Rania Habib, MD, DDS (Host): This is Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Rania Habib. The National Institute of Health estimates that roughly 1.2 million women enter menopause each year, roughly 6,000 women per day. On today's episode of Expert Insights, we will answer all of your questions about menopause, symptoms, and treatment. Joining me today is Dr. Beverly London, a Gynecologist with the Carle Foundation Hospital, and she is here to discuss important tips about menopause. Welcome back to the podcast, Dr. London. We are so excited to explore this very important women's health topic with you today.

Beverly London, MD: It's great to be back. I think this is the most pressing topic. It's been in the news. Women are very excited to talk about this topic, so I think it's very timely.

Host: Absolutely, and we're also seeing a lot of women's symptoms that are being overlooked, so I think this podcast will really help our listeners know what to look for. Most people have heard the word menopause before, but many might not know what it actually means. To begin, Dr. London, what is menopause?

Beverly London, MD: So we define menopause as 12 months after having no cycle. And this, for most women, occurs around age 52. But we do have some women that have premature menopause, which is menopause before the age of 40. And some women have early menopause, which is menopause before the age of 45. But we define it by having no cycle for 12 months and then we say that you're menopausal.

Host: And now that we have defined menopause, let's review the most common and uncommon menopause symptoms that these women will experience.

Beverly London, MD: So I would say about 70%, 75% of women have typical hot flashes and night sweats and that can include sleep issues because of those hot flashes and night sweats. But some of the other symptoms that women have, they may have fatigue, weight gain, headaches, they may have urinary symptoms like leaking urine or having frequency or vaginal dryness.

A lot of women will have some mood changes or irritability. They may complain of brain fog, which is a very common symptom or a memory lapse. Some of the least common symptoms, some women will complain of palpitations. They may notice that they have skin, their skin starts crawling or they'll have issues with their mouth burning. So the symptoms are wide and varied.

Host: Absolutely. Now, when someone comes to your office and they're experiencing these symptoms, how do they differentiate them between, you know, symptoms that might be associated with another illness versus menopause?

Beverly London, MD: Some women may be perimenopausal where they haven't stopped having their cycles. So we call those perimenopausal symptoms and you really need to distinguish that from premenstrual symptoms. So when it's perimenopausal, there's usually no pattern to it. It will come and go. Whereas if it's premenstrual, there's usually a pattern to those symptoms that they have. That's an easy way to distinguish.

Host: Dr. London, what are the three most important aspects of menopause to address in the office once we've established that the patient is in menopause?

Beverly London, MD: Really we're looking at three categories or three areas of symptoms that we want to address with patients. There's the systemic symptoms, which are like the hot flashes, night sweats, the irritability as well. There's urogenital symptoms and there's a whole new category for those symptoms. We call it genitourinary syndrome of menopause. And those are women that have vaginal dryness symptoms or urinary symptoms that go along with them transitioning to menopause. And then there's the psychologic symptoms, which is the irritability and mood swings that are really disturbing or distressing for some women as they go through menopause. So those are the three categories.

Host: Thank you for sharing those aspects, Dr. London. Now, we know that one of the most common treatments for menopause is hormone replacement therapy, also known as HRT. What is HRT and who is a candidate for HRT?

Beverly London, MD: Almost every woman can be a candidate for hormone replacement therapy. There's four categories where we need to use caution. But hormone replacement therapy is using the hormones that your body was producing that have decreased as you have transitioned to menopause; primarily estrogen and progesterone.

Women that we need to be more concerned about or need to really identify if they're a true candidate for hormone replacement are women that have history of blood clots. Women that have heart disease, women with a history of certain cancers, especially breast and uterine cancer, and women with a history of stroke.

Host: Now when a woman is placed on hormone replacement therapy, are you guys focusing on only one of the hormones, on both? Could you enlighten us a little bit about that?

Beverly London, MD: We have three categories. If they have a uterus, we give them estrogen and progesterone. We want to give both hormones because we don't want that woman to experience bleeding on hormone replacement. If they've had a hysterectomy and they don't have a uterus, we use estrogen by itself. And for the vaginal symptoms, the genitourinary symptoms, we use vaginal products to help with the dryness and the urinary symptoms.

Host: So we know that hormone replacement therapy obviously is very important to help with these symptoms. Could you discuss with us, Dr. London, the updated guidelines for hormone replacement therapy?

Beverly London, MD: Just to circle back, a lot of women stopped hormone therapy in the past because of a big study called the Women's Health Initiative. They had even ended that study early because they saw that there was some concern about cardiovascular risk. But when we now look back at the women's health study, we realize that that study was done on women that tended to be older in the study and not the women that are going to be more symptomatic, which are the younger patients that are just entering menopause. Most of the women in the study, the average age was like 68 and most women aren't using hormone replacement at that age.

 That study caused a lot of women to stop hormone replacement where we know it's probably safe in younger women. We know that hormone replacement is probably safe in women up until age 60 and within 10 years of use. So we use that as a guideline. We really want to encourage women to use hormone replacement if they're under age 60. We know the risks are minimal and there's so much benefit to using hormone replacement.

And more than 10 years of use, then we get more concerned is that women need to stay on hormone replacement.

Host: Wonderful. As we're talking about, you know, the symptoms, or women who are entering menopause, how long are those symptoms actually staying? Because you did mention that 10 year limit on using HRT therapy.

Beverly London, MD: So, if you have a woman that went through premature menopause, if her menopause started before age 40, she needs to stay on hormone replacement until age 52 at least, so we kind of make an exception for that patient. But most patients are starting hormone replacement either perimenopausal and they don't need to fear because even if they've been on hormone replacement longer than 10 years, we can always switch them to something that is non-hormonal as an option for managing their symptoms.

So it's just for the hormones itself, we want to stay in a 10 year range if we can. But perimenopause may start many years before the woman actually stops having a cycle.

Host: Now that you've mentioned the non-hormonal options for menopause, let's actually discuss those. So Dr. London, what are the non-hormonal options for menopause, including new treatments that might be on the horizon?

Beverly London, MD: Yes, this is very exciting. So we have the traditional SSRIs, SNRIs, so things like Brisdelle, which is one of the FDA approved medications. The generic name is paroxetine. So we use that as a non-hormonal option for menopause symptoms. We also can use gabapentin. We can actually use oxybutynin, which they use for women that have problems with leakage of urine. Also, an option for your non-hormonal management of menopause symptoms.

We do have a new medication that came out a year ago, called Veozah, which acts on the brain to stop the hot flash. And we're very excited for that, because a lot of patients that have, for instance, history of breast cancer, and cardiovascular risks that weren't able to use hormone replacement or some of the other options; Veozah has become an option for them.

Host: That's fantastic. Now when we're talking about these non-hormonal options, how is the success rate compared to the hormone replacement therapy if we looked at them side by side?

Okay. Mm

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Beverly London, MD: So when we look side by side, estrogen works the best, absolutely the best. With these medications, success rate about 70 to 75 percent in terms of how effective they are.

Host: The women will still experience hopefully a lot of resolution of their symptoms if they're on the non-hormonal therapy options.

Beverly London, MD: Yes, absolutely.

Host: That's fantastic. Now you've left us with a ton of information. We went from the definition of menopause to common signs and symptoms, what to address in the office, and then with our treatment options of hormone replacement therapy versus the new options including the non-hormonal options.

What is your final take home message for our audience, Dr. London, regarding menopause?

Beverly London, MD: To find a provider that is comfortable prescribing hormonal or non-hormonal therapy, and to address your issues that you're going through with menopause.

Menopause costs the United States about $26 billion per year because of the issues with sleep and the hot flashes and night sweats. So, when women are symptomatic, it affects all aspects of their life. So you really need to not ignore those symptoms, but find a provider that can help you get relief and that's not going to ignore your symptoms.

Host: That is wonderful advice. And I didn't really realize that statistic of how much money the U.S. loses when women are symptomatic. So thank you for sharing that really important statistic with us.

Beverly London, MD: Yes, when women are symptomatic, it affects the whole family and it affects the work environment.

Host: Absolutely. Now, Dr. London, if someone wanted to come to your office or be a patient within your group, how would they do that?

Beverly London, MD: Well, Carle, we have a large OBGYN group and many of the family medicine and adult medicine providers at Carle also are able to manage menopause symptoms. So they could just tell that they want a consult for menopause and we'll get them with the correct provider.

Host: That's perfect. Thank you so much for joining us today, Dr. London. We really appreciate all the information that you were able to give us about menopause.

Beverly London, MD: Thank you.

Host: Once again, that was Dr. Beverly London, a Gynecologist at the Carle Foundation Hospital. For more information and to get connected with one of our providers, please visit carle.org or for a listing of Carle providers and to view Carle sponsored and educational activities, head on over to our website at carleconnect.com. I'm your host, Dr. Rania Habib, wishing you well. That wraps up this episode of Expert Insights with the Carle Foundation Hospital.