Kelsey Magnuson (Host): Hi everyone. I'm Kelsey Magnuson, Community Benefits Manager here at Emerson Health, and I'm here with Dr. Christina Thomas, OBGYN, at our affiliate office, Concord OBGYN. Welcome.

Christina Thomas, MD: Hi, Kelsey. It's so great to be back.

Host: Thank you. Yeah. We are diving deeper today into the topic of menopause and perimenopause, and you previously recorded an episode a few years ago providing a great overview. So if anyone is interested, hit pause and go back and listen to that one. But we know how fast things can change and wanted to bring you back to get an update, hear what your patients are saying.

And I know I'm hearing more and more about the topic and it's really gained traction in the bigger media. Even Oprah has been doing specials on the topic. So part of what we want to do today is just separate out what we hear on the internet and social media versus what is good, solid advice from our trusted doctors.

So as a quick refresh, can you give us an overview of menopause?

Christina Thomas, MD: Sure. So menopause is this time when women will stop having their period. So basically the rough definition is no period for one year and typical age is about 51-52. Now the caveat to that is many women will have lots of different symptoms leading up to this official life stage where they no longer are having their period.

And so that's, I think, where all this traction and internet craziness has come because women don't want to feel awful. Even starting early forties, maybe even later, 39, 38, 39, and we're not going to take it as, oh, this is just what happens and you have to get through it, and that's it.

So I think it's important to look at some of the symptoms, some of the treatments, because women are actually living a lot longer. Our lifespan is a lot longer and we want to be healthy. We want that longevity. And so the key is longevity and just being healthy and feeling our, you know, being our best self.

And so, I think women want to start doing these things, whether it's lifestyle modifications or different medications so that they feel their best in their fifties, in their sixties, seventies, eighties, nineties. We want to be carrying our groceries from the car into the house when we're 90.

So it's important that we dive into some of these things. I think women shouldn't feel embarrassed by some of these symptoms that they're having and really feel comfortable bringing it up, whether it's with their primary care or their OBGYN or whatever practitioner they're seeing, and bringing these symptoms up so that they can have a nice conversation with their provider, and really kind of get to the root of, is this actually perimenopause too? Is there something else going on?

Host: Yeah, I think that's going to be the message of today is talk about it and talk about it often. So if you don't like the answer that you're getting, keep talking about it with different providers and getting feedback and talk about it with your friends too, so that you don't feel so alone and feel like you're maybe going crazy through this time.

So so many health conditions, we are able to understand more from blood tests or different labs, scans, all the different ways that we can learn more about our body. So can we learn more by testing hormones or are there other tests that are available to help women as they're in this specific phase or even early in the phase to learn more?

Christina Thomas, MD: Yeah, it's tricky because that's probably one of the first questions I get asked is that, well, where am I in my journey to menopause? And it's not diagnosed by a blood test. And if we're still cycling and having our menstrual cycle monthly or even every other month, our hormones are going to change, day to day even.

And that's what's so difficult in quote unquote diagnosing perimenopause, and even menopause. I mean, we have some inclination of different labs. Obviously our hormone levels are going to drop in menopause. Something called the FSH, quote unquote is your menopause marker will be elevated, but even if it's elevated, you might still be having your period.

And so it's very difficult to, say, oh, your level is this. Yes, you're halfway through, or you're very close. It's really indicated by what your menstrual cycle is doing. However, there are other diseases such as thyroid disorder or any autoimmune disorder or rheumatologic disorder that is diagnosed with lab tests and could have some very similar symptoms, signs and symptoms of perimenopause or menopause. So it's something that there's a lot of talk on the internet about different labs, and check labs. Check labs. And I have to say, I do do labs for a variety of reasons, but you can't really diagnose perimenopause or menopause via labs.

It's really used as aid for us in making sure that we're not missing anything and that all the symptoms that the patient's having or the woman's having is probably related to perimenopause. So I'm not saying it's a bad thing. I'm not saying, don't ask for labs, but I think it's part of the shared decision making that you have with your provider.

And there's a lot of online services, a lot of online labs that are promoting this huge lab panels and there's very many. I keep hearing of new ones. Even this past week I heard of a new one, and I have a printout of one of my patients and I was like, oh, wow, I don't even know half of these metabolites.

So it's something that I would have to look at. Because it's not some of the usual labs that I draw. Again, I think it's just part of the conversation that I have with my patients. But to diagnose, quote unquote perimenopause, it's not very useful.

Host: Yeah, it can be so tempting when you're going through difficult symptoms or phase and you just want answers. And so when the internet hands you an opportunity for the answers, it's easy to cling to that, but again, going back to the importance of working with a provider, sharing what's going on and talking about it is key to get to what is the correct problem and what is the correct solution.

Um, and so with that, speaking of symptoms, seems like much of menopause is symptom management. So once you've kind of ruled out any of those other conditions or issues that you mentioned. And women are kind of, alright, I have all of these symptoms, what do I do?

So I want to go through and hear from you what are the symptoms that you are hearing of most often and how can we support people during that time and get some relief? Because that's really what we want during this.

Christina Thomas, MD: Correct. Everyone just wants to feel better. Do you want to start? Do you want me to start? Do you have questions on symptoms?

Host: Yes. I'm not experiencing these symptoms yet, but I did a survey, lots of people around me to understand what are you going through and different experiences. So kind of the key one that is most common everybody you talks about, you think about with menopause, I see commercials about it; the hot flashes or night sweats and those times when you're just overwhelmed with heat, at any time in the day. But, you know, I think that, it can happen more at night too. So.

Christina Thomas, MD: Yeah, the vasomotor symptoms, that's your classic menopause symptom, whether it be the day or the nighttime. It can be really awful and affect women quite significantly and just how they're feeling. There's always, we go through some of the holistic treatments that you could do through, and we can do this with the symptoms.

And then you do medication based with the holistic, there's also lifestyle modifications. Obviously with the hot flashes, like make sure you're dressing in layers. You know, a lot of my patients will carry around those personal fans just for when they really get that flushing. And it's embarrassing, right?

They start sweating even and their face might get red. And that, you know, if you're in front of clients or part of your job is to be face to face with people and you can't hide behind a desk. Like that's very embarrassing. Certain holistic options, black cohosh, chaste tree berries, some of these, some different herbal remedies sometimes can help bring down the frequency and severity of the hot flushes.

And then, you can look at medication and certainly gold standard for treatment of hot flushing, night sweats is hormone replacement therapy. That is the gold standard. Why we typically will talk about different hormone replacement therapies and that's in the form of estrogen and progesterone.

And this will significantly reduce the hot flashes and the night sweats. There's also other medications if a patient or woman cannot take hormone replacement or doesn't want to, wants to try something different, there's a medication called VEOZAH, which also is a newer medication that's only indication is to decrease the hot flashes.

And then there's different medications called Effexor, venlafaxine, sometimes Prozac or Zoloft that also can help reduce these symptoms. So again, lots of options, and again, something to discuss with your provider. But looking at the Menopause Society and their update, this is basically again, gold standard treatment is hormone replacement therapy.

Host: And I know that there's some controversy around that and some potential dangers. Do you want to just touch real?

Christina Thomas, MD: Yeah. I mean that's a big conversation in and of itself, but, the unfortunate part of it is there's not a lot of recent data and any really randomized controlled trials that have come out with regarding safety, different risks. We have old data from 2002 from the WHI. There's a couple other more observational studies and papers that the Menopause Society has compiled in their update.

So biggest risk that I tell my patients when you're using estrogen is really a blood clot. A venous thromboembolism, definitely decreased with estrogen patch use compared to a pill use. And the nice thing now compared to 2002 when they used Prempro in that trial, is that we have something called it's a bioidentical, meaning,

what your body makes and what your body recognizes as its own hormone. And so we have an FDA approved both estrogen, which is the 17 beta micronized estrogen, and then a micronized progesterone called Prometrium is the trade name. And so these two, the patch and this progesterone, we think has a little bit better of a safety profile.

And again, recommendation is to start within 10 years of menopause. Most women will want to start during the transition when their symptoms are worse, and so, less than 60 years of age, and or within 10 years of menopause transition is typically when women will see the most benefit of starting hormone replacement therapy and hormone replacement therapy will be a whole different podcast topic. We can go on and on with that one. But again, I more providers are feeling more comfortable prescribing them again, especially, taking the patient's medical history, risk factors, but again, could be even, and we'll talk about more of the symptoms that women are having. But we found that treating with estrogen and progesterone have helped many, many different perimenopause and menopause symptoms because we have estrogen receptors throughout our whole body, not just from our ovaries.

Host: Great. Well, thank you for going over that overview and the pros and the cons of it, and again, goes back to why you need to have the conversation, why you need to be open with your provider and figuring out what's best. And you mentioned that it can help with other symptoms as well. So let's go into what are some other big symptoms that you are hearing and that can cause a rough time during this transition?

Christina Thomas, MD: Right. I mean, with the night sweats, a lot of it is just sleep disturbance in general. Waking up that 3:00 AM, insomnia. Can't get back to sleep. And then your mind starts racing and then at 5:00 AM you fall asleep and then your alarm goes off at 5:30. So a lot of times my patients will be very, they'll just be exhausted because they're not getting great sleep. And I think being tired then affects the way they feel throughout their day to day, their hour and hour. If they're not well rested, they're going to probably have brain fog. Another big one is that, or that word finding, I'm having it probably now answer during this podcast.

Um, so like subtle things, you're like, wait, I know what I want to say, but it's just not there. And I think also having a poor night's sleep can affect the brain fog, but also just in general, brain fog is one of the perimenopause menopause symptoms. Some anxiety, a lot of spikes in anxiety.

Some depressive symptoms or emotional lability. A lot of my patients will come in just saying, I just, I'm so angry. I'm so angry all the time. I don't know why. And so again, hormone replacement therapy can help with this. Other times it's maybe we're talking about more of a mood medication or anti-anxiety medication.

Some more subtle things is joint aches. Frozen shoulder is a big one. Like I had frozen shoulder, like, you know, I'm doing my ex exercises and, all of a sudden like I couldn't do anything. And then the subtle things like, my hair is thinning, my skin's changing, all these other subtle things that I think when combined, just makes you feel not well and not yourself.

I have women coming I just don't feel like myself. What happened, like what happened to me, which is very concerning and frustrating. And again, and it doesn't happen, over time, a lot of times it's just like six months ago was fine and then all of a sudden I wasn't. And again, it's just really breaking down what their lifestyle is looking like, what's happening in their lifestyle, and in their life and kind of teasing out, okay, let's get to the bottom of what's really going on. Let's try to help. And then of course, weight gain. Unfortunately, it's a big concern. And, what happens is we have a different weight distribution as we enter perimenopause and menopause, and it's that central adiposity that increases instead of maybe some weight gain around the hips and the buttock area.

Even women who were thin their whole life, all of a sudden come in and be like, what is this? I have, I have a stomach now. Like, what's going on? And unfortunately we probably went on a little tangent, but unfortunately hormone replacement doesn't help that much for that weight gain. It can help decrease some of that central adiposity because then we have some estrogen receptors that can help redistribute the weight.

But then we kind of look at lifestyle modifications, which we can kind of segue in if you want. So really, hopefully if we start hormones and we have a better night's sleep, we have more energy to exercise and it's not going for 45 minute on the stair master or elliptical, it's, we really want to concentrate on strength training, and rebuilding our muscle mass.

Because we do, our muscle mass decreases as we age, actually starting after 35 even. And so it's strength training, even 10 minutes, three times a week has been shown to help maintain some muscle mass. Obviously if you want to build more, you probably need to do a little bit more, but that's what's going to keep our metabolism at a higher level so that weight gain isn't so pronounced or so quick.

Also it's good for any stress reduction and so you know, stress it's a nasty, nasty thing that we all have and carry and so trying to do and mitigate some of the stress in our lives, having a plan, whether it's meditation or something to help manage your stress levels.

It's also getting your steps in. So five to 10,000 steps a day. And so I usually say like, go for a walk when you get home from work or even after dinner. Summer's a great time. It's lighter later. And, take the whole family, make it a family thing. Like just get out and get your steps in and then do cardio.

Because you want to do cardio. That's also a nice stress relief, you know, but it doesn't have to be 45 minute just banging it out and you know, sweating. It's really maintaining your muscle mass and then cardio because you like it.

Host: I think each of the different exercise forms has its benefits and kind figuring out what you like.

Christina Thomas, MD: Cardiovascular health too, obviously.

Host: Yeah, cardiovascular health, being able to do that. So I guess I just wanted to go back to, you talked about the joint aches and strength training. Is there any concern or, how do those two play into each other?

Christina Thomas, MD: I think it does coexist. You know, if it's something that you have problems with your knees or something, definitely like look into that, go see a specialist or do some physical therapy. Sometimes strengthening the muscles around these joints is actually what we need to do.

And again, if we're trying to help decrease some of that inflammation in our body, sometimes that's a cause for joint aches. If we don't have any underlying problems, or any other diagnoses, then trying to decrease the inflammation with different dietary changes, the no fun diet, quote unquote, which everyone probably anti-inflammatory diet is another term.

You know, decrease the gluten, make sure you're not drinking a lot of alcohol, two to three drinks a week. Decrease your dairy if you're sensitive to dairy. The Mediterranean diet is a big one for anti anti-inflammation, berries, nuts, and having fiber, about 25 grams of fiber.

And then the big thing is protein and at least 90 to a hundred grams of protein. And that does vary based on your weight and your whole body composition. But, that's what's also going to help maintain muscle mass. And if you're strength training, and again, it could be chair yoga to start, no one's going to expect you to go do Olympic weightlifting, light weights, chair yoga, body weight training even, you have to start somewhere if you're not used to it.

I always say if you don't have time, like buy a weighted vest. You can get them on Amazon. Start low, five pounds, three pounds, and get something that you can increase as you get stronger, you can even do wrist weights and so move your arms while you're walking. So there are different ways to really help in terms of trying to get that strength in.

Host: Yeah, I think it's really encouraging that just a little bit can make such a big difference. And so I think that we often get overwhelmed with, oh, you have to do that 30 to 45 minutes of something. But really breaking it down and looking at what you can do and, and starting small. So starting small with the actual weights or types of exercise, and then starting small with the time too.

And then maybe you feel a little bit better and you're encouraged to do a little bit more. You can increase the weights or increase the time. There's lots of different ways to switch it up and get you feeling better again. So were there any other symptoms that you wanted to kind of go over?

Christina Thomas, MD: Um, I'm trying to think. I'm going to look at my, what we talked about, I think maybe the last thing I think that we mentioned is the libido. That's probably on the top five of complaints. And unfortunately, there's nothing great out there for us, unfortunately, especially in the United States, that's FDA approved. I do want to mention that if it's more of painful intercourse or some dryness, there definitely is treatment via local vaginal estrogen cream or tablet or ring. There's another medication, DHEA that also can be used for vaginal dryness and also some over the counter things.

Some either suppositories or medications that they can try. So if that's why you're not wanting to be intimate with your partner, there's definitely treatment for that. In terms of just in general low libido, again, it's, we didn't talk about testosterone, but that is another hormone that we have that significantly drops.

 And so using estrogen and progesterone, has not been shown to really affect libido that well. A lot of times I'll talk to my patients about adding testosterone therapy. Which again, is not FDA approved and off-label. So again, something to talk to your provider on. There is a couple, one in particular that I'm thinking of about FDA approved medication for hypoactive sexual desire disorder.

It's a pill and there's also an injection, that you can also use, again to help with intimacy and your libido. So there's a few options out there. I don't prescribe them often. There's a lot of side effects associated with that, but certainly options if this is something that's really affecting your relationship with your partner.

But again, one that I always say, if you get a little more rest, if you're feeling a little bit better about yourself, you're happier, you're less stressed, does that translate into having a better intimate relationship with your partner? That's a tough one, unfortunately, and it's very unfortunate, but maybe soon there'll be something.

Host: We can have hope for more research and more answers.

Christina Thomas, MD: For all of this. And, talking about hormone replacement, again, there's really not any randomized control trials recently. And hopefully that's coming. So we have good data. Well, we kind of talked about when you start, but when do you stop?

How long do you continue this treatment? Typically it's five to seven years, but could be longer, in the discussion if you're still having symptoms. And what age, can we start it in our sixties? There's certainly more risks in their sixties and when women they're in their seventies as well.

So again, recommendation is through that transition, which typically happens early fifties.

Host: Great. So I think that we've gone through a lot of different options and it seems like there are options. While some symptoms may have limited options, there still is, is some things to discuss and some things that can help. And so I think that really as we look a big picture and zoom out, it's thinking about talking about your symptoms and being honest with your symptoms.

As I was getting ready to have this conversation, I was asking different people and I talked to someone who was kind of at the end or almost on we might call the other side, and she said that she wished she talked about it sooner. And I thought that that was just such a great encouragement to people that no matter what you're experiencing, talk about it with your providers.

Talk about it with people around you who might be going through the life stage. Because we didn't really get into this, but the life stage comes with lots of different things. So, you're dealing with kids or work or aging parents and all of that creates, as you were saying, the stress and increasing these symptoms maybe even more.

So I know you talked a lot about lifestyle modifications. There's maybe, can we end with like wrapping up of like, what are the big lifestyle modifications that can really make a difference in all of these areas, all the symptoms and in all this phase of life?

Christina Thomas, MD: I think one, is just be kind to yourself. I think initially just have some grace with you and your body and try to accept some of the changes that are happening. It's frustrating. And we touched on trying to add in some exercise. Maybe if you start with like twice a week or three times a week, trying to add in all these different things doesn't work.

You're gung ho for, you know, a week or two, and then it just, you fall off the wagon that's okay. And then you get, and that's, it's not perfection. Just strive for progress too. And so some days you're not going to get even 5,000 steps. It happens. But I think making sure that you're walking. A lot of stress management. Trying to help your sleep and really trying to get a good seven to eight hours. And if you're not, again, talk to your provider. And having a healthy eating lifestyle, natural organic foods and fruits, trying to really decrease some of the fast food and fats, decrease your alcohol use.

And I think it all compounds to feeling better. But again, we strive for progress, not perfection. No one's perfect. And I just want to add too, that if you're not getting that answer that you want or you're provider's not listening to you, it's okay to change or seek a second opinion.

And I don't think you should feel embarrassed or ashamed. And like I said, some providers are more comfortable having a deeper conversation with you and really working with you compared to others, and that's okay. A lot of this is, we're just really, we're finding it out in real time just like everybody else.

Because we have the internet. And just because we start one treatment and you don't feel well, it's okay. We might not get it right. I tell that to all my patients, like, might not get the dose right. We might not get what we're starting with, right? And it's, it's just like I said, shared decision making, close follow up and really trying to get them to feel the best that they want to feel.

Host: And I know just kind of going back to the diet, you mentioned the no fun diet and I think that something encouragement is if you're having a no fun life, then a no fun diet could maybe help you have a little bit of fun in other areas. And it's not to say that you can't have any of those things, it's just trying to find the right balance.

Um. The balance of it all to help each person feel better and feel the best that they can, through the symptoms and through the crazy life phase that happens between 35 and 60. So,

Christina Thomas, MD: Right. It's probably the most time we'll spend in this phase.

Host: Yeah.

Christina Thomas, MD: Which is very sad, almost.

Host: Well, I think that you've provided a lot of encouragement, that there are solutions. So I think that we can go forward with that and just be able to talk about it and find what the right solution is and be patient through the trials.

Christina Thomas, MD: Yes, it's a lifestyle change and modifications to it. And it's a journey. It's a complete journey. So, yeah.

Host: Great. Awesome. Well, do you have anything else to add before we officially close out?

Christina Thomas, MD: No, I mean, I guess just be careful where you're getting your information. A lot of different social media platforms are out there, lot of different books, and they're actually all really good and we all are kind of saying the same thing, I think. But just be careful where you're getting the information.

And, the Menopause Society online, has some great patient tools and information which is where providers typically get our updated information as well.

Host: Well, thank you again and, hopefully we'll have you back again in the future.

Christina Thomas, MD: Yeah, Q and A or something. I don't know. Thank you, Kelsey.

Host: Thanks for listening to Emerson's HealthWorks Here podcast. Make sure to catch the next episode by subscribing to the HealthWorks Here podcast on Apple Podcast, Google Podcast, Spotify or wherever podcasts can be heard. And visit Emersonhealth.org/podcast to learn more. And to learn more specifically from Dr. Thomas or to schedule an appointment with her or any other women's health provider, visit concord obgyn.com or call 978-369-7627.