Scott Webb (Host): Managing menopause is no easy task for some women. And for those with complex complications, experts like my guest today are invaluable. I'm joined today by Dr. Reece Clark. He's a board-certified obstetrician and gynecologist at Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb. Dr. Clark, it's great to have you here today. We're going to talk through menopause and complex complications and what all this means for patients. And I just want to have you start by defining menopause from a medical standpoint beyond the obvious reproductive changes.

Dr. Reece Clark: So, menopause, the textbook definition is it's 12 months with no periods. Now, the only exception to that is that when let's say you've had a hysterectomy, you've had an endometrial ablation, so you maybe don't have periods, and that's a good thing, then we have to actually, you know, do a little bit of investigative work. So, part of it's going to be symptomatic diagnosis, And then there are some lab tests we can get if we're not sure of the diagnosis.

Host: For sure and it makes me wonder, you know, because I hear about this, I talk to experts at Franciscan Health and other places, like, why do we often see chronic or complex medical conditions emerge or maybe worsen around menopause?

Dr. Reece Clark: Yeah. So, menopause happens. The average age of menopause in the US is 51. And so, it's in, you know, midlife to getting a little bit older. And so, I think part of it is just, you know, the timing of menopause. But I do think that there is a physiologic relationship. We do know that estrogen, one of your two key female hormones, is good for your heart health. When your estrogen is low in menopause, your bones start deteriorating faster in men and women. Estrogen actually is important to support bone density. And I think it's complex and we're going to get a little into this later, but your metabolic profile shifts. I think your metabolic rate drops a little bit. We see people tend to gain weight even when they are not changing their lifestyle, even people that eat pretty clean, exercise pretty regularly have a normal weight, they hit menopause and the pounds just start coming on a little bit. I think it's a combination of just the natural timing of when menopause happens, but there are some changes that go beyond the GYN system that can affect your risk for chronic medical conditions.

Host: Yeah, I see what you mean. Since as you say, the average age is about 51, and that's a little bit closer to the finish line than the start line, you know, for patients. Is there a misconception or a myth doctor about menopause you wish you know more patients and providers understood?

Dr. Reece Clark: I think one is big. There's a big market for compounded meaning like pharmacy-produced, not like pharmaceutical company factory-produced for compounded bioidentical estrogen and progesterone supplements for menopause. And while these are effective and they do contain what they say they contain, actually the estradiol and micronized progesterone that are made by like the big pharmaceutical companies are also the same chemical compound as our natural hormones. And so, they both can be used just with the compounded bioidenticals. You have to be careful because their dose, it might not be exactly calculable as easily as if I give you a one milligram estradiol tablet, I know exactly what you're getting. So anyway, to keep it short, the compounded bioidentical versus the standard hormone replacement that we offer by prescription, the compounded bioidentical is not necessarily like way better.

Host: Gotcha. Yeah. And you mentioned just a bit earlier here about the benefits, heart benefits of estrogen, and perhaps just overall benefits of progesterone. So, how then do the declining levels of estrogen and progesterone impact the endocrine system as a whole?

Dr. Reece Clark: It's a pretty complicated question for sure. And it's not entirely understood to us. But like I was saying before, you know, you're talking about lower metabolic rate, tendency to gain weight, even when we don't want to gain weight and are taking steps not to. A little bit more abdominal obesity,

You know, insulin, which is the hormone that controls our blood sugar, you can see more insulin resistance after menopause. So, that is how most of us get diabetes. The most common type being type 2 diabetes or pre-diabetes. So, you're going to see more insulin resistance. That one's pretty important. And your GYN hormones, estrogen, progesterone, also. Contribute to a healthy cholesterol profile. People may not know women's cholesterol profiles tend to look a little bit better than men's. Their HDL good cholesterol tends to run a little bit higher and part of that is because of the effects of estrogen and progesterone. So after you lose that, after menopause, you could expect that your cholesterol profile's going to get a little bit worse, and then that can contribute to heart disease, things like that. So, it's definitely complex multifactorial for sure.

Host: Yeah. Yeah. Wondering, why menopause is considered an endocrine event and not just a gynecologic one, if you will?

Dr. Reece Clark: It ties in globally, you know? It's the things that we've just mentioned. And also, it does have to do with the thermoregulation as well. So, your low estrogen contributes to impaired thermoregulation, you overheat more easily in particular. People do get really chilled on the flip side as well. They wake up in night sweats. The range of temps at which a patient is comfortable gets a lot narrower, especially in the couple of years leading up to, and especially the couple years leading after menopause. So, it's very global, you know, and keep in mind that your GYN hormonal system, it's controlled by two structures in your brain, your hypothalamus and your pituitary gland, and the relationship between those and your ovaries. So, those are the three key organs.

And your hypothalamus and pituitary also control a lot of other things, they control your adrenal glands, they control your growth hormone, they control your thyroid, your blood pressure. It's really just all these systems, there's no black and white dividing line between your GYN and your overall endocrine system.

Host: Right. You touched on a little bit about the relationship between menopause and insulin resistance and type 2 diabetes. I want to have you roll up your sleeves a little bit more, tell us more about that, and maybe explain why fluctuating blood sugars intensify, maybe the classic menopause symptoms like what we're talking about here, hot flashes, fatigue, that sort of thing.

Dr. Reece Clark: Menopause definitely contributes to insulin resistance and increase your likelihood of pre-diabetes and type 2 diabetes. As for the whys and where fors, I'll just share one little aside kind of helpful nugget of information that might apply to some patients. If you are a patient who had gestational diabetes in pregnancy and you're in the menopausal transition, or you are already in menopause, that gestational diabetes diagnosis gives you about roughly a 50% lifetime risk of being diagnosed with type 2 diabetes. So, you need to be extra careful about, you know, avoiding a high carb diet, avoiding too many sweets, things like that, and just getting some good regular aerobic exercise. So, that's a little aside I can help you with.

Host: Yeah/. And I heard that from another Franciscan Health expert about what women go through, especially something like gestational diabetes during pregnancy and the effects after that and understanding the effects on the body for women, but also their hearts. And I guess it just makes me wonder, Doctor, like should diabetes management, should those strategies change for women when they're going through menopause? It sounds like they should maybe, perhaps.

Dr. Reece Clark: You should not base your decision to start or not start hormone replacement therapy if you're in perimenopause or menopause based on your blood sugars. I would not expect it to dramatically improve them one way or the other. Although I will say that people on hormone replacement therapy, they're at a slightly lower risk of developing diabetes.

I have this really useful chart that I refer to with all my patients. But for patients on combined estrogen plus progesterone, which is the regimen you get if you still have a uterus, for every 1000 women over five years of use, we will see five women fewer diagnosed with diabetes. If you have had a hysterectomy and you're just on estrogen hormone replacement therapy, and if I'm giving a thousand women hormone replacement therapy for five years, I'll see 12.5 fewer women diagnosed with diabetes.

So, I guess what I'm getting at is it is helpful, but it's a very slight help. The main reason to take hormone replacement therapy, number one, is treat hot flashes and impaired sleep. So, it's not going to like completely tip the scales. It's not a treatment for diabetes. It can be a little bit helpful, but I wouldn't base your decision on that.

Host: I see what you mean. Yeah. So, how then does a chronic stress or cortisol dysregulation play into menopausal metabolic changes?

Dr. Reece Clark: Unhelpful, as you could imagine. And that applies to any age. But certainly, when we are under chronic stress, we are pushed to our limits. You know, day after day, we are not sleeping well, we are anxious, we are tense, we're constantly in the fight or flight mode. And it just burns you clear out. You know, we know that that will overall increase the amount of cortisol our bodies are exposed to. Cortisol by its nature raises our blood sugars. Excessive cortisol does adversely impact your heart health. It lowers bone density. People are on chronic steroid therapy are at super high risk for things like osteoporosis.

So, chronic stress and cortisol dysregulation are going to definitely just worsen things for us. And like I said, that applies to any age. You know, being a physician during residency I've experienced chronic stress. Many of us doctors have experienced that through our training and it is not good for you.

 As an aside, I have had patients ask me to test their cortisol levels and things like that. Clinically speaking, unless you have an actual adrenal endocrine disorder, it's probably still going to be normal. But you can still know though that even though your test might be normal and it's not worth testing unless we have particular concerns for an adrenal type disorder, still, if your under chronic stress, you can just about bet your cortisol levels are higher than they would be if you were not stressed. And we don't want anybody to live in chronic stress. And it is very bad for us, metabolically and otherwise, and it's just no way to live. So definitely, taking strategies to help mitigate chronic stress will help us in the long run.

Host: Yeah. And you touched on this a bit earlier about weight gain, especially abdominal weight gain. It's obviously very common during menopause. What are your recommendations for patients who are concerned about the, you know, the added weight?

Dr. Reece Clark: When I have my patients consult for perimenopausal symptoms, you know, there are a constellation of symptoms people can experience and weight gain is extremely common. In this patient population, but I do share with them that hormone replacement, I don't expect it to change your weight, but it does. I'm sure that it partly pertains to that increased insulin resistance and that increased risk for pre-diabetes and diabetes. It's all interrelated for sure. But hormone replacement won't just totally reverse your weight gain.

But fortunately, you know, I would treat weight gain just as I would in a premenopausal patient or what have you. And nowadays, we have more options than ever. First of all, with any condition, you want your conservative intervention. So, I want you to optimize your diet. I want you to optimize your exercise and your sleep. You know, I can send you to a nutritionist, things like that.

And then, second of all, we do have medication therapies. The new latest and greatest thing everybody knows about are the GLP-1 medications, which I have used extensively. I did a lot of primary care in my last job. I've had dozens and dozens of patients on these drugs for over a period of months to years. And they're very helpful. We do think they need to be continued long-term. If you want to lose the weight and keep it off. But also, the GLP-1 medications, this is like your Wegovy, Zepbound, Ozempic, Mounjaro, they do reduce your risk of heart attack and stroke substantially. They do make a big difference.

So for my menopausal patients battling weight gain, you know, that's the approach that we'll take. And if diet and exercise are maxed out and you need some help, you know, don't be afraid to pursue that.

Host: Sure. Yeah, I've heard that from another Franciscan Health expert about the additional benefits of GLP-1s, like how they started, what they were intended to do originally. It just seems, Doctor, that there's just endless things that they help with in our bodies. Men, women or, you know, everybody, it's pretty amazing just how much we continue to learn about them.

Dr. Reece Clark: You're exactly right. You're exactly right. I think, over decades, the number of strokes and heart attacks that will be prevented. We'll have people who would be debilitated or would not be with us. That I think will be as a result of these medications. And I can tell you because I did people's primary care and their routine blood work, after GLP-1 medications are started, your blood sugars drop, your A1c drops. They are treatments for diabetes. And many people, their cholesterol looks better as well. So, it's different than a stimulant diet pill. It's not just that the weight is coming off and like you're happy, you know, people are super happy with their weight loss, of course, and their joint health is better. But it's also on a true like metabolic level, you are truly healthier.

Host: Wondering about your approach to treating complex conditions when menopause is also a part of the picture.

Dr. Reece Clark: Most of your chronic conditions are not going to be dramatically affected. One thing I did want to point out was osteoporosis. Because osteoporosis, which is defined as low bone density, greater than 2.5 standard deviations below the normal or having, you know, a classical osteoporotic fracture like a hip fracture.

So, osteoporosis patients could definitely benefit from hormone replacement therapy. Or if you're not osteoporotic, you have what's called osteopenia, which is a less severe, less dramatic decrease in bone density, that's kind of your like pre-osteoporosis, that is an added benefit of hormone replacement therapy. There is a substantial improvement in bone density, and your all fracture risk is definitely decreased by that.

So, osteoporosis is a big one. Certainly if I have a patient who's diabetic, you can expect that they might be a little more difficult to keep their blood sugars and hemoglobin A1c in a healthy range. High blood pressure may get worse. Menopausal patients are at higher risk for heart disease. And if they already have heart disease, you have to be aware that that is a life hormonal factor that can impact your risk. So, it's a big risk factor adjuster. But overall, your general medical management is going to be the same.

And, you know, your internal medicine specialist and I, as the OB-GYN, would support that. Largely, we're going to take a similar strategy. Although, like I said, the big one is like osteoporosis. If you have osteopenia or osteoporosis and you're in menopause or perimenopause, that is a really nice benefit. Estrogen is really good for your bones.

Host: Right. Yeah. Wondering, some tips you have, suggestions, expert advice, all the above, maybe some lifestyle interventions that are most impactful for women who are going through menopause and perhaps also have diabetes.

Dr. Reece Clark: Of course, the standard is, you know, a healthy diet, five servings of veggies and fruits a day. Avoiding the high carb diet. Avoiding sugary drinks. Sugary drinks are like a hidden culprit. Because in liquid form, there is a lot of sugar in drinks. And you can drink a big soda, you're not any less hungry, and then you go eat a full meal too. So, watching out for sugary drinks is a good one as well. I've got couple of like little home remedies you can use that actually have been shown to be helpful are cinnamon and apple cider vinegar. Actually, you might look those up. Those are actually helpful for your blood sugars. Again, it's not a primary treatment for diabetes.

And then, getting regular exercise, particularly you're going to want that aerobic exercise, that light to medium exercise, even just walking. Walking is surprisingly good for us, despite being relatively easy to do. So, regular aerobic exercise, even like 30 minutes a day on average is going to be really good for you. So, those are the big lifestyle interventions, which many of them, you know, you as the listener, the patients probably are already somewhat aware of. But yeah, the apple cider vinegar and cinnamon's a good thing too.

Scott Webb: That's a good one. It is good stuff today. Great to learn from you today. Final thoughts, takeaways. When you think about, you know, the topic here, we're talking about menopause and some of the complex health conditions, what would be your best advice?

Dr. Reece Clark: Yeah. My best advice would be that, if you think that you are suffering from perimenopausal and menopausal conditions and you're in your like late 40s to 50s, you probably are, as you've heard from this podcast, there is a link between your GYN health and your overall endocrine and systemic health.

And so, number one is have a good relationship with a good primary care provider. And then, number two is don't be afraid to enlist the help of your OB-GYN, and ask, "Is there any way that we could further optimize my overall health, you know, as it relates to both menopause and the bigger picture?" Because OB-GYNs, we're not as broad as like your family practitioner or your internal medicine specialist, but we are in the realm of primary care providers and we're happy to help you navigate these topics as I hope you've seen from our podcast today. So, don't hesitate to reach out to your primary care and to your OB-GYN. We're happy to help. That's what we're here for.

Host: Yeah, that's perfect. I appreciate your time, your expertise today. Thank you so much.

Dr. Reece Clark: Scott, thank you so much. I really enjoyed our conversation.

Host: And to learn more, go to franciscanhealth.org and search find a provider and OB-GYN. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.