Quaternary prevention and menopause.

In current years, the specialty of mid-life health has been criticized for having become “over medicalized.” Menopause and androgen deficiency of the male, which are supposed to be “physiologic” phenomena, are felt to have unnecessarily been branded “pathological” by some commentators. It is suggested that interest in the pathophysiology of aging has been created with a view to expanding the market for the pharmaceutical and the medical industry.[1]

The specialty of mid-life health is as much about health as it is about disease. The subject focuses equally upon prevention and upon cure. Both nonpharmacological intervention (diet, physical activity, and stress management) and pharmacological treatments (hormonal, nonhormonal) are given similar importance. The aim of practitioners is to add “years to life,” and life to years’ of people in their care.[2]

The concept of “quaternary prevention”, proposed by Jamoulle and Roland, helps us analyze both sides of the debate in a balanced manner.[3] Quaternary prevention is defined as’ “action taken to identify patient at risk of overmedicalization, to protect him from new medical invasion, and to suggest him intervention ethically acceptable.” Using this definition as a framework, one can assess whether various interventions in mid-life health fulfill the aim of health promotion, without the risk of over medicalization.

Use of various diagnostic tests and therapies to prevent known chronic complications is common in mid-life. A bone mineral density (BMD) estimation, for example, is an accepted test in postmenopausal women, Quaternary prevention may well be required, however, if BMD is suggested to asymptomatic premenopausal women, or to postmenopausal individuals every 3-6 months. Similarly, management of acute illnesses is often required in mid-life and beyond. A short term course of estrogens to allay disturbing hot flashes, which impact personal or professional life, is an acceptable medical therapy. Continuing that course indefinitely, however, without appropriate follow-up, requires quaternary prevention. Other clinical situations in mid life health also warrant the application of quaternary preventive principles. These principles help resolve equipoise in clinical conditions where no definite recommendations or guidelines exist. Advising appropriate cosmetic surgery or bariatric surgery, for example, to a person in mid life, is a decision, which will vary for each health care provider, each patient, and each health care system. Here again, quaternary prevention helps the medical practitioner decide the correct course of action.

The concept of quaternary prevention needs detailed study, especially in mid-life and geriatric medicine, which,as a rule, are characterized by an increased need for medical advice, intervention, and “invasion.” The ethical dilemma of “primum nonnocere” versus “primum succurrere” (“first do no harm” vs. “first hasten to help”) is an inescapable reality for health care providers. An elderly female with a hip fracture, for example, may have to decide between conservative treatment and surgical intervention. Both options are associated with risks. Does one “hasten to help” by scheduling a total hip replacement knowing that she can develop one of many potential complications including life-threatening thromboembolism. Or does one prefer to “first do no harm,” asking her to remain bed ridden as she is?

Guidelines and recommendations are available for aspects of midlife heath, and help the health care provider practice adequate prevention.[4] Guidelines are also published for geriatric management of various conditions,[5] and can be used to inform clinical decision-making. For many areas of this specialty, however, definite recommendations are lacking, and a state of “clinical equipoise” exists.[6]

In such case, it becomes the responsibility to the health care professional to ensure appropriate quaternary prevention. A team based approach, with an interdisciplinary discussion, may help resolve many ethical issues. Consultation with peers et al. also helps. Patient empowerment, achieved by explaining the exact condition, and all possible outcomes, to the patient and her family, is important. Effective empowerment will allow for the strengthening of shared decision-making, which should be used at all times. This is also facilitated by an understanding of the bio-psychosocial model of health. Decision making, whether related to diagnostic or to therapeutic intervention, should not be based solely upon “biological” considerations; it should be tempered by psychosocial reality, and practical considerations, to achieve holistic outcomes.[7]

Further discussion about the role of quaternary prevention in midlife health, continued through the pages of Journal of Midlife Health, should clarify our thoughts, and help plan our actions.