Emily Wade (Host): A while back, we asked our listeners here at Office Hours to send us that health question that you've been googling at 2:00 AM. It's no surprise our MIT night owls sent us back some very specific replies, but among them was this extremely relatable question.

"Dear Office Hours, if I'm googling at 2:00 AM, I'm asking about perimenopause symptoms. Am I on enough estrogen? Is my hair shed normal, or is it problematic? And how on earth did my mother survive her 40s and 50s? You know, normal stuff."

So, on today's episode, we have Dr. Adi Rattner Nevo from MIT Health Primary Care to help us unravel the mysteries of the internet's current favorite women's health topic. Welcome, Adi.

Adi Rattner Nevo, MD: Thanks so much, Emily. So happy to be here.

Host: I'm so happy that you are here because you had a presentation at our town hall recently where you actually specifically talked about how people are asking a lot of perimenopause questions. So, this is very exciting to have you here to talk about this hot topic. And definitely while I am not, you know, up at 2:00 AM googling perimenopause, at some point, my Instagram algorithm definitely decided I'm in hormonal peril. So, you know, I'm going to get a lot out of this too.

The question we have today is really interesting because there's two things about it that are really important, where it's like, you know, how did my mother survive her 40s and 50s is a very relatable and emotionally accurate medical question. But also, I think, a really key thing about this question is how are you supposed to find kind of like trustworthy and reliable information when the internet is, like, eager to give you 700 answers to every question, and many of those answers are advertising a product or service or patch or cream that's supposed to solve all of your problems? So, to get started there, let's just get to the basics. What is perimenopause?

Adi Rattner Nevo, MD: Thanks, Emily. These questions are very relevant. So, perimenopause is the transition leading up to menopause. During this time, the ovaries start producing hormones less consistently, especially estrogen and progesterone, and the fluctuations in hormone levels could be pretty significant. This can lead to a range of symptoms. Menopause is officially defined as 12 months without having a menstrual period, but perimenopause is the transition before that point that can last for several years for some people.

Host: So, it's kind of less of a moment, like a specific moment in time, and more of a phase. So, it's kind of funny that peri- is doing a lot in perimenopause. It's like it's shruggie pause really.

Adi Rattner Nevo, MD: Exactly. It is a gradual transition, usually not an overnight change.

Host: That's true. But I feel like sometimes emotionally, it can feel like you could go have a, you know, normal life and then, all of a sudden, you wake up in the middle of the night and you're like, "My mattress is like Death Valley, and I'm like covered in sweat. And what's happening to me?" So, it's like it does seem like there are pieces that can kind of come out of nowhere. Is that normal? Is that the case?

Adi Rattner Nevo, MD: So, that can be the experience of many people. You know, and the thing that I talk about with patients is that people, your friends can experience it very differently from you, but there are some common symptoms that this can include starting to see changes in menstrual cycle, hot flashes, night sweats you're referring to. Otherwise, trouble sleeping, mood changes, brain fog, vaginal dryness, changes in libido or sex drive, headaches, joint aches, changes in hair or skin, and there are more. But the most important thing to remember is that sometimes these symptoms can represent other processes or medical conditions, but they can happen in perimenopause.

Host: But if you're in, you know, your 40s, and these symptoms are starting to come along, s it a good guess to assume it's perimenopause?

Adi Rattner Nevo, MD: It's a reasonable possibility, but not always the answer that these symptoms are solely from perimenopause. So, a lot of these symptoms, you know, can come from the hormonal changes, but also can show up in other conditions like thyroid disorder, anemia, depression, sleep apnea, side effects of medications that people may be on, pregnancy, and chronic stress.

So, you know, I know a lot of people go online and try to find answers, which is totally understandable. And, you know, especially with AI now being a resource, that's quite widely available. But sometimes the self-diagnosis can lead us to anchor in on, you know, certain causes of things and can get people into trouble.

I think that if anyone is questioning whether these symptoms may be from perimenopause, it could be that in the end that's what is causing it. But it's really important, you know, to come and see your provider and work through some of those questions and concerns.

Host: Great answer for that. And I think you really touched on something, especially with AI. But also, it's just the general internet. It's like perimenopause content is having a moment. It is like the thing right now, at least. You know, judging from my Instagram feed, for sure. And I mean, on one hand, that's awesome because, you know, I think back to our listener talked about her mother and grandmother surviving this, and I'm thinking, like, my grandmother called this the change of life. So, you know, it's great that we actually have words to describe this. And we have like a language and a vocabulary to talk about it.

But it does also seem like, you know, there is this way where it's like, you know, if I'm over 35 and I woke up in the morning and I can't find my keys, suddenly, you know, the internet is ready to tell me that my hormones have just given up and they've left the building. So, it does seem like a double-edged sword a little bit.

Adi Rattner Nevo, MD: Absolutely. And, you know, social media can be a really great tool for raising awareness and making people feel less alone and finding community, but it does tend to oversimplify in particular in the area of medical education.

Host: Yeah. You know, I think I've definitely seen a lot of stuff that's like, "This symptom means..." or, "Doctors won't tell you this, but..." you know, those are definitely, like, running themes that are kind of all over social media and the internet right now.

Adi Rattner Nevo, MD: Absolutely. And I think when I talk to my patients, that's where I think people should be a bit skeptical or I caution people because, you know, rarely is there like one explanation. and when things tend to really simplify a concept into like one answer, I'm pretty wary.

Host: I think it's a good time to help some people out, you know? And I think I definitely keep holding this guy up because, in researching t this, interview, my phone is like, "You have entered your crone years, and I'm only going to show you this content." so, let's talk about, you know, if somebody is googling symptoms or getting bombarded with this content, what are some good ways to tell that it's actually reliable?

Adi Rattner Nevo, MD: So, some things to keep in mind, some of these things may help. First is who or what is the source? So, is this a licensed clinician, medical provider, or reputable medical organization, or sometimes, you know, academic center? Or is it somebody with a compelling personal story, and are they providing a discount code or any products that there's, like, brands that they're specifically promoting?

The second thing is—and this might be a little vague at first—but how do they sound? Typically reliable sources acknowledge that there is nuance in many conditions or, you know, life phases like perimenopause. So if someone's making sweeping statements or absolute statements like, "This always means..." or, you know, "No one has ever..." or, you know, "Doctors are ignoring or not listening to you always," you know, that's a red flag. You know, I do want to acknowledge that many individuals have experienced real, like, disenfranchisement or reasons to have mistrust in healthcare, but I would be cautious of just absolute statements, and black-and-white thinking.

And the third thing is, are they trying to sell you something? This doesn't automatically mean that the information they're presenting is wrong, but there's a clear financial motivation and bias there. So, I would be cautious.

And the next thing is, are they encouraging you to seek care if, you know, it makes sense or if things don't add up? So again, this is kind of feeding back into the idea of nuance. You know, they might present things in a certain way that's digestible. But ultimately, like, are they still suggesting if things don't fit this neat, you know, template of what they're presenting, like you should go seek care with your individual provider.

Host: Yeah. That last point, it definitely seems especially important where it's like good information should lead you to a next step and not necessarily, like, replace care.

Adi Rattner Nevo, MD: Definitely. And it can help you maybe recognize a pattern or like make some sense of the symptoms, the experiences that you're having and put the words to them, and help you feel seen, recognized. It does not take the place of, you know, having a provider talk to you and do a really comprehensive assessment of what is going on with your health.

Host: I am going to keep talking about my algorithm, which is deeply invested iin this conversation, which, you know, it's gotten rid of all of my heated rivalry reels. Now, it's just all perimenopause all the time. So now, that I'm being fed all of these things, I want to benefit our audience and make sure that we are separating the truth from the fiction on the reels that are coming up, because I'm sure it's not just me.

So, let's get to a little bit of a lightning round of questions. I'm going to read some statements that have come up in the course of my research here, and I just want you to kind of tell me if they are true, like generally accurate, or false, or just misleading, or just kinda incomplete. So, are you ready for the lightning round?

Adi Rattner Nevo, MD: Yes.

Host: Okay, great. Let's start with this one. If you're 35 or older and suddenly experiencing fatigue, anxiety, and brain fog, that's a sure sign that you are in perimenopause.

Adi Rattner Nevo, MD: I would say false. Those symptoms can occur in perimenopause as we, you know, talked earlier, but they can also be caused by other conditions. And so, especially I think you said suddenly experiencing, I would definitely want this individual to get checked and ruled out for other conditions. So, that's what I would say.

Host: Okay. All right. Question two or statement two. If your periods are still regular, you can't be in perimenopause.

Adi Rattner Nevo, MD: False. So, changes in the cycle pattern are common in perimenopause and some people will experience those. But sometimes the other symptoms can begin before periods become irregular or people notice any change in their menstrual bleeding. So, regular periods don't completely rule out the beginning or, you know, the presence of perimenopause.

Host: All right. This next question I am extremely, extremely invested in. Hair shedding in your 40s, is it often part of perimenopause?

Adi Rattner Nevo, MD: I would say this statement maybe is incomplete. Hair changes can happen during perimenopause, but hair shedding could be caused by other conditions. Again, so thyroid problems, stress, iron deficiency, nutritional issues, some medications or other, you know, skin or scalp conditions. So if, you know, hair loss feels significant, or, you know, sudden or new, it's definitely worth coming in to talk to one of the providers

Host: I'm going to carefully monitor that. Next statement. If your provider won't run a full hormone panel, find one that actually understands perimenopause.

Adi Rattner Nevo, MD: I would say false, and I know this may feel contentious. But, you know, what I talk about with my patients and when we talk about the meaning of certain labs, hormone levels can fluctuate a lot during me- perimenopause. So, a single lab value at one point in time or on one day may not tell us very much.

And in many cases, you know, it may be in the premenopausal range or, you know, what we'd consider normal in premenopause. So in many cases, our care and our decision to start different types of treatments is based more on the symptoms, the medical history, someone's age, possibly menstrual changes, you know, ruling out other medical conditions. And we go based more on that than necessarily the lab value. So, testing can be useful, in some situations, specifically, you know, regarding hormone level testing, but sometimes it doesn't necessarily add too much to the care

I did want to address, you know, the feeling of if your provider won't run a full hormone panel, find someone who actually understands perimenopause. I will say most importantly is finding a provider with whom you feel like you can openly talk about your experiences and symptoms and feel validated and heard. You know, then talking about what, you know, what data we have and the research supporting, you know, different decisions and treatment approaches. But very important, especially as this period of time can come with changes, as we said, in mood and, you know, cognitive function and other things, other symptoms that are really meaningful to people's day-to-day experience, is finding someone that you feel comfortable with.

Host: It kind of comes back to it really is kind of like peri, it's that kind of like shruggie pause, you know? It's like it's up and down all the time. So, that makes a lot of sense. Kind of related to that, and this is definitely one that this phone, it wants to sell me stuff. I'm getting two conflicting statements. Everyone in perimenopause needs hormone replacement therapy. But conversely, nobody in perimenopause needs hormone replacement therapy.

Adi Rattner Nevo, MD: So, both are false. And I think, you know, we talked about absolute statements. And I will say hormone therapy can be very helpful for some people, and it's also not right for everyone. So, there are benefits and there are some risks. And so, treatment depends on the symptoms, health history, goals, risk factors of individuals. And this is where I say it's really important to feel comfortable with your provider navigating kind of both the benefits and the risks in making that decision.

Host: That's very well said. And I'm happy to say I feel like we work at a place, I feel like MIT Health, you're going to find your person. I think we got a good crew. This one that's come up, I think this is fascinating. There's this very popular theory that a lot of women are getting diagnosed with ADHD and autism in their 30s and 40s, and they're noticing the symptoms because of perimenopause.

Adi Rattner Nevo, MD: So, that statement I would say is incomplete. Hormonal changes, sleep disruption, stress, and the general demands of midlife can absolutely impact focus, mood, memory, and coping skills. And so for some women, it's the time where maybe long-standing ADHD becomes harder to compensate for or finally kind of reveals itself or is recognized. But it is important to remember that perimenopause does not cause ADHD or autism. So, the symptoms like brain fog, difficulty concentrating, and fatigue can have lots of explanations. That is what makes it kind of nuanced and maybe challenging to figure out. So, this is something that is really important to give a thorough evaluation and, you know, just to have caution with what little bite-sized recommendations are found online on reels or Instagram post.S

Host: For sure. For sure. i have a final statement in our lightning round. This has been awesome. This one's been everywhere. I think the New York Times wrote about this. In fact, I know it did, because I read the article. So, it's this TikTok, Instagram thing, that a simple combination of an antihistamine and an acid reducer can help with lots of perimenopause symptoms.

Adi Rattner Nevo, MD: I would say incomplete for this statement. You know, you can find a lot of anecdotal or like case discussion online about this combination of medications. But this is not the standard of care for most perimenopause symptoms. And so, I would caution people against, you know, self-treatment based on internet advice.

There may be some risks. You know, while these medications are both available over the counter, they're not without long-term risks. If you're not sure or really seeking, you know, remedies for the symptoms you're experiencing, I would, again, come talk to your medical provider before attempting a treatment like this

Host: .So, I think that that is a really great segue into kind of like talking about—because I think that for a lot of people it's a little hard to decide when the moment is that it's like, "This is my moment. I need to talk to a clinician. I need to stop talking to my best friend ChatGPT, and I need to actually talk to somebody at MIT Health perhaps. Is this something to bring up at a routine appointment? Should you make a specific appointment to come in to talk about this? It's how armed with information and symptoms should you be before you make that appointment and come in and talk to a clinician?

Adi Rattner Nevo, MD: My inclination is to say, you know, if you're noticing a change in your body and how you're feeling, you know, in your concentration, noticing brain fog, anything, any of the symptoms we talked about, it's very reasonable to come schedule an appointment just for that, even if you're not due for your physical until, I don't know, six months from now or whatever it is.

Even if the symptoms maybe still feel vague and challenging to describe, it's something that's worth coming in and making a plan of how this will be evaluated and like what are next steps, when will we check in again. That's what I would say. We're always here. And I sometimes have patients kind of like apologizing because they feel like what they came in for is not a big deal. But I think any change that you're noticing is worth exploring, even if ultimately it resolves and we say, "This wasn't it. This was not a different medical condition or perimenopause." You know, it's great to have awareness and if something changes differently in the future, we've already touched base.

Host: Such a beautiful way to answer that question. And, you know, I think that it's really hard. I relate to a person who comes in and apologizes, because sometimes you feel like I need to prepare a PowerPoint presentation of evidence because it's like, you know, we know that it's like everyone in healthcare, your time is limited. So, it's like, "I need to make this count. It's important." So, that's really helpful to know that it's like I don't necessarily need to bring, you know, a mountain of evidence. I can just bring my concerns to an appointment.

Adi Rattner Nevo, MD: Absolutely. And I think that's the beauty of primary care is that we have the ability to follow up with you and kind of determine what that looks like. you don't have to have the diagnosis all figured out before you come to see us. That's partly our job and, obviously we partner with you. But, you know, that is our entire job. So, it's okay if things aren't so clear yet and we'll make a plan to figure it out.

Host: That's awesome. I mean, our MIT audience, they kind of want to have it all figured out before they come into any situation, which is why we love MIT. But we can help. You don't have to have everything figured out before you come in.

Adi Rattner Nevo, MD: I think one very important thing that, you know, I'm seeing online is a lot of services that are, you know, providing prescription for, you know, menopause hormonal treatment and additionally like weight loss injections and for many different indications. And it's just kind of blowing up of compounding pharmacies online, and patients have access for quite a lot of money to some of these medications.

And I would just say that, you know, we don't have enough information about how these pharmacies are being regulated. if you are considering getting those medications, I really do recommend that you come talk to us first, and we can hopefully help develop a treatment plan that feels right for you.

Many of the providers now at MIT Health feel comfortable prescribing menopause hormone treatment. We can address the fact that our mothers and grandmothers maybe didn't have access to this for reasons of probably history of medical research. And that's a whole other, I think, podcast. But we do have access to high-quality data now and feel comfortable prescribing this as is appropriate. And so, we're here for you and, you know, can come up with a treatment plan and hopefully one that doesn't leave people spending hundreds of dollars online after an evaluation of several minutes by maybe not a live provider.

Host: Thank you for pointing that out because I think that's another thing that it's really important to understand is, like, you know, we all live on the internet. We've all seen these ads. We've all seen these ads everywhere. And if you have had a moment where you clicked on something and went through an evaluation, that's not a moment to be embarrassed and not to feel comfortable talking to your clinician about that.

And so, in fact, i if you have those moments where, you know, you filled out an online form and suddenly you're getting emails with discount codes, it's okay and not embarrassing to talk to your clinician about that. No one's going to shame you. You know, we all live in this world. We all see the same content, and it's totally okay to take a beat before you put in your credit card info and say, "Hang on. Maybe this is a moment to talk to somebody at MIT Health. Maybe this is a moment to talk to my clinician." So, thank you so much for bringing that up because it feels like every time you look, there's even more of it. So, that's definitely something that is a trend.

Thank you so much, Adi, for being on this episode. I'm sure we will have you back soon. We have plenty of other topics. Maybe we can have one on the history of mental health of women's health research. I think that would be fun, who knows? But if you have a question for, office hours, please visit health.mit.edu/thrive to submit your question via our online form. And until next time, be well, and don't let your Instagram algorithm replace your primary care provider.