Joey Wahler (Host): This is Health Matters: Insights from WCH Medical Experts. Our guest is Dr. John Roost. He's an obstetrician and gynecologist. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome

John Roost, DO: Good to be here. Thanks for having me. I'm excited to do this.

Host: Same here. Great to have you aboard. We appreciate the time. So first, in a nutshell, what exactly is perimenopause and how does it differ from menopause?

John Roost, DO: Yeah. So, perimenopause typically is going to be that transitional phase where estrogen, estradiol, progesterone is all lowering and decreasing while the FSH is increasing. And that's when patients are going to start to notice a lot of the different basal motor symptoms, mental and cognitive symptoms, physical symptoms that they come into the office to discuss.

Menopause is going to be, by definition, 12 months without a period. So, the average age of menopause is roughly 51 years, 51.3 years of age. And perimenopause, that transitional phase, is going to be 5 years, give or take, is what I generally tell patients, that 45 to 55 age range. Although we do see women coming in, you know, even 39, 40, 41 years of age with these symptoms that can be characterized as perimenopausal symptoms and fluctuations in their hormones.

Host: You mentioned cognitive impact, which is interesting because I think most people associate perimenopause with more of the physical impact. So, what is the effect that it can have on someone cognitively?

John Roost, DO: Yeah. Cognitive issues are actually one of the highest complaints that we have. You know, the hot flashes, insomnia, the vaginal dryness, the decreased libido, those things are prevalent. But a lot of times women are coming in with brain fog, memory issues, difficulty focusing on things. And that is all attributed to that lowering estrogen level as well.

You know, before we, you know, get too far into it, there are a few things that I do tell all these women when they come in. The last couple of years, there's been so many patients coming in to want to discuss hormones, and it's probably due to social media and everything that's out there now with, you know, getting your hormones checked, these can be menopausal symptoms. You know, one is that this is going to happen to women whatever they do. It's going to happen regardless. And so, a lot of times there's a helplessness that comes with that, and that can bring with it mental and emotional distress as well that can also lead to cognitive issues.

The second thing is that a lot of this is multifactorial. Of course, the lowering estrogen and progesterone and the hormone difficulties that women are going through, that does lead to a lot of this. But also, there's social factors. There's other physical ailments patients have.

So, a lot of times it is multifactorial. And so, those are some things that I always tell women, along with that it's their journey. Their sister, their neighbor, their best friend might have a completely different experience with their perimenopausal transition into menopause than the patient I'm talking to.

And so, that makes them, "feel like they're going crazy," right? And all of that is to say that it leads to that cognitive impairment, the pathophysiology of the hormones changing, plus that emotional and mental impact that it has. So, the cognitive issues are significant, and they are improved with treatment.

Host: Interesting. I certainly, for one, was not aware that they were such a factor here. So, thanks for filling us in on that. Now, you touched earlier, Doctor, on a couple of the classic symptoms of this, the hot and cold flashes, et cetera. What are some early signs that women might not realize are hormone related here?

John Roost, DO: The most common are going to be, like I said, those hot flashes, the irritability, insomnia, vaginal dryness, decreased libido. Those are the things that you generally hear. But a lot of times, we have women come in also with joint pain, the brain fog, which we touched on: skin changes hair thinning. I've even had women come in with chest palpitations, itching ears, some things that you wouldn't typically think would be vasomotor symptoms of perimenopause.

But, you know, in the beginning of doing a lot of this hormone replacement, I was a little bit skeptical about some of those things. And then, you put patients on a safe treatment plan, and you realize they come back and they say, "My ears don't itch anymore," "My joints feel better." All of these things in a bubble are seeming to improve.

And so while there's good data and scientific evidence in medical literature on things like hot flashes and night, sweats and, you know, vaginal dryness and those kind of things, there isn't as much specific evidence on some of those other factors we just discussed. But they do seem to be improved with treatment.

Host: Now, you talked earlier about the fact that many women with perimenopause have things like brain fog, anxiety, mood swings, et cetera. So obviously, that's common stuff. Can you give us an idea please, why are those things in play here as a result to what's going on during this condition?

John Roost, DO: Patients who have struggled with anxiety and depression in the past, those patients are going to be most at risk of having exacerbations of those symptoms in those states with perimenopause. A lot of it has to do with just the whole disruption of what's happening. The hypothalamic-pituitary-adrenal axis, the HPA axis, is literally disrupted. And so, that's a big feedback loop to go, you know, releasing hormones. It has to do with neurotransmitters like serotonin and dopamine and norepinephrine. And so, there's a lot of different reasons why those women are experiencing those things. Hormones and hormone replacement and getting those estrogen and progesterone levels back to where they need to be is very important, but it's also equally as important to tell these patients, like, "Listen, you know, this may help you with your depression and anxiety because there's a reason why you're having an exacerbation right now." But add to that the cognitive behavioral therapy. Add to that, you know, exercise. Add to that the healthy habits, healthy eating habits and healthy social habits and things like that, because that's when you're going to get the most improvement in those symptoms.

Host: Well, you mentioned a moment ago, Doctor, that things that you have going on already can be exacerbated by perimenopause. Speaking of which, weight gain and sleep issues seem to be big concerns for these women as well. So, what's going on there? And can anything help with those symptoms?

John Roost, DO: Yeah, that's a good question. That's one of the common ones we get is weight gain. And I didn't include it in the beginning, only because weight gain really unfortunately for patients, and they don't like to hear this, is not really happening because of the hormone changes. The patients do have a redistribution of fat into the central area when they go through perimenopause and menopause. But really, it's more of an age-dependent and a behavior-dependent thing, the weight gain is.

Now, I do find that patients lose weight many times with therapy and with help on those symptoms, and I believe it's mostly because they feel better. When you feel better, you are more active. When you feel better, you go to the farmer's market that night instead of staying home. You go out with your friends. You do yard work. You do stuff around the house that you don't have the energy or the drive to do when you feel lousy. So, I do see women lose weight, but hormone replacement isn't going to be a weight loss strategy for patients.

Now, for insomnia and things like that, that is almost along the same lines as that. But in essence, what's happening with the hormones changing and the neurotransmitters changing is that women are having hot flashes and night sweats, and women are having decreased episodes of deep sleep, and they're waking up easier throughout the night. So, those things are improved indirectly by getting the hormones where they need to be.

But those are couple of the most multifactorial issues that the patients are going through. So, I do try and remind them of that as well. You know, patients who are struggling with weight, first line exercise and diet. But also, you know, GLP-1s are big now and, you know, some patients bariatric surgery is an option. Things like that are going to be more effective for your weight loss than simply just going on the hormones.

Host: Well, you've mentioned hormone therapy multiple times during our conversation already, so let's get into that a little bit, shall we? I'm sure we could probably do a whole other podcast just on that. But in a nutshell, Doctor, it's getting so much attention these days. Who is hormone therapy appropriate for when we talk about perimenopause? And basically, what are the benefits versus risks involved?

John Roost, DO: Sure, yeah. I break it down for patients into four categories. There's your non-hormonal treatments. Those are going to be most likely the way we go in the treatment strategy for the patients who have contraindications to the hormones, which I'll go through in a second.

There's also your supplements, which are not FDA-approved or ACOG, American College of OB-GYNs, recommended. They have not been shown with evidence-based medicine to be helpful. There's your compound pharmacies that do bioidentical, they call them, hormones. But these compound hormones again are not FDA approved or ACOG recommended, which I discuss with patients as well.

And then, you have estradiol patches, pills, gels, sprays, things like that, and your progesterone pills. One of the most important things with hormone replacement, speaking of risks, is going to be if the patient has a uterus still, uterus is intact, you want to always be on a progesterone with your estrogen. So, that you don't develop hyperplasia, abnormal accumulation of cells inside of the tissue inside of the uterus, and God forbid, you know, an endometrial cancer.

When I start talking about patients about risks and benefits, when you go on estrogen and progesterone or hormone replacement, with estrogen and progesterone, you're going to have a slight increased risk, which I quote to patients to be about 8 to 12 per 10,000 person years, which is a low risk depending on how severe their symptoms are. And we do a risk-benefit analysis on, you know, how impactful has this been to your relationships and your job and your hobbies and all that kind of things. But you know, you're going to have a slight increased risk of venothromboembolism, which is a blood clot, strokes, heart attacks, elevated risk of breast cancer, so you want to make sure that you're getting the routine screening, heart attacks, things like that. The benefits are going to be obviously the symptom treatment, but also it's good for bone health, and it is cognitively protective for patients.

The patients that I talk to say, "Okay. Unfortunately, we're not going to get too much into estrogen and progesterone replacement," are going to be your patients that have a undiagnosed vaginal bleeding. If they're bleeding for some reason, I need to figure out why that is, if they shouldn't be bleeding. If they're post-menopausal and bleeding, we need to figure that out first. Patients who have breast cancer or a history of breast cancer, patients who have liver function disorders or liver failure, patients who have severe coronary artery disease, those kind of patients are going to be patients that are not a good candidate. We usually like to start with patients before the age of 60 and within 10 years of menopause. And that is from in a nutshell kind of risks, benefits, different strategies, what we're looking for in terms of safe, you know, treatment planning.

Host: Of course, there's a lot out there as well on social media about supplements, which you mentioned, natural remedies, so to speak. Regarding those, simply put, what should women be most cautious about when looking into them?

John Roost, DO: I do have a lot of patients who say, "You know, Doc, I appreciate the information, but I'm happy with my black cohosh and I'm going to continue with that." And, again, these are patients who are educated making decisions for themselves. I just try and make it clear that these are not FDA-approved, not ACOG recommended.

I can't show them data on these things. So, the problem with though a lot of those supplements is that, A, they haven't shown a statistical benefit, but they have shown that they can be a risk to your liver toxicity, some of them kidney issues. Also, you're creating an estrogen-like response. And if you have a uterus, you theoretically are going to be at an increased risk for endometrial uterine hyperplasia or, you know, cancer.

Host: Couple other questions for you. All of the above being said, at Wood County Hospital these days, what are the main treatment options and support that are available?

John Roost, DO: I always try and encourage patients exercise, the diet. I always try and give them resources for therapy, especially if they're struggling with mood or mental, emotional issues, things like that. I think that gives the patients the best probability of success. And then, when we get towards medication, the transdermal route for estradiol, the patches, you know, they've been shown to have a slightly lower risk of blood clots. So, I usually recommend starting with a patch and then the progesterone pill, which does help patients sleep at night if they have a uterus, or we just do sometimes the estrogen patch alone if they've had a hysterectomy in the past. We will sometimes add progesterone even for those patients. But typically, that estrogen patch and that progesterone pill are the best place to start. And then, we titrate those, use the lowest effective dose that we can. We titrate them. Some patients end up on estrogen pills or the gel or the spray. You know, right now, honestly, we're having trouble with getting the patches in the patient's hands just due to national shortages and things like that. So, that's been a little bit of an issue. Typically, the majority of the patients will start on an estrogen patch, plus or minus that progesterone pill, depending on sleep issues and if they have a uterus and things like that.

Host: And then, finally, in summary here, Doctor, as you've mentioned here, this is not a one-size-fits-all condition, perimenopause. It affects all women differently. So speaking of which, when should someone typically talk to their provider about this condition? Where is that line? Because obviously it's not the same for everyone, right?

John Roost, DO: We do have a lot of patients that come in saying, "I have these symptoms, and they're making me nervous, and I want to know why they're happening." And then we get into treatment, and they're like, "I'm just not ready for that yet." So, I think a lot of this has to do with, you know, how much are these symptoms impacting your life? Are they affecting relationships with your partner? Are they affecting relationships with your family, your work, your hobbies, those sort of things? And so, some patients, if we try to quantify that, I'll say, "Why don't you just put a little check mark in your calendar if you find that it's affected you that day?"

And then, when we go back, we can say, "Oh, well, you know, three days this month, how important is that to you? Oh, well, it's been 15 days this month you've been affected by these symptoms. Well, that seems to be quite a quality of life issue. Maybe we need to dive a little deeper into these things."

And if you don't want to do hormones, that's fine. There's SSRIs, SNRIs that are FDA-approved for some of these vasomotor symptoms. There's a medicine called Veozah, which is approved for hot flashes only, and that is a medication you can take without hormones. it's bladder issues, we could do something for the bladder and not do hormones.

There's also topical estrogen for patients with vaginal dryness, painful sex, things like that, where you're not taking a systemic hormone. So, there can be a kind of a stepwise fashion you can start with patients. I find that it's best with patients to go over all the options and then let them know that, like, you aren't up a creek without a paddle if this doesn't work, right? You're not out of luck if this first thing doesn't work. Let's make a plan A, B, C, and D so that you know that it's not hopeless. Because a lot of women come in feeling so hopeless. I'm 48 years old, and all these things are happening to me," and I can only empathize. I won't have to ever obviously go through those things. So, I feel for them. I can imagine how difficult and helpless it would feel to have these things happening to you and not have much control over them whatsoever. And so, I think it's important to give patients that multiple treatment strategies and, "Okay, in three months, if this isn't helping you, you know where to find me, and we will try something different."

Host: Absolutely. Because I think if there's one takeaway from this conversation, it's that not just help is out there, but it comes in many shapes and sizes, all depending upon one's situation. Well, we trust you're now more familiar with perimenopause. Doctor, valuable information. Keep up all your great work, and thanks so much again.

John Roost, DO: Thank you, Joey.

Host: And for more information, please visit woodcountyhospital.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being part of Health Matters: Insights from WCH Medical Experts.