Karen Loftus (Host): This is Community Connect, presented by Tampa General Hospital. I'm Karen Loftus. Joining us today is Dr. Catherine Lynch. Dr. Lynch has more than 30 years of experience practicing women's health and is board-certified in obstetrics and gynecology with subspecialty certification in female pelvic medicine and reconstructive surgery.

She is a recognized leader in women's health, menopause management, pelvic floor disorders, and faculty development. As Associate Vice President of Women's Health at USF Health and Medical Director of Inpatient Obstetrical Services at Tampa General Hospital, Dr. Lynch is dedicated to advancing women's healthcare through expert clinical care, education, research, and leadership.

Dr. Lynch, thank you so much for being on the podcast.

Catherine Lynch, MD: Thank you so much for having me. I'm very excited to be here.

Host: You bring so much knowledge to the table in women's health, and one topic we're getting into today, for our debut video podcast, might I add, is something I think a lot of women are eager to learn more about, perimenopause and menopause.

Can you start us off by defining these two terms so we're all on the same page?

Catherine Lynch, MD: Sure. So, menopause, we'll start kind of at the latter part-

Because it's more, generally easier to define, is that time when, a woman transitions from her reproductive potential to no longer, ovulating and, going into the menopause, cessation of the periods.

so by definition, menopause is after you've had 12 months without a period. the perimenopause is that timeline generally up to about four years before the onset of menopause itself. And during this time, the cycles may be a little bit more irregular. women may experience some intermittent, episodes of hot flashes, night sweats, you know, symptoms of the menopause, go for a period of time without a period.

The symptoms then might get better, and then they have a period again, as the body begins that transition, from being able to have a baby to no longer being able to have a baby.

Karen Loftus: Okay.

Host: What age can most women expect to notice changes?

Catherine Lynch, MD: So, the average age of menopause in the United States is 51.5

Host: Okay.

Catherine Lynch, MD: so the perimenopause, on average, might start between 47 and 48. some women may undergo menopause a little bit earlier. Some women may undergo menopause a little bit later. One of the best ways to perhaps get an idea of when it might happen for, you would be if you know when your mom went through menopause- or if you have any older sisters- because you do tend to mimic what your family pattern has been, you know, to, a degree. Generally Under the age of 40, it would be called premature ovarian failure.

Karen Loftus: Oh, okay. Interesting.

Catherine Lynch, MD: so, you know, I know that we often get women who are in their late 30s or mid-30s who've got a lot of other stressors going on in their life and saying, "My hormones must be out of whack."

Host: Yeah. "This is it." "This is perimenopause."

Catherine Lynch, MD: Yeah. No, no. It, rarely can be, but that's a different diagnosis. I mean, it, is menopause, but it's an infrequent event- and, would require different management.

Host: Okay. Thank you for making that distinction. So there's a long list of possible symptoms that women can experience in perimenopause and menopause.

What are the most common ones you see, and then what are some that are maybe the lesser-known symptoms that are actually normal but could catch women off guard, like, "Oh, I had no idea that was a symptom"?

Catherine Lynch, MD: So certainly the most common symptoms are those of hot flashes, night sweats. The night sweats that can then disrupt your sleep.

you know, if you're having that sleep disruption, that can then make you a little bit more lethargic, you know, during the day if you're not sleeping well.

Host: Right.

Catherine Lynch, MD: you know, there may be symptoms of vaginal dryness. some skin changes, some drying of the skin. you know, there are some joint,

changes that can occur with, a little bit more increase in arthritis tendencies.

You know, kind of pain in the joints. changes that can, you know, go along with the menopause, as the body becomes lower in estrogen, the body's tendency to store energy, food, calories in muscle decreases, and the tendency is to, put that energy store into fat- which doesn't really burn the calories.

So the metabolism may slow some, and the distribution of, you know, muscle versus fat may- change a little bit. maybe a little central thickening.

Karen Loftus: The central thickening. Belly fat?

Catherine Lynch, MD: you could call it belly fat, yes. But keeping in mind that with those changes, you know, that you may need to do things to help maintain your muscle mass a little bit harder, to keep up your metabolism to avoid that, weight gain.

With that, the body's way that it rebuilds the bone, which we don't typically think of bone as being a really active, tissue, but it is in constant state of build and rebuild. Build and rebuild. And, So as the estrogen gets lower, the body's tendency is to keep wanting to rebuild. So the destructive, you know, cells are knocking things down, but the build cells aren't working as well.

so, they're called osteoclast and osteoblast. The big technical term, the easiest way I think about it is the blasts are those builders that want to reform it again. The clasts are the killers- that want to knock it down.

Host: Okay Got it

Catherine Lynch, MD: So the clasts keep going, and the blasts are on a little bit of a holiday.

So doing things like weight-bearing exercise, you know, again, maintaining that- muscle mass can help maintain your bone health and decrease your risk of osteoporosis or osteopenia.

Host: Okay. So those symptoms that you listed, those are the more common ones?

Catherine Lynch, MD: Yes.

Host: Is there anything that are sort of the, less common ones that maybe catch people off guard?

Catherine Lynch, MD: So there may be an increased risk of, depression.

for some women in menopause, as they go into that transition, There is a small component of women who are very hormonally sensitive. and in terms of, you know, their mood, depression can be more common.

you know, we've mentioned the sleep disruption. You know, a lot of people like to say brain fog. I've heard that a lot.

Yeah. So I mean, it's a very broad term. And somewhat ambiguous. so there are a lot of things that can disrupt your sleep.

Host: Yes.

Catherine Lynch, MD: you know, some of it can be having teenage kids.

Host: Exactly.

Catherine Lynch, MD: You know. it can be having your husband snoring. All of

Karen Loftus: the

things ... you know, the dog that wants to go out at 4:00 in the morning. That can make you tired the next day. That's not necessarily menopause.

Host: Ah, okay. So, take a look at your lifestyle choices and the big picture.

Like what's going on.

Catherine Lynch, MD: Right. Right. but if you're waking up three, four, five times a night with, you know, hot flashes that are waking you up, you know, and then you're falling back to sleep, having to change your, you know, nightgown because you sweat so much, those are going to be more likely to relate to a, brain fog because you're basically on call every night.

And, you know, it can be pretty exhausting.

Host: So of all these symptoms, they can vary so much from woman to woman. Why? Why, are they so different? Even with women who are the same age, you could be sitting next to somebody who's your best friend and they're like, "I don't have any of that, but I have this."

Catherine Lynch, MD: So the most common symptoms, as we said, you know, the hot flashes, the night sweats, you know, typically, about a third of women will have only, you know, mild to no symptoms, you know, of, of it's the transition.

Host: I

feel like that's pretty high. A third of women would have no symptoms.

Minimal.

Catherine Lynch, MD: Or, minimal.

Host: Minimal.

Catherine Lynch, MD: Minimal to no.

Host: Okay.

Catherine Lynch, MD: So two-thirds will have more significant symptoms. you know, it's hard to predict who's going to be more symptomatic. You know, you would think that someone who doesn't have that much extra body fat, because body fat actually produces some estrogen, of a different type, would maybe be less symptomatic.

But, you know, I've seen thin women who are asymptomatic, and I've seen, you know, more heavier set women who are terribly symptomatic. some things that, you know, have gone back and forth is, well, do foods play a role? you know, does alcohol, play a role? Are there different things that may be making it more, you know, prevalent than others?

with those body changes, you know, and your energy level and, the rest of it, you know, the tendency to start to develop other medical conditions like, you know, diabetes, you know, where fluctuations in the sugars may exacerbate your symptoms- are all things that may play a role.

So we don't really know the secret as to- why someone might be more symptomatic than others. but, you know, if you're not really symptomatic, be supportive of your friend.

Host: Yeah. That's very good advice. So let's say a woman comes to you. She's experiencing some of these symptoms. Can you walk us through how you determine appropriate treatment and even go into the role of maybe hormone replacement therapy as a, treatment modality?

Catherine Lynch, MD: Sure. So I think it's first very important to get an, understanding of what their symptoms are, and also if they're still having cycles, what those cycles look like.

Host: Okay.

Catherine Lynch, MD: because, you know, if you're having regular monthly cycles, you're probably not yet there.

Host: Okay.

Catherine Lynch, MD: so checking hormones is probably not appropriate.

for a woman who's having irregular cycles, who's starting to have symptoms of hot flashes and night sweats and other, you know, vaginal dryness, other changes, then probably if you're unsure as to whether or not they haven't yet made that definition of, 12 months without a period-

you can check a hormone level that's called, the FSH or the follicle-stimulating- hormone. And that is a reflector of what the brain is sending down to the signal, and it's a feedback loop from the ovaries back to the brain.

Host: Okay.

Catherine Lynch, MD: so if the ovaries aren't working well, then the brain has to send more signal, to keep banging on the ovaries to do something.

And so that FSH will start to rise.

and will get into a menopausal range.

Host: So if you got labs done and your FSH was rising in a- six-month span

Catherine Lynch, MD: Was high

Host: Then that's an indicator to you as a provider that they may be trending towards menopause.

Catherine Lynch, MD: Yeah. Yeah.

Host: Okay.

Catherine Lynch, MD: Now it's, going to be something where it's going to fluctuate.

So if they then suddenly have a period and the ovary responded, then the FSH is going to go down. So it's a single snapshot. you know, if the periods are still erratic, one important point to make is even if the FSH was high this month, that doesn't mean you're not going to ovulate next month. And if you don't want to be a 50-year-old mother, you probably still want to be mindful that, you know,

Host: It could still happen ...

Catherine Lynch, MD: it could still happen. It could still happen if you're you know-

not otherwise protected,

Karen Loftus: Okay. HRT specifically has, gotten a bad rap, and correct me if I'm wrong.

I feel like HRT has gotten a bad rap and, you can get into the why of that, because I know it's a little bit in depth. but now it seems like it's a different conversation. Can you explain how this treatment has evolved in, recent years?

Catherine Lynch, MD: So HRT got a terrible rap. Absolutely terrible rap. hormone replacement therapy is one of the most studied medications, you know, in the world.

and in the late 90s, you know, some of the data that was coming out of the Nurse's Health trial, which was a large population-based trial, was showing that women who were on hormone therapy actually were living longer with less, you know, cardiovascular, heart disease risks and other complications.

And so the, thought, you know, started to come out as, "Man, maybe everybody should be on hormone therapy. And if you have heart disease, perhaps, you know, we should put you on hormone therapy to help protect the, heart." And, so the, Women's Health Initiative, the WHI, was a large study sponsored by, the NIH But actually from the cardiovascular standpoint, looking at was hormone therapy protective against heart disease.

The study was designed by non-gynecologists. so they actually looked at women and equally enrolled women between 50 and 59, 60 and 69, and 70 to 79, who had not been on hormone therapy. they specifically enrolled symptomatic women, or specifically did not enroll, excluded-

symptomatic women, because they felt like, "Oh, well, if they're too symptomatic, then we'll know whether or not they got the placebo over the active drug."

Despite the fact that we know in gynecology that there is a somewhat of a placebo effect where some women will respond to the placebo. So that was, you know, not really quite correct. And then they enrolled women who had heart disease. They enrolled women who'd had coronary artery bypass graft surgery.

Host: Okay.

Catherine Lynch, MD: They enrolled women who had a history of blood clots. The average BMI was 30. Forty-seven had a history of smoking. and what they ultimately came out with, was that asymptomatic women who were, you know, over 65 shouldn't be started on a medication that they didn't need. You know?

Host: Got it.

Catherine Lynch, MD: And, with that, there was then increase in risk of- new onset cardiovascular disease.

Host: Okay. So that's the backstory of why HRT got a bad rap- because of this study with all of these other factors.

Catherine Lynch, MD: Yeah. So, suddenly in July of 2002, I believe, they came out with the findings that said, you know, "Oh, there's an increase in risk of heart disease."

They hadn't done the age-based analysis, there was actually some question as to exactly how they found that risk and, it, you know, didn't actually cross what they had determined as the predetermined risk threshold. They looked at a different data point. but needless to say, it was all over the news.

Karen Loftus: Yes.

Catherine Lynch, MD: And, you know, people were, dropping hormone therapy left and right.

Karen Loftus: So was that... Is--

Host: So is HRT something that you think is safe and something that you use and, is it for all women?

Catherine Lynch, MD: So it's not necessarily for all women.

Host: Okay.

Catherine Lynch, MD: so it is important to have a, discussion with your doctor- on what your individual risks are. So, you know, someone who, has a history of blood clots would not be a good candidate- for hormone therapy. someone with heart disease. There was a study that was done in the late 90s that looked at actually starting women on hormone therapy after their first MI, and randomized them to hormone therapy versus placebo, because as we said, we thought it was good protective for the heart.

four years after being on hormone therapy, the data did start to show that there was a protective benefit.

Host: Okay.

Catherine Lynch, MD: Only downside, there was an increase in risk of fatal heart attack in the first year, for women put on hormone therapy. So if you have really bad heart disease, you know, and you don't wanna live a long time with really bad heart disease, you can start the hormone therapy 'cause you probably won't make it through the first year, but then you won't have to suffer.

Karen Loftus: Yeah.

Catherine Lynch, MD: So, so we're not really enrolling women- Yeah ... on, you know, w- with, with, you know, heart disease who have, on hormone therapy because we don't know. We don't know who is, you know, has significant disease already. And if you've already had a heart attack, you should not be on it. If you have significant risk factors for heart disease- you should not be on it. If you have a significant risk factor for stroke, you shouldn't, be on the therapy. certainly, estrogen-dependent breast cancers, you know, shouldn't be on systemic therapy.

Host: Okay. Thank you for making all those distinctions too, and also emphasizing, you know, talk to your doctor because it is individualized and it's not like, "Well, everybody's talking about it, so I want it."

Catherine Lynch, MD: You're right.

Host: It's like, "Well, hold on. Let's look at you and see if this is even a viable, option for you." so women that are in the thick of having symptoms right now, whether that's the trouble sleeping, mood changes, hot flashes, are there some practical steps that they can take to feel a little bit better and manage those symptoms?

Catherine Lynch, MD: if they don't want to necessarily go on hormone therapy or perhaps they have a, contraindication to hormone therapy, then there are definitely things that, they can consider in terms of lifestyle changes that may be- a benefit. You know, exercise can be good for a lot of reasons.

it can be a great stress reducer. It may help you sleep at night, you know, general stress relief and exertion. watching what you eat, maintaining a healthy diet, you know, all those things can be a benefit. Trying to stick to a schedule of, good health, you know, sleep hygiene-

can be a benefit as well.

Host: All those are very important and hopefully, you know, something that they can take away from this. one of the things we want to make sure we're doing with these podcasts is getting information out to people, educating people, because especially in this day and age with social media, there's so much misinformation.

What are some of the misconceptions that you've heard either from patients or you've seen on social media that you would like to set straight about perimenopause or menopause?

Catherine Lynch, MD: So I think one of the biggest things that's got a potential for significant health impact is this concept of testosterone in women.

Host: Okay. Go

on.

Catherine Lynch, MD: it is not recommended by the American College of OBGYN nor the North American Menopause Society. And oftentimes patients who are receiving supplemental testosterone, particularly in this pellet form, which can't be undone once it's put in, are being supplemented with testosterone levels in the male range.

In what we would consider if you came to me because you were, you know, 20 and felt like you had excess hair growth and you were losing, you know, hair on your head, and I, you know, drew some, hormone levels and saw a testosterone level of 200, I would go looking for a tumor.

Host: Okay. I'm not familiar with ranges.

So 200 is very high for

a woman?

Catherine Lynch, MD: Two hundred is very high for a woman.

Host: Okay. What's a healthy range for a woman?

Catherine Lynch, MD: About 30.

Host: Oh, yeah, very high. Okay.

Catherine Lynch, MD: Somewhere between the

teens and, you know, 30, 40.

Host: Okay. All right. so that's one thing. So is that something that you've heard or seen if, like, women are getting hormone replacement therapy and testosterone is in the conversation, that shouldn't happen.

Catherine Lynch, MD: it should not. Generally, it's not recommended.

and You know, there are very few indications where we would consider doing testosterone. It does not help with libido.

Host: Okay.

Catherine Lynch, MD: the female sex drive is different than the male sex drive, and it does not benefit that. It Apparently makes you feel really good and gives you some pretty good muscles, but-

you know, it may also have other impacts.

Host: Okay.

Catherine Lynch, MD: Including on your cholesterol.

Host: Oh, okay.

Catherine Lynch, MD: you know, because men- tend to have heart disease younger because of the testosterone.

Karen Loftus: A lot of unwanted side effects- that you just want to stay away from them. Yes And the hair growth, the hair loss, other, findings.

Okay. as we wrap up this conversation, if our listeners take away one thing from this conversation, what would you like to share with them about perimenopause or menopause?

Catherine Lynch, MD: You know, I think if you have concerns about perimenopause or menopause, go to your gynecologist. talk to them and, you know, let them make a, full assessment.

you know, there are a lot of things out there on the web and even in our own community promoting all sorts of things, you know, benefits without really looking at is it right for the woman and are you really in that timeline of your life or not?

Host: At TGH, we talk about healing, teaching, and innovation as our shared purpose.

Which of those resonates with you right now, and why?

Catherine Lynch, MD: You know, I think that the teaching is probably what resonates the most with me, both teaching my patients as well as teaching the next, generation of providers. and I think it's important to make sure that we each have an understanding, whether you're the patient or the trainee, of what's going on with, the human body, and especially in terms of women's health.

so always ask your provider, you know, "Can you teach me something about myself?"

Host: I love that. What a great note to end on. Well, thank you so much, Dr. Lynch, for joining us on the podcast today.

Catherine Lynch, MD: Well, it's been my pleasure to be here.

Karen Loftus: That has been Dr. Catherine Lynch. For more information, please visit tgh.org/womens.

If you enjoyed this episode, please be sure to like, subscribe, and follow Community Connect presented by TGH on your favorite podcast platform. I'm Karen Loftus, and this is Community Connect presented by TGH. Thanks for listening