This month we are featuring a Q&A about menopausal care, with Ricshonda "Nickie" Milburn, DNP, MBA, APRN, WHNP-BC, RNFA, Women’s Health Care Nurse Practitioner for the Department of Obstetrics and Gynecology.
Dr. Milburn has been a registered nurse for more than 20 years, with a focus on women’s health. She has also worked as a part-time adjunct clinical instructor for the UTMB School of Nursing. A Galveston native, Dr. Milburn began her nursing career in 2003 after earning an associate’s degree in nursing, initially working in labor and delivery. She obtained a bachelor’s degree from the University of Texas at Arlington and a master’s degree in nursing from the University of Cincinnati, specializing as a Women’s Healthcare Nurse Practitioner. Driven by her commitment to excellence, Dr. Milburn became a Registered Nurse First Assistant (RNFA) and completed her Doctorate in Nursing Practice in 2020. Recently, she earned a Master of Business Administration, underscoring her dedication to integrating healthcare with effective leadership.
Could you provide an overview of menopause and your approach to managing menopausal care?
Menopause is a natural stage in a woman's life, signaling the conclusion of her reproductive years. It typically occurs around the age of 50, although this can vary for each individual. Menopause is defined as the absence of menstrual periods for 12 consecutive months. During this transitional phase, women may encounter a range of symptoms resulting from hormonal fluctuations, including hot flashes, night sweats, mood fluctuations, sleep disturbances, vaginal dryness, and reduced libido, collectively referred to as perimenopause.
My approach to menopausal care is comprehensive and tailored to the individual, emphasizing symptom management, patient education, and an enhanced overall quality of life. I evaluate each patient's symptoms, medical history, and risk factors to identify the most effective management strategy. This may involve lifestyle adjustments, non-hormonal treatments, or hormone therapy (HT), depending on the patient's preferences and needs, as hormone therapy is typically the most effective treatment for menopause.
What does menopausal management entail in your clinic, including follow-ups, titrations, and aftercare?
Menopausal management generally commences with a thorough assessment during the initial visit. This assessment consists of a detailed review of the patient's symptoms, menstrual history, and any pre-existing comorbidities. Following the establishment of an initial plan, regular follow-ups are important for monitoring the patient’s response to treatment.
Follow-ups: I usually schedule follow-up appointments three months after the initiation of treatment, contingent on the chosen plan. These appointments are focused on evaluating symptom improvement, managing side effects, and making adjustments to the treatment plan as needed, particularly if the patient is not achieving satisfactory results.
Titrations: For patients on hormone therapy, we meticulously monitor the treatment's effectiveness and any adverse reactions. Dose titrations may be necessary based on the patient's response, involving adjustments to hormone levels to alleviate symptoms while minimizing risks.
Aftercare: Ongoing aftercare includes consistent monitoring of bone health, cardiovascular risks, and mental well-being, given that menopause can elevate risks for osteoporosis, heart disease, and mood disturbances. Preventive measures, such as routine screenings and lifestyle recommendations, are critical in postmenopausal care.
What are the primary methods of menopausal management utilized in your clinic?
In my clinic, we offer a variety of treatment options tailored to the individual patient's needs and preferences:
Hormone Replacement Therapy (HT): This remains one of the most effective approaches for managing moderate to severe menopausal symptoms. We provide both systemic (oral, transdermal) and local (vaginal) options based on the patient's symptoms and preferences.
Non-hormonal medications: For women who are not suitable candidates for HT or who prefer non-hormonal alternatives, we may prescribe medications such as SSRIs/SNRIs, gabapentin, and clonidine to assist in managing hot flashes and mood-related symptoms.
Lifestyle modifications: Encouraging changes in diet and exercise, stress management, and smoking cessation are essential components of care. Supplements such as calcium and vitamin D may also be recommended to support bone health.
Vaginal treatments: For addressing vaginal dryness, local estrogen therapy or non-estrogen options such as lubricants and moisturizers can be highly effective.
How can Advanced Practice Providers (APPs) become more proficient in menopause management, particularly Hormone Replacement Therapy (HRT)?
Gaining proficiency in menopause management, particularly regarding HRT, necessitates a blend of education, practical experience, and continual professional development. Here are several strategies I have implemented as an APP to enhance my competence:
Education: Engaging with evidence-based guidelines and resources, such as the North American Menopause Society (NAMS) guidelines, as well as participating in menopause-specific conferences, contributes to a deeper understanding of the topic. I make it a habit to read relevant articles daily.
Mentorship: Seeking guidance from experienced practitioners who specialize in women’s health can offer valuable insights into complex cases and management strategies. I am fortunate to have Dr. Snyder as a mentor and have occasionally consulted other experts like Dr. Haver for additional perspectives.
Patient-Centered Approach: Actively listening to patients and addressing their concerns regarding HRT, including the associated risks and benefits, fosters trust and enhances the quality of care. Over time, as one works with more patients, the clinical management of menopause becomes more intuitive. I prioritize transparency in discussions with patients and collaborate with them to achieve their health goals.
Practice Guidelines and Protocols: Acquainting oneself with established clinical protocols related to HRT dosage, titration, and management of side effects can enhance confidence. Given that these protocols are continually evolving, it is crucial to stay updated by utilizing evidence-based guidelines.
Patient Education: Being knowledgeable about how to effectively educate patients about menopause and treatment options, including the safety profile of HRT, aids APPs in establishing rapport and managing patient expectations. Patients often appreciate when providers are candid about their own challenges in menopause management.
Can you share some successes you have observed in your menopausal care practice?
I have witnessed numerous patients experience significant improvements in their quality of life following the implementation of a personalized menopausal care plan. For instance, one patient who faced severe hot flashes, mood swings, and sleep disturbances successfully managed her symptoms through a combination of HRT (estrogen/progesterone) and lifestyle changes. Within a few months, she reported a considerable decrease in hot flashes, better sleep quality, and an enhanced mood, which allowed her to resume her daily activities with greater ease
Additionally, patients experiencing vaginal atrophy have responded positively to localized estrogen therapy. This treatment has markedly alleviated symptoms such as vaginal dryness and discomfort, thereby enhancing their physical and emotional well-being.
These positive outcomes highlight the significance of a personalized, patient-centered approach to menopausal care.
Any additional comments?
Menopause management is a dynamic and multifaceted aspect of women’s health. It is crucial for healthcare providers to foster an open and supportive environment for women navigating this transitional phase. As healthcare professionals, we must commit to continuous education and advocate for women's access to treatments and resources that effectively address their unique symptoms and concerns.
It is also vital to recognize the emotional and psychological dimensions of menopause, as they can significantly affect overall well-being. Furthermore, ongoing discussions with patients concerning preventive care—such as bone health, cardiovascular risks, and mental health—become particularly essential post-menopause.
Lastly, promoting a holistic approach to care that includes lifestyle modifications and support networks can amplify the effectiveness of medical interventions. By addressing the physical, emotional, and psychological challenges associated with menopause, we can empower our patients to navigate this life stage with confidence and achieve better health outcomes.
APP Corner is a monthly feature showcasing UTMB's Advanced Practice Providers.