Episode 7: Are We All In Perimenopause?

In this episode we discuss why perimenopause has become a major social media trend, the truth behind it, and where messaging can slide from empowerment into fear. We explore why women’s symptoms are often dismissed, while also noting broader stressors affecting millennial women’s health. We define menopause and perimenopause, outline typical ages and durations, and discuss how these conditions are diagnosed. We highlight which symptoms are most helpful in distinguishing perimenopause from other conditions discuss the dangers of anchoring on perimenopause for nonspecific symptoms. Finally, we discuss what the perimenopause movement has taught us as doctors and as Millennial women.

01:49 Perimenopause Everywhere

03:08 The Viral Claim Explained

06:35 Why It Went Viral

07:50 Women’s Health Neglected

15:12 Millennial Women Unwell

21:00 Girl Power and Burnout

27:06 Nugget of Truth

32:08 Menopause vs Perimenopause Basics

34:22 Age Ranges and Reality Check

35:53 Don’t Anchor on One Diagnosis

36:49 Perimenopause Without Labs

38:51 The Big Three Symptoms

39:59 Lancet Study Reality Check

43:34 Estrogen Risks and Telehealth

46:10 Gatekeeping and Pellets

51:28 When Labs Help Patients

56:12 Clinician Lessons Learned

59:32 Baseline Health and Risk Factors

01:06:49 Niche Experts and Consumer Savvy

01:11:17 Wrap Up and Disclaimer

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Transcript

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Sonia Singh MD 1:27

You are listening to the Antisocial Doctors Podcast, hosted by me, Sonia Singh, a board certified internal medicine physician with a Master's in nutrition and a special interest in health anxiety

Rebecca Berens MD 1:38

and me, Rebecca Barons, a board certified family medicine physician with a special interest in disordered eating.

Sonia Singh MD 1:43

We're also a millennial women anxious moms and curious humans navigating social media. We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.

Rebecca Berens MD 1:56

This podcast is meant to be the antidote to your doom. Scrolling, a, solve for the anxiety, stress, guilt, shame, and confusion. That comes from social media's messaging around health. In each episode, we discuss a health related talk trending on social media with curiosity, nuance, evidence, humility, and compassion.

Sonia Singh MD 2:12

This is not your average debunking podcast. We wanna explore not just what is trending on social media, but why? Why are so many people drawn to this? What is the nugget of truth here? What are the facts? What can we learn from this as patients and doctors? No shame. No blame, no snark.

Rebecca Berens MD 2:27

We're so glad you're here.

Speaker 3 2:42

Hey, how's it going? Oh, it's going how? I woke up this morning and I sounded like I've been smoking for 40 years. Like my voice was so bad, I don't feel sick, but it's just like, oh no, the residual, you know? And I was like, oh my God, I'm gonna have to cancel. But I've been drinking hot liquids and stuff, and I feel like I can get through. You sound fine, but

Rebecca Berens MD 3:05

you

Speaker 3 3:05

know, if we need to stop and you need to take a break, it's totally fine.

Rebecca Berens MD 3:08

Okay.

Speaker 3 3:08

Okay, good. All right, okay, so let's get started. Hi Rebecca. Hi Sonia. Today's episode we're both, very fired up about, we're very excited to talk about it. Usually we start the episodes with a patient story to introduce the topic. Honestly, I, I've thought about it and I could not come up with one single story just because this feels so, just like my daily experience, every woman I have seen in the past year or two between 35 and 50 has at some point brought up perimenopause people coming in with every different symptom under the sun. Somehow the conversation at some point goes to perimenopause. I'm 39, so my friends are talking about it. It's all over my social media feeds when I'm on social media. And it's really remarkable because I feel like nobody was discussing this maybe even five years ago, definitely not 10 years ago when I was coming out of medical school. So, The list of symptoms that we hear associated with menopause feels like it's endless and growing. Not just hot flashes, which we all have been aware of or taught about at some point. But also poor sleep, low libido, vaginal symptoms, fatigue, brain fog, weight gain, mood swings, skin changes, hair changes, headaches, joint pain, urinary symptoms, dizziness, vertigo, I mean, almost anything you can name. You could probably look up, is this associated with perimenopause and find an answer that says it is. So today we're gonna be talking about perimenopause and in terms of what is the claim, again, since this is on a very broad topic, I don't know if the claim is really something easy to distill down, but I I try to summarize it as. Every woman over the age of three, five is potentially in perimenopause and perimenopause wrecks your body and ruins your life temporarily. And doctors dunno enough about it and they're gonna try to deny that that's what it is and they dunno how to diagnose it or treat it. So you have to go in there and advocate for yourself and push for labs and push for hormone treatment. Or treatment I guess, of some type. So that's my general claim. I don't know if you have anything to add to that in terms of a personal anecdote of your own or what you think the claim entails.

Rebecca Berens MD 5:24

Yeah, no, absolutely. I agree. I think that is, it's, it's a lot of, I don't wanna say fearmongering because obviously, and we'll get into this, there are true lifestyle altering symptoms that people have in perimenopause that are real and deserve attention. So I don't wanna claim that it's not important, but I also think. It's been discussed in a way of if you don't treat this horrible, things are gonna happen to you. And I've had a number of patients that have had minimal to no perimenopause symptoms and have gone through menopause fully and are now coming back and saying Hey, what, when do I need to get on hormones? I was like, well, do you need to get on hormones? Why don't we talk about what's going on? What's bothering you? And it's, I think it's come to the point now where I think people feel like, oh, this is important to do if I don't do this, something bad will happen to me. Yeah. And and it's very much being sort of described as a, as a disease state. Rather than a transition, a natural transition. And doesn't mean that a lot of people don't benefit from treatment, but also doesn't mean that every single person needs treatment. And I think that's kind of where the pendulum has swung is like, you must be on treatment for this disease that you have, that every woman. Will have at some point. Yeah. Yeah. It's, that's, I feel like it's just gotten a little bit too strong the other direction. So yeah.

Speaker 3 6:41

Yeah, so that actually, I think that could be a full episode in itself I think there's a lot of buzz around hormone therapy for cardiovascular cardiometabolic protection that I think is a separate topic and more in like the official menopause post menopause, that chapter. So today we'll focus on perimenopause, but what, what you said, I think brings up a really important point and is again, one of the recurring themes here, which is that there's actually kind of a fine line between giving information that's informative and empowering and proactive and fear mongering. And it's so funny how quickly, I, I can see how a lot of the stuff that's out there on social media right now feels like. Empowering, validating information, but then the tables turn very quick to oh yes. And so now that you feel like you're seen and heard and we're validating that you're having this issue and it's a problem and it's a real thing, now here's all the things that you need to be doing to fix this. And if you don't fix it, bad things are gonna happen. And that's, that's something we see over and over. I mean, we've talked about that in other episodes as well. But yeah, that's one of the, so once again, I feel like a broken record here, but like a lot of the things we're gonna talk about, this episode we have talked about in previous episodes, they're gonna sound like you're gonna be like, didn't we talk about that before? And Yes, we did. We did. We talked about the thyroid episode, we talked about it in the, just it, a lot of the same themes emerging. So the first question we try to answer about our claim is, why is it viral? Why has this thing taken such a hold? Why is menopause and perimenopause having such a big moment right now? I guess before I launch into my theories, my hypothesis, maybe you can gimme your 2 cents.

Rebecca Berens MD 8:19

Yeah, I mean, I think we have similar theories given your notes here, but Yeah, you and I both are women in this general age range and having gone through medical training, like we know that women's health in general is not as well studied. Symptoms are more often dismissed. I think we're gonna get into all of that. But I think, so I think that conditions that affect women historically have been neglected. And so there is less information available to those women and less treatment options available sometimes. And so that is a true fact that people have experienced. Yeah. And so then now that there's, there's more women in medicine and there's more push to, to do something about this these things are coming out and it's great and it's empowering, like you said, but it also I think is being, Co-opted by people who profit from selling these treatments to kind of push it maybe a little bit further than it needs to be pushed. So, yeah. But let's get into all, 'cause I think we had some really good stuff here.

Speaker 3 9:16

Totally. So, okay. So I think the number one reason, the, the deep, deep root cause that has been going on for generations and generations is that, as you said, women's health is neglected. Historically it's been under researched, underfunded for research under taught in medical schools. Women have been, right now we're, I think, I haven't looked at the numbers recently, but I feel like we're reaching the point of 50 50 men and women in medical training. But, historically there were not as many women in medical training. So you're not gonna have, female professors who have been through this themselves or who have experienced some of these changes who are motivated to, impart upon young medical trainees and students what, what this thing is, and why it's important. So. We talked about that same theme when we talked about birth control and birth control pills and all the conditions that treat, are treated by birth control. And, again, a lot of those PCOS endometriosis fall into the same category where there's just, even if you go to their, your doctor and your doctor tells you the most UpToDate information and it feels inadequate, that's not your imagination. It is less robust than the information we have on diabetes and heart failure and so many of the other conditions that we deal with. So, there's that. I think the second thing which you touched upon is just that women's pain and suffering, sadly, in general in medicine and unexplained symptoms are viewed differently by healthcare providers. And it pains me, it breaks my heart to say that as a healthcare provider, and I'm happy to admit even as somebody who I think is very aware of this and tries to go to great lengths to not, fall into this hole. I'm sure that I also have some implicit bias about some of these things. And it, and it. It influences my practice. It, it's just a fact that has a lot of substantial research around it that when women present with unexplained symptoms, they are more likely than men to be diagnosed with something functional or psychosomatic. As opposed to a man who has the identical presentation. So they've set up studies in which two patients have come in presenting with the same complaints and the same history and the same similar exam. And the woman gets diagnosed with a psychosomatic illness where as the man doesn't. And so, I think one argument, which is a little bit of a side note, and which I think I tell myself when I think about this influencing my own practices, those conditions do appear to be more common in the female population. And I think it's almost impossible for us to say at this point whether that's. Because historically we have ascribed those conditions to women or whether there's something about women's physiology where there is a stronger mind body connection or something that is driving more of those types of, conditions to happen in women. I think that's really hard to say, the data shows us that clearly that is a thing that happens even when the presentations are exactly the same. So I think for a lot of women it's extremely validating when you hear these descriptions of people's experience and these potential symptoms that can happen with menopause and perimenopause. And just knowing that, okay, that's a real thing that has a physiologic basis and millions of other women are experiencing that as well. I mean that, I think, I feel sad for our mother's generations and the generations before that, that just never had that experience of, or maybe they didn't, I mean, of course there's other ways besides social media of communicating this to each other. But, I don't think there was this very broad awareness of. What menopause is and what it can do to somebody's life before this, this period. So I think that's another reason.

Rebecca Berens MD 12:36

Yeah. I just really quickly, sorry. Wanna add to that, that I think the sort of diminishing of women's symptoms is also something that I think women, we do as women are to ourselves because it's sort of societally expected. Yes, yes. It's not just a medical thing. We also tend to diminish our own symptoms. And and I think that may play into some of why there's more maybe somatization of some of the things that we experience. 'cause there has been historically an inability for women to have control over their finances, their livelihood. There's a lot of these things that, that has been societally diminished. And so you're kind of forced into. I just gotta keep the house running. I gotta keep all these doing. I can't, I don't have time to all have all of these feelings, so I'm just gonna suppress them. Yes. And I really think that, that plays a lot into it as well, and it's still a problem of course, but, um, I think we kind of also still do it to ourselves and it's because we've been sort of societally primed to do that. Um, yeah, that's

Speaker 3 13:39

a great point. I mean, when you say we do it to ourselves, I don't want anyone to read that as like it's our own fault. You just, yeah, no, of course not. But but yes, you're, what you're saying is we've been conditioned and programmed again over generations and many, many years to. Kind of, deal with and process our challenges and emotions and physical discomforts in a certain way. And often I think to prioritize the comfort and, yes, alleviation of suffering of those around us. And so we end up in this very unique position. I think that's so true. I'm actually reading Dr. Gabor mate, when the Body says No right now, I like just started a couple of days ago. But, he has this whole, a lot of doctors would disagree with some of his work, but like he has this whole, concept around repressed emotion and internalized stress and how that influences your health. And, if you just apply that, as you said to women historically Yeah. How much they have been asked to, absorb and repress. It would make sense that perhaps they have more manifestations of that in physiologic, ways. So, yeah,

Rebecca Berens MD 14:42

I think that it really plays out in like the man cold, that's like such a, like a meme, but I, I feel like this, I see this and like when. A man and woman have similar cold symptoms. Yes. Very often. I think it's much more destabilizing to one than the other. And this is of course not always true and I don't wanna make this into like a whole gender thing, but I think it is true that if you have kids you gotta deal with, you gotta cook dinner. You just gotta keep doing it. And historically it has been on the woman to just keep those things functioning despite having illness symptoms. Yeah. And so I think that is a really powerful illustration of it to me, that I have of observed and I think is very accurate.

Speaker 3 15:26

Okay. It's so ironic that you're talking about that. 'cause my husband has the man flu right now. But you know what? Legitimately. So we both got sick at the same time. He is legitimately sicker than I am. He just, I don't know. I'm convinced he's got some untreated sinus stuff or something because he's so congested. And I just have a slightly hoarse voice. So we got the same thing and he's way sicker and he's always just like, God, why are, why am I so much sicker than you? And I actually started reading, the Body Says No because I was telling him about that concept because I was like, you are working too hard. That is why you are so sick and I'm not sick. I have a life now where it's okay if I have to cancel one patient or two patients and be like, I'm ill today. And I can lay down if I need to, and I have created that, that work environment for myself. And he unfortunately does not have that. So he continues to work through all of it. And anyway, that's what prompted me to read the book was that I was like, the reason you are so sick right now is 'cause your body is literally revolting against what you're putting it through. But anyway, that's a reverse where I, the woman am somehow empowered and in charge doing my own thing. So anyway gender stereotypes be damned. All right, so. My next point, and this is the one where if I ever do a TED talk in my life, this will be the topic. 'cause I am just so passionate about communicating this to people. Millennial women are just unwell. That is the generation right now. You and I are in it. That is the generation that is currently on Instagram and being fed all of the stuff about perimenopause and is about to go into perimenopause and menopause and we're all feeling really bad. And I feel this in my bones because, I am a millennial woman, but also because my practice is built for women and this is the demographic I see all day, every day. And I feel like I get really in the weeds of their lives and understanding what their day-to-day looks like. And I honestly had not really looked deeply into the research on this until I was prepping for this episode. And I, I felt validated just reading all of the data on this topic because, I think every generation maybe has this tendency to think like we, we had it worse than the generation before us. Yes. It's like a, you know, every, everybody thinks that, but there does seem to be, data to support the fact that we are less well in a lot of ways than our mothers or grandmothers generation. So women aged 18 to 23 there, this was from a study done in 2013, so this was already more than 10 years ago. But women who were that age in 2013 were more likely to report. Poor self-rated health and more physical symptoms, especially, I don't know why urogenital and bowel symptoms than women who were that same age in 1996. And they felt in this study that stress accounted for a large proportion of those differences. Daughters in the millennial generation have persistently higher rates of generalized anxiety disorder and other less persistent mental health disorders compared to their mothers when they were the same age. And then lastly, among young women, specifically those who were born between 1989 and 1995, so a little bit younger than us, they were almost four kilograms heavier at age 18 to 23 and gained weight 1.7 times faster over the course of those years than women who were the same age, but born in 1973 to 1978. And the projections are basically that by age 41, these younger millennial women will be almost 20 kilograms heavier than their Gen X counterparts. I mean, just between millennials and Gen X, we're not even comparing with baby boomers. There does appear to be quite a significant, change in several health parameters. Now, it's not all bad news. We smoke less and our cholesterol seems to be a little bit better. So it's not like everything's going downhill, but clearly there is a decline in mental health. Clearly there's a decline. In just overall feeling of wellness. And then there does seem to be this increase in weight, which I'm not, saying anything else about that? Yeah, I'm actually curious

Rebecca Berens MD 19:30

about that. I wonder how much of that is the shift to not suppressing your weight with cigarettes and, uh, that's stimulants and all these things that were super popular back in the day. I don't know that that's necessarily a bad thing. Um, okay. Well think there were a lot of, uh, diety behaviors happening back in the day that, that we've sort of replaced with new ones. But that's true.

Speaker 3 19:51

And this is why I say I'm not necessarily saying anything about that, but we have larger bodies, we have more anxiety and we rate our health as poor generally it seems, than the generations before us. These things are all true and the question is why, and I think the thing that I see in here most commonly in social media is It's the food we eat, which I think is part of it. Oh, the food supply is poisoned. We're eating all these chemicals, blah, blah, blah. I do think that's a part of the picture. And then, there's all the talk about toxins and endocrine destructing chemicals and all the other things that we're exposed to in our daily life that, could be making us sick. But, in a lot of the studies that have looked at these factors and tried to drill down, what, what is driving some of these changes? The biggest ones they identify are usually socioeconomic and psychosocial stressors. And so those are things like social isolation, access to mental health care social media exposure rising income inequality, inflation, racism, exposure to gun violence, climate change, and these are smaller contributors, but decreasing marriage rates, declining religious participation. And, that's not saying. That we're pro marriage or pro religion or any of these things, it's just that some of those factors appear to be associated with better health outcomes and those factors have declined during this time. And so, those are potential contributors. So anyway, you know all that to say, when you go to your doctor's office and you're complaining about how tired you are and how unwell you feel and that you're gaining weight and all these things, your doctor's never gonna have a conversation with you about, socioeconomic factors that are contributing. And it's, and that's not our job. Our job is like clinical medicine and taking care of patients. But I wish people had a better awareness and. I wish we did a better job of acknowledging that these are really big picture systemic issues, and a lot of times they're not gonna be completely solved, one-on-one in a doctor's office, and a lot of the small things that we can do to tackle some of these issues, yes. You, you can eat higher quality food. Yes. You can have less exposure to some of these, chemicals. Yes. You can have, financial stability. Yes, you can have a partner. Yes, you can attend religious services. All of those things require resources and a certain amount of privilege and money, that not everybody has access to. So I think it's just it goes so much beyond. What we learn in medical school and what we talk about in a doctor's office. And I, and I think these are where a lot of the real root causes lie about what happens with people's health. And it's sad that it's just not really ever part of the discussion.

Rebecca Berens MD 22:27

Yeah. And I think adding onto the psychosocial stressors, I also think we are the girl power generation, I'm just thinking of the Spice Girls. Okay. So like we were coming of age with the Spice Girls and that was the whole, which I mean, I'm from the UK so I don't know maybe the Spice Girls were not as big here as they were. Oh no, they were, it was like, it was big. That was like the whole thing. Okay. And it really was this generation of you can do it all. You can do it all and you can do everything. Girls can do anything, which is great. And I think resulted in a lot of challenging of previous norms.

Sonia Singh MD 22:59

Mm-hmm.

Rebecca Berens MD 22:59

Which requires a lot of energy and then also requires you to be Doing your career and doing your kids, and since you had a career, you probably delayed having your kids, so your kids are younger when you're going through these changes. Yeah. I think that has such a huge impact on the psychosocial stressors that this our generation specifically experiences. Yeah. And it's, there's a lot of positives there, but I think there's a lot of negatives and it's also happening simultaneously with this social media decreased social positive social groups and more like polarizing negative social groups Yeah. Rather than a community group that is very social and, pro-social and together and there's community and we're helping each other. It's this like, yes, you can find your people online, but they're very siloed and there's very mm-hmm. Us and them sort of relationships that you find online and it's anti-social. And that's, another layer of psychosocial stress that is impacting this generation that did not impact any generation previously because we grew up on a LL instant messenger and the chat rooms, and now we're on Instagram and TikTok, and we are the only generation that's done that

Speaker 3 24:09

well. Yeah, and, I a hundred percent agree with you. I didn't. To look up any research on this, but this is something that I harp on a lot, especially when I talk to fellow physicians and encourage them to consider outside the box careers in medicine because, it's not just in medicine, but all across the workplace. I think women have reached a point where we're in the workplace, we're present there, and our expectations are the same as our male counterparts. But yet society in general has not caught up with that to support us in other ways. So division of labor at home is still gendered expectations of who's gonna handle most of the childcare is still, gendered pay is not equitable. So often you are working just as much, possibly more, making less, and you have more demands on your time. At home. And that's not even mentioning the pink tax and all of the things, you know, as I am becoming a woman entering my forties, the creep of the tiny things that I'm doing for maintenance and grooming. And I feel like I should, I'm ashamed to even be doing them. I feel like I should be not doing them and taking a stand against all of this. 'cause I think it's it really takes so much time and energy and money away from women. But, dying my roots every six months, getting a little Botox here and there, and I don't even do my nails. But once in a while for an event, I will do my nails and every time I'm there I'm just like, this is, an hour that my husband does not spend sitting in a chair incapacitated. And not fair. It's not fair at all. But yeah, I mean you just the upkeep of being a woman in society per se. And you know what the other thing I wanna say about that? Now we're getting on a little bit of a tangent, but I feel like this is an interesting topic. There's part of me that's like, oh, why do I even do those things? Let my hair go gray, let my wrinkles come in, wear it proudly, age gracefully, whatever, you know? But then I think there's also data to show that some of that self presentation makes you more successful in other ways. I am a walking billboard for my practice, so if I look tired and hired and distract Yeah. That, that presents my practice in a certain way. And so, I, I don't think it's, we shouldn't be shaming or blaming women and be like, you shouldn't be doing that. All that stuff is, it's actually, you're doing it usually to serve some purpose and for some other end. But again, that the purpose is there, like that expectation is there because of societal standards that again, we, we don't have a lot of control over at this point, and it's. It's hard. So anyway. Yeah, no, I totally agree. It really is

Sonia Singh MD 26:34

just,

Rebecca Berens MD 26:35

yeah, and it's like you said though, it sounds optional, but is it truly optional to do those things? Especially if you do have a career that's a person facing career? Yeah. And we know that appearance influences pay, in, in jobs. And like you said, if you're a visible promotion of your business, like it, it actually does kind of matter and in a different way than it matters to men. I think when men get gray hair, it's like, oh, look how, wise and distinguished he is versus what's wrong with this girl? Why can't she get her hair done? Right. What is she doing? Because I, I have given up on all things and I'm like holding on still young enough that it hasn't impacted me a lot yet, but I can just see it coming. You know? I'm like, Ugh, maybe I should do something about that. But it, um. It's a problem. And I think it is a unique to this generation problem in a way. Yeah. And I,

Speaker 3 27:24

and I just think so many women because it's, it feels so normal. Like in my friend group, everyone gets their nails done all the time. And so like you said, I don't think they perceive it as much as optional. And I don't think they ever stopped to be like. A man is not going to the hair salon every six weeks. I mean, I guess my hu my husband actually does get his haircut more than I do, but his is

Rebecca Berens MD 27:44

Yeah, but it takes like 10 minutes. Yeah. So bad. When I, when I used to get my hair dyed, it used to take like three hours. Yes. Yeah. Between the dye and the cut. I was like, I literally don't have time for this. I just don't, so twice a year I get my hair cut and it still takes over an hour, but that is cumulatively the same amount of time as my husband spends on his hair, right? Yes. Yes.

Speaker 3 28:03

I

Rebecca Berens MD 28:03

dye

Speaker 3 28:03

my hair every six months and my hairdresser knows that the time she dies it, I have to leave with my hair wet because I'm just like, I can't sit here any longer. It is just too long. Yes. I just can't be sitting in the chair that long. But yes, I mean, I, I just, we, I don't know that we recognize if you actually look at all those expenses and all the time and energy that it takes to do those things and arrange those appointments and go to those things, that is an insane amount of time and energy that's being taken up. So anyway. That was a tangent, but it is part of why we are all feeling so unwell and tired. Okay, so let's move on now. So what is the nugget of truth about this whole perimenopause movement? I would say perimenopause exists. It is very real as you mentioned. It can dramatically affect your quality of life and your wellbeing for a period of time. It can absolutely cause a huge range of symptoms. I am not somebody who's like, oh no, it doesn't cause joint pain. It doesn't cause headache. I absolutely think it can potentially cause all of those things that you're seeing, including the more, unusual ones. And I think it's also true that I think you and I are both of the generation that was. Still trained in the era of the Women's Health Initiative and kind of the tail end of that. Like we were all very scared. I was scared to use hormones in somebody who I was not. A hundred percent sure they were in perimenopause or menopause. And I didn't even know how to manage perimenopause. And now I think back to some of these, I had a handful of women who came to me desperate for help and I was like, I don't know, go see an endocrinologist or anything. Just like, I just don't feel that well versed on this. I'm not that comfortable. And it was because I just didn't receive that training. I just didn't get it in medical school. I didn't really get it in internal medicine residency. It wasn't a big part of my education and I just, I didn't feel comfortable with it. And I think because especially as an internist, I'm so comfortable with, mood medications, SSRIs with gabapentin, with all of the non-hormonal ways that we sometimes deal with menopause that I was very quick to offer those to people because I knew how to do those meds and titrate them. And in a lot of those cases, I can look back now and say, actually that woman just needed estrogen. Like she needed some estrogen and I was not equipped to give it to her. And I did send most of those people elsewhere if they felt like they needed that, but. I'm sad that I was not able to offer that as their primary doctor for so many years. I don't know if I, I don't know if you got more training as a family medicine doctor or if that was your different from your experience.

Rebecca Berens MD 30:27

Yeah, I mean, I definitely think there was still a lot of fear around hormones. And there was a lot of like, well, are you sure they don't have any risk of clots and are you sure they don't have any, yeah. All those things. And again, the data that's sort of since then been reevaluated and more clearly explained, these are the people who actually it increases their risk of cardiovascular disease. Yeah. And clots and like the transdermal estrogen is really not the same as the oral estrogen for clot. That was, that sort of nuance was lost. I think it was just like, oh, hormones are very dangerous unless it. Like a perfectly healthy, nothing wrong with them, no call history person. Right. Which is rare. Yeah. I also think, I trained in primarily safety net systems. Mm-hmm. And I think there were so many things Yeah. Impacting those patients that this was kind of not the thing that bottom of the list Yeah. Was they were bringing up. And so I don't doubt that many of the women I was treating struggled with this, but it never even came up because we were just like, do you have housing?

Sonia Singh MD 31:25

Do

Rebecca Berens MD 31:25

you have food supply? Can we control your diabetes? 'cause your A1C is 13. There was so many other things that we were focused on that, my training e even if I had had, attendings who were, more up to date and more aware, I don't think it came up just because we had such other focuses. Yeah. But yeah, I think it's something that I've had to sort of relearn myself in. Recent years as I've been in a different practice environment and I'm seeing more people with these complaints and especially now that it's so pervasive. Yeah. Like you said, it's like every visit with any woman over the age of 30, pretty much. That's like, when am I gonna be in perimenopause? When can I get on hormones? Yeah. Absolutely.

Speaker 3 32:05

So I also think there's a negative truth in the part about. Having to advocate for yourself a little bit. We talked about that there's substantial data that, women get taken more seriously. Their pain and suffering gets treated less aggressively. And so I do think there is even still today an element of self-advocacy that can be really helpful. But I think, as was kind of a theme in the thyroid episode, I think sometimes this desire to advocate for oneself gets misguided by things that people have seen and heard. And then there's a quick tendency to jump to the conclusion that the doctor is trying to gaslight you or minimizing you or doesn't believe you or whatever, when in fact they may be doing what's medically appropriate. It's just, it doesn't seem that way because you have been primed to think that you need certain things. And to me, I think the biggest thing that you can do to advocate for yourself or to, Make sure you're taken seriously when you're talking about perimenopause is to search out somebody who is clearly either a menopause society certified practitioner, or who, this is one of their areas of clinical interest or expertise. If you find somebody like that, they're usually going to be much more open to talking about having this discussion. Whereas, honestly, every PCP and maybe not even every OB GYN is, is really interested in this or eager to treat it. So, anyway, that's we'll put a pin in that. We're gonna talk a little bit about the end, about, what we would tell patients about this or what we would take from it. But I do think that's, all of that is true and valid and I'm glad that menopause is much more, in the zeitgeist and people are much more aware of it and what it can look like and that there are treatment options. So I wanna get a little bit into the facts. I thought we would start with just some basic definitions 'cause honestly it's not, it's a little gray. So, yeah. To talk about perimenopause, we first need to just talk about what is menopause. So you're actually officially in menopause when you have not had a period for 12 consecutive months. And usually what that is, is a signal that there's no more ovulation, that you're no longer fertile. The ovaries have essentially closed up shop. And along with that, there's this dramatic decline in, hormones that are normally produced by your ovaries, primarily estrogen. So the average age that that happens, the completion of that menopause transition is 51 and about 90% of women will have it happen somewhere between. 45 and 56. So the vast majority of women are going to reach menopause between 45 and 56. If you reach menopause between 40 and 45, that's considered early menopause. And then if you're under 40 and you reach menopause, that's considered premature menopause. So under 45 we're talking about 10% of women. And then under 40, that's actually 1.9. So about 2% of women and the reason I'm harping on all those numbers will become clear in a second. So perimenopause, you can imagine that, your period being gone for 12 months doesn't just happen overnight. It's not like you're having regular periods and all of a sudden it's gone and it's gone for a year. That transition period can take several years. So perimenopause is defined as the entire span that starts with the onset of menstrual irregularities or menstrual cycle changes and then ends. Up to one year after the menopause transition. And this is meant to capture that entire phase when hormones are starting to fluctuate unpredictably, but there may still be a period happening. And in fact, even after the menopause transition, there can be fluctuation of hormones they cannot stabilize for up to two years. So that's why kind of perimenopause also includes a year, even potentially after. So perimenopause has an average duration of three to six years, and during that time, you're having these wild fluctuations, but you are still potentially having some periods. Now, the reason I harp so much on the ages is that if you think about, okay, so the, the vast majority of women, the youngest age they're gonna reach perimenopause is maybe 45, like 90% of women fall into that category. People who are below that. It's kind of more pathological. So. 45 being the youngest age, that like most women are gonna reach it. And if you take six years before that as maybe having a really long perimenopause or long transition, that would put you at 39. So what I see a lot in practice is that if you're just looking at social media, anybody over the age of 30 thinks that they could potentially be having perimenopause. And if you just look at the raw data on this, is it possible? It's possible? And, for a certain type of patient, maybe with some family history, maybe with some personal circumstances that make me think they're at risk for having premature menopause. Yeah, I would consider it. But do most women 30 to 35 need to be worried that they're having perimenopause Probably not based on this number. I mean, 90% of women really should not be falling into that category. And we always say the patients don't necessarily read the textbook. So like maybe you have somebody who's perimenopause is eight years long, but the idea that, that's happening to a huge percentage of the population who's in their mid thirties right now is, it's just, it just seems very unlikely from a statistical standpoint. I don't know if that's what you're seeing as well, or that's what you're hearing from patients,

Rebecca Berens MD 37:20

Yeah, a lot of, 'cause a, a lot of what I'm hearing is people who are having some symptoms, but there's been no menstrual changes yet. And they're like, is it perimenopause? And it's like you're in your mid thirties, it's possible, but if nothing's changed with your period, there's lots of other explanations for the symptoms you're experiencing. And so for me it's also a case of we don't want to anchor ourselves on a diagnosis. Yes. That. We can't prove, there's no way for us to prove that you're in perimenopause. Yes. So particularly if you're still having regular periods with no changes from your usual periods and you're having all these other symptoms, it's certainly on the list, but it's not highest on the list. And I, I don't wanna miss something else because I'm so anchored on this. And then give you an inappropriate treatment

Speaker 3 38:00

Yes.

Rebecca Berens MD 38:00

And miss the actual diagnosis and actual treatment that you need for that condition. Yes, yes. So yeah, I think it's, that's the other part that I think people forget. It's like they're, well, they're just not, they don't understand perimenopause. It's like, well maybe I'm just looking at the other options.

Speaker 3 38:14

Right, right. There's more than one thing

Rebecca Berens MD 38:15

that

Speaker 3 38:15

could

Rebecca Berens MD 38:15

be

Speaker 3 38:15

wrong. Yeah. Okay. So you bring up a really important point, which is one of the common points, which is that perimenopause is a clinical diagnosis. So as you said, we're really not gonna be able to prove it with some objective lab tests or a scan or anything like that. So. What this means is that we're definitely not required to do labs. And in fact, by the Menopause Society guidelines, they're not recommended for making the diagnosis of perimenopause, and they're not really that helpful in guiding, our recommendations for how we treat those symptoms. So when you go to a doctor saying, I think I'm in perimenopause, and they may even agree with you, and they don't order labs that, does not mean necessarily that they don't believe you or that they're not taking it seriously or that they don't wanna treat you or that, they think it's something else. They are following, the guidelines from the Menopause Society, which are really the world's experts on this topic, or at least the US experts on this topic. But that makes it really, really hard and that makes the history part of this and the discussion of symptoms around this. Really critical to figuring out whether something is or is not perimenopause. So one question that I think is at the root of a lot of the controversy around perimenopause or a lot of the disconnect when patients come in with symptoms and doctors are like, oh, I don't know if it's perimenopause, is the question of, if you have no menstrual changes at all. 'cause technically the definition of perimenopause is that you have started to have changes in your menstrual cycle that are greater than seven days. So it's not even like, oh it's now a couple days shorter. It's greater than seven days. 'cause a couple days here. And there can be within the physiologic, normal premenopausal women realm. So if you have not had that level of menstrual change. Can it technically be called perimenopause? Is that perimenopause if you're having other symptoms suggestive of perimenopause? So I think if you look at social media, it will tell you yes. It will be, like, your period can be totally regular. And if you have, you know, X, Y, and Z, you should definitely be thinking it might be perimenopause and looking into that. What I would say in the way I practice, with my patients is that I really try to drill down to the symptoms that are most specific to the menopause transition and to, erratic estrogen levels. And so those to me are like, there's like the big three. So menstrual changes are obviously one. If that's happening, I'm my ears perk up and I'm much more, likely to consider. The diagnosis. The other one is vaginal changes. So, you know, all your vulvar and vaginal tissue is hormone sensitive, and so fluctuations in your hormones there can give you dryness, can give you urinary symptoms that are part of the genital urinary symptom of menopause. And then lastly, vasomotor symptoms. So those are things like hot flashes, night sweats, honestly, any kind of new temperature regulation issue catches my attention. So those three menstrual changes, vaginal changes in vasomotor symptoms are really the most specific to menopause. Meaning they are less likely to be caused by other things as compared to brain fog fatigue. Headaches, joint pain mood swings. So there was actually a study in the Lancet that was conducted in Australia, so not the US but it was a survey of over 5,000 women, aged 40 to 69. So these women really are in the perimenopause range, and they ask them about a variety of common perimenopause and menopause symptoms. And then they categorize these women as premenopausal, early perimenopausal, late perimenopausal, and postmenopausal based on this validated set of criteria that includes a detailed menstrual history and also actually some lab work. So, basically doing their best to try to find truly where does this person fall in the menopause transition. And what they found was that symptoms like fatigue, brain fog, mood changes were extremely prevalent in actually every category on the spectrum, including the completely premenopausal, no hormonal fluctuations category of women. And so Those symptoms cannot reliably distinguish people who were going through. The perimenopause and menopause phases. Whereas vasomotor symptoms and vaginal symptoms were helpful in predicting who was in which phase. They did note importantly that all those other non-specific symptoms, like the mood changes, the energy the brain fog, all of those things appear to worsen in conjunction with vasomotor symptoms. So it was not just like this woman's getting older, those things are getting worse. It was when they had new onset of those vasomotor symptoms indicating that their hormones were starting to fluctuate, often those other baseline symptoms became worse. So to me that suggests that perimenopause was not necessarily the root cause of those other symptoms which were present even before the hormonal changes happened. But they certainly exacerbated them once, they, that transition started to happen. So to me, if someone comes in with a plethora of of nonspecific things, they're like, I've got brain fog. I'm anxious all the time. I'm so tired, my joints are hurting, I'm gaining weight in the midsection. But they do not have any menstrual changes. They do not have any vaginal changes. They do not have any vasomotor or temperature regulation issues to me that is going to be a lot less likely to be perimenopause. And then again, you'd have to take into factors like age and their whole medical history and their family history and, look at the entire picture. But I think right now social media would lead you to the conclusion that all of those non-specific symptoms. Are probably perimenopause. And as you mentioned, the harm of that I think is going down the wrong route of treatment because if it is not, in fact perimenopause that is driving someone's headaches and weight gain and low libido, putting them on estrogen other than placebo effect is not going to treat those things or make them any better any more. Well, and so that's the harm I think of going, going to that conclusion. And lastly, I wanted to point out. That list of perimenopause symptoms, gosh, that sounds a lot like hypothyroid symptoms. There's, I think a lot of these, especially hormonal issues and, some chronic infections, some autoimmune disease, the symptom list can look incredibly similar, and so it's just a matter of what rabbit hole you fell down in terms of what conclusion you, come to when you're navigating like, all this social media information. So if you're somebody who's getting a lot of like Lyme disease information served to you, you may think all of this stuff is Lyme disease. And if you're getting a bunch of thyroids that served to you, you may be like, oh, it must be my thyroid. And if you have two X chromosomes, then your breast is getting perimenopause info as well. So anyway, that's kind of how I, I try to approach, my evaluation of perimenopause. But I'm curious to hear your take.

Rebecca Berens MD 45:02

Yeah, I mean, I totally agree with you and I think. Like you said, the biggest thing for me is if we're gonna treat you with estrogen, like estrogen is safer than it was taught to us. Yes. But it is still not risk free. Yeah. And with anything, it is always a risk and benefit ratio. And if you are having predominantly not vasomotor symptoms, but you're having fatigue, joint pain, headache, we can give you estrogen. Maybe it helps, maybe it doesn't, but where is the risk benefit balance? How much is it helping versus the risk that you're getting versus with vaso motor symptoms, it's so clear that it will help you, you know? Yes. And so that risk benefit balance is, is shifted, but I've seen some patients who were in their mid forties and had a lot of these symptoms and were like, yeah, maybe that's what it is. But they hadn't had menstrual changes yet. And I was like, well, it's reasonable to try it, and it didn't help.

Sonia Singh MD 45:48

Mm-hmm. You know,

Rebecca Berens MD 45:49

and so it's like, okay, now we've exposed you to something that didn't actually help with your symptoms. And again, if you're anchoring on that. Maybe miss other things. Now, I did obviously do other evaluation, but if you were to go into a doctor that has five minutes, or if you go to a telehealth company that only does menopause care, right? And you're like, I have these symptoms. They're like, here you go. Right? Let, they all use some hormones. They didn't do a full assessment. Right. You know, they didn't actually figure out what was happening. They were, this is like a direct to consumer hormone purchasing mill. You know, and that's where I see the real harm. And like you said, If your algorithm is perimenopause focused, you are gonna attribute these very common symptoms to that. I also think, there was that, study, which I wanna find it so we can include this, but there was, this case of, ticks being spread through children via TikTok. Like there was a TikTok video of a person who had facial ticks and then kids were showing up in neurologist offices. Yes. And it was like they were contagious through social media. Yes. And I am quite sure that if you get served content about, if you're in your late thirties, you're gonna start feeling like this, you're gonna start feeling like that. Yes. Yes. You can't, not, it's not possible that you wouldn't. Be more prone to notice and so yes, it empowered you with information, but it probably made you feel worse. 'cause you probably would've just been like, and I'm having an off day move on with my life. Yeah. But now you're perseverating and you're noticing that symptom so intensely that it probably feels worse to you that it would've if you had never seen any videos about perimenopause and you never would've necessarily gone into the doctor asking about it. And we could argue about whether that's better or worse for people overall, but I think there's definitely cases where it probably makes people feel worse when they're constantly seeing this content.

Speaker 3 47:36

I totally agree with you. And I also, the thing that I have noticed is that because of the excitement,, excitement, I don't know if that's the right word, just the whole, movement around menopause. Sometimes I'll have patients come in where I almost feel like they come in expecting that I'm going to be like. Yeah, it's not that it's not very menopause, it feels almost adversarial. There can be expecting that I'm going to say no, it's not that. And no, you don't need hormones. And I think there's this perception of maybe that the doctors, gatekeeping the solution for you. Because they don't believe you. They're not giving you the hormones and the hormones are what would fix everything, you know? And I think part of that distrust is also people want they believe that they should be getting labs. And some providers will tell you that labs are really helpful and they're really necessary. But again, the menopause society does not recommend labs. And so I think when they don't get labs, there's this perception even if the person's verbally telling you, yeah, it could be perimenopause that they haven't agreed or that they don't agree or that they're not being thorough or they're not gonna treat you. But I also think. That there's a lot of misunderstanding about what is even on the other side of that gate, what, what is, what is even gonna get offered to you? I've had women who are on. Combined oral contra be like, I'm having this, that, this, it's perimenopause. And I'm like the thing is, you've already got hormone therapy, like you're on it right now. You know? Yeah. And so there's, I think there's this idea that, oh, if my doctor would just believe it would, it was perimenopause. Everything would, would get better. And like you said, what I always tell people is, I am always open to a more, and thankfully we have practice models that allow us to do this. To have a longer conversation about these topics to really go into risks and benefits. I just like have, you have said, have definitely treated people without menstrual irregularities that had other symptoms that suggested to me that this was perimenopause and I had ruled out other things. And okay, let's, let's try a low dose estrogen patch. I think the harm of it is very low and we've talked through the risks and benefits and we'll do a little progesterone, we'll try it. But what I tell people. Started in those circumstances is look, I feel really confident about my ability to fix your hot flashes and fix your vasomotor symptoms. I feel really good about using vaginal estrogen and fixing some of those urinary symptoms in the vaginal dryness. I even feel good that your bone density might be a little bit better. Yeah, I do not make any promises about your energy level, about your brain fog, about your headaches. Those may or may not be related. And as that study suggests, oftentimes they're preexisting or they. I'll have some other cause and perhaps the hormone fluctuations are making them worse. But, I, I am, I'm very clear with people upfront that this is not, all encompassing magical solution that's gonna make you feel like you're 30 again. Which I think is what social media kind of projects to people that oh, if you just take this supplement and you eat this much protein and this much fiber, and you do this and dah, dah, and then the doctor gives you the right cocktail of hormones, you're gonna feel amazing and, look like Mary Claire Haber, whoever the menopause poster woman is. And I think that's just, that's not the reality that, that most women experience.

Rebecca Berens MD 50:42

Yeah. And I also think what, just with that adversarial relationship that's built, it's sort of like they don't know. I'm the only one who knows. And usually this person offers some treatments that are not f FDA a approved, like maybe they do pellets. Yeah. You mean Or the

Speaker 3 50:58

alternative providers? Yeah. Yeah. The,

Rebecca Berens MD 51:00

the alternative person is like, yeah, your doctor they just don't know how to treat it. There's other things. And so sometimes I'll see people who are not getting, they don't magically feel better with the hormones, so they're like, what else can I add? And they're adding thing upon thing. Yes. Or they're going and getting a pellet. Yes. And they're, the risk benefit ratio for those things is shifted a lot because we have a lot less data on things, especially like pellets that are not FDA approved. Right. Yeah. So It's, it becomes dangerous. Right. You know, I think you and I probably have both seen the effects of pellets on patients. I think every ER doctor in the country probably also could tell you about the AFib and all the other things that they see the strokes that come in on pellets. Yeah. And that's where it gets really dicey. And it, it does start with this sort of fueling distrust and then shuttling people to the alternative practitioner who offers all the things that the regular doctor doesn't, um mm-hmm. That have a different harm. Benefit ratio and not really fully explaining that nuance in a, one minute reel.

Speaker 3 51:57

I completely agree. I we could do a whole separate episode about treatment because that's, that's its own Pandora's box and there's a lot to talk about there. Yeah. Pellets is just such a lightning rod topic. We can't even mention that without like, yeah. Anyway, we should, we'll table that and we'll talk about pellets in a, in a, in a different episode, but yeah. Yeah, again, going back to this, this idea that, the doctor's withholding something from you or withholding the right treatment, as you said, I mean, I think the intention there is really To avoid prescribing you something that is, has potential risks and, may not benefit you at all if we're, going down the wrong path. And as you said, like I think we're so much more, I'm so much more comfortable now with the safety of a lot of these that I'm a little bit like in my art of medicine realm, I feel a little bit more like, okay, if, you know, if you and I both agree and we've talked through this and we, you understand that this is not a hundred percent likely to not gonna for sure help this issue that we're talking about. We can do a trial of it and see. The other thing I wanted to mention is going back to the topic of lab work. I had this experience with a patient once where, you and I are both in direct care and so, we're not necessarily having to get insurance approval for all of our tests. We have longer to talk about what tests we want and do not want, and. Review those results with patients. So I think we're in a different practice environment, so this is not right for everybody. But I think I've mentioned before, in the case of perimenopause and menopause, even though the labs are not required to make the diagnosis, they're not recommended by the menopause society. If a patient wants them, I am open to ordering them and I will a conversation with about them. That's basically like, look, 90% of the time I don't get anything from this. Probably more than 90% I don't. Occasionally I will see a major outlier that, suggests perimenopause, like a really low estrogen or a really high FSH. And sometimes that's a clue. Again, it does not make the diagnosis, but it's a clue. And then sometimes it serves as, maybe a baseline for if we start them on some hormone therapy and we're not sure if it's not working 'cause it's not perimenopause or menopause or it, it's not working 'cause the dose is not right sometimes then we can check another one and kind of see where we're at. So it, it's not totally out of the question and I do order it sometimes, but. I had a patient come in once and I actually strongly suspected that she was in perimenopause. She was having horrible hot flashes. She was waking up at night, she was still having a period. But she had all the other classic textbook things, but in her mind she still had some resistance about like, I don't know, should I go on hormone therapy? She had a bit of a history that made it such that she was maybe slightly higher risk in terms of clotting and some other things. And so it really was like a risk benefit discussion. And so, I was like, okay, well let's do, let's, we'll do the labs. And she came back with an estrogen of zero. And I still remember she came in after she had gone to a workout class and she was really, she was like. I'm still hot. The workout class was 30 minutes ago and I'm still hot. I'm just so hot and I, I don't wanna sweat on your couch. I'm gonna sit on the floor 'cause I don't wanna sweat on your nice couch. And so the two of us were sitting on the floor in my office and I had the printout of the labs and I was going over it with her and I showed her the estrogen of zero and she just burst into tears. And it was like this big, revelation moment for her where she was just like, there's a reason, I feel so bad. And I was like, yeah, I was telling you that this is the reason. I completely thought she was in perimenopause. I felt that I was very validating from the very first visit that that is what is happening. And I'm gonna offer you some hormone therapy and we're gonna talk through the risks and the benefits and even if there's some increased risk, we're, I'm gonna let you to make that decision. 'cause I really think this is affecting your quality of life. But for some reason, seeing that lab result. She needed that. That was such a, a pivotal moment for me as a doctor of just seeing the power of seeing something concrete like that for people. And so now I'm just a lot more likely to have that conversation. And if they push for it, I'll order it and if I don't think it's perimenopause, then it's probably gonna be normal. Even if I tell them, even if it is perimenopause, it's probably gonna be normal. And that doesn't mean it's not perimenopause. I believe you. And that's based on, other things here. And then if it's, if that's what it is, then that's what it is and we can check it again later if we want. But, so anyway, my practice does deviate now a little bit from, what the recommended guidelines are, but again, I consider that part of the art of medicine and something that has other therapeutic value. Beyond changing my treatment recommendations or guiding my treatment decisions.

Rebecca Berens MD 56:19

Yeah. And we've definitely talked about that before. I think there is, for whatever reason, there is just more, sway behind a red value on the lab sheet Yeah. Than like a verbal clinical diagnosis. It just doesn't feel as real to people, even though it is still real. Yeah. I think, and, and maybe part of that is some of the distrust that there is now and physicians that even if you have a really good relationship with the patient, there is just sort of this inherent how do they really know? How can we prove it? And if you could prove it with some data that's written down on a piece of paper and marked red, flagged by the lab, it feels more real than if the doctor just says it. But yeah, I mean, I think, we are, we are the same on, on that regard. I think there's a lot more reasons than managing treatment decisions to order labs. And this is one of them, it really is, there's a lot of labs that I order that are for the patient's more so than any medical benefit, just to yeah. Their understanding of their conditions. So,

Speaker 3 57:14

yeah. So anyway, if you're, if you're listening out there and you're thinking, oh, I really want labs, if your doctor says no, they're not doing the wrong thing, this is probably the right thing to do. But, oftentimes I find that people who are, more specialized in the menopause space, even completely, evidence-based using only FDA therapies, not doing pellets, even those people a lot of times will do a little bit of lab work for you and kind of help you, get a better understanding of where you are in the transition. So, okay, well maybe, we'll, we'll go to what can we learn from this as doctors and as humans? I think I, just the entire movement around menopause and perimenopause has taught me so much, clinically and as a person. It's, it's been a quite a journey for me. I think I recognized that there's a lot of deficiencies and gaps in my education and training, and I think I also learned and had the experience of. You can go out and learn these things afterwards. I've always had this fear of oh my God, I'm just gonna be stuck practicing like 2016 medicine for the rest of my life, because that's when I was up to date and up to speed on everything. And fortunately because our practice model gives us more time, I think, to do continuing medical education and to explore our own clinical interests, I've been able to do that and learn. And it's been uncomfortable for me, doing things that I've never done before, suddenly. And being like, okay, you're my first patient that I'm putting on testosterone. This is very scary. There's no f FDA approved product for women, but we're gonna try it. I think, it, it's, I've learned a lot just as a doctor from this. Again, it's forced me to reflect more deeply on just what leads patients to have that kind of distrust and what creates that tension in the room sometimes around these issues. And, I mentioned from that last story, I've just learned a lot about, what it takes sometimes to make patients feel seen and heard even when you're doing all the right textbook things. I don't know if you have anything to add to that.

Rebecca Berens MD 59:10

I totally agree with you. So my mom is on hormone therapy. She had a, um, ectomy when she was in her early forties. Hmm. And I remember at the time I was, I think I was in. Early med school and I was so afraid of her being on hormones and I've been harassing her to get off of them for a while. And then finally I was like, this is great. Stay on it forever. You know? So it's like she's sort of seen my evolution as I've learned more about this. 'Cause she, I think, having seen her experience, which is very different than going through natural menopause, surgical menopause absolutely hates hormones. But I think it, she's told me I would rather die than go, go off of my patch. So, and I think, I think that has been very illuminating for me of the quality of life stuff really does matter. Yeah. And it's important that we're taking that into account when we're talking with our patients, but it's also important that we're not prescribing things that don't have clear evidence of benefit and have some potential risk of harm. So I think it's, it's a double-edged sword there, but I think it's really important for us to keep that quality of life in mind.

Sonia Singh MD 1:00:10

I totally agree. And how would we talk to our patients about this topic? So, the thing I usually tell people is that I know you're seeing a ton of information on this. I try to reassure people that, I take this really seriously. I believe perimenopause can cause a lot of, seemingly unrelated, changes in your life and symptoms. I'm here for you in terms of investigating that, but I just want you to remember, from social media, makes it seem like everything all the time is attributable to perimenopause. And my concern is just making sure that I'm addressing the actual issue. And then I just try to be really transparent about the risks and benefits of different therapies and that,, like I said, I just try to be really clear with them that for all of those other non-specific things, it may help and it may not. Yeah. And then lastly, I think I mentioned how I think a lot of people, they social media has made them very aware of all the potential symptoms and presentations, but they're often not that aware of what the treatments are. They're just getting thrown supplements and diet plans and eat this much protein and just do this type of exercise or whatever. I think ultimately the best most women can do to prepare for the menopause transition is to optimize their baseline health with the normal things that we talk about all the time. Which are, are you getting good nutrition? Are you getting good sleep? Is your stress manage? Are you moving your body? Are you hydrated? Are you making time for social connections? All of those things are going to play a role in how well prepared you are for menopause. And I thought this was really interesting. I actually looked up like what are the different factors that seem to influence the severity of symptoms during the menopause and perimenopause transition? You're never gonna, so the ones that come up are demographic and socioeconomic factors. So lower education level is more strongly associated with worse vasomotor symptoms. Race and ethnicity plays a role. So black women experience the longest median duration of vasomotor symptoms. Tapped to 10 years on average. Followed by non-Hispanic white women at nine years, Hispanic women at nine years, and then Chinese women at five years. So there seems to be like substantial variation just across ethnicities. Psychological factors, as you might have guessed, are very influential. So higher anxiety levels are associated with more severe vasomotor symptoms. So it's funny, as you said, if you're already anxious about having these symptoms it perhaps may exacerbate them, rather than make them better. So depression and stress also seem to correlate with higher vasomotor symptoms and worse sleep. And those things probably all feed each other. We know how important sleep is for some of those other, for managing depression and things. So. There probably is a bi-directional relationship there. Lifestyle and body composition also plays a role. So women with BMI is greater than 30, have a, 1.5 fold higher risk of frequent or severe vasomotor symptoms compared to women with BMI of less than 25. Smoking is detrimental, in terms of vasomotor symptoms as a sedentary lifestyle, history of trauma, post-traumatic stress disorder, partner violence or sexual assault. So it's funny because these are not anywhere on social media, the things that actually influence your risk of having a terrible perimenopause. It's boring stuff like optimizing your baseline health and a lot of factors that are really not totally in your control. So, when someone tries to sell you a certain supplement or, very specific diet or very specific exercise, I would take that with a grain of salt because a classic theme we see is convincing you you have a problem that you didn't know you had and then selling you a solution. And so I think we see that a lot and, the real solutions and proactive measures are honestly not very sexy or easy to. Clickable affiliate links. So, yeah,

Rebecca Berens MD 1:03:58

ex. Exactly, exactly. And, and I think the more that people overcomplicate it by trying to follow all these protocols and buying all these supplements, the worse their life gets. Now, now your life is complicated and expensive 'cause you're buying all this programs and supplements and stuff and it didn't actually help you. So yeah, I have this conversation with patients a lot and I've actually found that like the discussion of the impact of seeing symptoms fed to you all the time and experiencing those symptoms People really resonate with that. It's really, it's understandable to them that that's possible. Yeah. And I hesitated the first time I brought it up because I, I never want me to be sounding like I'm saying, you're making it up or it's all in your head. Yes. Right. But I think that's why that, that TikTok tick case was so powerful to me. I'm like, this is not fable, yes. This is real contagion. Yes. And, and there really is this real effect. 'cause we mirror what we see. That's what we, that's part of our human nature. Yeah. And so I think, as we talk about a lot on the show, there are harms to social media. This is one of the harms that I think is important. And I've been just surprised at how well received that has been when we've had that conversation. Mm-hmm. And yeah, like you said, just when there are symptoms, again, we're talking about risk and benefits offering it when it's appropriate and it's generally been going well.

Speaker 3 1:05:18

Yeah. I don't know if you've had this experience or if I'm just a total weirdo, but there's times when a patient is telling me about a very specific symptom, and then a few days later I'm like, I have that crick in my shoulder. Or oh, my lower lip is kind of tingly. You know? And it's just, I mean, I think it's just so human, to see these people be influenced by them and Yeah. I think, in the wrong hands saying something like that can come across as oh, you saw it and now it's like in your head, and now you're making Yeah. But that's truly not at all, you know? Yeah. We're saying it's just, it's, it's a very natural human response to just have this heightened awareness in certain parts of your body or for certain symptoms when you've been prompted to have that for some reason. And so it's, IM, it's, yeah. It's impossible to not think about. I think I'm in perimenopause.

Rebecca Berens MD 1:06:02

Yeah, same. Same. I, I'm not probably, but it's just, yeah, it just is, when you see it and hear it constantly, you do wonder. But at the end of the day, it is a question of is it actually gonna make a difference to do Yes. Yes. The treatment. And that's the part that is the longer conversation. But I think, like you said, with our practice models, we do have the ability to more over time, explore this rather than, I think what also happens is people feel when they go to a doctor's appointment, this was hard to get, I had to wait a while for this appointment. I only have 10 minutes. It cost me a lot of money. I wanna get everything. I wanna get this done today. Yeah, I want the answer today and I want the prescription today. And sometimes that's not the right approach to actually handle the situation. And unfortunately, most people in their, the way that they interact with the healthcare system, that's kind of what they're forced into. But that's where that again, that adversarial relationship comes from of It's hard for people to get in, it's hard for them to get the appointment. They don't have a lot of time to talk about it. And so they don't wanna have to keep doing that over and over again. Yeah. They just want the solution today. And I think that pushes on, that relationship a little bit, but we are very lucky to not have that issue so much with our patients.

Sonia Singh MD 1:07:06

Yeah. I, I think a common thing that happens is you may go there with the expectation that you're like, oh, this is obviously perimenopause. I can tell from all of my symptoms and what I'm seeing, and then maybe they say, oh, I don't think it is. But then like you said, there's not enough time to untangle, well, what is it? And so then you're sort of left with this and maybe you have normal labs, which even with perimenopause, you can have normal labs. I think people, are sort of left feeling like, okay, there's no explanation, or this person doesn't know or they don't care, or, whatever. And the reality is for that long list of non-specific symptoms that as we've mentioned, can be attributable to so many different things it often is not a one visit solution and it takes a lot of time to untangle and go deeper. And often the answer lies in, multiple factors and multiple visits. And so it's just, it's not a realistic outcome, to expect out of a visit. And unfortunately that's, like you said, I don't think it's the patient's fault that they're expecting that. It's kind of the sys the healthcare system is sort of built to work that way as if you go there and there is one sol one problem and one solution and you leave with that. Yeah. And that's almost never the case. So.

Rebecca Berens MD 1:08:16

Yeah. But then it does shuttle people into these purpose-built telehealth companies where like, we only treat this thing. Yeah. And I'm like, if all you have is a hammer, everything looks like a nail. You know, like that's, you know, the classic phrase.

Sonia Singh MD 1:08:30

I haven't thought about that deeply, but you're right. If somebody goes to a place that, is that a telehealth company that, specializes in menopause therapy? Are they gonna go through the work of being like, oh, do you snore? Oh, do, have you ever had a sleep study? Maybe you should get a sleep study before we attribute this to your, your fatigue to this and put you on estrogen. And I don't know that, that, I, I'm not sure if they do that. I'm curious. Yeah. I

Rebecca Berens MD 1:08:53

mean, I've even heard of patients who never actually have a synchronous conversation with the person they're talking to on telehealth. It's like, you click a bunch of things on a form and they chat you back and forth a couple times, and then they send you the prescription. There's so many, options of telehealth companies out there. And, I think. It's unfortunately that, that patients are getting shuttled in that direction, but I also think they have a lot of marketing dollars behind them, and that's probably influencing a lot of the content that people are seeing and then shuttling them there. So that's, I think just savvy consumerism for patients is really important. I've even had patients who see me in my practice, they can talk to me anytime they want and they'll reach out to me like, oh, I was gonna join this thing, this membership on this company. Yes. And I'm like,

Sonia Singh MD 1:09:35

I, why? You just had somebody ask me that last week. She, I was thinking about joining MIDI and I was like, I can give you all of the things. I'll give you all the things, not do that.

Rebecca Berens MD 1:09:46

Um, because you're literally already paying me. So, yeah. Why, why? You know? And and I've, I know you very well, like we can talk about it, but the marketing is so good. They're like, we are the only ones that can do it. Yeah. So they, even though they have a good relationship with us, they're like, oh, this is not a thing that they do. This is a thing that only these people do.

Sonia Singh MD 1:10:04

Yeah. I almost feel like this is another theme, and maybe we could come up with an episode around this topic, but there's something about when people become niche experts in something, especially when they're doing things that diverge from what, the major societies in that field will do. And I see this a lot with like certain, rare diseases like, POTS or MCAS where someone's like, I'm an MCAS expert, and then almost anybody could go to them with a variety of symptoms and they seem to have a little bit of a bias towards diagnosing the illness that they're experts of. And then they start doing out of the box things, but then that's justified as being like, well, but this is the world's expert on that thing. And even the, the Allergy Society and the Infectious Disease Society and this other society, oh, all those people are not experts on this particular thing. And this person is an expert on this particular thing. And I see that with a thyroid. I see that with, I, I have patients who still see a separate thyroid doctor to manage their thyroid, and they're managing it in ways that are not, traditional. And I think that their perception is like, well, yeah, my PCP doesn't agree because she's just, now she's not a thyroid expert. So this person is an expert and that's what they do. Yeah. That is like a common, thing. And I, I, and I see this, I follow a lot of the menopause experts, and I'll see sometimes they'll do a q and a where someone's like. Can vertigo be a symptom of menopause? And yes, it can be. And the menopause expert will be like, yes, and you have estrogen receptors in your vestibular system, but they won't talk about all the other potential costs of vertigo that are way more common, and so they're not saying anything wrong, but you just get this perception, you start having this skewed perception about the reality. Yeah.

Rebecca Berens MD 1:11:44

Yeah. And I mean, I think it, it's so tricky 'cause like for some of these under researched, underfunded conditions and MAS is another one that we could probably do a whole thing about. I think there's a lot of hidden truth in some of what these experts are saying, but it is also, again, the thing of Risk benefit. Yeah. And what do we actually know? What is a theory? Are we giving informed consent about experimental things that we're trying, you know? Right. I think it's, it's just important to, to keep that in mind and, if you're finding that you're being shuttled away, from a specific society or specific group, it's not necessarily that they're wrong, but you just, you have to have so savvy consumer Yeah. Approach. Yeah. And yeah, and I think, most good PCPs will admit when they don't know something and if they don't know, they can refer you. But just because someone tells you Hey, this is not evidence-based, and this is what I recommend, They're not gaslighting you, you know, they're, they're trying to go with what information they do have. And I think it's, IM, it's just important to be savvy as a, as a patient.

Speaker 3 1:12:44

Okay. So in terms of where patients can go for more info in the show notes, I'm gonna put, all the references as well as a few, links, people to follow that share, good quality, evidence-based information. And that brings us to the end of the episode. Well, thank you, Rebecca.

Rebecca Berens MD 1:13:00

Yeah, thanks so much for doing this one. This was highly topical. Okay. Bye. All right, bye.

Sonia Singh MD 1:13:08

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