Perimenopause & Menopause: Stop Pulling up Your Big Girl Panties!

Healthcare guidance, pricing, and availability may change. This episode is for educational purposes only and is not medical advice.

Rebecca: You'll

know a hot flash when it happens. Yeah. There's nothing like it.

Tristin: Yeah.

Yeah. I'll be that person in the commercial where they stand in the CVS and find the AC that's blowing on that one spot and just...

yeah.

Rebecca: Yes,

and putting your head in the freezer.

Yeah. Yeah. it's debilitating, and can go on a long time.

And no one wants to spend the time doing that. why should I? Why should I have to find the freezer and put my head in it?

Tristin: in it?

Rebecca: I don't need to do that. I don't have time for

Tristin: that.

Welcome to Please Health Me. I'm Tristan, and each week I bring real health questions from around the internet to my mom, Rebecca, a board-certified family nurse practitioner with 45 years of experience. Together, we try to make healthcare a little easier to understand so you know more about what's happening, what questions to ask, and what options you might have.

We're here to educate, not diagnose or treat medical conditions. What we discuss should never replace advice from your own healthcare provider.

Okay. So we started this episode thinking that we were gonna talk about menopause and HRT, but the more we got into it, the more obvious it became that there's this whole stretch before menopause that deserves its own conversation called perimenopause. And it turns out that there's a whole lot of confusion,

so symptoms can start, years before menopause. They don't always look the way you'd expect. And when we started looking through listener questions and some of the internet chatter, there were a lot of women asking some version of, "Wait, is this what's happening to me?" I'm 44, so this is also suddenly a lot more relevant to me and to conversations I'm hearing from friends.

So before we even get to menopause and HRT, Mom, let's start there. What exactly is perimenopause?

Rebecca: Well, perimenopause is the transition phase before you actually begin menopause. Um, it's a time of declining hormone levels that can cause a multitude of symptoms. it usually starts mid to late 40s with the median age of about 47.5. And symptoms usually start with vasomotor symptoms, meaning hot flashes or night sweats.

these symptoms occur in 74% of perimenopausal women, and then they're followed by others like urinary and and reproductive system disorders, sleep disturbances, mood changes, a whole slew of things

Tristin: Okay, so I'm actually right in the middle of that age range, and I think that alone probably explains some of the confusion. we hear the word menopause and picture something happening later, but perimenopause may already be starting while you're still in your early 40s. And that, one of the questions that I came across, that's exactly what Jennifer, 41, in Seattle was wondering.

She said, "I'm only 41, but I've started waking up drenched in sweat, and my sleep is terrible. I assumed I was just too young for perimenopause. How early can this actually start?"

Rebecca: that was the median age, the 47.5, but certainly you can start in early 40s and some poor people can start even in their late 30s. not common, but it can happen. and her symptoms certainly could be due to perimenopause.

Tristin: And even if you're the right age, I think there's another thing a lot of women are waiting for before they believe, like this could be happening, their period changing, honestly. That, that seems to be the biggest, the biggest notation made by a lot of women. And because if you're still getting a normal period every month, why would you think that you're entering menopause?

And that's-- We had another question Melissa, 43, in Denver was running into. She wrote, "My periods are still completely regular, so I was told it couldn't be perimenopause, but I'm having night sweats, "Can I really

be in perimenopause if I'm still getting my period normally?"

Rebecca: Yes. people key in on the period disruption, but generally the very first signs of perimenopause are the vasomotor symptoms like she has,the hot flashes, sleep disturbance, and feeling anxious. That's really the first thing. So no, it isn't true that she can't be perimenopause.

Many times you can continue to have normal periods while starting a host of other symptoms. the hormonal fluctuations are causing her symptoms, but not enough to disrupt her periods.

Tristin: Which makes this a lot less obvious than I think people expect. You can be the right age, have things starting to change, and the thing that you thought would be like the big giveaway, your period, may still look pretty normal. but eventually periods can start changing too. Monica, 49 in Boston sounds like she's right in the middle of that: "My periods used to be completely predictable.

Now I'll skip one, bleed for 10 days, and then get another one three weeks later. I keep telling myself it's probably perimenopause. How do I know when weird bleeding is actually something I need checked?"

Rebecca: yeah. Common complaint in perimenopause once it involves the period is irregular bleeding, light bleeding or heavy bleeding, that you can have all three of those things. all can be a part of that erratic ovarian function. birth control pills can control these symptoms generally, but if you're not taking hormones, then you're gonna, be having these period disruptions that bother you.

if you experience bleeding symptoms, then you should be recording your bleeding. how many tampons or pads, you use in a certain period of time, clots or any other symptoms over a period of several months, and then you have a little bit of data to see what's going on there. of course, heavy bleeding can also be caused by lots of things, uterine growths, even cancer.

but if you are in the age range for perimenopause, you have vasomotor symptoms and other issues, and then you have irregular bleeding, chances are perimenopause is the cause. now, if you haven't had regular Pap smears or seen a provider in years, now's the time to do it probably.

Tristin: Yeah. I like the tracking part because, my periods have gotten weird" doesn't really give your provider much to work with.

Rebecca: Right

Tristin: but if you can walk in and say, "I bled for 10 days. This is how often I was changing a pad or tampon. I was passing clots, and then it happened three weeks later," that's much more useful.

the other thing I'm hearing is that being 49 doesn't automatically mean every bleeding change gets blamed on perimenopause. So now that you've figured out that yes, this is actually could be perimenopause, I think the next question is probably, okay, how long am I going to be doing this? Lisa, 47, in Atlanta, was pretty direct about it. She said, "I've already been having hot flashes for two years.

Please tell me I'm not going to be doing this for another five."

Rebecca: I can't really, I can't really tell you that. how long do they last? unbelievably seven to 10 years.

Tristin: No

Rebecca: in 10% of women, they last over 10 years. Now, of course, everyone is different. I've had friends that have had changes over a year's time, and then it's over. They seem to sail right through it.

but that isn't the majority of women. And some, some women start their perimenopausal symptoms just before true menopause, so the duration of symptoms for them will be shorter than someone who starts their symptoms way early in perimenopause. actually, menopause is defined as no period. Let's establish that. There's no period for one year. That's true menopause. but the average total duration is seven, almost seven and a half years for symptoms. And vasomotor symptoms, like we talked about, last more than seven years in 50% of women

Tristin: Wow. Seven years is the average. That's way longer than I would've guessed.

Rebecca: Right

Tristin: And I think when you hear seven years, it sounds like seven straight years of feeling exactly the same way every day. does it actually work like that or can symptoms kinda come and go or change over that time?

Rebecca: they can. They can fluctuate, and they do. They, You know, it's not like seven years of hell. I mean, can have a bad, time, and then it seems to even out a little bit and you get a break, and that's just because of those fluctuations of hormones and,and it just can wax and wane in that time period in frequency and severity.

and then as you hit towards true menopause, that's when it's gonna peak and become the worst.

Tristin: And that's where some of the questions started getting really interesting to me. like periods and hot flashes make sense. Those are things everybody knows. But when you start hearing about like sleep, mood, urinary changes, anxiety, things you would never necessarily put in the same bucket.

One that really surprised me was heart palpitations. Michelle, 46, in Phoenix described it like, "Every once in a while my heart suddenly starts pounding or feels like it skips a beat. It goes away pretty quickly, but it scares me every time. Could this actually be related to perimenopause?"

Rebecca: yes, it can. There's-- there's so many strange, symptoms and complaints. most common, of course, are the hot flashes and the period disruptions. And so people really sort of key on, "Well, that's what tells me." But you can have psychological symptoms such as depression, anxiety, irritability, or just labile moods.

though it's been a long time since my perimenopause, I remember thinking one day, "I want a divorce," but then I couldn't really explain why. So that kind of weird stuff goes on. you have brain fog, you have sleep disturbances such as insomnia or fragmented sleep, which of course can exacerbate the brain fog.

Another one, that surprised me is joint or muscle pain or stiffness. I had been taking some HRT and then I thought, "I don't need this anymore. I'm just gonna quit." So about a month after, I suddenly just hurt all over and felt so stiff. I was walking across the room like a 90-year-old, and I was 51.

Um, I still didn't connect the dots until I went back on HRT, because of other bothersome symptoms, and all of that stiffness went away. It just all went away, and I was just amazed. and you can have headaches, dizziness, of course, fatigue, decreased sexual desire, skin and hair changes, and yes, heart palpitations.

they are a recognized and common complaint in perimenopause. But, have you heard about that? No. roughly 50% of women experience palpitations. They're benign, not linked to underlying heart disease, and it's not fully understood why, but thought to be related somehow to the vasomotor symptoms of the hot flashes and night sweats.

So yes, that's a true part of perimenopause.

Tristin: Yeah. I, that one to me was actually very fascinating. I had mentioned to you that Carrie had heart palpitations so far that she had to do a stress test in the hospital 'cause they couldn't figure out what was going on. She actually was hauled out of work, and they took her in, and later she had to do a stress test, and they couldn't find anything out.

And, knowing this, I told her. she was blown away. She was like, "I'm not surprised." to put someone through all of that and realize that it's most likely perimenopause. I bet you anything

that's what it was.

Rebecca: I'm sure it was because it went away, right?

Tristin: Yeah. now it's, yeah, gone. And she has family history with heart, so of course they're gonna just go right there and peg it Right. there

Rebecca: you can't-- I guess you can't-- that's a rock and a hard place.

Tristin: Yeah, you have to be

careful

Rebecca: provider can't just say, "Eh, it's, eh, it's perimenopause," if she has some heart family history. But,on the other hand, like for me, in, in my clinic, in my population, there's no way they're gonna go get a stress test.

They can't afford that. we would have to just take it as it comes and say, "This is probably perimenopause. I'm pretty sure. Let's put you on some birth control pills. Let's see if it goes away. but if sh- anything like chest pain should occur, then yes, you need to go to the ER." that's how I would've had to deal with it 'cause I couldn't send people to just get this test and that test.

in some ways people don't get over-tested when you don't have any money.

Tristin: Right. Right. Exactly. Well, and I mean, they never attributed to anything after that. That was the end of it. And heart palpitations, like that would honestly freak me out, and it did freak me out. it wasn't even happening to me, but if my heart started, pounding or skipping, I don't, I wouldn't think perimenopause.

I don't think it'd even make my list. I think I would personally say something's wrong with my heart.

Rebecca: And I, that happened to me, and it did freak me out at first 'cause I didn't know. and now, here we are how many, decades later,and we still-- people don't know that. They don't really, aren't really informed that, "Oh, yeah, this could be, this is a normal thing of perimenopause."

Tristin: And that's what's so strange about this stage. like my friends,at my age will talk about not sleeping anymore. Somebody suddenly feels more anxious. Somebody's periods have changed, and it's like really easy to think that those f- those four are like completely unrelated

Rebecca: right

there are a lot of systems affected. I also don't think that when you, if you don't know that, if you don't know that these are related, and it can be from perimenopause, then yes, you tend to be more anxious and feel worse, right? 'cause you don't think it's related.

And what is going wrong with me now kind of thing. so it's nice to know a lot of these, symptoms can, that they are related and that, that will help you be less anxious about it.

Tristin: Yeah, I think that's, it's actually really helpful to even know that. there was one topic that we kept finding that neither of us actually expected, and that's ADHD. And this one really stood out because women weren't necessarily describing a brand new problem. They were saying something they had managed for years suddenly felt different.

So Rachel, 45 in Austin, said this: "I have had ADHD my whole adult life, but suddenly everything I used to do to manage it feels like it stopped working. I'm more scattered, more overwhelmed, and even my medication doesn't seem to work the same. Does perimenopause actually make ADHD worse?"

And I think we saw versions of that enough times that you actually went and looked into the research. So what did you find?

Rebecca: Yeah. I was-- I thought, "Oh, this doesn't have anything to do with it." so I had to figure that out. and then, finding that the largest survey comparing women with ADHD to women without found nearly double the prevalence of severe perimenopausal symptoms in the ADHD group. They also had earlier onset of symptoms, suggesting perimenopause happens earlier than the normal age ranges for those women.

another survey of 600 women found 97 and a half percent worsening of their symptoms, of their ADHD, uh, symptoms during menopause. the women related an increase in psychological symptoms such as anxiety and depression, but complaints, interestingly, complaints of hot flashes were similar to women without, ADHD.

So it was really keyed in on the psychological, the things that they already suffer from or did suffer from w- that, that brought them to being medicated for that. estrogen stimulates the dopamine synthesis,and it reduces its uptake in the brain. f- falling estrogen levels cause a worsening of mood, concentration, and attention.

So if you already have those symptoms, you may feel your medication suddenly is not working as well as it did, because it also was found that or thought that it may decrease the effects of their medication. so if,if they're perimenopausal, they should be put on birth control pills, or if they're menopausal, HRT, and those things should be tried to see if that will all settle down or for them.

You should not just try upping their, ADHD med. The best way to go is to try to,to deal with the estrogen loss. because this possible relationship of menopause, and ADHD is rather new, w- just within the last two years. All the studies I saw were just between '24 and '26. So this is a new finding, and studies need to be done to clearly define what the relationship is.

Tristin: Wow. Yeah, that's fascinating. So we can't say, this is exactly what estrogen is doing to ADHD because the research just, it isn't there

yet. It's... Yeah. But we can say that women with ADHD are pretty consistently reporting a harder time during this transition

Rebecca: A lot of this, all these are surveys and data collected. but when clinicians begin to see a, a, a large increase in something like that, in similar complaints, from a particular population, then you are alerted to the possible relationship. that's how studies happen, is "Oh, all these people have this as their symptom."

so it, that's what guides these studies to say, "Whoa, is there a relationship here?"

Tristin: Right. And that's what makes me wonder about, the woman who's never been diagnosed. if you've spent your whole life compensating for attention or executive function issues, could perimenopause be the thing that suddenly makes that, much harder to do?

Rebecca: Yeah, it sounds like from this-- these surveys that it could. And,how many times have you heard the stories about someone diagnosed with ADHD late in life? they're way later adults and they never knew they had it. if all your symptoms worsen as you're experiencing perimenopause, that could be a tip-off of that underlying ADHD

Tristin: yeah. So let's switch gears

now we've got somebody who finally understands what's happening. she is the right age, the symptoms fit, maybe her periods are changing. She's been dealing with this for a while. at that point, I don't think she wants another explanation of perimenopause. She actually wants to know, what can I actually do about it?

Rebecca: Right. the treatments, ACOG, which is American College of Obstetrics and Gynecology, recommends birth control pills as the first-line treatment in

perimenopause. If you are on birth control presently, you should not be experiencing symptoms of perimenopause unless you maybe are on a very low dose pill, such as a 20 microgram pill or

lower. If on a low dose pill and you're having symptoms, then you should just ask for an increase in your pill dosage. this will take care of your vasomotor symptoms and sleep and mood disorders. there are a variety of non-hormonal options, and those all tend to be in the antidepressant, anti-anxiety class of meds.

They're a lower dose of these meds that you would give for, depression. one example is paroxetine 7.5 milligrams. If you absolutely don't want to take hormones, but I personally feel in-- that taking estrogen is a preferred method that we know that works.

Tristin: yeah. Okay, I have a very personal question, myself because I'm 44 and I'm on birth control. if I started going through perimenopause, would being on the pill actually change what I experience, and could it be masking some of this then?

Rebecca: Yes. you shouldn't be having any perimenopausal symptoms if you're on birth control pills. as your hormone level starts to drop, your pills should help with that. so they might be taking care of all the symptoms you might have experienced, or you may not be there yet.

it's hard to know. You don't know because you're, in some ways, treating perimenopause, so you haven't given yourself the opportunity to have all those wonderful hot flashes and all that kind of thing. so-- And there's no reason that you need to know, right? why would you want that?

So continue your pill and then know, as things get worse, then you may be, yes, maybe you do need a higher pill. it probably will not bother you until you really are hitting menopause. but again, you won't know truly if you're hitting menopause 'cause you will have your pills and you'll have that week that you have some withdrawal bleeding, so you won't be sure.

most providers, how we deal with it is just,if people are on the pill and they just stay on the pill, and you can,take it until you're at an age where we feel like, "Oh, okay, they must be through or must have been through menopause," and then it's a decision whether, to go on HRT or not, which is hormone replacement therapy, which is different from birth control.

Tristin: Yeah, and I think that's what's interesting, because, like birth control and perimenopause seem like completely separate conversations. and we had someone say, Danielle in Chicago was confused about that too. She suggested putting her back on the pill, and she's "I'm 46. I'm not really worried about getting pregnant.

Why would my doctor put me back on birth control for perimenopause?" what is that birth control actually doing for her?

Rebecca: Yeah. hopefully she has a good reason not to be worried about pregnancy at this age since it could still happen. but if she's experiencing perimenopausal symptoms, that means her estrogen levels are decreasing, right? So birth control pills have estrogen, and it will act to increase your estrogen level, and that will relieve you of those symptoms.

Now, I was just thinking as we were talking, "Hey, this is a marketing opportunity. Maybe they should take birth control pill packs and, re-rename them as a perimenopausal pill."

Tristin: Ah, yeah

Rebecca: Because yes, it's like, "Why am I taking birth control?" it's like people who have these symptoms, they're put on birth control and their husband had a vasectomy and they're thinking, "Hi, are you kidding me?

I'm back on birth control? I don't need it." But yes, you do, if you wanna control those symptoms. And truly, I mean, maybe I'm onto something there. They should re-rename them as perimenopausal medication.

Tristin: Yeah, like low dose HRT or something. that's

Rebecca: people wouldn't be confused or wonder about it if you're-- they go and say this and their doctor said, "Oh, you need perimenopausal medication, and here's the meds." they would never think twice about it, but they're confused because it's birth control,

Tristin: Yeah. Yeah.

The birth control is distracting in this

Rebecca: Yes. Yes.

it's really estrogen is what you're doing.

Tristin: Estrogen and progestin if you have a uterus.

Rebecca: two different things.

Tristin: I'm surprised they haven't

Rebecca: I'm surprised too.

Tristin: thing. It's coming.

Rebecca: it's an opportunity to make more money, right?

Tristin: Yep.

Rebecca: That, those pills would be more money than birth control 'cause birth control would be

cheap

Tristin: And they're later in the age, so they can afford it, right?

they're in

their 40s. They got more

Rebecca: my gosh. Sure. So yeah.

Tristin: yeah

Rebecca: so birth control, it's a simple, safe, inexpensive way to deal with a host of these symptoms. no one should be afraid of taking birth control pills. They have a long track record of safety. Y- years and years, decades and decades. when you're suffering with all those symptoms, why wouldn't you want to easily rid yourself of that?

I certainly did

Tristin: Yeah. And as you mentioned, there are options that aren't hormonal too. So for somebody who doesn't want hormones or maybe isn't a good candidate for them, that's where something like low-dose antidepressant or anti-anxiety medication, comes into the conversation.

Rebecca: Yeah. if there's a real medical reason for not using hormones, this is your second choice. if you think hormones are not safe, then you're misinformed. And I would say that going on an antidepressant or an anti-anxiety med is not safer than hormones

Tristin: Yeah. So those are the actual, like, treatment options. But then there's another version of treatment, which I'm air quoting, that happens outside the doctor's office. and I hear this from friends all the time, and I see it, on social media. somebody bought a supplement. Somebody heard black cohosh works.

Somebody's taking a menopause gummy. Somebody found a powder online that's supposed to balance your hormones. and some of this stuff is not cheap.

Rebecca: No, never is

Tristin: I looked up some of this because I was curious,how big this has become, 'cause it seems to be pretty prevalent. one market estimate put the US menopause market at about five and a half billion in, and that's billion, in 2024, and the dietary supplements represented more than 94% of the treatment revenue, in that particular analysis.

So women are spending real money here. Susan, 50, in Portland, basically asked what I think a lot of my friends would ask: "My feed is full of menopause gummies, black cohosh powders, and supplements that promise to balance my hormones. Some of this stuff is expensive. Is any of it actually worth buying?"

Rebecca: ACOG doesn't think so. they don't recommend it, and they don't recommend the phytoestrogens, meaning the plant-based estrogens that mimic estrogen such as soy, the cohosh, other botanicals, or even acupuncture. They have not shown any benefit over placebo. and you know, as all over-the-counter supplements or herbals, they're not required to prove efficacy," so they can promote them without proof.

These are easy to obtain, and so women are desperate for relief, so they try them. But there's no proof of that they work to relieve symptoms.

Tristin: Yeah, there it is. So don't waste your money.

Rebecca: No, don't waste your money

Tristin: But I think it's actually useful to hear because when there's an entire industry built around this, and literally you see these products everywhere, so it's really easy to assume, somebody must have proved they work. a big market is-- and, good evidence aren't necessarily the same thing, honestly.

I think that leaves one last practical question. If something like birth control is working and helping you through this transition, you obviously don't just stay on the pill forever. What happens next?

Rebecca: Well, birth control pills can be safely taken,roughly age 50 to 55, if you're a healthy woman without any kind of, contraindication such as heart disease or clotting disorder or cancer history. and then after this period, that's what I was saying, that, because you're on the pill, we don't really know that you went through menopause.

So this is kind of where they judge, well, yeah, 50 to 55, they have-- a majority of women have gone through menopause. So after that period, of age, group, a transition then to hormone replacement therapy or, would occur, or a trial of discontinuation to see if symptoms occur and then how bad are they, and if they're bad, then you can then just transition into HRT, hormone replacement therapy.

And that can be taken till age 70 and sometimes beyond. at age 70, discussion of health and risks with your provider should take place. medical things change your, the whole conversation about that because if you're having some, medical problems, then you would be revisiting that.

everyone's different. You may take birth control pills through perimenopause and maybe a year of HRT and then go off and do just fine. you may opt to gut your way through your symptoms if they're not that bad and not deal with anything, any hormone replacement. or you may take HRT well into your 70s or even 80s.

It's entirely up to you to decide and your provider. at present, many healthy women are continuing their HRT, and that's because it's for their bone density, especially if this-- you have a strong family history of osteoporosis.

Tristin: Yeah. And I think that's where these two conversations finally meet. perimenopause is this transition that can start years earlier than people expect, and there are things, you can do while you're going through it. But eventually, for some women, the question shifts from, "How do I manage perimenopause?"

to, "Does hormone replacement therapy make sense for me?" And that's exactly, where you and I originally started this conversation. So let's get into HRT.

This next part of our conversation was actually recorded before we realized how important perimenopause is to the bigger menopause story. So from here, we're picking back up with that original conversation about menopause and starting with HRT

Rebecca: I think everybody's familiar with HRT, or at least women are.

Tristin: Women of a certain age

Rebecca: Yes, they are.

Tristin: Okay.

Rebecca: it seems to be a hot topic now, but it was always a hot topic for me as a female provider.

women were hoping another woman would understand, especially one who is old enough, like me, to be affected.

Tristin: And then when women came to see you about this, what were they usually asking for?

Rebecca: women, they'd make an appointment, usually 45 to 55 years old. They'd come into the clinic with a variety of symptoms and they said, "I need my hormones tested."

And this would drive me crazy because hormones fluctuate at times of the day and days of the month, and it really isn't in the guidelines to test for hormones. for this reason, they aren't that... They aren't reliable, that's the reason, and they're expensive. And in this age group, yes, your hormone levels are declining.

Do we need a number? No, we don't need a number. We know they're low.

Tristin: Yeah. I... So you don't necessarily need a hormone test. If you don't, what are you actually looking at then?

Rebecca: the symptoms, right? women will come in because they're suffering.

many women don't seek treatment. this, they just feel like they have to go through this and this, everyone goes through this. And, and there's a large percentage of women who are afraid of taking hormones or just not wanting to go somewhere and having their symptoms dismissed by a provider.

So they just don't wanna pursue it. and you know, they get this-

"Women

are busy. They just pull up their big girl panties and move through the day, and think that they just have to do that.

Tristin: Yeah. I think when we were looking at some of the communities on Reddit, we were noticing, a lot of women feeling like their symptoms were just sort of brushed upon or not, not even heard.

But I feel like there's still this idea that menopause is just something you're supposed to suffer through. Like, where did all that fear around treating it come from?

Rebecca: it mostly came from the 1990 Women's Health Initiative study. It was a huge study. it ended in 2002, because they had concerns of increased breast cancer risk, stroke, cardiovascular risk, and women went off HRT en masse and suffered.

many years later, it became known that study was flawed. So while there was a slight, very slight increase in breast cancer, there is not the cardiovascular risks that they were talking about at the time. Yeah. But the damage done by that study was huge. Women were afraid to take HRT, and providers were afraid to prescribe it.

Everybody was afraid, and menopause just took a backseat and it... They didn't even talk about it that much in medical schools. it was just, there was a 20-year span of women suffering Because of that study. Wow. We are now prescribing for symptoms and women are demanding it. a woman... we don't have the patience or the time to suffer these symptoms, when there's a medication that will totally eliminate that problem.

we also have different mechanisms of delivery now than we did then. new studies should be undertaken, but there's no funding for this. suffice to say that women have been safely taking hormone replacement into their 70s, and currently there's no magic age at which patients should discontinue taking HRT.

Tristin: Yeah. And actually, even having just come back from that knee replacement surgery that my mother-in-law went through, the orthopedic surgeon that we spoke with, was going through her chart and even saying that there had been studies about how, estrogen, is really good for bones and keeping those healthy.

So that was also interesting. And he even mentioned, it used to be that we didn't think that was a good thing- but now studies have shown that actually it's great to have that. So- even in his... And he was an elderly man, but even him watching throughout the years and was very familiar, apparently, with what the studies were and where the trends are now.

So that pretty cool.

okay, so when we're talking about symptoms, what does menopause actually feel like? Because I think most people immediately just think hot flashes?

Rebecca: Yeah, they do. hot flashes. people, especially men- ... take that to mean, "I feel hot." No. a hot flash is a tremendous burning heat that starts in your chest and spreads upwards to your face, causing flushing and dripping sweat. It's not only distressing and, feels bad, it's embarrassing.

If you're out in public or at work, you suddenly, you turn bright red and you're dripping down the front of you. you're so hot. and these symptoms affect 80% of women, and they can last an average of seven to eight years. That's an

Tristin: Wow.

Rebecca: You also get sleep disturbances, 'cause those things can come on at night and you're just flinging the covers off.

You can't s- it wakes you up. You're sweating. urinary and sexual symptoms for sure. vaginal dryness, painful intercourse due to the dryness and thinning of the vaginal wall, burning and itching Due to the disruptions of the vaginal microbiome, women have been treated for decades with antibiotics for urinary symptoms of burning and frequency, and they really did not have a UTI.

I saw that in the clinic all the time. Come in, classic UTI symptoms, dip their urine, nothing.

And we're going, there's nothing here." and truly, we'd end up s- sometimes giving them, three days of Solva or something Oh ... because they're so uncomfortable. it wasn't a UTI. It, their symptoms, we now know, were from lack of estrogen.

there's estrogen receptors at, present throughout the vagina, the urethra, bladder, pelvic floor muscles, and when estrogen levels decline, these tissues undergo changes that just really impair their function. they can be serious and debilitating

Tristin: Yeah, that one really, surprises me if s- I...

Someone that thinks they're having these UTIs and the estrogen is actually part of the problem.

Yeah. as I said, there's the estrogen receptors in this area, and directly surrounding the urethra, which is the opening from which we urinate. when I would do an exam, a pap, or a vaginal exam on women in this age range, you could actually see redness all around the urethra from lack of estrogen.

Gosh, that's crazy.

Rebecca: You can also have joint and muscle pain, headaches, decreased libido, as well as low energy levels. And a fre- frequent complaint is weight gain, increased abdominal fat, and that- ... associated declining bone loss. Yeah. the bone loss was really important to me personally, since I came from a long line of osteoporotic women.

I have good bones, I feel, for my age, even though I have all the risk factors. I'm small framed, blue-eyed, pale skin with freckles, and a family history. Couldn't be worse. But I have worked out my whole life, and I love dairy, but I know the main reason is the HRRT

take-

that's saving me.

Fatigue, headache, anxiety, and brain fog,are highly prevalent in menopause.

Menopause, it's, is easy. It's diagnosed after a woman does not have a period for one year, and the average age in the US is around 51.4 years old.

Tristin: That's a very specific

Rebecca: number. I always say 51.

Tristin: 51.4775.

Rebecca: I don't get

accuracy.

Tristin: But

Rebecca: is the truth.

Tristin: so i- you know, once somebody does realize, "Okay, I think this might actually be menopause," what can they do about it?

Rebecca: there's different ways to go. if a woman has a uterus-

Tristin: they, they need both estrogen and progesterone to be taken when they do HRT, like if that's a pill, you need that combination. There are combination pills where you just take one, or you can take estrogen and progesterone separately. estrogen alone can cause an overgrowth of the uterine lining, which is worrisome for uterine cancer risk.

Rebecca: That's why. but, with progesterone in addition, there's no risk. If you had a hysterectomy, then taking estrogen alone is completely safe.

Tristin: And from what I read, HRT isn't necessarily just one pill, right? What are the different ways

Rebecca: Yeah, there's different delivery systems. you can take that oral medication.

they look much like birth control packs, if they're a combo. transdermal patches, these are just a patch, like a nicotine patch, only it's a, it's an estrogen patch. And they're preferred for extended hormone use, as, as women reach their 60s and 70s. So as you get older, you wanna switch to the patch.

the local delivery reduces any kind of stroke or card- cardiovascular risk or clot risk, because you already have that risk when you're older.

Tristin:

Rebecca: vaginal creams, and suppositories, these are estrogen only methods, but, they can even be prescribed fine i- if one has a uterus.

It's just locally absorbed, so it, it doesn't put you high risk for anything. and these methods are the best for, vaginal problems like the dryness, or pain, and the urinary problems, right? there is a ring, which is a plastic ring inserted in the vagina which emits estrogen locally also.

And of course there are also hormone containing IUDs. Most women in menopause or that timeframe, they don't do that, the others. But there is that option

Okay. So who needs to be more cautious about HRT or have a, maybe a bigger conversation with their provider before starting?

yeah, everyone w- if they're going to start should... they should take in all the considerations with your risks. you gotta balance the risks with the benefits. and most women can safely take HRT. But if you have a personal or family history of heart disease, stroke, or cancer, you need to discuss that with, that risk with your provider and make a, make an informed decision.

Tristin: So if somebody listening recognizes themselves in all this, but they've been putting off talking to someone, what do you want them to know?

Rebecca: s- seek help if you're suffering. Don't be afraid of HRT. It is quite safe for most women.

It's gonna improve your quality of life. It's gonna improve your sex life.

And if your symptoms are not taken seriously, seek another

Tristin: Yeah.

that's why they even say sometimes second opinions are always

Rebecca: Yeah, if you don't feel like you're being listened to or they're, I have been working a long time, and I've seen, and in a lot of places. And I w- have seen many a provider take the chart out of the, their rack and go, "Oh, God." It's that middle-aged woman, that 50, 60-year-old woman, she's gonna have all these complaints.

there's already, always has been a bias about that, but these are legitimate

Tristin: Yeah.

and I feel like lately, especially within the last five years, there's been a big surge in research, in funding, and, And I would say social media helped sort of- bring and shed a light on this, phase of life for women that has been basically just kinda shoved to the back burner.

get your panties, pull up your big girl panties.

Rebecca: women are more educated. Yeah. They're busy. They're professionals. they don't have time for this.

And why should they? it's not, the old school thought was this is your burden to bear,

This is normal. And yeah, it's normal, but you don't have to bear all these symptoms. and I don't think it was well known how long this can last for people.

And it really affects your life.

And you don't need to have that happen.

Tristin: And I think that's really the point. These symptoms may be common, but that doesn't mean you're supposed to just quietly live with them while they affect your sleep, your work, your relationships, or even just your ability to feel like yourself. Perimenopause and menopause can look really different from one person to the next, and there isn't one right way to go through it.

But if something has changed enough that it's actually affecting your life, it's worth talking about. You don't have to wait until it becomes unbearable, and you don't have to accept being brushed off because someone thinks this is just part of getting older.

Thanks for listening to Please Health Me. If you found this episode helpful, pass it along to someone else who might too. And if there's a health question you want us to talk about, send it our way at pleasehealthme.com. We'd love to hear what you're wondering about, because chances are, other people are wondering about it too.

And as always, this podcast is for education only. It is not medical advice, and it shouldn't replace the care from your own healthcare provider. If you enjoyed today's conversation, be sure to follow Please Health Me so you don't miss future episodes. You can also visit our website for all our episodes, show notes, and additional resources.