Scott Webb (Host): Perimenopause is a part of life and aging for women, but my guest today wants us to know that women do not have to suffer during this time of life. And I'm joined today by Dr. Lydia Garcia. She's a Gynecologist who's Fellowship Trained in Minimally Invasive Gynecologic Surgery, and she's a North American Menopausal Society Certified Menopause Practitioner.

 This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb,

Doctor, it's so nice to have you back again. Today, we're going to talk about essentially perimenopause. Uh, so it's great to have you here.

Lydia Garcia, MD, MIGS, FACOG: Thanks so much for having me. I think this is a really important topic. You know, we talk a lot to our daughters about what's going to happen when they first get their period, how to use tampons, how to use pads, and we don't spend a lot of time talking about what happens on the other side of this hormonal transition, so I'm really excited to be here.

Host: Yeah, you're so right. We tend to talk about those early years, but now we're going to talk more, focus more today on the later years, perimenopause specifically. So what is perimenopause?

Lydia Garcia, MD, MIGS, FACOG: So the literal definition of perimenopause is peri, time about, menopause. And so menopause is a natural event that happens in women's lives when their ovaries stop producing estrogen. Essentially, estrogen is what makes the lining grow so you can have a period, and then progesterone is what sheds off the period.

So if you don't have estrogen, you're not going to have a period. And so you're menopausal when you've gone 12 months without a period without any other interventions. Usually on average, this is about the age of 52 for most women, but it can happen earlier and it can happen later. I've had patients who have it as early as 40.

That's usually only 1 percent of the population and I have patients who go up to 60. So perimenopause is this time period before menopause where the hormones start transitioning and these can cause physiologic changes in a woman's body.

Host: Yeah. I'm wondering if you can clarify whether or not every woman who goes 12 months without a period is always menopausal? Is that just an automatic thing?

Lydia Garcia, MD, MIGS, FACOG: So not always, and so this is important to talk to your doctor if you are starting to skip periods, especially before the age of 45, because there are other things that can cause you to skip. You can have thyroid disease, you can have polycystic ovarian disease, and especially if you're on hormones, that might mask whether you're actually in menopause or not.

So, for example, if I have a 51 year old on birth control with estrogen and progesterone, they're still going to continue to have periods while they're on this pill. But if they were off the pill, they might actually be in menopause and we don't know it because they're on the pill. Another example for the other side, a Mirena IUD is a contraception that a lot of women use.

And essentially it's thinning out the lining of the uterus, so you're not having a period. So many women on the Mirena IUD don't have a period, but they're not essentially menopausal because their ovarian function is still working. So I would say it's 12 months without a period without being on hormones or having some other medical condition.

Host: So then you mentioned 52 is sort of the ballpark figure there, you know, the average age, uh, but generally speaking though, when does perimenopause start?

Lydia Garcia, MD, MIGS, FACOG: Perimenopause is this five to seven years before the last menstrual period, and there's two phases of perimenopause. The first is the early transition, and usually this happens at the age around 46 and 47, and so this is where you don't have a of deficit hormones, but actually magnification of hormones, which can cause some conditions that you normally have to feel normal can be more exacerbated.

For example, so if you have your periods once a month, maybe they last three to five days, maybe you have some minimal cramping. Now with these hormonal shifts, periods can be very heavy. They can last longer. They can be more severe with cramping. Another symptom that can be magnified is PMS. So some women usually have some mood changes or more anxiety, depression right before their periods.

And so essentially with perimenopause, this can be exacerbated because of the heightened hormones in this first stage of perimenopause. And so where it was minor before, now it might be more interfering with your life. Another example that can happen in the early transition is because of these heightened hormones, people who used to have maybe minor headaches with their periods, now they're more severe and they need some more medications.

So that's the early transition, but there's also the late transition, which is where most people are talking about these symptoms like your wife. So this is the late transition where there's actually an estrogen deficiency. And this is usually one to two years out before the last menstrual period.

So on average, most women are usually between the ages of 49 and 50. And because of the drop in the estrogen, this is where we start to see hot flashes, night sweats. These are symptoms that people describe usually as they're just sitting there normally or sleeping normally and then in one second their temperature goes from zero to a hundred and they're hot and they're sweating and their face feels flushed and their heart is palpitating, and then essentially all of a sudden they're cold because the hot flash goes away, so that can happen during the day, which is a hot flash, or at night, which is a night sweat.

 Other symptoms that also occur in the late transition is some sleep disturbances. A lot of these can be due to hot flashes, but some people just have difficulty sleeping. And this is where we hear a lot about brain fog and memory loss as well.

Host: Yeah, I'm just checking off the boxes, you know, dealing with my wife, uh, you know, trying to support her through menopause. So, so she was in perimenopause and now menopause and I'm checking off all the boxes. I'm like, yep, this all sounds right to me. This all checks out, but great to have an expert here to go through this. Then wondering what are some of the possible treatments for perimenopause?

Lydia Garcia, MD, MIGS, FACOG: Yeah, I think it depends on phase of perimenopause that you're in. So in the early transition when you have these heightened hormones, again, it's not that you have a deficit of hormones, but the hormones are just kind of out of whack. So a lot of times we use hormonal contraceptions to even out the hormones.

So estrogen and the progesterone will give you a steady state of hormones so you don't have these big jumps. So the periods won't be as heavier. They won't be as crampier. They won't last as long. Another option for heavy periods, if you don't want to use hormones, is a medication that basically thins out the clots in the blood.

 This is called Lysteda. It's also known as tranexamic acid. So it has no hormones in it whatsoever, and you can take it up to five days a month to make your periods lighter. Also, if you're not interested in hormones, there are surgical options. There is an endometrial ablation where we can cauterize the inside of the uterus.

 And it decreases your bleeding by 80%, and then, of course, there's always hysterectomy well. Again, we talked about PMS symptoms. A lot of times we still use hormonal contraception to even out the hormones, but if we don't want to use hormones, we can use little medications that can help with mood.

 They're called SSRIs, and so sometimes we use that just a week before the period to kind of even out the mood, or we can use a continuously throughout perimenopause. For the late transition, and this is the one that everyone's always talking about, especially with hormone replacement therapy, hot flashes and night sweats.

I think that's the biggest complaint. And this is the biggest disruption in most of women's lives. And so essentially, as we discussed, these symptoms occur when the estrogen drops. And so most women in this late transitions can skip their periods up to 60 days, up to six months, up to 11 months. And these hot flashes can go into menopause a year or two or three or four after your last menstrual period and so they tend to be the most bothersome.

And so what we do is we can use hormone replacement therapy for this. So instead of using a hormonal contraception, we can use a lower dose estrogen to help decrease these hot flashes and night sweats. Hormone replacement therapy does tend to be the gold standard for treatment. However, it does have risks with risks of blood clot, increase of breast cancer.

 But in young women within 10 years of the year, last menstrual period and under 60, hormone replacement therapy is relatively safe for most women, and so it's a great option. For those women who have contraindications to hormones. Let's say they have breast cancer or if they have a history of a stroke or a blood clot; there are non-hormonal medications that we can use for hot flashes and night sweats.

 There are two FDA approved medications. One of them is called Brisdelle, and the newer one on the block that came out last year is called Veozah. Both of these work on different types of hormones in the brain, to help with thermoregulation. Another common, a symptom in perimenopause is sleep disturbance.

And my number one question for most women is, are you not sleeping because you're having a night sweat or a hot flash? And so by treating those symptoms, that usually helps women sleep. But it's also important to know that there are other causes of not sleeping well, right? Stress, anxiety, depression.

So a lot of women, when they're getting to be perimenopause, their kids are going off to college, their work life balance is starting to change. And so there's a lot of changes that can contribute to that. So maintaining a healthy lifestyle, eating well, exercising, not right before bed. Right. Cause that can keep you up at night. But these things can help. Avoiding caffeine, avoiding alcohol before bed is very helpful as well. And then really another thing is we've got so much technology, like good sleep hygiene, like don't look at your phone an hour before bed, no TV, no e-readers, just getting a good book or meditating before bed also helps with sleep as well.

 And then the third most common symptom that I get questions about is brain fog. The cognitive abilities in women do change in life as they get older, but it's been proven that during perimenopause and this menopausal transition that it's memory loss is a common symptom, and it does come back for a lot of women.

And a lot of this is also related to the lack of sleep, so if I can get women sleeping, their brain fog usually feels better as well.

Host: Yeah, so true for all of us really. The more we sleep, the less foggy we are, for sure. Yeah. Now when my wife, when we got pregnant with our daughter, my wife was 36 and she was told she was of an advanced maternal age, which was quite a blow to both of us. We didn't, we didn't expect to hear that. So I don't know that women generally have babies during perimenopause or menopause, but is it possible to get pregnant?

Lydia Garcia, MD, MIGS, FACOG: I feel for your wife, Scott. I, too, of advanced maternal age.

Host: Okay.

Lydia Garcia, MD, MIGS, FACOG: It's not a kind term.

Host: It kind of hurt. He didn't prep us for that.

Lydia Garcia, MD, MIGS, FACOG: Yeah, but essentially I like you to think about is if you have a period you're usually releasing an egg and therefore technically you can get pregnant. So it's really important if you're even if you're skipping periods if you haven't gone 12 months without a period, yes, technically it could be harder to get pregnant, but you still can get pregnant. So as long as you're still having periods, I recommend that you're on contraception.

I think the other thing to realize is as women age, you can have more medical conditions. Maybe you have hypertension, maybe you start having migraines with aura. And so sometimes a birth control that you've been on the entire time and was safe might not longer be as safe. And so you might want to talk to your OBGYN cause you might have to switch to a different type of birth control just during this transition if you have new risk factors.

Host: Yeah, I see what you mean. You know, it's always great having you on. We always have some laughs along the way and we get to a lot of good information. Just want to give you a chance here at the end, as always, just final thoughts, takeaways about perimenopause, transitioning to menopause, all that good stuff.

Lydia Garcia, MD, MIGS, FACOG: Yeah, I think my biggest advice to women is yes, this is a natural event, but you don't have to suffer through it, so please talk to your OBGYN, or a practitioner who specializes in menopausal medicine. There's lots of treatments out there, even if you have contraindications to birth control; sometimes you can still have hormone replacement therapy. And then my second word of advice is, I know, I see a lot of women in my clinic that, you know, sometimes they get medications from med spas or they can get medications online without a doctor monitoring them. And again, some of these hormones do have risk factors, increased risk of breast cancer, increased risk of cardiovascular disease, but relatively it is safe in most women, but doing it under the guidance of a doctor will keep you safe and then you can be on it longer as well.

Host: Yeah, it makes sense. That's why we have the experts, you know, there's so many things we can buy online or we see on social media, but you know, meeting with a medical professional, a doctor and going through patient history and symptoms and all of that just seems prudent, but I'm not here to judge. Uh, so, uh, thank you so much for your time and you stay well.

Lydia Garcia, MD, MIGS, FACOG: Thank you for having me.

Host: And for more information, go to SNHHealth.org and search gynecology and surgical services.

And if you enjoyed this podcast, please be sure to tell a friend and share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.