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Melanie Cole (Host):  Menopause affects every woman differently and I know this because it affects me differently than it affects all of my friends. And as we are all kind of in this time together; it’s so interesting for me when I get to interview doctors that are discussing this. Because these questions are so important and so many women have the same questions. My guest today is Dr. Irene Wahba. She’s an Obstetrician Gynecologist with BayCare. Dr. Wahba, as I said in my intro, I’m going through this right now. Please tell us what exactly is happening with our bodies during menopause.

Irene Wahba (Guest):  Well Melanie, it’s a very interesting phenomenon because it’s such a big changing point in women’s lives. We are so accustomed to the regularity of a menstrual cycle and the physical, emotional, many changes that go along with every cycle, every month. So, all of the sudden menopause, there’s an abrupt change. It’s actually a gradual change at times. But it’s a definite difference in how you are feeling day to day and it affects us medically. So, we define it as the absence of a menstrual cycle for a full year. And the average age of menopause is 51. But of course some women will start earlier, some will start later. So, it’s very particular and unique to each person and may be related to family history.

But what’s really happening is that our ovaries are failing us. So, over time, we rely on those ovaries through our reproductive years to produce a follicle every month, to make the hormones that give us those cyclic changes and then as they stop functioning; we start feeling the absence of the estrogen and progesterone that are produced. Some testosterone as well. But we start feeling the way that our bodies have changed as a result of those drops in hormones.

Host:  That was a great explanation Dr. Wahba, so what are some of the indicators of perimenopause and when do these menopause symptoms typically start?

Dr. Wahba:  Menopausal symptoms will typically start about four years prior to that one year mark of no periods. So, when they start, you may experience hot flashes here and there. You may notice a change in your cycles. Sometimes the cycles will start coming sooner than expected so you might have a 23 day cycle rather than a 28 day cycle. Bleeding can be heavier or lighter. Heavier is probably more common and every so often, we’ll go through months where we don’t ovulate and when we have those anovulatory months; we might not bleed for a month, might not have a period at all and then the following month, we may bleed for six weeks. Something strange may happen like that.

So, erratic unexpected bleeding cycles is one of the most reliable indicators of menopause. There are hormonal tests that can be done but it’s actually not recommended because it’s a clinical diagnosis. And I’ve done this with many people at their request and a lot of times, we’ll get a normal value one month and an abnormal value the next month when trying to pin down am I going through menopause or am I not. This is tricky because the ovaries vary in their function. So, one month, your ovaries are great, and they are doing everything they are supposed to do so you get a normal value. The next month you don’t.

Symptoms that may go along with these changes and why people ask to have tests to try to clarify what’s going on are that they may have in addition to the irregular bleeding; they may start feeling fatigue, breast tenderness, weight gain, weight gain is probably the most common and it’s usually around the midsection. Moodiness, mood irritability. Hot flashes, night sweats, insomnia, vaginal dryness, sexual desire changes. So, all of these are components of perimenopause and they all become more pronounced probably during that year of change into menopause as well as the few years that follow.

Host:  Then how do we know when we are in full fledged menopause and what if we are told we are and then we experience bleeding after menopause, is that concerning?

Dr. Wahba:  That’s a great question. So, we know we are in menopause when we go a full year without a period, for those of us who have a uterus and should be otherwise getting cycles. So, that’s a defining point. If you have bleeding afterwards, it’s basically a concern for uterine cancer. So, anytime there is bleeding after a year of no bleeding; that’s definitely concerning, and you should be evaluated by an OBGYN.

Host:  So, as long as we’re talking about concerns, very briefly tell us about some special health concerns. Because it feels like as a woman, when we hear we are in menopause; now we are at risk for so many other things whether they are cardiovascular, or certain types of cancers. What should we keep in mind when we are thinking about that time?

Dr. Wahba:  When we go through menopause, there are definite changes in our cardiovascular profile. So, you may notice labs afterwards will change. Cholesterol levels will go up. And it’s the bad change like the good cholesterol goes down, the bad cholesterol goes up, the total cholesterol will rise. Women rarely have cardiovascular events prior to menopause. Because there is a protection with estrogen which actually translates into why estrogen replacement therapy or hormone replacement therapy may be beneficial. It has it’s risk and benefits but when we do go through menopause, we are more likely to develop cardiovascular disease as well as breast cancer, uterine cancer and several other basically strokes, other issues that may relate to our heart health.

So, in women who decide to take hormone replacement therapy; it’s confusing because you’ve had these similar types of hormones so even if we use say bioidentical hormones, we do find definite benefits and one of them is cardiovascular benefit. So, they did a big study in Europe a few years ago with a national database and what they found was women who took hormone replacement therapy developed cardiovascular disease later than women who were not taking it. And as a whole, women have decided to veer away from taking hormones unless they really need them over the past 20 years.

So, they found that this was actually detrimental to cardiac health. And the concerns that drove this veering away from hormones was the study called the Women’s Health Initiative in 2002 which stated that there was an increased risk of breast cancer and more aggressive more fatal breast cancer in follow up studies in women who are on hormone replacement therapy, especially the women who were taking combination of estrogen and progesterone because they needed the progesterone to protect the uterus.

So, those women were at higher risk for breast cancer and they were also at higher risk, we think the estrogen component does this; higher risk for clotting events like heart attacks and stroke. What’s often glossed over is the fact that there was also protection so in addition to now what we know about the protection that the hormones may offer; we know also that there’s a decrease in risk of osteoporosis and colon cancer in women who take hormone replacement therapy. So, there is – there are definite pros and cons and that’s a complex discussion that each woman should have individually with her provider based on her past medical history and her family history and her symptoms.

Some women, about 15% of women go through menopause relatively unfazed. They don’t even notice that they are getting hot flashes or night sweats or that their estrogen levels have dropped. So, those women are a variant, but it does happen a fair amount of the time and it’s hard to justify taking a hormone that may have risks especially when factoring in the big picture.

Host:  This is such a huge topic and thank you for clarifying about hormone replacement and bioidentical hormones because those are questions women should have in depth with their providers. So, what about as we get close to wrapping up this segment; what about some of these other things? We look to some holistic or complimentary treatments, black cohosh. There are so many side effects and you’ve mentioned a bunch. But there’s also heart rate, anxiety, you mentioned weight gain and insomnia. There are so many things, hot flashes, that women look to other treatments. So, what do you recommend as far as complimentary and you can include exercise, yoga, meditation, any of those things. What do you tell women as we are going through this?

Dr. Wahba:  Well I think what a lot of what you just mentioned is critical. So, as we go through this, I always advise women as they are approaching menopause, I always say this is a time when you can’t trust your metabolism so it’s not time to overindulge in food, it’s not time to become sedentary. We need our bones to be strong, osteoporosis is another big change that happens after menopause. So, we need to definitely take calcium supplements, vitamin D, increase exercise and it should be the variety of exercise that bears weight. So, anything that’s weight bearing is going to improve that bone density because the first five years after menopause we have a significant drop in bone density, and we don’t often test for that until almost a decade after menopause.

So, that’s something that we need to be very cognizant of and then we want exercise to produce endorphins. So, the mood changes are something that is very hard to control. You can’t really reel in your mood changes when you have these big fluctuations of hormones and when you are not getting enough sleep and when you are frustrated and may be your relationship is changing, the relationship sexually may be changing just because of the changes that you and possibly your significant other are going through at the same time.

So, diet and exercise again, customized to your particular needs and to your – what works for your lifestyle and how you’ve been in the past – how you have been successful in the past and what you tend to do, what your hours are like. So, that’s a conversation that you should have. As far as holistic medications and herbal treatments; black cohosh is definitely known to be effective. There are combination herbal supplements. I don’t want to mention brand names. But there are several combinations that have been studied a little bit better than others. One of the hardest things for doctors in recommending herbal supplements is the non-standardization because they are not FDA regulated. So, if you look at the American College of OBGYN’s official recommendation, they’ll say that we should not be recommending herbal supplements because we can’t rely on what product they are going to pick up and whether it has what it’s supposed to have in it.

So, there are natural plant-based estrogens that are effective as well, like soy-based products but there is a concern in those that the soy or the plant-based estrogens may also stimulate breast tissue in a certain way. So, we don’t really know the big picture and there are not as many standardized studies that may be able to provide us with the full picture and the full risk profile that we can give patients.

As far as the changes and how long they should last; these will be the most intense for the year or two. The year that you are not getting your period and then when we define menopause and the year after. Those are the most pronounced during that time. But gradually, you’ll notice some of the symptoms go away. The hot flashes and night sweats may be less intense. They will still probably go on indefinitely. You’ll have some periodically through the rest of your life, I’m sorry to say that. But some of the things like vaginal dryness and a change in sexual desire are definitely things that will be progressively worse and sometimes there are piecemeal options of treatment that may not involve much risk.

So, that’s something that we should consider and there are other medications. So, breast cancer survivors still have medication options as well as herbal supplements that may benefit them. And like I said, sometimes just treating vaginal atrophy or particular symptoms, one at a time. You can always separate out the symptoms and find out what is most problematic to that patient and decide okay I’m just going to address your insomnia and maybe I’ll give you some progesterone, some natural progesterone before you go to bed and that might help your insomnia. Maybe I will just address the vaginal dryness and I’ll give you vaginal estrogen. So, there are a lot of different treatment options and some women if the mood symptoms are most pronounced; some of the selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors, SSRIs or SNRIs may really help to diminish the hot flashes and night sweats as well as controlling the mood symptoms.

So, sometimes there are other medications that may be available and even blood pressure medications that can control the tone of the blood vessels so that women don’t get those big flushes. So, there are a lot of options and any OBGYN is going to be well-versed in walking a patient through this. and it really is the kind of thing that should be based on the composite of that patient as well as her family history and her lifestyle.

Host:  Wow. Really great information Dr. Wahba. So, wrap it up for us, your best advice for women. You’ve given us great advice about discussing these things with our provider, things that are out there for us to try. So, what would you like us to think about first off as we know that we are starting to enter this phase of our lives and to try and enter it with a healthy mind to get through it?

Dr. Wahba:  Exactly. So, I think a healthy mind, healthy body and if possible healthy relationships but basically anticipating the changes that are going to happen and knowing that it’s not a time to neglect your health or to get bogged down with social stresses that you can avoid. So, it’s a time in life where you should pay attention to your health, be aware of the changes that may be happening and don’t hesitate to bring them up with your provider. A lot of times, women will hear these days that a PAP smear is no longer necessary every year. And it’s hard for women to realize that a PAP smear is just a very small component of an annual exam with an OBGYN where you may be benefitting from a conversation, advising about bone health, exercise, weight gain, mood stabilizing, exercises or habits. So, these are important times in a woman’s life and we pride ourselves as OBGYNs as being that guide through the various transitions in life starting from puberty to the reproductive years and pregnancies and miscarriages and all the things that we go through on to these menopausal years where a lot of changes are still happening and we still want to be a part of that conversation and a part of the guidance that we can help you live a better quality of life.

Host:  Absolutely. Thank you so much Dr. Wahba. You’ve really filled us in and educated us today on so much great information and thank you so much for joining us. That wraps up this episode of BayCare HealthChat. Head on over to our website at www.baycarewomenshealth.org for more information and to get connected with one of our providers. If you found this podcast as informative as I did, please share on your social media, share with your friends, share with other women you know because we are all going through this and we are all going to go through it and this way we can learn from the experts at BayCare together. And be sure not to miss all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.