In the world of menopause and perimenopause, women have few verified, well-informed allies on our side by name. My story of navigating the world of doctors was quite dramatic; in fact, I still can’t believe I survived it at times.

I saw nine or 10 doctors before I finally landed on the main one who provided most of the help I needed. These included multiple general medicine physicians, two psychiatrists (one of whom agreed the issue may have been perimenopause and encouraged me to pursue that lead), a psychologist (who told me it was probably perimenopause), two OB/GYNs (one told me I was too young for perimenopause and another prescribed me some highly ineffective birth control pills), a neurologist and, finally, my big win: a reproductive endocrinologist who was speaking my language, totally “got it” and did not hold back on prescribing hormone replacement therapy (HRT) for me.

The irony in this is that both OB/GYNs I saw were “Certified Menopause Practitioners” by the North American Menopause Society (NAMS). Physicians who earn this credential are referred to as NCMPs, or NAMS-Certified Menopause Practitioners. In fact, for this reason, I had sought out those particular doctors.

NAMS is akin to a nonprofit professional association of physicians in this specialty, but it is also a clearinghouse for health guidance and information related to menopausal and perimenopausal women, and our adjacent issues, and could also be considered as a semi think tank of sorts. From here stem multiple clinical recommendations and best practices that should inform the work of those who treat women at this stage of life.

Interestingly, the doctor who confirmed what was happening to me and that I was not crazy was not NAMS certified, though she dealt with women’s hormones and reproductive issues every day. Given that my experience with a NAMS-Certified Menopause Specialist was such a bust, I have wondered what it even takes to become one.

Is it a rigorous process? Do you have to prove and demonstrate your expertise in women’s midlife issues? How much do you need to know about prescribing, dosing and tweaking HRT? It is only for OB/GYNs, or can other doctors belong as well? This information is not easily findable, but here is what I have been able to determine.

What kind of doctors are NAMS doctors?
NAMS-certified clinicians are not necessarily of a particular discipline. Naturally, one might presume that NAMS-credentialed doctors are OB/GYNs, fertility specialists or hormone experts. But this is not true. Among those who qualify for the credential are nurses, nurse midwives, nurse practitioners, pharmacists, physicians and physician assistants. Aside from the credential, NAMS also has among its 2,000 members professionals who are pharmacists, nurses, anthropologists, psychologists, complementary / alternative medicine practitioners, OB/GYNs, internal medicine doctors and others.

Why would a doctor become NAMS-certified?
The reasons doctors may pursue NAMS certification is not necessarily about helping women lead better lives. Among the benefits NAMS touts for being certified are “possibility of more patient referrals, job promotion and higher salaries” as well as more industry credibility, legitimate logos for presentations and literature, media relations, permission to use the NCMP acronym professionally and a certificate for framing. Obviously, these perks are about the total value proposition and don’t necessarily mean those who seek NAMS certification don’t fundamentally care about their patients first. NAMS doctors are also featured in a special NAMS provider online directory, a precious resource for women seeking care for their perimenopausal and menopausal symptoms, and basically a pipeline for doctors’ ongoing self-directed patient referrals.

What are NAMS practitioners supposed to know?
The program objectives to be NAMS certified include being well-versed and authoritative on a number of things, including:

• menopause terminology
• endocrine and physical changes associated with reproductive and physiological aging
• risk factors related to lowered ovarian hormones
• performing a physical examination and conducting a health history
• selecting and interpreting appropriate laboratory and diagnostic tests
• describing current research on complementary and pharmacological treatments
• helping patients make informed decisions
• addressing psychosocial issues
• recognizing when referral to other services is appropriate and more

How hard is the test?
The NAMS test features 100 multiple-choice questions, with each question having three presented answer options (e.g. A, B or C). Once earned, NAMS certification is good for three years, but individuals must attain 45 credit hours of continuing medical education (CME) within that time frame. One representative sample question is:
Which of the following is a risk factor for postmenopausal osteoporosis?

1. Genetics
2. Moderate alcohol consumption
3. Regular exercise

What does the test content consist of?
The NAMS Certified Menopause Practitioner exam breaks down the test content as follows: 19% on physiology and pathophysiology of the menopause transition; 20% on symptoms and concerns; 21% on health disorders of midlife; 19% on preventive care and counseling; and 21% on treatment options for common menopausal symptoms. The index of specific topics, concerns and issues covered under these headings appears to be quite comprehensive, which provides the impression that no provider who is NAMS-certified should be minimizing women’s symptoms or writing them off as unrelated to perimenopause.

How much does the NAMS certification test cost?
For NAMS members, the test fee is $200, and for non-members, it’s $400.

Why are women’s experiences with NAMS-certified providers so mixed?
I visited two NAMS-certified OB/GYNs. One agreed I was likely perimenopausal, but prescribed birth control pills, which are not recommended first-line treatment for perimenopause or the specific symptoms I was enduring. The other was skeptical that I was in perimenopause, told me I was “too young” and wanted to prescribe an SSRI antidepressant. From what I’ve seen online, mainly in virtual communities, women have very mixed experiences with NAMS providers. Some had very positive encounters and were treated seriously and given effective options, and many have had poor reports of not being taken seriously, being told perimenopause was an impossibility, being told to do more yoga and take deep breaths, and other unbelievable, incredulous things.

I believe there should be some reporting system in place, one wherein women could share with NAMS their experiences with such providers, both good and bad. Without this mechanism in place, and with such discrepancies in reported experiences with NAMS providers, the organization is risking its reputation by extension. There needs to be more quality assurance in place to ensure greater consistency and continuity among providers who hold the NAMS badge.
 

Now that you’ve decided to finally get that long-delayed annual physical and have gathered an understanding of what to look for in a good doctor, it’s time to take things up a notch. Finding a quality physician and getting a yearly checkup provides a solid baseline for the fuller continuum of your personal healthcare portfolio.

And that broader picture requires building your total healthcare team. As you get older, having a complete medical squad ready to deploy in the backdrop of your ongoing wellness is vital. Sure, you’ll still see your core primary care physician (PCP) for routine office visits and once-a-year follow-ups to monitor your baseline health and get meds for things like sinus infections or UTIs. But creating a comprehensive care team goes beyond these minimums.

In some cases, it can be challenging to construct your healthcare team due to insurance red tape. For example, your internal medicine doctor may be the gatekeeper – the one you through which you must funnel most specialized medical requests. In such cases, the PCP largely holds the cards in determining whether, or when, you get that prized referral to see a specialist who focuses on a particular area of the body (e.g. a cardiologist for heart concerns, a neurologist for nerve-related issues). However, even if this is true for you, you can still build a go-to care team by doing the legwork now to determine precisely which doctors in what areas you want to see if or when circumstances dictate.

For those who have a primary care physician but who also have the autonomy to see other doctors without going through PCPs for a referral, you’re probably wondering, “What is a healthcare team? What kind of doctors need to be on it?”

A care team is akin to a team in sports: Everyone has a role, a position to play, with expectations of what that title conveys. Similarly, it is understood that most people who are 40+ years old currently need, or will need, more than the garden variety family medicine doctor to deal with all the medical concerns they face. Your PCP cannot be all things to all of your problems. So let’s call the other care providers “reinforcements,” though this is not intended to belittle the critical role they play.

Your body is unique, and the needs you have from a medical standpoint are, too. So these are simply recommendations, or considerations, of the various provider types who you’ll need to recruit as part of your total healthcare team.

Dentist. Oral health is important. People should visit their dentist twice a year for cleanings. Assuming no other issues are discovered, such as early stage periodontal disease or failing teeth, these two outings will be the only times you see your dentist annually. Though this may seem “low level” when it comes to overall health, it’s not: oral health is connected to diabetes, heart disease, oral cancer and stroke, according to many reputable health sources.

Dermatologist. Skin changes at midlife. You may start to see more moles, new wrinkles, a return of acne and changes in skin texture. Yes, in most cases these are more superficial, aesthetic considerations rather than medical needs. But feeling good about how you look is an important aspect of well-being. Dermatologists provide treatments and medications that can help women feel better about their changing selves at middle age without going under the knife.

Endocrinologist. With hormonal havoc happening during perimenopause, some women in the 40-and-over camp may find themselves visiting an endocrinologist for the first time. Most endocrinologists don’t treat perimenopause, but instead focus on diabetes, cholesterol issues, thyroid problems, adrenal disorders and hypoglycemia. The caveat to note is that reproductive endocrinologists are trained to deal with hormonal problems and can be well suited to manage hormone replacement therapy (HRT).

Gynecologist. This is perhaps the most obvious recommendation to have on your personal care team as a woman. Though we may not be entertaining the idea of reproduction at this stage, there are other elements of your reproductive health to maintain. It is now recommended to get Pap smears every three years (often along with HPV testing). Some women still opt to visit their GYN annually for an exam. It is important to find a doctor or practice skilled in, and attentive to, treating patients who are not obstetrical cases (in other words, women who are neither pregnant nor interested in being so).

Optometrist / Ophthalmologist. Most people’s vision changes around the age of 40, even for those who’ve never needed glasses before. Getting your eyes checked every year or two should be pretty customary for the 40+ set. This evaluates any changes to your vision and ensures you get the right prescription to see clearly, and also checks for any underlying eye diseases, like the beginnings of glaucoma.
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Orthopedist. The aches and pains of advancing stage start to hit many people going into their 40s or 50s. In many cases, the discomforts are short-lived and benign; other times, there is actually a structural and functional problem involving the musculoskeletal system. These problems could be degenerative in nature (think arthritis), acute (think runners knee) or require surgery (like bone spurs impinging on nerves). Achy necks, back pain, knee stiffness and the like are common symptoms that lead to orthopedic care.

Psychiatrist. A perimenopausal woman, or one going through the menopausal transition, has at least double the risk of first-time anxiety or depression than a pre-menopausal woman. The risk ratio is higher for women who’ve previously experienced postpartum depression or who’ve had prior depressive episodes. For many women, this will be the first time in their lives that they are offered or prescribed an antidepressant or anti-anxiety medication. Sometimes these medications have other benefits, such as treating hot flashes or reducing hormonal headaches. In any event, it’s probably better to have a professional trained in this pharmacology to manage this than a general medicine doctor. And this type of physician just happens to be a psychiatrist.

Your situation is as unique as your biology, and you may need other types of providers in your wheelhouse as you navigate the changes of age and time. Coming up soon in this series will be a list of the specialists and providers that are “nice to haves” in enhancing your total well-being and health.

​Whether you’re approaching or are already in midlife, one thing is for sure: it’s important to begin taking your health and well-being seriously. This includes various lifestyle enhancements, like getting serious about diet and nutrition, taking up regular exercise, reducing stress and getting basic checkups, like annual physicals.

The truth is, middle age is when health problems usually start making an appearance. After the age of 50, the most common diagnoses are hypertension, high cholesterol, diabetes, arthritis, osteoporosis, cancer, and anxiety or depression. Other relatively common medical problems that can pop up from age 40 onward include kidney stones, urinary tract infections, food allergies, overactive bladder and, yes, perimenopause.

With so much going on and so many health issues at stake, it’s critical to find a quality healthcare provider. But where to start? Of course, there are the practical concerns, like finding a physician who accepts your insurance, but what else?

The most important variable, in my estimation, is finding a good doctor. In my experience, a truly good doctor is like finding a needle in a haystack. The odds are better than winning the lottery, but the climb is still steep.

Here are some things to consider in determining if a doctor is a good one:

They don’t have medical Board violations. In each state, you can look up doctors’ medical board records. This enables you to check on the licensing status of physicians and also see if there are any complaints or findings against them. You can also see basics, such as where they completed their education and residencies, as well as any supplemental information they’ve disclosed, such as medical publications.

They have positive online reviews. Just as you search social media and other sites for recommendations on restaurants, plumbers and carpet installers, you can do the same for doctors. There are a variety of sites that post reviews expressly about medical providers, but I find the data integrity of those results are somewhat questionable. From my perspective, there are often far too many gloating, overwhelmingly positive reviews on the medical review sites. This may be because there are ties to insurers or certain healthcare practices operating in the advertising or sponsorship backdrop. So, to that end, I think Google reviews can provide a more realistic snapshot of how doctors perform and how patients feel about them. You will want to pay attention to the overall star ratings but even more attention to the actual narratives of the reviews themselves. Be mindful of how patients report being treated, listened to and followed up.

Their office experience is up to par. Sometimes decent doctors deliver horrendous patient experiences. Just like you probably wouldn’t keep going to a restaurant with great food but horrible wait staff, you shouldn’t tolerate a negative patient experience in order to see a pretty good doctor. Signs of poor patient experience outside the clinical scope include ridiculously long wait times, onerous times to be able to get in and see a provider (e.g. calling in May for an appointment but unable to get on the calendar until December), inadequate insurance processing or improper medical billing, dirty patient rooms and unkempt waiting rooms, rude or dismissive front office staff, condescending or unfriendly nurses, and outdated facilities and equipment.

They went to quality medical schools. The average person has no idea where his or her doctor went to school. But some people would actually benefit from knowing. When you look up a doctor’s bio, or pull their Medical Board record, you can see where they went to school and did their training. For those interested in taking quality control up a notch, they can then see how the medical school ranks, what its reputation is and how rigorous its programs are considered.

You get a good personal referral. Just like the best jobs are usually captured through a personal reference, having a positive referral of a doctor from a trusted friend, relative, neighbor or colleague can be a good baseline for sound medicine. If someone you know well and whose judgement you have faith in attests to a doctor being great, that is an added boost of confidence.

The doctor – himself or herself – delivers on the promise of good patient care. Sometimes you won’t know . . . until you go. The best indication of whether a doctor is a good one is going to be your own personal experience and judgement call. Things to look for are the doctor’s bedside manner – that is, how he or she interacts with you. Did he introduce himself? Did she ask how you’d been? Make sure the doctor seems to have reviewed your chart before entering the room. See if they seem familiar with your medical history and the reason for your visit. Check and see if they listen to your concerns, not interrupting or minimizing any questions you may have. Monitor if they talk “on your level” – for some people, that may mean not feeling like the doctor is “dumbing down” or oversimplifying information in talking to them; for others, it can mean that the doctor speaks in commonsense, plain language, not medical jargon. Does the doctor look you in the eye? Do they not rush through the visit? Do they follow up with you as needed or as they said they would?

They promptly respond to medical portal questions and concerns. Most modern medical practices now have patient portals that hold information related to previous appointments, test results, prescriptions and more. They also often feature a messaging platform where doctors and patients can communicate about non-emergency matters. If you send a doctor a question, and they either respond after a very long time (over a week) or not at all (which is unconscionable), that can be a tell-tale sign that you cannot trust this person with your life. After all, that is what is really at stake in designating a doctor to monitor your health and make vital decisions as a result.  

If all else fails, you can fire your doctor! One of the only good things about living in a capitalistic medical system is that people have choices. On that front, if you’re dissatisfied with your doctors, you can “fire” them. And one of the best parts about this is that it can be very undramatic. You don’t have to write a breakup note or give them notice. You simply find another doctor! Sometimes the best medicine is to vote with your feet and your wallet.