S12 Ep3 - Perimenopause: Audio automatically transcribed by Sonix

S12 Ep3 - Perimenopause: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Intro/Outro:
Hi, I'm Kristyn Hodgdon, an IVF mom, proud women's health advocate, and co-founder of Rescripted. Welcome to From First Period to Last Period, a science-backed health and wellness podcast dedicated to shining a light on all of the women's health topics that have long been considered taboo. From UTIs to endometriosis, we're amplifying women's needs and voices because we know there's so much more to the female experience than what happens at the doctor's office. With From First Period to Last Period, we're doing the legwork on your whole body so you can be the expert in you. Now, let's dive in.

Kristyn Hodgdon:
Hi, everyone, and welcome back to From First Period to Last Period. I'm your host, Kristyn, and I'm here today with Dr. Shannon Klingman. Hi, Dr. Klingman.

Dr. Shannon Klingman:
Hello.

Kristyn Hodgdon:
For those of you who don't know Dr. Klingman, she is an OB/GYN and the inventor of Lume Whole Body Deodorant, and I'm really excited to dive into all things perimenopause today. For those of you who don't know this, Rescripted started as a fertility company. We branched out into all of the women's health, and I think perimenopause is like, where can fertility and women's health meet? In a way, it's so many considerations with family planning and what your body is up to mentally, physically, etc. So, really excited to learn more.

Dr. Shannon Klingman:
I'm excited to talk about it. It has not historically been talked about enough. So, as much as the sisters who are living in the menopause years can help advise the sisters that aren't far behind, I think is great. So, thank you for the opportunity to meet with you today.

Kristyn Hodgdon:
Absolutely. So I guess, first and foremost, what is perimenopause as it relates to menopause, and how do women know that they're in it?

Dr. Shannon Klingman:
Yeah, I think it's an inevitable reality that perimenopause begins 10 to 15 years prior to the actual menopause. And so the age ranges that we think about are perimenopause between the ages of 35 and 45, and it's normal to have an experience of menopause, which is the ceasing of periods or the ovarian decline between the ages of 45 and 55, but the average age is 52 years old in the United States.

Kristyn Hodgdon:
For menopause?

Dr. Shannon Klingman:
For menopause. Yeah, that's on average. Most women are going to experience menopause at the age of 52 or around the age of 52, but it's not abnormal to experience it sooner or a little later. But this process of perimenopause really starts in our mid-30s.

Kristyn Hodgdon:
Oh geez. You're telling that to someone who's 35.

Dr. Shannon Klingman:
So, just so everybody knows what we're actually talking about here. We're talking about the peak ovarian function decline as we age. So, we say ovarian failure. I just think of it as evolution and transition of one season of life to another. It doesn't have to be the really negative, scary thing that it has been for women. If you're more informed, there are things that you can do to weather the storm very effectively and with grace.

Kristyn Hodgdon:
Yeah, absolutely. So, what are some of the early signs that could tell you that you may be in perimenopause?

Dr. Shannon Klingman:
Most women won't necessarily pick up on the symptoms in their mid-30s and attribute it to ovarian function decline, But they'll say that I'm starting to notice more noticeable changes throughout my menstrual cycle. So I'm actually sleeping. My quality of sleep is way worse. I'm noticing hot flashes around the time of my period. Nothing too dramatic, but if you're noticing this little puff of heat and dewiness on your skin or when your estrogen levels are at their lowest during the time of your period, you may experience more vaginal dryness than what you expected. And I think some women think I've been with the same partner for ten years. Maybe sexual arousal isn't what it is because of relationship fatigue or something like that. But really, it could also be related to the perimenopausal or the decline in estrogen that women experience as we age. One thing that might give you a segue is that when I say menopause, most people think they're treating hot flashes. They'll say, I'm starting to notice that I'm going through the change, or I'm experiencing signs and symptoms of menopause, and they will almost always have a singular symptom that they're referring to in its hot flashes. But menopause is so much more than hot flashes.

Kristyn Hodgdon:
It's interesting because my mother-in-law has been dealing with, like, hot flashes for ten-plus years, but then my mom didn't have any of those physical symptoms, but she had a lot of, like, mental health sort of related symptoms. So it was just like my first foray into how different the experience can be for different people, and my question based on that is, are there genetic factors that kind of expose people to having earlier menopause, later menopause, or specific symptoms related to it?

Dr. Shannon Klingman:
Yeah, I think you can look back on when your grandma and mom went through menopause, and you can say there's a likelihood that's something that I can look forward to as well. So, if your mother went through menopause earlier in life, it wouldn't be too surprising if you did as well. My mom, I think, was 56 or 57 years old when she finally had her last period. I'm 54 and still waiting for my last one. Every month I go, here she is again, and I'll, maybe this will be the last time, but it's actually a sweet, special transition in your life that can be slightly unnerving. Here you are. You identify so many qualities about yourself, who you are physically, right, and the well-being that estrogen brings. And then it slowly, it's like a balloon, right, where you're full of estrogen, and that balloon is really tight. And then slowly, it starts to deflate, and pretty soon you're having a hard time just continuing, like the lofty feeling of your life. Like you're no longer floating. You're feeling like you're dragging a little bit. You feel your vitality start to slip. And it really takes, I think, an awareness of how to remedy that by improving, like, your sleep hygiene, what supplements you should be taking dietary-wise like you want to. Women need to increase their fiber. They become more prone to insulin resistance. So, you need to be minimizing your processed sugars. And exercise is never more important than when you're in your 30s through menopause because you're building that peak bone density in your 20s to where it peaks in your 30s, and you want to try to hold on to that for dear life. And so you should be thinking about being strong rather than thin. I think about myself and I'm always thinking, how can I lose some big events coming up? And be like, it creeps into my head too, and it's toxic. That voice in your head that says, like, how do I lose this belly fat? Or how can I lose 10 pounds in a month, when really, we really should be thinking more about preserving our muscle mass and our strength for our bone density to reduce the risk of osteoporosis, to improve our sleep, and just overall sense of well-being? Because if you are noticing a shift or a symptom, chances are you can attribute it to the estrogen, the catastrophic decline in estrogen that women experience over that 10 to 15-year span. Once your ovaries are no longer functioning, she's not ever coming back. And so you want to make sure that you're building those best practices beforehand. You're talking to your doctor about whether you're a candidate for hormone replacement therapy or not, which I would argue everyone is in one way, shape, or form, and we need to be initiating those conversations early because estrogen replacement doesn't just start when you have your last period, you need to be having those conversations in your 40s.

Kristyn Hodgdon:
I was just going to ask when do you suggest that. Because it's such, it can be like a 10 to 15-year process. When do you suggest going to your healthcare provider and talking about options like that, or even just some of the lifestyle changes you recommended, or even just is this perimenopause versus I have a thyroid condition? Sometimes, when I'm feeling fatigued, it's oh, it's probably just my thyroid condition. Like, how do you start that conversation with your healthcare provider?

Dr. Shannon Klingman:
I think there's a lot more awareness on social media right now that you can use as a really easy segue. It can give you the language like, hey, I'm in my mid-30s, want to think about this transition into pre and post-menopause. But quite honestly, your doctor is likely way under-trained to be able to serve you. So you want to do your best to seek out healthcare providers who are pro this narrative. They are on the menopause train. They understand the disservice that was done to women during the WHI trial, where we took a generation of women, and we dramatically compromised their quality of life by fear-mongering and hormone replacement therapy with really crappy data.

Kristyn Hodgdon:
Yeah, so that wasn't the whole myth that it can cause breast cancer.

Dr. Shannon Klingman:
Yes, yeah. But what we know now is that there are the benefits of estrogen way outweigh the risks of estrogen. And if your healthcare provider is telling you no, it's because they are not comfortable. They have not done the additional research necessary to continue their education beyond what they learned in residency or from outdated data. That isn't even true any longer. And we know that it's been debunked. So, if you have a healthcare provider who is unwilling to continue the learning process around Peri and Postmenopause, it's time to find another doctor, and it's not easy to do. I wish it was as easy as just saying, oh, here are the ten people in your area, but you want to seek out resources that are pro this conversation so that they are listening to you and not dismissing you as, oh, we can check your thyroid, but that's probably what it is, or telling women that you probably just have depression. I think that men have perimenopausal symptomatology that just mimics depression in so many ways, and it's so easy for healthcare providers to dismiss it. Now, depression is a very real thing our intolerance for liability does grow, and it's more likely to be a challenge for people as we age. But if you think about it, in fact, I was just talking with some of the people here with me in our studio, which was to the men, and I'm saying, can you imagine if tomorrow you woke up and you had no testosterone? Like, what would that impact be on your sexual health, your cardiac health, and your vitality? Are you feeling good about yourself? Your mental health is literally a catastrophic decline in estrogen that women experience, and for some reason, we create value judgments around it. It's as if women are weak because of it. When it's like we get our legs kicked out from underneath us and we're expected to still stand, and it's possible to do with the right dietary support, sleep support, pharmacology, support of estrogen, and when you need a progestin. So it all starts with you raising your own personal awareness and advocating for yourself in the room with your healthcare provider. I'm passionate about this. Can you tell?

Kristyn Hodgdon:
Absolutely. HRT and replacing the estrogen. My question, or what I'm confused about, is if you're replacing the estrogen, at what point do you stay on it? Indefinitely? Or because what I'm thinking is, at some point, it is going to go down if you come off of it. Is that like a weaning process?

Dr. Shannon Klingman:
As far as I'm concerned, I'm going to be on estrogen until the day I die. They will have to tear that part off of my rigor mortis body in order to put me in the ground or whatever it is I decide, but I will likely be on estrogen for the rest of my life. And I think as research continues, the data will improve. The quality of the data has to improve. Women are demanding it. We know that the National Institutes of Health spends $45 billion on health-related research. Of that, only 10% is dedicated to women, and only 0.03% is dedicated to women in the menopausal time in their life. So, the research can only get better. It's like there's it's virtually nonexistent now. But one thing that we do know is that the Menopause Society has said that the benefits of estrogen outweigh the risks up until the time that a woman is 60 and I'm swimming like hell towards 60 right now, I'm 54 years old. I'm not ending this at 60. Hopefully, the data will continue to support, I would say, evidence-based decisions around hormone replacement therapy rather than fear-based decisions.

Kristyn Hodgdon:
Yeah, yeah, and like, providers catch on and then spread that evidence to their patients, for sure. Can you speak a little bit about your own experience with perimenopause? What advice do you have for women who may be currently experiencing it?

Dr. Shannon Klingman:
I think that I, like all women, experience the multitude of symptoms of perimenopause and menopause, and I started like this self-deprecating conversation. Like I'm weak, I lack self-control. I'm gaining weight because I don't. I'm not making wise choices around my diet. I need to be exercising more. You start like the narrative in my head was. I began really shaming myself and feeling like if I was a stronger person, I would be able to get a grip on this. But what I want women to know is it's really beyond your control, and this is a chemical change that is happening within our bodies, and it impacts our minds, our memory, and our ability to tolerate challenges. You have just a diminished thrust-like tolerance threshold for a lot of things. And I thought about those and I started to make value judgments against myself for that. And I think even in our training as OB/GYNs, we were woefully under-trained, inadequately, embarrassingly so, where we would dismiss and discredit the health of women. Once they're beyond their childbearing years, we start to just treat them like men. And unless you have a healthcare provider who is going to be sensitive to the nuances of menopause, it's so easy to lump everything into. You're lazy, you're depressed, you're not making wise choices, you lack self-discipline, and you've gone through the change. And this is the new reality for you, which is absolutely not the case. I started on hormone replacement therapy in my 40s. So, what I started to notice in myself was PMS. There were times during my menstrual cycle, like right before my period, when my husband just breathing in and out, was enough to make me think I'm going to kill him in his sleep. And I thought this was irrational, right? Like you're having these thoughts that are just not who you would say you are. And nobody could convince me that it was PMS. And my husband, who's an OB/GYN, would say, you're just mad because you're probably going to get your period. And oh my gosh, that just enraged me even more for him to make that assumption. But when I started to mark it down on a calendar, what I noticed was those moments of just where you just have despair, where you, nothing is good in your life. You're just, everything is negative. You've lost your spark. You're just in the lowest pits of it, and you are having a hard time seeing your way out of it. And it's one day it happens, and then you get your period the next day, and you're like, oh my gosh, that those swings for me just became really severe in my 40s. And I opted to go on hormone replacement therapy while I was still having regular menstrual cycles because I was still ovulating more regularly. I wasn't on the progestin component of it because if you are on estrogen and you still have a uterus, you need to be on progestin as well. But because I was ovulating, I only required the estrogen part of it for a time. And it was as if someone just turned my life from black and white into color, and it happened very quickly. Within five days, I felt like there was considerable relief present. And so and now I've done things like I try to pay attention to if we recommend 25g of fiber per day for menopausal women, it's 35, and it's very difficult to get 35g of fiber in per day, and so, you have to, probably supplement with something. And I think about my exercise more as a lifestyle, like never take an elevator, just you always take the stairs. You always park a little bit further out. You are happy to carry the groceries in. You want to be doing all the things to remain strong and living an active life for sexuality or like your sexual well-being. Women should be using lubricants every single time they have sex in the menopausal period. Don't let pain or discomfort of vaginal dryness be a reason to say no to intimacy. And so every woman, even women who've experienced breast cancer, are candidates for intravaginal estrogen, to preserve the integrity of the urogenital tract and the vaginal sidewalls to make sex more comfortable. And so I think I'm treating myself more kindly now that I understand what it is that I am asking of myself and my physical body because my desires are identical to what they were when I was in my 30s. But I'm noticing these changes when I look in the mirror even, or physically. When I'm going up and down stairs, I'll be like, oh, I'm more short of breath than I feel like I was maybe a year ago. And instead of slowing down, I start skipping steps as I climb the stairs. Okay, what can I do? I have to just yeah, push a little bit harder to get there. So, probably more information than you really wanted from me.

Kristyn Hodgdon:
No, we are all about TMI at Rescripted, and thank you for sharing, I appreciate it. I feel like one of the silver linings, if I can call it that, about going through IVF and infertility is that I'm weirdly in tune with my body now. I know how certain hormones affect me, and I like to think that, and obviously, from doing all these podcasts. But I'd like to think that I would notice the change in myself, but not everyone has that same knowledge. And if their doctor is telling them, oh, don't worry about depression, you're not there yet. Yeah, that's very invalidating. And they might just be like, oh, you're right, it's nothing. And then they don't get the treatment they need. And yeah, it's like a vicious cycle for sure.

Dr. Shannon Klingman:
You are absolutely right, though, because IVF does create a pseudo-menopause. So you have experienced small stretches of time where you know what those symptoms are. And oftentimes, women want to get a hormone panel drawn or whatever. And really if you're symptomatic, there's reasons for treating. It's more I always used to say to my patients, what is the don't miss diagnosis here? You don't want to make an assumption it's thyroid and miss the opportunity to really improve the quality of life of your patient by replacing estrogen. But there really isn't a one-size-fits-all with every woman. You need a physician who's going to understand that the menopause perimenopausal process is a bit of a spectrum. It's syndromic. Like not everybody's going to have the same symptoms and the severity of symptoms. But just about everything that women experience from urinary, increased frequency with urination, you're not able to sleep at night. You notice that you're more irritable. Your short-term memory is fleeting. Like you feel like, why can't I remember things like I used to? Those things are all repairable. You can reverse pieces of that with hormone replacement therapy. And if you have a doctor that's not listening to you about that, you need to go find another doctor.

Kristyn Hodgdon:
Speaking of syndromes, we spoke a little bit about PCOS in the last episode, but I'm curious: do women with PCOS, because they often have a high AMH or egg reserve, do they go through menopause or perimenopause later?

Dr. Shannon Klingman:
I don't know, I can't say that I know that for sure. I do know that with polycystic Ovarian syndrome, though you are, those individuals are far more likely to have hyperlipidemia. So, like cholesterol lip challenges, they can overcome either with diet, exercise, and maybe even pharmaceutically. They're more likely to have central obesity. And we know that the secondary medical conditions that come with that are hypertension and diabetes. So if you indeed know that you have polycystic ovarian syndrome in your 20s, most doctors are going to say, oh, so your periods are irregular here, go on the birth control pill and that'll be it. But there are secondary risk factors that come with that condition that become more and more important into your 30s, 40s, and the menopausal stage. You need to be diligent about your weight, diligent about hypertension, diligent about insulin resistance and diabetes. Those topics are not often talked about in the childbearing years. It has more to do with infertility and period irregularity.

Kristyn Hodgdon:
Yeah, absolutely. But that's really helpful. Thank you. Obviously, with age, the risks of all those different chronic conditions that PCOS can lead to become higher.

Dr. Shannon Klingman:
We do know is that people with polycystic ovarian syndrome have fewer periods per year. So you're more likely, if you're getting 3 to 4 periods a year with PCOS, that you could be confused as having gone through menopause. And so that's where just being in tune with your doctor and staying close to when to worry. You need to get comfortable with your own understanding of that condition, because if you are not advocating for yourself, I have to say I overall am disappointed, generally speaking, about everybody's understanding of menopause that I've ever talked to. It's that they're discredited. Women are they're talked down to or dismissed. It's as if we just don't care enough as a medical community around this stage in a woman's life. And, of course, we don't know enough about women because we're not doing the research on women as we've talked about that. So there's a lot of changes that need to happen, and so I appreciate the Warriors. And you can find them on social media that are huge advocates for women advocating for themselves. And they're basically saying, here are the things you need to worry about. Jot that list down, take it to your healthcare provider.

Kristyn Hodgdon:
I love that. What would you say to someone who might be skeptical about going on hormone replacement therapy?

Dr. Shannon Klingman:
I think it's understandable. We've done a really good job of making everybody afraid that hormone replacement therapy is going to cause cancer. But what I will say is that the consequence of that is the dramatic decline in estrogen that women experience. You're saying, okay, that while that's normal and natural and you can live with it, the consequence of that is mental decline, increased risk for dementia, cardiovascular disease, diabetes, central obesity, hypertension, metabolic dysfunction, vaginal dryness, aging, all the signs and symptoms related to aging, and the quality of our skin and collagen. And just every single aspect of our life is impacted by that dramatic decline in estrogen. And so, hormone replacement therapy can prolong the inevitable. It can also dramatically improve the quality of your life, which, in the end, that is the most important thing, is making a day at 85 as enjoyable and energizing as a day when you're 45. And so women do have a sense of well-being; they have more vitality, they feel better on estrogen, and so just know what you're saying no to. And if you the good news is that if they're skeptical and they don't want to go on it, they don't need to, right? This isn't how they can make the choice. But hopefully, they're making an informed decision with a healthcare provider that is evidence based and is willing to listen and maybe try to negotiate that with them. I would never try to convince a patient to go on estrogen, but I would say that estrogen offers the majority of the relief that women are looking for at this stage in our lives.

Kristyn Hodgdon:
And is there a difference between the patch, the pill, or any of that stuff?

Dr. Shannon Klingman:
Yeah, so that's a really great question. There's another concern that people have that oral contraception or hormone replacement therapy. Does it increase your risk for stroke? And it's the oral form that impacts the clotting factors because it goes through first-pass metabolism through the liver. And so it can have a negative impact on clotting factors and increase your risk of blood clot formation and stroke. But the patch bypasses that first-pass metabolism of the liver, and so, the patch form is the safest form of hormone replacement therapy.

Kristyn Hodgdon:
Okay, that's really good to know.

Dr. Shannon Klingman:
And it's also regulated by the FDA, and you know what's in it. So there are a lot of witchcraft out there around HRT, a lot of compounding pharmacies that are putting things together. They really do not just because something is all bioidentical; your body recognizes it as estrogen. And so my preference would be that women would stick with something that is regulated and controlled by the FDA. So you know that what's actually in it is what's in it.

Kristyn Hodgdon:
Yeah, great point. So, what would you rescript about the way people think about perimenopause and menopause? Like even partners, what would you say to someone who might be skeptical of their own partner's symptoms and any other tips for how to deal with it?

Dr. Shannon Klingman:
That's a really great question, and I think that the most important thing is to understand that this is a very, this is physical thing that is happening and that if you're not experiencing it, we wouldn't necessarily expect anybody to understand it firsthand. But if they can understand that much of this is beyond a person's control and it's something that's happening to them, just like you would get diabetes or hypertension, the perimenopausal period can be explained, and it can also be remedied. So, I think it's important that you continue to talk to your partner about what it is that you're experiencing physically, and attributing it to menopause can only be helped through hormone replacement therapy, exercise, or sleep hygiene. So it's a matter of respecting the lifestyle necessary to continue to improve your quality of life, like the lifestyle of a 20-year-old would be a total disaster for someone in their 50s. Like you have to respect sleep, you have to respect diet, you have to respect exercise. And so you want to make sure that you're keeping all of those things in check because they are underestimated in terms of their potential ability to improve the symptoms of peri and post-menopause. So they should be like more critical than ever at that stage in our lives. And the thing that I've even said with my husband is like my husband, who is a gynecologist, practiced for years, respected and beloved. He would sometimes dismiss me like, are you going through the change? And I'm just like, oh, have the change, man. It's, oh yeah. The reality is that this is just the way it is. Like you're washed up now and the way that it gets sometimes communicated. And I mean my husband, no disrespect, but it's I am going to go through this kicking and screaming, and I am doing everything I can to hold on to my vitality and my sense of well-being for as long as possible. And that dismissive, you're going through the change that just says, I guess we're done now, and that is so far from the truth. I think I'm just getting started. I'm 54 years old, and I started Lume when I was 47, I think I could go do it again. I have no doubt in my mind that I could start another business and probably do it even better than I did the first time. So, in many ways, with age comes experience and wisdom, and also I no longer care about what anybody thinks. So there are some good things that come from this stage in our life as well.

Kristyn Hodgdon:
I love that perspective, for sure. We definitely know ourselves better and are more confident in our choices as we get older. Amazing! This was full of gold that's going to send this to every woman in my life. Thank you, Dr. Klingman, I appreciate your time.

Dr. Shannon Klingman:
Thank you. Have a great day.

Kristyn Hodgdon:
You too.

Intro/Outro:
If this podcast means something to you, be sure to hit Follow or Subscribe. This helps you because you'll never miss an episode, and it helps us because you'll never miss an episode. For science-backed women's health content that meets you exactly where you are, head to Rescripted.com or follow us on social @HelloRescripted.

Sonix is the world’s most advanced automated transcription, translation, and subtitling platform. Fast, accurate, and affordable.

Automatically convert your mp3 files to text (txt file), Microsoft Word (docx file), and SubRip Subtitle (srt file) in minutes.

Sonix has many features that you'd love including automatic transcription software, upload many different filetypes, share transcripts, transcribe multiple languages, and easily transcribe your Zoom meetings. Try Sonix for free today.