Once Used to Keep Women from Top Ranks, Menopause Now Managed Within VA, Military Health Systems

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When President Harry Truman signed the Women’s Armed Services Integration Act into law in 1948, it was touted as opening full military service and veterans’ benefits to women, but many restrictions remained in place. Women were not allowed to fly aircraft engaged in combat or serve on ships engaged in combat. No branch of the armed services could include more than 2% female members, and promotions were limited to one full colonel or Navy captain as chief of the Nurse Corps and/or service director, with a limited number of female lieutenant colonels or Navy commanders permitted.1

“When I came into the Air Force, I couldn’t hope to be a general because the law said women couldn’t be generals,” Brig. Gen. Wilma L. Vaught, USAF, Ret., recalled in an interview with National Public Radio.2 One of the reasons for the restriction, Vaught noted, was that the congressional committees drafting the bill realized that most women under consideration for admiral or general, would be in their 50s and going through menopause, and the bill’s drafters were concerned that the women might make “irrational decisions” because of this.2

A lot has changed since then for women in the military, for female veterans, and in societal attitudes about menopause and the management of its symptoms.

Women in the Military

Today, more than 213,000 women are on active duty in the Army, Marine Corps, Navy, Air Force and Coast Guard, representing 14.5% of all military personnel. An additional 190,000 serve in the Reserves and National Guards.3 They serve at every rank. In 2008, when Gen. Ann E. Dunwoody was named the first female four-star general, 57 women held the rank of general or admiral, including five lieutenant generals or vice admirals.4

Impact on the VA

Today, women make up only about 8% of all veterans but, considering the number of women presently serving in the armed services, that number is expected to double within the decade.5

“According to the Department of Veterans Affairs, the current number of overall veterans has decreased from 23.4 million down to 22.7 million; however, the number of women veterans has increased by 8.1%,” explained Col. Shirley Quarles of the Army Reserve, who chairs the VA Advisory Committee on Women Veterans. In addition, female veterans tend to be younger than their male counterparts. “Overall, in the fiscal year 2009, the average age of a woman veteran was 48 years, compared to 63 years for males,” she added.

Furthermore, many of these women now turn to the VHA for health-care services. “We are seeing an increased number of women veterans seeking health-care services through VHA. The VA reported that 52% of women who are Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans have received VA health care. Of these, 88.2% have used VA health care more than once,” said Quarles, EdD, RN, FAAN, Department Chair, College of Nursing, Georgia Health Sciences University in Augusta. In fact, the number of women turning to the VA for health care was reported to have increased by 20% in 2009 alone.5

“Even more so, women are coming to VA at a younger age,” added Quarles, pointing out that “47.8% of women veterans from OEF/OIF who used VA health care between 2002 and 2010 were 30 or younger.”

Yet, as recently as three years ago, two-thirds of VA medical centers and clinics did not offer women’s health-care services.6 “We are late, and the surge in women veterans has begun and will continue,” said Veterans Affairs Secretary Eric K. Shinseki, speaking at the Women in Military Service for America Memorial at Arlington National Cemetery in July 2010. To address this concern, Shinseki has secured $217 million for gender-specific programs designed to provide better care and more privacy for female patients within the VA system.5

“The changing demographics are really impacting our future in terms of how we plan and in terms of how we base our primary care, and in terms of how we offer interdisciplinary care in order to address gender-specific needs,” noted Quarles.

“VA recognizes the need to continually improve our services to women veterans,” Patricia Hayes, Ph.D., Chief Consultant, Women Veterans Health Strategic Health Care Group told the Senate Committee on Veterans Affairs in July 2009. “[The VA] has initiated new programs, including the implementation of comprehensive primary care throughout the nation, enhancing mental health for women veterans, staffing every VA medical center with a women veterans program manager, creating a mini-residency education program on women’s health for primary care physicians, supporting a multi-faceted research program on women’s health, improving communication and outreach to women veterans and continuing the operation of organizations like the Center for Women Veterans and the Women Veterans Health Strategic Healthcare Group.”7

“The VA definitely has a 21st century patient-centric vision,” added Quarles. “This vision has definitely changed from several decades ago, whereby today this vision focuses on vets’ care for all veterans, including women veterans. We have done a lot of work regarding outreach to ensure that women veterans recognize that they, too, are eligible and can receive great care from VHA. As chair of the Advisory Committee on Women Veterans, we have really advocated for joint outreach to educate and raise the awareness of women veterans and, we have done that in collaboration with VA Administrations, Offices of Rural Health and Tribal Government Relations. We’ve also collaborated with Public Affairs to include states and counties and private organizations. We are trying to ensure that we continue to be out there in the media to continue to educate women veterans about benefits and services.”

As more women heed this call and turn to the VA for their health-care needs, particularly for primary care, an increase in female reproductive health services will be required, from contraception through childbearing to menopause management.

Managing Menopause

Menopause is commonly defined as the end of menstruation resulting from the loss of ovarian follicular activity (see box).8 Because the actual point of menopause is the final menstrual period, it can really only be known in retrospect, typically after 12 consecutive months of amenorrhea. Prior to this final period, most women experience five to 15 years of hormonal changes known as peri-menopause. Menopause can also be brought about suddenly by the surgical removal of both ovaries.

While menopause is a biological process and not a disease, changes in hormonal status can produce a wide range of bothersome symptoms. The Association of Women for the Advancement of Research and Education, through its Project Aware, sought to catalog the most common symptoms of menopause and perimenopause. Through the experiences of hundreds of women, they developed a list of 35 common symptoms (see table at left).9 Each symptom was reported by many women, was cyclical in nature and/or responded to treatments designed to address hormonal imbalances.9

Treating the Symptoms of Menopause

An extensive range of therapies is available to treat the symptoms of menopause. For women whose symptoms interfere with their quality of life, the mainstay of treatment is hormone replacement therapy (HRT). In HRT, estrogen is given to replace the hormones no longer produced by the ovaries. For women with a uterus, the synthetic version of progesterone, progestin, is added to protect the lining of the uterus.10 HRT can be given in a variety of forms, including pills, vaginal rings or skin patches.10 Estrogen can also be given in the form of creams and tablets to treat vaginal dryness, but these formulations do not work well for the other symptoms such as hot flashes.10

Research has shown, however, that HRT does carry risks. The FDA requires a warning label on all estrogen products approved for use in postmenopausal women, stating that long-term use of these products could increase the risk of heart attack, stroke, blood clots and breast cancer in some women.10 To lessen these risks, the FDA advises that women use the smallest effective dose of HRT for the shortest possible length of time. Women whose only complaint is vaginal dryness are advised to consider topical therapy rather than systemic therapy.10

In addition to HRT, a number of therapies can be used to treat the individual symptoms of menopause.11 For example, low-dose antidepressants, clonidine and gabapentin have all been used to treat hot flashes. Bisphosphonates and selective estrogen receptor modulators can be used to prevent osteoporosis. For women with low testosterone, testosterone replacement therapy can sometimes increase libido.

Conclusion

Much has changed for women in the military since 1948. Women now comprise nearly 15% of the armed forces and more than 8% of all veterans, and these numbers are only expected to increase. Attitudes about menopause have changed too, since the 1940s. Today, many women view menopause as a time of renewal, and health-care providers, including those in the VHA, have many tools available to help women manage its symptoms as they navigate their way through this natural biological process.

References

  1. Bellafaire J. America’s Military Women—The Journey Continues. Women in Military Service for America Memorial Foundation, Inc. website. Available at: http://www.womensmemorial.org/Education/WHM982.html#8. Accessed March 17, 2011.
  2. Martin R. General Remembers Her ‘Different’ Military Days. National Public Radio website. Available at: http://www.npr.org/2011/ 02/23/133966767/general-remembers-her-different-military-days. Accessed March 17, 2011.
  3. Statistics on Women in the Military. Women in Military Service for America Memorial Foundation, Inc. website. Available at: http://www.womensmemorial.org/PDFs/StatsonWIM.pdf.Accessed March 17, 2011.
  4. First Female Four-Star U.S. Army General Nominated. CNN – US website. Available at: http://articles.cnn.com/2008-06-23/us/woman.general_1_fourth-star-elizabeth-hoisington-third-star?_s=PM:US. Accessed March 17, 2011.
  5. Rein L. VA is stepping up its services for female veterans. WashingtonPost.com website. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2010/07/28/AR2010072805872.html?hpid=topnews. Accessed on March 17, 2011.
  6. Morris F. Veterans Affairs Scrambles To Serve Female Veterans. National Public Radio website. Available at: http://www.npr.org/templates/story/story.php?storyId=131073909. Accessed March 17, 2011.
  7. Hayes P. Testimony before the U.S. Senate Committee on Veterans’ Affairs. July 14, 2009. Available at: http://veterans.senate.gov/hearings.cfm?action=release.display&release_id=842d6fd1-43d7-4521-ba1c-2d8a4797b4d7. Accessed March 17, 2011.
  8. WHO Technical Report Series 866. Research on the menopause in the 1990s. World Health Organization, Geneva 1996.
  9. The 35 Symptoms of Menopause. Project Aware. Association of Women for the Advancement of Research and Education website. Available at: http://www.project-aware.org/Experience/symptoms.shtml. Accessed March 23, 2011.
  10. The Menopause Years. The American Congress of Obstetricians and Gynecologists website. Available at: http://www.acog.org/publications/patient_education/bp047.cfm. Accessed March 17, 2011.
  11. Menopause Treatment and Drugs. Mayo Clinic website. Available at: http://www.mayoclinic.com/health/menopause/DS00119/DSECTION =treatments-and-drugs. Accessed March 17, 2011.

Menopause and Veterans

A recent study looked at menopause symptoms in female veterans receiving health care within the VA system. The study compared three ethnically diverse groups of postmenopausal veterans: 90 women without diabetes, 135 women with well-controlled diabetes (hemoglobin A1c [HbA1c] <7%) and 102 with poorly controlled diabetes (HbA1c >7%). In general, the study found that these veterans were obese, of low income and had more than one chronic illness. Veterans in this study were also found to have greater menopause symptom prevalence rates than those noted in previous investigations of ethnically diverse, community-based non-veterans.

When comparing participants with diabetes and those without, the study found that the patients in the diabetic groups had higher body mass indices and more co-morbidities than those in the non-diabetic group. The two groups (diabetic vs. non-diabetic) experienced menopause at the same age and reported similar menopause symptoms. However, the study found that female veterans with poor glucose control “demonstrated higher menopause symptom severity scores (total score, psychological and somatic factor scores) than their controlled peers of comparable body size, years postmenopause and psychological status. Further, both menopause symptom severity and glucose control were significant correlates of perceived physical health in the diabetic cohort.”

The author concluded, “These findings substantiate the importance of addressing menopause health issues in the clinical management of women veterans with diabetes using services in the VA health-care system. For this group already in poor health, interventions targeting glucose control may also improve their menopause symptom experience. Future studies are warranted to better understand the relationship between military service and the menopause experience of women veterans, and confirm these findings in non-veteran diabetic populations.”

Reference

Rouen PA. Study of Women Veterans in Menopause. Available at: http://hdl.handle.net/2027.42/62196. Accessed April 13, 2011.

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