Ep. 17 - Perimenopause & Menopause: Breaking the Silence, Understanding the Science

This episode of the UB Medicine Podcast explores perimenopause and menopause — an inevitable stage of life that affects half the population, yet remains widely misunderstood. Host Dr. Allison Brashear, dean of the Jacobs School of Medicine and Biomedical Sciences, is joined by Dr. Sarah Berga, professor and chair of obstetrics and gynecology, to bring clarity, context and science to a topic often shaped by confusion and myth.

Together, they discuss why menopause is not a single moment but part of a longer, highly individualized reproductive lifespan. The conversation unpacks common symptoms such as sleep disruption, mood changes, and brain fog, and explains how hormonal fluctuations, not just decline, drive many of these experiences. Dr. Berga also addresses longstanding misconceptions about hormone therapy, the lasting impact of the Women’s Health Initiative, and how evolving research is reshaping care.

Importantly, this episode highlights a critical gap in education and access: many women seek care from a range of providers who may not be fully trained in menopause management. The discussion underscores the need for better awareness across the health care system and encourages listeners to seek informed, personalized care.

With a focus on evidence-based medicine and patient empowerment, this episode offers practical insight for women navigating midlife health, and reinforces the importance of being informed, asking questions, and finding providers who are prepared to answer them.

Transcript

SPEAKER_01 0:03

Hello everyone and welcome back to the UB Medicine Podcast. I'm Dr. Allison Brashir, Dean of the Jacobs School of Medicine and Biomedical Sciences, and Vice President for Health Sciences here at the University at Buffalo. Today we're talking about something that affects half of the population, but that many women still feel unprepared for when it happens. Today we're talking about perimenopause and menopause. For many women, this stage of life already comes full season. Well, there's start over. For many women, this stage of life arrives during an already full season. Careers, families, caregiving, busy lives. And then suddenly there's sleep changes, mood shifts, brain fog, or physical symptoms. Not to say there's something called hot flashes. And so now women are thinking differently about this, and there's a lot more open talk. There's progress, but there's still more to do, and there's many myths that just continue to persist. So today's conversation is about making sense of what's happening with clarity, empathy, and good science. And it's also about setting the stage for the opportunities at UBMD for this type of care. So joining me today is Dr. Sarah Burgos. She's professor and chair of the Department of OBGYN or obstetrics and gynecology at the Jacobs School of Medicine and Biomedical Sciences. Dr. Burga is a nationally recognized effort expert. Dr. Berga is a nationally recognized expert in women's reproductive health and has spent her career studying how hormonal changes across the lifespan affect both physical and emotional well-being. Sarah, thank you so much for joining us. So let's just jump right in here. So many women expect menopause to be a date on the calendar, and that's just not the case. Can you help us understand why there's so much confusion about perimenopause and menopause?

SPEAKER_00 2:08

Well, I think it's important to think of it as a reproductive lifespan. And you know, there's um not a crisp beginning and not a crisp end, and people might think of it that way because that's how we teach it sometimes in the textbook. But um puberty can be variable, and reproductive aging is very different in person to person. And we now know that you're born with all the eggs you're ever gonna get. And the most number is when you're in utero and they start to age or die as soon as we're born. And there's at least a hundred genes that determine how many eggs you get and how fast they die. So I sometimes say the Easter bunny is better to some than others, um, but we don't influence that. We can now test for it, and we have been able to, over the last 20, 30 years, measure things more accurately. So the first great leap with being able to measure reproductive hormones like estradiole and progesterone and understand the life course of the ovary. And since that time, we've been able to make even greater strides. So, you know, that is the huge explosion in information. But it took a while to get into the public.

SPEAKER_01 3:27

So I think some people are surprised that before they even think they're gonna have menopause, they develop symptoms. So why is that?

SPEAKER_00 3:36

So, what really triggers symptoms is hormonal fluctuations. And there are lots of reasons for hormonal fluctuations. Perimenopause is just one. Um, and sometimes it is perimenopause at an earlier age. Some people actually have uh long perimenopause. They start in their 30s and they don't finish for 20 years. That shocks people. So it's a long period of time and it overlaps with still having fertility. So we think of perimenopause as when the egg count starts to be low. The hormonal fluctuations are now more exaggerated, and the aging of the ovary is mostly around the eggs and their quantity and quality declines. But the rest of the ovary still keeps working. So that is a really soft landing, if you will. Uh, a lot of times in the past, people had their ovaries removed. When I was an intern, we were taught to remove ovaries. We no longer do that. So surgical menopause is really dramatic for people. And if people have their ovaries out before the time of menopause, they actually accrue a number of conditions, mostly in the neurological category. Stroke for one, bone. Well, actually Parkinson's and depression and um premature aging, like dementia syndromes. So now we understand that estradiol, the hormone that the ovary makes, actually, a couple fun facts. It goes everywhere in the body and it has an effect on every body system, every organ, every tissue. And men have the same estradiol levels as women. They have higher testosterone levels, and that is what makes the difference. But men have estradiol forever, and women lose estradiol around the time of menopause. So now we have a whole, you know, mindset shift of like, let's understand this better.

SPEAKER_01 5:44

So, of course, the eggs are releasing estradiol, and those are, and they're, you know, obviously now that you can measure hormone levels. So, how does this change the care that women get now, today, for perimenopause and menopause and that their mothers didn't have?

SPEAKER_00 6:03

So some of the options are the options we've always had. So in the 80s, we sort of invented something called estradiol patches. And the first ones to market were a little clunky, the next ones were really amazing, and they've been on the market since the 80s. When I was first setting up our IVF program, we never used anything other than natural estradiol. By that I mean it was identical and it was often in a patch. And then what we were using for menopause was actually horse estrogen. And people said it's all the same. Well, if it was all the same, why weren't we using it for IVF? We weren't using it for IVF because we didn't think it was all the same, and that was actually in the 80s and 90s. So the study that was conducted that made everyone anxious was the Women's Health Initiative. And I was the co-investigator for the Pittsburgh site, and I saw all the women that were enrolled for like several years. Um, and I was there the day when we decided to terminate the study. That put a lot of misinformation into the newspapers, and I think it took a long time for the dust to settle.

SPEAKER_01 7:19

So let's talk about that. So let's talk about the dust settling. It's settled now. It's settled. And so, what is the care that a woman who is perimenopausal, going through menopause with symptoms? So not everybody has symptoms. Well, let's say they have incapacitating symptoms, sleep disturbance, hot flashes, brain fog, those types. What care is out there today? And second part of the question, how do those women find the right doctor?

SPEAKER_00 7:47

So I that is actually the biggest problem. You've hit the nail on the head with that one, because after the Women's Health Initiative, the teaching around this, the education, and I'm actually have an editorial in the proceedings of Mayo Clinic about this, who's gonna take care of all the people? Because as you you pointed out, 50% of the world is going to need some care. And some are gonna need it earlier than others, and some are gonna have more dramatic symptoms than others. A lot of people actually don't present to an OBGYN. If they come in and they have joint pain, which is really common, they may report their symptoms to an orthopedic surgeon. Um, they may actually see their family doctor. Sometimes they're going to see their internist and say, I'm just not feeling good. And so we need to train many more people of many more categories to understand what's going on. There's just not enough big of a workforce in OBGYN to take care of everyone. And we need to do a better job of educating OBGYNs as well because in the 20 years after the WHI, where the dust settled, people didn't get an education. So it seems like it's new. It's just really a return to what we used to talk about with every woman, and now we have to weave it back into our care.

SPEAKER_01 9:11

So, why do you think hormones are so scary? People are scared, and what are some of the contraindications as you think about treating the symptoms? Because when someone has some of these symptoms, the hormones can be very effective. But why do things are scary? And secondly, what are some of the contraindications?

SPEAKER_00 9:30

Yeah, why are they scary? That I think somebody will have to tell me, because I think they're actually really clear, and we are able to describe the excursions of estradiol in a menstrual cycle since the 1990s. Even maybe in the 1980s, we understood what is new for us is to be able to measure egg count, the AMH, and that is a helpful thing to have. But the symptoms overlap with lots of other disorders, and estradiol, which is the estrogen our own ovaries make, got confused with estrogen, the classification. And there's over 300 estrogens, and it seemed scary to people, I think, because it got linked to conditions like breast cancer that made people think estrogens cause breast cancer. And that actually has been debunked. But getting good news out into the newspaper is harder than getting bad news into the newspaper. So I think the bad news has a long legacy.

SPEAKER_01 10:32

So let's just put uh two really specific questions. Number one, is there a blood test for menopause?

SPEAKER_00 10:41

There is not a discrete menopause blood test. There is, though, a test for AMH, and that's often helpful. Um AMH is. And it's a long, this is I always love saying this. It's called anti-malarian hormone because that's how it got named in the beginning. And one medical student at a southern school not so far from here said to me, That's the wrong name. I said, Yeah, but I didn't name it, so we just call it AMH. So it's a count of eggs. It doesn't tell you about quality. But it's a blood test. It's a blood test, and it's just been available since the 2005-2010 range and didn't get really in in interwoven into our thinking until recently. So we use it a lot in the fertility world, um, but it also helps to define when menopause is going to be. The other hormones that we measure, like estradiol, are going to be fluctuating and are not that reliable. And so we used to say, oh, they're not through menopause until LH and FSH are really high. Well, perimenopause can be 15 years of low estradiol interspersed with high estradiol, and that's actually that fluctuation, the roller coaster, is what causes a lot of the symptoms. And for some people, actually going into menopause is calmer than the kind of crazy 15 years of perimenopause.

SPEAKER_01 12:09

Very interesting. So I could just see now women listening to this, going out and asking for this blood test or perimetopause. And as we talked earlier, you know, um that we're experiencing people with long COVID and people who have all kinds of other reasons to feel poorly. So they really need to go see a doctor, ideally, someone who has, you know, your skill set, but at least a primary care doctor and get some of these things evaluated because it could be menopause or it could not be menopause. Um again, let's just put a finer point on it. You know, how does somebody screen for someone who may I mean, obviously, if someone has breast cancer or had, then they don't take estrogen.

SPEAKER_00 12:55

So actually, recent studies show that women who have an increased risk of breast cancer or or who have had breast cancer do not have a higher incidence of either a recurrence or don't have a higher incidence of breast cancer if they take what are now called physiologic levels of estradiol. So it is important to remember not all estrogens are the same. That's actually the sound bite that I think people need to remember. And not all women are the same. I never have any trouble with that one.

SPEAKER_01 13:26

Yeah, no, I'm thinking that too. Not all women are the same.

SPEAKER_00 13:30

Not all women are the same. Not all estrogens are the same, and some people need protection for their uterus, and then we use progestadens, and there's a huge family there as well. So it does require that people get a diagnosis, but you know, by a certain age, everyone will have perimenopause. So if you haven't seen someone by 45, you will be in perimenopause, whether you think you are or not. Um, it's really, really rare to go past 55. People do sometimes go to 60, who have some hormonal secretion from their ovaries. But then after that, the ovary stops having eggs that can ovulate. The ovary still makes hormones, but it doesn't make estradiol.

SPEAKER_01 14:13

Very interesting. I I think it's so exciting that we have a lot more data to unpack here for women. And, you know, uh there's also a deeper lens on these issues for women, and it just highlights the importance of getting plugged in to get your care in a place where they're keeping track of the innovation, such as your department and such as um where people are getting care at, you know, listening and learning, uh, lifelong learning, I think is what we talk about. We talk about learning health systems, and this is a great example because you know, my mother's menopause is not the same as now. And so we have so much that has gone on, and so much opportunity to think about the multifactorial risk factors for things that you mentioned: cognition, bones, neurologic system, those are all really important. I think um as we talk about and wrap up, and of course, it's hard to talk about this in such a short time, but um, what is one thing that you wish women and the people who cared for them, the doctors, the nurses, the pharmacists, what do you wish those people knew, both the patient as well as the providers?

SPEAKER_00 15:35

So the menstrual cycle hasn't changed in half a million years. So it I say this to the medical students, you only have to learn it once, it's never gonna change. But anybody can learn about the menstrual cycle, right? And that's when you start the conversation, right? You have to understand the menstrual cycle, it's the core. And then if you understand the menstrual cycle, understanding perimenopause and menopause is somewhat easier. Um, and then you have to understand, well, what estrogens are the safest? And it's a conversation, and what I hope is that women will be brave enough to ask, and that practitioners of all kinds will be askable. They'll have enough fund of knowledge and they'll feel comfortable enough with the topic that they can at least start, and that someone like me, I used to do this in a city nearby, I used to run a center for complex menopause, the ones that were different or had special conditions or where there was some reason to think they needed to be highly individualized. But I hope every internist, every family doctor, every nurse practitioner in those domains, plus gynecologists, can actually be an askable practitioner.

SPEAKER_01 16:49

So we're gonna step up at a higher level. And this is one of the questions we ask everybody at the end of this podcast. What do you hope listeners will take away about the future of science and health in Western York? What would be that one thing?

SPEAKER_00 17:04

I think that if you are a well-educated person, health is on your list of the areas that you're educated about. And I think we sometimes miss the mark in thinking that patients don't want to know more. So it's every patient is we are all patients, everybody's a patient sometimes, needs to be able to and feel entitled to ask good questions about their condition. And whomever is caring for us needs to know that it's our right to know that. So I'm I'm on a campaign to be an askable doctor.

SPEAKER_01 17:40

I love that to be an askable doctor. What a great way to close it out. And I just that want to thank you, Sarah, for helping to bring clarity and calm and and some science to urban legends. Um, it's incredibly helpful, and I hope it's helpful to the 50% of the population that are listening to this podcast. I'm Dr. Allison Brashir, and this is UB Medicine Podcast. I want to thank our listeners for tuning in. If you have an idea, please let us know. We want to hear from you.