Melanie Cole, MS (Host): Thanks for tuning in to Back to Health, the podcast that brings you up-to-the-minute information on the latest trends and breakthroughs in health, wellness and medical care.

Today's special episode is part of our Women's Health Wednesday series, which features in-depth conversations with Weill Cornell Medicine's top physicians on issues surrounding women's health throughout the life course. Listen here for the information and insights that will help you make the most informed and best healthcare choices for you.

I'm Melanie Cole. And today, on this Women's Health Wednesday, we're discussing menopause and hormone replacement, and new treatments and options for women that are going through menopause. Joining me is Dr. Susan Loeb-Zeitlin. She's an Assistant Professor of Clinical Obstetrics and Gynecology, and she's the Director of the Women's Midlife Center at Weill Cornell Medicine.

Dr. Loeb-Zeitlin, it's always a pleasure to have you join us today. I'd like you to just start by telling us about the new Women's Midlife Center at Weill Cornell Medicine. What services are offered to help women on this journey? How do you approach menopause? Tell us a little bit about your philosophy of care for women at this stage in our lives and about the center itself.

Dr Susan Loeb-Zeitlin: Thank you so much for having me today. And I'm thrilled to talk about our center, which is such an important part of women's healthcare. Why is this important? Because up to 40% of a woman's life is spent in menopause. And our center was created with three goals: to educate women about this transition, to teach our providers and our patients about it; to do research, but really to have one on one visits with our patients to talk about this transition and what's going on.

We begin our visits with a telehealth comprehensive visit where we spend about 40 minutes getting a history, learning about our patients and really individualizing our care. And that's one of the most important points because there's no one universal menopause syndrome. Everyone goes through it differently. Everyone experiences different symptoms. So, we tailor our patient care to the individual needs of each woman. It works super well. Our virtual visits provide so much more time than we have in the office to really delve into this and address this important time in a woman's life.

Melanie Cole, MS : Well, I thank you for that. And as someone who is postmenopausal at this point, I can appreciate that we do all go through it in our own unique way, and we have to be our own best health advocates, right, Dr. Loeb-Zeitlin? Because if we're not, then we really can't help ourselves to get through this journey, this different part of our lives. So while we're talking about this, I'd like you to tell us exactly what's happening in the body during menopause. What symptoms are we looking for? How do we know? Because some women start in their 40s. Some women like me didn't start until their late 50s. Tell us a little bit about that.

Dr Susan Loeb-Zeitlin: What is menopause to start with? It's the final menstrual period after a woman goes 12 consecutive months without a period. That's the actual definition. What happens is the body stops producing estrogen and we no longer get menstrual periods. But the time leading up to menopause, which is we call it perimenopause, is a time when the ovaries are erratically producing hormones. So, there are a lot of hormonal fluctuations, and that can be the time when there are menstrual irregularities, but also sometimes it's the time of most symptoms for women. This happens in a woman's 40s. The average age of a final menstrual period is about 51 and a half. So, that's biologically what's happened. Again, the symptoms can start years before that final menstrual period, and it can be an alarming time for women as their bodies are changing. And that's exactly what we try to address.

Melanie Cole, MS : You mentioned perimenopause. Tell us a little bit about those symptoms. What are we feeling? Because let's be honest, we feel some of these symptoms throughout our life course and we feel bloating and we feel headaches and we feel fat and we feel all of these things, anxiety and all these things. So, how do we know that it's something just a little bit different?

Dr Susan Loeb-Zeitlin: Well, again, it starts with those menstrual changes, right? And so first in early perimenopause, there are some really subtle menstrual changes. Maybe your cycles vary about a week or less. And then later perimenopause, we start skipping cycles. And once we start skipping two, even three months at a time, we know that that final menstrual period is coming.

But you asked about symptoms. So, the most common symptoms and up to 80% or even more of women experience them are the hot flashes and the night sweats, which we call vasomotor symptoms. They can be really troubling in that they can impact our sleep, they can impact our mood. They're also shown to be not so good for our cardiovascular health. Black women tend to get them worse and for a longer period of time. And so, it's important that there are some ethnic differences with our hot flashes and our night sweats. But as I said, also along with those symptoms are mood changes, insomnia, vaginal dryness, some sexual changes, and maybe brain fog is a very common one that women will complain of also.

Melanie Cole, MS : Doctor, before we get into some of the medicational interventions, I'd like you to speak to women about symptom management, some of the things that we can try ourselves at home, in our lives to deal with hot flashes and bloating and all of the things, the anxiety that we go through and that we're all going through. Some of the things you want us to look to that can help us get through to the next end of this.

Dr Susan Loeb-Zeitlin: Yeah. I think there's some important lifestyle modifications that can make a difference as we're going through this transition. We know healthy eating and exercise are important. So, what do I mean by healthy eating? Focusing more, I'm not saying vegetarian, but focusing more on plant-based eating; definitely fewer carbs, we find that that gets harder to metabolize; and lean protein. Focusing on exercise. The number of minutes of exercise that's recommended keeps going up, but at least 150 minutes a week of some good, moderate exercise is encouraged. But also, mindfulness practices, relaxation techniques, all of those are helpful. Yoga is another one. They're all helpful in helping us get through this transition.

Melanie Cole, MS : Well, and I think it really is a good time to assess where we are and where we're headed because one of the things that I dislike most about menopause was the increased risk for other things, heart disease, cancers. As we're talking about interventions that you can help us with, Dr. Loeb-Zeitlin, tell us about hormone replacement. It's gotten a bad rap and a good rap and all kinds of things over the years. Tell us a little bit about how it's used, what's new and exciting in that field. And speak to women about the risks that we've all heard for breast cancer and heart disease and whether it helps or hurts.

Dr Susan Loeb-Zeitlin: We've come a long way during my 25 years of practice in understanding hormone therapy. So when I was first in practice, everybody was on hormones. And then in 2002, that came the Women's Health Initiative study that was looking at how hormones are going to prevent health problems, and it showed an increased risk of heart disease, stroke and breast cancer in women who are taking hormones.

But in the 20 years since that study was halted, so they stopped that study because they were showing an increased risk, we've learned a lot about hormone therapy. And we know that in the carefully selected patients, it is the most effective thing for those hot flashes and night sweats. And there are other health benefits associated with it, especially with the bones. So, we currently think that women who are within the first 10 years of menopause and under the age of 60, and ideally use hormones for up to 5 years, although continuing that is what we call a shared decision, between a woman and her provider. But in that carefully selected group, we actually believe that the risk of heart disease, breast cancer and stroke is minimal and the benefits for many women can outweigh the risks.

Melanie Cole, MS : I'm so glad that you cleared that up because it is confusing and has been confusing. Now, you mentioned bones because one of the things we hear about that happens to us is bone loss and bone mineral loss and osteoporosis risk. So, speak about that. You can also add in hormone replacement there and not using hormone replacement. Tell us about our bone loss during and after menopause and what we can do about it.

Dr Susan Loeb-Zeitlin: There is an accelerated rate of bone loss that happens during the menopause transition, and we know certain women are more at risk of it than others. There are certain risk factors, such as a family history, a small built, smoking, alcohol consumption. Those are all risk factors. And it actually is one of the FDA approved indications for hormone therapy to give it to women who are at risk of osteoporosis. And what hormone therapy can do during this time is stabilize and prevent that increase in bone loss that happens during the menopause transition. The other really strong indication are the hot flashes, high risk of bone loss is another indication for hormone therapy use.

If a woman is not eligible for hormone therapy use, there are other options and there are many specialists who deal with this. But in terms of medication, those are the things that we can recommend. But also weight-bearing exercise is super important throughout life to help maintain good, strong bones.

Melanie Cole, MS : One thing I think that is also a little bit confusing, Dr. Loeb-Zeitlin, when a woman has gone through perimenopause and even to menopause, does this mean, especially in peri, that she can no longer conceive? Does she still have to use protection when she has sex? Because now, we're learning more about the rise in STIs among women of a certain age.

Dr Susan Loeb-Zeitlin: That is such a great question and I speak about that a lot because, as I mentioned, perimenopause, you're still producing hormones and they're irregular. So, they're not as predictable, your cycles, as they were before you entered perimenopause. And if you're getting a cycle, it usually, not always, but usually means you're ovulating. If you're ovulating, you produce an egg. And therefore, that egg can get fertilized if you are having unprotected intercourse. And so, yes, a woman can get pregnant until her final menstrual period. And that is such an important thing to note.

Melanie Cole, MS : It is. And how long is menopause supposed to last? How long does it take? We haven't gotten our period in a year. And so then, we are in official menopause. How long does that take to kind of get through to the other side?

Dr Susan Loeb-Zeitlin: Usually about one to two years. For some women, it can take longer. Sometimes the symptoms can continue for a longer amount of time, but we're considered sort of in that past the menopause transition after about two years after the final menstrual period.

Melanie Cole, MS : One of the things, Dr. Loeb-Zeitlin, that I think women worry about, certainly men do, is our libido. And as we go through menopause, does our desire, does our libido change automatically? I mean, some of the symptoms, vaginal dryness is one of them, a loss of libido is another one. Tell us a little bit about that part of it, because that is really an important part for many women.

Dr Susan Loeb-Zeitlin: Yeah. Libido comes up very often, but menopause doesn't have to cause a change in the libido. It's a very multifactorial type of concern for women. So of course, it is a change in the hormones that contributes. But then there's all other life stressors and everything else going on in a woman's life that can impact libido.

Vaginal dryness, as you mentioned, is such an important component of it. And that is actually one of the best things we can do to help a woman. Where I told you most symptoms will get better after the menopause transition, after some time after the menopause transition, actually vaginal thinning, vaginal atrophy or what we prefer to call the genitourinary syndrome of menopause, can get worse with time. And giving estrogen back vaginally can improve the quality of a woman's vaginal tissue, make more blood flow going there, improve the moisture in there. I like to say make it a little bit more juicy and can actually make one of the better things we can do to improve a woman's libido as she goes through this transition and beyond.

Melanie Cole, MS : So, that's just a cream we would use and get from our obstetrician gynecologist.

Dr Susan Loeb-Zeitlin: There are different forms of vaginal estrogen. It's a cream, a suppository or a ring, and that's based on personal preference. The nice thing about using estrogen vaginally, it's a very much a local treatment. It doesn't really raise our blood levels above a normal menopausal blood level, and so women can stay on it for a longer amount of time and will only get the benefit of it while they're still taking it.

Melanie Cole, MS : We are giving so much great usable advice. Dr. Loeb-Zeitlin, as we wrap up, I'd love you to give us some ideas for non-hormonal alternatives, things that we can do to live this healthy lifestyle, to get through menopause and perimenopause and to feel our best selves while we're doing this change, while we're feeling all these things and looking towards the future, because it is a pretty exciting time and I was not unhappy about going through it and being here where I am now. So, give women your best advice for some non-hormonal alternatives, because we also do hear about things like black cohosh and whatever we hear, you know, for hot flashes. So, I'd like you to go through some of those.

Dr Susan Loeb-Zeitlin: Yes. So, the North American Menopause Society just came out with a new position statement during 2023 about the non-hormonal treatments of menopausal symptoms. And while we all know there are some supplements, maybe the black cohosh, maybe some soy, there is some evidence to support those, and for some it does work, as well as the exercise and the yoga and diet modifications as I already mentioned, those also, there is some evidence to support it.

But what's really recommended, which is very interesting, are certain mind-body techniques, such as cognitive behavior therapy, and even clinical hypnosis. And both of those have really good evidence that they can help a woman with get through this menopause transition better. And so, it's interesting, and that doesn't come up so often. There also are non-hormonal medications that we haven't gone into yet. But in terms of doing something that's non-medication, it's interesting that cognitive behavior therapy and hypnosis are those that have been shown to be the most effective.

Melanie Cole, MS : What great information, doctor. Thank you so much for joining us today and really helping women to know and clear up some of that confusion. This was really educational. Thank you again. And Weill Cornell Medicine continues to see our patients in person as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine.

We're so glad you joined us for Women's Health Wednesday. We hope you'll tune in and become part of a community and a fast-growing audience of women looking for knowledge, insight and real answers to hard questions about our bodies and our health. Please download, subscribe, rate and review Back to Health on Apple podcast, Spotify, Google podcast. And for more health tips, please visit weillcornell.org and search podcasts. And parents, remember to check out our Kids Health Cast too. Lots of great podcasts there. This is Melanie Cole. Thanks so much for listening.

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