Amanda Wilde (Host): Welcome to the Kirby Connections Health Podcast, where we help you nourish your wellness journey with Kirby Medical Center. I'm Amanda Wilde, and in this episode, we'll talk about perimenopause and menopause with Dr. Nada Lygrisse, physician of Obstetrics and Gynecology at Kirby Medical Center. Good to see you, Dr. Lygrisse. Thank you so much for being here.

Nada Lygrisse, DO: You are welcome, excited to be here.

Host: So to be clear, perimenopause is the stage of transition to menopause, correct.

Nada Lygrisse, DO: Yes, yes. So we know that, I think the clarity there is the transition of perimenopause to menopause, to post menopause, and the distinction there is really just related to symptoms and when your last menstrual cycle is. So we know that perimenopause is really that phase, when you get your first signs that are, you kind of start to develop signs after your final menstrual period, and can last for several years affecting like your physical, emotional, and all of the social wellbeing that you might have.

Host: And what are the common signs and symptoms of perimenopause?

Nada Lygrisse, DO: So generally, and it really does vary for each individual. Some women tend to have more of the obvious ones, which we hear a lot about at the hot flushes and the night sweats, and that's just when kind of feel that flushing of the skin, the palpitations, sort of the feelings of discomfort over several minutes.

The other one that tends to be very common would be difficulty sleeping, changes in mood, depression, main mood changes. And then of course, where your entire menstrual cycle just stops. And some of the other ones they experience more physical would be some of the vaginal dryness and painful intercourse, incontinence.

I'd say probably the more common ones that most women when they come into our clinic and you know, are complaining of symptoms would be hot flushes. Brain fog is a common one. You hear that all the time. That word. When I first got into this subject, I used to think brain fog, you know is that like a real thing. It's a very real thing and I think a lot of women can definitely resonate with that one. So more common than that. And then also, some of the libido changes that tend to happen as well as women start to transition.

Host: And how do hormone levels fluctuate during perimenopause?

Nada Lygrisse, DO: Hormone levels are sort of an interesting, I'd say, so a lot of women come into our office and the first thing they ask for is, you know, the first thing they say is, I'm, you know, my hormones are outta place, outta whack. I feel like I need my hormones tested. And so I always reassure them that, you know, when I draw your hormones or when I draw your labs at one point in time, it can vary. You know, if I draw your estradiol level at 7:00 PM on Tuesday night, it's going to be different than 11:00 AM on Sunday morning. So just because in that perimenopausal transition, your levels are all over the place and, very much irregular, it's very hard to track those.

But in general, especially if you want to confirm that someone is in perimenopause or menopause, there are two specific markers that we can draw, which would be your FSH and LH, which would signify whether they are at that stage or not. So those are very much, constant. The rest of them I say are very variable.

Host: You just mentioned the symptoms of perimenopause and the hormone changes and how you might diagnose those. How does that differ then from menopause?

Nada Lygrisse, DO: So generally when you are in full menopause, we know that the levels are pretty constant at that time. Generally, when I draw women's levels in menopause, I know what I'm going to find and their symptoms do match up.

 When you get to post menopause, they say, oh, well I'm past that. I don't have any more symptoms. And that you can expect a certain level there. So there are some things that are a little bit more predictable, especially if you're looking at different phases of life.

Host: Can you talk about hormone replacement therapy? What role does HRT have in treating menopause?

Nada Lygrisse, DO: So HRT has become, it's a very popular topic now, I'd say one of the more common things that I have women coming in for. It's one of those things that if you take it back to the several years ago, actually it was in 2007 and there was a huge study called the WHI. And in that study there were three different arms where they were testing women to see the effects of hormone replacement therapy.

In summary, that study led to a lot of physicians and a lot of hype about hormone replacement therapy and how it was a contributing factor to breast cancer and other forms of cancer. Of course, we know now looking back, that that study was very flawed in many aspects namely being the number or the age group of the women that they were testing were 63 and up.

So we know, as that stands, those women already at other higher risk factors. From that, now research and lots of publications and lots of societies, in fact, I'm a member of the National Association of Menopause Society, which they follow a lot of ACOG rules and regulations and have published a lot about hormone replacement therapy, which I would say the pendulum has now swung quite a bit towards advocating for women to get their hormones replaced and that, you know, the publication of the WHI was probably more flawed than it was beneficial for women.

Host: How do women know if HRT is right for their situation?

Nada Lygrisse, DO: I would say because of the positive benefits to HRT, you know, some women come and they don't have symptoms of hot flushes. They don't have any of the libido changes and, and that's going to happen. There are some who have absolutely no symptoms for whatever reason, and genetic I think, is a big part of that as well.

 But I do tell them that some of the benefits of HRT are more than just you know, the way you feel. So for example, the three things I try to harp on would be bones, as far as like, we know that estrogen helps with growing the anabolic or the building of bones. And we know that as we age, we tend to break bones down more and are at more higher risk of osteoporosis, osteoarthritis.

So I tell them, for your bones, you know, if you've ever gotten a DEXA scan, you know, we know that estrogen does help with bone growth. There's now been tons of publications on early Alzheimer's and dementia and how that is affected by low estrogen levels as well. So I tell them the brain, you know, brain, bones.

And then the other one would be cardiovascular risk. And we know that cardiovascular risk is pretty big for women. As far as, risk factors and how estrogen can help. We know that in general, cardiovascular disease is actually the leading cause of death in women. So if we try to harp on how estrogen increases elasticity and stretchiness of the vasculature, that's going to lower our risk of cardiovascular strokes and MIs.

Host: No wonder people are really saying what a great thing it has been for them, for women who taken it. Are there other supplements that we can take to alleviate menopause symptoms?

Nada Lygrisse, DO: There definitely are. I do tell my patients, you know, if it's not FDA approved and there's really been no benefit to them, you, you'll see things on there about black cohosh and, you know, some of this, the herbal remedies and things like that. Because there's no efficacy that's been proved by FDA, I'm very much kind of by the books. If it doesn't say that there's support for it, I can't advocate for it. But I do have some patients that are more into that natural and herbal and do say that that has helped them. I mean, there are some over the counter things you can get any local drugstore or even Amazon now. But what I try to tell people is that the true physiology there is that your estrogen has been depleted, so you can replace with all the herbal supplements and you know, ingredients that you like, but if you're missing the real ingredient there, you'll never get the true benefits.

Host: Well, does that apply too to lifestyle changes or physical activity? Can that help ease the transition into menopause or is that sort of like what you just said, that you've lost the estrogen, so that's not going to bring that back?

Nada Lygrisse, DO: Yeah, this whole topic is sort of a domino effect. I mean, if you don't feel good because you're not sleeping due to hot flashes at night, then how do you expect a woman to get up in the morning and exercise? So I think that it's all this, this phenomenon, I was starting, you know, helping yourself feel better so that you can actually do better for yourself. We know that weight training and, and, cardio, but mostly weight training, I think is even more effective than any sort of cardio activity. Running, walking is always good, but weight training, we know that we lose muscle as we age too with a decline of our testosterone as well, and estradiol that we are not able to build as much muscle as before. So a lot of women can resonate also with a theory of that they have lots of weight gain around their midsection. That's a very common thing as well. And that's because we do have a lot of muscle there that gets replaced with fat.

Host: Oh, nice.

Nada Lygrisse, DO: I know the fun things.

Host: What is the impact of menopause on sexual health?

Nada Lygrisse, DO: That's a whole, I think a whole nother discussion as far as like the hormones that are contributing to that. A lot of, there's been a lot of controversy over testosterone replacement and whether a woman should receive testosterone. And that's something that, I really do delve into with women because I think that what happens is called genitourinary disorder of menopause. Where first because you are losing that estradiol and that elasticity in your tissues, you're not able to, you know, intercourse is very painful for women. A lot of women actually show up to the clinic and think they have UTIs, and I actually tell them it's probably not a UTI.

What's probably going on there is that you're lacking estrogen inside of your vaginal tissues, which is also causing micro abrasionsinside of your bladder wall that feels like a UTI, but really it's not. So, you know, with painful intercourse, that of course affects the libido of women and that does affect the mood.

So again, that's that domino effect where all of it, you know, if it's not comfortable, of course you're not going to want to have intercourse. And so, women do experience a, a huge hit with that. I think that's probably the more touchy topics that a lot of women just don't want to talk about maybe or don't bring up.

So I always make it a point to bring that up with patients because I think most women are coming in thinking menopause is all about hot flushes and that's about it. But there's so much more to it.

Host: So there's brain, bones, sexuality, you mentioned increased chances of osteoporosis or cardiovascular disease. What does research say about that?

Nada Lygrisse, DO: The easiest way to break it down to like a patient that comes in the office, I tell them estrogen equals elasticity. So if you think about it from that perspective, if you have estrogen inside your vasculature, your vessels and blood flow can move more appropriately to the heart. So if you don't, then we know that there are more risks of plaques, from atherosclerosis, and from cardiac events. So there have been several studies now showing that your risks of cardiovascular disease and stroke do go down as we do hormone replacement in women.

Host: All this is making me think that when you're perimenopausal it might be important to develop a personalized treatment plan. How can you collaborate with your doctor to develop something like that?

Nada Lygrisse, DO: I would agree and actually I tell my patients it's sort of a cocktail for each individual, and your cocktail might be different than your mom's or your sisters. You know, if your mom is using a patch and she loves the patch, well they may not work for you.

What I try, to do is I think the biggest thing that we are probably lacking as physicians, and I'm working with patients is just listening to the patient. I think if you listen to the patient, all your answers are there. As opposed to all the lab work. We're looking for zebras and you know, patients come in and saying they're having palpitations and immediately they get the million dollar cardiac workup when really it's just menopause.

So I think if you listen to the patient and ask them what their, I always say, what's your biggest symptom? What's your biggest concern that you have? And if it's hot flushes, I focus on estrogen. If it's libido, I focus on testosterone. If it's fatigue, I focus on progesterone, I really kind of each individual is different.

And then what I try to do is just sort of like a puzzle. So take one component of them and start them with that as opposed to just polypharmacy where we throw a bunch of medications on the patient and then just say, oh, hope you feel better. Because you'll never really know is actually helping them.

Is it the estrogen? Is it the progesterone? So I sort of start with one piece and have them come back. And if they're feeling better, their hot flushes have improved, then we focus on the next aspect, which would be, they're not able to sleep well. So I think if you piece that puzzle together and use that analogy of each individual has their own cocktail, I think that works really well for patients.

Host: But it sounds like really important that you have a relationship with an OBGYN, to tackle and address these potential issues.

Nada Lygrisse, DO: I would agree. I think there are some great primary physicians who do some of this as well and can do the basics of hormone replacement. I do find a lot of patients come from a PCP though, unfortunately, and have been taken off of their medication or off of their hormone replacement because I think of the fear of you know that WHI study that scared everybody. So I think probably what needs to happen is more physician to physician collaboration too, and us discussing and educating our peers as to why we would endorse hormone replacement therapy as opposed to taking them off of that.

Host: Right. Dr. Lygrisse, thank you so much for this great information. This is really helping me to understand the implications of perimenopause and menopause, and you've given us lots of suggestions to ease through that process.

Nada Lygrisse, DO: You're welcome.

Host: That was Doctor of Obstetrics and Gynecology, Dr. Nada Lygrisse. For more information, visit Kirbyhealth.org/services/gynecology. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. Thanks for listening to Kirby Connections Health podcast presented by Kirby Medical Center.