Maggie McKay (Host): When it comes to menopause, sometimes the stages can be confusing. So today, obstetrician and gynecologist, Dr. Irene Wahba, will fill us in on what perimenopause is, signs and symptoms, perimenopause transition and stages, and testing. Welcome to BayCare HealthChat. I'm Maggie McKay. Thank you so much for being here today, Dr. Wahba.

Dr. Irene Wahba: Thank you so much. I'm happy to be here.

Host: To start off with, what is perimenopause?

Dr. Irene Wahba: So, this is a confusing diagnosis, but it's a true diagnosis. Menarche, or the start of your period, is clearly defined, but perimenopause is sort of this vague in between when your ovaries are inconsistent. So, it's really hard to put a finger on it and say when exactly it starts. And this gets confusing, especially when patients go to physicians and ask questions and say," I think I'm in perimenopause," because there's no testing to really verify that.

So, although it is a true phenomenon, a lot of times the testing will not reveal it. So, a lot of women will say that they kind of felt blown off by their physician. The definition is unclear, the treatment is unclear, and it really involves informed decision-making between physician and patient.

Host: Well, I'm glad I'm not the only one confused on this. That makes me feel better. What are the signs and symptoms of perimenopause?

Dr. Irene Wahba: So, they can be very dramatic and obvious, like hot flashes =and skipped periods. Those are really classic for you're getting there, you're almost to menopause. But some people date perimenopause symptoms as far back as seven to 10 years before menopause starts. So, I mentioned that menopause is clearly defined as a year without a period. And this is obviously assuming that that's the only thing that's changed. You haven't had a hysterectomy or your ovaries removed, or you're not on any other hormones that may obscure the picture, but menopause is clearly defined.

Then, the average age of menopause is 51. So say, anywhere in your 40s, you may be suffering from perimenopausal symptoms. These can be hot flashes, night sweats, as mentioned. You can also have this vague sense of bloating, brain fog, changes in your intestinal function. You may have irregular periods. You may have closer together periods. So instead of being every 30 days for the past 20 years, now all of a sudden you're getting periods every 23 days or every 24 days. It may be a decrease in fertility. It may be a change in libido or sexual desire, maybe vaginal dryness. There are so many different aspects to it, but they translate well and they become a little more pronounced as you go into menopause. Oh, an important one that I forgot to mention is insomnia or sleep disturbance and weight gain. Those are two big ones that women come in and complain about often.

Host: So many things to look forward to. I think you answered this, but I'm just going to ask it just to make it clear again. Perimenopause and menopause transition stages, when does it begin? What's the differentiator?

Dr. Irene Wahba: So, perimenopause, the textbooks will define it as about four to five years before that last menstrual period. And that's because everybody can agree that the symptoms at that time are really obvious, but as much as seven to ten years beforehand. Average age of menopause is like 51 years and four months or something like that. And that's a clinical diagnosis. So, menopause is a single day in your life. You're defined as, "Today, I hit menopause. It's been exactly a year since my last period." Going forward, you become post-menopausal. So, everybody feels like, “I'm in menopause," well, really you hit menopause at a certain point, and you're either premenopausal or perimenopausal. Everybody who still gets a period is premenopausal. You're perimenopausal if you are in this state in between where your hormones are not doing exactly what you're expecting them to do, whether or not you're having the actual period part of it. And then, post menopause is thereafter.

Host: See, that's why I always thought when people talk about it, I think it's too confusing to figure out. So, does it really matter unless you're trying to get pregnant? Do you need to know what stage you're in?

Dr. Irene Wahba: That's a super valid point, actually. And this is where forgive your providers, forgive your doctors and your nurse practitioners and the people that you're seeing, because we are fuzzy on this too to some extent. We're taking your word for it a lot of times, and the options we have to fix it, you may not love, because a lot of them involve overriding your hormones, by giving you something like birth control pills, or just addressing individual symptoms. If they're mood symptoms, if they're sleep symptoms, if they're libido symptoms, we can kind of target what you're specifically asking of us. We sometimes don't have satisfactory testing that really gives us a clear answer, "Oh, that's what it is. You know, you gained 10 pounds. Clearly, it's this. So now, I have a clear option to give you that's going to fix everything." It's not like that, unfortunately.

And I'm also going to apologize that our training is really not great on this too. I mean, I'm an obstetrician-gynecologist. And when I trained, we talked a lot about the Women's Health Initiative Study, which was published in 2002, and it's a world that's been shaken up so many times since then. There's so many subsequent discussions. So depending on who exposed you, who speaks to you about it, there is often a bias that you hear in their voice, and it's difficult to take out your bias based on how the data was presented to you or how much you've trained since then, what you've been reading about, how much experience you have with dealing with this. Even OB-GYN residency is notoriously inadequate in teaching us about menopause. We don't have enough patients during that training period. It's just a different clientele than is typical of residency period.

Host: I also learned to take with a grain of salt all the advice you hear from friends because everybody is different. You can't possibly know what the next guy's going through. So, is that right?

Dr. Irene Wahba: That is actually great advice. I really appreciate that.

Maggie McKay (Host): We hear so much. And you mentioned testing. What testing is appropriate?

Dr. Irene Wahba: We can do testing that involves checking not so much any one hormone, but the relationship of different hormones. So, we can check follicle-stimulating hormone or FSH. We can check luteinizing hormone or LH. We can check estradiol levels, progesterone levels. Sometimes we have to check your thyroid or prolactin levels, which aren't necessarily causing perimenopausal symptoms, but can change your periods in a way that can make the picture muddy and difficult for us to interpret. We also sometimes need diagnostic imaging like ultrasounds or sometimes invasive testing like biopsies of the uterus, depending on what pattern of bleeding you're presenting with. Sometimes we even do brain imaging if some of the previous tests will come out suggesting that need.

Host: Well thank you so much for sharing your expertise about perimenopause, this has been very educational.

Dr. Irene Wahba: My pleasure. Thank you.

Host:. Again, that's Dr. Irene Wahba. And that concludes Part 1 of our 2 Part series on perimenopause. And if you'd like to find out more, please visit BayCare.org. I'm Maggie McKay. Thanks for listening. That wraps up this episode of BayCare HealthChat. Head on over to our website at BayCare.org for more information and to get connected with one of our providers.