Maggie McKay (Host): Welcome to Conversations Like No Other, presented by Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. I'm Maggie McKay. Thanks for listening.

Today, we have with us gynecologist Dr. Kathlyn Kim to discuss perimenopause, the change before the change. Thank you so much for joining us.

Dr. Kathlyn Kim: Thank you for inviting me.

Host: You know, Dr. Kim, there's so much information out there about menopause and perimenopause, and I wonder sometimes if we're getting the accurate facts. So, let's start with what is perimenopause and how is it different from menopause?

Dr. Kathlyn Kim: Well, Maggie, so certainly, people are more familiar with menopause, which by definition means that a woman has stopped getting her menstrual cycle. And perimenopause really refers to any time prior to that, and that can vary greatly in many women. It could be a couple of years or it could be 10 years, because there's a tremendous variation in this transition period.

Host: And why do so many women not know about perimenopause?

Dr. Kathlyn Kim: I kind of like to think of it as the quiet little shy sister that stands behind menopause in particular. Lately, there's been so much information and so much in the public eye and social media about menopause. There's a lot of misinformation, lack of education, even in clinicians and physicians who don't really even understand that perimenopause is a distinct and different time period for women.

There's not a lot of research that we've devoted, unfortunately, to this time period. And in some ways, it's also very vague. It's very common for women to know that, "Oh, hot flashes means I must be in menopause." But some of the other, what I call soft signs of perimenopause are very indistinct and hard to know. Is this something from perimenopause? Is it my thyroid? Is it stress? So, I think in fairness, it's a very indisintinct period of time and there's so many variable symptoms that it is difficult to understand it.

Host: Right. Speaking of symptoms, what's the most common one that you hear that makes women say, "I thought I was losing my mind"?

Dr. Kathlyn Kim: Well, I hear that a lot actually. And what that really reflects is a lot of things all rolled up into one that makes you think, "Okay, what really is this?" Things that are described as sort of brain fog, forgetfulness, moodiness, sort of I'm just not feeling like myself, and it's all rolled into one. So, sometimes people will not really even understand. Women will say, "I'm not really even sure what it is, but I just don't feel like myself."

Host: And why are so many women told that their labs are "normal" when they feel anything but normal, like you were saying? They just know something's not right.

Dr. Kathlyn Kim: Correct. Right, right. So, that's really common. And so to understand that, just a quick little physiology. And we do blood work, people always come in for blood tests for all kinds of things, their cholesterol, all sorts of different measures.

But when it comes to hormone levels in particular in perimenopause, there is wide fluctuation. So, one blood test is one point in time, which doesn't always reflect what's really going on. So, the brain hormones, there's something called FSH, which comes sort of from the central control tower of your brain, has a lot of fluctuation. So if you take someone's blood at 10:00 AM, take it at 4:00 PM, take it the next day, you won't really be able to get a single value.

And that's why oftentimes I tell patients it's really not about the blood work, it's really about what's going on with you. What are you experiencing? That's really how we make sort of the diagnosis of perimenopause.

Host: What is brain fog? We've been talking about it, but why is it so unsettling?

Dr. Kathlyn Kim: So, brain fog, it usually refers to a lot of cognitive challenges or difficulties, things that people, women in perimenopause will complain of. Trouble concentrating, they're forgetful. They, "Oh, I can't remember that name. I can't remember that word. Oh, you know that girl I went to high school with? But what was her name again?" Slower processing, feeling that they're in a cloud. These are really common symptoms, and they can be very distressing. They can interfere with people's work and their personal life. And a lot of these are physiologically related to declining estrogen levels.

Very commonly, there are lots of sleep disturbances that people have. You know, interrupted sleep. They don't sleep through the night, or if they do sleep, they don't feel rested. And other things such as, you know, we can't discount stress, anxiety, professional and personal responsibilities, perhaps even medical conditions.

But what I do want to say though is there's a lot of studies looking at perimenopause, and the good news is it is definitely transient. It doesn't last. It tends to kind of get worse and then improve. So, it is not a reflection of cognitive decline or future dementia. So, I always tell patients, "Don't worry. This will get better."

Host: Yeah. You mentioned sleep. Why does sleep suddenly just fall apart during perimenopause?

Dr. Kathlyn Kim: Right. So, sleep fragmented, what we call interrupted or poor quality sleep in insomnia is so common. Up to 50% to 70% of perimenopausal women will experience it. And this is also a feature very related to the shift in the hormone levels. It has many times been related to what we call vasomotor symptoms. You know, the night sweats, the hot flashes. But even independent of that, there are lots of women who will still experience insomnia. They may get up to go to the bathroom, because they have urinary symptoms or urgency. Also, a lot of women will experience sort of racing thoughts. They can't settle their mind.

That's very common as well. So, it is important to, number one, understand that it is common. It's very important to have a thorough evaluation to make sure that there's no other causes like sleep apnea, restless leg, maybe some other changes with medication, even alcohol, drug use. You know, there are lots of other things that can impact sleep disruption in perimenopause.

Host: Let's talk about it. We have to. Weight. Why does weight shift even when nothing else changes?

Dr. Kathlyn Kim: Yeah. So, this is a super common complaint and concern of perimenopausal women. And again, declining estrogen levels, it sort of tells the body to store fat. And unfortunately, it's not even just storing fat, it's the distribution of the fat, which is kind of commonly referred to as that, you know, that mid-belly pooch that a lot of women complain about.

Some women may not even actually gain weight on the scale, but where it is changes, the distribution changes. So, in the midsection. So unfortunately, there's aging and metabolism changes that occur. So, women naturally lose about 3% to 7% of muscle mass naturally over each decade of life, starting even in the 30s. That's just what happens. So, muscle tends to be a better user of calories than fat. So if you're losing muscle mass, and I hear this all the time, "I'm not doing anything differently. I'm eating really well and eating healthy." Even if you're doing the same, unfortunately, you may gain weight. And so, that's the reason why some of the lifestyle factors and changes are so important to make changes right away.

Host: It's so unfair.

Dr. Kathlyn Kim: Exactly.

Host: It's so unfair, isn't it? Oh, women, I mean, of all the changes our bodies go through, life, you think like, toward the last part of your life, we should be like free of all that, but no. Just a fact of life. Like you said, that's the way it is. So, what treatments do work and which are mostly hype?

Dr. Kathlyn Kim: So, I do always start with talking about the basics, which are not really all that glamorous or sexy, but they still are the tried and true methods and those lifestyle modifications, high protein diet, low fat. Exercise in particular, as I just mentioned, weight training or building and maintaining muscle is very important for all women, even younger women, but in particular in perimenopause.

And then, if appropriate, menopausal hormone therapy, and that will be in the v-various forms of estrogen and typically estrogen and progestin therapy, if the woman is an appropriate candidate, can help with a lot of these symptoms. It certainly treats vasomotor symptoms, hot flashes, night sweats, helps with insomnia. We know it has great protection on the bones and prevents osteoporosis. And there's some good data to show that it has a vascular benefit. We don't tell people it's gonna protect your heart completely, but it's an added benefit, I tell people, in terms of protecting your brain, protecting your heart, protecting your bones.

So, those are the things that we do know. I have to make a little comment about GLP-1s because it's so common now. Certainly, we know that that in conjunction with menopausal hormone therapy can be very, very helpful for reducing the risk of hypertension, cardiac disease, even diabetes in a lot of the perimenopausal women. It can be a good thing, again, in an appropriate patient, so under the care of a well-trained physician.

So, the other things I'll say that we do have data on is, creatine, which I know a lot of people are interested in. There is a good body of data on that in terms of helping muscle mass, again, in conjunction with a diet, the exercise, all the lifestyle modifications. There is really good data on calcium and vitamin D supplementation. The other peptide craze that people are talking about, there's really not a lot of good scientific data that these sort of wellness peptides that are being advertised have shown any proven benefit. So, I tend to caution patients against those.

Host: Okay. What about supplements? Are there any that actually help?

Dr. Kathlyn Kim: As I said, the creatine has some data. Vitamin supplements, I think if you cannot get it through your diet, let's say you're a vegetarian or vegan, sometimes it's very difficult to get some of the sources of minerals and vitamins from your food source. But always, always, I think the food source is your primary source. And I caution relying too much on supplements.

So, I think again, healthy diet, watching, what this Mediterranean diet is sort of what we model most, healthy diet recommendations for both cardiovascular, menopause, perimenopause, and neurocognitive health. That's really the basis. And then, if you feel that you've been diagnosed with a vitamin D deficiency, et cetera, things like that, of course, you can do extra supplementation.

Host: Dr. Kim, we talked about symptoms a little bit, but what symptoms should never be brushed off as "just aging"?

Dr. Kathlyn Kim: Any kind of bleeding, what we call post-menopausal bleeding of any kind, whether it's associated with urinating, associated with sexual activity or trauma, should never be ignored. That's the number one and should immediately be evaluated by gynecologist. That's one of the things that comes to mind, right away.

But even other things, someone who may have bloating symptoms, their abdomen, vague symptoms, I think you don't want to ignore. You want to make sure if they've had unexplained weight loss, something unusual. And then, pain, any kind of pain that doesn't seem to resolve quickly on its own, pelvic pain, painful sexual activity, if there's pain with urination. I always tell patients, "Listen to your body. And if you're having symptoms, then really make sure that you are fully evaluated."

Host: What's one thing you wish every woman knew before perimenopause hits?

Dr. Kathlyn Kim: I counsel patients all the time here at my hospital, at the menopause clinic. I really want all women, but in particular perimenopause, to really understand, listen to your body. You know, it's a good time for you to say, "All right, you know what?" If that inner voice tells you, "I just don't feel right. Something is wrong. I'm just not sure what it is," you should advocate for yourself and seek care. And it really is about general women's care, honestly. You know, it's a lot of times, particularly in this time of life, women have been caretakers for their kids. They're the sandwich generation taking care of their elders. They've been working, they've been juggling, and oftentimes ignoring their own health.

So certainly, it's more than just about checking your hormones. It's really making sure that your cardiovascular health is good, that your bone health is good, that your general health, both physical and mental, is really taken care of. So, that's really kind of what I want everyone to remember, that you should listen to your body and try to get the best care that you can.

Host: Right. The whole picture. Well, this has been so informative. Thank you so much for sharing your expertise

Dr. Kathlyn Kim: Thank you for having me.

Maggie McKay (Host): Of course. Again, that's Dr. Kathleen Kim. To learn more about women's health services at Valley, please visit valleyhealth.com/women. Thanks for listening to Conversations Like No Other, presented by Valley Health System in Paramus, New Jersey.

For more information on today's topic or to be connected with today's guest, please call 201-389-0104, or you can email valleypodcast@valleyhealth.com.