Applied Science, Faculty of
Nursing, School of
DSpace
UBCV
Hood, Kirsten
Menopause is part of a woman’s natural aging process; it is a transitional period that affects women across Canada with no regard for rural or urban living location. The purpose of this literature review was to provide insight into the specific health needs of rural women, explore the period of menopause, and address health literacy and knowledge translation needs within the rural midlife women population. It was found that access to reliable and accurate menopause educational materials can be challenging for many women who live rurally. By providing access to trusted educational materials and resource people the feelings of fear, confusion, and misinformation can be addressed and diminished. Nurse Practitioners (NPs) have the knowledge, skills and scope to aid women through this transitional time. Health literacy is complex and requires specific attention when providing health educational teaching. The literature recommended the production of a community specific educational pamphlet for this population group. A pamphlet was subsequently created after consultation and review from a sample group of midlife rural women.
Running Head: MENOPAUSE INFORMATION FOR RURAL WOMEN 1 MENOPAUSE: HEALTH INFORMATION FOR RURAL WOMEN by KIRSTEN HOOD, RN (C), BSN Bachelor of Science in Nursing, Vancouver Island University, 2009 A CULMINATING PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF NURSING – NURSE PRACTITIONER in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (School of Nursing) THE UNIVERSITY OF BRITISH COLUMBIA Vancouver February 2017 © Kirsten Hood, 2017 MENOPAUSE INFORMATION FOR RURAL WOMEN 2 Abstract Menopause is part of a woman’s natural aging process; it is a transitional period that affects women across Canada with no regard for rural or urban living location. The purpose of this literature review was to provide insight into the specific health needs of rural women, explore the period of menopause, and address health literacy and knowledge translation needs within the rural midlife women population. It was found that access to reliable and accurate menopause educational materials can be challenging for many women who live rurally. By providing access to trusted educational materials and resource people the feelings of fear, confusion, and misinformation can be addressed and diminished. Nurse Practitioners (NPs) have the knowledge, skills and scope to aid women through this transitional time. Health literacy is complex and requires specific attention when providing health educational teaching. The literature recommended the production of a community specific educational pamphlet for this population group. A pamphlet was subsequently created after consultation and review from a sample group of midlife rural women. Keywords: Rural women, menopause, health literacy, nurse practitioner MENOPAUSE INFORMATION FOR RURAL WOMEN 3 Table of Contents Menopause: Health Information for Rural Women ...................................................................4 Rationale for Project .................................................................................................................4 Rural Women’s Experience of Health ........................................................................................6 Research Strategy .....................................................................................................................6 Health Care Accessibility .........................................................................................................7 Social Connections ....................................................................................................................8 Technology .................................................................................................................................9 Menopause and Rural Women ..............................................................................................10 Lived Experience ...................................................................................................................11 Cultural Considerations .........................................................................................................12 Menopause ...................................................................................................................................12 Research Strategy ...................................................................................................................12 Menopause defined .................................................................................................................13 Diagnosis ..................................................................................................................................14 Symptoms .................................................................................................................................15 Therapies and Treatments .....................................................................................................17 Lifestyle ................................................................................................................................18 Non-hormone .........................................................................................................................19 Hormone therapy ..................................................................................................................20 Bioidentical hormone therapy ...............................................................................................20 Alternative and complementary therapy ...............................................................................21 Associated Health Concerns ...................................................................................................21 Urogenital health ...................................................................................................................21 Osteoporosis ..........................................................................................................................22 Knowledge Translation ..............................................................................................................22 Research Strategy ...................................................................................................................22 Health Equity ..........................................................................................................................23 Health Literacy ........................................................................................................................24 Readability ...............................................................................................................................26 Primary Care Strategies .........................................................................................................27 Project Details .............................................................................................................................28 Conclusion ...................................................................................................................................28 References ....................................................................................................................................30 Appendix ......................................................................................................................................35 MENOPAUSE INFORMATION FOR RURAL WOMEN 4 Menopause: Health Information for Rural Women Canada is a diverse nation made up of urban, rural and remote areas, culturally distinct populations, genders and ages. Within this country it is estimated that areas classified as rural make up about ninety percent of Canada’s land but just one third of its population (Kulig & Williams, 2011). As per Statistics Canada (2011), women encompass slightly more than half the population of Canada – 50.4% of the total population. Overwhelmingly, Canadian women live in urban areas. Perhaps because of this urban density, research in the field of rural women’s health is limited. The available research shows that rural women face greater challenges to their health than their urban counterparts (Leipert, 2006). Access to health care and accurate health information is one of the greatest obstacles faced by rural women throughout their lives, and is further highlighted when women start the menopause transition. (Leipert, 2006). As a Nurse Practitioner (NP) working in a rural context it is essential to understand the challenges and concerns of rural women to provide adequate women centered care. Women have identified that having knowledge of what to expect in regards to menopause, knowing where to find reliable accurate information, and knowing who their resources and supports are would have helped them through this often-stressful time in their lives (Duffy, Iversen, & Hannaford, 2011; Madden et al., 2010; Marnocha, Bergstrom, & Dempsey, 2011; Price, Story, & Lake, 2007). This literature review will focus on three main areas with the hopes of addressing and understanding the above-mentioned challenges: the health and health education experiences of rural women, menopause best practice guidelines, and finally knowledge translation in respect to conveying health information taking into consideration health literacy, health equity, and primary care implementation strategies. Rationale for Project MENOPAUSE INFORMATION FOR RURAL WOMEN 5 Menopause is a natural aging process that affects the lives of women regardless of where they live and therefore is a condition that many Family NPs will encounter in their practice. NPs are masters prepared Registered Nurses (RNs) who practice with an expanded scope of practice. Family NPs provide comprehensive care throughout the lifespan including diagnosis and treatment of acute and chronic illnesses, prescribing medications, ordering and interpreting laboratory and diagnostic tests, and referring to specialists as needed (BCNPA, 2017; CRNBC, 2017). NPs have practiced autonomously in British Columbia since 2005, with the number of NPs growing steadily since then (BCNPA, 2017). The College of Registered Nurses of British Columbia (CRBNC) provides professional, practice and scope of practice standards for NPs (CRNBC, 2017). Within these standards menopause falls under the category of “D” meaning that NPs can independently and autonomously diagnose and manage menopause (CRNBC, 2017). Many rural NPs are ideally positioned to provide menopause related care and education, and therefore this project aims to capitalize on this influential position. By providing access to health education and resources for women in rural areas, it is hoped that the experience of menopause can become less complicated and stressful. The area of menopause education and resources was identified as lacking by the interdisciplinary healthcare team in my home community of Masset, BC. The final product of this project will be a culturally appropriate paper based educational pamphlet that can be used within the community and at the two health centers (Northern Health and First Nations Health Authority). The aim of this project is to address challenges and gaps in health education by starting dialogue with women in a rural community, providing a reliable education resource, and identifying health care practitioners who are willing and able to assist women in this transition in their lives. MENOPAUSE INFORMATION FOR RURAL WOMEN 6 Additionally, both women’s health and rural healthcare are areas I have great personal interest in. Once graduated I plan to work primarily with the community and healthcare team in Masset. As a NP working in a rural environment I believe that it is essential to understand the challenges and concerns of rural women to provide adequate and appropriate women centered care. Rural Women’s Experience of Health Research Strategy A search for relevant literature was conducted using a variety of databases including: The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Web of Science, and Google Scholar. The search was restricted to English publications, peer-reviewed scholarly articles, and by date. The initial date range was for articles written within the last 10 years (2007-2017). However, this was expanded as few articles were found within that timeframe that fit the purpose of this literature review. The final search was expanded to include research from 2003-2017. Key terms used in this search included “Rural”, “Women’s Health”, “Rural Women’s Health”, “Menopause”, “Perimenopause”, “Climacteric”, “Experience”, and “Canada.” A combination of these terms were used to populate relevant research articles. An additional search strategy included looking at the references and cited articles of articles that were deemed relevant. This additional search strategy generated many articles that were referenced by other researchers, and were added to previously obtained articles. These search strategies combined provided a good base for the literature review. Key themes identified from the literature include health care accessibility, social connectedness, and technology. These areas were recognized to be major contributing factors to MENOPAUSE INFORMATION FOR RURAL WOMEN 7 the health of rural women, and therefore will be discussed and expanded upon. By looking at the foundation of health and health education needs for rural women, the more specific needs these women have in relation to menopause can then be addressed. Health Care Accessibility A disadvantage Canadian rural women identified was deficiency of healthcare services within their community. Jackson, Unruh & Donahue (2011), Leipert & George (2008), Leipert & Reutter (2005), Paluck, Allerdings, Kealy & Dorgan (2006), Price et al. (2007), Thurston & Meadows (2003) and Wathen & Harris (2007) all discussed health care access in their research. While primary care services were generally available within rural communities, specialized services were predominantly lacking as discussed by all researchers, with the exception of Paluck et al. Identified lacking specialized services included emergency, mental health, specialist, acute care, diagnostics, health promotion, illness prevention, alternative therapies, and diverse women’s health education (Jackson et al., 2011; Leipert & George, 2008; Leipert & Reutter, 2005; Price et al., 2007; Thurston & Meadows, 2003; Wathen & Harris, 2007). Access to services was only one obstacle that rural women faced when looking at healthcare accessibility. If a woman could access primary care and find a practitioner to work with her, transient practitioners and lack of long term physicians was an identified barrier to maintaining health for rural women (Leipert & Reutter, 2005; Price et al., 2007; Wathen & Harris, 2007). Difficulty recruiting and retaining qualified healthcare professionals lead to fear and concern for ongoing care (Price et al, 2007). Rural women felt they were at a disadvantage in relation to their urban counterparts in maintaining healthcare practitioners. They believed that lack of longevity affected the care they received in acute situations as well as education, health promotion and disease screening (Leipert & Reutter, 2005; Price et al., 2007). MENOPAUSE INFORMATION FOR RURAL WOMEN 8 Providing access to safe confidential care is a cornerstone of healthcare practice. Establishing a trusting relationship and having confidence in both the care received and the practitioner are aspects of healthcare that many urban women may take for granted. Rural women reported that they often felt a lack of confidentially and anonymity and attributed this to living in a rural community (Leipert & George, 2008; Leipert & Reutter, 2005; Wathen & Harris, 2007). Contrasted with the negative reports of healthcare access, Paluck et al (2006) stated that women interviewed in their study felt living in a rural community enabled them to establish relationships with their healthcare practitioners. Building relationships, being neighbours, and seeing their healthcare practitioners around town doing the same errands as they do, allowed women to feel comfortable asking health related and personal questions, thus improving the quality of life for these rural women. While the above-mentioned challenges are not generalizable to every rural community and every rural woman, a foundation is laid that outlines some of the key concerns with health care accessibility. For effective health education and holistic management of the menopause transition, it is imperative that these areas be addressed. This is an area where NPs can play an important role. Social Connections Within the literature being reviewed, no common definition of “rural” was made. Communities ranged in size from 800 to 10,000 people, and were located varying distances from urban centers. However, one unifying characteristic of study participants was that they referred to themselves as rural residents and felt a connection to being rural. Rural living and health often MENOPAUSE INFORMATION FOR RURAL WOMEN 9 were discussed in relation to a sense of social connectedness that was experienced by women. This social aspect had both positive and negative associations for the women and their health. Women in rural communities noted that social support might come from less traditional sources, but that it was “vital to the health and resilience of northern women” (Leipert & Reutter, 2005, p. 59). Family and friends made up the primary support system for many rural women, but this network could also include co-workers, neighbours, and healthcare practitioners (Leipert & Reutter, 2005; Paluck et al., 2006; Price et al., 2007; Wathen & Harris, 2003). Women could share their experiences of health with each other, using their support system as informal health education (Leipert & Reutter, 2005; Price et al., 2007; Wathen & Harris, 2003). By acknowledging and incorporating the various support systems that rural women identify with and use, NPs can work to become a valued part of that support system. Once trust is established there may be more opportunities for effective health education, both with individual clients as well as with the greater community. Technology Rural physical environment and technology were closely linked in relation to Canadian rural women’s health. Due to the physical location of many rural communities, access to technology was limited or non-existent. Leipert & Reutter (2005) discussed how inadequate roads, sometimes in combination with inadequate vehicles, impacted women’s ability to access health related services. On top of having poor infrastructure, many women did not have access to a telephone, internet or even electricity adding to the burden of accessing and maintaining physical and mental health (Leipert & Reutter, 2005; Wathen & Harris, 2007). For those rural women who did have access to internet, it was often used as a primary source of health information. However, this system of information gathering also provided MENOPAUSE INFORMATION FOR RURAL WOMEN 10 challenges. Women found that the amount of health information available on the internet was overwhelming, stating often after researching a health topic they felt overloaded with information and did not know how to move forward (Price et al., 2007; Wathen & Harris, 2007). Many women did not have access to or relationships with healthcare providers to discuss the information they had found on the internet. This could lead to misinformation and delay in seeking appropriate healthcare resources, consequently impacting health. While physical environment and distance to health care providers are not factors that the NP can generally address, the idea of information overload and confusion is an area where the NP can positively influence the lives of rural women. By providing a community specific menopause information pamphlet, the need to look to the internet is lowered. Building relationships with women and being able to discuss what resources are appropriate and helpful will also help to decrease this anxiety and misinformation that so many rural women experience. Menopause and Rural Women There are many aspects to consider when looking at the experience of menopause, including biological, societal, psychological and cultural factors. Rural women share these same experiences, but can experience added challenges based on the physical location they live in. Throughout the research it is suggested that many women enter menopause with feelings of fear, confusion, denial and misinformation (Duffy et al., 2011; Price et al., 2007). Historically menopause has been viewed within a biomedical context and highly medicalized by health care practitioners (Duffy et al, 2011; Marnocha et al., 2011; Price et al, 2007). Given this medicalization, traditionally the focus of health education has been placed on symptom management with medications, with little regard for the lived experience and fears women have going into the menopause phase of their lives. MENOPAUSE INFORMATION FOR RURAL WOMEN 11 Lived experience. Duffy et al. (2011) and Price et al. (2007) both describe how important the availability of support was for women entering menopause. Support as mentioned previously could come from a variety of sources, with healthcare professionals, friends, family, and other women being the major sources (Duffy et al., 2011; Price et al., 2007). Many women expressed the desire for their healthcare professional to be a woman and felt that many male healthcare professionals did not understand or take their concerns seriously which led to feelings of frustration. Many women did not feel that they could go to their healthcare professional for general support, but rather felt they needed a specific symptom to address in their appointment (Duffy et al., 2011). This led the women to search for other sources of information, which in turn led to continued confusion surrounding the symptoms they were experiencing. Many women commented on the lack of available information, or the challenges associated with obtaining accurate, relevant information, noting that often there was information overload. (Duffy et al., 2011; Price et al., 2007). Price et al. (2007) state that women wanted credible menopause information from people that they trust but so often were not able to obtain this. Women reported being shocked by both symptoms and the intensity of symptoms, unaware of which symptoms were attributed to menopause, often thinking that their symptoms were from other causes. Women expressed concerns with memory loss; without the support and accurate education they often believed that this was related to early onset Alzheimer’s disease rather than menopause (Price et al., 2007). These concerns highlight the importance of providing an easy to access, accurate, reliable education source for rural women. Gaining and building trust is a process that will enable the women to be able to bring their concerns to the NP. However, by providing an educational information source that addresses more than just symptoms, these women can work towards MENOPAUSE INFORMATION FOR RURAL WOMEN 12 better understanding of the process that they bodies are going through, improving their sense of self confidence and control. Cultural considerations. While limited research is available in regards to rural women’s experience of menopause, there is even less research that looks into the Canadian First Nations women’s experience of menopause. As the community that I plan to make this menopause information pamphlet comprises of a large population of First Nations women, it is important that cultural considerations be looked at to ensure appropriate information is included. Madden et al. (2010) highlights the importance of being aware of the different experiences and perceptions that First Nations women may have when compared with other western women to provide effective and holistic care for menopausal women. In many First Nations languages, the word menopause may not exist, and symptoms that are associated with menopause may not be identified as connected to the menopause experience. It is crucial for the healthcare provider working in these communities work towards understanding the local knowledge and practices surrounding menopause (Madden et al., 2010). For many the topic of menopause may not be one that is discussed and could bring up feelings of discomfort and confusion. While this may be a topic that generally isn’t discussed, the desire for information remains. Women identified the importance of a more holistic approach from healthcare providers, stating that the process of menopause is not just a medical experience, it involves mental, emotional, spiritual and physical (Madden et al., 2010). Menopause Research Strategy A search for relevant literature was conducted using a variety of databases including: CINAHL, PubMed, and Google Scholar. The search was restricted to English publications, peer-MENOPAUSE INFORMATION FOR RURAL WOMEN 13 reviewed scholarly articles, and by date. The initial date range was for articles written within the last 10 years (2007-2017). Key terms used in this search included “Menopause”, “Best Practice”, Evidence-based”, “Guidelines”, “Canada”, “Hormone Therapy”, “Climacteric”, and “SOGC.” These searches provided a large quantity of articles, including outdated guidelines and information, and therefore the date range was narrowed. Focus was paid on the most up to date articles as it was thought this would provide the most current guidelines and relevant information. The final date range was from 2014-2017, and includes guidelines and articles from Canada, the United States and the International Menopause Society. In addition to the above literature searches, information was gathered from current textbooks and evidence-based information sources such as UpToDate. This combination of information forms a well-balanced overview of menopause and menopause information for the NP. Guidelines provide the healthcare provider with the most up to date relevant information, but also provide a substantial amount of detailed, technical information. For this review, the topics that will be focused on are those that have been identified as important to include in the education pamphlet. These include the definition of menopause, how diagnosis is made, symptoms associated with menopause, therapies and treatment methods used, and associated health concerns. Menopause defined Natural menopause is defined as the permanent cessation of menstrual periods after twelve months of amenorrhea (Casper, 2015; HealthLink BC, 2016; Lumsden, 2016; Goroll & Mulley, 2009; North American Menopause Society, 2017; Society of Obstetricians and MENOPAUSE INFORMATION FOR RURAL WOMEN 14 Gynaecologist of Canada, 2014; Uphold & Graham, 2013). The average age of menopause onset is 51, with a range from age 40 to 58 (Casper, 2015; Goroll & Mulley, 2009; Uphold & Graham, 2013). Menopause is a normal physiologic event that reflects the loss of ovarian follicular development and subsequent hormone depletion (Casper, 2015; NAMS, 2017; Uphold & Graham, 2013). Negative feedback on the hypothalamic-pituitary unit is decreased leading to increased levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH). When ovaries are no longer able to produce estrogen, and cannot respond to FSH, ovulation ceases and menstruation ends (Casper, 2015; Uphold & Graham, 2013). The menopause transition, also known as perimenopause, occurs after the reproductive years, but before menopause. This transitional period reflects the natural decline of ovarian follicular estrogen production (NAMS, 2017). Characteristically during the menopause transition there are several menstrual cycle changes and increasing episodes of amenorrhea. Symptoms tend to cluster in a 2 to 4-year window before and after the final menstrual period (FMP), but can continue for years (Casper, 2015; NAMS, 2017). These symptoms include several physiologic changes that affect a women’s quality of life, including irregular menstrual cycles, endocrine changes and vasomotor symptoms (Casper, 2015, NAMS, 2017). Menopause can be premature, artificial or delayed, however these variants will not be discussed within this review to keep the topic concise and relevant for the intended audience. Diagnosis Diagnosing perimenopause in healthy women over the age of 45 is based on the symptoms described above – irregular menstrual cycles with or without menopausal symptoms. There is no need for establishing the FSH, estradiol or ovarian antral follicle count level to make this diagnosis (Casper, 2015; NAMS, 2017). It is important that the healthcare provider take a MENOPAUSE INFORMATION FOR RURAL WOMEN 15 history, including complete gynecologic, medical history, family history, medications, including birth control, and full symptoms analysis to accurately and appropriately diagnose a woman with menopause or perimenopause (Uphold & Graham, 2013). The best way for a woman to best determine the course of her menopause transition is by using menstrual cycle tracking. The definitive diagnosis is made when there are no menstrual cycles for 12 months (Casper, 2015; HealthLink BC, 2016; Lumsden, 2016; Goroll & Mulley, 2009; NAMS, 2017; SOGC, 2014; Uphold & Graham, 2013). Symptoms Many symptoms are attributed to menopause and the menopause transition (perimenopause), but generally they are grouped into vasomotor, sleep disturbances, mood and cognitive changes, urogenital symptoms, and sexual function. These symptoms are generally what brings a woman in to see their healthcare provider, often seeking reassurance, information and methods to cope. Vasomotor symptoms are commonly known as hot flashes or hot flushes and are the most common symptom during the menopause transition and menopause. Up to 60-80% of women will experience hot flashes, many for a period of 6 months to 7 years (Casper, 2015; NAMS, 2017; SOGC, 2014). Vasomotor symptoms often are accompanied by sweating, night sweats, palpitations, apprehension, and anxiety (SOGC, 2014). These symptoms can adversely affect the quality of life for women by causing physical discomfort, social embarrassment, sleep disturbances, inconvenience, and distress (SOGC, 2014; NAMS, 2017). Vasomotor symptoms are thought to be a result of a disturbance in the temperature-regulating mechanism in the hypothalamus due to low estrogen levels (SOGC, 2014). Prior to menopause, the body can maintain its optimal temperature through vasodilation and sweating when too hot and shivering MENOPAUSE INFORMATION FOR RURAL WOMEN 16 when cold, but in menopausal and postmenopausal women this thermoneutral zone is narrowed which leads to increased symptoms of sweating or shivering with only small changes (SOGC, 2014). Certain factors put women at a high risk for hot flashes which include: obesity, limited physical activity, cigarette smoking, alcohol, warm ambient temperatures, and hot drinks (SOGC, 2014; NAMS, 2017). Hot flashes generally begin as a sudden sensation of heat centred on the upper chest and face which becomes generalized. This sensation typically lasts 2-4 minutes and can occur several times a day, ranging from 1-2 a day to 1 per hour day and night (Casper, 2015). Often hot flashes are more common at night which can lead to sleep disturbances. However, difficulty sleeping is not always associated with hot flashes (Casper, 2015). Other factors affecting sleep include: primary sleep disorder (insomnia, sleep apnea, and restless leg syndrome), anxiety, and depression (Casper, 2015; Goroll & Mulley, 2009; NAMS, 2017). The psychological symptoms of depressed mood, anxiety and decreased sense of wellbeing are common during the menopause transition (NAMS, 2017). Clinical depression is uncommon, however, women with a history of mood or anxiety disorders are at higher risk (Casper, 2015; SOGC, 2014; NAMS, 2017). Because of these changes in mood, it is important that the healthcare provider screen and treat as indicted. Effective education can help women to understand and cope with menopause related mood symptoms (NAMS, 2017). Difficulty concentrating, poor memory, and trouble multitasking can affect women during the menopause transition and early post menopause (Casper, 2015; SOGC, 2014; NAMS, 2017). These symptoms can be influenced by the above-mentioned sleep disturbances, depressed mood, vasomotor symptoms, as well as midlife stressors and medication use (SOGC, 2017; NAMS, 2017). While memory declines slightly during the menopause transition, it appears to MENOPAUSE INFORMATION FOR RURAL WOMEN 17 return to premenopausal levels after menopause, therefore education should be provided to women to provide reassurance. The decrease in estrogen and other sex hormones can lead to a collection of symptoms known as genitourinary syndrome of menopause (GSM). GSM includes: genital symptoms of dryness, burning, irritation, lack of lubrication, discomfort or pain with intercourse, urinary symptoms of urgency, dysuria, and recurrent urinary tract infections (Casper, 2015; NAMS, 2017). As these symptoms can be very bothersome and negatively impact quality of life, it is important that healthcare providers inquire about these symptoms as many women may not volunteer this information (NAMS, 2017). GSM can contribute to sexual function concerns; estrogen deficiency leads to a decrease in blood flow to the vagina and vulva which causes decreased vaginal lubrication and sexual dysfunction in menopausal women (Casper, 2015; NAMS, 2017). Vaginal dryness can lead to dyspareunia further impacting sexual function (Casper, 2015). Other physiological, psychological, sociocultural, interpersonal, and lifestyle factors can also contribute to sexual problems in midlife women (NAMS, 2017). The symptoms caused by vaginal atrophy can be treated and it is an important topic to be discussed with women. Symptom management, regardless of the symptom, is important to discuss with women at every comprehensive visit. Providing education about various treatments and therapies can help alleviate concern and anxiety. By allowing women to take control of their symptoms, by educating them about symptoms and how they relate to menopause, the NP is in a better position to provide the best patient and women centered care. Therapies and Treatments MENOPAUSE INFORMATION FOR RURAL WOMEN 18 Lifestyle. The first therapy that women can utilize involves maintaining a healthy lifestyle. Diet, exercise, weight management, stress management, and reducing alcohol, tobacco, and caffeine have all been shown to make a positive difference for menopausal women. Simple measures to address mild hot flashes can include lowering room temperature, dressing in layers, the use of fans, and avoiding triggers such as spicy food and stressful situations (Santen, Loprinzi & Casper, 2016). The SOGC (2014) states that diet and healthy eating can work towards preventing or reducing the risk of conditions that may develop during or after menopause. The Canada Food Guide provides detailed advice for women to reference, explaining which foods are important to focus on ensuring they consume daily (Ministry of Health Canada, 2011). Regular exercise does more than just positively benefit physical health; it can help with mental and emotional health as well. Exercise can reduce stress, help with weight management, build bone and muscle strength helping to combat osteoporosis, and can lead to a general feeling of wellbeing (SOGC, 2014; SOGC, 2017). A combination of weight-bearing and stretching is recommended, leading up to 150 minutes a week in at least 10 minute intervals (SOGC, 2014; SOGC, 2017). Maintaining mental health and reducing stress can help women through the emotional aspects that menopause brings. Knowing that mood changes are common and taking steps to improve mental health such as regular exercise, engaging with a support network, and knowing when to engage with a healthcare provider can help women through this often-stressful period in their lives (HealthLink BC, 2016; SOGC, 2014). Women who smoke cigarettes may experience menopause up to two years earlier than non-smokers (SOCG, 2017). Smoking cessation is highly encouraged as smoking increases the MENOPAUSE INFORMATION FOR RURAL WOMEN 19 risk for many chronic diseases, and reduced the options for therapies used to treat symptoms (SOGC, 2014). Women should be encouraged and supported in their decision to use this midlife change as a time to stop smoking. Alcohol use can also increase the risk for chronic diseases (SOGC, 2014). It is recommended that women consume at most 10 drinks a week, with no more than 2 drinks a day (SOGC, 2104). Alcohol can increase vasomotor symptoms, sleep disturbances and depression (SOGC, 2017). Caffeine has also been shown to increase hot flashes and sleep disturbances, and therefore it is recommended to limit caffeine intake to help minimize these symptoms (SOGC, 2017). Non-hormone. For women with moderate to severe hot flashes where hormone therapy is contraindicated or who do not wish to take hormones other options exist (HealthLink BC, 2016; SOGC, 2014; NAMS, 2017). Antidepressants that affect the release and reuptake of the neurotransmitters serotonin and norepinephrine (SNRIs and SSRIs) have shown great promise in treating vasomotor symptoms (SOGC, 2014; NAMS, 2017). Venlafaxine, paroxetime and fluoxetine are the antidepressants that have shown the most promise in reducing hot flashes as well as improving mood (SOGC, 2014; NAMS, 2017). However, currently in Canada they are not approved for the treatment of vasomotor symptoms and are prescribed off-label, stopping the NP from being able to prescribe these medications. Gabapentin, an antiepileptic drug, has been shown effective for treatment of hot flashes in some women (Santen et al., 2016). A single dose of gabapentin given at bedtime helps stop the hot flashes that cause many women awaken from sleep (Santen et al., 2016). Gabapentin’s sedating effects work in combination with its effects in reducing vasomotor instability to minimize nocturnal hot flashes (Santen et al., 2016). MENOPAUSE INFORMATION FOR RURAL WOMEN 20 Clonidine, an antihypertensive medication, has been used in the past for treatment of hot flashes (HealthLink BC, 2016; Santen et al., 2016; SOGC, 2014). However, the side effects that many women experience with this medication have decreased its prevalence as an option for treating vasomotor symptoms in menopausal women (Santen et al., 2016; SOGC, 2014). Hormone therapy. Hormone therapy (HT) is used for the treatment of moderate to severe vasomotor symptoms. HT is the most effective treatment for these symptoms; however, it is not the right choice for all women, especially those with history of breast cancer, coronary artery disease, previous venous thromboembolic event or stroke (NAMS, 2017; Santen et al., 2016). There are benefits but also risks associated with HT. For symptomatic women, younger than 60 or within 10 years of their final menstrual period, with no contraindications it is considered safe to use (SOGC, 2014; NAMS, 2017). The lowest dose of HT should be used for the shortest amount of time to relieve symptoms, the women should be fully educated on the risks verses benefits prior to and during HT (NAMS, 2017). HT can consist of estrogen only (ET) for women who have undergone hysterectomy and no longer have a uterus, or combined estrogen-progestin therapy (EPT) for women with an intact uterus (Martin & Barbieri, 2016; NAMS, 2107; SOGC, 2014). Progestin prevents estrogen associated endometrial hyperplasia (Martin & Barbieri, 2016). For vasomotor symptom control women require systemic estrogen, whereas women who are being treated for GSM should be treated with low-dose vaginal estrogen (Lumsden, 2016; Martin & Barbieri, 2016; NAMS, 2107; SOGC, 2014). HT is no longer recommended for prevention of CHD or osteoporosis, cognitive function and dementia (Martin & Barbieri, 2016, NAMS, 2017). Bioidentical hormone therapy. Bioidentical hormone therapy refers to custom-compounded multi-hormone regimes that are made by a pharmacist duplicating hormones MENOPAUSE INFORMATION FOR RURAL WOMEN 21 produced by women (SOGC, 2017; NAMS, 2017; The Endocrine Society, 2006). The use of these medications is not supported as there is no scientific evidence about the effects, the compounds do not have FDA approval, and there is potential harm associated with their use (SOGC, 2017; NAMS, 2017; TES, 2006). Alternative and complementary therapy. Non-prescription therapies are very popular and used by many midlife women. These complementary and alternative (CAM) therapies used to address menopausal symptoms include: phytoestrogens, black cohosh, St. John’s wort, dong quai, ginseng, evening primrose oil, wild yam, ginkgo, acupuncture, mind-body techniques (HealthLink BC, 2016; SOGC, 2014; NAMS, 2017). While research in the field of CAM exists, the current evidence-based data concludes that these forms of symptom management are not as effective as hormone therapy (SOGC, 2014). Women are encouraged to view Health Canada’s Licensed Natural Health Products Database to find products that are approved for use in menopausal women as many products are not approved and can be harmful (SOGC, 2014). Associated Health Concerns Urogenital health. Loss of control of the bladder is a common complaint of postmenopausal women (SOGC, 2014; SOGC, 2017; NAMS, 2017). Incontinence can come in three different forms: urge, stress, or mixed (SOGC, 2017). It is estimated that 50% of midlife women have one or more forms of incontinence, but embarrassment and lack of awareness regarding treatment options prevents them from seeking help from their healthcare provider (NAMS, 2017). There are a variety of treatment options available, and therefore it is imperative that this topic be brought up with women. Other urogenital symptoms may include: vaginal dryness, dyspareunia, vulvar puritis, and vulvar burning or pain (SOGC, 2014). MENOPAUSE INFORMATION FOR RURAL WOMEN 22 Osteoporosis. Increased risk of fracture presents with postmenopausal osteoporosis, as decreased estrogen production is linked to increased bone loss (HealthLink BC, 2016; SOGC, 2017; NAMS, 2017). In the 10 years following menopause women are at risk of losing up to 30% of their bone mass (SOGC, 2017). Because if this increased risk of fracture, it is suggested that all postmenopausal women obtain adequate calcium and vitamin D (SOGC, 2014; NAMS, 2017). Bone mineral density screening is recommended in women over the age of 65 and earlier for those at higher risk (NAMS, 2017). Given the results of the bone mineral density treatment should be offered, however, consensus is that treatment should be individualized and based on the woman’s potential benefits and risks (NAMS, 2017; SOGC, 2014). Menopause is a normal physiological transition that all women will go through. By increasing awareness of the what is involved in this transition, common symptoms, treatments and associated health concerns, the healthcare provider can assist midlife women in reducing the stress and anxiety that is often related to this life transition. By looking at the bigger picture, NPs are better able to address concerns beyond physical, looking at emotional and cultural aspects leading to holistic care and improved health outcomes. How best to pass on this information and education will be discussed in the next section. Knowledge Translation Research Strategy A search for relevant health literacy literature was conducted using a variety of databases including: CINAHL, PubMed, and Google Scholar. The search was restricted to English publications, peer-reviewed scholarly articles, and by date. The initial date range was for articles written within the last 10 years (2007-2017). MENOPAUSE INFORMATION FOR RURAL WOMEN 23 Key terms used in this search included “health literacy”, “readability”, “patient education”, “Primary Care”, “Patient Engagement”, and “Menopause.” These searches provided a sufficient quantity of related articles to health literacy. Unfortunately, there was a lack of health literacy information directly related to menopause, and as such general health education will be discussed with implications for menopause made. Health equity information was sourced from previous Health Promotion course (N506) readings and literature. When looking at how best to disseminate health related educational materials there are many aspects to consider. Firstly, the idea of health equity must be looked at, demonstrating the importance of inclusivity within health education. Knowledge translation strategies are varied, but consistently when discussing patient education, the theme of health literacy was paramount. This section will focus on health equity and health literacy. Translating findings into strategies for the completion of an educational pamphlet for rural women will be proposed. Health Equity When exploring health promotion and education strategies, viewing programs and materials through a health equity lens allows for optimal patient centred care. Health equity “is a social justice goal focused on pursuing the highest possible standard of health and health care for all people” (Browne, Varcoe, Ford-Gilboe, & Wathen, 2015, p.2). Meaningful focus and attention is given to individuals and groups most vulnerable for health challenges, with the goal of closing the health equity gap (Browne et al. 2015; Browne, A. 2016, PHABC, 2012). Utilization of a health equity lens enables one to address unjust and avoidable inequities to provide equitable health care for all (Browne et al. 2015, PHABC, 2012). Traditional health promotion generally reaches only the top ten percent of the population. Reframing the health promotion and educational approaches affords the opportunity to balance the health of the other MENOPAUSE INFORMATION FOR RURAL WOMEN 24 ninety percent offering inclusive improvements that can be seen within the entire population (Raphael, 2012). When health education materials are provided for patients who cannot properly understand what is being said, health equity is not applied. By becoming aware of the principles of health literacy, it is hoped that the process of producing an educational pamphlet becomes clear and the best possible health education for rural women experiencing menopause can be created. Health Literacy Health literacy has been acknowledged as a determinate of health for Canadians, but unfortunately many do not possess adequate health literacy skills to positively influence their lives (Public Health Association of BC, 2012). Health literacy is defined as “the degree to which people are able to access, understand, evaluate and communicate information to engage with the demands of different health contexts in order to promote and maintain good health across the life-course” (PHABC, 2012, p.4). It is estimated that 88% of older adults and 60% of adults over the age of 16 are not health literate enough to fully understand health information and make appropriate health decisions (PHABC, 2012). Low health literacy can lead to patients being unable to make necessary decisions regarding their health, create difficulty in following guidelines prescribed by a healthcare provider, create confusion surrounding medication instructions and use, impact the likelihood of accessing health promotion services, and contribute to overall lower understanding of their health status (DeMarco & Nystrom, 2010; PHABC, 2012). Not only is lacking health literacy influencing the quality of life of Canadians, it is also impacting the health care budget, costing Canada approximately $8 billion a year in unnecessary health care costs (PHABC, 2012). MENOPAUSE INFORMATION FOR RURAL WOMEN 25 Health literacy encompasses more than the ability to simply read health materials; to be considered fully health literate one must can understand the health care system they are using, know their rights within that system, have a basic knowledge of science, culture and health, and know that they have the confidence to ask for help in maintaining their rights and health (PHABC, 2102). The importance of health literacy does not fall solely on the patient, but includes the healthcare professional and health care system working with them. Patients should be empowered and made comfortable to ask health questions. Healthcare professionals need to ensure that their methods of education are appropriate and patient specific, trying to correct power imbalances whenever possible (PHABC, 2012). While there are many aspects to health literacy, the ability to read and understand patient education materials is one that patients encounter frequently. Many healthcare providers overestimate the literacy levels of their patients which directly impacts the care provided (Boivin, 2013). The general recommendation is that health education resources be written at a sixth-grade reading level (Boivin, 2013; Charbonneu, 2013; DeMarco & Nystrom, 2010; Sand-Jecklin, 2007; Stossel, Segar, Gliatto, Fallar & Karani, 2012). However, most available pre-written education resources are at a much higher reading level, anywhere from the eighth-grade level to well above the twelfth-grade (Boivin, 2013; Charbonneu, 2013; DeMarco & Nystrom, 2010; Sand-Jecklin, 2007; Stossel et al., 2012). When looking specifically at hormone replacement therapy written education, Charbonneu (2013) assessed 31 different resources and found just one that was at the sixth-grade level. When provided with materials that are supposed to help inform important health and health care decisions, many Canadians are not receiving adequate information or health teaching. If healthcare professionals are aware of the discrepancy in health literacy and education materials MENOPAUSE INFORMATION FOR RURAL WOMEN 26 steps can be taken to work towards improved health. Knowing the literacy level of materials can be a challenge whether it is a pre-printed education source, or tailor made education materials produced specifically for a group of clients. Readability formulas can aid in this aspect of improving health literacy. Readability There are a variety of readability indices available to assess the grade level and comprehensibility of written materials. These indices use mathematical formulas to assign a grade level based on word and sentence length (Charbonneau, 2013; Stossel et al., 2012). Two of the most common indices used in analysing health care materials are the Flesch-Kincaid Index (FKI) and the Simple Measure of Gobbledygook (SMOG). The FKI provides both an ease of reading score and an estimated reading grade level (Charbonneau, 2012). The SMOG is a readability formula that estimates the years of education a person needs to understand a piece of writing (Stossel et al., 2012). Generally, the FKI is used for new materials and the SMOG for pre-printed materials, but both can be applied to new or existing health documents (Charbonneau, 2013; Stossel et al., 2012). The use of illustrations and visual aids has shown positive improvements in recall and comprehension (Boivin, 2013; Charbonneau, 2013; DeMarco & Nystrom, 2010; Sand-Jecklin, 2007). Information should be clear, using simple language and avoiding as much medical jargon as possible; if a medical term is necessary, it should be properly defined (Boivin, 2013; Charbonneau, 2013; DeMarco & Nystrom, 2010; Sand-Jecklin, 2007). Essential information should be streamlined and to the point (DeMarco & Nystrom, 2010). Headings should be used to provide visible breaks and indicate subject change, but also to provide easy reference points (DeMarco & Nystrom, 2010). Instructions or symptoms should be listed bullet form instead of in MENOPAUSE INFORMATION FOR RURAL WOMEN 27 a paragraph, and instructions should be listed in order of importance (DeMarco & Nystrom, 2010; Sand-Jecklin, 2007). Finally, prior to dissemination of the health education material providing a draft to a sample group of patients is essential to allow for revisions and the best possible understanding within that group (Boivin, 2013; Charbonneau, 2013; DeMarco & Nystrom, 2010; Sand-Jecklin, 2007). Primary Care Strategies The Primary Care Provider can actively participate in addressing health literacy with their patients. By addressing written materials with the above-mentioned readability indices, health education materials can be evaluated and work can begin on making appropriate education documents. On top of printed education materials, healthcare providers can also address health literacy in their patient appointments. Focusing on one to three key messages per visit is suggested, as any additional information can lead to the patient feeling overwhelmed and impact their ability to take away any meaningful health education (Charbonneau, 2013). Delivering the key messages with plain and simple language, free from as much medical jargon as possible is another effective strategy (Charbonneau, 2013). The use of visual aids and illustrations has been shown to enhance understanding, comprehension, recall and adherence (Boivin, 2013; Charbonneau, 2013; DeMarco & Nystrom, 2010). By getting the patient to demonstrate back what they have just been taught, the healthcare provider will be able to gauge the degree to which the patient understands (Boivin, 2013; Charbonneau, 2013; DeMarco & Nystrom, 2010). This engages the patient and makes the conversation interactive, allowing the patient to take some control, build confidence and identify areas where further information is needed (Boivin, 2013; Charbonneau, 2013; DeMarco & Nystrom, 2010). MENOPAUSE INFORMATION FOR RURAL WOMEN 28 Project details The concept of this project is to create an educational pamphlet for rural women to provide guidance during the transition of menopause. There are many factors to consider before beginning this project, including the lived experience of health and menopause for rural women, the information that is desired, factual menopause education materials, and the best way to present this information. The process of producing a pamphlet will require strict adherence to readability guidelines to ensure that health literacy is addressed. By creating an inclusive educational guide that can be used widely it is hoped that this pamphlet will contribute to more equitable health care for rural women experiencing menopause. Dissemination of this educational material will also be an important aspect. Women identified the desire for a trusting relationship with their healthcare provider, where they felt safe and confident to discuss important health matters. By opening the discussion of menopause, through the distribution of the educational pamphlet, I hope that the healthcare providers in Masset will have increased willingness to address this transitional period with their female patients. The concept of health education, including key application strategies will be discussed with various healthcare providers, with encouragement to incorporate these approaches into their practice provided. Conclusion This literature review has identified that rural women have slightly different health education needs than their urban counterparts. While a large quantity of menopause information is available, rural women may not have access to these educational materials. In addition, feeling overwhelmed by the amount of educational materials available on the internet was identified as MENOPAUSE INFORMATION FOR RURAL WOMEN 29 prevalent in this population group. Rural women still desire the chance to be well informed about their health prior to and following discussion with their healthcare providers. When discussing the menopause period women are interested in learning more about symptoms and treatments, but also about the menopause experience that they share with other women. Menopause is a life event that occurs in all women, with a wide range in symptoms and treatment options. Nurse Practitioners are ideally positioned within healthcare to aid women through this life change and to increase health equity for rural women. By addressing and incorporating health literacy factors, the production of a community specific educational pamphlet should help to address some of the uncertainty that surrounds the menopause transition time for many rural women. MENOPAUSE INFORMATION FOR RURAL WOMEN 30 References Boivin, N. (2013). Rx health literacy for a service that empowers the client. Info Nursing, 44(2), 15. British Columbia Nurse Practitioner Association. (2017). NPs in BC. Retrieved from https://bcnpa.org/npsinbc/. Browne, A. (2016). What Does a Health Equity Lens Add to Patient-Centered Care? Newsletter Item Oct 1, 2016. Prince George Division of Family Practice: Prince George, BC. Browne, A, Varcoe, C., Ford-Gilboe, M., & Wathen, N., on behalf of the EQUIP Research Team. (2015). EQUIP Healthcare: An overview of a multi-component intervention to enhance equity-oriented care in primary health care settings. International Journal for Equity in Health, 14(152). doi: 10.1186/s12939-015-0271-y. Casper, R. (2016). Clinical manifestations and diagnosis or menopause. In UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-menopause?source=search_result&search=menopause&selectedTitle=1~150#H952677165. Charbonneau, D. (2013). Health literacy and the readability of written information for hormone therapies. Journal of Midwifery & Women's Health, 58(3), 265-270. doi:10.1111/jmwh.12036 College of Registered Nurses of British Columbia. (2017). Applying the competencies required for Nurse Practitioners in British Columbia. (Pub. No. 440). Vancouver: BC: CRNBC. DeMarco, J., & Nystrom, M. (2010). The importance of health literacy in patient education. Journal of Consumer Health on the Internet, 14(3), 294-301. doi:10.1080/15398285.2010.502021 Duffy, O., Iversen, L., & Hannaford, P. C. (2011). The menopause 'it's somewhere between a MENOPAUSE INFORMATION FOR RURAL WOMEN 31 taboo and a joke'. A focus group study. Climacteric, 14(4), 497-505. doi:10.3109/13697137.2010.549974 Goroll & Mulley. (2009). Primary Care Medicine: Office Evaluation and Management of the Adult Patient (6th Edition). Philadelphia: F.A. Davis. Harris, R., & Wathen, N. (2007). "If my mother was alive I'd probably have called her.": Women's search for health information in rural Canada. Reference & User Services Quarterly, 47(1), 67-79. Retrieved from http://goo.gl/asL7PG. HealthLink BC. (2016). Menopause and perimenopause. Retrieved from https://www.healthlinkbc.ca/health-topics/hw228763#hw228766. Jackson, L. A. (04). Living in a rural community is good for your health... or is it? Young women talk about rural living and their emotional and mental health. Canadian Journal of Community Mental Health, 30(1), 45; 45-60. Kulig, J. & Williams, A. (2011). Health in Rural Canada. Vancouver: UBC Press. Leipert, B. (2006). Rural women's health issues in Canada: An overview and implications for policy and research. Canadian Woman Studies, 24(4), 109-116. Leipert, B., & George, J. (2008). Determinants of rural women's health: A qualitative study in southwest Ontario. The Journal of Rural Health, 24(2), 210-218. doi:10.1111/j.1748-0361.2008.00160.x. Leipert, B. & Reutter, L. (2005). Developing resilience: How women maintain their health in northern geographically isolated settings. Qualitative Health Research, 15(1), 49-65. Lumsden, M. (2016). The NICE Guideline – menopause: diagnosis and management. Climacteric, 19(5), 426-429. doi: 10.1080/13697137.2016.1222483. MENOPAUSE INFORMATION FOR RURAL WOMEN 32 Madden, S., St Pierre-Hansen, N., Kelly, L., Cromarty, H., Linkewich, B., & Payne, L. (2010). First nations women's knowledge of menopause experiences and perspectives. Canadian Family Physician, 56(9), E331-E337. Marnocha, S., Bergstrom, M., & Dempsey, L. (2011). The lived experience of perimenopause and menopause. Contemporary Nurse, 37(2), 229-240. doi:10.5172/conu.2011.37.2.229. Martin, K. & Barbieri, R. (2016). Treatment of menopausal symptoms with hormone therapy. In UpToDate. Retrieved from https://www.uptodate.com/contents/treatment-of-menopausal-symptoms-with-hormone-therapy?source=see_link&sectionName=OVERVIEW%20OF%20APPROACH&anchor=H3#H3. Ministry of Health Canada. (2011). Eating well with Canada’s food guide. (HC Pub.: 4651). Ottawa, ON: Publications Health Canada. Paluck, E., Allerdings, M., Kealy, K., & Dorgan, H. (2006). Health promotion needs of women living in rural areas: An exploratory study. Canadian Journal of Rural Medicine, 11(2), 111-116. Retrieved from http://goo.gl/FXh3tA. Price, S., Storey, S., & Lake, M. (2008). Menopause experiences of women in rural areas. Journal of Advanced Nursing, 61(5), 503-511. doi:10.1111/j.1365-2648.2007.04522.x Public Health Association of BC. (2012). An inter-sectoral approach for improving health literacy for Canadians: A discussion paper. Victoria: BC. Public Health Association of BC. Raphael, D. (2012). Implications of inequities in health for health promotion practice (pp. 224-240). In Rootman, I., Dupere S., Pederson, A., & O’Neill, M., (Eds.), Health promotion in Canada: Critical Perspectives on Practice (3rd ed.). Toronto: Canadian Scholars’ Press Inc. MENOPAUSE INFORMATION FOR RURAL WOMEN 33 Sand-Jecklin, K. (2007). The impact of medical terminology on readability of patient education materials. Journal of Community Health Nursing, 24(2), 119-129. doi:10.1080/07370010701316254 Santen, R., Loprinzi, C., & Casper, R. (2016). Menopausal hot flashes. In UpToDate. Retrieved from https://www.uptodate.com/contents/menopausal-hot-flashes?source=see_link#H10329502. Statistics Canada. (2011). Women in Canada: A gender-bases statistical report. Ottawa, ON: Ministry of Industry. Stossel, L., Segar, N., Gliatto, P., Fallar, R., & Karani, R. (2012). Readability of patient education materials available at the point of care. Journal of General Internal Medicine, 27(9), 1165-1170. doi:10.1007/s11606-012-2046-0 The Endocrine Society. (2006). Position Statement: Bioidentical homes. Retrieved from http://www.menopause.org/docs/default-document-library/bioidenticalht_endosoc7FEEC6FE637F.pdf?sfvrsn=2. The North American Menopause Society. (2017). Bioidentical hormone therapy. Retrieved from http://www.menopause.org/publications/clinical-practice-materials/bioidentical-hormone-therapy. The North American Menopause Society. (2017). Clinical care recommendations. Retrieved from http://www.menopause.org/publications/clinical-care-recommendations. The Society of Obstetricians and Gynaecologists of Canada. (2014). Managing menopause. The Journal of Obstetrics and Gynaecology Canada, 36(9), S1-S80. The Society of Obstetricians and Gynaecologists of Canada. (2017). Menopause and u. Retrieved from http://menopauseandu.ca/index_e.aspx. MENOPAUSE INFORMATION FOR RURAL WOMEN 34 Uphold, C. & Graham, M. (2013). Clinical Guidelines in Family Practice (5th Edition). Gainesville, Fl: Barmarrae Books. Wathen, C., & Harris, R. (2007). "I try to take care of it myself.": How rural women search for health information. Qualitative Health Research, 17(5), 639-651. Appendix 35 MENOPAUSE HOW TO FEEL MORE COMFORTABLE: HOT FLASHES: Dress in layers Keep rooms cool Use a fan Have dry pajamas beside your bed Avoid hot or spicy food Drink less alcohol and caffeine Quit smoking Reduce stress Regular exercise Healthy diet Some medications can be helpful MOOD & SLEEP: Regular exercise Healthy diet Meditation Yoga Support network – friends, family, other women Reduce stress Some medications can be helpful VAGINAL DISCOMFORT: Moisturizer Lubricant before and during sex Hormone therapy can be helpful for some women Nurse Practitioner: 626-4702/ 626-3911 Family Doctor: 626-4702 Community Health Nurse: 626-3911 Primary Care Nurse: 626-4728 Pharmacist: 1-866-403-7320 menopauseandu.ca GET MORE INFORMATION: Talk with your health care provider to see if there are medications or treatments that might be right for you. Appendix 36 B O D Y & M I N D C H A N G E S It is normal to notice changes to your body and mind during this transition time. They can last from 6 months to 10 years. You may experience some, all, or none of these changes. What is menopause? MENOPAUSE: A normal change that all women go through. The time when your monthly cycles stop. No period for a full year. You are not able to have children any longer. For most women during their late 40s and early 50s. PERI-MENOPAUSE: The time before menopause. Changes to your monthly cycle: longer or shorter time between periods, longer or shorter periods, heavier or lighter flow. Many changes in your body and mind during this time. POST-MENOPAUSE: The time after menopause. Changing health needs. MEMORY SLEEP • Most common symptom • A feeling of heat on your chest and face that spreads over the whole body. • Can last 2-4 minutes and happen many times a day and night. HOT FLASHES • Less sleep • Poor quality • Hot Flashes • Difficulty remembering and concentrating • Normal memory will return after menopause for most women • Linked to problems with sleep • Most common: irritability, tearfulness, anxiety, depression and lack of motivation and energy • Dryness • Irritation • Burning • Discharge • Bladder infections VAGINA SEXUALITY • Vaginal dryness, soreness and sometimes pain during sex • Physical and emotional changes • Sense of loss and/or freedom MOOD
Graduating Project
eng
Unreviewed
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
University of British Columbia. NURS 596
Rural women
Menopause
Health literacy
Nurse practitioners
Menopause: health information for rural women
Text