Dr. Mike Smith (Host): Welcome to Southwest General Health Talk, the podcast that brings you insightful health discussions every month. And with me today is Dr. John Alton, an esteemed OB-GYN from Southwest General Health Center. And today, we're going to dive in to the topic of perimenopause and menopause, exploring everything from symptoms to treatment options.

Dr. Alton, welcome to the show. Let's start with perimenopause, okay? And I think this is something a lot of women hear about now, right? It's kind of all over the place. But I'm not so sure if everyone fully understands what it is, like when it typically starts. Can you just kind of help us with that to begin?

John Alton, MD: Sure. Well, thanks for having me on, Dr. Mike. I really appreciate it. This is a great opportunity to kind of present some facts and separate them from myths. So, you know, the ovaries are an organ that secretes hormones. And obviously, women go through puberty. And then after puberty, that's kind of my joke is that's when perimenopause starts because the of the ovaries start dropping off.

Perimenopause is kind of anti-puberty. During puberty, women have tons of energy. They can sleep all the time. They can do anything. Then after puberty, this perimenopause thing starts. But the average age, to answer your question, you know, usually around 40s, mid-40s is the classic definition of perimenopause.

And like I was saying, the ovaries function, you know, as they get into the mid-40s and 50s, they're kind of like—you know, I use the description of flashlight batteries that are old, I hate to say it. But sometimes, you turn it on and they're acting like they're 20. The next time, they dim and hit them a couple times and they're working great. And the next time, they're not even on. And that can go from day to day to month to month. So, that's kind of my, you know, easy way of thinking about perimenopause.

Host: I guess, maybe this is the big question now. Why is it though that some women definitely have symptoms of perimenopause and a lot of women don't feel nothing?

John Alton, MD: That's a great point. Eighty-five percent of women that go through menopause do not have significant symptoms. Now, it depends on who you're asking if it's significant: the spouse, the partner, the kids, the patient, right? But the patient's self-reporting is significant. I kind of tell people they're just wired. They're either lucky or unlucky. Some people's pregnancies go great with no problems, and they zoom through it and love it. Some people's pregnancies are rougher, just like with menopause. Some women go through and have no issues. Some have significant problems.

And I think that's the big breaking point is the last five years, women decided they're done with it. Historically speaking, and I don't want to dive deep in the weeds, but when I started doing this job thirty years ago, I would have women come in and we would test their ovaries through a blood test. And if they were in menopause, pretty much every woman got hormone replacement. It was thought to help heart disease. And then, the reason this kind of taken over a little bit is that WHI study came out about twenty-five years ago, really put a lot of scare into women about using hormones. So when that went aside, so did the whole talk about perimenopause.

Host: Gotcha. Makes sense. But if a woman is going to experience symptoms, what are we talking about here? Like, what's the most common complaints they have?

John Alton, MD: It's changed through the years. It used to be hot flashes, night sweats. Now, a lot of women come in, they're just not feeling like themselves. The libido's low, the metabolism's changing, so they're gaining weight even though they're doing the same thing they did, you know, five or six years ago for weight maintenance. Those are probably the top four to five complaints. And those are all very separate issues. Some have directly to do with hormonal changes, some have to do with simply living through life and getting—the word—older.

Host: How do you distinguish that then? Because as you just mentioned, some of those symptoms are kind of vague, right? They can mean a lot of different things. How do you know they're perimenopause? How do you know maybe they're hormone-related? Is it just a simple blood test and showing that there's some hormonal changes?

John Alton, MD: When I think of the hormones, I wish I could say it was one blood tests that did it. I kind of picture perimenopause as kind of like a ballet. There's so many things involved. It's very intricate in how the hormones work and combined with aging. So, a provider, good clinician basically listens to the patient. That's the best. That's better than any lab test, better than anything else. That is just listen to the patient, hearing what the problems are, and then dissecting that down to try to figure out, "Okay, how do we minimize those?"

Suffering's different than symptoms. Remember, suffering's an emotional part, and no woman has to suffer through perimenopause. Not saying we can't get rid of hot flashes or night sweats or weight gain or decreased libido, but suffering with it is the job to take care of.

Host: With those symptoms—now we're talking just about perimenopause here, right? So again, there's still some ovulation going on occasion and maybe they skipped and stuff like that. But they're still having their period. When they have these symptoms, are they timed to a certain part of the cycle or does it start kind of getting all over the place?

John Alton, MD: It does move all over the place, but you bring up a solid point. When it comes to laboratory testing as part of that, that ballet of figuring out what's going on, if a woman's still having these cycles, I make sure and get their hormone levels at day three of their cycle. The test they generally get is testosterone, estradiol, estrone, FSH. And then, vitamin D and ferritin are very important non-hormonal factors in one's body that can affect a lot of those symptoms.

But you want to do it day three because everyone remembers that eighth grade family planning, family life thing where they show the hormones kind of going up and dropping down, those hormone fluctuations really are difficult to interpret when you're getting them at different times in a cycle. So, a woman that's having irregular cycles, you do want to get towards the front so you can see what the lowest point of the testosterone is, the lowest estrogen. And it's also hard to really relate that to what they were when they were 20. You can give me all the testosterone I was when I was 20, my cells aren't going to take those little hormones and do what they used to do.

Host: Yeah. So, we don't really know what their baseline was, and they're older now, right? It's not going to have the same maybe effect. I want to move in to, you know, we mentioned mood and all that and the hot sweats, hot flashes. But boy, it does seem a lot of women this time of the year or this period of their lives, Dr. Alton, where they talk about weight gain.

John Alton, MD: Yeah.

Host: Is that just age or is it perimenopause or both?

John Alton, MD: It's both. When we talk about hormone replacement real quick, so hormones, there's two hormones. One is estradiol that's made by the ovaries and adrenals. That's the good stuff. There's actually three, and the third one we won't talk about. It doesn't do anything. But then, there's estrone, estradiol 1, and I test for that. That comes from fat cells. And the balance between those two are important. So, women putting on weight and fat cells is their body's trying to compensate to make this estrone in their fat cells to help them get through menopause. That's kind of body's way of doing it, although that hormone is not a very good one.

But basically, you know, with your metabolism slowing, you want to maintain that weight, to lose that weight, you got to work on muscle resistance. I mean, our generation was run, run, run, aerobics, aerobics, aerobics. Now, you know, muscles make up an organ that burns calories all the time. So, resistance training. But every good weight management plan centers around mindful eating, and that's what I tell my patients.

Mindful eating are three simple things: knowing your serving size with calorie input devices like, you know, Weight Watchers, MyFitnessPal, Lose It! You got to do that. High protein to kind of keep that insulin level. And high protein's almost a gram per pound. Obviously, you got to talk to your doctor about, you know, kidney function, make sure you can handle that protein. And then, the last one is intermittent fasting. I think that's the key to the whole thing. It keeps your insulin levels a more level. Tons of apps and information out there regarding intermittent fasting. And obviously, again, you have to talk to your doc because anyone that has diabetes or sugar issues, their intermittent fasting issues are going to be different. But that's why the GLPs work because basically men and women that use those medications go on a fasting state, and they can lose that weight.

Host: With intermittent fasting—this is a little bit of a tangent, but I'm curious.

John Alton, MD: Sure.

Host: There's different, you know, some people say you have to fast for 10 hours. Some people say 12. Like there's different timeframes, right? Where do you think the sweet spot is?

John Alton, MD: I think everyone's individual. And I'll tell you how I intermittent fast because my wife makes great meals. And if I come home and fast and don't eat that meal, our marriage is going south real quick. So, I work my fast around my wife's dinners. And so, during the day is when I do my fasting.

Now, time-wise, you know, someone starting off, just start off with a 12-hour fast or an overnight fast. Then once you start getting the hang of the overnight fast, then you can move that up to maybe a 16-hour fast or 18 hours. You're also kind of cramming those calories in a window that you're going to feel satieted and full during that window timeframe with protein. It's not easy.

I also think intermittent fasting works well for a lot of people. You're doing it for mindful eating. So in other words, at lunch, I'm not just going to, "I'm done fasting," and shovel everything in. You have your chicken, you have your salad, you have your little cookie because you got to have something nice, you know, and that's your lunch. And, you know, that's where you break your fast.

I also think fasting works well if you're fasting for something higher. You know, I fast for my kids, I fast for my wife. I kind of bring in something so when I feel those hunger pains, I tell my patients, if you're fasting for someone or maybe you're fasting so hopefully when you're 10 years from now, you're down that weight and you're going to be happier 10 years from now with five to 10 less pounds on. So, you know, it's multifactorial.

Host: Yeah. When I was younger, I worked out to look good, right? But, you know, believe it or not, that wasn't much of a motivator, right? I got to a point where I was like, "Well, maybe I don't care if I don't look all that great." But now, it's more family, it's more health, it's more—I think those things are motivating, and I think that's a great, great point.

But I think just to wrap this up about the diet part here, and I think we would both agree, resistance training, muscle training, all that's great. But you can't really exercise yourself to weight loss. Food has to be key component of what you're focused on, right?

John Alton, MD: Exactly. So much of it.

Host: How much, when you're eating it, all that kind of stuff.

John Alton, MD: When you think about eating, it becomes our higher brain. It's mindful eating. Our lizard brain will eat everything it can because our little lizard brain is worried about, you know, evolutionary not being able to eat tomorrow. Our bigger brain has to sit there and say, "Hey, it's going to be hard to lose weight now, but it's going to be hard when I'm 60 and 70 to be 10 to 15 pounds overweight, and my joints are going to hurt, and my diabetes risk is higher." So, both those things are hard. You just got to pick your hard.

Host: Right. You got to pick your hard, I like that. Let's go back now into the perimenopause situation. We've talked about a bunch of symptoms. We just talked about weight. Irregular bleeding is another, I think, big symptom. It's confusing. Help us out there.

John Alton, MD: The number one thing is understand that the ovary's cyclic hormonal release is going to change; therefore, a woman's cycle is going to change. Some women are blessed with 28 days on the nose, five days of bleeding, that's it. Twenty years, 30 years of their life like that. And then, menopause hits, and they call me and they're like, "Hey, I skipped a cycle." I'm like, "You know, it's not uncommon to skip cycles, you know." And I think that it's important to bring it up to your clinician, your provider, your doc, because bleeding's the one area that we can do a lot about to manage, non-hormonal and hormonal management. So, suffering through that or dealing with that on top of all the other stuff.

Then, of course, we worry about pre-cancers, cancers, management plans that can fix that problem without too much investment by the patient. But I'm a firm believer that when someone comes in with abnormal bleeding, if they think it's abnormal, I think it's abnormal. I've never had a cycle in my life, so any bleeding that's abnormal, I trust the patient. That is that. We're going to fix it.

Host: You got to really go with what their normal pattern was, right? There's really no textbook, you know, days, whatever.

John Alton, MD: Right.

Host: I like that approach that you take. You mentioned something that at some point, usually women will start complaining of some skipped cycles and stuff. That was something you just said. And I want to just see what you think about this, because this is something that I was taught in medical school a long time ago, and I don't know where it kind of falls now. But a lot of doctors back then, endocrinologists back then would believe that the skipped cycle was the key to menopause because you were losing progesterone. You weren't ovulating, right? So, all that progesterone stuff wasn't going on. And now, you kind of had like this imbalance between estrogen and progesterone. Where are we at with that kind of thinking?

John Alton, MD: Dr. Mike, you were taught very well. That's classic approach to menopause management. Think of it kind of two ways. A woman that naturally goes through menopause, they skip a couple cycles, they go three months, they go four months, then they get one, then they're upset because they thought they were done. Then, they go six months, then they go nine months. Then, they see me at 12 months, and I'm like, "Well, officially by the textbook, you're not making progesterone anymore. You're not having cycles." But then, Murphy's Law rolls in. As soon as they see me, like the next day, they have a cycle and it's full-blown. And then, the next year, they see me for their annual and they say I jinxed them.

But in seriousness, you're exactly right. You know, a woman in her 40s that's skipping significant cycles needs to be worked up to make sure there's nothing else. You know, you still have your thyroid, you know, you still have endocrine issues that could be causing it. And especially if they have a risk for polycystic ovarian disease, which is a huge talk in and of itself beyond this, you know, that's where progesterone deficits lead to endometrial overgrowth and possible cancer. So, a clinician needs to figure out which way it's going. Is it just normal menopause and they're skipping cycles, or are they still ovulating but not making the progesterone? And that can lead them to higher chances for endometrial overgrowth and cancer down the road.

Host: Yeah. Great point. I want to move into treatment now. Again, perimenopause, it's a little vague with symptoms. It's sometimes hard. I mean, obviously, you have a woman whose maybe cycles are changing. She's in that age, so you can kind of make the call from there. Obviously, you're ruling out other stuff, right? Thyroid, all that good stuff too. We don't want to forget that.

John Alton, MD: Exactly.

Host: So, you're kind of left with, "Okay, this looks like perimenopause to me." How do you treat this?

John Alton, MD: I look at it from the perspective of what their problems are. So, let's go with the classic hot flashes, night sweats, but still getting cycles. It is not a problem to work to do the hormone levels and decide whether or not I'm going to replace them because I will be replacing their troughs. Low-dose, oral contraceptives, OB-GYN's classic, everything's a nail in your hammer. So, it's, you know, contraceptives, contraceptives, contraceptives, but it does do a great job. There's some progesterone-only contraceptives out there that are derivatives of spironolactone that manage weight, acne, and hair growth, and that's probably one of my go-to. It's a progesterone that levels out the hormones and levels out their symptoms.

The post-menopausal treatment plan, obviously, hormone therapy is a mainstay. Women that have contraindications like, you know, history of—not history of leg clots, but active leg clots. You know, women that have a history of breast cancer that can't take systemic hormones, there are some options out there. These pharmaceutical companies are coming out with some options to treat those. And that's pretty exciting areas to work at.

And then, there's a lot of nutritional supplements that have taken over the market. I always tell my patients, though, if you're doing something that you saw online or a pharmacy or someplace in nature's pharmacy to pick up, I'm a firm believer, only give it about ninety days. Because if this supplement doesn't work in ninety days, like a soy supplement, it's probably not going to do much long term.

Host: Let's move then iinto menopause now. So, that was the setup. That was perimenopause. Now, we're going to talk about menopause. What's the official definition of menopause?

John Alton, MD: For taking our boards, Dr. Mike, you know, it's one year without a cycle. So, that's our board management. Someone comes in at nine months or, you know, short of that and having significant symptoms—and again, I use the word significant, it's bothering them, I'll start offering them treatment plans.

The hormone replacement labs, I do order a testosterone. I do order an estradiol and estrone and FSH. I think that those—and I try to get them, you know, if they're having a cycle once in a while that you can't really use it, you just have them get it point blank. And it does give me a little bit of a baseline. I've had some patients where I've referred back to that when they weren't getting results from hormone replacement to look at that and say, "Okay, let's try bumping this up or maybe adding testosterone to the plan."

But hormone replacement is the mainstay for therapy. And we're not even talking about the vaginal atrophy and pain with intercourse that can occur. Vaginal estrogens are very, very safe.

Host: Estrogens, even creams and stuff have shown to be very effective, right? For vaginal dryness, pain, stuff like that.

John Alton, MD: Right. Exactly.

Host: What about long-term health here when it comes to menopause? The bone density issues, heart health. What kind of conversations are you having there with your patients?

John Alton, MD: If they're going on hormone replacement, I let them know the safety's been well-established. The WHI study that was done a couple years ago—decades ago, they really didn't do a good job. The average age of woman was sixty-five starting on hormone replacement, which really—and that's average. That means for every woman that was fifty-five started, there was one that was seventy-five that started it. But long term, they're going to notice, their bone densities will be maintained. The skin, they're going to notice their skin's a lot less dry. The heart disease improvement stats are there because it helps. The cholesterol panel look a little better. You know, when you look at Alzheimer's, no one's ever linked it, but the decreased Alzheimer's risk.

But I tell you, the number one thing about women on hormone replacement is just the sense of wellbeing. They feel more like themselves when they're on hormone replacement. And that's a long-term issue. You know, that's not something that's necessarily health-related. But then, they feel like themselves. They sleep better. They have more energy. Then, they're able to maybe stick to their mindful eating a little better. Then, they're maybe having more time to get their workouts in because they're not taking afternoon naps.

Host: Let me just back up for a sec. So when it comes to initiating hormone replacement, it should be earlier, a little bit younger in life. Is that what we're saying?

John Alton, MD: That's where I'm at.

Host: But where does this—because you also hear this sometimes, no more than five years, is it? Like, isn't there a time limit that some of the institutions think that's about it?

John Alton, MD: Yeah, that came from that WHI study, and to kind of break that data down, it's complicated, but this made it really simple for me. And if I'm off on a couple numbers, I'm sure some people will put in the comments below. When they did the WHI study, they had a thousand women. And first of all, we're talking about estrogen and progesterone. Estrogen alone is a whole separate—If you've had a hysterectomy and just estrogen, that's another discussion, and a lot more things are in your favor for long-term use.

But that WHI study used a progesterone that no one uses anymore. And they had women on it in one arm, and the arm that didn't have it, the risk of breast cancer was like 3.8 per thousand for women that took no hormones. The women that took hormone after five to ten years, it went up to four point two, so that's 0.4 person per thousand. So, the huge numbers of it were not—you know, if you're giving it to millions, that's a huge impact. If you're giving it to each person individually, it doesn't increase the risk significantly.

I tell my patients that weaning off is a question of how long should you be on hormones. I tell them, "If you're weaning off every couple years and you're still having significant symptoms, go back on it." The data does not show an increased breast cancer risk when they relooked at that WHI data for young women. And I mean, young by 50s too. I'm not talking, you know, 40s. I'm talking 50s, early 50s, and, early 60s.

Host: Talking about the type of hormone, do you think that plays a role too? Because, you know, you have, you have bioidentical or I think they're called bio-biosimilar now. And then, then you have the more synthetic-looking ones that really, you know, came from horses at some point, right?

John Alton, MD: Sure, yeah.

Host: Does that not have an impact as well?

John Alton, MD: Huge impact. First of all, I tell my patients the optimal hormone is a transdermal of some sort of patch or cream, for two big reasons with it. Number one is we talked about that bad estrogen, that estrogen 1. When you take oral estrogen, your liver metabolizes it. And actually, your estrogen 1 does go up. So, you might not have that balance, that two to one ratio you're looking at. So, that's number one.

The other reason that, the patches, they're more biosimilar to your point. But they also don't have a first pass effect through the liver. So, a lot of the clotting risks aren't there. I do believe, when you look at absorption of steroids, you know, a fatty meals affects absorption. You know, if a patient's taking their estrogen with a fatty meal, you know, they might have less absorption. I can't prove it, but it just makes sense to me. If you're putting a patch on that's a steady release, you're going to have a lot more steady hormone. And in my world, that's what we're trying to do is keep things steady. We're not trying to get things to bounce around. So, that's why I optimize for the transdermal, which are very biosimilar.

Host: We touched on this a little bit, but I think it's wise for us to mention this again. Who should not be on hormone therapy?

John Alton, MD: Active breast cancer patients should not be, if patient's being treated. Even the data, you know, five, 10 years, it depends on you have a good discussion with your oncologist and your either GYN or whoever's providing the hormones regarding that. If you have active embolic disease, like you have active DVTs or PE or you're on a blood thinner, that's one you need to talk about it.

Now, remote history, you start getting into some gray areas with that. Supposedly, the—and this is, you know, based in science and, in fact, the transdermals don't have a first pass effect through the liver, so therefore their clotting risks are a lot lower.

Anyone that has abnormal bleeding, bring up a good point. A woman comes in and has abnormal bleeding, they're not getting hormones till I figure out where that bleeding's coming from.

Host: What's some of the biggest myths and misconceptions you deal with or you hear about every—I guess, probably everyday?

John Alton, MD: Yeah. That's a tough one.

Host: Because this is what you do, right?

John Alton, MD: You know, and what I'm going to say sounds so—it's true though. It's a transition, it's not a decline. If women and spouses can get that in their head, it is a pure transition from one part of your life to another. It's not a decline. You know, your life and a woman's life, you know, can take off and flourish at any age. It's what you choose to do with it, I think, is the biggest myth with it.

You know, I think you can feel better when you're older. You know, the confidence we have as older, you know, people in life goes a long way compared to us in our, you know, 20s and 30s. And it's not your personality changing. I think people see it as a personality change. That's not happening. You know, you're being inundated with some hormonal changes that's affecting your attitude and your mood, but it's not your personality. And those can be adjusted too.

And I think the last one is you don't have to suffer with it. Even if hormones aren't your gig, you don't want to do it, there's lots of other options, and finding a provider that works with you is the key. And at Southwest, we have some great docs that they take care of this.

Host: This has been fantastic, Dr. Alton. I feel like we could talk a lot longer on all this.

John Alton, MD: Yeah, sure.

Host: But it really has been great information, and I want to thank you for coming on. As a matter of fact, for those listening, you can request an appointment with Dr. Alton. You just go to swgeneral.com. If you found this episode helpful, please share it and check out our full podcast library for topics of interest to yourself. And this has been another episode of Southwest General Health Talk. Thanks for listening.