Hormones and Menopause

Menopause is a natural occurrence in the cycle of a woman’s health, marking the end of the reproductive stage. While some women complete this stage free of symptom, most experience hot flashes, sleep issues, mood swings, pain during sex and/or depression. There are temporary solutions for these symptoms caused by an hormonal imbalance, but not all are effective or equal.  

Listen as our experts talk hormones and menopause on this edition of the Baptist HealthTalk Podcast featuring: 

Host: 

Jonathan Fialkow, M.D., chief of cardiology at Baptist Hospital and Chief Population Health Officer at Baptist Health. 

Guest: 

Natalia Echeverri, M.D., gynecologist and obstetrician at Baptist Health South Miami Hospital, as part of South Miami OB GYN Associates

Transcript

At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist Health Talk podcast where our respected experts bring you timely, practical, health and wellness information to improve your family's quality of life.

Dr. Jonathan Fialkow:

Death, taxes, and if you're a female in your forties or fifties, menopause, the three hard realities in a lifetime. And yet of those three, menopause is one of the most nagging domains in women's health. It's often painful and hated, yet indisputably a normal phase of a woman's life. While some women make the transition symptom free, many others experience hot flashes, sleep issues, mood swings, pain during sex and or depression.

There are temporary solutions for these symptoms caused from the hormonal imbalance, but not all are effective or equal. With hormones at the root of the issue, are they also the solution? I'm your host, Dr. Jonathan Fialkow, a preventative cardiologist and leader at Baptist Health South Florida. Here to help you and me understand the intimidating horizon all women must pass through is Dr. Natalia Echeverri, a gynecologist and obstetrician who practices at Baptist Health South Miami Hospital as part of the South Miami OB/GYN associates. Welcome to the podcast, Natalia.

Dr. Natalia Echeverri:

Hi, Jon. Thank you for having me today.

Dr. Jonathan Fialkow:

All right, so let's jump right into this and I think we'll talk about over the course of this conversation the symptoms of menopause, how it affects a person, their loved ones, and we'll also talk about the physical, metabolic, psychological and then of course what a woman can do to decrease all these symptoms.

And then mostly a conversation about hormone replacement therapy, which could be somewhat confusing. But Natalia, let's start with the basics. So what is actually happening to the body in menopause and what would be the more common symptoms a woman might experience?

Dr. Natalia Echeverri:

Okay. So let's first talk about menopause. Menopause is a time in your life when you stop having menstrual periods and it does mark the end of the reproductive years. The average age of menopause in America is 51 years old. And menopause happens when the ovaries stop making estrogen, which is the hormone that helps control the menstrual cycle.

Something that there's a little bit of confusion about is what is perimenopause in compared to menopause? Perimenopause is the years leading up to menopause and they can begin as early as your forties and which the amount of estrogen in the ovaries begin to fluctuate and your menstrual cycles can begin to change. And some women can actually start to experience some of the menopausal symptoms just not as strong as when they actually go through menopause.

Dr. Jonathan Fialkow:

So is there a timeline, I mean, quickly, is there a timeline of perimenopause or is that a variable as well? I mean, in other words, a woman might have perimenopausal symptoms for six months before menopause, a year, five years. Is there any kind of standardization of what a woman might expect and experience prior to menopause?

Dr. Natalia Echeverri:

So it can't be standardized, it's very patient specific. And it does relate to when their mothers went into menopause. So that's one of the main questions we ask our patients, is when did your family members, moms, sisters, even aunts go through menopause? Because it can give us a rough idea of when to expect menopause in a patient.

It can happen in the early forties, mid-forties, or it can start happening even six months before menopause actually hits. During that time again, they start to experience a little bit of the symptoms of menopause, just not in full force. Their menstrual cycles might begin to change, they might begin to get irregular or heavier or lighter. But menopause has not really hit until the woman has gone 12 months with no menstrual cycles.

Dr. Jonathan Fialkow:

So do you find there's a period of time where women may be in that perimenopausal state and they may not even know what's causing some of the changes or might not think about it? I mean, do you find women, and again, I'm speaking from complete ignorance here, they're so in tuned in a menstrual cycles and such that when they become irregular, they're like right away, "Hey, this must be perimenopause." So I guess, the question is what's the level of knowledge that a woman has when her body starts going through these changes?

Dr. Natalia Echeverri:

So I actually feel that a lot of women don't realize that they're in perimenopause. They begin to have some changes in the menstrual cycle and they attribute it to, most recently to the COVID vaccine, but they'll attribute it to other things, stress in their life, other, just other psychological factors going on.

And they're not as in tune with the menstrual cycles in their forties because women are busy, they're having responsibilities at home and at work, and they're just not paying as much attention to the menstrual cycle. Versus when they're in the reproductive years and they're actively trying to get pregnant, women are very in tune with their menstrual cycles.

They usually come to the office saying little things like, "Oh yeah. No, my period's regular, it's just a little bit lighter than before." Or, "I've been having weight gain and it's not as easy to just shed off the pounds as before." Sometimes it's the insomnia, they're like, "I'm having trouble sleeping at night, but I think that's due to stress." When in reality it can be due to some of the hormonal changes that they've already began to experience in their forties.

Dr. Jonathan Fialkow:

So I'm bringing it back again when we're saying that a woman may come to you with not really realizing that her complaints are perimenopausal related. Can you talk a little bit about the mood swings? And again, there's sometimes jokes made about it, but are there really changes in a woman's moods around menopause? I mean, can you speak a little bit to that?

Dr. Natalia Echeverri:

Yes, of course. So the mood swings when they're in perimenopause, it's very difficult to differentiate if they're actually due to a premenstrual syndrome or due to menopause. So that's a little bit of a difficult differentiation because they're still having menstrual periods.

So they're perimenopausal, but they might still be having mood swings. So is it because they're just having very strong premenstrual syndrome either a few days before their period or during ovulation, or is it because of the hormone fluctuation because the ovaries are starting to make less estrogen?

Dr. Jonathan Fialkow:

So does a woman who has a lot of mood changes in the premenstrual cycle state, would they be more likely to have those mood changes in perimenopause? Is there a correlation? I mean, I guess, what I'm trying to get at is are things a woman who might feel well could start being aware of to look for, or is there something that someone experiences and they say, "Hey, wait, I'm in this perimenopausal state." As you say, many don't realize they're in it. So are there any predictors that you might be able to establish based on someone's regular menstrual cycle symptoms?

Dr. Natalia Echeverri:

No, I wouldn't say that. I wouldn't definitely not conclude that just because a woman has a premenstrual syndrome, they're going to have more mood swings during menopause. It's during premenstrual syndrome, they're still secreting estrogen. And some women can be sensitive to estrogen and it might be due to that, versus in the menopause state, it's because of a lack of estrogen.

Dr. Jonathan Fialkow:

Well, that's great. You did mention a couple of the symptoms. If you could talk about what would be the more common ones, again, I know you mentioned for example, sleep and some weight gain and change in menstrual cycle frequency as the most common things, let's say in a perimenstrual perimenopausal state. But are there other symptoms that a woman might experience that might trigger an association with menopause?

Dr. Natalia Echeverri:

So absolutely, the hot flashes are definitely one of the main symptoms that are most disruptive to a woman's life and can become so severe that they actually, it interferes with their everyday life. Either at work or at night, they can't sleep because the hot flashes wake them up from sleep. And then insomnia also is one of the symptoms that we see very common.

Again, throughout the years, beginning in the thirties, trying to shed off the extra pounds becomes more difficult for a woman, especially when they hit menopause, it does become a lot more difficult for them. So we really do encourage for women to eat correctly, the usual, the exercise, routine health visits so we can help them and guide them through this transition by promoting healthy living.

Dr. Jonathan Fialkow:

Well, actually, I'll bring my area of specialty into the conversation. It does seem like a lot of the hormonal changes of menopause has to do with insulin sensitivity and specifically how insulin's triggered by carbohydrates. So a lot of that weight gain may be tied towards this carbohydrate intake.

And what we may be thinking that if a woman increases carbohydrate intake as they get older, they might be more successful at maintaining weight as opposed to total calories. But your recommendations are totally spot on appropriate, continue exercising, if not increasing your exercise and avoid those process refined foods which consistent with other dietary recommendations.

So going back, so now a woman comes in to see you complaining of something that is in fact perimenopausal or menopausal. And you identify something, what's the conversation? Is it more you just educate them about their feeling or about the what's going on in their body. Is a woman more... Are there things a woman can do to decrease some of their concerns regarding some of these symptoms?

Dr. Natalia Echeverri:

Absolutely. So when they're in their forties, we actually do recommend they start birth control pills. Although birth control pills are used to prevent pregnancy, it also gives the woman back estrogen and progesterone. The progesterone is given in order to protect the uterus from the effects of the estrogen.

So because they are in their forties, their ovaries are starting to produce less estrogen, which are causing some of these symptoms. By giving them a little bit of estrogen back in birth control pills, we are counteracting those symptoms and then the progesterone is protecting their uterus from the extra estrogen we're giving them.

Dr. Jonathan Fialkow:

So that's a great recommendation. And then again, from your experience, do women basically say, "Hey, that sounds great, I'll do that." Or do you kind of get pushback with some of the recommendations? What's the experience in your practice? How does this message resonate with the patients that you see?

Dr. Natalia Echeverri:

No, usually in their forties they're very amenable to taking birth control pills. I get more pushback about hormonal therapy when they're actually in menopause because there is a lot of misconception about hormonal therapy and menopause and there's a lot of fear around it.

Dr. Jonathan Fialkow:

So Natalia, let's talk about hormone replacement therapy because that seems to be a significant area of confusion. And I'm old enough to remember when we used to recommend it in women to prevent cardiac events, then we said it's dangerous and it could lead to blood clots. And then we said, just take it if you're symptomatic and stuff where, talk a little bit about that evolution and also where we stand now in terms of the benefit of hormone replacement therapy in what kind of situations in a perimenopausal and menopausal woman.

Dr. Natalia Echeverri:

So let's first talk about the positives of hormone therapy. It has been shown that systemic estrogen therapy is the best treatment to relieve hot flashes, night sweats, protect against bone loss and decrease the risk of colon cancer. Now local estrogen therapy has also been proven to relieve vaginal dryness.

So that's what we would use it for. And those are very important things. However, over the years we have noticed that of course with everything comes risks. So estrogen therapy alone when a woman has a uterus, can increase the risk of uterine cancer, which is why we add progesterone in order to decrease that risk.

Now combined hormone therapy has also been associated with a very small risk of a heart attack, which would be your area of specialty. So you can elaborate more on that. But we've also noticed that this may be related to the age, existing medical condition and when the woman starts taking hormone therapy. And as you mentioned, there is an associated risk with stroke and deep vein thrombosis, which are the DVTs.

Dr. Jonathan Fialkow:

So as you articulated, there's a benefit and a risk of pretty much everything we do, and in particular with hormone pleasant therapy just very eloquently listed, the kind of variables. So the reality becomes very individualized. Right? Very customized. Is that how...

Dr. Natalia Echeverri:

Yeah.

Dr. Jonathan Fialkow:

You don't come in and prescribe and say everyone needs to do this, you kind of get a feel for what the woman's looking for, what their symptoms are, and then of course what the risks would be based on other medical conditions and then you make your decision. Is that fair to say?

Dr. Natalia Echeverri:

Absolutely. So we have to treat every single patient as an individual. There is no standardized plan for any patient, man or woman, but especially in my field for women, we need to look at their risks, their medical conditions, and kind of see where they land and what would be the best treatment option for them.

For example, a patient that comes in complaining of vaginal dryness because of menopausal system, the decrease in estrogen causes this. For her, the best option would be local therapy, meaning vaginal inserts or creams that would not go systemically and would not increase her risk of breast cancer. It would not increase her risks of DVTs or cardiac events.

Dr. Jonathan Fialkow:

So again, going back to the customizable, and it seems like you're saying let's give the woman the least amount of therapy necessary to achieve the goal, which in that case might be symptomatic relief. Right?

Dr. Natalia Echeverri:

Correct.

Dr. Jonathan Fialkow:

So...

Dr. Natalia Echeverri:

And that's actually the recommendation from the academy, which is the smallest amount of therapy for the shortest amount of time in order to relieve symptoms.

Dr. Jonathan Fialkow:

So I think that's a valid statement. I'm just thinking again, from my perspective and the lay public's perspective, when you see people say, "Well, my daughter doesn't want me to do this" or "My friend said I should be doing this," the reality is, talk to your gynecologist, talk to your doctor, make the decisions based on the assessment of your risk and benefit and tell everyone else to shut up. Is that a good way to put it?

Dr. Natalia Echeverri:

That is an excellent way to put it. We will guide you and a lot of the time with the help of a cardiologist like yourself.

Dr. Jonathan Fialkow:

Sure.

Dr. Natalia Echeverri:

We will come in with a team approach and see what is the best therapy for the patients.

Dr. Jonathan Fialkow:

And I think that is again, well said, that there's no absolute risk to, that's the same for every woman. A smoking woman with a long history of cardiac disease will have a distant risk than the otherwise healthy woman who's fit, has no other metabolic disturbances. So it goes back to that customizable component.

So a few other questions if you will. I want to go back towards the concept of mood swings and other, let's say, psychological aspects of menopause and whatnot. Sometimes when describing, let's say a brain fog or just not a clarity, is there a correlation with menopause or is that just more of an aging type of thing? Is there any other kind of psychological or cognitive type of perceptions that a woman may have at menopause?

Dr. Natalia Echeverri:

So no, I don't want to dismiss it saying that it's just an aging kind of thing in general because it does make patients feel like they're crazy. So we have noticed it's difficult for us to find a direct correlation, but we have noticed that some women in menopause do experience what you are describing as brain fog, which is forgetfulness, difficulty concentrating and thinking clearly.

And there are studies being done currently to try to find the correlation between the dipping estrogen levels. Essentially, what we're finding is that the hormone levels are related to the activity in part of the brain. Okay. And in the study that's being currently done, it's showing that women with lower levels of estrogen did worse on memory tests. So we are finding that there might be a correlation between the dipping estrogen.

However, in one third of these women, it was also found that they scored fine. So we're thinking that it might be also female dependent, meaning what are they doing with the rest of their lives? Maybe it's not estrogen alone, but maybe some of these women are resistant to these changes because of their exercise levels or mental exercise levels over a lifetime. So a woman that has been exercising, not only her body, but her brain might be a little bit more resistant to these changes.

Dr. Jonathan Fialkow:

Interesting. And then as a follow-up, for some women who have these types of complaints, when you prescribe appropriate hormone replacement therapy, they'll say these symptoms improve? I mean, are these things that actually get better?

Dr. Natalia Echeverri:

Some women do say it, but when I prescribe hormone replacement therapy, I also encourage the patients who go on a nutrition plan and to exercise. So it might also be part of the lifestyle changes that are helping this.

Dr. Jonathan Fialkow:

Correct. Okay. Many factors involved. This is very helpful. Here's my last question, and again, hopefully it's a fair question. For where I come from and in my area of the preventive cardiology and working with various metabolic disorders and whatnot, I always go back towards evolution and having an explanation of why the body does certain things.

Is there any thought of evolutionarily? Is there a benefit to menopause or what's actually going on in a woman as they develop that menopausal state that might be, we'll say, beneficial to the body or society or anything like that?

Dr. Natalia Echeverri:

That's a very interesting.

Dr. Jonathan Fialkow:

And I'm going to pause for a second so you don't have to answer that question if you don't want to.

Dr. Natalia Echeverri:

It's a very interesting question. I haven't done research on that aspect per se. However, just from thinking about the common sense, if we are bleeding every month, evolutionary speaking, we are losing blood and we are becoming slightly anemic. We know that a lot of women have anemia, so as we age, the body might be trying to shut that down in order to conserve some of that for the woman, meaning.

Dr. Jonathan Fialkow:

Sure.

Dr. Natalia Echeverri:

Not allow the woman to become anemic as she ages in order to continue a flight or fight response when we used to have to do that.

Dr. Jonathan Fialkow:

It's fascinating if you think about it. I think about it for most things that I deal with, and I'm thinking even this standpoint that you think men evolved, men and women evolved in a very scarce food supply. And if a woman during her childbearing years needs to have a significant amount of energy that might be scarce, well, now you're not having children anymore.

So maybe you don't need as much energy again to sustain the blood loss and everything else. But again, higher level conversations that may not be as helpful for our listeners. Anyway, you've been extremely helpful in defining what a lot of these types of symptoms, as well as what your approach is and what's out there for women. So I appreciate that. Any final comments or anything you want to...

Dr. Natalia Echeverri:

Yes, I...

Dr. Jonathan Fialkow:

Get to that we didn't mention?

Dr. Natalia Echeverri:

Actually, I would like to mention that there's some women that really don't want to go on hormone therapy either because they have medical condition or because they are afraid of the risks. And there are options for them as well. We have noticed that there's certain antidepressants to relieve hot flashes that are very, very effective.

And when a woman comes to me with these complaints and I offer her these, I make it very clear, I do not think that you are crazy or depressed. I do not think that I'm treating a psychological issue here. I know that you're real. It's a very physiological issue. However, it has noticed that antidepressants can relieve hot flashes when used appropriately.

So there are other options, and there's also selective estrogen modulators, which is a different kind of medication to relieve hot flashes or even pain during sex. There's some seizure medications that we also use for sleeping problems or the hot flashes, and of course, that there's some plans and herbal supplements that can be used.

Most of these do contain soy products. The main thing with this is that women should always discuss it with a provider because the plant supplements and soy products are not FDA controlled. So we want to make sure that we're aware of what you're taking in order to help you navigate it.

Dr. Jonathan Fialkow:

So again, again, well said, there's lots of weapons in our armamentarium to improve a woman's quality of life through the menopausal state, but best to speak with your doctor to make sure what you're doing is appropriate, safe and monitored, which is again, great recommendation. So...

Dr. Natalia Echeverri:

Absolutely.

Dr. Jonathan Fialkow:

Well said. So thanks again, Natalia, for your expertise, obviously your passion in the subject in helping your patients. And again, to our listeners, if you'd like, what you've heard on this or any of our other podcasts, please be sure to tell a friend or a family member about us. And if you have a comment or a suggestion for a future topic, please email us at BaptistHealthTalk@BaptistHealth.net. That's BaptistHealthTalk@BaptistHealth.net, and we'd love to hear from you. Thanks for listening.

Speaker 1:

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