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Bill Klaproth (Host): So, what is menopause and its cousin perimenopause? What are the physical symptoms and the emotional symptoms? And what can you do for a successful menopause transition? Well, here to talk with us is Dr. Beth Rutherford, partner at Obstetrical and Gynecological Associates.

Host: This is the Top Docs podcast. I'm your host, Bill Klaproth, Dr. Rutherford. Thanks for being here.

Elizabeth Rutherford, MD: Hi, Bill. It's really good to be here with you. Thanks so much for having me.

Host: You bet. This is a big important topic because all women go through this, right? So first off, explain this to us, what is menopause and its cousin perimenopause?

Elizabeth Rutherford, MD: Well, as you said a minute ago, one of the most important things is that every woman will go through it in one way or another. And so, it'll also take up a substantial part of life. The chapter perimenopause, which is the five to 10 years prior to menopause, and then menopause will really take up 3, 5, 10, 20 years of a woman's life. And so, to explain a little bit about what happens when you're an embryo, when a female is an embryo and she's inside her mother, she has six to seven million egg cells called oocytes. By the time a female is born, it's down to one to two million. And now when she hits puberty, it's 300,000. It's a huge depletion.

So now, you think about those ovaries having a finite lifespan. It's plenty for a lifetime of fertility. But as they diminish and the hormones diminish, you can see what paints the picture to perimenopause and then menopause. And so when my patients come in and they talk to me about in menopause, feeling like there are a bunch of ups and downs, the ovary some months is overproducing hormones. There's too much estrogen and progesterone and testosterone, which makes her feel a certain way. Some months the production is normal and right on schedule. And other months, the ovary is underproducing hormones. There's a deficiency of estrogen, progesterone, and testosterone. And so, what I tell my patients when perimenopause feels like a roller coaster, it's because it is. It's a literal and figurative hormonal roller coaster.

So now, Bill, now comes menopause. The ovaries are done. There's no more hormones left. There are no more oocytes or egg cells. The woman's period has stopped now for 12 months. Some women feel a bit of relief at menopause. They no longer have to worry about unplanned or unwanted pregnancy. Their periods stop. Some period symptoms like cramps or PMS go away. But 85% of women say, "I have symptoms of menopause that are enough, that they disrupt my life." So, it's worth women knowing about and talking to their doctor or their nurse practitioner or their provider about.

Host: So, it sounds like there are symptoms for perimenopause and then symptoms for menopause. So, can we talk about those physical symptoms that a woman would feel? And then, also the emotional symptoms too, because that shouldn't be overlooked?

Elizabeth Rutherford, MD: Sure. So, physical symptoms, hot flashes, when those hot flashes happen overnight, those are night sweats changes down below in the vagina, which could make the vagina feel dry or burning. Women have urinary changes. They get more urinary tract infections, or they feel like they have frequency, they have to go all the time. Women have joint pain, dry skin, dry eyes, hair thinning or hair loss.

So now, let's go to some of the emotional or mental symptoms many women talk about. We'll say cognitive decline. They feel like they can't find words. They feel like they can't remember where they put things or when they normally feel able to and accomplished at making decisions, they feel indecisive. Remember those night sweats we talked about ,that can cause insomnia and now a woman has disturbed sleep and feels that through the course of the day. Menopause can trigger or exacerbate depression in some women, changes in sex drive, which can alter relationship with a partner, and I'm probably forgetting some even as we talk today.

Host: So, these symptoms really can disrupt a woman's quality of life. Is that right?

Elizabeth Rutherford, MD: Yes. And you know, as I said before, there are going to be a few lucky women who say, "Gosh, my menopause experience was seamless," but 85% of women saying that there's enough symptoms to disrupt her life. And every woman will have a different fingerprint. Somebody will have hot flashes that make her feel frustrated because she's sitting in a meeting and getting hot and red and sweaty in front of her work colleagues. Another woman will feel the vaginal dryness and feel like it changes her sexuality and her sex life, but that different fingerprint means that each woman should be as knowledgeable as she can be about perimenopause and menopause, and have a doctor or a practitioner that she feels comfortable talking to about, "These are my symptoms and what are the options? What can I do?"

Host: And do we know why symptoms vary greatly from woman to woman?

Elizabeth Rutherford, MD: Some of it's cultural, some of it's ethnicity. Some may just be based on perception or tolerance. But it's certainly okay and normal that it's different in all different women. Just because one woman's getting hot flashes and another doesn't mean that anybody is better or worse, just different.

Host: Absolutely. Well, I've seen that from the women in my life. The hot flashes and you're sitting at a restaurant, you're out and all of a sudden, "Oh, my God. The sweaters are coming off and the coats are coming off and this..." Right. So, I know how this goes for sure. And speaking of that, so women in my family have heard from their family doctors and their moms for years that hormones are not safe. So, why are you telling us differently? Why are hormones safe? And you said earlier that when a woman reaches menopause, no more hormones. So, tell us about this relationship with hormones and how we should look it.

Elizabeth Rutherford, MD: Yeah. So you know, there are few medications or therapies that have had as much research or as many test subjects as menopausal hormonal therapy. That's good news because a lot of research helps us identify safety, efficacy, schedule, pattern. The biggest study that we need to know about as women is called the Women's Health Initiative out of Boston in the 1990s. So, it studied women in menopause who took menopausal hormone therapy for years, and it studied how they did and how they felt, and it looked at their concerns about breast cancer and stroke and dementia and so on.

Well, in 2002, some study results were released. And many gynecologists, including myself, feel that when these study results came out, not the results, but the way they were reported and the way they were spoken about has changed the landscape of the perception of safety of menopausal hormone therapy and probably done a disservice to women's health for two decades.

So, let me give some examples because I think hearing the numbers helps. Now, what the researchers could have said when they went on talk shows and interviews and had magazine articles, I'm talking about the cover of Time Magazine, they could have said that, "In this research, we found that eight of 10,000 women were at an increased risk of breast cancer when they took menopause hormone therapy." They could have said nine out of 10,000 women had an increased risk of heart attack and heart disease, and they could have said 12 out of 10,000, increased risk of stroke, but not until they're after 60 years old or older than 60 years old. That's what they could have said. What they said was 25% increase in breast cancer, 28% increased risk in heart disease and heart attack, 41% increased risk in stroke. Well, that sounds scary, right? But I want to do a quick mathematical example. If I tell you, Bill, that you have a risk of something happening two in 10,000, you'll probably give me a little bit of a shoulder shrug.

Host: Yeah. Like, "Eh, not too bad."

Elizabeth Rutherford, MD: Right? And then if I tell you, "But ,Bill, now your risk went up to four in 10,000," you'll probably still give me the same shoulder shrug.

Host: Right.

Elizabeth Rutherford, MD: But if I said it in a different way and I said, "Bill, your risk had doubled..."

Host: That would be more scary. That would be a lot more scary, for sure.

Elizabeth Rutherford, MD: And that mathematical example is a perfect example to use in what happened to menopausal hormone therapy. Because overnight women's prescriptions for menopausal hormone therapy dropped from about 25% to 30% of women who were in menopause were using menopausal hormone therapy to 2% to 3%.

And so, I've just described to you a medication. It's safe, the risk factors are really overall very low. It improves quality of life in women, and every woman is going to go through it. But now, physicians and nurse practitioners wouldn't prescribe it. Medical students and residents aren't even being trained on how to use it and learn about its safety. And just like you said to me at the beginning of this question, Bill, women hear from their sisters, their moms, their friends and neighbors, "Don't take hormones. Those are dangerous." And women really deserve to know what the true statistics are so they can make an informed decision. I'm not saying menopause hormone therapy is for every woman, but I am saying that every woman deserves to know what the correct information is so she and her provider can make the right decision for her.

Host: And that's all anybody is looking for. So, it sounds like we need to start looking at hormones through a different lens basically, instead of what we've been told otherwise.

Elizabeth Rutherford, MD: Right. And one of the things that I think is most important, and I use this information when I counsel my patients, since the release of that data in 2002, of course, ongoing research is always done. That's what scientists do, that's what medical professionals do. You know, we could sit and I could probably outline for you five out of 10,000 reduction in this disease and a five out of 10,000 increased risk in this disease. And we could talk through a half a dozen or a dozen diseases, but this really resonates with me. In women who take menopausal hormone therapy at the right time in life, and you take 1000 women, five out of a thousand women on menopausal hormone therapy will live longer, less mortality, less death compared to five out of 1000 women who didn't use menopausal hormone therapy. We call that all-cause mortality. You add up everything, and frankly, that means that menopause hormone therapy used in the right circumstances saves lives and, as I said before, really improves quality of life and comfort.

Host: Which is really important. Absolutely. So, menopausal hormone therapy, we should start looking at this differently. And for some woman, this really can be and make a big difference in their life.

Elizabeth Rutherford, MD: Absolutely.

Host: So then, what are some of the top tips that you can share with us for a successful menopause transition?

Elizabeth Rutherford, MD: Well, just a couple of quick talking points to go over. We've spoken about menopausal hormonal therapy, but I haven't really identified what it is. For some women, it's estrogen alone, if they don't have a uterus anymore, they've had a hysterectomy. For other women, it's estrogen plus progesterone, and it's available in many different types, pills, patches that you apply to your skin, creams and gels that you apply to your skin. And then, there's also the topic of vaginal estrogen, which women use, as the name says, vaginally to improve urinary function, sexual function, sexual lubrication, et cetera. So, that's kind of the nuts and bolts of, well, you're talking about menopausal hormonal therapy, what is it? Couple of things to think about, lifestyle changes, like if a woman is menopausal and she's at increased risk for osteoporosis, the bones thin, the bones become more fragile, she's more at risk for a fracture. She might talk about menopausal hormone therapy, which helps protect her from fracture, but she also might want to be sure that her calcium and vitamin D from her diet and supplements is optimal. And that she's doing exercise to stress her bones. We call that weight-bearing exercise to keep them strong and exercise types to enhance balance, so she's less likely to fall.

When we talk about things like lifestyle and diet, women come to my office and what do they want to talk about? They want to talk about breast cancer. Breast cancer really scares women. But Bill, the number one cause of death in women in the United States is heart disease and heart attack, not breast cancer. So again, we have an opportunity to educate, "Hey, engage in cardiovascular exercise. Try to keep weight maintenance the best you can. Consume a diet that's lower in the unhealthy fats and higher in fiber. And see your primary care provider to be sure your cholesterol is in line, your blood pressure is in line, you don't develop diabetes."

We've talked today, also another talking point, about menopausal hormone therapy. But the good news is for women, that's not the only thing out there. You could meet a woman who says, "I just choose not to take menopausal hormone therapy." And frankly, Bill, there will be some patients that we see who have contraindications. It's not safe for them to take or, medically, they can't take it. But there are so many other options. There are vitamin supplements that have been studied that can help with a variety of symptoms. There are herbal supplements that can be helpful. And there's a really cool thing called off-label use of medications. So, what does that mean? If patients go to their doctor and they get a prescription for a condition, and later they come back and they say, "You know, since you put me on that pill, I've noticed that this other unrelated symptom has improved in my life." And when this happens a few times, doctors start to pay attention. And so then, doctors are many times provided with medications that aren't FDA approved for that specific symptom. But they're safe and they're effective, and they can decrease suffering and improve lifestyle and wellbeing by prescribing something to help with a specific symptom. And there's a long list of these type of things that can help.

Now, I always have a little word of caution. When people use vitamins or supplements, and I'm very in favor of them, be careful about sales pitches. Be careful about somebody on a program who says, "I can cure this." Remember, I said it's not a disease, it doesn't need a cure. And if somebody is taking a vitamin or supplement, I always ask them, "Take it. And then after a matter of time, four weeks, six weeks, evaluate and ask yourself the question, 'Is this helping the symptom that I originally decided to take the supplement for?'" If the answer is yes, okay. But if the answer is no, maybe consider stopping or discontinuing that. We don't want people taking a handful of pills and herbs and supplements and not really knowing why they're taking them or enjoying the benefits from them.

Host: So, it sounds like there's a lot of tools in the toolkit, if you will, to help a woman manage this menopause, perimenopause transition.

Elizabeth Rutherford, MD: That is precisely what I say. There's so many options to help women enjoy quality of life. And as we talked about very early in the podcast today, because this is a stage of life that is normal, but it's going to take five to sometimes 20 years for a woman to get through, I do think it's critical for women to understand as much as they can about menopause and perimenopause and feel comfortable asking their doctor or their provider questions, and I believe it is imperative for physicians and providers to ask patients about menopausal symptoms. Sometimes patients don't bring them up to me. Maybe they feel ashamed or they feel embarrassed, or they've just been told, "Hot flashes, that's normal." Maybe they've heard messages from people that there's no safe options to treat their symptoms. So, I really feel like our responsibility is to ask our patients, "Tell me about your menopause. How's it going? And what symptoms are you struggling with?" So that then we can have that informed decision about what's going on and what options there are to help improve quality of life.

Host: I think that's a great point. I think there's a lot of women that are probably suffering in silence, thinking, "Well, I'm not going to bring this up. It's just normal. Everybody goes through it." When in reality, if they were to bring it up, there are tools, as we were talking about, or tips to help them manage this menopause transition.

Elizabeth Rutherford, MD: That is completely true. And I think when I brought up the Women's Health Initiative as a person who's passionate about caring for women, it makes me sad to know that I think there's been a couple of decades lost and countless number of women who have suffered needlessly when there are options just to be had at the fingertips with a discussion with your doctor or a provider.

Host: Right. So if you're feeling something, if it doesn't feel right or you're wondering about it, please go see your physician and don't be afraid to bring it up basically is the message

Elizabeth Rutherford, MD: Absolutely. And with all information gathering, these days it's very easy to type something into the search bar on your computer, and I have no problem with that. I do encourage my patients to use reputable medical websites because otherwise information, like I just pointed out, can be distorted. And I think our responsibility is to dispel myths about what's safe and what's not safe. So, I recommend, of course, the American Congress of OB-GYN, that's my own sort of college. NAMS, that's easy to remember, NAMS, the North American Menopause Society. And I think in our country, Mayo Clinic and Cleveland Clinic are two very well known, well recognized medical institutions that have excellent information on their websites.

Host: It always pays to educate yourself. That's for sure. Dr. Rutherford, this has been great. Thank you so much for your time. If someone wants to learn more or book an appointment with you, what should they do?

Elizabeth Rutherford, MD: So, our practice is obstetrical and gynecological associates. We're in Northwest Indiana. And my website is weunderstandwomen.com. Altogether, weunderstandwomen.com and there's a tab there to schedule an appointment. Also, our office phone number is (219) 462-6144. I'm not the only physician here. I have three terrific partners. I have two terrific nurse practitioners. And if somebody needed to see us, we'd be just delighted to see them.

Host: Well, that's great. And thank you again Dr. Rutherford. We appreciate it.

Elizabeth Rutherford, MD: Bill, thank you so much. This has been enjoyable and you're a terrific host. I've had a lot of fun today.

Host: Well, thank you for that. I appreciate it. And if you found this information helpful, please share it on your social channels and check out the full library for topics of interest to you. This is the Top Docs podcast. I'm Bill Klaproth. Thanks for listening.