Cheryl Martin (Host): There are some critical healthcare challenges facing women in midlife and beyond. Dr. Juan Manuel Arreguin, a seasoned OB-GYN, is here to share valuable insights into preventive care, reproductive health, and the unique healthcare needs of women midlife and beyond. Get ready to gain knowledge for navigating these important years with confidence.

This is Medical Minds: Conversations with Guthrie Experts, a podcast from the Guthrie Clinic. I'm Cheryl Martin. So delighted to have you on, Dr. Arreguin.

Manuel Arreguin, MD: Aragine. Thank you, Cheryl.

Host: I'd love for you to start by sharing your insights on the unique healthcare needs of women who are midlife and beyond in the context of gynecological care.

Manuel Arreguin, MD: Thank you for having me on. I think that very clearly now at this point in my life, I've come to understand much more menopause and midlife crisis. I think that when you're a young resident, you see these patients, but it oftentimes doesn't make sense. It's probably more theoretical and book knowledge. But when you finally get into this middle age yourself, you begin to really understand because you see obviously not only your own family, but other patients that you take care of and you recognize how real this scenario is.

One of the biggest things that we see is that, no doubt, midlife doesn't mean that you're at the end of your life. Really, it means that you're probably just starting a whole new facet of your life. And so, some of the issues that we deal with oftentimes have to do with issues that perhaps have been building up over the years. Certainly, issues related to childbirth and now seeing women who present with uterine prolapse, vaginal prolapse, stress urinary incontinence, those are some of the issues that we deal with. We clearly deal with the new changes that women are seeing as a result of the declination in estrogen. And so, we see a lot of the typical menopausal symptoms, the vasomotor flushes, the sleep disturbances, the memory loss, just the lack of energy, the decrease in libido, all those things that ultimately start to affect women, because they're still very much active. They're still very much involved with our workforce. They're involved with our families. And so, they start to recognize that something inherently is happening in their bodies, and they're not always quite sure that they're welcomed changes. And so, oftentimes, they come and seek care to find out what can be done about some of those changes.

Host: So, doctor, how do changes in hormonal balance during menopause affect women's health? And then, what role does gynecology play in managing these changes?

Manuel Arreguin, MD: We know that probably in the mid-40s, estrogen levels start to decline and, certainly, after women go through that menopause. And currently, in the United States, the typical menopausal age of women is about 51 years of age. And so, at that point, the ovaries really start to undergo cessation. They start to decline in their estrogen production. And as a result, women feel this. And so, what we see is oftentimes as those estrogen levels begin to fall, so do energy levels, so do memory levels; sleep disturbances, those start to increase. They begin to experience a lot of changes as a result of that declining estrogen level. It's directly related to estrogen levels falling.

Host: Well, that's a perfect segue then to my next question, because preventive care is crucial at any age. So, what specific preventive measures should women who are midlife and beyond prioritize in their gynecological care? What can they do when these things start happening in the body?

Manuel Arreguin, MD: Well, certainly, menopausal symptoms have been something that we've known for centuries, centuries. And about 50 years ago or so, the use of estrogen started to increase in this country and really looked at it probably as the fountain of youth. We were giving women estrogen levels that were far greater than what we use currently. And unfortunately, 10 years after that, we saw an increase in endometrial cancers.

And then, in the early 1990s, there was obviously research going on on how do you prevent some of these negative effects while giving women still the positive effects of estrogen. And I had the pleasure of training at UCLA under the great Dr. Howard Judd, who is really a world authority with the use of estrogen replacement therapy. And unfortunately, it wasn't until about the 1990s that we started to see that estrogen therapy led to increased cardiovascular heart disease. We saw increases in breast cancers and strokes, pulmonary embolus, heart attacks. We did see that it still had some influence in decreasing the fracture risk of osteoporosis. But as a result of a large study, the Women's Health Initiative, right in around the 1992s, we saw about 50% of women started to decline in their use of estrogen. And about a quarter of them declined their use in the combination estrogen and progesterone.

So where do we stand today? We know that estrogen was really touted as the fountain of youth, and it does do a lot of great things. But at the same time, it can have some real negative side effects. So, what should women today look for? I think that we need to re-evaluate estrogen. What is the use of estrogen right now in women who are going through this transition menopausal period? And this is what we know. We know that estrogen is helpful. But we also know that estrogen in higher doses is very detrimental. And so, what we're encouraging women to do is, if you're within six years of menopause, and you're having some of these vasomotor symptoms, there is a role for estrogen. If you have obviously your uterus in place, then we would be adding progesterone to protect that uterus so that you don't develop the endometrial cancers. We also know that women who are more than 10 years out or maybe at a cutoff of 60 and above, that probably the use of estrogen is the wrong thing to invite into your body. We recognize that estrogen in this case may lead to some of those untoward effects that we learned about in the early 1990s.

So, I think the biggest thing is can estrogen have value today in women who are going through menopause? I think typically it's going to come down to how long have you been menopausal and what is your current age? And most would agree that if you're more than 10 years out, probably there's no role in initiating hormone replacement therapy.

Host: Is there something else that women should use? Anything else that's popular now?

Manuel Arreguin, MD: Well, I think the good news is that just as medicine begins to evolve, so we've seen some great introduction of medication that now begins to address some of the prolonged symptoms that occur beyond the menopause. So, let's say, we're looking at women who are 60 and above. Well, certainly that group can still have hot flashes. That group can still have some of the general urinary dysfunctions, some of the dryness that occurs, and certainly we hear about that oftentimes. So, in that age group, obviously, especially if you're having, let's say, vaginal dryness, the temporary use of local estrogen is helpful, and we would most likely recommend that.

Now, we would have some caveats, obviously, women who are being treated for breast cancer or recently been diagnosed with breast cancer, we probably want to stay away from estrogen. The good news is that there's some better medication that's on the horizon now for some of the hot flashes. And some of these other genitourinary symptoms that are occurring. And one of those drugs that's currently on the market, obviously, we know its straight name by Veozah. And you've probably seen certain commercials. But the compound nd name or the generic name is the fezolinetant. And that's a very different type of medication because, one, it's not hormonal and it's what we call a neurokinin-1 antagonist. So, it ends up affecting that brain center that is responsible for hot flashes. So, this drug actually works and blocks that so that it prevents the hot flashes. And we've seen excellent results with this medication.

Now, at the same time, there's medication that's further being developed that probably will be a little bit better than this medication, although this one helps with hot flashes. There's a new drug on the horizon. Currently, it's in a clinical phase III trial that is a medication not only to decrease the frequency of hot flashes, improve sleep, and overall menopausal quality of life. And that is because that's a dual neurokinin-1, 3 receptor antagonist. So, that works a little bit differently, but certainly gives you probably more relief in the long term. So, those are some of the two things to look forward to right now.

Host: That's good news. Now, doctor, there's a significant focus on reproductive health in younger women. So, how does the narrative around reproductive health change for women who are midlife and beyond, and what should be emphasized?

Manuel Arreguin, MD: Well, we've all been taught that obviously there is some benefit of having children, right? Whether or not that benefit is to protect breast cancer, ovarian cancers. I think that equally for the woman who has never had children, we know that there is benefit of birth control pills. So, the contraceptive medication that we give today also has some benefit for prevention of ovarian cancers in the future. .

So, how is all this related? So, whether or not you have children or not have children, we know that there are things that we can do while women are in their pre-menopausal state to help protect that post-menopausal state. And I think it's with all things, when you look at what can we do when we're younger, well obviously we can try to maintain our weight, we can try to improve our diet, our exercise, really sort of stay away from that sedentary lifestyle, because it does pay big dividends as we get into the 50s, 60s, and 70s.

Host: Anything else on that?

Manuel Arreguin, MD: Well, I think the other thing would be that, certainly when you talk about screening, and we'll just kind of make a short statement about what women can do to prevent future cancers, we know that a lot of these are genetic, a lot of these are environmental, but I certainly am a strong believer that prevention is the best cure, obviously, for a lot of these early cancers. So certainly, we encourage women to do their pap smear routine screening, their mammograms obviously, careful with things that may affect that, nicotine in particular. Obviously, minimize the amount of alcohol use. Those would all be things that women should certainly think about as they grow older.

Host: Now, you've shared a lot of good information about life for women, midlife and beyond as it relates to health. Just as we wrap up, what message would you like to share with women who are midlife and beyond about taking charge of their health? You've touched on this, but anything else you want to add not only about taking charge of their health, but also advocating for themselves in the healthcare system. Just some final thoughts?

Manuel Arreguin, MD: I think the biggest thing is that oftentimes, as women get older, they just make the assumption that this is sort of what life is intended to be. They heard about this from their mothers, they probably heard about this from their grandmothers. And oftentimes, there's a delay in getting treatment, whether it's, for example, delay in things such as stress urinary incontinence. It's not a disease or a problem exclusively to women who are 70 or 80 and above. I would encourage women to think about issues like this and recognize that it's women in their 40s, these are the women that probably should be seeking that type of treatment because these are the women that are still going to be very much active with their physical health. So, they still want to go out and obviously be active. And these are the areas that we can really begin to address.

In terms of hormones and non-hormonal therapy, again, don't settle for this being just the assumption that this is the cost of growing older. It really isn't the cost of growing older. The cost is that we have the opportunity right now. And we really owe this to our middle age population. We can help. And I think the best thing is reach out. Certainly, get answers. I think that, unfortunately, a lot of us look to Google as our answer to things, but I think that we should probably look at organizations like Guthrie. We are in the process of developing more infomercials, more websites that women can dial into and get information that is up-to-date, current, and relevant for their lives.

Host: Very well said, Dr. J. Manuel Arreguin. Thanks for empowering women with knowledge and encouraging a proactive approach to our health decisions and advocacy within the healthcare system. Thank you.

Manuel Arreguin, MD: Thank you so much, Cheryl, for having us this morning.

Host: To learn more, visit guthrie.org/services-treatments/women's health. If you found this podcast helpful, please share it on your social media and be sure and check out our entire podcast library for other topics of interest to you. This is Medical Minds: Conversations with Guthrie Experts, a podcast from the Guthrie Clinic. Thanks for listening.