Amanda Wilde (Host): Ninety-five percent of women will reach menopause by the time they're 55 years old. You officially reach it when you haven't had a period for a year. However, there will be signs for many years leading up to that point - hot flashes, weight gain, mood changes, and difficulty sleeping are just a few of the symptoms that may begin to bother women as they enter perimenopause.

The good news is options are available to best treat your individual symptoms and meet your personal goals. Dr. Jane Limmer, an OBGYN and Menopause Society Certified Practitioner at VCU Health wants patients to know that there is relief and help so you can live your best life.

This is Healthy with VCU Health. I'm Amanda Wilde. Hello, Dr. Limmer. Welcome to the podcast.

Jane Limmer, MD: Hi. Thank you so much for having me.

Host: In addition to being an OBGYN, you are a menopause certified practitioner. What does that entail?

Jane Limmer, MD: The Menopause Society is an international organization that provides both provider and patient education. And they also participate in and sponsor research and education events throughout the year online, in person. They came up with a certification exam that they sponsor and providers of all levels and disciplines, not just OBGYNs can prepare for and then take an exam to get the certification.

It means that you have a special interest in caring for women in perimenopause and menopause and that you have met their standards to say that you've had that specialty training.

Host: So, you have an expertise in that area.

Jane Limmer, MD: That's right.

Host: I know there are a lot of myths around menopause. What are the most common misconceptions about menopause that people should be aware of?

Jane Limmer, MD: Gosh, there's so many. For a long time, there was the misperception that this is just how life went, and it wasn't something that needed to be discussed nor addressed, and that women just needed to feel this way for a time and grit their teeth and get through it. And it was the way nature intended.

Fortunately, that is changing. Patients are less willing to tolerate the symptoms, and rightly so. And more and more providers are better educated on how to help them.

Host: That it's all just normal.

Jane Limmer, MD: That's right. Even if it is “natural”, it doesn't mean that that's how we have to feel.

Host: You don't have to suffer.

Jane Limmer, MD: That's exactly right. I think for a long time, really in the last 20 years, hormone therapy went very much out of favor in the medical community, and I think there's still a lot of fear both from healthcare providers and patients about hormone therapy, and fortunately, there's better research to support its use that's ongoing right now. I encourage patients to be more open-minded in considering it and also in advocating for themselves to have access to it.

Host: I wanted to ask about the various treatments, both hormonal and non-hormonal. What are the non-hormonal treatments? Before we get to that, let's talk about how menopause affects mental health. Is there anxiety and depression that comes with menopause?

Jane Limmer, MD: What we think is that menopause does not cause anxiety and depression, but in women who either have a history of that or are predisposed to it, it can certainly exacerbate those symptoms and diagnoses. In addition to that, of course menopause happens at a time that is otherwise typically quite challenging, where women are in that sandwich generation of raising their children and also having aging parents and other health issues start to arise with age. And so, it is a particularly stressful time. Add in physical symptoms and changes, which can contribute to worsening anxiety and depression, such as poor sleep. It’s hard to parse out anxiety and depression as individual specific things that menopause causes, but it can absolutely exacerbate them.

Host: And mood and cognitive changes. Are those real issues in perimenopause and menopause?

Jane Limmer, MD: Yes, they are real issues. There has been medical research looking at the cognitive changes during menopause, and they are real things that happen like word finding difficulties, and trouble with memory. Fortunately, women should know that they are not developing dementia.

Host: Yeah. It feels that way sometimes.

Jane Limmer, MD: I hear that a lot and, there's a lot of fear around, you know, is something wrong with my brain and am I ever going to be the same? The good news is no there's nothing wrong with your brain. And yes, you can continue to be a high functioning person. It’s extraordinarily rare to develop dementia at this age, but the changes are quantifiable and studyable, so they are real.

And I think acknowledging that as a first step towards trying to do things to make it better is helpful.

Host: How do you make your mental health a priority? What can we do to address what we were just talking about?

Jane Limmer, MD: Gosh, great question. So, number one, making space for it, both in your own life and in your healthcare. And whether that is establishing with a therapist or a mental health professional that you trust. Finding joy in some small part of your everyday life, whether it is exercise or time with friends, or time with family, the things that build your mental health up, eliminating the stressors that you can.

I also think sleep is a huge portion of that. Poor sleep leads to worsening mood disorders, to worsening memory, to all sorts of negative things in our health. And so, finding ways to improve sleep, which can be through your physician certainly is important.

Host: Those are great suggestions and really beautifully takes us into what other treatment options we can look at and the benefits of treatment, which can affect your physical and mental health. There are additional therapies and treatments available to help manage menopause symptoms.

Can you talk about, first of all, what are some of the benefits you've seen of these treatments, whether they're hormonal or non-hormonal?

Jane Limmer, MD: Certainly. Hormone therapy in particular, is most effective at decreasing what we call the vasomotor symptoms of menopause. So those are the hot flashes, night sweats that sort of most commonly depict what people experience as menopause. Estrogen, in particular, is most effective at decreasing those events, both how often they happen and how severe they are.

And by extension, if you can decrease the number of times that a woman wakes up at night with a hot flash, you can improve her sleep and thereby improve a woman's mood and her cognitive function because she's not sleep deprived. In addition to that, hormone therapy can help with the genitourinary symptoms of menopause.

Those are vaginal dryness, urinary frequency, urinary urgency, pain with sex, things that can become more common as women get older and further past the menopause transition. They are very real and bothersome issues. Medical benefits of hormone therapy, a really big one that I think we have neglected to talk to a lot of women about, is the prevention of osteoporosis. This becomes, again, a bigger problem the older that we get.

There's a lot of research ongoing right now about the role of hormone therapy in cardiovascular health. The Women's Health Initiative, which was the big trial in the early 2000’s, hoped to show a decreased rate of cardiovascular disease – but it showed the opposite.

Now, newer studies are being done with more precision and looking at if a woman has healthy arteries and you give her estrogen early in menopause, maybe the arteries stay healthy. You have to really look at that particular woman and her other health issues to determine whether or not hormone therapy might actually protect her cardiovascular health.

In addition to that, you have to think about what hormones are you giving because they're not all the same.

Host: So not all hormone therapy is the same. What are the different types you and how is that decided?

Jane Limmer, MD: Great question. Some of it depends on the experience and education of your provider, and so it’s important to ask questions as a patient. There are different chemical compositions of hormones and there's different ways that women can deliver it to their body.

There are pills and patches and vaginal inserts and creams. In general, I recommend patients use a formulation that is FDA regulated rather than compounded simply because the components are more carefully studied, controlled and safe. Compounded medications can be helpful, and I do sometimes use them, but it's harder to control the dose that women are getting, which can lead to safety concerns.

There's a lot that women will hear and come in asking for “bioidentical” hormones. And bioidentical is really a marketing term. It's not so much a medical term. I like to reassure my patients that we do now have FDA approved, well studied formulations of prescription hormone therapy that insurance will pay for that is considered bioidentical, and they're some of the newer formulations of estrogen and a progesterone that's called Prometrium.

Host: So, hormone therapy is becoming more and more sophisticated, and you've mentioned many of the benefits. Are there risks associated with hormone therapy?

Jane Limmer, MD: Yes, there absolutely are. This is an area of ongoing study. It’s not as simple to say that hormone therapy does or does not, for example, increase the risk of breast cancer. There's research that has said that it might. If it does, it's in very small numbers of women.

But again, I think what we're going to hopefully one day understand is that it depends on the individual woman's risk factors and what type of hormones they took and for how long. Those things need to be part of the conversation. But there is a possibility that hormone therapy can increase the risk of breast cancer over time.

We know that estrogen carries a very, very small, but potential, risk for blood clots, which can be in the big veins of the legs or lead to a heart attack or a stroke. Those risks are pretty small in an otherwise healthy patients at the time of menopause but can become more meaningful as women get older.

It's one of the main reasons that as women get past age 65, we really try to have them come off of estrogen because of the risk of stroke.

Host: Are there effective non-hormonal treatments?

Jane Limmer, MD: Yes, there are, and more and more every day, thankfully. There are multiple medications in the antidepressant family such as Paxil or venlafaxine that can be helpful. In addition, there's a medication called gabapentin, which can help with night sweats and hot flashes. There's a newer medication on the market that works in the part of the brain where we think hot flashes originate, that's non-hormonal. It has a good safety profile and it’s effective at decreasing the severity and frequency of hot flashes. So, there are more and more options. As with all new drugs, the problem that we run into is cost and availability.

Sometimes it takes time, trial and error to get the newest ones covered. But there are sponsorships from pharmaceutical companies and things like that that we can try for. So, it's worth trying.

Host: And are there any lifestyle changes that affect how we go through menopause?

Jane Limmer, MD: It's such a great question, and I think a difficult one to answer on some levels because it is true that, and again, more research is being done in this area, that the more you can take care of your general health, meaning your weight, your exercise level, blood pressure, cholesterol, all of these things improve your overall wellbeing.

Exercise is closely tied again to sleep which can be really helpful. There have been a tremendous number of lifestyle interventions recommended for women, specifically for menopausal symptoms. When you study them, they don't actually help that much, which is troubling. There are some cognitive behavioral therapy sessions that have been shown to decrease hot flashes and night sweats. But things like dressing in layers and using a fan, might make it more tolerable, but they don't actually decrease how often they come.

Host: They don't change anything.

Jane Limmer, MD: That's right. I also think for so many different reasons, there's a tremendous amount of profiteering going on, on very vulnerable women who are going through this challenging time in life with various supplements and things of that nature that probably don't actually help any more than a placebo. But women are just so desperate to feel better that they'll try anything. I really try to caution people to be mindful of cost when looking at those options.

Host: Maybe check with your doctor first, if you are considering some of these supplements, because your doctor is really your partner in this process.

Jane Limmer, MD: That's absolutely right. I've been so grateful in the last few weeks as I've seen multiple women who've said, “I keep getting these ads on my social media, and I thought I should check with a doctor first before I actually take these things”. I was grateful that was their approach and grateful to have the opportunity to talk to them first.

Host: Social media can be so immediate and convincing, so you do have to take that breath. Should you check your hormone levels to create the right treatment or to confirm that you are in menopause?

Jane Limmer, MD: Most of the time, no, you do not need to check your hormone levels. With a few exceptions. If a woman has had a hysterectomy or doesn't have changes in their menstrual cycle to base knowledge of their menopause transition on, then it might be relevant to check hormone levels.

There is no normative range, of estrogen level that says, if you're below this, you're going to have terrible symptoms, and if you're above this, you are not. And so, it's really not relevant, the majority of the time, what your levels are. It's relevant how a woman feels. If a patient tells me that they feel a little bit better on their current dose of estrogen, but they're still having three nighttime awakenings with night sweats, I don't really care what her estrogen level is. I probably need to give her a higher dose. We very rarely check levels and definitely do not trend them with treatment because it is not necessary.

Host: And not all people will be symptomatic in the same way, obviously.

Jane Limmer, MD: That's exactly right.

Host: Well, thank you so much for this conversation, Dr. Limmer. Is there anything else you want to mention about treatments for menopause?

Jane Limmer, MD: Most of all, I want to normalize the experience and to make sure that women use each other as resources and feel empowered to talk to their doctor. If they don't get the answer that they want, keep looking because there are more and more people joining the Menopause Society, getting the certification, reading the articles.

My colleagues and partners across VCU Health and different departments are looking for this education. My hope is that there are going to be more and more people out there who are ready and willing to take care of women in this important time in life. So, keep asking. Don't lose hope.

Host: Thank you, Dr. Limmer, for enlightening us today on all these aspects of menopause and options of addressing it. And for helping to create a new normal for women with menopause.

Jane Limmer, MD: Absolutely. Thanks so much for being interested in having the conversation.

Host: It is important to talk to a menopause specialist to manage your symptoms and create a personalized treatment plan together. Women's health experts at VCU Health are ready to help you live your best life.

Call 804-828-4409 to make an appointment. That’s 804-828-4409. To listen to other podcasts from VCU Health, visit VCUhealth.org/podcast.

This is Healthy with VCU Health. Thanks for listening.