Cheryl Martin (Host): It's a rite of passage for women that usually occurs when we're in our 40s or 50s. We don't look forward to it, but it's a natural biological process. Menopause. You can empower yourself when you know the right questions to ask your doctor about menopause symptoms. So let's get some tips from women's health expert, Dr. Briana Walton. She's a Urogynecologist at UM Capital Region Medical Group, Women's Health. Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm Cheryl Martin. Dr. Walton, so glad to have you on this episode.

Briana Walton, MD, MPS BAD, FACOG: Thank you for having me. I was very excited when you asked to talk about this subject.

Host: Glad you're on to break everything down for us. So first off, what is menopause?

Briana Walton, MD, MPS BAD, FACOG: I loved your intro and I think, kind of a quirky way to think about it is the reward for surviving middle age in many ways. You know, many of us have gone through raising kids, going through our jobs. And so the icing on the cake once you've turned a certain age. And most women in the United States will go through this sort of transition between the ages of 45 and 54. But classically, we describe it as either the spontaneous or induced loss of menstrual periods, and that has to happen for about 12 months.

Host: What are the common symptoms of menopause that women should be aware of?

Briana Walton, MD, MPS BAD, FACOG: So, most women in the United States will have what we describe as vasomotor symptoms or hot flashes. About 70 to 80 percent of women will have those changes, that they will notice their core temperature is higher, they'll have sweats at night, but less common symptoms and sometimes even more troubling are the findings of vaginal dryness, urinary symptoms.

And even physical changes, such as joint discomfort, hair loss, changes in our libido. But I think what I find most discomforting for most patients is the brain fog and the mental changes, the anxiety, the depression, the attention deficit. It just becomes a bit frustrating.

Host: What can be done about that brain fog?

Briana Walton, MD, MPS BAD, FACOG: That brain fog is an interesting topic because it is related to menopause happens in our brain because our hormones are regulated by hormones that are secreted from the brain. And so key sort of principles are to control those hot flashes, either with or without hormone therapy. But the other thing is really just to have a healthy lifestyle. So we often talk about sleep deprivation as a part of menopause, and that's a key principle to make sure that we're well rested and whatever we need to do to become well rested and observe our sleep hygiene, I think is very important. The other piece of it is to exercise and many of the literature talks about doing high or moderate to high intensity exercise about 150 minutes per week in order to keep our bodies healthy and to help some of that cognitive decline change.

It's frustrating when you can't find the words, when you don't know exactly what to say, when you get stuck on a subject and you're, you can't quite get past it. And that for women, I think is a key principle to try to switch and get back to your youthful self, not just the way you look, but the way you think and feel.

Host: You have talked about symptoms, so at what point should a woman who's experiencing these symptoms consult her gynecologist?

Briana Walton, MD, MPS BAD, FACOG: It's interesting. So many women know that, especially in the United States, about most women will go through menopause at the age of around 50, 51. But the symptoms of menopause can occur as early as age 45, and we would actually consider it premature or early menopause if it occurred around age 40.

So any of these symptoms such as hot flashes, changes in your sleep, vaginal health or urinary health issues, we should really feel comfortable and have this open dialogue with our providers, whether it's a physician or a nurse practitioner, to be able to address their concerns.

Host: So what are some key questions she should ask her doctor about managing her menopause symptoms?

Briana Walton, MD, MPS BAD, FACOG: I think anything a patient wants to ask me, they should be able to ask me. You know, I really focus on trying to create a sacred space for a patient where we can have an open dialogue especiallyas a urogynecologist when I'm talking about very sensitive subjects such as urinary incontinence or sexual dysfunction or prolapse. But I think the key questions should be, is this normal?

Yes. Is this a symptom that can be treated? Yes it can. Are there things to help prevent it? Yes there are strategies. But each one of these questions will have customized or individualized answers, so there's really no generic answer for one or a group of patients. I think you really need to focus on, well, what are your risk factors? What is your history? How do we incorporate non hormonal and hormonal options into your life or lifestyle?

Host: Good, so you recommend a patient then have a list of these questions in advance before the appointment.

Briana Walton, MD, MPS BAD, FACOG: I think that's really key, especially since now we have the patient portals that we can send the questions in even ahead of time so that the physician has an opportunity to review them and address them much more intentionally. A lot of patients feel like, you know, our visits are so short that they don't have a chance to ask or hear all the answers.

So, being able to sort of predicate that with information ahead of time is very helpful, or even afterwards.

Host: That's a great idea. I'm not sure if a lot of patients were aware that they could do that. So, typically, how long do menopause symptoms usually last?

Briana Walton, MD, MPS BAD, FACOG: Highly variable, depending on if you start menopause fairly early at, we would consider early menopause around age 45. So no periods at starting at the age of 45. And many of the symptoms last somewhere between 5 to 10 years, but they can persist. And that's where it becomes a little more troubling for women, when they have these persistent symptoms like, when is it going to end?

I'm tired of hot flashes. I'm tired of sleep deprivation, or I'm tired of feeling my joints, like they're not able to move in the way I want to. A key question that I would ask is, while you're sort of waiting for this natural evolution to get through the transition of menopause, what are some things that you can do as a patient to try to alleviate or make yourself much more comfortable?

Host: And that leads me to the next question about treatment options that are available for alleviating menopause symptoms because you even answered before with questions. Yes, there is treatment available. Talk about some of them and their effectiveness.

Briana Walton, MD, MPS BAD, FACOG: Yeah, I'd be happy to. Many patients will tell us that they are using over the counter either minerals or vitamins or supplements to help with some of the symptoms. And that's fine. Many people are familiar with things like black cohosh that help control some of the hot flashes. Or they're using vitamin D to make sure that they don't have bone loss.

And even vitamin C has been shown to be helpful for breast health. But there are times when these therapies aren't enough. And you have to start to consider hormone options, and some women have extended the time that they use birth control pills or some sort of contraceptive therapy in order to control their symptoms.

Contraceptive therapies are usually a combination of estrogen or estrogen and progesterone. That is very similar to our traditional hormone therapies, it's just a different formulation. Women are commonly told that they want a bioidentical hormone, which is a hormone that is chemically identical to what your body produces in the ovary. They come in a lot of different forms, so, whether you use estrogen alone, it can be applied as a patch or a topical, it can be ingested orally, it can be even placed as a pellet underneath the skin, so there are a lot of different formulations to deliver hormone to the body. The key is you don't want unopposed estrogen if you have a uterus.

So if you think about estrogen, it's our growing hormone and our counter hormone to that is progesterone. So for those women who have a uterus, you need the counter hormone or progesterone.

Host: So, how does hormone replacement therapy fit into the treatment plan for menopause symptoms and what are the potential risks and benefits?

Briana Walton, MD, MPS BAD, FACOG: So again, I think that it is very individualized and for women who have mild symptoms, you really don't have to do hormones. But the key is if you are going to do hormone therapy, you need to do it before you're the age of 60 and you need to do it within 10 years of menopause because the risk factors increase significantly beyond that. So if you've made the decision, I'm going to use hormone therapy for moderate to severe symptoms because they're having an impact on your life and your lifestyle; then you have to say, okay, what am I a candidate for? And either you will use estrogen alone, if you do not have a uterus or estrogen and progesterone therapy.

The key for, and the recommendations by most of the bodies out there like ACOG and North American Menopause Society really state that we should use the shortest duration of hormone therapy to control the symptoms. That is variable depending on how long your symptoms are lasting. So we try to wean the medication down, if we can, to the lowest dose possible.

Host: So are you saying that a woman needs to know in advance, even before she starts menopause, if she wants to go the hormone replacement therapy or HRT route?

Briana Walton, MD, MPS BAD, FACOG: I think the key is you need to be ready. If we think about menopause like the new puberty, your mom prepared you, like you're going to get your period, this is going to happen. Who's preparing us for menopause? That has to happen so that we are ready to make some strategic decisions that are best for our overall health.

And some of the conversations, and that doesn't have to necessarily be with a physician, it can be with a nurse practitioner or a PA, or even there are great resources now that are online, to really try to start to think about, is this going to be safe for me? And if it is, what are some options for me to take that would have the least amount of risk?

Now, if you've had issues with heart health or a history of stroke or a history of blood clots or any kind of breast disease, breast cancer, then hormone therapy may not be the right option for you. And so there are some alternatives, which I don't think we're going to have time to explore all those alternatives, but there are some really good options that are out there now that help to alleviate a lot of these symptoms.

Host: I am so glad that you are sharing this because I'm not so sure that a lot of women have been taught that this is something that you plan for and it's important for you to have these discussions and to be proactive on the front end with your gynecologist years before it happens.

Briana Walton, MD, MPS BAD, FACOG: I think women are very good about creating a birth plan when they're going to have a baby. They're creating plans for their kids, but we need to take ourselves a little more seriously and know that we don't have to necessarily suffer in silence when it comes to a lot of the symptoms, especially when it comes to the brain fog, because many of us are like worried, am I getting early dementia because I can't remember like I used to, or is my body giving out because I don't have the energy that I used to?

Menopause is knocking at the door, so unfortunately, if we're not necessarily prepared for it, it's still going to happen. Like I said, it's the gift that keeps on giving. So we need to know and be armed with resources to help control and help to make sure we can maintain self.

Host: Great, now you have mentioned some self care strategies like exercise and more sleep. Any other lifestyle changes or self care strategies that can help women cope with these menopause symptoms?

Briana Walton, MD, MPS BAD, FACOG: That's a great question. I really have started to because again, menopause is a brain disease because there's an alteration in the regulation of hormones that are emitted from the brain. So one of the things we know that happens is that what we put in our mouths in terms of food will directly end up in our brains eventually, especially as we get older, we become more sensitive to certain foods and we can't eat everything that we used to. So healthy eating and figuring out are there things I have to eliminate, are there things I have to do more of, is it a time for me to start to regulate how much alcohol intake I have now, you know, in some cases we talk about how certain alcohol intake is healthy, but you have to watch how much you're doing.

We need to also pay attention to smoking. Smoking is not as popular as it used to be, but it does have an impact on menopause and menopause symptoms. And then for the woman who is experiencing symptoms early on in her 40s, make sure you get evaluated just because I think, with the diagnosis of a premature ovarian failure, it usually is accompanied with something else.

And we want to make sure we're investigating to make sure there's no thyroid problems or any other processes that might affect you.

Host: So, how important is ongoing communication and follow up with the doctor when managing menopause symptoms? And then what should a woman expect in terms of long term care?

Briana Walton, MD, MPS BAD, FACOG: I think our relationships become even more important as we age. Where we are used to sort of a transactional visit to show up for our PAP smears when we're in our reproductive age and we don't really need to see our primary care providers because we're just really worried about surveillance.

I think it's even more important as we start to age to maintain a higher level of contact. And it doesn't have to be mutually exclusive. You see the doctor at some time point, you see your nurse practitioner, you see your primary care, you see the gynecologist. So a variety of your health team in order to help you make good decisions for yourself.

Because it's confusing. If you try to do a lot of this on your own or with just one person; they perhaps don't have either the time or the bandwidth to be able to help you navigate some of the complicated questions that you might come up with. Long term, I think the key concerns are if you're going to start with non hormonal options, if hormone therapies become something that you're going to consider, when do you make that transition?

What is the right formulation for yourself? And then what are some alternatives in case you cannot use those hormone therapies?

Host: And what are your top pieces of advice in closing for women who are beginning or in menopause? What do you want them to walk away and remember more than anything?

Briana Walton, MD, MPS BAD, FACOG: I would say that there aren't any merit badges for suffering.

We have a habit of, you know, saying, well, I can do it. I can do it. I can deal with this. Stop, just stop. Get over the suffering in silence or not suffering in silence and get some help. Speak up. Talk about yourself. It's time to be an advocate for your health and your own health needs.

You've been very good about focusing on your family. It's now time to look in the mirror and say, how do I want to spend 40 percent of my life because most of us who go through menopause at 50, we've got a good amount of time left, like 33 years of life left. So I think for most women who tend to believe that it's just going to go away and I'll be just fine, be more aggressive. Be more proactive about this topic because it can make some significant changes in your overall well being and not just your health.

Host: Dr. Briana Walton, you have done a great job on educating us on what to expect during menopause and you've also told us the importance of asking our doctors the right questions about it. You've guided us in that area as well. Extremely helpful information. Thank you so much.

Briana Walton, MD, MPS BAD, FACOG: Thank you very much. Thank you.

Host: You can find more shows just like this one at umms.org/podcast and on YouTube. Thanks for listening to Live Greater, a Health and Wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this episode on your social media.