Телефон: 8(962) 7600-119

Главная / Архив / 2023 год / MEDICUS № 3 (51), May / MODERN INTEGRATED HEALTH CARE MANAGEMENT MODELS AND APPROACHES IN PRIMARY MEDICAL CARE FOR CLIMACTERIUM OF WOMEN

MODERN INTEGRATED HEALTH CARE MANAGEMENT MODELS AND APPROACHES IN PRIMARY MEDICAL CARE FOR CLIMACTERIUM OF WOMEN

Дата публикации: 16.05.2023

UDC 61

 

MODERN INTEGRATED HEALTH CARE MANAGEMENT MODELS AND APPROACHES

IN PRIMARY MEDICAL CARE FOR CLIMACTERIUM OF WOMEN*

 

Antoaneta Dimitrova, PhD, Assistant Professor

Department of Health Care

Faculty of Public Health “Prof. Dr. Tzecomir Vodenitcharov, PhD”

Medical University of Sofia

(1227, Bulgaria, Sofia, str. White Sea, 8)

E-mail: dimitrova9111@abv.bg

 

Tanya Veselinova, PhD, Chief Assistant Professor

Department of Health Care,

Faculty of Public Health “Prof. Dr. Tzecomir Vodenitcharov, PhD”

Medical University Sofia

(1227, Bulgaria, Sofia, str. White Sea, 8)

E-mail: tanq_veselinova@abv.bg

 

Boryana Traycheva, PhD, Chief Assistant Professor

Department of Health Care

Faculty of Public Health “Prof. Dr. Tsecomir Vodenitcharov, PhD”

Medical University Sofia

(1227, Bulgaria, Sofia, str. White Sea, 8)

E-mail: bobytraich@abv.bg

 

Abstract. Climacterium is a physiological period which is accompanied by a number of symptomatic manifestations in the short and long term, which are individual to each woman. This article presents integrated models of health care in the management of the climacterical period by applicable comprehensive approaches, focused on preventive medicine. Increasing the professional competences of health care specialists and facilities for provision of health education and health behaviour to women are required in order to optimise health within a period of transformation from a reproductive to a non-reproductive stage.

Keywords: women, climacterium, menopause, integrated approaches, care.

 

Introduction: Climacterium is a biological “transition” period of passing from reproductive to old age, throughout which the functional activity of the ovarian function gradually stops. This physiological process is related to short-term, mid-term and long-term expectations and symptomatic manifestations which have adverse impact on the quality of life of women. The process of biological natural transformation from a reproductive to a non-reproductive stage, accompanied by the disruption caused in the physical, psychological and social wellbeing, demands the employment of any facilities for a change in the health behaviour, improvement of knowledge, methods of motivation and enhancement of the perception of the menopausal period in women. Specific measures are required for the mitigation of the negative implications in this period as well as efforts for the inclusion of a series of health care and non-health care professional from various backgrounds and competence into a single comprehensive aggregate [11].

Presentation: Modern international recommendations constitute a complete programme which is directed towards upholding women’s health and quality of life during the menopausal period. According to the National Programme for Improvement of Maternal and Child Health 2014-2020, there is no implemented policy and an integrated approach in existence for women in menopause yet in Bulgaria [10].

Worldwide, there are menopause associations with representatives and experts involved from various health care, medical and non-medical professions and non-governmental organisations. They engage with the management of health care during climacterium and organise scientific and clinical studies, and provide evidence related to the processes of aging of the reproductive system in women, as well as the determiners affecting their health status. One of the tasks of the associations is to take part in the elaboration of national programme criteria and standards which are suggested to policy makers in the health care and social health system, for integrated management of the issues concerning the quality of life during climacterium. The guidelines come down to provision of preventive and prophylactic care for dealing with undesired effects, assessment and management of risk factors and promotional activities aimed at improving knowledge and creating useful habits in the behaviour and lifestyle of women during the perimenopausal and postmenopausal periods [7]. Prevention is achieved through educational workshops which have a reflection on the knowledge and skills for self-management and self-control of women during these periods.

The largest association is the International Menopause Society (IMS) and its mission is to work globally to promote and support access to best practice health care for women through their menopause transition and post-reproductive years, enabling them to achieve optimal health and wellbeing. The vision of IMS is that all women across the world will have easy and equitable access to evidence-based knowledge and health care, empowering them to be adequately informed and have health alternatives [9].

  • Supporting and promoting research into all aspects of the menopause and aging in women
  • Disseminating evidence-based knowledge to doctors and health care professionals all over the world through multi-lingual and multi-cultural educational resources, programmes and events
  • Facilitating collaboration and information-exchange between health care professionals, medical societies and organisations with shared interests and goals
  • Supporting and promoting excellence in the multi-disciplinary delivery of health care to women through the menopause transition and post-reproductive years
  • Development of evidence-based guidelines and position statements on issues related to the menopause and post-reproductive health
  • Increasing awareness and understanding of the menopause transition and post-menopause amongst the global community, health care professionals and policy makers
  • Providing health information to the global community, health care professionals and policy makers
  • Guiding the media in the communication of new research findings and consistent health messages.

The sections of the IMS website are related to an integrated approach which is focused on promoting education and study of the health of middle aged, based on scientific evidence-based knowledge of menopause management in primary health care. Recommendations are updated regularly on the basis of multi-disciplinary clinical trials in various stages of climacterium regarding the benefits and the risks of hormone replacement therapy (HRT) and preventive strategies. In the section for women and patients, information is brought down to public health education.

The focus in the recommendations [2] relating to the protection of middle aged and hormone therapy in menopause is on the following key points of which health care professionals and patients should be informed:

  • Consideration of HRT should be part of an overall strategy including lifestyle recommendations regarding diet, exercise, smoking cessation and safe levels of alcohol consumption for maintaining the health of peri- and postmenopausal women;
  • The risks and benefits of HRT differ for women during the menopause transition compared to those for older women;
  • HRT includes a wide range of products and routes of administration which may lead to a confusing and inappropriate effect;
  • Women experiencing a spontaneous or iatrogenic menopause before the age of 45 years and particularly before 40 years are at higher risk for cardiovascular disease and osteoporosis and may be at increased risk of affective disorders and dementia;
  • The safe use of HRT for at least 5 years in healthy women starting their treatment before the age of 60 is disputable;
  • HRT should be titrated to the lowest effective dose which reduces symptoms and maintains in the long term optimum quality of life for women, that is, the dose, regimen and duration must be individualised.

While hormone therapy helps many women during menopause, there also exist health risks which include:

  • Increased risk of endometrial cancer;
  • Increased risk of thrombosis and stroke;
  • Increased risk of breast cancer after prolonged use;
  • Moderate risk of cholecystitis.

According to the British Menopause Society (BMS), each primary medical care team must have special knowledge of the climacterical period in women. BMS offers continuous training for certification and specialisation of midwives and nurses. The idea is to provide high quality and good care to the women in climacterium, which includes education, lifestyle counselling, evidence-based information and need for therapy in order to optimise post-reproductive health [4].

The European Menopause and Andropause Society (EMAS) is concerned that there are not enough prepared health care professionals trained in the provision of help to women in climacterical period and encourages actively governments for the accreditation of the “Women’s Health” sub-specialty. [1] A conceptual framework of care in post-reproductive health is also proposed. The recommendations in this document are focused on preventive medicine through a holistic and multi-disciplinary approach towards an overall evaluation of the menopausal symptoms and long-term effects, associated with risk factor assessment, screening of cardiovascular, osteoporotic and gynaecological health, as well as breast health. Strategies include optimisation of diet and lifestyle. The team of the health care model in primary medical care consists of a leading clinician, a certified a midwife, or a certified nurse, and the woman, supported by an interdisciplinary network of health care experts and providers of alternative/complementary medicine [13].

Funmilola M. et al point out that many health care professionals have knowledge deficiency in middle-age women management and avoid any contradictions related to the use of hormone therapy and holistic approach in climacterium management, which requires additional training [5].

The Ministry of Health Care of Chile has developed technical guidelines for overall care for women at climacteric age at primary level in the health care network, which are based on a comprehensive model of a family and community approach. They state that a number of health-related, somatic and bio-psycho-social issues during the climacterical stage may affect the quality of life of women, due to the effect of the symptoms or the morbidity which occurs with age, mostly cardiovascular conditions, gynaecological cancer, osteoporosis and health-related medical conditions, highlighting the high level of distribution of depression. The guidelines pay attention to the multi-disciplinary and consistent work of teams, of health promotion, prevention of symptoms and medical conditions, as well as the control for the improvement of wellbeing of women in climacterium. The target population includes women aged 45-64, with or without menstrual cycle disorders; with premature, surgical and iatrogenic menopause and health care professionals – gynaecologists, endocrinologists, psychiatrists, internal disease physicians and general practitioners. This range also includes health care professionals engaged with primary medical aid (primary health care units), with the relevant competences: midwives, dietologists, nurses, kinesitherapists, psychologists, social workers and statisticians. It has been pointed out that health care for women in a climacteric period is the responsibility of all members in the health care system, and in the public health care network access is achieved through the midwives working in an obstetrics and gynaecology office or as a member of a health care unit. The preventive model includes a full medical examination of women: establishing and promoting regular prophylactic and screening tests, level of education for healthy way of life, symptom assessment by menopause rating scales, establishing any psycho-social conflicts within the family, work environment and public and social communication [15].

Bharti et al point out that optimal management of climacterium requires the expertise of a multi-disciplinary team which possesses various skills and applies a holistic approach, which conceptualises the participation of women’s physical, psychological and social need in the planning of the therapy. The holistic approach includes the effect of psychological and social factors on the diagnosis, therapy, diet, exercises, food supplements and other forms of treatment, and such care is patient-oriented [3]. The authors suggest the following framework of cares for women in climacterium:

  • A holistic approach oriented towards aetiology – a care model upon the onset of the symptoms and long-term chronic medical conditions; a multi-disciplinary approach to overall care, including coordination and continuation in work; intercultural issues based on age and symptoms in various cultures and multi-ethnic populations;
  • A holistic approach oriented towards medicinal targets – for comprehensive management of the following three items: bones, joints, muscles; factor assessment, prevention and therapy; comorbid medical and surgical conditions;
  • A holistic approach oriented towards therapy – physical activity and diet, fitness systems; isoflavones, calcium and vitamin D containing nutriceuticals;
  • A holistic approach oriented towards delivery of care – patient centred care; shared decision making, after a consultation with the health care provider and adequate information has been granted about the condition;
  • A holistic approach oriented towards support – stress management, psychological support; therapeutic education for women, including information about menopause and the effect of physiotherapeutic and natural procedures; compassion fatigue and burnout in health care professionals; mutual trust through seeking and delivering education, and use of available health care resources for active self-care (self-management); minimising the discomfort of change associated with the onset of climacterium through the internalisation of strategies and development of management plans;
  • Holistic ecosensitivity – the morbidity and impact of climacterium are related to the nature of the environment that women live in. Both physical (natural), and social (human), environment influence the natural history or clinical course of climacteric; the concept of ecosensitivity leads to the realisation that the family must be involved in the management of climacterium and in the provision of physical and emotional environment for the optimisation of the quality of life of women; spreading public awareness about climacterim, its implications and management strategies are essential for reducing the burden of this condition; policy makers and health care system administrators should advocate in favour of women in climacterium to improve knowledge and increase the facilities available for diagnosis and treatment; financial issues, implying practical, pragmatic and realistic approaches to the aspects of the care for women in climacterium.

A number of studies focus on education, knowledge and the role of the obstetrician in primary medical help for the management of the care for women during the climacterical period.

A study on women in perimenopause and postmenopause in Sri Lanka conducted by S. Ilankoon et al found that they lack knowledge about having screening tests done for uterine cervix and breast cancer, as well as information about the benefits and risks of additional hormone therapy. According to the authors, the provision of midwives in support of women during the menopause period would improve their health education and health behaviour [8].

M. Sasanpour et al pointed out that obstetricians have an important role in promoting women’s health and reported that training in group discussions conducted by obstetricians had a positive effect on the beliefs of sexual dysfunction in climacterical women living in rural areas [12].

M. Taebi et al pointed out that the strategies focused on educational intervention, including stress management, physical activity, healthy diet and healthy behaviour, are options in health care programmes for the improvement of the attitude of women towards the climacterical period and for coping with the symptoms during this stage of their lives. Provision of up-to-date information in the education of women has increased awareness and understanding, and has improved their adaptation through the regular and uninterrupted contact with the midwives [14].

The research conducted by S. Tork-Zahrani et al, and A. Gutierrez reported that the life expectancy of women coinciding with the biological changes and medical implications in the period of climacterium require serious preparation in the knowledge levels of health care professionals. The authors highlighted continuous education of midwives and the necessity to assess their educational needs as a determining factor to ensure efficient educational programmes aimed at providing support for the national health and wellbeing of women during the perimenopause and postmenopause periods. The challenge which midwives face is to increase the volume of scientific research and develop strategies for consulting interventions which allow paying attention to overall care for women during the menopausal period, where education is of major significance and is an important benchmark for the promotion of healthy lifestyle at that stage [6, 16].

Conclusion: Climacterium is a natural period of transition which is accompanied by a series of changes which may affect the quality of life of women.

Modern integrated health care models during the period of menopause in women are an aggregate of comprehensive biomedical and holistic approaches focused on preventive medicine. Their key importance consists in increasing both the qualification of medical and health care professionals, and also the public awareness for the protection an optimisation of the health of women in the transition from reproductive to non-reproductive age. As part of the multidisciplinary team, midwives need to possess professional competences for the delivery of health education, promotion of health support and increasing the quality of life of women in climacterium.

* Acknowledgments:

The article was published with the support of the Bulgarian Ministry of Education and Science

under the Young Scientists and Postdoctoral Candidates-2 National Programme.

 

REFERENCES

  1. Armeni, E, Lambrinoudaki I, Ceausu I, et al. A care pathway from the European Menopause and Andropause Society. Maturitas, 2016, 89:63-72. doi: 10.1016/j.maturitas.2016.04.013.
  2. Baber, RJ, Panay N & Fenton A. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy, Climacteric, 2016, 19(2), 109-150. doi: 10.3109/13697137.2015.1129166.
  3. Bharti, K, Agarwal S, Magon S. Holistic care of menopause: Understanding the framework. Midlife Health, 2012, 3(2):66-9. doi: 10.4103/0976-7800.104453.
  4. Currie, H, Abernethy K, Hamoda H. Vision for menopause care in the UK. Post Reproductive Health, 2021,27(1):10-18. doi:10.1177/2053369121989230.
  5. Funmilola, M, Olorun O, Shen W. Menopause. Global Public Health, 2020.
  6. Gutierrez, A, Teresa M. Y baltica cabieses valdes, climacteric and postmenopause: educational aspects to consider according to the stage of the period. Science. Nursing, 2006, 12(1):19-27.
  7. Holloway, D, The menopause: symptoms, treatments and implications for women’s health and well-being. Primary Health Care, 2022, 32(4). doi: 10.7748/phc.2022.e1759.
  8. Ilankoon, IM, Samarasinghe, K. & Elgán, C. Menopause is a natural stage of aging: a qualitative study. Women's Health, 2021, 47. doi.org/10.1186/s12905-020-01164-6.
  9. International Menopause Society, Mission and Vision of the IMS, https://www.imsociety.org/about-us/mission/
  10. National Program for Improving Maternal and Child Health 2014-2020, Ministry of Health, Bulgaria.
  11. Noble, N, Symptom management in women undergoing the menopause. Nursing Standard, 2018, 32(22):53-63. doi: 10.7748/ns.2018.e11041. PMID: 29363891.
  12. Sasanpour, M, Azh N, Alipour M. The Effect of a Midwife-Based Group Discussion Education on Sexual Dysfunction Beliefs in Rural Postmenopausal Women. Womens Health, 2020, 12:393-397. doi: 10.2147/IJWH.S242621.
  13. Stute, P, Ceausu I, Depypere H, Lambrinoudaki I, et al. A model of care for healthy menopause and ageing: EMAS position statement. Maturitas, 2016, 92:1-6. doi: 10.1016/j.maturitas.2016.06.018.
  14. Taebi, M, Abdolahian S, Ozgoli G, et al. Strategies to improve menopausal quality of life: A systematic review. Health Promot., 2018, 6(7):93. doi: 10.4103/jehp.jehp_137_17
  15. Technical guidelines for the comprehensive care of women of climacteric age at the primary level of the health network, Ministry of Health, Government of Chile, 2014, ISBN: 978-956-348-050-4.
  16. Tork- zahrani, S, Lotfipur- Rafsanjani M, Ahmadi M, & Alavi- Majd H. Midwives’ views regarding educational needs in perimenopausal health and care. Advances in Nursing & Midwifery, 2007, 17(57):26-31. Retrieved from https://journals.sbmu.ac.ir/en-jnm/article/view/683

 

REFERENCES

  1. Armeni E, Lambrinoudaki I, Ceausu I, et al. A care pathway from the European Menopause and Andropause Society. Maturitas, 2016, 89:63-72. doi: 10.1016/j.maturitas.2016.04.013 (In English).
  2. Baber RJ, Panay N & Fenton A. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy, Climacteric, 2016, 19(2), 109-150. doi: 10.3109/13697137.2015.1129166 (In English).
  3. Bharti K, Agarwal S, Magon S. Holistic care of menopause: Understanding the framework. Midlife Health, 2012, 3(2):66-9. doi: 10.4103/0976-7800.104453 (In English).
  4. Currie H, Abernethy K, Hamoda H. Vision for menopause care in the UK. Post Reproductive Health, 2021,27(1):10-18. doi:10.1177/2053369121989230 (In English).
  5. Funmilola M, Olorun O, Shen W. Menopause. Global Public Health, 2020 (In English).
  6. Gutierrez A, Teresa M. Y baltica cabieses valdes, climacteric and postmenopause: educational aspects to consider according to the stage of the period. Science. Nursing, 2006, 12(1):19-27 (In English).
  7. Holloway D, The menopause: symptoms, treatments and implications for women’s health and well-being. Primary Health Care, 2022, 32(4). doi: 10.7748/phc.2022.e1759 (In English).
  8. Ilankoon IM, Samarasinghe, K. & Elgán, C. Menopause is a natural stage of aging: a qualitative study. Women's Health, 2021, 47. doi.org/10.1186/s12905-020-01164-6 (In English).
  9. International Menopause Society, Mission and Vision of the IMS, https://www.imsociety.org/about-us/mission/ (In English).
  10. National Program for Improving Maternal and Child Health 2014-2020, Ministry of Health, Bulgaria (In English).
  11. Noble N, Symptom management in women undergoing the menopause. Nursing Standard, 2018, 32(22):53-63. doi: 10.7748/ns.2018.e11041. PMID: 29363891 (In English).
  12. Sasanpour M, Azh N, Alipour M. The Effect of a Midwife-Based Group Discussion Education on Sexual Dysfunction Beliefs in Rural Postmenopausal Women. Womens Health, 2020, 12:393-397. doi: 10.2147/IJWH.S242621 (In English).
  13. Stute P, Ceausu I, Depypere H, Lambrinoudaki I, et al. A model of care for healthy menopause and ageing: EMAS position statement. Maturitas, 2016, 92:1-6. doi: 10.1016/j.maturitas.2016.06.018 (In English).
  14. Taebi M, Abdolahian S, Ozgoli G, et al. Strategies to improve menopausal quality of life: A systematic review. Health Promot., 2018, 6(7):93. doi: 10.4103/jehp.jehp_137_17 (In English).
  15. Technical guidelines for the comprehensive care of women of climacteric age at the primary level of the health network, Ministry of Health, Government of Chile, 2014, ISBN: 978-956-348-050-4 (In English).
  16. Tork- zahrani S, Lotfipur- Rafsanjani M, Ahmadi M, & Alavi- Majd H. Midwives’ views regarding educational needs in perimenopausal health and care. Advances in Nursing & Midwifery, 2007, 17(57):26-31. Retrieved from https://journals.sbmu.ac.ir/en-jnm/article/view/683 (In English).

 

Материал поступил в редакцию 02.04.23

 

 

СОВРЕМЕННЫЕ ИНТЕГРИРОВАННЫЕ МОДЕЛИ И ПОДХОДЫ

В УПРАВЛЕНИИ ЗДРАВООХРАНЕНИЕМ В ПЕРВИЧНОЙ ПОМОЩИ

ЖЕНЩИНАМ В КЛИМАКТЕРИЧЕСКОМ ПЕРИОДЕ

 

Антоанета Димитрова, PhD, ассистирующий профессор

Кафедра здравоохранения

Факультет здравоохранения „Проф. д-р Цекомир Воденичаров, к.м.н.“

Медицинский университет

(1227, Болгария, София, ул. Белое море, 8)

E-mail: dimitrova9111@abv.bg

 

Таня Веселинова, PhD, ассистирующий профессор

Кафедра здравоохранения

Факультет здравоохранения „Проф. д-р Цекомир Воденичаров, к.м.н.“

Медицинский университет

(1227, Болгария, София, ул. Белое море, 8)

E-mail: tanq_veselinova@abv.bg

 

Боряна Трайчева, PhD, ассистирующий профессор

Кафедра здравоохранения

Факультет здравоохранения „Проф. д-р Цекомир Воденичаров, к.м.н.“

Медицинский университет

(1227, Болгария, София, ул. Белое море, 8)

E-mail: bobytraich@abv.bg

 

Аннотация. Климактерий – это физиологический период, сопровождающийся рядом симптоматических проявлений в ближайшем и отдаленном будущем, индивидуальных для каждой женщины. В данной статье представлены интегрированные модели медицинской помощи при ведении климактерического периода с применением комплексных подходов, направленных на профилактическую медицину. Для оптимизации здоровья в период перехода от репродуктивного к нерепродуктивному этапу необходимо повышение профессиональных компетенций как медицинских специалистов, так и расширение возможностей просветительской работы здорового образа жизни женщин.

Ключевые слова: женщины, климактерий, менопауза, интегрированный подход, забота.