Amanda Wilde (Host): Welcome to the Live Greater podcast series, information for a Healthier You from the University of Maryland Medical System. Perimenopause and menopause are more than just changes to the reproductive system. They affect the whole person, from mood swings and brain fog to sleep problems, joint pain and bladder changes. The symptoms can touch nearly every aspect of a woman's health. That's why it's so important to have a team of providers, primary care doctors, gynecologists, and urogynecologists working together to guide women through this transition.

Today, we talk with three experts about how comprehensive personalized care can make all the difference during perimenopause and menopause. Dr. Priya Ponnaiyan is a family medicine provider at UM Capital Region Health; Dr. Pooja Uppalapati is a gynecologic surgeon at UM Capital Region Health; and Dr. Briana Walton is a urogynecologist and Director of Female Pelvic Medicine and Reconstructive Surgery, and the Director of Robotic Surgery at University of Maryland Capital Region Health.

Welcome to you all. Thank you for being here to provide insights for women navigating these life stages. I'm going to go to you first, Dr. Ponnaiyan. You're a family medicine physician, so you are generally the first line of defense when someone starts feeling sick or experiencing changes in their body. What are some of the first symptoms that women will come to you with that indicate the beginning of perimenopause?

Priya Ponnaiyan, MD: Thank you, Amanda, for having me here. Let me define what is perimenopause is, and then definitely I'll go to the symptoms. Perimenopause is the transition time that leads to menopause, which is when women stop having their menstrual periods. It doesn't happen all at once, but it can happen gradually. For some women, it usually starts around 47 years of age. But some women, it can happen a little earlier and some it can happen a little later too. So for the most part around this menopause transition, the hormonal changes occur, which has been causing this perimenopausal symptom.

The most common clinical symptom that we encounter is changes in the menstrual pattern. Most often, the length in between the menstrual cycle get varied. Some of them get it more frequent cycles and some of them gets it as a less frequent cycles, and some of them have a heavy flow and some of them have a lighter flow. And some of them, duration of their menses can also differ. It could be shorter cycles or it could be longer cycles. The duration can last for few days to few weeks. This is a main symptom that we see.

Other than that, these hormonal changes can also cause other clinical symptoms, which we call it as a vasomotor symptoms. Most common symptom that we come across is hot flashes. Almost 80% of women around this perimenopausal period can experience these hot flashes. Everybody can perceive it as different. For the most part, they feel as a sensation of heat that starts from the face that's going on to the neck and throughout the body. It can last for one to four minutes, and it could also be associated with chills and sometimes shivering and sometimes palpitations. The way they perceive it is a rapid heart rate too.

And apart from hot flashes, mood symptoms are also more common during this perimenopausal period. And perimenopausal women are more vulnerable to the hormonal changes that could happen around this period. So, they feel depressed and they feel anxious. And then, apart from this mood symptoms, they can also have sleep disturbances. When these, hot flashes occur at night, we call it as night sweats, and these people wake up from the sleep with night sweats and also the mood symptoms makes them hard to sleep. That could also be causing them to have sleep problems. So, these are the most common symptoms that we see as a perimenopausal woman during this transition period.

Host: Are there any symptoms that might be surprising? Like, we develop a superpower or we can fly. Any surprising symptoms?

Priya Ponnaiyan, MD: So, yes, there are some surprising symptoms too. Brain fog. So, the studies has proven that 40-60% of the women can have a brain fog. They may have difficulties in recollecting names, recollecting words, recollecting numbers, and sometimes people have difficulty in concentrating and easy distractibility. And some even worry that they may have like an early onset of dementia. That is one thing.

And again, the genitourinary symptoms. Estrogen plays a major role in keeping the vaginal mucus elastic. And when these hormone changes happens, this estrogen fluctuates that results in dry vagina and people can have a burning sensation, itching or irritation in the vulvar area, and some urinary problems that comes along with it too.

And then, patients also can have bone pain, muscle pain, breast changes. Sometimes they feel breast pain, because of this fluctuating hormones. And then, menstrual migraine worsening. Some women, they have migraine episodes, like a headache episode, throbbing and pulsatile headache episodes around the time of menopause. But when they reach these menopausal transition, they could see that these migraine headaches get more intense and they can feel it more. But as they course along, the symptoms get better for most patients when they reach the menopausal stage.

And then, of course, weight gain. I've seen it as sort of a surprise. Some people, during this menopausal transition can also develop weight gain. And we highly recommend our patients to watch what they eat and also be involved in activities that could merit helping them to keep their weight under check.

Host: None of these symptoms sound welcome at all. So, what role do you play in care for these symptoms and even starting the conversation, and then when do you refer your patient to the gynecologist?

Priya Ponnaiyan, MD: When it comes to perimenopause as a primary care physician, what I have seen is most of our women do not know what is perimenopause, what to expect, and when to when this happens. So as a PCP, I would recommend to initiate those conversation in their mid-40s to see if they have any of these perimenopausal symptoms that we discussed sometime back. And if they have those symptoms, there is no lab test or like blood tests that we need to confirm these symptoms if it's in mid-40s. But in case, there are always exceptions, right? So if it has to happen like early 40s, then we can make sure to rule out any pregnancies and rule out any hormonal imbalance that could be contributing to it.

Once we confirm this is perimenopausal symptom as a PCP, always for mild and moderate symptoms, we can start with lifestyle changes. And definitely, if patients have hot flashes or night sweats, quitting smoking helps them greatly. Even if they need help in quitting smoking as a PCP, we can definitely offer that help. And then, mood symptoms, exercises, will help a lot when it comes to mood symptoms. Exercises increases their happy hormones, what we call endorphins, in their brain and keeps their mood elated. And if my patients have sleep disturbances, then I would also tell them to have sleep hygiene. Go to sleep at the same time and wake up at the same time no matter what, whether you have a good sleep or not. At one time, at one point, you can kind of quiet these sleep disturbances if you're doing it religiously. And then, also, I say, "Hey, if you are a caffeine intaker, don't take it in the evening and also limit alcohol." So, these are the lifestyle modifications that I can try for a mild to moderate symptoms, which also help the patients.

And then, of course, apart from lifestyle modifications, hormone therapy and non-hormonal therapy is also available, depending upon the patient's age, the years into menopause and their personal history, family history, and also the risk factor for developing breast cancer and also cardiovascular disease. We can choose hormone therapy or non-hormonal treatment for them.

And then, again, referring to a GYN is also a thing that primary care physician do. Sometimes some primary care physicians prefer to refer the patients to GYN if it is out of their comfort zone, because hormone replacement therapy comes with surveillance and also comes with monitoring for any adverse effects because of the medication. So, they prefer to refer the patients to GYN. Sometimes patient's preference too, if they want to get treated by GYN, that they can also have that option. And then, if the symptoms are not responding to the traditional hormonal treatment or a non-hormonal treatment that a PCP can start, then just refer it to a specialist. They can help us with those.

And then, of course, when you notice the history, like when they say, "Hey, I have prolonged periods and I have a heavy periods." And it may trigger you, "Hey, there is something else happening in the uterus that would be contributing it," maybe the patient needs some procedures and need more than a primary care physician's care, then of course we refer them to a GYN.

Host: So, let's turn to our GYN. That is Dr. Uppalapati, as you are probably the first call for women when they have typical women-specific health concerns, or as we just said, they are referred by their family care doctor, at what point should women start talking with someone like you about their symptoms?

Pooja Uppalapati, MD: Yeah. I think it's really up to the patient. I do have some patients who are really educated. And they come in and they have all their questions written down, and they said, "Okay, I know my friends have gone through this. I think I'm in this age group. I've been reading articles about it. And, you know, I'm concerned that I might be going through perimenopause." So, there's definitely patients coming in that they make the whole appointment about that. A lot of times, I am getting referrals, like from Dr. Ponnaiyan. She's been talking to this patient, they did their annual. She's like, "I think you might want to to talk to a specialist about this." And then, I would say the other third are patients who are coming to me for their regular care.

And I do ask these questions pretty much on all my patients, especially those in their mid to late 30s, all the way into their mid to late 50s, you know, I really ask, "How's your sleep? How's your mood? What's going on with your libido? And do you have pain? Do you have dryness? What are complaints you might be having?" It's not just what she comes in with telling me, I kind of go through my checklist to see what I can assist her with.

Host: So you can better understand everything that's going on. As we mentioned, it's the whole person involved in these changes. How does your care complement PCP Care?

Pooja Uppalapati, MD: Yeah. I think our primary care physicians do so much, and sometimes you just can't sit and go through every little symptom related to the perimenopause. Like Dr. Ponnaiyan was saying, it's a long list to go through and you really do have to sit with the patient and discuss what are their salient symptoms, but also what are the health conditions that they might have, because that really dictates what treatments you can offer the patient. And having that individualized treatment plan takes a lot of time and care between the provider and the patient to come together to make that. So, I really go through their health history. I go through their obstetric history, their surgical history, their cardiovascular health is extremely important, especially if we're thinking about hormonal therapies-- that does impact what we can offer-- their kidney and liver disease if they have it. And also, their goals, what are they trying to do when they take this treatment? What are they trying to achieve? Or what symptoms are they really worried about fixing? And if you have realistic goals, I think you can get a much better treatment plan.

Host: So, you can really help us cope and adjust with the specific resources you have beyond the care even that we're getting from our PCP. And then, many women don't realize menopause can affect bladder, pelvic floor, and sexual health. So, I would like to ask you, Dr. Walton, you're a urogynecologist, what changes do you see most often and how do you help women manage those symptoms?

Briana Walton, MD: Sure. Thanks, Amanda. So, first of all, I want to say we're really fortunate to have sort of this trifecta of PCP, GYN, and uro-GYN in one setting. That's not often the case. And so, we each have our own vantage point from seeing the patient who comes in with either perimenopausal, menopausal symptoms.

But for me, when I am focused mostly on pelvic floor disorders, either urinary, bowel or bulge symptoms, I'm looking at the vagina, right? I'm looking and seeing, "Well, what's the state of the union? Is there any dryness? Is there any change in the tissue? Are there changes in the anatomy? What's their nerve function? What's their muscle function?" And quite frankly, it's being a little cheeky. The answer is menopause. What was the question, right? Most of the time the answer is related to menopause. So, most of the patients are so surprised that like, "Hey, we're going to focus on menopause." "Menopause? That's not why I came here." No, I know, but that's a part of why you are here. And if we don't treat it, we're going to undertreat you.

Host: Can you describe a little further how primary care, gynecology, and urogynecology work together to provide this complete care for women in this stage of life, perimenopause to menopause?

Briana Walton, MD: Sure. So, I'm going to reverse engineer it, because very often if I have a patient who is requiring some form of, let's say, surgical intervention for changes in her anatomy, something's not in the right place, the bladder is dropped, the rectum is pushing up into the wrong place, and they're having symptoms, I'm going to want to make sure that that patient is not a high risk for surgery. So, I need to talk to Dr. Ponnaiyan and say, "What are her risk factors that I need to pay attention to in order to make sure that this patient is safe during and after the procedure. I don't want her afterwards to have any cardiovascular events. I don't want her to have a clot. Should I consider other alternatives besides surgery?" I need to talk to Dr. Uppalapati about, "Well, she's on hormones. Should we take her off or should we keep going? I'm not quite certain." And sometimes I just need a little extra help in the operating room. We can work together as a team when it comes to surgical interventions for these women who have sometimes complicated care.

I love the ability to be able to do that because the patient who often feels like they're in a little bit of a silo with each one of their providers, now it feels like I got a team, I got three people who are all talking to each other and they know me.

Host: Dr. Ponnaiyan, back to you. Some women worry that their symptoms will be brushed off as just getting older because that has definitely happened in the past. How do you approach validating and supporting your patients?

Priya Ponnaiyan, MD: Perimenopause is definitely a significant and a real change in any women's life. It's not just getting older. Whenever my patient brings in complaints and I always pay attention without any judgment to see what they have to say, and then make sure that they get listened to what they have to say. And I'll also tell them, "Hey, these symptoms looks like perimenopause." And then, you are not alone. We have a lot of treatment to help with it. And then, she doesn't have to worry about those symptoms. So, I'll also tell her, "Hey, don't worry about it. We are going to find a perfect plan with my help or with the other specialists that we have in our office," of course, Dr. Pooja also Dr. Walton, to see depending upon the symptoms, that we can make sure that she gets every care that she needs in to order to lead a good and quality life. We just literally work in unison to make her life better.

Host: And, Dr. Uppalapati, what treatment options from lifestyle changes to hormone therapy do you discuss with patients? How do you guide them through the choices?

Pooja Uppalapati, MD: Yeah. So, the first thing I actually do is I try to tease out their symptoms and also make sure that we're not pigeonholing ourselves. I do think, yes, we often don't think about menopause when treating a patient just in a medical field. However, I also don't want to say, "Oh, everything you're going through is menopause," and then brush off very serious conditions.

So, sleep apnea can also cause sleep issues and tends to show up at this part of life. Patients can be stressed and maybe needing both psychiatric, and maybe just help taking care of their aging parents, their families, work-life stress, that can also have a significant impact. So, you want to look at" are there other medical conditions that could be causing these problems, vitamin deficiencies, et cetera?

Then, when we're really talking nitty-gritty about menopause, yeah, I really start with lifestyle changes. We all have things that we can improve, and there's all things that people are doing that are probably affecting their urinary habits, their sleep habits, that are affecting their mood or interpersonal relationships. So, we do spend time talking about that.

When talking about treatments, it really, again, is individualized based on the patient. I do look at her risk factors, her conditions, her goals, her desires, also risks for potential cancers that she might have that we do have to balance. And so, there are non-hormonal options. I do want patients to know that there are things out there that doesn't have to be hormones. However, my philosophy is if a patient is a good candidate and she understands the risks and benefits and has symptoms that can definitely be helped by hormone therapy, I'm always going to start there, right? And then, kind of work backwards if we need to. There are different doses, there's different methods, like there's a lot we can try. It's very similar to birth control. It's just at a different point in your life. We have a lot of options and we just got to find one that fits.

Host: I like how you encompass, as we said earlier, the whole person and look for other things and don't just assign everything to menopause right out of the gate, which leads me to question for you, Dr. Walton. What myths or misconceptions about menopause do you hear most often? And how do you help patients see the facts?

Briana Walton, MD: Oh, there is a lot of education that happens behind the doors. Primarily, the myth I think that is most common is leaking, bladder issues, and menopause symptoms are just a part of aging and you're just going to have to deal with it, and there aren't any options. Or, you know, "My mom had it, my sister had it, so I'm just going to have it and live with it."

And I think that's part of our goal is to say you do not need to survive menopause. You can thrive through menopause by just treating some of the symptoms. If you're worried that your activities are changing, you're not going out, you're not participating in exercise because you're afraid you're going to leak or you don't go to social activities because of odors, those are things that we need to get ahead of because there is a relationship between these symptoms and anxiety and depression. So, I try to really jump on this for patients and say, "You have permission to treat yourself. It's okay for us to move forward with treating something that may just seem like a rite of passage."

I think the second myth also is related to what Dr. Uppalapati was talking about is the use of estrogen. So many women now have been counseled improperly that estrogen is the devil drug that it just doesn't fit most patients. When in fact, when you're looking at applying it in the vagina, there's very few patients who aren't candidates for it. And when we look at the ability for estrogens in the vagina to improve not only dryness, but decrease the risk of recurrent urinary tract infections, cut down on frequency, cut down on nighttime urination, which in fact makes me very worried, because that's an independent risk factor for hip fractures. So, we want our patients to sleep and stay in the bed through the night so that they don't fall.

Sexual dysfunction. So many women feel like, "Well, if I'm not sexually active, I don't need it." But that may not be true. You never know when intimacy is going to happen in your life. And so, it's not something that we can normally just say, "Hey, jump into it. We want the tissue to be ready. We want the muscles to be comfortable so that intimacy isn't a hurdle for them."

And I would say, finally, if we are going to prepare for some sort of intervention because the organs are not in the right place or space, estradiol is very helpful in improving the collagen and the way that those tissues operate. So if we use a pessary, a device to help hold things up in the right position and/or do surgery, we want the tissue to heal as best as possible.

Host: So, there's lots of resources, so we know we really don't have to suffer. Dr. Walton, if you could give one piece of advice to women who do feel unheard or unsupported during menopause, what would that piece of advice be?

Briana Walton, MD: Ask, ask, ask. Don't be silent. Don't sit and just suffer with your symptoms. Speak up. Be an advocate for yourself. Ask multiple providers. Ask if you have all three of us, a PCP, a GYN, and a urogynecologist, ask each one of us what could you do. It's not a bad idea to get more than one opinion. And if those opinions agree, then that should give a patient a lot more confidence that what they're hearing is right for them.

Host: Dr. Uppalapati, can I ask you the same question? What one piece of advice would you give to women who feel unheard or unsupported during menopause?

Pooja Uppalapati, MD: Yeah, definitely. I feel like I say this a lot to my patients, not just menopause, but other things. They suffer for so long, and then I feel like they come kind of closer to the end of their journey or when, you know, some of these symptoms do tend to improve. But a lot of them tell me, "Oh yeah, I suffered for like five years, six years, seven years, and now I'm finally better." And I just keep saying, "I wish you saw me sooner. I wish we talked about this sooner. I wish we talked about this 10 years ago. You would've had so many more options." So, that would be my number one piece of advice.

Host: How about you, Dr. Ponnaiyan, and I don't want to deprive you the opportunity to tip in on this.

Priya Ponnaiyan, MD: Yeah, definitely. I would just say to them, "You are strong, you are wise. You are not alone. Don't stop until you get your answers."

Host: Wow. That is a great piece of advice as well. And thank you all for your advice, your insights and the work you're doing to help women maintain their overall well-being during these challenging times of perimenopause and menopause.

Pooja Uppalapati, MD: Thank you.

Host: Find more shows just like this one at umms.org/podcast and on YouTube. Thank you 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 on your social media.