Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole and joining me today is Dr. Marcia Klein-Patel.

She's a specialist in Obstetrics and Gynecology, and she's the chair of the AHN Women's Institute. She's here today to highlight menopause transition for us. Dr. Klein-Patel, thank you so much for joining us today. I'd like you to start with a short overview of AHN's Women's Institute. Tell us a little bit about the services that you offer and what women can expect.

Marcia Klein-Patel, MD, PhD: Thanks, Melanie. I appreciate you having me. So, AHN Women's Institute is a full spectrum health care group. Of course, we provide obstetrical, meaning delivery services, gynecologic care, gyn oncology, so those patients who unfortunately have cancer of the reproductive organs. We provide complex family planning, maternal fetal medicine, urogynecology, and menopause services. I sometimes make a joke that if there's a reproductive healthcare need that you could have, we have you covered.

Host: Well, thank you for going over that for us. Now, one of the new terms we're hearing more often is called midlife medicine. Tell us what that is and how it's implemented at AHN.

Marcia Klein-Patel, MD, PhD: I have always done the work in this time frame, and I'm really grateful that people are starting to talk about it now. And so when we think about epochs in people's lives, we tend to think about, you know, before puberty, so when we're children, puberty and reproduction, so if we have children and we reproduce, and then what happens after reproduction, and we call that the menopausal transition.

And so for us, because menopause, most women will spend a half to a third of their lives in that time period, we call that midlife. We're in the middle of our lifespan, and we're trying to plan for health moving forward.

Host: Well, it certainly is a complex time for women during those years, as I know that myself. Now give us a general overview, Dr. Klein-Patel of menopause and menopause transition. What are the indicators, first of all, of perimenopause? When do these symptoms typically start and when do we know that it is transitioning into menopause and then postmenopausal?

Marcia Klein-Patel, MD, PhD: That's such a great question, Melanie. And I think that people had historically thought about menopause as off or on, you are either after menopause or before, but of course that's not how the body works. And there are phases through perimenopause through the menopausal transition until we have that final menstrual period.

So menopause is defined as being one year after the final menstrual period. In the United States, the average age is 51 or 52. But the average time frame to go through that process is about 10 years. So at first, people's periods might get closer together, although they should never be closer than 21 days together, and then they'll start to skip.

And the signs and symptoms that people have are really different depending on where they are in those phases. Early on, so early usually in our 40s to 45, people's periods might be a little bit closer together. They might find they have more breast tenderness with their cycles. They might find that they have more irritability with their cycles.

They also might, even if their headache suffers, start to have more headaches. And then gradually as our ovarian reserve continues to decline and be unable to respond to the signals from the hypothalamus to release an egg, we start to skip. And as we start to skip, people can tend to experience more hot flashes as their primary symptom.

And then hot flashes can continue on average for 18 months, two years. For some people it's much longer, but they do then tend to defervesce after that time.

Host: That was a very comprehensive explanation and thank you. So many of the symptoms that women feel as they start into perimenopause and enter into that transition are along the lines of anxiety and fear of the unknown, heart rate increases, blood pressure changes, we're feeling anxious all the time. And I'm not just talking about me and what I went through, but generally women.

So some of these symptoms can be mistaken at the time for depression or mood disorders in general. How do we best deal with some of those? How do you want us to talk to our physicians? And for referring physicians, primary care providers that may see these women as they're beginning to deal with some of these symptoms, what would you like them to know about counseling patients through this and things they can try?

Marcia Klein-Patel, MD, PhD: So I always take a symptom history, and I think every physician would do that. And really relating what symptoms they're having to their cycle. We can see a little bit increase of anxiety in that early 40 to 45 perimenopausal transition, but actually hot flashes can feel like a panic attack to some patients.

And so, gosh, that might increase our anxiety if we're in a boardroom or we're in front of patients, when we have some and we are having hot flashes. So I think, getting a good history about what symptoms are occurring, when are they occurring in relationship to the cycle? When are they occurring during the time of day?

What triggers? Alcohol will always trigger a hot flash, hot rooms, spicy food, what kinds of things do patients notice that make their symptoms worse? And then we say that look, a third of women will have true depression at the time of menopausal transition. Risk factors for that are having had postpartum depression or other premenstrual mood disorders.

And the treatments for those are the same as we would use for mood disorders in other times of people's lives. But our general guidance is to always review with our patients what we say are the keys to health. Eating well, sleeping well, having good relationships, and exercising. And when we can maximize those things and we can say what symptoms are left and do targeted interventions to those symptoms.

Host: Dr. Klein-Patel, as we transition and our ovarian reserves diminish, things change within our body and we've just talked about some of the symptoms. However, additional health risks come with menopause. Can you speak to those and what you want providers that are counseling patients, whether they are another obstetrician, gynecologist, or primary care, as they're going through these additional health risks, which come with additional screening.

Marcia Klein-Patel, MD, PhD: I love this question, Melanie. It's actually why I went into menopause as a field, because we are looking at our opportunities to be healthy for the rest of our lives. So cardiovascular diseases increase as we get older, not just because of the menopausal transition or maybe even not at all, it's really because of aging.

So making sure we're exercising and we're eating well. We need to make sure we're up to date on all our screenings, we need to make sure we're getting an annual mammogram every year. We also need to make sure we're up to date on our colon cancer screenings. Colon cancer screening should start for all patients.

Those patients who are not at elevated risk at 45 and should be done with a reliable method, either colonoscopy or one of the stool test kits that are available. We should be focusing on our bone health. Again, exercise, adequate vitamin D, and calcium possible in our diet and starting with bone screening for the average risk patient in age 65.

And so I think of these as really preparing ourselves to continue to have healthy, independently living, lifestyles well into our 80s, 90s and beyond.

Host: What would you like to say to other physicians about understanding these menopause symptoms, what women are going through, stigmas surrounding it and how to help women coping when maybe they're not transitioning that well.

Marcia Klein-Patel, MD, PhD: So, you know, the first to say is that menopause is not a disease. And nationally speaking, in a Gallup poll of 752 women, women view this as a very positive change in our lives. So for our patients who are doing well, we should say, great, keep doing the things that you're doing. They're clearly producing health.

But you're right, 25 percent of women will be bothered by their symptoms. And then I think our approach, is to really center what the patient's goals are in their treatment, what their main symptoms of bother are, and what's acceptable for them for risks. Certainly, hormone therapy is the right decision for some people, but certainly for others, it is not.

And we have multiple non hormonal pharmacologic options for patients, including SSRIs, SNRIs, gabapentin, and the new KNDy neuron inhibitor and K3 antagonist, Fezolinetant. And these are all good options to help patients get to their health care goals. The only other thing I didn't bring up, is vaginal dryness or intimacy concerns.

Those are not generally treated with systemic medications, but topical agents. And we should make sure that even our patients who are remote from menopausal transition, that they have the intimacy goals for them and their partner are being met.

Host: This is very informative episode, Dr. Klein-Patel. As we wrap up, I'd like you to speak about referral and how a patient goes about getting in to see a midlife specialist and what you would like other providers to know about when it's important they refer their patients.

Marcia Klein-Patel, MD, PhD: We certainly think that provision of menopausal care is within the purview of many primary care doctors and many gynecologists. If you have a patient who isn't getting better on standard therapy or for whom they has contraindications or maybe they have high risk breast or ovarian cancer conditions and you want another opinion or you'd like some assistance, certainly you can refer them to our menopause practice and we're called Midlife Women's Associates and you can find us through Care Connect or Find a Doc, and we are more than happy to help your patients help you to get their goals met and then can return them back to you and be there for support for questions at any time.

Host: Thank you so much, Doctor, for joining us today and sharing your incredible expertise as we talk about menopause transition. And to learn more or to refer your patient, please call 844-MD REFER or visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network.

Please remember to subscribe, rate, and review AHN MedTalks on Apple Podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.