ZACH MOORE: Welcome to On Health with Houston Methodist. I'm Zach Moore. I'm a photographer and editor here, and I'm also a longtime podcaster.

KIM RIVERA HUSTON-WEBER: I’m Kim Rivera Huston-Weber and I’m a health writer for Houston Methodist.

ZACH: And Kim, we are joined by our colleague, Stefanie Asin. What’s up, Stefanie?

STEFANIE ASIN: How is everybody doing? Thanks for having me.

ZACH: Great. Thanks for being here. And we’re talking about menopause today which is something that you are familiar with.

STEFANIE: Unfortunately, I am familiar with it. I’ll tell you anything you wanna know.

[Laughter]

ZACH: Well, I am very unfamiliar with it.

KIM: Yeah.

ZACH: And I don’t know what my place is in this conversation as a male. Like, I don’t know -- I don’t wanna intrude on a female topic. Like, I -- what are your thoughts of that, Stefanie?

STEFANIE: It’s the opposite. The more you know, the better friend, husband, son, everything you will be. You should pay more attention than the women actually.

KIM: For sure, and I think a big part of wanting to do an episode on menopause is it’s a topic that just doesn’t get talked about even among women.

STEFANIE: So true. I have thought about my journey through menopause, which I’m pretty much done with, and about seven years ago it started, and I kept asking myself, “Why is this the best kept secret when half the population’s female will be going through menopause. I still can’t figure it out. Doctors didn’t talk to me about it. My own girlfriends didn’t talk to me about it. It was like, the way I kinda look at it in my mind is like the tsunami came and the Weather Channel didn’t warn me.

KIM: I think just as a culture right now, I think we’re on-ramping to a millennial pause. So, the oldest millennials are now in their early 40’s and, I don’t know, maybe it’s going to be an avocado toast type situation, where we think we’re going to hack menopause but there are so many devices and supplements. I’m getting all of these ads in my social media feeds right now. So, it does feel like menopause is having a moment, but I also feel like my grandmother, my mom, nobody sat me down for the talk.

STEFANIE: Well, you’re too young right now. I wouldn’t worry about it right now. And you can’t avoid it. There’s nothing you can do, and so, you just have to go through it. But it would have been nice to have known what to expect. For example, mine started about seven years ago. I am almost 60. And I knew I’d heard of hot flashes, I’d heard of night sweats, and it all sounded terrible, but you don’t really know until it happens. And what I would have done from my male gynecologist at the time who sat -- would have -- I would have loved it if he had sat down with me and said, “Okay, STEFANIE, this is what is going to happen.” Oh, and by the way, it doesn’t just happen over a 48-hour period. This is years you guys. This is the other thing that no one talks -- It’s years. It’s not like having the flu. “Whew, got through that. It’s week two.” Oh no. And it -- I can go into any details you want about the symptoms, but one of my main things I wanna express today is you should talk about it with your friends. You should talk about it with your doctors, and you should have a sense of humor about it. I have an amazing sense of humor about menopause. I was never shy. In the middle of a meeting, as corporate as you could be, if I was having a hot flash I’m standing up and taking off some clothes. Because this is my main advice, and again, I’m willing to get into any specifics, is talk about it. No one talks about it. And I would have been better prepared mentally.

KIM: Yeah, and I think it’s something to think about as United States is aging and with millennials now in their perimenopausal years or creeping up to them. They are the largest generation in the workplace today. So, we’re going to have to find solutions to help with this. And I think it all starts with talking about it.

ZACH: Well, you guys talk about education, like, you get with, like, puberty. Right? You’re in school, so you’re in a, you know, environment that can sit you all down in the classroom and talk about the change of life and the first change of life, right? And, you know, when you get to menopause age there is no infrastructure to, like, sit everybody -- like, whether you’re gonna do a workday, I don’t know. I don’t know what the answer is. But I can understand how they’re, like, the infrastructure is not there to educate the masses, so to speak, about this.

STEFANIE: And a lot of women are embarrassed. It’s a very personal, intimate thing that a woman is losing her menstrual cycle. It is a -- it is a sign that a woman is getting older. It is a very intimate thing and I think that is why no one talks about it. And even with my girlfriends, and I talk to them about everything, we really didn’t compare notes. And now that I think about it, that’s so stupid. You’d hear someone, every once in a while, say, “Yeah, I had quite a night sweat last night.” And I’m -- We’d be like, “You get those too? You have to change clothes and your sheets in the middle of the night?” And that is not a lie.

ZACH: It’s the whole, “I thought I was the only one situation,” right?

STEFANIE: Exactly. And what if we had been laughing about it the whole time. “God, didn’t that suck getting up at 3:00 in the morning and telling your husband to go to the couch ‘cause you have to change the sheets?” I mean, we could have laughed about it, but it’s just -- there still is a taboo about it, there is.

KIM: And I think a lot of it comes down to how we treat aging as a society. And I think, you know, men get to be silver foxes, but, you know, women become crones and just all of the horrible things that you can think of, and what is that tied to? Menopause. And so, do you really wanna have that conversation with your friends? So, I don’t know, I like joking about that stuff. You know, my friends and I have been like calling it puberty two, just because, you know, you know it’s going to happen so why not have a little fun with it?

STEFANIE: And you don’t kno -- you know it’s going to happen, but you have no idea. I mean, I remember a fight I had with my husband. I came home from the gym, and he had started cooking dinner. “Oh my God, how nice.” under any other circumstance. I had a full-on meltdown. Like, I was a witch on a broom. I mean, I was yelling at him about chicken in the oven. I could see my kids on the couch. They were in high school, and they crept upstairs.

[Laughter]

And I thought I had a moment. I thought, “Oh My God, this is ridiculous. I need to talk to the family.” Because they would never say, “Oh, it’s menopause, Mom.” Just like a woman never wants a man to say, “Oh it’s PMS.”

ZACH: Yeah.

STEFANIE: Same concept. You’re scared to say it even if it’s true.

ZACH: Yeah, yeah.

STEFANIE: Well, I got my family together that night. I said, “I just had the biggest fight I’ve ever had with my husband over chicken in the oven. So, from now on, call me out on it. We’re gonna laugh about it. We’re gonna diffuse the situation.” So, even families don’t talk about it. I noticed everyone stayed very far away from me for about a year. Don’t be sad for me. I am through the oth -- I am -- I mean, I am through the other side but I --

KIM: You know, I wouldn’t say I have anger problems, Stef, but, you know, I’ve been known to dabble. So, that is something that I’m worried about, are the mood changes that can accompany it.

STEFANIE: Well, there is, of course, some women can medicate to make their symptoms better. I chose not to. So, if you are someone who perhaps needs a little help as you’re going through this, you have to remember don’t be shy to ask your doctor for help. There are medications to take. They are controversial. Some women don’t want them. I didn’t want them. I thought I could do it without. So, there is help out there and if you are angry, you just have to have an understanding family and you have to believe that it is going to pass, and again, keep laughing. I laugh -- I still laugh about the chicken in the oven.

[Laughter]

KIM: I mean, it’s kind of nice to have a, “This is the chicken in the oven. We can move on.”

STEFANIE: It’s true. And the things that -- there’s couple things with menopause. There’s the physical symptoms, that no one has warned you about, that are terrible, and then the psychological. It’s like I would wake up some Saturdays, my favorite day of the week, the only day I don’t have to work. I just -- it’s a great day and I would have unexplained anxiety. Imagine waking up after a long sleep and you, for no reason, you’re just completely anxious about the day. I was very unaccustomed to that as someone who doesn’t suffer from anxiety. I was very unaccustomed to that. So, you have both sides. So, again, laugh about it with the people you love. Talk to your doctors. Talk to your friends and laugh about it because it will pass.

ZACH: Well, speaking of talking to it, who did we talk to about menopause, Kim?

KIM: Sure, we talk to Dr. Erin Manning, gynecologist with Houston Methodist, and she is a certified Menopause Practitioner with the Menopause Society.

ZACH: Great. Let’s get into your conversation.

KIM: So, I hit a milestone birthday last year and I’ll admit it’s made me somewhat hypervigilant. So, when I was younger and would wake up in the middle of the night feeling hot, I’d attribute it to, you know, I’ve got a husband and three stinking cats hogging the bed, I’ve got too many blankets on, that’s why I’m feeling hot. But now, I’ve started thinking -- when I wake up hot, I’m thinking, you know, “Was that a hot flash? You know, what’s going on? You know, am I in puberty two?” And puberty two is what my friends and I have started calling menopause, I think, just to make light of this thing that we know is going to happen to us at some point. So, I’d like to start our conversation by asking, is menopause really the other side of puberty? And is it fair of us to be calling it puberty two or is it something else?

DR. MANNING: You’ve brought up a really good point and some good questions right there, smack dab in the middle of it, Kim. Menopause officially -- the official definition is the cessation, the permanent cessation of the menstrual cycle. But that’s a pretty technical definition and it doesn’t really help us, you know, as women and as patients for what’s actually going on in our bodies. And I like the fact that you’re already thinking about it as a transition, and as the opposite of puberty, or the backside of puberty. Because that’s a really nice way to think about it. Menopause is not just one day. It is a transition that occurs in a woman’s life. It’s the transition that occurs from between the reproductive period and the post-menopausal period. The way I like to think about it conceptually is this. When you are six years old your female hormone levels are down here, rock bottom. When you are 26 years old your female hormone levels are up here, way up high. When you are 66 years old your female hormone levels are back down here, rock bottom. Now, you don’t just go from rock bottom to up here in one day. Your hormones levels go up and down, and up and down, and up and down, and up and down, until they finally reach this peak of the curve. You’re there at those levels for, you know, 10, 15, 20 years. And then, again, you don’t just go from high levels to low levels in one day. The hormone levels fluctuate. They go up and down, up and down, up and down, until they are down low again. So, it’s a natural physiologic process and, yes, I do like to think of it as kind of the backside or the other side of puberty.

KIM: And so, with our definition that we’ve set with menopause how does it differ from perimenopause? What’s the definition for it?

DR. MANNING: Yeah, I really like the term perimenopause better than the term menopause simply because, I think, perimenopause really implies the transition itself rather than just the one day stopping of the period. So, perimenopause is that five-to-ten-year window around the time of the final menstrual period. The average age of the final menstrual period is 51.5. Now, that’s an average. Some women will continue cycling well into their mid-50s and some women have stopped, for example, by 45. There’s no way to know for sure when your final menstrual period is going to be, or when any woman’s final menstrual period is going to be. It ends up being somewhat of a  retrospective diagnosis. And by that I mean this, when you go for 12 months without a period that’s when we say that was -- okay, that was the final menstrual period. The time period leading up to that final menstrual period would be termed perimenopause. And the symptoms of perimenopause can begin anywhere between two and five years, sometimes even seven years, before that final menstrual period.

KIM: It sounds like women are in perimenopause for a significant amount of time. So, what’s usually the shortest and what’s the longest a person might be in perimenopause?

DR. MANNING: Yeah, that’s a great question. So, the average number of years of symptoms is 7.4, but that’s an average. Some women will continue having hot flashes and night sweats well into the decade of their 60s, and 70s, and beyond. And then, there is another subset of the population that will never have a single hot flash at all. Now, those are two extremes, hot flashes and night sweats into the decade of the 70s and beyond, and no hot flashes at all. Most women fall somewhere in between that period. Again, the average number of years being 7.4.

KIM: We’ve kind of mentioned or alluded to night sweats and hot flashes. What are some of the other symptoms that women can experience during perimenopause, and what are some of the most common ones, and what are some of the weirder ones that you’ve heard from patients in clinic?

DR. MANNING: As you’ve mentioned, you know, hot flashes and night sweats, those are what I like to call the classic menopausal symptoms. Those are the ones that are the most common, that are usually the most bothersome, and that we also have some pretty good treatments for. But there are any number of symptoms, other symptoms, that can go along with the perimenopausal transition. And in some women, those can be as bothersome or even more so, than what we would call the classic perimenopausal symptoms. One of the more common symptoms during perimenopause is there’s an increased incidence of both depression and anxiety. It’s more common in women who’ve maybe already had a diagnosis of depression and anxiety in the past. However, there are some women who that will be their first time to develop either one of those what we call mood symptoms or mood disorders. So, we definitely see an increased incidence of what we will call mood disorders during the perimenopausal transition. I see and hear a lot about weight gain which is common, and it’s well documented during the perimenopausal transition. One of the interesting things that happens -- well, it's interesting to me as a clinician, it’s not very interesting as a patient, but -- or very fun as a patient, but one of the things that happens is there is a pretty steep decline in the basic metabolic rate. The rate at which we burn calories during the perimenopausal transition. There is a natural slow decline in the basic metabolic rate starting at age 30 all the way until, you know, we die basically. But that’s sort of a slow aging process. During perimenopause, that five-to-ten-year window the curve is even steeper. And so, if you eat the same amount and exercise the same amount during the perimenopausal transition you will gain weight. There’s just really no way around it. So, we do have to think about that and work on that during the perimenopausal transition. One of the other things that we see is, the term is actually brain fog, and we actually use that term in the literature as well. But basically, it’s -- there is a documented cognitive decline if you will during that five-to-ten-year window around the final menstrual period, it is different than the age-related cognitive decline. And we know, it’s well documented, there is gonna be a slow decrease in cognition over time that’s age-related and it’s a natural process, but there’s a little dip in that, again, right around the perimenopausal transition. Most of the time, most women will then go, at some point, five to ten years later -- will go back to whatever that natural cognitive level was for them. But it is -- it can be significant around the time of final menstrual period. And it’s worrisome and can be pretty bothersome for patients. Other things that we hear about joint pain tends to be a little more common around the time of the perimenopausal transition. Mood irritability, so not clinically diagnosed depression and/or anxiety but just more of what we could call irritability, shortened fuse. Those kinds of things are -- I hear a lot about in my practice.

KIM: Yeah, I’m sure. One of my girlfriends refers to it as “the rage.”

DR. MANNING: Mhmm. Yeah. And women have varying degrees of that.

KIM: Yeah.

DR. MANNING: But yes, it’s documented.

KIM: I’d love to know, since this is a natural process, women have been going through this since, you know, time immemorial, how has care for perimenopause developed, how it changed over time? In looking at how my mother and how my grandmother, even, spoke about, you know, their change of lives, as they called it. They took different approaches. So, I would just love to know how has care changed over time for women experiencing perimenopause?

DR. MANNING: So basically, we’ve been using medications to try to manage perimenopausal symptoms for decades. You know, hormone therapy continues to be, you know, the gold standard for management, our first line treatment for management of perimenopausal symptoms. Interestingly, one of the things that did happen historically that changed a lot of how we practiced was back in 2002 when the WHI study came out. At that time, I believe around 70% of women were on hormone therapy and this study was published. It was actually, I remember it ‘cause it was my birthday, but released on July 9^th, 2002. I was a year into practice, and I was on vacation celebrating my birthday. And the next day coming back in the office was the busiest day in the office in my entire 23 years of practice. The phones were ringing off the wall ‘cause the front page, I believe it was the New York Times, had the results of this study. So, there is a large cohort of women that essentially flushed their hormones down the toilet that day or that week because of the findings of that study and because of how the findings of that study were presented. It turns out over time we’ve been able to look at that data again. Tease out some of the data. It was a good study. It was well designed. The problem probably was more in how we presented it to the public. But we still use data from the WHI today. The more important data that we use came out about ten years later, in 2013 I believe, is when they rehashed it and looked at hormone therapy administered to women at a younger age. The average age of women in the initial study was 64 and that’s not the women that we are treating now. So, they teased out the data and looked at the women who were in their 50s and the number were a lot different. So, with that being said a lot of women went off hormone therapy and we’re off of it for a long time. Thankfully, the pendulum is swinging back the other way. Again, we’ve relooked at the data. We have more science and so, we do know that hormone therapy can be used safely in many women to manage menopausal symptoms.

KIM: I’ve remembered when my mom and my aunts were going though -- they were in their late 40s and early 50s during the time of that study and I remember it being a big topic of conversation. And then, we also had my grandmother chiming in that, you know, she felt like hormone therapy increased your risk for endometrial cancer which might have been something that she picked up around the time, but she was going through the change. So, what -- are there risks to hormone therapy? Because if I -- I’m trying to understand if, you know, most of that is coming out of the Women’s Health Initiative study or has -- or did something preexist that as well.

DR. MANNING: You know, hormone therapy is medication. So, any medication is going to have risks. I mean, if you read the package insert even on Tylenol you probably wouldn’t take it. We have to approach it from that standpoint that yes, it’s a medication. There may or may not be some risks associated with it. We’ve got hundreds of studies now about hormone therapy, safety data, efficacy data. And, you know, some of -- unfortunately, some of those studies conflict. Some of that probably has to do with the study design and the patient population. So, it’s important for us to sift through that literature and try to get to the meat of what really are the risks involved. And here is what we can say with fairly good certainty. There maybe a slightly increased risk of breast cancer in women who are on hormone therapy. In the WHI study there were nine more cases per 10,000 women of breast cancer. That’s a low number but it was statistically significant. An interesting caveat to that statistic is that that was in the women were on both estrogen and progesterone. In the estrogen only arm there was actually not an increased risk of breast cancer. But we’ve got enough literature out there to support the fact that we can say there may be a slightly increased risk of breast cancer in women who use hormone therapy. Another risk you brought up earlier is endometrial cancer. Endometrial cancer is cancer of the uterus or of the uterine lining. And initially, when we started using hormone therapy, we were using estrogen alone. That was certainly a very concerning risk. Now we’ve learned that in women with a uterus who’ve not had a hysterectomy, as long as we add progesterone or a progestin to the estrogen regimen then we really don’t have to worry about that endometrial cancer risk. So, unless the medication is dosed inappropriately, the likelihood of it increasing the risk of uterine cancer is very low. You know the biggie, the big question  is the incident -- is the heart disease, heart attack, and stroke. And it turns out there may be a slightly increased risk of heart disease, heart attack, and stroke. That same WHI study which, again, was a large study, well designed, randomized, controlled. There were 11 more cases per 10,000 women of heart attack or stroke. So, again, a low number but statistically significant. And that’s actually the reason why they stopped the study. Since the publication of that though we’ve learned where we’re calling it now sort of the timing hypothesis. It turns out that taking hormone therapy at an earlier stage so -- and by that I would mean closer to the time of that final menstrual period  i.e. 51.5. So, starting hormone therapy around that time period actually may have a decreased risk of cardiovascular disease later on in life. So, that’s kind of hot of the press and it maybe that the starting women -- or not maybe, but starting women on hormone therapy more than ten years past the final menstrual period. Those are the women that it increased the risk of heart attack and stroke, because it’s a blood clotting risk.

KIM: So, we’ve talked about hormone therapy, are there other treatments that are used to help with sort of all of these halo symptoms that we’ve got going on during this time of life?

DR. MANNING: Yeah. Yeah. That’s a great question and thankfully, we do. Again, hormone therapy is our first line treatment and quite frankly, it usually works better than anything else. But we do have other treatments that can help. I like to kinda divide our treatment options into pharmacologic and non-pharmacologic. And so, in the pharmacologic bucket I’ve got hormone therapy, I’ve got a class of drugs called SSRIs or SNRIs, and then there’s several other drugs, Oxybutynin, Gabapentin, and Clonidine. They are kind of random drugs that also can help with hot flashes and night sweats. And then we actually have a new class of drugs called Neurokinin 3 Antagonists that can also help with hot flashes and night sweats. I’d say for me and my practice the most common go to non-hormonal medication is gonna be usually Effexor or Lexapro. Effexor is an SNRI. Lexapro is an SSRI. But basically, those are drugs that were originally designed to use for depression and anxiety, and it turns out in lower doses or in half strengths they actually help with hot flashes and night sweats. And I have found Effexor really to be the most effective one but again, I use Lexapro, Paxil, Prozac, Zoloft, and all of those in that drug class at low doses can help with hot flashes and night sweats. So, that’s a really nice option. The newest class of drugs which really exciting, the Neurokinin 3 Antagonists, the only one that FDA approved so far is called Veozah. It was just recently approved within the last year, and it works at the level of the hypothalamus which is up here in the brain. And it actually affects the -- what we call the candy neurons which are directly involved in basically our thermoregulatory system. So, the system that helps manage your body temperature. So, it acts directly there at that level. So, it’s a really nice option. There is at least one other drug that’s coming down the pipe in that same class that I think should be approved sometime this year. So, that’s kind of our non-hormonal pharmacologic treatment options. Now, we also have non-pharmacologic treatment options and those are, you know, lifestyle things. We know that, you know, a healthy, well-balanced diet, we know that exercise can help. There are some limited data about yoga. There’s some limited data about mindfulness. There’s limited data about acupuncture as well. So, lifestyle issues and treatment options can also help with menopausal symptoms. I like to think about it like this. It’s kind of similar to when we talk to patients about PMS and about management of PMS symptoms. So, what I like to think about with PMS is all of those things -- all of those health things that you know to do to take care of your body properly. So, eating a healthy, well-balanced diet, drinking your eight glasses of water a day, getting seven hours of sleep every night, exercising regularly. Specifically focusing on those during the time right before your period is gonna help your symptoms. It’s the same thing around the time of perimenopause. Focusing on those things and really being disciplined about that can help. Now, again, you can do all of the right things and do them perfectly and still have symptoms, and thank goodness we have meds for that. But we definitely know that lifestyle choices can affect menopausal symptoms.

KIM: You know, we have so many conversations and it’s always mind blowing that -- I guess not really mind blowing but just -- it all kind of comes down to doing all of those things that you need to do to keep your body healthy no matter what stage of life you’re in, always seems to be the answer and the best medicine.

DR. MANNING: Well, at least part of the medicine.

KIM: Yeah.

DR. MANNING: For sure.

[Music plays to indicate a brief pause in the interview]

ZACH: Menopause has been described as far back and ancient Greece with Aristotle writing about the age range when women lose the ability to bear children between the ages of 40 and 50. In the 19^th century a French physician gave the transition a name, menopause, which comes from the Greek word pauses which means pause, and men which mean month. The idea that a substance was the missing factor in a woman’s body after menopause, originated during the same time when cow ovarian tissue was injected into German women in a successful attempt to reverse the sexual symptoms of menopause. The role of estrogen was first accurately described in guinea pigs in the early 20^th century. And the first hormone replacement therapy Premarin, a complex of conjugated equine estrogens, was first marketed in the U.S. in 1942. Approximately 1.3 million women will go through menopause each year in the U.S. according to the National Institutes of Health. And while menopause is diagnosed retroactively, after 12 consecutive months without a period, women will have five to ten years of perimenopause often experiencing symptoms at ages when they’re balancing a myriad of responsibilities. From being at the height of their careers, raising families, and caring for aging parents. And we’re officially entering a millennia-pause, by 2030 the median age in the U.S. will be 40. And there will be more women between the ages of 40 and 64 than women under 18 according to the U.S. Census Bureau projections. Millennials currently make up the largest generation in the workforce. And the oldest millennials, now in their early 40’s, are entering the perimenopausal age window.

[Music plays to indicate resumption of interview]

KIM: We’ve sort of talked about that perimenopause is a natural process and the body is gonna go through it. I know that there are probably some women who experience symptoms who think that interventions may not be warranted and there maybe women who have -- simply have difficulty with access to care. So, are there any long-term health implications if you’re going through symptoms and you don’t receive care or interventions?

DR. MANNING: That’s a really good question and it’s one that we’re really starting to pay more attention to in the field of menopausal medicine. I mean, we’ve had an inkling that these symptoms can cause some long-term health issues, but we really haven’t had the science to back that up. But there are some new data out suggesting that women who experience more severe hot flashes and night sweats do have some poorer long term health outcomes, you know, mostly that would fall under the cardiovascular category. Again, that data is still actively being looked at. And the next question we should ask ourselves really is, okay, if we have shown that an increased incidence of those symptoms causes these outcomes the next question is, well, if we intervene and try to help those symptoms does that change the outcome? And that conversation is still ongoing. We know the interventions help the immediate symptom management. But we are still working hard to answer that question properly and scientifically. I would think that we are going to learn that intervention treatment of symptoms does improve certain health outcomes. And when you think about what’s going on with the sleep literature right now, I mean, we’ve been -- we’ve shown poor sleep patterns can lead to cardiovascular disease, pulmonary disease, I mean, the list goes on. So, I think it’s going to be similar ‘cause, I mean, part of one of the big symptoms is sleep disturbances. So, I think we’re gonna learn that as time goes on. But we’re still -- we’re still studying that.

KIM: In my research for our conversation, I saw that there have been some studies that neurological changes that accompany menopausal symptoms are linked in dementia for some women. So, I think, there was one study that showed that hot flashes during sleep were associated with an increase in blood-based Alzheimer’s biomarkers, and there was another study that showed hot flashes are associated with an increased amount of tiny lesions in the brain. But since all women go through menopause not all of them are going to develop Alzheimer’s. So, for someone who might have a family history of dementia, or Alzheimer’s, or someone who simply wants to stay sharp as they age, do you have any advice or thoughts on that?

DR. MANNING: You know, the dementia question has been asked for a long time about this. And we’ve been looking at the question, you know, specifically, does intervention with hormone therapy change the chances of developing Alzheimer’s or any other type of dementia later on in life? And, you know, there have been conflicting studies. There have been studies that have shown a slightly increased risk of dementia in hormone therapy users, and there have been some other studies that have shown a decreased risk. Most of the data now suggests that hormone therapy is essentially neutral as far as -- so in other words, we don’t use hormone therapy to try to prevent dementia later in life. But we feel pretty certain that it’s not gonna increase the risk either. The one thing that we have been able to -- the data has come out pretty clear on is this. Starting hormone therapy after the age of 65 definitely increases the risk of dementia so that’s a no no. So, we use hormone therapy for symptom management around the time of the final menstrual period. We don’t start it at 65 or older. And that data is pretty clear, but the rest of it, I think, that the final say will be that it’s neutral. You know, anytime you’ve been researching a scientific question for so long and we haven’t figured it out -- like, we know smoking causes lung cancer. We figured that one out. We’ve been looking at this question long enough. I think if there was a big enough difference, one way or the other, we would have teased it out by now.

KIM: I’m sure that you are no stranger to the horror stories that exist online or the stories that women tell each other about having experiences in clinics when they’re bringing up that they think that they might be in perimenopause or having symptoms. So, for women who might come to you and say, “Dr. Manning, I think I’m in perimenopause or I think I’m going through the change.” Can you walk me through how that conversation should go and if someone is with a clinician and they are feeling dismissed or not heard how could that person advocate for themselves in that moment?

DR. MANNING: One of the first things I will usually ask about when a patient asks me, you know, “Am I in menopause or am I in perimenopause?” Is I like to walk it back to the menstrual periods and I’ll say, “Okay, so, let’s talk about your periods. What are they doing?” And part of the reason why I direct the conversation to that is because it’s really important that women track their periods during the perimenopausal transition. I mean, it’s important all the time, but especially during the perimenopausal transition ‘cause that’s actually how we figure out where you are in the process. And so, by starting with that I’m hoping to emphasize that, “Hey, it’s really important that we look at your periods, and think about your periods, and see what’s going on with your periods. While that is one of the hallmark symptoms of perimenopause is menstrual changes, there are some menstrual changes that occur that are not normal, and we would wanna evaluate. And so, again, I wanna make sure my patients are educated about that because I certainly don’t wanna miss something that needed to be evaluated. So, we usually start by talking about menstrual periods and then I lead into questions about symptoms. So, you know, something like, “Well, what kind of symptoms are you having that make you think this process might be going on?” Because what I really think that we need to focus on is the treatment of the symptoms. So many women will come in and ask to have their hormones checked which is, you know, probably a very similar question to the one that you just asked me. And those same symptoms are probably prompting that question, and again, we don’t treat hormone levels, we treat symptoms. So, we don’t typically need to draw blood to determine where or where you are in the transition, or whether or not you are in the transition. The blood levels don’t really particularly help us. You know, if it looks like a duck, and it quacks like a duck, it’s a duck. You know, if you’re 42 and your periods are irregular and you’re having some night sweats, you’re in perimenopause. I don’t need a -- I don’t need a blood test to tell me that. So, then once we’ve determined “Yes, you are,” then we launch into, “Okay, what are we gonna do about it?” And my first job usually before we start talking about treatment options is I do like to kinda explain the process itself a little bit, kind of like we’ve talked about today. I usually like to use that graphic about, you know, you know, being the backside of puberty. I love that you and your friends are talking about that. That just warms my heart. But I usually try to talk a little bit about the process itself, the physiology, of the process but really not focusing on hormone levels. Then we start talking about symptoms and what are we gonna do about your symptoms, how are we gonna manage your symptoms. So, the problem with checking hormone levels is they’re gonna be different at 3:00 p.m. versus, you know, Monday versus Friday, versus 10:00 a.m. So, hormone levels are over the map by definition in the perimenopausal transition. So, it’s not really helpful.

KIM: That leads to my next question. So, as we’ve established, I am a person of a certain age and I’ve started getting all sorts of promoted content and ads because it seems that perimenopause is really having a moment right now, or at least it is in my Instagram feed. So, I’m getting all of this content about, you know, you should have your levels checked when you’re in your early 40’s. So, you’d then down the line you’d know what’s happening with you. And there are a lot of new telehealth and medical device companies that -- startups, that have celebrity funding or celebrity CEO’s. And so, it just seems that, at least for me, it’s everywhere right now. So, where do you fall on -- well, we know how you feel about the level checking, but what do you think about using telehealth as potential care? Since at least so much of it that I’ve seen it’s really marketed to, you know, some of the, like, weight gain and some of the other, maybe, visual symptoms of the condition.

DR. MANNING: Telehealth, you know, is a great thing for very certain, specific things. I would have concerns about telehealth for a new patient, you know, that hasn’t been seen in person when the outcome of that telehealth visit is a prescription of a medicine, a hormone therapy. I mean, I feel pretty strongly that you need a breast exam and a pelvic exam before you start on hormone therapy or another other therapy for menopausal symptoms. And it doesn’t have to be the same day that you start the medicine, but we need to know that that is an ongoing process. And how often that needs to happen, that’s a whole nother conversation. But telehealth visits with the physician or provider that you’ve never met and then ends with a prescription, I have some concerns about that just from a medical safety standpoint. You know, certainly if it’s just an educational telehealth visit or informational session then great. I don’t necessarily have concerns with that.

KIM: And there are lots of over-the-counter supplement type things out that are emerging that I keep getting ads for. What level of caution should women have when, you know, getting ads for things that say that they are going to help with their hot flashes, you know and they’re not working with a gynecologist.

DR. MANNING: Yeah, I mean, obviously, the, you know, the herbal supplements and treatments are, you know, the common approach these days. My concern with any of the over-the-counter supplements, or herbal supplements or treatments, fill in the blank with whichever one, is just the level of evidence-based medicine that we have to support them. And we have very little safety data or evidence-based medicine to support any of those supplements that are over the counter. That industry is not regulated by the FDA. I mean, say what you want about the FDA but at least there are some regulatory oversight. So, I just have safety concerns about that, and they can pretty much say whatever they want as far as management of symptoms. I don’t think you’re allowed to say you can treat diabetes or treat sleep apnea, but I think you’re allowed to say you can treat symptoms without really having much science or data to back that up. So, I just have concerns about that. And the nice thing is that we do have so many options now that we can use to treat the symptoms, and options that have been studied, and studied, and restudied. So, I just like to go with things that we have data and science about. But I’m sure it must be overwhelming to have all that in your inbox all the time.

KIM: Yeah, and I just think it’s something that with so many companies entering this space because they feel that there is a void for it, there just seems to be a lot of noise. And maybe it’s just because us elder millennials are now getting to that age and maybe we’re going to biohack perimenopause too. But --

[Laughing]

DR. MANNING: Well, menopause can be a particularly vulnerable time in a woman’s life. I mean, let’s just be frank about it. It can be quite challenging. Some women breeze through it with really no big deal, but other women it can be debilitating. And so, I understand that  -- I’m sad that my profession is not doing perhaps a good enough job to help those women. I hope that we’re getting better at that, and I’m disappointed that we’ve not been able to reach women properly with the medications and treatment options that are available that we’ve studied, and restudied, and poured so much of our money and our resources into. So, shame on us for not getting the word out properly so that now there are other people sort of stepping in for that. So, I, as a physician, I’ll shoulder some of the blame of that but I hope that we’re doing better.

KIM: There are over-the-counter tests that are alleging that they can tell where women are in their perimenopause or menopausal journey. What do you think of these tests and, you know, you said, “if it acts like a duck, if it quacks, you know, it’s a duck.” What value would an over-the-counter test have for a woman potentially?

DR. MANNING: I can really think of a reason why a test like that would be helpful or particularly appropriate. Again, for the diagnosis and management of menopause we are -- since we’re not really using hormone levels to diagnose or treat, you know, doing that, I mean, it’s just -- it’s data that may or may not be accurate, and is not really going to be particularly useful. Now, I will say this, sometimes we do blood testing to rule out something else. The most common thing would be thyroid abnormalities. Sometimes thyroid abnormalities can actually mimic some of the perimenopausal symptoms. So, you’ll find we sometimes ordering thyroid studies on a patient who comes in maybe she’s outside the range that I would expect, or maybe her symptoms are not quite exactly what I would expect, and so, I need to rule out other reasons or causes for her symptoms. So, I use blood levels there but it’s not -- I’m not gonna add in an FSH and an LH and an Estradiol because those aren’t really gonna help me. I just need to know that it’s not this. So, again, I don’t know that I really see any great opportunities for that to help our patients through the transition.

KIM: So, I started our conversation by sharing how my friends and I have been calling menopause puberty two, and you know, we’re using humor to face this looming transition in our lives. And a big reason I wanted to do this episode was to get a better understanding about it and to help kind of calm my nerves. So, I’d like to end by asking you what you would tell a patient or perhaps a friend who might be at the start of perimenopause and they’re feeling scared or they’re just having feelings about it? What would you tell them?

DR. MANNING: In my perfect world, you know how we sit down all of our nine-year-olds and ten-year-olds in P.E. class, and we separate the girls and the boys and we talk to them about puberty. “These are the changes that are gonna be happening to your body in the next few years. Here is why those changes are happening. Here is what to expect and here is what’s not normal, and here is where you should talk to somebody. If this, this, or this happens, this is when you should talk to an adult or talk to your doctor.” We do a great job of that as a society. In my perfect world we would have that conversation again at 35. We would sit down all the 35-year-old women and say, “Here’s what’s about to happen. These are the changes that may or may not occur. These are the reasons why these things are happening to your body. And we have some things that can help the symptoms, but some of it is just a transition and know that eventually you’ll be on the other side of the transition.” So, that would happen in my perfect world. Is that we would address this on a large scale. This is what’s going on. This is what’s gonna happen, why it’s gonna happen, and here is what we can do to help. And this is not normal, and this is when you should talk to somebody about it.

KIM: I’ll say in response to you that I would love for when I turned 35 that someone would have that conversation with me. Because, you know, I’ve sort of -- evoking your imagery, you know. I remember when my mom had the talk with me, but I didn’t follow up with my mom to be like, “So, how was your perimenopause? When did you start?” And, you know, I think that’s probably a lot of some older generations didn’t really, like, enjoy having those conversations. You know, I don’t think my mom particularly relished giving me the talk, but it was informational and helpful. But I think having that on the other side would be just as helpful. What would you say to someone if you had a patient who was at that start and felt like they were perimenopause and they were actively afraid of the transition? Is there anything you would say to help calm them?

DR. MANNING: I mean, I would try use the language of, again, it is a natural physiologic process that your body is gonna go through. And that the way that women traverse, there’s a wide spectrum, a wide variety of ways that women traverse through the process. Some women have severe debilitating symptoms, and some women have hardly symptoms at all. But if you do end up being one of those women who does have severe debilitating symptoms please reach out because we do have things that can help.

KIM: And something that you’ve said sort of throughout I think I’m going to take for my self after leaving here today is the idea that you’re really traversing through this change. And I find that immensely helpful, so I think you’ve answered a lot of my questions personally, and I hope you’ve answered a lot of our listeners’ questions too.

DR. MANNING: Well, thank you, and thanks for having me.

ZACH: Alright. Well, I definitely learned a lot about menopause. Something that, honestly, right, I haven’t put a lot of thought into ever really. But, you know, we all have women in our lives, right? Moms, significant others, sisters, friends, right? And this is helpful information for men too because how do you react to this massive change, the change of life for women, right? How do you react to that and interact? It’s good to be as informed as you can be. So, even though you think, “Well, I’m a guy, this doesn’t apply to me.” You should ne paying attention to these details, right?

STEFANIE: I love that you said that because, Zach, you are right on. Men want to know. Men want to be there and to support women, but they have no idea what to do or what it is.

ZACH: Yeah.

STEFANIE: So, you’re right.

ZACH: Okay. So, Kim, as you kind of stared down the barrel of menopause here, what are your thoughts after this conversation?

KIM: I feel better educated and it was really the reason why I wanted to do this episode, was to get an understanding of what to expect. Because I don’t think, as Steph said, at the top you really don’t know what it’s going to be like for you individually, but knowing the experiences of other women, knowing what the average ranges and kind of what you can expect, I think can only help me feel less intimidated by it. Because, you know, like, no one wants to think, “Oh great, I’m going to go through puberty again and have acne and sweat profusely. That sounds like a really great time.” But, you know, looking at it with humor and being able to be educated only benefits you.

ZACH: Yeah, I mean, again, the least we can do as men is to try to understand what you guys are going through, right? Because we know -- and we all go through puberty at the same time, but then men don’t have to worry about puberty two as you put – I love that terminology you used there, Kim.

KIM: Just, I don’t know, it’s my way of thinking of it. And that was something that Dr. Manning said and really focusing on the transition of it. And that for some it might go a little bit longer than you want it to even after you have your final period.

STEFANIE: There is no finality. It is the gift that keeps on giving. I hate to depress you, Kim. Not for everybody, and not as frequent, and not as bad, but I can tell you I still have hot flashes and it’s not every day, but it comes on and you know it. It’s unlike anything else you’ve ever felt. I still have night sweats maybe once every couple months. It’s way better, I’m normal, but it is the gift that keeps on giving, that is for sure.

ZACH: Well, I have a question for you guys, like, well, especially you Stef. So, like, you go your whole life you have your period and you’re like, “Oh, wow do you think -- I can’t wait till this is over and I have menopause.” Was that your initial thinking until you experienced it for yourself?

STEFANIE: Zach, I’m glad you asked. It is the one awesome thing about menopause.

[Laughter]

ZACH: Okay.

STEFANIE: It is. It is so freeing to not have your period anymore. There you go, I said something positive about menopause.

ZACH: There we go. We found it.

KIM: Yeah, I don’t know. I think maybe I’m still at that point where it’s annoying, but it’s there so might as well just deal with it. But, I don’t know, maybe not having to pay the female tax would be kind of nice.

STEFANIE: And you don’t ever have to worry about getting pregnant again.

[Laughing]

ZACH: Another positive.

STEFANIE: Another positive. You know, it’s funny there’s also some other things that happen through menopause, and not to every woman, of course, but I didn’t realize that many women have some medical issues. Estrogen apparently has some protective qualities as well. I have never in my life had a cholesterol above 140. I’m a vegetarian. That’s not why I was mad about the chicken dinner, by the way.

[Laughter]

But --

ZACH: “You know I don’t eat this.”

STEFANIE: Exactly. So, I, after menopause go for my annual physical, 250. And I asked the doctor, I exercise every day. I eat right. It’s like menopause, your hormonal imbalance and the changes can cause this to happen. And I am now like the average 59-and-a-half-year-old person on a statin, and I blame that on menopause also. I know I’m sounding really depressing but this not something that women should be depressed about. It is a normal part of life. You just have to know it’s coming. And women can handle these kinds of tough situations way better than men, so just remember that. We are equipped to deal with this, and it will be over and just keep on laughing.

ZACH: Alright. Well, that was some great advice, Stefanie. And thanks for joining here on On Health with Houston Methodist. Be sure to share, like, and subscribe wherever you get your podcasts. We drop new episodes Tuesday mornings, so until then stay tuned and stay healthy.