Here we are, at the end of October, Menopause Awareness Month, and we hope that your social media feeds have been as full of amazing menopause-related content as ours have been. But the truth is, for many, menopause is still rarely talked about. The way it’s portrayed culturally leaves little room for nuance, and many people, including women ourselves, are underprepared to deal with it both emotionally and physically. This month’s edition of Normalize This engages in a robust and deeply informative conversation between our Co-Founders, Alex and Mia, and Dr. Barbara Frank, Harvard-affiliated OBGYN and Attn: Grace Medical Advisor. The conversation has been transcribed and lightly edited for readability.
Alex: I am so glad that we are talking about this today. You know, my mom, may she rest in peace, didn't really talk much about menopause.
Barbara: You’re not alone in that. But honestly, there’s a lot to talk about! An estimated 6,000 women in the U.S. alone reach menopause every day (more than 2 million per year). But in reality, menopause is very fluid. People think of it as, you're gonna wake up one day and it's going to be like, ta-da, but that is not how it works. It is continuous. From a numbers perspective, on average, most women in the U.S. go through menopause by age 51. But when we think about menopause, you also have to think about perimenopause, menopause and post menopause.
Mia: So true. We featured an article about this recently, but let’s pause there for a second (no pun intended). Can we define what we mean by perimenopause versus menopause and even post menopause?
Barbara: So perimenopause are the years that lead up to menopause. Here’s what’s happening during that time. When you're born with ovaries, those ovaries have millions of eggs. And when those eggs run out (because they've died off, you've ovulated enough, you've had some kids, maybe you needed radiation or took some chemotherapy medications, whatever the reason), once those eggs are all gone, that leads to a drop in estrogen. And a drop in estrogen leads to the cessation or the stopping of a normal cycle or ovulation. After that has happened for about one year, meaning you haven't ovulated for one year, that is menopause. Perimenopause is those years leading up to it. Women might say that they're getting irregular cycles, maybe they're becoming a little longer. They used to have perfect 28 day cycles. Now they're 45 days, maybe they're skipping three months, etc.
Alex: So I’m pretty sure I’m squarely in perimenopause. But how do we know exactly when we’ve started menopause?
Barbara: That is a really, really tough question to answer because some people will go through it and have no symptoms. I hope that that is me one day-- to not have to deal with menopause at all and just, you know, swim right through it. But a lot of times in perimenopause, or those years leading up to it, women might notice things like vasomotor symptoms, which is the fancy word for hot flashes. So out of nowhere, you have a hot flash, that's kind of the first sign of the hormone shifts for most people. Other people will have other complaints like vaginal dryness. They might feel like they're having more sleep disturbance, even insomnia. And then there’s other mood changes that come along with menopause symptoms. What have you been experiencing, Alex?
Alex: Well, there have been a few so far. Certainly some night sweats, which thankfully haven’t been super bothersome for me thus far, but they’re uncomfortable to be sure. Just the whole waking up feeling all soppy in my PJs. It’s not ideal, but I’ve always sort of expected this symptom because I think it’s one women have been most comfortable talking about historically. One that really caught me off guard was a shift in my (sorry, all) body odor to be perfectly blunt. I’m 45 and I’ve always been someone who could skate by with minimal or no deodorant — even when I was an athlete. But suddenly, in the last year or so, I’ve seen that really change and I now need to wear a deodorant pretty consistently or I’m just uncomfortable. Is what I’m describing normal? What else is to come?
Barbara: Absolutely. Not uncommon. But you know, there is no “normal” — everybody has different symptoms. Sure there are hot flashes, and sleep disturbances, vaginal dryness, mood issues, your smell is different, your hair changes, your libido changes, there’s a change in body composition. Us ladies lose bone density starting as early as 35. These can all be menopausal symptoms. What was your experience like, Mia?
Mia: I hit menopause when I was 45, which is maybe a little earlier than most? The most significant issue for me, other than the weird weight gain in my middle section, was the hot flashes. It would be like someone flipped a switch and all of a sudden I’m so hot, you’d think I was in southern Florida when it was actually the middle of winter in Boston. Every window would be open to help me cool off. Then, maybe 30 minutes later, it’d be gone and I was fine. The whole situation lasted for maybe four months, and that was it! I never experienced it again. I think I got off pretty easy!
Alex: You sure did! For others, they’re trying to ease through the transition over years. Can we talk a little bit about HRT?
Barbara: Sure. HRT stands for hormone replacement therapy. And it used to be something that wasn't really talked about. Just about every doctor gave women a pill like, “here are your estrogen pills, it's time for menopause, you're 50 years old.” But in the 1990s, a study came out, the Women's Health Initiative, that really brought questions about this medication to the forefront. And it brought up that taking hormone replacement therapy is not without risk. So I think that a lot of what people know now about HRT is from this study. And so women are asking the right questions now about HRT — Is it safe and how can we use it?
Mia: So now I’m curious — what’s the answer? Is HRT safe?
Barbara: It’s definitely something you need to talk to your doctor about, because everybody has different risks. Your own personal medical history needs to be evaluated when you decide on hormone replacement therapy. The specific risks that came up in the Women's Health Initiative that really got buzz were related to VTE or venous thromboembolism — those are things like deep vein thrombosis or DVT, or a blood clot in the leg, or stroke. And those got people really nervous because the numbers in these studies were higher than what you would expect. However, the Women's Health Initiative studied women that had an average age of about 70. When we're talking about HRT now, we’re talking about starting it on women in their 50s when our risk profile is typically very different, the risks are much lower than when we are older. So I think that it scared a lot of people out of maybe trying HRT. But anytime you add a medication or add hormones, there is increased risk of side effects. If you or your family have a history of breast cancer, you might want to avoid extra estrogen. If you have any blood clotting risk, it might not be right for you either.
But there are also a ton of benefits of HRT, for example when it comes to cardiovascular disease and a decreased risk of colon cancer. Sometimes it just gives you a little bit of boost when it comes to your day-to-day activities. The goal of HRT, from a medical standpoint, is to use the lowest dose possible for as short a period of time as you need it. So when you're in that perimenopausal phase, and you're getting closer to menopause, that would be a good time to start. So that you're not having this abrupt shift of going from absolutely no estrogen in your body to “here's brand new estrogen!”. And then typically every year or so I'll try to wean women off by trying a couple of days or even weeks without it and see how they do. For every woman it’s different — I have some women that come off by 55, and I have other women that want to take it into their 60s.
So the other type of hormone replacement therapy, that I don't think a lot of people ask about, is therapy aimed specifically at the vagina. Your vagina goes through menopause too, which I'm sure people know and hear about. When you talk about things drying up during menopause, the vagina can get kind of dry, too. This dryness can not only be irritating but can increase your risk of urinary tract infections. And so, say you are one of those people that is too high-risk for oral supplements, or maybe you’re someone who doesn't really have those vasomotor symptoms and you only have the vaginal dryness, you can actually do local estrogen just to your vagina - it’s a miracle I’ve been told!
Alex: Tell us more about that. What are women’s options when it comes to localized estrogen?
Barbara: So the original estrogens come in a plethora of different options. You can have a tablet, you can have a cream, there's a ring, there's a string (which kind of looks like a rubber band for your hair ), etc. They're really easy to use. With the rings, maybe you change it every three months. With the creams, it's really only twice weekly. And the way that these work is by giving local estrogen, which we think has less systemic absorption. So it's less risky for those who are too high risk for oral supplements, or even people that have a history of breast cancer. Some patients of mine went into early menopause because of breast cancer medications. They are young and want to have sex, but they have issues with vaginal dryness or vaginal atrophy (when you've lost that elasticity and collagen). Local estrogens really work wonders for them, and a lot of oncologists will be ok with it too.
Alex: Are there alternatives to traditional estrogen replacement therapy?
Barbara: Yeah, there are. What I want people to be very cognizant of is that a lot of the things you might buy are not actually FDA-approved and tested. So the amount of “estrogen-like product” is not regulated, so you might not know exactly what you're getting. Do I think that there are holistic and alternative means to help you through menopause and perimenopause? Yes. You just have to make sure you find somebody that's trusted and really knows what they’re talking about. There are also a lot of nutritional changes that you can make that can also help ease the transition. There’s things that you can work on even in perimenopause. Now, I don't feel like I'm at the tip-top of my game when it comes to knowing all of the nutritional science, but I do know that there are some really great nutritionists out there that can help women go through the menopausal transition.
Alex: Let’s talk about life post-menopause. What happens?
Barbara: The same things that happened before, you keep living your best life! It's a medical definition of your ovaries being fertile or not fertile. As we age, a lot of things change, but we shouldn't be defined by our menopausal state.
Mia: Do our hormones continue to shift after menopause?
Barbara: So your hormones won't be doing the same up-and-down as they’ve been doing your whole pre-menopausal life, where every month you had a menstrual cycle. And you won’t have the same drastic decline in hormones like you did after menopause.
Alex: Ok, in closing, what’s the most important thing our community of women should know about menopause?
Barbara: So I think number one is not being afraid. I think that we get set up for menopause to be this day that’s going to come, and all of a sudden, we're just going to crumble to pieces. And I think that it's really not like that for everybody. So the best thing that you can do for your health now, is just be really in tune with your body. It really doesn't have to be a scary time, and take the time to talk to your doctor about it, talk to your mom too (because most women will go through menopause around when their moms went through menopause). It doesn’t have to be scary. Wear layers, have a fan, you know, do things that will make you feel like you're prepared, so that you don't feel like this whole change just hit you like a ton of bricks.
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