Midlife Women’s Menopausal Transition Symptom Experience and... : simplebooklet.com

Original ArticleGlobal Advances in Integrative Medicine and HealthVolume 13: 1–13© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/27536130241268355journals.sagepub.com/home/gamMidlife Women’s Menopausal TransitionSymptom Experience and Access toMedical and Integrative Health Care:Informing the Development ofMENOGAPLisa Taylor-Swanson, PhD, MAcOM, LAc1, Kari Stoddard, BSN (Hons), RN1,Julie Fritz, PhD, PT2, Belinda (Beau) Anderson, PhD, LAc3, Melissa Cortez, DO4,Lisa Conboy, ScD5, Xiaoming Sheng, PhD1, Naomi Flake6,Ana Sanchez-Birkhead, PhD, WHNP-BC, APRN1, Louisa A. Stark, PhD6,7, Luul Farah8,Sara Farah8, Doriena Lee8, Heather Merkley, DHSc, RHIA9, Lori Pacheco8,Fahina Tavake-Pasi, MA8, Wendy Sanders, MFA10, Jeannette Villalta8,Camille Moreno, DO4, and Paula Gardiner, MD, MPH11AbstractBackground: Individuals with a uterus experience menopause, the cessation of menses, on average at age 51 years in theUnited States. While menopause is a natural occurrence for most, over 85% of women experience multiple interferingsymptoms. Menopausal women face health disparities, including a lack of access to high-quality healthcare and greater disparitiesare experienced by women who are black, indigenous, and people of color. Some women are turning away from hormonetherapy, and some seek integrative health interventions.Objective: Some menopausal women who seek healthcare do not receive it as they lack access to medical and integrativehealthcare providers. A potential solution to this problem is a medical group visit (MGV), during which a provider sees multiplepatients at once. The aims of this study were to gather women’s opinions about the menopause, provider access, andconventional and integrative health interventions for later use to develop a menopause MGV.Methods: We conducted a Community Engagement Session and a Return of Results (RoR) with midlife women to learn abouttheir menopause experiences, barriers and facilitators to accessing health providers, and their interest in and suggestions fordesigning a future integrative MGV (IMGV). Thematic qualitative research methods were used to summarize session results.1College of Nursing, University of Utah, Salt Lake City, UT, USA2College of Health, University of Utah, Salt Lake City, UT, USA3PACE University, New York City, NY, USA4School of Medicine, University of Utah, Salt Lake City, UT, USA5Instructor in Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA6Utah Clinical and Translational Science Institute, University of Utah, Salt Lake City, UT, USA7Department of Human Genetics, University of Utah, Salt Lake City, UT, USA8University of Utah, Salt Lake City, UT, USA9College of Health Professions, Weber State University, Ogden, UT, USA10Southern Utah University, Cedar City, UT, USA11University of Massachusetts Medical School and Director of Primary Care Implementation Research, Cambridge Health Alliance, Cambridge, MA, USACorresponding Author:Lisa Taylor-Swanson, PhD, MAcOM, LAc, College of Nursing, University of Utah, 10 S 2000 E, SLC, UT 84112, USA.Email: lisa.taylor-swanson@nurs.utah.eduCreative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative CommonsAttribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use,reproduction and distribution of the work without further permission provided the original work is attributed as speciﬁed on the SAGE andOpen Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

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Results: Nine women participated in the Session and six attended the RoR. Participants were well-educated and diverse in raceand ethnicity. Themes included: an interest in this topic; unfamiliar medical terms; relevant social factors; desired whole personcare; interest in integrative health; barriers and facilitators to accessing healthcare. The group expressed interest in ongoingparticipation in the future process of adapting an IMGV, naming it MENOGAP.Conclusion: These ﬁndings highlight the importance of stakeholder engagement before designing and implementing ME-NOGAP and the great need among midlife women for education about the menopausal transition, integrative self-care, andhealthcare.Keywordsintegrative health, integrative medical group visits, medical group visits, health care access, menopause, menopausal transition,perimenopause, post-m enopauseReceived September 18, 2023; Revised June 14, 2024. Accepted for publication July 3, 2024BackgroundAll individuals with a uterus experience menopause,1thecessation of menses, which is a natural occurrence experi-enced during midlife. In the United States, the mean age ofmenopause is 51 years.1The menopausal transition leads upto menopause and may last a decade. Even though meno-pause is a natur al occurrence for most, over 85% of midlifewomen experience multiple symptoms that interfere withtheir quality of life and daily activities.2Individuals mayexperience irregular periods, vaginal dryness, sleep problems,mood changes, weight gain and slowed metabolism, thinninghair, dry skin, vasomotor symptoms (VMS) including hotﬂashes, chil ls and night sweats, or loss of breast fullness.1,3However, symptom experiences varies, and multiplestudies report greater menopausal symptom severity andbothersomeness among black, indigenous, and other peopleof color (BIPOC) women.4,5The Study of Women Across theNation (SWAN) was launched to study physical, biological,and social changes experienced by African American, His-panic, Chinese, Caucasian, and Japanese women.6TheSWAN study is a multi-site, longitudinal, epidemiologicstudy designed to examine the health of diverse midlifewomen.6For example, this study informed us that African-American women are more likely to report heavy menstrualbleeding and to undergo hysterectomy and more severeVMS.3Notably, this study did not include American Indian/Alaska Native (AI/AN) women and very little is publishedabout their menopause experiences.7A common treatment for women experiencing bothersomemenopausal symptoms is Menopausal Hormone Therapy(MHT). The Women’s Health Initiative (WHI) conducted astudy in 2002 about the safety of MHT and later conducted arisk/beneﬁt analysis study of MHT in 2013, concluding that itis appropriate management for most women and contra-indicated for women with estrogen-sensitive cancer or ahistory of coronary heart disease, blood clot, or stroke.8Datawere re-examined in 2016, and MHT is listed as a ﬁrst-lineintervention to treat menopausal symptoms such as hotﬂashes, vaginal dryness, and mood changes.1Recent studieshave indicated minimal to no contraindications to MHT beingutilized by women younger than 60 without the contraindi-cations mentioned above and during the 10 years aftermenopause.9MHT is a ﬁrst-line treatment in The MenopauseSociety’s hormone therapy position statement,10and eventhough it is indicated for most women, there is a gap in care asnot all women can access or choose to take MHT. For ex-ample, the State of Menopause Survey conducted in2021 with 1039 women aged 40-65 across the United Statesfound that more than 72% of surveyed women were familiarwith MHT, but 65% said they would not consider using itunless their provider recommended it (32%) or a new clinicalstudy emerged proving its safety (29%).11Further, a sys-tematic review of nine surveys reported that 50.5% of womenreported using non-pharmacologic interventions speciﬁcallyfor their menopause symptoms.12Thus, the present study wasinformed by these trends in the utilizat ion of evidence-basedintegrative health and self-care information. The study teamsought to gather midlife women’s feedback about the futureprocess of designing an intervention that includes bothmedical and integrative healthcare interventions.Women face many health disparities, high mortality rates,and healthcare access concerns. These problems can partiallybe attributed to the poor education of medical residents.13Only 6.8% of surveyed medical residents indicated that theyfelt adequately prepared to manage the care of women ex-periencing menopause.13Within the medical and nursingeducational systems, there is a demand for better traineeeducation regarding care for women in the menopausaltransition.14Insufﬁcient training translates to poor care: onesurvey of midlife women reported that one-third of womensaid they felt their doctor isn’t comfortable talk ing aboutmenopause, causing them to look elsewhere for support.15This could potentially be due to a lack of in-depth educationof medical students. Approximately one-third of the surveyedresidents opted not to offer MHT to a symptomatic, newlymenopausal woman who did not have any contraindicati onsto receiving MHT or to a prematurely menopausal woman2 Global Advances in Integrative Medicine and Health

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until the natural age of menopause, despite the overwhelmingevidence that MHT is efﬁcaciou s and safe for these twocategories of women.16As previously discussed, MHT doesnot come without side effects, nevertheless, some medicalresidents are not providing what is currently the ﬁrst-linetreatment for symptomatic menopausal women. Few publi-cations highlight the attitudes of Nurse Practitioners (NPs)and other healthcare providers toward managing varioussymptoms and conditions during the menopausal transition.Still, literature does exist to educate NPs about the care ofwomen during the menopausal transition.17,18Another barrier midlife women face is the miscommu-nication of menopausal terms. Some cultu res refer to theperimenopausal term as “ th e change” or “a transition” in -stead of using a medical term. In Europe, menopause isreferred to as the “climacteric stage” .19In addition, highcosts fro m the healthcare system, lack o f insurance cov-erage, geo graphic location of residence, life priorities, andnative languages are all barriers women may face to re-ceiving a dequate care.There are numerous ways to decrease these health dis-parities. From a clinical standpoint, imp roving access tohealth care is a critical solution. Because of the potentialnegative consequences of MHT and health disparities, morewomen are turning away from MHT. Medical group visits(MGVs) are one efﬁcient way to ﬁll the gap in disparities incare so that whether a woma n wants to take MHT or does not,she can receive medical care in a group setting.MGVs, also known as shared medical visits, are medicalappointments in which one to two providers deliver medicalcare for a group of patients with similar diagnoses orquestions instead of a on e-to-one medical appointment.MGVs ar e one potential solution to the shortage of pro -viders because they allow for more individuals to be seen bya provider trained in concerns of the menopausal transition.MGVs allow individuals to be more easily seen by providersand create a community for the patients bec ause they canmeet others experiencing the same problems.20A qualita-tive study was performed on the delivery of MGVs, con -cluding that MGVs “successfully deliver on the promise ofpatient-centered care”.21MGVs have been designed forwomen receiving antenatal care,22for patients with diabetesmellitus,23and for psychiatric patients24– and participantsin all 3 types of MGVs reported a preference for the groupformat over a return to individual med ical visits.There is minimal literature on MGVs for menopause.25Ofthe few studies of MGVs for the menopausal transition, onestudy included annual examinations, follow-up menopausalconcerns, hormone thera py, bone densitometry results, andosteoporosis treatment follow-ups. The authors concludedthat shared medical visits increased physicians’ productivityby 20% compared to individual appointments. The partici-pants were surveyed afterward and responded, with themajority stating that they would prefer to go to another sharedmedical visit instead of the individual visit.26The aim of the present study is to ask a sample of midlif ewomen about their experiences of the menopausal transition,what medical attention they sought out when they hadbothersome symptoms, and whether they were interested inMGVs with integ rative health components and if theircommunities might ﬁnd a MGVof interest. The present studyis the ﬁrst step in a planned series of studies to adapt a MGVfor peri- a nd post-menopause and test it for efﬁcacy. If foundefﬁcacious, future studies of effectiveness and im-plementation in health systems will be conducted. The resultsfrom this ﬁrst study will inform the future detailed devel-opment of an intervention to bridge the gap in knowledgeabout whether midlife women would prefer MGVs andcomponents of evidenced-based integrative health and self-care information.MethodsEthics StatementThis study was approved by the University of Utah Insti-tutional Review Board and each participant provided in-formed consent before the start of the session.Community Engagement SessionsWe conducted two sessions with the same communitymembers: (1) a Community Engagement Session (similar toa focus group) and (2) a Return of Results. The EngagementSession (“Session”) was designed to elicit communitymembers’ opinions about th e menopausal transition an daccess to medical care and n on-pharmacological interve n-tions such as ac upuncture, acupressure, massage therapy,and chiropractic. We also asked about th eir preferredevidence-based, non-pharmacological components anddelivery format. Community Engagement Sessions provid ea format for researchers to consult with communityexperts – people with e xpertise about a particular top ic fromtheir lived experience.27The Meharry-VanderbiltCommunity-Engaged Research Core27has identiﬁed bestpractices for enhancing community engagement in com-munity consultations: early input, researcher coaching,researcher humility, balancing power, neutral facilitator, andpreparation of community stakeholders.28These practicesare also used to increase participant participatio n, to inc ludevarious viewpoints, and avoid conﬂa tion or squelching ofany idea or voice. We incorpora ted these best practices intothe c onduct of the Session, the results of which arepresented here.Our partic ipants were recruited through referrals withThe University of Utah’s Clinical an d Translational ScienceInstitute’s (CTSI) Community Collaboration and Engage-ment Team (CCET). This team is expert a t conductingSessions. Recruitment involved ﬂyers, existing communitypartnerships, word of mouth, so cial media, and referralsTaylor-Swanson et al. 3

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from past participants. Screening of eligibility to participatewas conducted by telephon e and ema il. Potential partici-pants were considered for inclusion if they were female,self-described, other, or prefer not to disclose sex/gender;had an intact uterus; within the ages 40-55; report poormenopause-related quality of life (≥3ona0-6scale)andexperiencing hot ﬂashes (severity ≥3 on a 0-10 scale) lastingfor 6 or more months; were willing to provide menstrualhistory which indicates either late transition (1+ missedperiods in the last year) or early post-menopause stage(within 1 year of the ﬁnal menstrual period); and were ableto provide informed verbal consent.The following questions were asked in the Session:1. What interested you in this discussion?2. Are the terms perimenopause, menopausal transition,and post-menopause familiar?3. What is your experience with the menopausaltransition?a. What age is relevant to this topic?b. What about social changes or social pressures?Are there any social aspects relevant to your ex-perience of the menopausal transition?c. Are there any healthcare aspects to your experi -ence of the menopausal transition?4. What are the barriers to accessing healthcare providers(e.g., primary care providers, gynecologists, etc.)?What are the barriers to accessing inte grative healthproviders (e.g., acupuncturists, massage therapists,chiropractors, etc.)?a. What helps you access healthcare providers? Whathelps you access integrative health providers?b. Where should resources for the group interventionbe posted?5. What are your feelings about the proposed groupintervention?These questions used lay language and were open-endedwhen possible. The questions were written to avoid negativeor positive bias and allowed for any amount of detail and self-disclosure. Participants received a short verbal description ofthe Session and the proposed group medical intervention andwere emailed the Session questions at least a week before theSession.The Session was held on September 28, 2021, and wasled by a CCET staff member experienced in facilitatingthis type of group and is independent of the researchteam. During the 2-hour Session, a facilitator led adiscussion of the questions with the aim of elicitingresponses from all Session participants; an experiencedCCET scribe summarized the discussion on large paperas part of the facilitation. Several members of theresearch team observed the discussion. Session partic-ipants were provided with a $75 gift card to compensatethem for their time.Data AnalysisConventional content analysis, an inductive method ofqualitative research,29,30was used to analyze the CommunityEngagement Session results. The Session was audio-recordedand transcribed. The de-identiﬁed transcription was read andre-read, after which coding was performed to identify themesand subsequent sub-themes by the ﬁrst and second authors,with recoding until consensus was achieved. Participants’comments are direct quotes, except that they were edited forbrevity while maintaining the origi nal meaning. Descriptivestatistics, performed on de-identiﬁed data, were used to an-alyze the participant demographics using SPSS Version 27.31Return of ResultsWe conducted a Return of Results (RoR) to review the datatables with Se ssion participants. This was an o pportunity toobtain feedback from women about whether the ident iﬁedthemes were accurate and whether community memberswould suggest any additions, deletions, or changes to the dataanalysis.ResultsTwenty-two individuals were screened, and nine met theinclusion criteria to participate. All nine women chose toattend the session, and six attended the Return of Resultssession. Participants ranged in age from 41 to 55 years.Most had completed a highe r education degree (associatethrough doctorate) and lived in an urban a rea (55%). The rewas broad diversity i n race and ethnicity: ﬁve of nineparticipants (55%) w ere leaders in their respe ctive com-munities, representing Black/African American, AmericanIndian/Alaska Native (AI/AN), Hispanic, Refugee, andPaciﬁc Islander communities. For reference, the state ofUtah is 23.3% B IPOC.32Other demographic data are listedin Table 1.Participants’ responses to the session questions aresummarized in Tables 2–9. We anticipated that the question“What interested you in this discussion?” would elicit par-ticipants’ desire to learn more about the menopausal tran-sition based on the literature.33-36This was the case; inaddition, participants indicated that they felt alone and wouldlike to talk with other women in addition to learning moreabout the menopausal transition (see Table 2).Are the Terms Perimenopause, MenopausalTransition, and Post-menopause Familiar?Several views were presented concerning terminologies suchas perimenopause, menopausal transition, and post-menopause (see Table 3). Several women reported thatthey had not heard of various terms before attending thissession. Women also noted that, for example in a Latino4 Global Advances in Integrative Medicine and Health

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communities, the terminology is less important than havingconversations on the topic while in a Polynesian commu-nities, the change of life is a term that is used, but not reallytalked much about so it was difﬁcult to know what age(s)were relevant. It was noted that in the Somali language thatthere was not a word for menopause. Women noted termssuch as ‘change of life’ or ‘transition’ were helpful.Tables 4–7 include the following four topics: 1) women’sexperiences with the menopausal transition; 2) ages relevantto this topic; 3) social dimensions; and 4) healthcaredimensions.What is Your Experience With theMenopausal Transition?Concerning experiences, participants reported experiencingheadaches, hot ﬂashes, irregular menstrual periods, loss ofmemory, changes in mood, sleep disturbances, and vaginaldryness, as well as having no symptoms being experiencedand being unsure about experiences. See Table 4, which alsoincludes perceptions, or appraisals, about the varioussymptom experiences.What Age is Relevant to This Topic?Participants also mentioned age dimensions. Six of ninewomen commented about age as related to this topic. Somewomen reported that they had irregular periods in their late30s and 40s and had problems with mood and sleep. Somewomen also reported that they did not have particularsymptoms in their 40s and did not have the symptoms theythought they would in their 50s (see Table 5).Are there Any Social Aspects to Your Experience of theMenopausal Transition?Social dimensions reported by women (see Table 6) includedbeing in the “sandwich generation,” trying to conﬁde infriends but ﬁnding they were not also in the menopausaltransition, basing anticipated menopausal experiences ontheir mother’s experiences, and that communication wasneeded about the transition.Are there Any Healthcare Aspects to Your Experienceof the Menopausal Transition?Participants reported healthcare dimensions (see Table 7)such as unhelpful care from a provider, helpful care from aprovider, the sex of the provider being relevant, and interest inwhole person care vs pharmacologic treatments.What are the Barriers to Accessing HealthcareProviders (e.g., Primary Care Providers, Gynecologists,etc.)? What are the Barriers To Accessing IntegrativeHealth Providers (e.g., Acupuncturists, MassageTherapists, Chiropractors, etc.)? What Helps youAccess Healthcare Providers? What Helps you AccessTable 1. Demographics of Engagement Session Participants.Demographic Topic N (%) RangeNumber of participants 9 (100%)Age (years) -- 41-55Race/ethnicityNot reported 0 (0%)African american 2 (22%)Alaska Native/American Indian 1 (11%)Asian 1 (11%)Caucasian 5 (55%)Hispanic 2 (22%)Paciﬁc Islander 1 (11%)Multiple reported (Yes)Religious afﬁliationAgnostic 2 (22%)Atheist 1 (11%)Christian 3 (33%)Muslim 1 (11%)Other 2 (22%)Approximate household incomePrefer not to disclose 0 (0%)<$10,000 0 (0%)$10,000-$24,999 1 (11%)$25,000-$39,000 3 (33%)$40,000-$49,000 0 (0%)$50,000-$74,000 2 (22%)>$75,000 3 (33%)Educational levelNot reported 1 (11%)High school or equivalent 1 (11%)Some college 0 (0%)Associate’s degree 2 (22%)Bachelor’s degree 1 (11%)Master’s degree 1 (11%)Doctorate degree 3 (33%)Number of members in the householdNot reported 0 (0%)Lives alone (1) 1 (11%)One other person (2) 1 (11%)Two other persons (3) 1 (11%)Three other persons (4) 4 (44%)Four other persons (5) 2 (22%)Five other persons (6) 0 (0%)Geographic areaRural 0 (0%)Suburban 4 (44%)Urban 5 (55%)Taylor-Swanson et al. 5

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Integrative Health Providers? Where ShouldResources for the Group Intervention be Posted?Participants provided detailed comments regarding barriersand facilitators to accessing health care – both conventionalhealthcare providers and integrative healthcare providers,such as acupuncturists, chiropractors, and massage therapists(see Table 8). Concerning accessing Integrative Health careproviders, participants noted that location and avail abilitywere an issue and a lack of awareness about what acupunctureor massage could be used to treat. With respect to accessingconventional care, COVID-19-related concerns were noted,as well as issues with the location and availability of theprovider, the need for childcare, lack of information aboutgoing in for preventive care, and ﬁnding that providers werereactive and not preventative. General limitations were noted,such as time and ﬁnding a provider they liked. A frequencycount of barriers is included in Table 8, with the physicallocation being the most frequently mentioned barrier.Facilitators to accessing healthcare providers (both con-ventional and integrative) included word of mouth, havinginsurance coverage, education about the insurance plan,doing their research, and having easily access ible publicinformation (along with suggestions as to where we couldpost information about the proposed integrative medicalgroup visit, IMGV).What are Your Feelings About the Proposed GroupMedical Visit Intervention?Participants’ perceptions of the proposed IMGV are listed inTable 9. They indicated several positives about the proposedIMGV, such as a safe and designated time and place to talkTable 2. What Interested you in this Discussion?.Themes Example Quotes (Edited for Brevity)Interested in this topic The journey into menopause is very new to me, and I would like to be a part of this importantconversationLearn more Want to learn ways to get through symptoms and menopause in generalWant to understand what [my) body is doingSomething that she does not know a lot aboutWould like to talk with women I am going into menopause, and I don’t know who to talk to other than an MDWanted to be in a space where I could freely talk to other women and share experiencesInterested in integrative health (IH)interventionsI am interested in integrative and western medicine and headed into menopauseHeading into the area of menopause and I do not usually use traditional medicine health care systemsNot talked about/taboo My community and society, in general, does not talk about thisThis is a taboo subject in my community and I wanted to step out and learn more and to help out mycommunitySelf-help I am looking forward to this group for self-help options and acupunctureFeeling alone Stage in our lives where we feel awkward. Want to hear that I’m not the only one that this is happeningtoIt’s nice to hear from women who are also experiencing the same thingTable 3. Are the Terms “Peri-Menopause” and “Post-Menopause” Familiar?.Term Used Example Quotes (Edited for Brevity)Culture (ifStated)“Peri-menopause” I had never heard of perimenopause until joining this group --I feel that it encompasses the pre, actual, and post --I’m in health research and I’ve never come across that term [perimenopause] before“Post-menopause” Post menopause: I am not familiar with that term at all --Which terms to use The terms are not as important as the conversation --One is not better; they’re all important Latino“The change of life” Almost like a timeline. Although it isn’t really talked about, so I’m still trying to ﬁgure out what age is thetimelinePolynesian“Transition” or“Transitioning”I like it because I am becoming something else, although there are a million different ways we transition,and one term does not acknowledge this uniqueness--“The change” Feels like a colloquial term --No word for it Familiar as in hearing about the [terms], but what do they mean? We do not have a word for menopausein our languageSomalia6 Global Advances in Integrative Medicine and Health

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about the menopausal transition, desire for a follow-upsession, excitement about the IMGV, and that it is a wholeperson approach. Another expressed theme was that womenfeel unheard and unseen at this age and in this transition andthat the IMGV would give acknowledgment to women.Several barriers were described, such as midlife womenbeing very busy and lacking time to devote to a multi-sessionintervention, that childcare may be needed, and that perhapsthe IMGV would need to be tailored for various cultures (anddelivered in various languages), and that the IMGV might beoverwhelming with many different components such asjournaling and healthy eating. The name of MENOGAP wasproposed and discussed, with the idea of the IMGV ﬁlling aGAP in MENOpausal women’s healthcare. Suggested for-mats included online, either synchronousl y or asynchro-nously, with a learning management system such as Canvasor via discussion boards.Return of Results SessionWe conducted a Return of Results Session on May 19, 2022,and 6 of 9 participants attended. The research team reviewedthe data tables presented here with the midlife women.Participants provided input regarding clariﬁcations andconﬁrmed the identiﬁed themes in each of the tables.Table 4. What is Your Experience With the Menopausal Transition?.Theme Experience PerceptionHeadache Headaches started coming since hot ﬂashes --Experienced headaches Are others having headaches?Hot ﬂash Have had hot ﬂashes --Irregular period Skipping and intermittent periods Not knowing what to expect or when, that can be stressfulWeird ﬂow changes, weird consistency, moreclumpy--Last period was 7.5 weeks long Feeling is a loss of control; I feel crazy, it’s so hard to cope withcomplete extremesMore inconsistent It’s been frustratingChanges in menstrual period --Memory loss Lately having trouble communicating because offorgetting certain words--Feel like losing her memory --Forgetfulness all the time --Mood change PMS is getting more severe; feeling unraveled Overwhelmed, it’s unpleasantSometimes crying, having feelings of loneliness andnobody loves herIt’s difﬁcult; not knowing why it is so difﬁcultThe feeling is a loss of control It is so hard to cope with --Anxiety and quick to be unnervedSleep disturbance Have to take 5HTP and melatonin to shut off herbrain--Usually comes home so tired, and sleeps on the wayto bed--Lack of sleep --Vaginal dryness Experienced some vaginal dryness --No hot ﬂashesexperiencedNever once had a hot ﬂash and if anything felt colder No idea what that’s likeNever experienced a single hot ﬂash --Unsure aboutexperiences-- Something is weird, something is going on Don’t know what isgoing on basically-- Going to be 50 and not having the symptoms that wereanticiapted-- Did not relate these symptoms to menopauseMood and sleep problems What is this, what is going on? Why are there mood and sleepproblems, plus hot ﬂashes?Table 5. Age Dimensions.Age Onset of Symptoms39 Intrauterine device removed, and periods have beenirregular sinceEarly40’sSkipping and intermittent periods41 Having troubles with mood and sleep42 Never experienced a hot ﬂash, so maybe it’s on its way?Mid 40’s Period stopped50 I’m going to be 50; I haven’t had the symptoms I thought IwouldTaylor-Swanson et al. 7

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Feedback on Table 4 included that after the discussion in thefall, women’s thinking changed, and that hearing otherwomen’s perspectives changed their own perspective. Sev-eral women mentioned that they had sought care from ahealthcare provider; one participant found a menopausegroup on Facebook and found the discussion online helpful.Participants mentioned that having community and culturallyspeciﬁc tailoring to the IMGV would be appropriate and thatthe biggest identiﬁed need is education for midlife womenabout this topic because every woman will some day gothrough menopause.DiscussionThe Community Engagement Session with nine midlifewomen and Return of Results (RoR) session with six womenyielded important information about their lived experiencesduring the menopausal transition and provided valuableadvice about the future development of MENOGAP. Par-ticipants were diverse in terms of race/ethnicity and hadvarious levels of post-secondary education. Fifty-ﬁve percentwere black, indigenous, and people of color (BIPOC)compared to the state of Utah which is 23.3% BIPOC.32Themes included an interest in participating in this conver-sation; medical terms were unfam iliar and less important thanhaving a conversation; this sample of midlife wom en ex-perienced many symptoms; many social factors affectedparticipants; receiving unhelpful and helpful healthcare; adesire for whole person care; a need for information aboutwhat conditions Integrative Health interventions can treatduring menopause; and barriers to accessing both conven-tional and integrative care were identiﬁed. The group ex-pressed great interest in the proposed IMGV model butexpressed barriers such as a lack of time available andneeding childcare. Women indicated that an online formatmay be helpful to overcome these barriers. Participants alsoindicated that cultural and linguistic adaptations of ME-NOGAP may be needed, so it could be culturally relevant fora speciﬁc community and offered in languages besides En-glish. These ﬁndings highlight the importance of extensiveTable 6. Social Dimensions.Themes Example Quotes (Edited for Brevity)Participants in the “Sandwich Generation” I’m taking care of my elderly parents and my kids are in middle schoolParticipants trying to conﬁde in theirfriendsThey have no idea what I am talking aboutFriends do not know anything about menopause. They make fun of me and may say things like, “Oh,you’re old.”I currently do not have friends who are experiencing any symptoms and I do not really have anyone totalk to about thisAnticipating menopausal experiences frommothersMy mom had a hysterectomy in her 40s, and she did not have perimenopause either. Her [menopausaltransition] was immediateCommunication about the menopausaltransitionCommunication is needed in my community and between community people and their providersTable 7. Health Care Dimensions.Themes Example Quotes (edited for brevity)Unhelpful care from a provider My doctor never associated my symptoms with menopauseMy doctor thinks my symptoms have something to do with my medicationIt’s frustrating to listen to my doctor when I go in. It seemed like a 15-minute ofﬁce visit with my doctor because ofsymptoms, then blood work, and the doctor said that I was ﬁne. Yet I felt “crazy.”The doctor has not associated my symptoms with menopause or had a conversation with me and I’m 50 years oldHelpful Care from a provider The Nurse Practitioner was profoundly different than being with a male gynecologist, it was helpful, and shetreated me as a whole personThe gynecologist I saw was great, but only had “medical ﬁxes.”I appreciated that my male healthcare provider immediately asked if I was having irregular periods regarding mysymptoms of trouble sleeping and mood changesSex of the provider I’m more comfortable talking to women providers that are within the menopausal range versus those in their 20’sor being maleA male doctor ran bloodwork for me and said I was not in perimenopause even though I had many symptomsPharmacologic ﬁxes vs wholeperson careAm I in need of a change of dose or a change in medication?There should have been a discussion before giving me a different medicationI just thought I needed a change of medicationThis is not just about the medication or prescription; it is about helping me as a whole woman through this process8 Global Advances in Integrative Medicine and Health

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Table 8. Barriers and Facilitators to Accessing Healthcare.Healthcare Setting Barrier Example Quotes (Edited for Brevity)Accessing acupuncturist, massage,chiropractor?Location and availability There is a chiropractor who focuses on women’s health, and to get into her is a3-7 months wait, depending on when you callUnaware We never talk about anything like that [referring to acupuncture]. No onewould even think of doing it. We just see it on TV. As far as a Chiropractor, itis only if it is really needed. Massage is just looked at as a luxuryLacking information I never would have thought acupuncture could help with perimenopausalsymptomsAccessing healthcare provider, primarycare provider, gynecologist?COVID-19 I just went for my annual exam it was hard to get an appointment. Then one ofmy other visits I went to, I was automatically put in a virtual slot withoutbeing told that was going to happenLocation/availability Any which way, it’s a 2-3 hour drive, just for the healthcare or that referralFinancial Copays for gyn and acupuncture things can be anywhere from $20-60. Do wepay a bill, put gas in the car, or do we feed the family? Of course, everythingelse will come before [copays]Childcare They only allow a patient to come in or a child patient and a parent. If youhave babies or grandkids, what do you do?Lacking information In our community, it seems that nobody really takes their health seriously, untilthey are about to die. They don’t really have a lot of outreach to come intoour communities, and let us know, hey, you need to do this and this and thisReactive, notPreventativeIf you say “I’m going to the doctor” the ﬁrst thing you’re asked “is everythingok, are you ok?” and that is the ﬁrst thing askedHealthcare in general Time Limitation A lot of people I know don’t even have the time to get a yearly physical check,let alone maintenance visits like massage or chiropracticDisliking change inhealthcare providersI am also someone who does not like changeBarriers FrequencyPhysical Location 4Time Limitation 3Financial Limitation (lackof insurance)3Finding a provider oneliked2Unaware of options 2Childcare 2COVID-19 2Reactive, notpreventative2lacking information 1Limited Availability 1FacilitatorsWhat helps you access healthcare andintegrative healthcare providersWord of Mouth There are a lot of providers out there… It is hard to know which providers aregood or badInsurance CoverageEducationI’m ﬁnding out new things about my insurance and I’ve been with the companyfor 7 yearsKnowing what is on your insurance, and what’s covered, that is importantResearch I do a lot of Google searches for my healthcare ﬁrstEasily Accessible PublicInformationInformation needs to be accessible. Where are those places we naturallyinhabit so the information can be easily accessible - as it is for young moms?Newsletters within our communitiesHow about the gym?Taylor-Swanson et al. 9

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engagement with potential stakeholders before the futuredesign and implementation of MENOGAP. We plan tocontinue engagement with this group of community mem-bers, forming a Community Advisory Board (CAB), tocollaboratively design an IMGV called MENOG AP.Our ﬁnd ings are in alignment with existing literature –most of which is conducted with White women – on women’sexperiences of the menopausal transition. Yet, our work isalso aligned with studies focusing on a speciﬁc community.For example, a qualitative study asking Black women abouttheir menopause and weight gain concerns reported that theirsample was unprepared for changes experienced duringmenopause and were interested in receiving informationabout menopause.37Unfortunately, the same concerns ex-pressed by a focus group conducted over a decade ago wereechoed in the session we conducted: lack of support andconfusion about symptoms attributable to the menopausaltransition, as well as difﬁculties in obtaining helpful care fromhealthcare providers.36Midlife women want reliable infor-mation and opportunities to discuss the menopausal transitionwith (preferably female) health professionals is another themefrom the present study that aligns with prior literature.38Although the Session provides important preliminaryinformation about midlife women’s beliefs about peri-menopause, the menopausal transition and post-menopause,symptoms experienced, and access and barriers to medicaland integrative care, there are several limitations associatedwith our study. We had a slightly younger sample that washighly educated (compared to general US and Utah rates),and we did not have any participants who were post-menopausal. We also had a relatively educated sample liv-ing in urban and suburban a reas. Thus, results may not berepresentative of women living in rural or frontier areas, aswell as those with less education. Furthe r, we did not askabout menopausal hormone therapy (MHT) directly, whichnegated our ability to discern interest in MHT as well asintegrative health, or separately. Perhaps most importantly,we conducted the study with a small group of women, thusresults of the study must be taken with caution as they maynot be reﬂective of women’s experiences in other regions ofthe country and may lack external validity. While a con-versation was had among women of varying races and eth-nicities, this study did not take a “deep dive” into any onecommunity’s experiences of menopause. There is a risk ofpotential bias of minimizing experiences due to a lack ofinformation. However, only so much depth may be obtainedduring a 2-hour focus group, and that is indeed a limitation ofthe present study. One step we did take to increase rigor wasto conduct a follow up session, a RoR, in which results werepresented back to participants for clariﬁcation, change orimprovement.Our study suggests the great need for education about themenopausal transition for midlife women. A novel ﬁnding isthat a whole person health perspective to managing men-opausal transition and post-menopausal symptoms is ofgreat interest to midlife women who participated in thestudy. Future research can be informed by one ﬁnding fromour study, to develop interventions in different languagesand reach out t o different cu ltures: we recommend thatfuture interventions be developed w ith appropriate culturalTable 9. Perceptions of the Proposed IMGV Model.Themes Input About IMGV (Example Quotes are Edited for Brevity)Positives We have this designated area to talk, and it’s safe. It is nice to hear that others have similar or different experiences. Having adesignated area and time to set aside to do this seems like a fantastic ideaI like that there is actual maintenance after. I could spend a lot of time through a program and often that is on your own. I like thataspectWhen you started talking, all I could think was, ‘Can I sign up today’?! That is the most profound thingI like that is a whole person approach that addresses a wide variety of needs. But most importantly, women are actually being seen.That is the key, in a lot of spaces, we are not feeling seen. When almost all the women go through this in their lives. So a huge partof the population never feels seen and addressedThe most valuable thing that this program seems to be addressing, is that acknowledgment. The value of having space for a discussionIt’s in-depth teaching and amazing. I am grateful that it is going to be something available for a lot of usIamdeﬁnitely getting lots of different ideas that could be possibilities that I could integrate in our community. I’ve had ideas in just inthe couple of hours that I have experienced tonightBarriers/AdditionsDeﬁnitely, lack of free time is a barrier, and it’s an investment we will need to ﬁgure out – but I will do whatever I can to be thereMany women have small children. Maybe add childcare somehow. Then you could get a lot of women interested in having 2-3 hoursof space without having to worry. If barriers were removed, I think women absolutely could participate and would want toMaybe add different languages and reach out to different cultures. That would be wonderfulI feel a little bit overwhelmed by it. … To ﬁnd time, journaling, and trying to eat healthy and all of that. Just to me the whole thing I keptthinking, ‘ would I even have time to do all that??’ I would love to join it but I don’t know if I could really commit to itFormat forIMGVI love online. If I have to travel, bad weather, construction, trafﬁc… I like zoomMaybe a/synchronous, alternating may be beneﬁcialCanvas would be a terriﬁc online formatDiscussion boards: done on your own time, in your own space. Not live10 Global Advances in Integrative Medicine and Health

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and linguistic adaptations to be relevant to various cultures.For example, some communities h ave long-standing tra-ditions of herbal or tea consumption and massage. Werecommend that provide rs discuss natural folk remedies thatare culturally relevant but also have safety data, and ideally,efﬁcacy data. For example, Black Cohosh has been u sed byAmerican Indian/Alaska Native women for centuries39andis likewise evidence-based.40Further, information providedin interventions should inc lude symptoms co mmonly ex-perienced, the timing of symptoms during the stages of thetransition (late reproductive, early and late transition, earlyand late post-menopause), and variability in symptom ex-perience (symptoms may last for years for some womenwhile others are asympto matic or experience minimallybothersome symptoms). Education could include self-caresymptom man agement tips, pharmacological and non-pharmacological care, and informa tion that is culturallyrelevant and tailored. Our participants repeatedly stressedthat the social nature of the session was helpful and thatwomen felt reassured they “weren’t going craz y” becauseother women in the group expressed hav ing s imilar expe -riences. This points out the need for information and supp ortfor midlife women in the menopausal transition. The socialsupport, education, and self-care included in an IMGV mayprovide much-needed care during this natural, but some-times problematic, life transition experienced by everyonewith a uterus.The information gained from this qualitative data con-tributed to plans to engage in the future adaptation of anIMGV called MENOGAP, designed to ﬁll these gaps inmenopausal women’s care. Session participants expressedinterest in joining a Community Advisory Board (CAB) toprovide ongoing collaborative design of the MENOGAPintervention. Mixed-methods and application of the Meharry-Vanderbilt Community Engaged Research best practices28will be used to assess participant feedback in an iterativefashion to adapt MENOGAP to suit midlife women’s pref-erences for health education about menopause (“menopause101”), pharmacological and non-pharmacological treatmentoptions, and evidence-based self-care for behavioral changeand improving patient activation and self-efﬁcacy. Just asMGVs are preferred over individual visits by patients withdiabetes, psychiatric disease, and women receiving antenatalcare, we anticipate that MENOGAP may be acceptable, andperhaps even preferred to one-on-one visits, by some midlifewomen as social support has been identiﬁed as being ben-eﬁcial to midlife women,41women report high levels ofsatisfaction42and appreciating the group medical visitformat.43Summary SentencesThis study engaged midlife women before the design andimplementation of MENOGAP, a proposed multi-componentintervention with group medical visits and evidence-basedintegrative healthcare information. Participants reiterated thegreat interest in a whole-person health intervention and theneed among midlife women for education about the meno-pausal transition, self-care, and healthcare.Declaration of Conﬂicting InterestsThe author(s) declared no potential conﬂicts of interest with respectto the research, authorship, and/or publication of this article.FundingThe author(s) disclosed receipt of the following ﬁnancial support forthe research, authorship, and/or publication of this article: This workwas supported by funding from the Undergraduate Research Op-portunities Program at the University of Utah, which was awardedto KS.ORCID iDsLisa Taylor-Swansonhttps://orcid.org/0000-0002-9116-6369Belinda (Beau) Andersonhttps://orcid.org/0000-0002-9978-9034Paula Gardinerhttps://orcid.org/0000-0002-3663-000XNote1. While menopause is typically discussed as a cisgender women’shealth topic, not all people identify as cisgender women whoexperience menopause. 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