alter the perceived severity of menopausal symptoms and the overall knowledge and attitude surrounding menopause [18]. Conversations with health care providers, and the resulting education gleaned from these conversations about the assessment and diagnosis of menopausal symptoms, are essential. One of the principal factors to consider in assessing diagnoses is the ways in which quality of life is affected. Health care providers can get a better sense of how to best diagnose and assess symptoms when patients share the ways in which their symptoms have affected their quality of life [19]. Support group participants are often queried about the severity of their symptoms, frequency, and intensity and are encouraged to share this information with their health care providers in a clinical setting to better assess the best therapeutic strategies for them [20].

Choosing the topics of discussion 

Sessions cover a wide array of topics (Table 3). They are carefully chosen by the providers leading the group. These include breast health, sexual health, bone health, weight gain in midlife, depression, menopausal hormone therapy, hot flashes, and genitourinary syndrome. Additionally, participants were encouraged to weigh-in on various issues that they felt needed to be further addressed or required additional support. Women were encouraged to present topic ideas that particularly affected their daily lives.

Annual needs assessment survey is performed by the marketing team in collaboration with the menopause providers to determine factors and discussion topics that affect participation. Ongoing feedback from participants is also obtained by marketing personnel regarding support group sessions and strategies that increase their participation.

Importance of peer support group

Support groups provide safe, non-judgmental spaces to share anecdotal experiences with other participants in the menopausal transition, connect with peers who may be enduring similar changes, and experience much-needed community support during a pandemic. Akin to prenatal group sessions, this program emphasizes the importance of community. In the presence of peers, individuals are more likely to share their concerns openly and seek care with a provider. These relationships may facilitate connection for vulnerability and support even outside of structured support group sessions [21].

One of the most essential functions of a support group has been providing a space for patients to meet with health care providers outside of the clinical setting. This facilitates a preventative strategy and promotes a focus on general well-being of the individual rather than treating a disease. Topics such as this are covered often in our support groups, e.g., preemptive use of vaginal moisturizers and vaginal lubricants.

Ongoing challenges

Menopause provider-led peer support groups have ongoing challenges. While maintaining a space of trust in times of a pandemic and adjusting to the ever-changing needs of our community, we encountered challenges in continuity, use of conference room space, timing, and meeting frequency. We recognize the importance of holding regular meetings at a predetermined time each month. Availability of credentialed menopause care providers is also imperative to its success, as it facilitates trust [22]. When a virtual platform was adopted, participants entered and exited the virtual platform at will, thus providing appropriate space for flexibility and comfort.

As we transitioned the group to a completely virtual platform, a few topics, e.g., bone health, faced challenges of diminished open communication. While the first meeting, after pivoting from an in-person to online format, provided strong momentum of engagement, it was more difficult to maintain long-term involvement when participants did not turn their cameras on to show their faces and reactions while engaging in the virtual presentation. We found many participants would silently watch the presentation without providing insight or contributing to the conversation. While this reaction may be appropriate in some instances, considering some participants desire privacy, are suffering from “Zoom burnout,” or have other distractions occurring in their individual environments (versus a distraction free conference room environment), it complicates the process of creating and fostering a productive community atmosphere for a virtual support group.

To retain participant engagement and comply with local health directives, the support group sessions regularly assess safe ways to adopt a hybrid model of holding in-person and virtual meetings. Consequently, menopause support groups were held in-person and adapted to a virtual format during the COVID-19 pandemic to adjust to present health mandates while also continuing the momentum and connection of the group before the pandemic.

Support group in the time of a pandemic

A decrease in participation was evident in Spring 2020. We attribute this to the start of the COVID-19 pandemic when adjustments were being made to improve retention and attract more participants. Some of the considerations made for changes included incorporating relevant topics and presenting them in a virtual format while retaining the interactive nature of a support group. Key factors to consider were the virtual platform structure of the meeting, limited availability of smart devices, and internet coverage for some participants and its effect on the overall level of participation. The marketing team continued to monitor ongoing challenges to prepare team leaders and generate conversations that could catalyze interactions of those individuals whose participation decreased; these steps are crucial to promoting continued engagement [23].

The Future of Menopause Support Group

The field of public health education related to menopause transition has immense potential to grow; for instance, more long-term studies measuring the effects of support groups during and after the COVID-19 pandemic and the ways in which they adjusted or failed to adjust are essential. Additionally, studies measuring the effects that women experienced, whether educationally or physically—especially for those patients whose experiences may have been interrupted by the pandemic— are important. Other studies show that support groups have significant positive outcomes for participants. For instance, one randomized controlled study found that support groups were an effective strategy in reducing symptoms of menopause that present early [24]. Additionally, some of the literature provides evidence that peer support groups can lower depression levels among menopausal women who are especially vulnerable to emotional and hormonal changes [25]. Thus, further amplifying support groups’ roles and benefits can provide avenues for prevention and treatment of menopause-related symptoms.

Future directions for menopause support groups lie in the continued assessment of the needs of its participants, their experiences, and creative ways to convey key information to them (Table 4). Formal surveys and informal interactions have resulted in new menopause topics, such as those related to mental health, weight and nutrition, sex, menopause 101, the importance of physical activity, and menopause myths versus facts. Additionally, evening group meetings were founded after participants demonstrated an interest and need for post-work meeting times.

Designing comprehensive, literacy-adjusted needs assessments to collect this information will be pivotal to the future and progress of the support group. Participant retention remains crucial in the evolving COVID-19 pandemic. There remains an unmet need to reach out to more participants inclusive of all levels of health literacy, gender identification, and diversity in our community. This would include introducing relevant topics, having team leaders with appropriate clinical training to facilitate these discussions, and reaching out to the community to market the same information.

Additionally, further research should be conducted through simple random sampling surveys to assess impact of menopause support groups on long-term health. Implementing mechanisms of transparent and open communication and collaborative efforts with team leaders in related fields such as endocrinology, plastic surgery, neurology, lifestyle medicine, etc. should be further explored to expand upon these topics, making them more pertinent to this phase of life.

Low health literacy rates generate a great need for menopause education and support. Menopause support groups are an integral part of a health care setting and provide a platform for medical education, emotional assistance, and a sense of community [1].

1.  University of North Carolina at Chapel Hill. Health LiteracyData Map. Accessed July 13, 2021.
2.  McCloskey CR. Changing focus: Women’s perimenopausaljourney. Health Care Women Int. 2012;33(6): 540–559.
3.  McNamara M, Batur P, DeSapri KT. In the clinic. Perimenopause.Ann of Int Med. 2015 Feb;162(3):ITC1–IT15.
4. Horbaczewska A, Jach R, Zmaczyński A, et al. Challengingiatrogenic menopause. Oncofertility programme in Poland- a single-centre experience. Prz Menopauzalny. 2019Jun;18(2):63-67.
5. Sabbatini AR, Kararigas G. Menopause-Related EstrogenDecrease and the Pathogenesis of HF p EF. Journal of theAmerican College of Cardiology. 2020 Mar;75(9):1074-1082.
6. The North American Menopause Society, Ch 1.
7.  Potter B, Schrager S, Dalby J, Torell E, Hampton A. Menopause. Primary Care: Clinics in Office Practice. 2018;45(4):625-641. doi:10.1016/j.pop.2018.08.001
8.  Ceovic R, Mance M, Bukvic Mokos Z, Svetec M, Kostovic K,Buzina D. Psoriasis: Female skin changes in various hormonalstages throughout life—puberty, pregnancy, and menopause. BioMed research international. 12/28 2013;2013:571912.
9. Dibonaventura MD, Wagner JS, Alvir J, Whiteley J. Depression,quality of life, work productivity, resource use, and costsamong women experiencing menopause and hot flashes:a cross-sectional study. Prim Care Companion CNS Disord.2012;14(6):PCC.12m01410.
10.  Levine ME, Lu AT, Chen BH, et al. Menopause acceleratesbiological aging. Proc Natl Acad Sci U S A. 2016Aug;113(33):9327-9332.
11. . Monteleone P, Mascagni G, Giannini A, Genazzani AR, SimonciniT. Symptoms of menopause - global prevalence, physiologyand implications. Nat Rev Endocrinol. 2018;14(4):199-215.
12. . Bjørnerem Å, Wang X, Bui M, et al. Menopause-RelatedAppendicular Bone Loss is Mainly Cortical and Results inIncreased Cortical Porosity. Journal of Bone and MineralResearch. 2018 Apr;33(4):598-605.
13.  Scavello I, Maseroli E, Di Stasi V, Vignozzi L. Sexual Health inMenopause. Medicina (Kaunas). 2019 Sep;55(9):559.
14. Soares CN. Depression and menopause: Current knowledgeand clinical recommendations for a critical window. PsychiatrClin North Am. 2017;40(2): 239–254.
15.  Rangel-Zuñiga OA, Cruz-Teno C, Haro C, et al. Differentialmenopause- versus aging-induced changes in oxidativestress and circadian rhythm gene markers. Mech Ageing Dev.2017;164:41-48.
16. Doshi SB, Agarwal A. The role of oxidative stress in menopause.J Midlife Health. 2013 Jul-Sep;4(3):140-146.
17. Wang Z, Chandrasena ER, Yuan Y, Peng KW, van BreemenRB, Thatcher GR, Bolton JL. Redox cycling of catecholestrogens generating apurinic/apyrimidinic sites and 8-oxodeoxyguanosine via reactive oxygen species differentiatesequine and human estrogens. Chem Res Toxicol.2010;23:1365–73.
18. Koyuncu T, Unsal A, Arslantas D. Evaluation of the Effectivenessof Health Education on Menopause Symptoms and Knowledgeand Attitude in Terms of Menopause. J Epidemiol Glob Health.2018 Dec;8(1-2):8-12.
19. Woods NF. Assessing menopause-specific quality oflife in studies of the menopausal transition and earlypostmenopause. Menopause. 2014 Aug;21(8):792-793.
20. Pimenta F, Leal I, Maroco J, Ramos C. Menopause Symptoms’ Severity Inventory (MSSI-38): assessing the frequency andintensity of symptoms. Climacteric. 2012 Apr;15(2):143-152.
21.  Devlin RA, Rudolph-Zbarsky J. Social networks and the probability of having a regular family doctor. Soc Sci Med.2014;115:21-28.
22. Leversedge FJ. Guidelines for short-term hand surger you treach trips: Building trust and establishing continuity. Hand Clin. 2019 Nov;35(4):449-455.
23.  Ford R, Piccolo R, Ford L. Strategies for building effective virtual teams: Trust is key. Business Horizons. 09/01 2016 Jan-Feb;60.
24. Sehhatie Shafaie F, Mirghafourvand M, Jafari M. Effect of education through support group on early symptoms of menopause: a Randomized controlled trial. J Caring Sci. 2014Dec;3(4):247-256.
25. Yusuf A, Armini NKA, Hardiyan D. Peer group support decrease depression level in menopause woman. Jurnal Ners(Surabaya). 2017 Nov;3(1):61–66.