Melanie Cole, MS (Host): We hear a lot about how to treat illness, but really not as much about how to prevent and even reverse chronic disease through our lifestyles. Today, we're learning about healthy lifestyle for women in midlife and menopause. Yours truly.

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I'm Melanie Cole. And today, joining me is Dr. Susan Loeb-Zeitlin. She's an Assistant Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medical College Cornell University, and she's an Assistant Attending Obstetrician-Gynecologist at New York Presbyterian Weill Cornell Medical Center. She is also the Director of the Weill Cornell Women's Midlife Center.

Dr. Loeb-Zeitlin, thank you so much for joining us today. As we get into this topic, and as I said, I'm right there in the thick of all of this as I am post menopause and 61, and so many women in my situation are not quite sure as we're getting older, whether we're still in this sort of younger group in the middle age, older, what we're considered, you know, it's a confusing time of life, but there's a lot going on. So as we start, what can we do to sort of set ourselves up to age well and how do our concerns, and specifically our health concerns, change as we age?

Susan Loeb-Zeitlin, MD, FACOG: Thank you so much, first of all, for inviting me to be here today, and that is such a great question, because I talk so much about this all day, that midlife is the time in our life where we are setting ourselves up for the rest of our lives. So, it's a time, a transition time. Transition times, of course, are hard times. Our bodies are changing, our health status is changing. But there also are so many changes in our lives, maybe adult children, elderly parents, professional challenges. So, it's like the perfect time in our life to assess where we are and how we want to spend the rest of our lives. So, there are many things we can do during the midlife to set us ourselves up well for the rest of our life, starting with working on healthy lifestyle choices, making healthy decisions, and also doing preventative healthcare screenings and make sure we're maintaining good health.

Melanie Cole, MS: Well, that's really all very good advice. And as we think about it, I'm going to jump into the first thing that I think that we notice is as we get into this certain age group, and we worry about now our risk for disease goes up in so many diseases, as we start to lose our estrogen. And we talk to you, our obstetrician-gynecologist about whether we should be in hormone replacement or not. All these things come into our minds. But Dr. Loeb-Zeitlin, one of the things that I think about is the anxiety and we know what's going on in the country today and in the world is enough anxiety. But as you put perfectly, we've got elderly parents, older children, jobs, challenging careers, things are going on in so many ways. And then, we've got this increased risk of disease as our bodies are going through these changes. How do these changes contribute to some of those mood disorders and anxiety that we're feeling?

Susan Loeb-Zeitlin, MD, FACOG: It's a great question. We're actually studying that. We're doing a multi-centered NIH study right now looking at why women during the midlife experience mood changes. So, there's something probably biochemical going on. At least 40% of women going through a midlife transition do experience some mood changes. They can linger or they can get better. We know that women who have had a depressive episode in the past, whether it's postpartum or any other major depressive episode, those women are more likely to experience something, but we're actually studying why. Sure, there are things we can do. I think that's what you want to know. What can we do when this happens during midlife? But the actual why, sure, it's all the stressors in our life and probably something more biochemical going on.

Melanie Cole, MS: What can we do about that?

Susan Loeb-Zeitlin, MD, FACOG: Yeah. So, of course, seek help, right? So, there's therapy, there's psychiatrists, there's medications that can be used. Mindfulness practices are helpful. So, cognitive behavior therapy is something that's very helpful, and it's been shown to be effective both for menopausal symptoms and for the mood changes that go on during the menopause transition. But sometimes medications are needed, medications that treat the anxiety or depression, and maybe although it's not FDA approved for this indication, but maybe hormones can help that too.

Melanie Cole, MS: Okay. So, you mentioned in your first answer about screenings, those certainly change. I mean, we didn't get a colonoscopy before we become around this age. And we see our gynecologist every year. What are you doing for us as we get into this life and this stage of our lives? Are we still having Pap smears? Obviously, we want to make sure to get our mammograms. Tell us what we're doing at this time of life.

Susan Loeb-Zeitlin, MD, FACOG: That's a big question. So, there's lots we do. Pap smears probably, if your paps have always been normal, that's not something we have to do every year anymore. Very clearly that's understood. And while people are so used to getting their annual Pap smears, they definitely don't have to be done every year. But regular screening tests are super important. Mammogram, you're right; colonoscopy, bone density screening, checking for osteoporosis.

And then, another one that's so important. Many women don't know that the lead and cause of death for women is cardiovascular disease. So especially, if there's a family history or if you have personal risk factors, getting preventative cardiac screening is something critical and so important to do.

Melanie Cole, MS: Those are all great pieces of advice and important screenings that we do get, and thank you for clarifying about Pap smears. And if we've gotten normal ones, we don't really need them. I think I get them every three years at this point now. And so, I mean, that's really good for us to know. Now, you're mentioning cardiovascular, and yes, heart disease is the leading cause of death for women. So, as we think about exercising at this time of our lives, what do you tell your patients every day about trying to get involved in some sort of an exercise program? Because you also mentioned bone health and bone density, and that starts to go down as we lose those hormones as well. Gosh, it all kind of happens, doesn't it?

Susan Loeb-Zeitlin, MD, FACOG: So, there's a lot to talk about with that. American Heart Association recommends 150 minutes of moderate intensity exercise a week. So, that's not high intensity necessarily, but that's 30 minutes a day for five days a week, getting the heart racing a bit. And that's really good and really important. But there are other things that I think are super important too, and that the weightbearing exercise, which could be part of that moderate intensity exercise, is of course the exercise that's really good for the bones.

But women and midlife, almost universally, no matter what their body build is, notice a change in their body and they notice weight that develops in the midriff. Thin women, heavy women, everybody notices that their body shape changes. So, really important is incorporating some core strength exercises. That's the best we can do to combat what the body naturally wants to do, and that's how we can kind of make our body stronger and fight what the body's instinct is. Even five minutes a day I think is beneficial. But adding some kind of core strength is not only important for maintaining our body the way we want it to be, but also it's really important for our balance. And that's something not to take lightly as we age also, because hip and vertebral fractures are a major source of morbidity and mortality as we age. Falls are the main reason why that happens. So, working on maintaining balance and strength is such an important part to incorporate that as we go through our midlife and beyond.

Melanie Cole, MS: I couldn't agree more. And posture's important too. So, we're not this old lady like this walking around with our nose down to the ground. We're sitting up straight while we're doing this here today. But really, working on our posture and all of these things are so important.

Now, another important aspect that you and I have discussed is brain engagement. I mean, Doctor, we think to ourselves, "Geez, I can't come up with that word. What is that word that I wanted to come up with?" And that really is an important thing that happens to us as we get a little older. And it can be worrying. Sometimes we think, "Oh my gosh, is this the first signs of something terrible?" But it's not necessarily, right? But it is important that we do things to keep our brains engaged and to keep learning all the time.

Susan Loeb-Zeitlin, MD, FACOG: There's so much that can be said on that topic, and it's so relevant. But I do also tell my patients that my husband also complains about not being able to remember words and remember names. And so, therefore, it's not strictly estrogen-dependent. But there are many things that go into it. And so, when I talk about this with my patients, and it is so common and it's so incredibly concerning, number one, we know that some women going through just the midlife transition experience this and that ultimately does get better. But sometimes it lingers.

And that cognition, also brain fog, which is cognition, is so related to our mood, which we've already talked about and our sleep. And so, sleep, mood and cognition are all connected. So, that's always the question I ask when someone has brain fog. How are you sleeping? How's your mood? And addressing those are really important parts of addressing brain fog. Sure, sometimes hormones can help. They especially help this, if, for example, someone is not sleeping because they have hot flashes or night sweats. So then if we give hormones, they might sleep better and that might help the brain fog. There's some studies showing that estrogen might just help cognition during the midlife transition too. That's not well completely percolated yet. But there is evidence for that. But really, making sure you sleep, you address any mood concerns, and also keep your brain challenged, right? Learn new skills, fun skills, intellectual skills. Keep learning throughout your life is such an important way to maintain good brain health as we get older.

Melanie Cole, MS: I agree. And I'm glad you brought up sleep because certainly with our anxiety and our fluctuations in hormones, sleep becomes a thing. So, I'm going to throw my own recommendation in here, which is if you're having trouble sleeping, speak to your doctor and maybe a sleep study, because I just found out that I have apnea, which I never knew, and I mean, you know, I found out I snore. But it does teach us a lot and we're learning more and more about our risk of heart disease and diabetes and obesity, all linked to sleep and poor sleep habits. So, I know that those are all linked.

And while I'm bringing that up, let's talk about weight for a minute because our weight goes up. I mean, it's almost inevitable that some little bits of changes in our weight. Some women get real skinny and some we put on a little in the middle. Tell us a little bit about what you tell your patients about that, a little extra pounds that we put on every couple years.

Susan Loeb-Zeitlin, MD, FACOG: Sure. So, that's a lot also to talk about. And I just want to go back to your obstructive sleep apnea. That just like the body, I already spoke about how we get weight in our midriff, a lot of women get weight up here and that can lead to the apnea that develops as women go through midlife. So, you are a hundred percent correct to make sure if you're not sleeping, that you address if there's actually a medical reason why or everything else going on. But this apnea is something that should not be ignored. And a sleep study is super important for women who are waking up and not sleeping well during the night.

But weight, of course, a universal concern for everyone and especially during midlife. Like I've already said, the body changes, but it's not inevitable. People do put on weight though. Is that hormonal? Is that age-related or is it a little bit of both? It probably is a little bit of both. Our metabolism changes. People say to me, "I haven't changed the way I eat." Well, guess what? We probably have to change the way we eat. We can't eat the way we ate when we were young adults. And so, it's not inevitable, and that's something we definitely talk about, that you gain weight. And it's so important to maintain a good body weight just for our, again, for our disease progression in our long-term health. But it is some diet modification. That's probably the most important thing. And of course, continuing exercise, but really watching the diet is really what we need to do.

Melanie Cole, MS: So, I'd like to touch on that for a minute. As we think about trying to eat healthier as we get older, and of course back to that anxiety thing, which lends itself to comfort food, which don't help us in our weight maintenance journey that we're all on at this time of our lives. But, you know, the supplement world industry is huge. Dr. Loeb-Zeitlin, can you tell us a little bit about anything you could tell us about supplements would be helpful? Are we supposed to be taking calcium now because we are worried about our bones? Are we really looking at a multivitamin as we get older? Should we be doing that stuff? And of course, we're going to always talk to our doctor about it, but what do you think personally that we should be doing?

Susan Loeb-Zeitlin, MD, FACOG: So, I'm not an expert in supplements. I do believe I know enough about supplements to tell you which ones are the appropriate ones to take. There are, as you correctly said, so many supplements out there. They are not well studied. And so it's hard to make recommendations regarding a lot of the supplements. Calcium, so important for the bones, best to get it as a dietary source. But if you're not getting it from your dietary source, then a supplement. Vitamin D, D3, super important to help absorb the calcium. So if you're not getting enough sunlight, and most of us are deficient in Vitamin D because we block out the sun so much, a vitamin D supplement.

There are other supplements that are better studied, such as like, if you're a vegetarian, you might need some zinc, you might need some B12. If you're going through perimenopause and having heavy bleeding, you might be iron deficient. If that's shown, that's a really important one to supplement.

But really, a multivitamin, we really say if you're eating a well-rounded diet, which maybe our diets are not quite as well rounded as we think they are, then a supplement is not necessary, but also a multivitamin for women is probably not harmful either.

Melanie Cole, MS: Wow, you've given us a lot to think about. We've talked about screening and exercise and eating healthy and our weight and anxiety and sleep. We've packed in a lot of information. So now, Doctor, how do we be our own best health advocate? As we wrap this up, and you've given us a lot to think about, I think one of the most important things that we women don't realize or don't know is if we don't put our own mask on, we can't put on the mask of our loved ones. And if we are not taking care of ourselves, we are the caregivers to society, right? We are the caregivers, and if we're not taking care of ourselves, we can't do that. I'm always pushing my husband to go to the doctor, but am I pushing myself to do the same and get my screenings? And we're taking care of our kids, but are we taking care of ourselves?

So, I'd like you to speak on how we can be our own best health advocate. And when we're speaking to you, our doctor, and certainly our most personal doctor, our obstetrician-gynecologist with which we have such a special relationship from a very young age. I mean, I could get choked up thinking about what you guys do for us. Tell us what you want us to know, what you want us to ask you when we're sitting there with you at our most vulnerable. What would you like us to know about our relationship with our doctors?

Susan Loeb-Zeitlin, MD, FACOG: I think you hit the nail on the head too, because I think the gynecologist, a gynecologist, has a unique relationship with her patients and hopefully opens up the door to their patients to talk about things that they might not be able to speak with anybody else in the whole world about. So, having a doctor, a provider really, with whom you're comfortable having an open, honest interaction is so important and that goes into issues such a sexuality. Those are things that come up at this time of life, that having an open platform to discuss that is really important. But being honest, talking about what's going on in your both medical health and your personal life is really how to advocate for your best health and how we can help you most as we age.

And then, really living the healthy life. Eating that healthy diet, exercising, avoiding alcohol, really avoiding alcohol, getting enough sleep, avoiding smoking, and keeping your weight at a healthy weight, as we've already discussed, are the most important things that we can really can set ourself up beyond medications for living a healthy, long, and productive life.

And I also think it's really important at this time in our life and going forward to focus on the things in life that matter the most to us. And that's sort of a luxury that goes along with midlife and aging, that may be like the other things you don't have to focus as much on. But what really matters to you, what brings you fulfillment is really what you should be focusing on at this point in your life.

Melanie Cole, MS: I agree completely, and our loved ones, our friends, our support systems, our circle, our little pods are so important and as are you, doctors, that really take care of us. Thank you so much for joining us today and giving us so much to think about. Thank you again.

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