The Group Chat | Menopause

The Group Chat | Menopause | AHN

This part of life is more than just hot flashes. Learn about the stages of menopause, symptom relief strategies, treatments, and coping tips.

all right welcome everyone to another session of the group chat we're so excited you decided to join us today uh just some quick housekeeping to go over um there will be a Q&A at the end of the presentation so if you submit questions into the Q&A bar at the bottom of your screen they'll go in uh they'll go to me and then our speaker will answer them at the end of today's presentation this presentation is being recorded however no um attendees will be identified and as a reminder the information shared in this presentation is not medical advice but we will be providing additional resources at the end of today's talk so with us today we have Dr marshia Klein Patel Dr Klein Patel currently serves as the system chair of the women's Institute at alagan Health Network she co-founded the inaugural midlife medicine practice at Ahn to support women as they navigate men at pause she's a true expert on this topic and we're excited to have her here with us today and so without further Ado I'll pass along to her well thanks for everybody for taking your lunch hour with me um happy to have you all join me um I am also as as Brie said this is the um only practice I've ever done it's it's the um practice that I came in out of my residency doing for me this is a real opportunity to focus on healthc care as a window into the rest of our lives I've been really excited about the fact that menopause is finally part of the national conversation but I also think in some of that National conversation it's really hard to sort out like what is true and what is not true and I'm hoping today that I can give some I'm going to say like fundament m al Basics by which you can think through all of those things that you're hearing and reading and certainly as Brie said this is just general advice um anything we do individually may be different based on someone's symptoms or their personal concerns or their background medical history um but I hope that we can have a a starting place for us all to be able to have shared dialect um as we try to help people be healthy through the midlife so when we talk about manop fundamentally I think about this as sort of two different things par menopause or the menopause transition is that like one to five years around the time of your last menstrual period um it is characterized by less regular periods in the onset of H flashes and menopause is the is defined by one year after you're done bleeding and can occur anywhere and be normal between age 40 and 56 and so why do we undergo menopause we all have as many oos sites as we're going to have actually one more 20 weeks in utero and even be even at that time then our ovarian reserve starts to go down and then it's stable until we start having our reproductive lifespan so we start having menarchy and we start um ovulating every month and so gradually there's a depletion in the O sites that are available um and so your brain asks your ovary I say to like release an egg and at some point your ovar is like no I'm tired I don't have anything left and the brain keeps yelling louder and louder and and in the early par menopause this is fine it works your overy gets on board and it gives what it has left but then at some point it no longer can release that egg because there are no active or uh follicles left um and so um those we stop releasing eggs and so hormones are the communicating system between the brain the ovary and the uterus for me um I think it's really helpful to think about the uterus as being the sign for what's going on with the hypothalamic pituitary ovarian access so if we're bleeding and we're bleeding every month then I know relatively where people are in their cycle because they're bleeding every month um so as we get closer to our final menstrual period the pituitary hormone FSH will continue to go up and estrogen will continue to go down because we're not releasing follicles every month there's another chemical inhibin that plays in this role and so after menopause those things stay steady state um we'll hear a lot of people talk about like hormone balancing after menopause for me that's a little bit of aoma because if you can see in that bottom graph there are stable they're doing what they're doing um but we doesn't mean that we necessarily feel well and I think that that's a very different conversation and then I always press the buttons and have to figure out where to move myself forward so if we then take at that stage before menopause then break that out again into two parts there's the part that's right before we start we we stop bading and then the part before that so an early per menopause from most women this will start somewhere after 40 maybe 45 if they are not using any hormonal methods for contraception or for any other reasons like heavy bleeding people may notice that their Cycles will be three to five days closer so instead of being a 28 day cycle they might be at a 23 day cycle or 25 day cycle they may notice at the time of ovulation that they have more breast tenderness more mood changes and more headaches these are specifically to the ovulatory time period and so if they're occurring all of the time then they're not related to the cycle if they're only occurring in that time period the 14 days before your period Then they are and some of this is again because the pituitary is yelling at the ovary and the ovary is like yelling back and is making it work out later in the per peral pule transition the pituitary is yelling your OV says like leave me alone and so we start to space out our cycle we'll start to have ovulatory Cycles um and we'll start to skip this is the time of the most wide hormone fluctuation that people will see and again on average three years before the menstrual period can be five but the worst of those symptoms tends to be about 18 months before done so the symptoms are caused by these like change in that late par menopausal in the hormone balance but no single hormone is actually the culprit the most common symptoms the par menopause are going to be hot flash and night sweats irregular bleeding I'm going to pause there in irregular bleeding it should only be a cyc length difference so people should not have heavier bleeding they should not have longer bleeding and they shouldn't have um intermittent unscheduled like I bled three days and I bled three days after that and then I bled three days days after that those things would should all prompt you to see um your OBGYN but if your Cycles are um you know every you know 36 days and they're lasting two to three days and they're relatively light that's actually really normal in that late par menopausal Time s mood changes in the late par menopause we tend to see a little bit more decreased mood patients who've had prior um premenstrual symptoms of mood disorder or have had postpartum depression are at increased risk in the par menopause I do ask ask all my patients about that and do make sure you tell your provider if you're worried that you could be at risk of a hormonally mediated mood change um people can report poor sleep and fatigue that poor sleep is generally caused by those night sweats um and then that precipitates fatigue joint pain is real and can be really limiting symptom for some women and then the irritability again related to poor sleep um and some hormonal fluctuations and I mentioned the headaches for earlier so when we need to be treated during the per menopause and frankly for us in our practice r at large it's what are our symptom control goals for quality of life I bring the discussion about premenopause or per menopause and postmenopause separately because those treatments that we commonly use for menopause are not all effect effective in par menopause so you'll see that in par menopause we tend to use birth control pills or something that can override that hypothalamic pituitary ovarian access in a way that hormones therapy cannot hormone therapy treats the Hof flashes but they don't they can't keep your cycon regularity it doesn't change ovulation and so um it doesn't change the communication which is really what we're going for in the per menopausal time period for for um this symptom we do oral contraceptive pills we also you'll also hear me call them combined oral contraceptives um or non- hormonal use of hormone therapy um progestin or progestagens when we use the word progestagens we mean synthetic progestogens um anti-depressants so antidepressants can be used either cyclically because the mechanism of moood disorder um is different it's um the it is the impact of the metabolite of progesterone on the amigdala of Alo prenolone and so that blocks that if people are having symptoms all month we will prefer to use anti-depressants through the whole month we cannot um overemphasize how much like taking care of your mind body um is important and this and we'll talk about this a little bit later um you know making good choices about eating sleeping um and exercising and techniques to manage stress um paast deep breathing actually is really helpful and it's been shown to have good data for this and actually also for hot flash management which I think is really important and cognitive behavioral therapy has also been shown to be helpful for hot flash management when we think about the menopause I eluded to it a minute ago it's a different time period it's your last period no bleeding should ever occur again if you have been 12 months and that's the definition and have had no bleeding and then after that bleeding recurs you again need to proceed to your OBD1 actually relatively emergently well most of those reasons are fine there is a small risk of cancer associated with postmental puzzle bleeding we always just want to make sure everybody is safe and okay it's diagnosed in retrospect as I said the average age in the United States is 51 52 depending on ethnic background and again it's that steady decline of ovarian hormones until you really don't have any uh ovarian hormonal activity your adrenal glands are still making hormones and any uh fat tissue is also still making hormones but the ovaries themselves are making very little um so I think that I hope that helps sort of like set the table of how we think about those things separately the symptoms of menopause I sort of saying that they divide them as to primary and secondary those things that we know are directly related to lack of estrogen in that time period are hot flashes or night sweats vaginal dryness and muscle pain those are directly related to estrogen deficiency I think maybe I'll take a minute to describe like a hot flash because while after menopause we can have a little bit less heat tolerance or I say we have heat intolerance which has been particularly great this last week um they're not um whole body in general sweating that lasts a long time um it is a sense of heat or warmth that usually starts in the chest goes up through our neck into our faces which is unfortunately very public especially for many of us who might be on meetings all the time um and then quickly dissipates in a feeling of cold afterwards if I put a temperature thermometer on our chest when that happens we could measure it um it is a real vasil dilation it is um it is not just a symptom of getting hot it is getting hot um but if patients say like oh I've been hot for hours I tend to think about like what medications are they taking what's their blood pressure doing what's their blood sugar one was the last they' eat what are they doing diet wise and just making sure that there aren't any other nonovarian hormonal causes for that some people are less bothered by their night sweats they just use a fam but excuse me day sweats but the night sweats can be really challenging and can really impact Sleep Quality um and so we talk about staying cold at night and I'll talk about that in a little bit later vaginal dryness um occurs because the two reasons one there's a decrease in secretions and the second is there's a decrease in the thickness and ration or the bumpiness of the vaginal mucosa that someone can appreciate um particularly if they have penetrated vaginal intercourse and then the muscle and joint aches they tend to be symmetric so if somebody says just my right ankle hurts I injured it when I played volleyball when I was a kid that's probably arthritis but if there's like bilateral knee hip shoulder pain that's actually probably menopause and that can be really limiting for some people the next group I say like go together with the primary symptoms so if people have decreased Le uh if people have increased vaginal dryness if they're not sleeping well um if they're not generally feeling well because of the hot flashes that's going to make liido go down um they might have difficulty concentrating um again primarily related to sleep there is um one specific menopausal change that gets back so anybody who's going through this I'm going to give you reassurance that you are fine it's anomia so if you're like um I need a a pen right it that will come back but the specific anomia related to menopause is true and and not related to sleep all those sort of the other brain fog and fatigue is primarily related to sleep and if we can help fix sleep for people um even if we're doing it with combination of medications or Mind by stress reduction techniques it can really improve memory um moood swings again can be um both hormonally mediated as I said some increased depression in that 18 months before and after 18 months after the menopausal transition but you know look we treat those consistent with how we would treat new disorders outside of the menopausal transition there's a lot of talk about weight change and I think I disappoint my patients all of the time on this one is to say actually it's true right we might have been in a pair a whole Liv and people are going to say I have more weight distribution in my abdomen than I had before that's true when you look at large studies around weight gain and you look at both International and National studies it probably is not the menopausal transition specifically that relates to weight gain it's probably more the eing process and loss of muscle mass um I know that that is not a kind thing to say and I sort of always apologize to my patients certainly are there some studies that say like 3 to five pounds maybe can be attributed to menopause there is in general um if people have 20 or 40 pound weight gain excuse me 20 to 40 pounds of weight gain I really do think we need to be looking for other reasons and other methods of treating that we G because I know can be really distressing for people um Huff flashes and night sweats are the most uh common presenting symptom 25% of women won't have them I like tell them congratulations and don't tell your friends um 75 % of women will um but 25% will be truly impacted by the amount of hu flashes and the night sweats they have the peak is in that first one to two years out um for women who are not in on any like breast cancer medications or any other medications they can be related um they can be ranked as like mild Moder severe for us that's the disruption and the number is how we we come to some decision of making about how much those are bothersome and then and then as I said they can six months in general two years there are studies that for a small percentage of women they can last 10 years or more I'm really in about that 2% range I think I'm also going to take a pause about um some misunderstanding about Hof flashes and N sweats let's say I go through menopause and I go through menopause at 52 and I have hot flashes till I'm 55 and then I start having H flashes again at 65 that's not um ovarian mediate that's not estrogen that's probably me need to buy something else and that's a health uh care warning sign for us to go look for other causes of Hof flashes so while Hof flashes in this time frame I always say are predominantly mine I did it when we start to see them outside of the final menstrual period or really remote or they have completely resolved and then they come back we do look for other causes for Hof flashes sex after menopause look many people say this is a great time pants optional no pregnancy no bleeding that said um it can have some women can be really bothered by pain with intercourse um which then decreases liido the other thing that some people will find is that they can have uh increased time to orgasm um I don't address this later so I'll just talk about it a little bit second here for those patients who know um increased time to orgasm will say warming lubricants to the clitoris um forplay as a must and if at all possible orgasm P prior to penetration um but those things can all be really helpful for people who notice increased time to orgasm there are FDA approved devices for orgasm they are not covered by Insurance despite being FDA approved the two um best study that I had the most experience with are Aeros e r oos um and Fiera f i r a um and so those are really helpful so if you are finding that you are struggling in this area this is the reason to come see a gynecologist and we'll talk about how you can see one of the Met menopausal gynecologists a little bit later all right menopause is not a disease um it doesn't have to be treated our goal is to help patients who are not feeling well feel well okay um people deserve in their lives to feel well uh but if if you're like no I feel great this is fine awesome and I'm excited for you right and and it doesn't have to be treated just because you've hit um menopause and so our goal is symptom relief broadly speaking when I'm counseling patients in the office I start from um lifestyle modifications through non- hormonal medications to hormonal medications lifestyle medic um excuse me modifications we should all be doing um pulling our hair off the back of the our necks having short or short hair I'm having fans on our desk so we can cool down short sips of ice water will help us um break a hop flush um and then keeping the bedroom like painfully cold right so 60 outside of recent heat waves um where I think many of our air conditioners probably couldn't do it really keeping that bedroom down like 64 degrees will be really helpful things like chillo pillows or cooling blankets can be helpful and a fan at our feet specifically I know a lot of people have the overhead bedroom fans being able to have that fan at your feet and stick your feet out at night if you get hot and then pull them back in can be really helpful exercise will help it helps build uh like cardio uh vascular um health and uh vascular health and and while we might have hot flashes while we're exercising overall our he flash burden will improve dressing and layers um and then you know limiting things that can be triggering so um alcohol can be triggering for a lot of people um particularly you know wine things with sulfates in them and spicy food for some people um can be a trigger not for everybody but if you find that do a trigger for you it's probably worth stopping again behavioral techniques we've talked about pasty breathing some people call that square breathing they really do shorten the half flash duration and also shorten the distress around those half flashes meditation and relaxation can do that as well and there's good data that hypnosis can help I don't have a particular hynosis recommendation in Pittsburgh um but it can help when we talk about herbs you know in general uh the data for Herbal supplementation for hot lashes speciic really very specifically not otherwise um overall health um hot flashes uh are the data really doesn't support except for with the example of black kohos the thing about black kohos is because it works it actually is um hormones um it's a selective estrogen receptor modulator and we should treat it as such and I do recommend my patients if they're going to use that as their preferred method uh to try to limit it to six months and again in my patients have breast cancer we don't is it at all acupuncture can help some patients and is great for joint pain so if your only symptom is joint pain actually acupuncture could be a really good option for you there are three FDA proved and a studied treatment options for um hu flashes that are not har so the anti-depressants things like AER which you'll see most commonly in our office paxel but even Zoloft proac those can all help with H flash is Gabapentin which is a neurotransmitter um and fezal lintin feol lintin is the newest um medication on the Block I'll talk about that in a second but your first to say that like all three of these will all decrease hot flash is about the same about 50% and so really gets to be about which of these things will meet your symptoms goals your like other medications that you're using um your like you know look some people think like one thing is not tolerable to them or another might be able to tolerate it right so Gabapentin can have some sedation you have to be able to stay in bed long enough some people might have had nausea for example with an anti-depressant before so just really figuring out which side effects people can can tolerate a word about feal [Music] limitantes about that medication but I'm going to um as just that for a second um the things that make us less excited about is cost um and so depending on your insurance it has to be prior off it may not be covered at all um the um cost is $20 a day if not covered and so as a practice that like makes me feel a little bit bad um but some people have good coverage for it it is the first medication that we have specifically at the um re s that cause hop flashes um those are the candy neurons and it's an a Candy Neuron antagonist um does have some side effects like nausea and headache that you can see with anti-depressants as well there are an um has been shown to be increased lft so liver function test operations or changes in patients taking Falin tin and so um you know and so we would say like you have to get by by directions you have to get liver function tents before you start this medication so if any of you are on it please do make sure you get your liver function tests and then every three months thereafter to make sure that you're that there's no metabolites causing any liver damage um I would say for us that those are the liing factors it is um got a long list of medication contraindications which are not readily accessible by the company's website um and so you know if there are any providers on this call it's a sip 2A um it is a very long list it's actually Contra indicative of vaginal estrogen and so while I think it's a great medication and know patients are happy on it just be very careful to make sure that we are helping and not harming patients um in general answer comments at the end but I see this one about supplements um vitamin E I love in the vagina actually um I think it's fantastic systemically I don't know that it helps as much um and there's a question about evening primrose oil is good for breast health has has no support for menopausal halfof flashes um but for patients who have cyclic breast pain um ining primose oil can be really helpful um so but not so much for H lashes um for hormone therapy again this is a risk benefit discussion with your provider um estrogen um is uh the main hormone that we're using to minimize hot flash is um but progesterone is needed in our patients who have a uterus and so we think about the use of estrogen estrogen is preferred to be given transdermally or through the skin um the um transdermal root is safer because it bypasses that liver metabolism right and so estrogen has a metabolite um when taken orally that can increase the risk of heart of attack stroke transdermally we do still say that there is an increase of heart attack stroke or blood clot but that's less than if we were taking it orally so in our practice you will always see us use transdermal only also in our practice um I say that we prefer the patches as a primary delivery system because there are so many options that we can almost always find one that's covered by your insurance the creams the sprays in the rang there's all one they're expensive the manufacturing doesn't um sometimes goes down unfortunately during covid most of Europe is actually on the mist and then that manufacturer went down and like all of the UK was out without hormones and so now you're in lockdown with no hormones I I bet it was really pretty um for progesterone again we need that progesterone to protect us from uterine cancer if I give people estrogen without um uh without uh progesterone we will get uterine cancer um and someone commented about the type of patches I think you guys can't see it some people do have better luck with some patches than others and um and and so myin is a brand that we do have good uh response to um the progesterone is oral um because topical progesterone is not well absorbed and so if I'm using it to um keep people from getting uterine cancer actually really want them to have good absorption the downside of progest estone is estrogen and progesterone together do increase the risk of breast cancer that breast cancer risk continues to go up the duration that you're on it right and so the longer we're on hormone therapy the more our breast cancer R goes up and which is why you'll hear us in our practice sort of talk about the shortest amount of time for the benefit that's needed right because we're really trying to keep people from having that rest we have always believed that progesterone um sort of the natural form of progesterone versus progesta gin which are testost derive was um more bre safe than um the testosterone derive that data finally has come in and appears to continue to be true but that's why we do it that way um testosterone we really use tremendously sparingly there is no FDA approved form of testosterone for women in the United States um it really has shown the best benefit for women who have had iatrogenic men pause um related to may like surgery or cancer anetria transition and again we use it for a really short period of time primarily because there is some blood clot risk associated um there um there's some hematologic risk related to it um and any changes around unbalance like voice changes or cliteral changes tend to be permanent um also locally um vaginal estrogen um I joke that like I use um except for my patients with breast cancer I kind of use it with impunity I don't have a favorite and it doesn't have any of those risks that I just talked about related to systemic hormone therapy um so what it does is thicken the vaginal mucosa and increase the secretions to make sex less painful that is the only thing that's approved for right so if you're like I feel great except for sex hurts this could be a great option I also say because I don't like to use things that are expensive for my patients we'll just play with your formulary until we find one that's works and you can and is not expensive right I don't like people to pay 350 for something when I can find something that's $15 it works for that just as well so um I tend to uh I tend to believe those things um I will I will we talk a little bit about I think the bladder in this section um and we'll talk a little bit about um breast cancer because I see them come up bladder can be a couple of things it can be bladder irritant it also can be vaginal dryness um and so sometimes people have po flashes they wake up and then they have to go to the bathroom because they're awake sometimes it's the vaginal ginus that causes people to feel like they have to have increased urinary frequency and then sometimes it's things that are bled irritants that maybe didn't bother us before we were and menopause that are bothering us now things like again alcohol unfortunately spicy food unfortunately but also acidulated water right like a lot of us are putting like lemon in our water because it tastes good the platter hates it um and so uh you know thinking about those those things and then again like broadly speaking for hormone therapy family history outside of a known gene mutation of a breast cancer is not a contraindication now if somebody has a strong family history of cancer so what that would be is a breast cancer or uterine cancer age under 50 or two second degree relative degree relatives with either those things or anybody with ovarian cancer male breast cancer at metastate prostate cancer I do recommend all my patients get genetic testing um to make sure that we aren't missing anything that could put their health otherwise at risk um and so that we can like help them well through that time so family history is really about the number degree of relatives and any other risk that we can mitigate for you um you know again treatment I think I've know said this like six times treatment does vary by individuals um and no one treatment is right for you and and I you know this particular slide's actually old for me and I think um I'm going to spend a minute on that you know sometimes I have patients come into my office and I say like well my my friends said I should or my family said I shouldn't I think those are worth an actual discussion um with your doctor about what's right for you and I think um bizarrely like people in the lay public have really strong opinions about what we should do about our hormone management and and I think um you know that really has to be like a a driven decision about your personal risks your family health history and your own preferences about again what risk you're willing to accept and what rest you're not willing to set and there is no one right answer um and so you should always with your Phan discuss your options your risk and the benefits um of your treatment um so um you know I we say uh this pretty regularly borrowed it from Dr Sandy Chapman who is at UT Dallas who um is uh a neurologist actually and studies brain health and menopause and we say all of health is eating well sleeping well having good relationships and exercising if you have those four things you actually have health and we can manage all of the other symptoms around it but they really are uh a crucial um beginning and understanding to um how we are safe in menopause I'm going to go back and uh we'll talk about some of the other questions that we have uh in the in the chat box at the end and um so you know just some things to think about living healthfully when I started the menopause practice I think people were really surprised right like a why not obstetrics and and and for me it really was like patients walked into the office they're like I want to take good care of myself for the baby and I was like okay that's nice in this time frame we walk into the office like all right now how do I take care of myself and for me that's way more fun right like how do we live this last half of our Lives as like healthfully as we can so look don't smoking is not great right increase heart attack stroke decrease life years um actually also increased risk of things like cervical cancer and vvar cancer amongst like we think of M and bladder but those things as well exercise regularly everything counts for me right so if you do if like I walk my dog you know two miles a day that's gorgeous if you do Mall walking that's fantastic if you do chair yoga fantastic we really do need to be moving our bodies and whatever work we can do to eat well and being a healthy weight is also really helpful we know these sound easy um and then I always say to my patients if it was easy we'd all be like exactly what we wanted to be every time and so we acknowledge that this is really not easy um what a lot of people ask me what to eat um the best source of nutrients is in your diet right so we do believe in careful supplementation we really prefer people to get as many of their macro micronutrients in their diet we you know we say like basically Mediterranean um low red meat low saturated fat high fiber High vegetables and fruit any of those sort of superfoods um that have a lot of Omega-3 blueberries and the four greens the darker the better pattern um the only FDA study on um actually excuse me NIH study on diet and hearth health is actually the DASH diet um and you can find that just by going to das.gov d. n.gov um and it's it is right there and it's the only studied um diet plan that helps promote cardiovascular health and so we'll often recommend our patients take a look at that but fundamentally it's the mediter diet really thinking about a balanced plate uh and you know I often have you know um patients like I eat really good quality food that's like amazing and it's a great place to start but thinking about that like sort of like whole balance and overall like amounts of each of those portions is also really important um it is important to get regular preventative care so um seeing an OBYN every year establish care with a primary care provider if you have not already done so needs will change as we um continue to Ag and I it's hard for me when I have patients who uh we say healthy biom Mission which is they haven't received care and then they come in to care and there's kind of a lot of work that I give them and it can feel really overwhelming and things change um and and there you know as as more research comes out and I'm not a primary care doctor I think there's new data um lipids those things are important there's new data on alcohol right so we should not be drinking as women more than two drinks um in any given sitting um and those are 6 oun glasses of wine um not eight or 12 and and those really do increase the risk of cancer and that's actually changed quite a bit we should really be thinking about if we drink alcohol daily just one drink a day um to minimize those Health RIS and that's actually been a big change over the last 10 years for women um preventative care we need a lot of things right so we need our regular mamogram and a clinical breast exam you need a Pap test the Pap test frequency has changed uh which has been I think in our lifetimes um uh has been a big adjustment for patients so as long as your HPV test has been negative um you've never had any high- grade disease that is actually five years and we do recommend an HPV test screening for col rectal cancer has got age has gone down to 4 45 we do recommend everybody get colon cancer screening who is low risk hopefully if you are family history or at elevated risk we've gotten to before them um the two um tier one recommendations for colon cancer screening are colonoscopy and fit test um colonoscopy um we will say is the gold standard because if there are any um pups or precancerous lesions we can take them out and prevent cancer later the fit test is an annual home stool test it saves almost as many lives as colonos you really have to be committed to doing it every year and it doesn't do any of the preventative care that we talked about with colonoscopy we got to make sure we don't have elevated blood pressure that our cholesterols are normal keep our vaccines up to date um and thinking about when we need to start being screened for osteoporosis and a general risk population for women that's 65 but if you're on steroids or you have other medical comorbidities have received chemotherapy or I've had a parent specifically a mom or a dad that had a hip fracture all of those are reasons why you might need a dexus screening a little bit earlier and if you've ever fallen in adulthood and broken a bone that actually also does require a dexos scan and so make sure you're discussing any additional screening with your health care provider um you know for our patients who are over 50 if you smoked more than 20 pack years we actually do recommend a lowd dose screening CT scan um to look for evidence of lung cancer um so we say you know what is a healthy life which is a a you know and we just like straight from the who we couldn't agree more um health is a state of complete physical mental and social well-being and not merely the absence of disease and that's our goal to help our patients uh every day um and uh this is our practice so it's h Dr Prairie and I and we have two nurse practitioners Dean anemic and Kayla vanelli now Redmond um and Dr Kathy stugs will uh be uh with us here in a couple weeks and so we look forward to her joining her practice um and I hope that was helpful for everybody um and then they got some like Baseline understanding of how we approach um you know our you know menopause thank you so much that was great we had lots of questions get sent in so we'll start working our way through those um to start off um you mentioned you can kind of track if your periods are becoming irregular as you approach menopause we had a question that said how what are other indicators or how do you know if your periods are becoming irregular if you're on birth control and maybe don't have a regular period great question all right so for those patients who are not using birth control or or hormonal contraceptions or Marina IUD or didn't have a hysterectomy right um there are period tracker apps um and they're free and some of them are even FDA approved so clue is one of the FDA approved period tracker apps um is recommended by our organization which is why um I tend to recommend it and actually Bri let me go ahead and f one more slide while we're talking um the but if you have are on hormonal contraception if you have a marina IID or you've had a hysterctomy can be a little bit harder for those patients who have hormonal contraception if you're on continuously frankly we won't know and if you're asymptomatic I not to be Cavalier we're sort of okay about it right if you're like not having hot flash and night sweats and you're you know feeling great like fine is fine um for patients who have a marina IUD or um a hysterectomy I tend to ask them to track their symptoms a little bit so I combined their like symptom tracker with their age right so if you're 50 and you're having hot flashes all the time like it's it's probably menopause um if you're 46 and you've had a hysterctomy and you have sickly breast symptoms it's probably par menopause and so um I don't generally um and not to say not never but don't generally order Labs um because um because it it they are accurate on the day you get them but not accurate over time they Bounce Around particularly in the per menopause right and so any given day you could look premenopausal you could look postmenopausal like and that could vary within two days um and so I tend to think um for patients who are not having menes um that the symptom tracker combined with ages ends up being far more relevant um than end of the other things Bri what else you got uh somebody asked if you get night sweats but no hot flashes does that mean you can have one without the other or the hot flashes coming down the road yeah no some people just get them at night right absolutely you can have one and not the other and I'm sad because they're easier to manage during the day but absolutely um one can happen without the other and to some extent I think people will say um to me the hot flashes even if there are having them just aren't impacting their quality of life what is impacting their quality of life is the fact that they're waking up um and and so you know uh those those can be more bothersome um on the night sweats there are some things that are uh high alert for us right night sweat should be just as I described the day sweats but if you're waking up and you're like I'm soaking wet and my sheets are soaking wet we do need to look for other causes because in general like uh we do worry about risk of um you know diabetes and thyroid disease but also lymphoma right and so while that is very rare um I think if if your night sweats don't kind of fall into what I describe it is probably see something and sticking to that topic is there a connection between hot flashes and an increased urge to urinate during the night yeah you know I think I tried to answer one this one a little bit um what I what we think right is that you have a night sweat and you're awake and you're like oh well I might as well go to the bathroom or I could go to the bathroom and it's probably the night sweat that's waking you up um and that if we help people sleep better they would wake up and go to the bathroom less but do limit fluids two to three hours before bedtime no alcohol no spicy food no lemon in your water um and and really just try to go to bed with as as empty of a bladder as you can but we for most women that's not to say everybody but for most women it's primarily the night sweats that wake you up and then you're like all go to the bathroom up and then another question came in um if someone had a menopause symptoms and then had a hysterectomy and now kind of still experience those same symptoms is that something you see and what might be causing that yeah I mean look the history the uterus is just the bystander your ovaries and your Patu interior marching on right and so absolutely um removal of the uterus if it was the uterus alone is not going to impact the other sort of menopausal symptoms um and um for patients who have had a hysterctomy who are premenopausal they can't go into menopause on like 18 months up to two years earlier than they might have otherwise um but if you had hot flashes before and you had hot flashes after but you're the uterus is removed there you know menopausal hormonally there's no difference um I hope that answered that question uh did you treat well sorry uh do treatment recommendations change for women who have a his a family history of breast cancer yeah just depends on how many relatives which relatives um and uh you know what people's risk tolerances are right most breast cancer is actually not familial but that said for some people any risk might not be tolerable right um so this you know this really gets to be about who in your family had cancer um who you know do were they tested for any genetics do um do you know should we test you for genetics and that can really Drive our conversation but family history alone doesn't you know really doesn't play a role only plays a role in how people calculate their think about their risks and then I had a lot of questions I don't know if you see them pop up about um hormone replacement therapy and is it protective against osteoporosis or brain health and risk of Alzheimer's when's the best time to start or stop using it um and what are some risks yeah so um so it's complicated so you know for us we don't use the words hormon replacement therapy like we're such stick for semantics and I'm so sorry hormone replacement therapy for us is for those patients who had menopause early under 40 everybody else is just getting hormone therapy they don't feel well right and that's totally fine there is it um hormones are FDA approved to prevent osteoporosis but not to treat it um but we fundamentally think that there are better options for prevention of osteoporosis than hormones the data on brain health is messy and I think we're going to know a lot more about it in the next three to five years maybe you know I'm hoping that it pans out a little bit like the cardiac literature which is probably helpful early not helpful late that's what the neural literature so far looks like that you know early On's probably fine later on maybe increasing the risk of dimension but I'm just going to say like messing and that's actually how I'm counseling my patients right now like um probably isn't perfect um and again the lowest amount of time we needed for the symptoms that were taking it we don't recommend mend it as a preventative the um and then again you know sort of the like the fatigue and overall wellbeing we just think is related to sleep um and I just cannot I can just not underestimate um it I cannot underestimate uh risk uh I mean I me sorry importance of sleep I see some risk stuff coming up I'm so sorry like I just can't under you know underestimate the importance to sleep all right and do foods and drinks that include soy affect your estrogen estrogen or hormones yeah I love this question and I love this question because it depends on who's asking it about what the importance is right um you know cavalierly I will say if you feel better that it's probably got enough um it's probably got enough hormones to to make you feel better but look in the in the best data that I know actually looks at really large amounts of soy protein and breast cancer survivors actually out of China right they're they're they're eating more even in those studies women who have soy as their regular part of the diet was like oh my gosh I can't eat this much soy and they really didn't see an impact on breast health um and so um I say like all things of moderation it's probably fine but probably is of no specific benefit um but um let me asterisk a lot of the current over-the count of products say soy or yam actually do have added synthetic hormones to them right now so be really careful about what you put into your body it may seem natural yam estrogen and have other stuff in it that is in fact synthetic and that's why it's active so just um sort of a little bit of a a word to the wise I'm I'm paying attention to what you're getting is there a difference between the risks associated with transdermal estradi dial versus taken oral estrogens well done Bri with your estral um so yeah so there there is an increased risk of heart attack stroke and blood clot with coral so um we really do um um for patients who need hormone therapy we really do try to have them only on transdermal um even patients like like there are so many different formularies and there are so many different medications I can almost always find more that helps I get that for people who take daily medications oral just is easier but it really isn't as safe um and we and because the cardiovascular risks are the wor risk that's why the Women's Health Initiative came out that's why everybody kind of backed off of hormones and why we're having this discussion today it was primarily because it was oral estrogen or oral estrogen with synthetic progestagen so we really do think those two are far uh inferior to transdermal estradiol and oral progesterone um with patients who have been prescribed the patch and may have gone off of it have you observed an increase in this person said cholesterol blood pressure and migraines um not regularly um and so um again everybody is different everybody's different um usually when patients come off they actually feel fine and that's actually like our goal um right that like we transition people slowly down we do titrate people down because if we stop relatively rapidly they will uh feel not as well um but you know most people by time we titrate them down actually can feel better off that there gets to be a point where it's like no longer helpful to them um the other half of that question is though is that like aging is also true um and so as we get older um you know even if we're eating well exercising sleeping well sometimes genetics just catches up with us um and we can't start to see some elevations in cholesterol in particular now estrogen does uh increase um and you know uh HDL or good cholesteral it shouldn't impact uh and specifically in transdermal and alal or total cholesterol or total triglyceride measures is there a recommended treatment for vaginal atropy other than hormones yeah so uh we would say I'm smiling because like cavalierly we say like lube for life right like my chief residents all say like they're going get t-shirts to say lube for life having a good lubricant that you and your partner will consistently use and you like is really important um lubricants come in three types water-based silicone based and oilbased look some women like oilbased some people are really happy with coconut oil um but one in three postmental Pals of women will find oil upsetting so someone's already using it and they're happy like cool and like happy for whatever is working for them uh the other thing like I'm like a working mother like I want do more laundry like I want like like more work right so they tend to be a little bit Messier our favorite water Bas are going to be things like Astroglide you can find that everywhere um silicone Bas are a little bit harder to find but can be truly lifechanging for some women and Uber Lube is going to be our favorite interestingly the New York Times had an article this week that said that was also their favorite so we've been saying that for 10 years now so it turns out we're just right for the New York Times um vaginal moisturizers are also hormone FR here I don't really have a preference Lavina and replans are are going to be your two easiest to find there's also an organic one you can usually find at whole plutes called good clean love those are um you're going to use them two to three times a week with regardless of sex just as maintenance and so if you think about how our skin can get a little drier it's the same with the vaginal tissue it just keeps moisture in that tissue is not going to improve ration but can improve comfort and then I also do recommend vitamin E suppositories we talked about vitamin E as a H flash maner which I don't tend to recommend but I do recommend it in the vagina um and Carlson's vitamin E suppositories are really well tolerated have been very well studied in breast cancer patients um and so you can get them online again you just use two to three times a week to improve um moisture in the vagina do you have any recommendations on losing hair during menopause and and Global hair loss you know um this one has been interesting which is to say that like we do have some patients lose hair um in menopause sometimes our patients like Marsh I'm gaining hair where I don't want it and I have hair where I right like where I don't want it and anyway so um honestly for this I do do this with my dermat Dermatology colleagues if it's patchy we do need to look for an autoimmune cause and if it's just general thinning and there are no um vitamin D or iron causes or anemia causes that actually things like roguing can be really helpful I do rely on my dermatologic colleagues here to make sure that we are are doing the right thing by patients the other thing that I say is a little bit tricky is that um in covid we have seen some pretty significant delayed hair loss um that does regrow after having been sick so people have been sick with covid and then a couple of months later they'll report like massive hair losses that does come back but that has been I would say newer in our practice compared to sort of like you know sort of our other Baseline metop our longer periods and shorter Cycles normal for someone in param menopause yeah so yes and right so here's what we will accept any cycle that is day one to day one so first day of bleeding to first day of bleeding that's over 21 days under 21 days we can't really ovulate that fast so if you're day one to day one is under 21 days you should see your G col So eventually okay after that um any bleeding look we say up to 10 days but really shouldn't see much more than seven so any bleeding more than 10 days you should call us and then any bleeding where you're soaking a pad an hour or a tampon an hour for a couple of hours that's also not like not uh helpful um and and there are many causes could be PS could be fibroids could be ad iosis can be an ovulation and so each of those treatments are really different um so if your bleeding Falls outside of those parameters then you should see your provider if your bleeding Falls inside those parameters then it's it's actually fine um you can if you're someone who can take ibuprofen or people can take Ibuprofen cyclic Round the Clock ibuprofen starting with the first beginning of bleeding will actually decrease menstrual bleeding by 30% super simple you can have it anywhere um but just make sure you're somebody who doesn't have an gii Contra indications or reasons that they can't take Advil if someone has joint pain due to param menopause do you recommend they either PCP or OBGYN what a good question uh my answer is both right I would just like to make sure it's me right um and and look there are no FDA approved treatments for joint pain but if I think it's menop AAL by history I do use estrogen and if it gets better then it was me and if it wasn't better it's not me um so I I think it's worth seeing we also do see and the why I say it's complicated we also do start to see increased autoimmune disorders around the menopausal transition rates we see them at pregnancy post pregnancy um and then we see them again at menopause and if there are any my Immunology colleagues on the line if they're not mad at me for kind of simplifying it that way that's how it impacts My Life um so just making sure that we aren't you know I'm not missing arthritis so I'm not missing um ptic arthritis because those are really lifechanging and important otherwise for your health and so my sort of cavalier answer is sort of both and I will pause for a moment I know it is one o'clock so we're out of time um we do have about five or six questions left so we'll stay on and keep going through those but if you have to drop off thank you so much for joining us and we hope we'll see you at one of our upcoming group chats the next two topics are migraine management and birth control planning so thank you thank you for joining and so go through these last few questions all right yeah um are trying to move as fast as I can we're doing good um are treatment recommendations different for um people with type two diabetes going through param menopause yeah param menopause can be a little bit challenging um because some of the hormonal contraception um depends on sort of what your control is and any other risk factors so um the there is something called the CDC medical eligibility criteria for contraceptive use and so that's something I rely on really heavily um and so that's part of Shar decision- making we would pull that up and sort of figure out if that's the right for otherwise non hormonal options are totally reasonable if prostate cancer and breast cancer run in a family is the risk for gynecologic cancer increased depends on which relatives um and depends on the age prostate cancer in general no unless it was metastatic we think of metastatic prostate cancer as being something different so metastatic prostate cancer is more likely to be um associated with highrisk breast ofan cancer genes um and then breast cancer again like one in eight women will have breast cancer so most of us will have someone in our family with breast cancer just depends on what age they were under 50 is really different whether they were first degree or second degree relative and how many of those first or second degree relatives were so it's it's not a it it deserves an actual discussion about who um and what was and and when are there risks with taking a weight loss drug while on hormone hormone treatment you know this is a super interesting question and and and it's new right uh and so we don't know we don't know um I am I am certainly not counseling people with hormone therapy any differently if they need a glp1 um and the um I have not seen any impact um currently with my patients who are doing both we don't know right and um I think more data to come um at this point I have no Contra indication to doing that but again it's something that we would just talk about every year but right now I don't I don't have any reason to say no uh if someone has been on the patch to treat hot flashes night sweats and mood swing fatigue about how long can they expect to be taking this treatment oh yeah so you know this is a this is you know decision making you know sort of depends about the age of menopause and the Dee of symptoms when we started I'll start to try to transition people down their doses in their late 50s um and see if I can really get people off by their early 60s um again this is just about breast cancer R and so um you know three to five years would be sort of standard duration of use um but we just we just do it as a discussion but three to five years is what you'll see basically in the literature all right and then last question should I steer clear of over-the-counter supplements such as estban yeah you know I think again if if it doesn't work you just spent your money for no reason if it does work there's something in it and we don't know what it is right and so and and that's not speaking about EST Vin itself um I don't uh you know I I think all supplements with caution you know the other thing about supplements is that you know because they're not regulated people are taking a lot of them we do see real deal liver damage with them because of the additives and things that are in the supplements so I think it's really worth taking like a risk benefit calculation reviewing the specific medication I pull up the ingredients list with my patients for individual medications and taking a look at them but every you know even every brand I you know Estrin per se is an old medication but I don't know which version of estrogen there Estroven there's so many and so really looking at the list of what those Med what's ingredients are and I'm happy to do that with my patients to go by one by one through those medic ingredients and see what they are all right thank you so much everyone for joining thank you Dr Kel for your time and expertise that was wonderful all right thanks everyone have a wonderful day and enjoy the summer

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