Canadian women are struggling to find care for menopause in the public system, and many desperate patients are paying exorbitant fees to go to private clinics. The Society of Obstetricians and Gynaecologists of Canada (SOGC) calls this situation unacceptable and has ideas about how to improve it.

In 2002, the Women’s Health Initiative trial revealed unexpected risks associated with menopause hormone therapy (MHT). This finding led to an overcorrection in the form of an inappropriate, dramatic reduction in the use of MHT and in the education on its use across medical specialties. Although updated research demonstrates that the benefits of MHT outweigh the risks in many women, a whole generation of physicians has been scared away from MHT or has no idea how to prescribe it. 

Systemic Issues Created a Perfect Storm

The confusion about the role of MHT is the tip of the iceberg. The issues that Canadian women in menopause face reflect larger problems with the healthcare system. “We’re stuck with a system that is falling apart in Canada,” Nicolas Leyland, MD, professor of obstetrics and gynecology at McMaster University in Hamilton, Ontario, and SOGC president, told Medscape News Canada. A substantial portion of the Canadian population cannot even access a primary care doctor.

Under the fee-for-service model in primary care, counseling women about menopause is poorly compensated. This circumstance, combined with a lack of mandatory training in gynecology for primary care providers, creates a perfect storm for women in menopause. The primary care providers who are interested in women’s health gravitate toward obstetrics because it is better compensated than gynecology.

While lack of access to menopause care is garnering attention today, the problem reflects the neglect of women’s health in general, Jen Gunter, MD, a Canadian-American obstetrician, gynecologist, and pain medicine physician at Kaiser Permanente in San Francisco, told Medscape News Canada. “We need a cultural reckoning with how women are treated in medicine. Don’t tell me that if tomorrow [physicians] got reimbursed double for doing everything for women that you did for men, that all of a sudden people wouldn’t be interested in healthcare for women. Of course they would be!” Gunter, the author of bestselling books such as The Menopause Manifesto, is an outspoken advocate for women’s health.

Finding Solutions

The path forward, according to Leyland, includes mandatory training in gynecology for primary care providers, as well as training in menopause care for physicians, nurse practitioners, pharmacists, and naturopaths. This training must be coupled with expert oversight to ensure that quality remains high. Canada should also be exploring new models for delivering care, such as offering patient counseling sessions in small groups instead of one-on-one, he said. Such initiatives, however, are stymied by the lack of billing codes for novel approaches to care. Moving to a capitation model of compensation would allow primary care providers to focus more on patient education and disease prevention, said Leyland.

Education remains a cornerstone of improving care, and the SOGC is developing initiatives to get information on menopause care to primary care providers. These initiatives include point-of-care apps and guideline-driven treatment algorithms. Leyland also sees public education as part of the solution. As more women demand care for menopause and wait times for specialists increase, primary care physicians will be motivated to learn more about it.

It is essential for Canadian women to raise their voices and demand better care, Gunter agreed, and the threats to reproductive care among women in the US provide a cautionary tale. “It’s easier in Ontario for a family doctor to get the billing code to do sports medicine than the billing code to do menopause care,” she said. “That says everything.”

Gunter would like to see the federal government appoint a “women’s health czar” to bring needed attention to the field. The idea has legs. Senator Danièle Henkel has already sponsored Bill S-243, an act to establish a national framework for women’s health in Canada, which is currently wending its way through the Senate.

Is There a Role for Private Care?

It is not realistic to ban the private sector in Canada, said Leyland, noting that a de facto two-tiered system has always existed in Canada because of the ability to pay for care in the US and because medications and ancillary care are not fully covered in the public system. Many countries with publicly funded healthcare systems use private systems to reduce the pressure on them, he said. What is currently missing in Canada is good regulatory oversight of private clinics to ensure they deliver high-quality, evidence-based care.

But private care has its detractors. “In Canada, there are good studies in other areas [of medicine] that show that when we develop a private sector model, it pulls away from the public [sector],” said Gunter. Private menopause clinics often make the misleading claim that they provide care that cannot be offered in the public system, she added. Some doctors at private clinics charge upwards of $500 for menopause care instead of accepting a fraction of that amount as reimbursement in the public system.

“It’s about the money,” said Gunter. “I’m disgusted by the narrative that they are somehow better trained and better able to do this care. [They] have better marketing…. That doesn’t necessarily translate into better care. It translates into better access. Those are different things.”

But one private model can improve access to menopause care without taking away from the public system, according to Michelle Jacobson, MD, corporate chief of obstetrics and gynecology at the William Osler Health System in Ontario. Jacobson has been treating complex menopause cases for years in the public system and lamented her long wait list and her inability to provide adequate care to patients who cannot afford the medication or ancillary care that is not covered by the public system.

While continuing her work in the public sector, she co-founded Coven Women’s Health, a private clinic that offers multidisciplinary care from counselors, physiotherapists, social workers, registered nurses, and dieticians — whose fees are not covered by the public system. “I trained nurse practitioners who didn’t previously do menopause care, so we’re not taking people out of the public system, and I continue to deliver care that I love to do [in the public sector],” said Jacobson. She personally reviews every patient file to ensure quality of care. Since founding Coven, her 2.5-year wait list has shrunk by about a year.

Gunter, Leyland, and Jacobson reported no relevant financial relationships.