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Melanie Cole (Host):  Welcome to Back to Health, your source for the latest in health, wellness and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I’m Melanie Cole and I invite you to listen in as we discuss menopause, and the changes women can expect. Joining me in this panel is Dr. Susan Loeb-Zeitlin. She’s an Assistant Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medicine. And Dr. Margaret Polaneczky. She’s an Associate Professor of Obstetrics and Gynecology at Weill Cornell Medicine. Both ladies, have extensive experience providing care to women of all ages with special interests in the care of women in menopause and perimenopause. Ladies, thank you so much for joining us today. What a great topic. Dr. Loeb-Zeitlin, I’d like to start with you. First tell us a little bit about the Midlife Program at Weill Cornell Medicine before we get into the specifics of menopause.

Susan Loeb-Zeitlin, MD, FACOG (Guest):  Sure thank you. So, our Midlife Program at Cornell is a new program that we are establishing with a multidisciplinary group of physicians who all have an interest in the care of women during this time in her life as she’s making her menopause transition. So, we have providers from primary care, psychiatry, neurology, integrative medicine, physical medicine and rehab, endocrine, cardiology and even others and the goal of the program is just the comprehensive care of women and also to educate women and also educate our healthcare providers about this time in a woman’s life.

Host:  It’s so important. I mean as somebody who is going through it; it’s important to be educated. So, Dr. Polaneczky, educate us. What is menopause? What is it? What’s our body doing during this?

Margaret Polaneczky, MD, FACOG (Guest):  Well first of all, thanks for having us. Menopause is very defined as the final menstrual period. So, once a year has passed, we call a woman postmenopausal and until that time, we call her perimenopausal. So, the key event is the last menstrual period. But actually, that’s just an external sign of what’s going on in the background which is a little more complicated. As we get older, the number of eggs in our ovaries begins to decline. This is actually declining our entire life. And as we hit the cutoff point of around 1000 eggs or so, we call ourselves menopausal. And this decline in eggs leads to hormonal fluctuations and that causes symptoms like hot flashes, sleep disturbances, vaginal dryness, urinary problems, irregular periods, weight gain and even new or worsening mood changes including worsening PMS.

And then finally, as we hit menopause and beyond, we experience increased risks of cardiovascular and bone health.

Host:  Yes, that’s also nice as I remember all of these things and women can look forward to this time of life. You know it’s really not that bad and Dr. Polaneczky, I’m sticking with you for just a second. As you just gave us a very good definition of what’s happening in our bodies during menopause; what are the indicators of perimenopause? When do these symptoms typically start and how do we know?

Dr. Polaneczky:  So, the most common sign that you’re heading into perimenopause is either a change in your periods such as heavier or lighter flow or a change in the frequency, how often you’re bleeding on a monthly basis. Or hot flashes even with no change in your period at all. Some women will tell us they’re beginning to have hot flashes around their period or the week before their period. Other women never have hot flashes but find that their cycles are becoming less and less predictable. They are more like a teenager in many ways. We begin to act the way we did many years ago. And these changes can begin years before your final period so, in your early 40s but for some women, they never happen, and women just one day stop having a period. So, it varies from one woman to another and it varies even for the same woman from one cycle to the next.

It's important to know though, that sometimes these changes like menstrual changes, heavy menstrual bleeding, can be caused by things other than menopause. Things like uterine fibroids, uterine polyps, thyroid disease and even stress can change our cycles. So, it’s important not just to assume it’s menopause but to sit down with your doctor and try to tease out what’s actually going on.

Host:  I love your point about the fact that it’s like going back to being a teenager again. So, Dr. Loeb-Zeitlin, once a woman’s going through perimenopause, does this mean she can no longer conceive and while you’re telling us that, tell us how do we know. How is menopause diagnosed?

Dr. Loeb-Zeitlin:  Great question. So, one can definitely conceive. What makes it harder during perimenopause is that the cycles become irregular and so, if one was using a rhythm method of contraception, it’s no longer reliable. And so we recommend the use of contraception until one is defined as being menopausal. So, until a year has passed since the last menstrual period. These change of life babies definitely do happen. So, how do we diagnose menopause? It’s not based on bloodwork. It’s typically based on the symptoms. We find that checking hormones is fairly useless although many women ask for it because they fluctuate very much between a cycle from cycle to cycle and within a given cycle. So, sometimes in a younger woman who is experiencing these symptoms, it’s helpful but they’re pretty unpredictable. So, we go by the symptoms.

Dr. Polaneczky:  It I could just add the age is really important for us. So, the average age of menopause is around 51 ½ years. So, a woman in her 50s who is presenting with irregular periods, hot flashes, vaginal dryness; there’s not much else that’s going to do that at that time in life. We might check thyroid just to be sure that’s normal because that can present at that age group but again, as Dr. Loeb said, it’s a clinical diagnosis. But if someone comes in at a much younger age; then the hormone testing might be useful.

Host:  What great points. Thank you both for making those important points for listeners. Dr. Polaneczky does our desire for sex automatically change as we enter perimenopause and menopause? I’m quite sure my husband would like to know.

Dr. Polaneczky:  Not necessarily. And in some women, actually not having to worry about pregnancy or even having the kids out of the house actually improves their sex life. It’s a myth that testosterone levels decline with menopause. They actually decline with age but there’s nothing magic that happens at menopause that lowers our libido. And so our testosterone levels don’t necessarily decline. In some women, actually, the amount of testosterone in their body increases in menopause leading to things like menopausal acne and the ubiquitous chin hair. But no, you should not assume that your libido is going to go away. But don’t forget this time of life is a stressful time of life for a lot of women. For some women, the empty nest is not such a happy thing and concerns about aging and our appearance can impact how we feel about ourselves and that can impact our libido as well.

Dr. Loeb-Zeitlin:  If I can add too, I think libido is very multifactorial problem. So, sometimes delving into what’s going on in a woman’s life can certainly help us. It’s not specifically perimenopause or menopause.

Host:  Well as we’re talking about our ubiquitous chin hairs, and Dr. Loeb-Zeitlin, anxiety, depression, these symptoms that you talk about and hot flashes and those not withstanding; but how can perimenopause and menopause cause mood disorders? Because it is pervasive. It’s common. Tell us a little bit about some of those types of disorders and how long do these symptoms – how long are they supposed to last?

Dr. Loeb-Zeitlin:  So, these symptoms typically last from two to five years. Sometimes longer for a few women. Usually they start and can be worse in the perimenopausal time and so by the time a woman stops getting her period, these symptoms may start to improve. For a few women, it’s lasts a lifetime but generally, it doesn’t. And so these are symptoms that we can deal with as they present.

Dr. Polaneczky:  If I could just add, I think for women who have a history of depression or PMS in the past, particularly women with postpartum depression; they’re telling us that their brain is sensitive to hormonal shifts. So, even though menopause is a totally normal life process; their brain may react in an adverse fashion for them. So, I think it’s a time to raise awareness in this group of women to really make sure we ask them how they are feeling emotionally. But it’s not fait accompli that everyone is miserable at menopause.  A lot of women sale through this time of life, I would count my mother among one of those people. And to be honest, myself a little bit. I didn’t have too much trouble with hot flashes. So, every woman is different, and I think we need to be careful that we allow for the variability and understand that it’s all normal.

Host:  I think that’s the most important take home message right here is that it is, but when we’re thinking of things that are not normal Dr. Polaneczky, what if we experience bleeding after menopause? We’ve talked about all of these things that are normal, what are some things we need to be concerned about that are not normal?

Dr. Polaneczky:  Well typically, once it’s been a year since your last period, a woman should not expect another period. So, if she does bleed at that point, it’s important to let us know. It’s interesting though, at menopause, we still have 1000 eggs left and it’s not uncommon for an errant period to occur. As I say to my patients, your body doesn’t always read the textbook. So, I saw a patient today who had an episode of postmenopausal bleeding preceded by breast tenderness and bloating and moodiness and you would have though she was 15 years old and sure enough she had a period. But we don’t know that until we investigate and make sure that it’s not something concerning such as precancerous or cancerous lesions of the uterus. So, it’s really important that you see your doctor if it’s been more than a year and you have a period or even if you just have any kind of bleeding that’s unexpected, different, concerning; that’s what we’re here for. Give us a call.

Dr. Loeb-Zeitlin:  If I can add, what I always tell my patients if it doesn’t look or feel like a period, you should let us know. Any kind of abnormal bleeding is not always a problem but needs to be evaluated.

Dr. Polaneczky:  Absolutely.

Host:  That’s so important and as we’re thinking about concerns that women have; Dr. Loeb-Zeitlin, are there any special health concerns we should be keeping in mind at this phase of life? Are there diseases now that we’re at higher risk for, osteoporosis, heart disease, any of these things?

Dr. Loeb-Zeitlin:  Sure. So, those two you just said it, are the ones that are most pronounced during the menopause transition. We see many women have an elevation in their lipid profile and many women will show their most significant bone loss during that time period. So, those are the main concerns. Definitely, it’s a great time to assess just where we are with our health and our lifestyle, healthy eating, healthy exercise, watching out for our sugar levels are all really important during this phase of life.

Dr. Polaneczky:  Yeah, I think I could just add, the word menopause, I like the pause part. It’s really a good time to just pause. And take a time to assess where you are, what choices you’ve been making up until now, the things we got away with when we were 25 in terms of diet and exercise; we’re not going to get away with now. So, it’s time to really stop and take assessment and take charge of our lifestyle and dietary habits going forward. Ok at things like smoking, look at things like alcohol intake and just be sure that you are really setting yourself up for a good second half of life. I also think it’s really important that women be careful of healthcare providers who use their interest to try to sell them testing and supplements. There’s no data that supplements for the average person prolong their life or their health in the absence of a vitamin deficiency. And many of these supplements are not FDA approved. So, just be careful that people don’t misuse your interests by trying to sell you products.

Host:  What great points. And I love that you say meno-pause. It’s a chance for women to pause and I know that because I’m feeling that and Dr. Polaneczky, what about sexual concerns. We’ve mentioned just very briefly vaginal dryness, sometimes libido. What else? Are we worried about anything in that regard?

Dr. Polaneczky:  Well I think actually vaginal dryness is probably the most common symptom that my patients present with in menopause and it’s one of the symptoms – unlike hot flashes that gets better with time; vaginal dryness gets worse with time. And particularly if you add in a partner with erectile dysfunction, because our partners are getting older as we are, you often have a couple who just kind of give up because it’s getting too hard to pull this off. And I think it’s important to assess what you can do to keep a healthy sex life with your partner and sometimes that’s using vaginal moisturizers, lubricants, thinking about vaginal estrogen if you are comfortable using that and continuing to have sex if it’s something that’s enjoyable and pleasurable for you. There are many nonhormonal strategies we can use to address the issue and luckily most of them work well. It’s important not be embarrassed to bring the issue up and really talk to your provider, if they don’t take the initiative to ask you first.

Dr. Loeb-Zeitlin:  And if I can just add, I agree. This is definitely one of the most common complaints women come in with and fortunately, we find it’s one of the easiest ones to help women with. I mean there’s definitely truth to the use it or lose it and so encouraging more sexual activity is definitely helpful. But then we have a whole bag of tricks that we can recommend as Dr. Polaneczky said from hormonal to many nonhormonal regimens that work really well.

Host:  Well then let’s talk about those Dr. Loeb-Zeitlin. How do we treat these symptoms of menopause? Speak about hormone replacement therapy, the types of hormone replacement that are available. Tell women what you want them to know about this because it’s a pretty confusing world and we hear about bioidentical; we hear all these terms thrown around. Tell us what that means.

Dr. Loeb-Zeitlin:  So, let’s start, the very first thing we recommend is just health management. So, watching out your lifestyle, your drinking, your exercise. Weightloss can often help these symptoms. Just dietary changes. So, we talk about what a woman is doing in her lifestyle that we can modify. And then the decision to use hormone therapy is very individualized, taking into account the severity of symptoms, risks for breast cancer and heart disease and personal biases about the use of hormones. For the average woman, with increased risk of heart disease or breast cancer; hormone therapy is definitely a viable option. And we talk about that. And there are different forms of hormone therapy from vaginal which is just mostly a localized form of hormone therapy to transdermal which goes through the skin and is definitely safer in terms of risks of clotting. We can virtually eliminate that risk. And then some women will prefer an oral form of hormone therapy.

When you asked about bioidentical hormones, many of those are compounded hormones that are not FDA approved or regulated. And the ones we prescribe are the same hormones, but they are FDA approved and they are more regulated and so, in our opinion, there’s more quality control to them.

Dr. Polaneczky:  If I could just add and reiterate a previous point. This is a place where a lot of misinformation is being sold to women by providers who are selling bioidentical hormones as risk free. If you use bioidentical estrogen it doesn’t carry any risk of breast cancer. And there’s no data to support that. And so, again, it’s really important that women really talk to their doctors and stick with evidence based regimens and we stick with that in our practice. If we’re going to treat you with hormone replacement, we’re going to use a product that’s FDA approved so that you know that what’s in that patch or that cream or that gel is what it says on the package. And that the manufacturing process is overseen by the FDA.

Dr. Loeb-Zeitlin:  And the good news is there are so many different ways we can do it with FDA regulated products that it’s so individualized and each person and their physician can come up with a regimen that works for them.

Dr. Polaneczky:  Exactly.

Host:  It’s such important advice. I’m listening so closely because this is really touching me and all of the people that I know in my age group right now and Dr. Polaneczky, one of the other concerns that we have, are there additional considerations, if you are looking at the science based evidence about hormone replacement, are there additional considerations for women who have a family history or genetic predisposition for certain types of cancers? We all want to know do they contribute or not? Are these things myths? Give us some of the pros and cons and tell us about genetic predisposition.

Dr. Polaneczky:  Okay so, when we’re considering the use of hormone replacement with a woman, the most important thing is to determine based on her family history and her own personal history if she’s at increased risk for any of the side effects of hormone replacement. The one that more patients worry about the most and the one that I think has gotten the most press, is the risk of breast cancer. It’s small, but it’s real. And the way I like to explain it to my patients in a way that we can get our head around is that if you choose to use hormone replacement for 20 years, your risk of breast cancer will be one to two percent higher. So, if you use it for just a few years to get through the hump of perimenopause; your risk is going to be well less than one percent. But it’s not zero. And for women who walk in the door with an increased risk because of family history, they may not want to increase that even a half of a percent higher than where they started.

And it’s important that we recognize their concerns and that we don’t sell them a bill of goods and that we’re giving them something that doesn’t have a risk. The other risk is a small risk of blood clots or stroke but we can practically eliminate that as Dr. Loeb mentioned by using transdermal preparations of estrogen. For women who have a uterus, it’s critical that she takes progesterone along with the estrogen because estrogen alone can increase the risk of uterine cancer. But when you take progesterone, that risk is gone.

Host:  That is fascinating. And so Dr. Loeb-Zeitlin, as we’re talking about the benefits of these treatments, what they can do for us; what are they doing? What are these hormones doing?

Dr. Loeb-Zeitlin:  So, where they benefit us the most is for the symptomatic relief of hot flashes which can improve sleep because many women get hot flashes during the night which we also call night sweats and definitely can improve our bone health. So, in doing all of this, it can also help anxiety because one is sleeping better and those are the areas where the systemic hormone will really help us the most.

Host:  Dr. Polaneczky, give us some ideas for holistic or alternative treatments. We hear about black cohosh; people talk about all of these things. Tell us about them. Do they work?

Dr. Polaneczky:  Sure. So, black cohosh is interesting. It’s an herb that actually binds to the estrogen receptor. And so, I tell my patients if you’re going to use that, you should assume it has the same risks as estrogen because your estrogen receptor doesn’t know where that binding came from and as I sometimes say, estrogen is estrogen, whether it comes from a horse or a plant or the moon. It all should be assumed to have the same risk and the same effect. You shouldn’t use black cohosh for more than six months even though it’s marketed and sold as safe. It is somewhat effective for some women but not as effective as hormone replacement.

The other thing holistically that patients can do is think about mindfulness based stress reduction. For women who have anxiety particularly, this can really be magical in terms of helping calm the mind and make one feel better by increasing parasympathetic tone and really creating a more neutral environment to exist in. Exercise, exercise, exercise. I can’t say it enough. I’ve had patients who eliminated their hot flashes, just totally lifestyle. Exercising, giving up alcohol, caffeine, doing mediation and find that they don’t need to take hormone replacement or other medicines.

And acupuncture is an interesting alternative regimen. It certainly isn’t harmful. And there’s some data that for some women it may be effective. Again, none of these things alone is an effective as hormone replacement but many women want to avoid taking the risks of hormone replacement particularly around breast cancer and these, I think are safe an certainly harmless activities to do. It’s important to avoid other herbs and supplements. Again, I’ll say it. just be careful our there.

Dr. Loeb-Zeitlin:  And if I can add, I’ve had women just through yoga improve their symptoms of menopause. So, really as we’ve been saying, it’s so individualized and each woman can find her own way to get through it. Sometimes in the office, we’ll just practice some deep breathing and that can help with the hot flashes too and also just with the anxiety that people are feeling. So, real important that each patient is taken individually, and we find a way to help get through this normal body process.

Dr. Polaneczky:  And one thing we didn’t mention, and we probably should is that there are nonhormonal prescription medications that can be quite effective for some women in alleviating the symptoms of menopause and perimenopause. Here, we’re talking about the serotonin reuptake inhibitors or SSRIs and other SNRIs, other psychiatric meds that are normally used for depression and anxiety. Actually at very low doses, treat hot flashes and can be helpful for sleep. So, drugs like Lexapro, Prozac, Effexor are just a few that may be helpful for some women particularly if they’re experiencing anxiety as one of their symptoms or depression and mood swings in menopause. Certainly, worth thinking about.

There’s another drug called gabapentin which is an antiseizure and antipain drug that actually decreases hot flashes as well. And can be helpful for sleep since one of the side effects it has is sedation. So, I make sure that we lay all these out on the table for our patients when they come in asking for help and help them choose the option that not only will help their symptoms but fits their comfort level, make sure we respect their choices and their desires and find the thing that works for their menopause.

Host:  What a comprehensive episode this is. We’ve covered so much ground and listeners, I can attest to the exercise, as an exercise physiologist, it helped me get through all of those symptoms and so as a result I was lucky, they were very light. So, everything these doctors are saying is spot on. I’d like to give you each a chance to say some final thoughts. Dr. Loeb-Zeitlin, starting with you. What do you want women to know, at this time of our lives about being our own best health advocate. Because that – we cannot take care of our loved ones and sometimes women in this age group are taking care of parents and kids still. So, we can’t take care of them unless we take care of ourselves. What would you like to tell the listeners about that?

Dr. Loeb-Zeitlin:  Well I think you just said it really well. I think it is a challenging time for a lot of women as they are in that sometimes sandwich generation and often forget about their own health. But just not being afraid to bring up symptoms with your provider because there are things we can help with and we’re comfortable talking about it all. And it doesn’t have to be a stressful time in your life. We can make it very pleasant and we can help you get through it in a very pleasant way and just talking about all the symptoms that are going on both mental and physical, we’re here to help you in every step. And again, as I mentioned at the beginning, our multidisciplinary Midlife Program at Cornell, will be a way for us to help with all the different aspects of menopause and the midlife transition.

Host:  Dr. Polaneczky, what would you like to add to that. Your final thoughts as well about women, menopause, perimenopause and the program, the Midlife Program at Weill Cornell Medicine.

Dr. Polaneczky:  I think it’s important to remember that menopause is a totally normal life transition that we use this as an opportunity to stop and assess how we’re living our life, how we’re taking care of ourselves and I think as Dr. Loeb said, you said it really well. To just pause and make the changes we need to make to enter the next hopefully many further years of our lives in a healthy way. Be wary of people that are using that interest to try to sell you products. Make sure you stick to treatments that are safe and effective and that anything you use, someone has explained to you not just the benefits but the risks and that you make informed choices to do what’s best for you.

Host:  One hundred percent. Thank you so much ladies, for joining us today and sharing really your incredible expertise. What an informative episode 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. That concludes today’s episode of Back to Health. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back to Health on Apple Podcasts, Spotify, Google Play Music. For more health tips please visit www.weillcornell.org and search podcasts. And parents, don’t forget to check out our Kids Health Cast. I’m Melanie Cole. Thanks so much for tuning in.