Navigating Perimenopause and Menopause

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To celebrate Health Lab’s 10 year milestone, Health Lab recently hosted its the first Health Lab Live Show, which brought a Health Lab article to life by interviewing experts on stage in front of a live audience. Here, John Randolph, M.D., a reproductive endocrinologist and infertility specialist at Michigan Medicine, discusses hormones, hormone replacement therapy, perimenopause, menopause and so much more.

Transcript

Mary Masson:

Thank you to everyone here. We're so excited to celebrate our 10-year anniversary and actually bring a blog article to life. 

So, I think we're going to have some really interesting information here that you'll get to hear and get to experience Health Lab in a different way.

So thank you, Dr. Randolph, for joining us. Just to get that conversation started, can you talk a little bit about menopause and perimenopause - so people have a basic understanding of what that means.

John Randolph, M.D.:

Absolutely. Menopause actually is an event. Menopause technically, and the medical definition, is the last episode of spontaneous bleeding, so your last period, basically. 

And it's an anchor that we can use to study, and we can use medically. And basically what it means is it's the point where the ovaries no longer are able to produce enough estrogen to support a pregnancy, and therefore the uterus is no longer able to bleed. And that's sort of at the end of the long, long, long process whereby the total number of eggs that are there at birth gradually decline until there are no longer any healthy eggs that can develop and produce a pregnancy and produce estrogen.

Mary Masson:

And what would perimenopause be? 

John Randolph, M.D.:

That's the hot topic that's gotten lots and lots of interest. Perimenopause is a process, and it's a long duration. It's a little tricky to figure out when it starts, but it's anywhere four to eight years before bleeding stops. Typically then towards the end of that there's a period of time with increasingly changing in bleeding before bleeding stops. And then probably for a couple of years at least afterwards when hormones are still actively changing. 

And so kind of the way to think about it - we compare it a lot to going through puberty when things are changing. That's the acquisition of the capacity to have kids. And this is sort of the resolution of that capability being able to have children. 

And it's a good way to think about it because for those of you who went through puberty, as we all did, you know how difficult that time can be and how the changes can be very unpredictable and difficult to deal with. And we see the same thing with perimenopause.

Mary Masson:

So we get two puberties. Lucky us. 

John Randolph, M.D.:

Fortunately, most people have figured out the social behavior, and so you're not likely to do quite the same things you do at 13 and at 43. But yeah, in terms of changing things hormonally, there's some similarities there.

Mary Masson:

Okay, okay. So maybe you could talk a little bit about the symptoms and what happens, what people feel when they're going through. perimenopause, and then menopause.

John Randolph, M.D.:

Absolutely. I mean, the classic things people have talked about for years and years and years are hot flashes. Sometimes people call them night sweats, a whole variety of different names for them. But that's been the hallmark and been one of the main things that has been studied. And then the other big one are changes in the urogenital system, the vagina, with vaginal dryness and increase in urinary tract infections. A ton of research has been done for years and years and years on those two particular areas.

But there's sort of an expanding recognition that there are probably a whole host of other symptoms that very well may be associated with this whole change process. And so much more recently, people have talked much more about things like cognition, cognitive changes, that infamous phrase brain fog, which doesn't have a medical definition, but kind of everybody sort of knows what that is. 

Things like increase in joint problems, I've heard of itchy ears, dry skin, a whole host of things. And then clearly body composition changes where your shape shifts, from curves to the things going to the middle, and we actually have great data to demonstrate that's exactly what happens, is the location of your body fat tends to change - so people, they lose their waist, and that's a problem sometimes.

Mary Masson:

I'm interested that you said itchy ears, because we were already talking. I mean, I'm at the age where, you know, I've been through it, but I'm going to... I've shared with Dr. Randolph, it doesn't end. It goes on for a long time. But my ears are itching, and now maybe I've got a reason for it.

So are there symptoms of menopause? We talked about these things start in perimenopause, right? And then what do you feel when you actually hit menopause? Does it change? 

John Randolph, M.D.:

Again, it's part of the process. It's sort of a measurable point within that process. Most women will experience increasing variability in their bleeding. In fact, that's how we, from a research perspective, will define the entry into early perimenopause is when cycles start to become more variable. And in fact, most women will go through a phase where they have increasingly heavy periods. So heavy bleeding is a really common thing. And that frequently is what has brought women to their healthcare provider is changes in bleeding and when that gets really really heavy that can be a problem, and so that's usually what most women will experience some degree of that for up to several years prior to when they stop bleeding. And then about 10 percent of women will will have at least one episode of bleeding more than a year after their periods stop and that sometimes indicates some health concerns, and so at that point we recommend people seeking care. 

So funny bleeding is - almost everybody has that, that's expected.

Mary Masson:

So let's talk about what could help. What do you advise for your patients to try to manage this?

And when do you know it's worth talking to your doctor about? Or is it always worth talking to your doctor about? 

John Randolph, M.D.:

I would say always worth it. Whether your doctor agrees with that is a whole different story. A lot of, I mean, I think that women are smart. and especially those that start to have symptoms, will seek out options. 

For women who have relatively modest hot flashes, things like layering their clothing so they can take things off when they're basically hot flashes, your body's trying to dissipate heat. It thinks it's too warm, and so you perspire to lose heat. And so avoiding things that are triggers, so spicy foods, alcohol, caffeine can trigger hot flashes. Interestingly, there's more, you have more hot flashes and hotter weather so right now is our prime time. We actually had great data to show that there's a seasonal variation of hot flash frequency. 

And changes in an environment so going from a hot or cold environment to something else can trigger hot flashes so avoiding those kinds of things people will do And then that's sort of the, I mean, most people figure that stuff out and can actually apply those things. 

And then there's a whole host of medical options that we can consider.

Mary Masson:

You talked about eating. and clothing, but are there other lifestyle changes that you should make? Is there a certain type of exercise that is more recommended or avoiding certain types of exercise?

John Randolph, M.D.:

Activity usually is not a big trigger. Again, there's lots of variability from woman to woman, so that potentially could, but not that particularly people talked about certain foods or certain...supplements that potentially can help. 

There's lots and lots of natural estrogens and a lot of different plant products. And so for women that have relatively mild symptoms, that may be sufficient to do things. And there's many, many options for that, a lot of herbal remedies.

For women who have really significant symptoms, that typically they're not going to be potent enough to take care of things. And that's when you might want to consider medical therapy. 

Mary Masson:

Okay, so let's talk about that. What kind of medications are out there? Because there has been this narrative for some time, about hormone replacement therapy, and the issues with it. And, you know, I don't know how tied I am into this, but, you know, my personal viewpoint is, oh, that was a bad thing. HRT was a bad thing.

So tell us about, like, where we started with medication and where we are now and what is a good recommendation? 

John Randolph, M.D.:

I mean, you can divide things into hormonal and non-hormonal. It's a whole host of things that are, at least for hot flashes, will offer some relief. So a lot of the antidepressants, SSRIs, gabapentin, some of the brain drugs will sometimes help things because hot flashes are triggered in the hypothalamus in the brain, and so things that affect that can help. 

In general, they're pretty good, but don't typically take care of things completely. But for women who can't take hormones, like in breast cancer survivors and some other individuals, they may be a good option.

There's a brand new class of medications that just were approved in the past year and a half that work directly on the part of the brain that induces hot flashes, the NK1, NK3 antagonists.

And so that's really exciting, but they're a bit expensive right now, and a lot of health plans aren't covering them yet. So that may not be an option for everybody. 

And then we get into hormone therapy. I'm trying to get away from the concept of hormone replacement therapy. Menopause is not a disease that has to be replaced, so we prefer to use the term menopausal hormone therapy, so treating something, some kind of symptoms. 

And if you look historically, we've had estrogen therapy since 1942, so it's been around for a long time. And it really took off in the 60s and 70s and 80s, such that by the 1990s, estrogen was the most prescribed medication in the United States. So lots and lots of women were on estrogen. But at that point in time, women weren't being included in research studies, and so Bernadine Healy was the first woman head of the NIH, spearheaded the inclusion of - an enormous study, the Women's Health Initiative - which remains today as the largest single randomized controlled trial that just enrolled women. It was enormous, and it was specifically to look to see if hormone therapy would be a good strategy to help prevent heart disease, actually.

And so that was the target, because the thinking at that time is that may be true. And in 2002, the trial was actually stopped early because it hit the trigger, a slight increase in blood clots and heart disease. And actually in the women who took both an estrogen and a form of progesterone, had an increase in breast cancer. And so it kind of, it hit like a thunderclap. We all remember the day when the news came out, when the phones were clogged with women who were panicked because the way that it was introduced in the media was big splashy news and basically we're saying that the medical profession is trying to poison women and it's dangerous and you shouldn't take it. 

And unfortunately that became the data which remains today at the federal level in terms of recommendations in terms of who's eligible, even though we have a lot of information since then. And we have a lot more data to suggest that for healthy midlife women, hormone therapy generally has more benefits than risks. 

And so what it did was it completely changed medical education. So we have a whole generation of health care providers that...taught that this was something that they probably shouldn't prescribe unless somebody really really really had symptoms, and so many people didn't learn how to prescribe it, and so it's become difficult to find people that are comfortable and capable of prescribing it. So it was a really interesting sociologic time and just watching how things happen.

And some of that was, there was a little bit of mistrust and big pharma tied in with that at the same time. And unfortunately, it really disenfranchised, again, a whole generation of women who very well may have benefited from that therapy and were basically told that this is dangerous and you shouldn't be taking it. 

Mary Masson:

Yeah, that's so interesting how, and we've seen it in other places too, right, where a headline sticks with people and it is so hard to unring that bell, right? 

John Randolph, M.D.:

Yes. Well, part of it, it was such an enormous study that the data are very, very... And so you could detect even relatively small differences that were statistically significant, even though the clinical implications were not nearly as concerning as the newspapers made them seem. 

And, you know, in fact, the reality is that taking hormone therapy, even with that time, was in the same ballpark as taking Motrin on a regular basis in terms of cardiovascular issues. But that's not how it was presented to the public and, for that matter, to the general medical community. And the thinking was is, why would we prescribe something this dangerous for something that is not life-threatening? 

And so, if that's your benchmark, life-threatening, ignoring the fact that menopause and perimenopausal symptoms may be life-altering, and for many women, that's the truth. 

Mary Masson:

Yeah. I often talk with my team about how important it is to make sure that when we put out information about research, that we make sure that, you know, it's well-rounded and it's, you know, we don't want to say, you know, blueberries will save your life, right? You know, or turmeric. Sam always writes about, am I saying it right? Turmeric? Turmeric? Yeah. Anyway, okay. 

I don't want to get off topic here, but tell me when you are concerned about a patient and when they should be seeking medical care. What are the red flags that you look for?

John Randolph, M.D.:

Yeah, I mean big things i mentioned is oftentimes uh in fact the hallmark is bleeding changes so when somebody's having persistent really heavy periods uh seek medical attention because we've actually documented that someone will become anemic because of their kind of chronic blood blood loss and so and it could be a sign that there's something more serious going on, some kind of uterine problem, fibroids, that kind of thing. 

So that would be one big red flag. And then the tricky one is when the symptoms are interfering with your lifestyle. And so that's a judgment that I think every woman has to make for herself in terms of how much bother is there. You know, traditionally... people have been taught that if it's really bad then we'll treat it but if it's not so bad and we actually have really good data that about 15 or so of women will start having symptoms well before their bleeding changes and that those women tend to have those same symptoms way beyond when they stop having bleeding whatsoever, and interestingly is the women who have really significant hot flashes at least, there's very good data to say that they have an increased risk of cardiovascular disease, and we don't know why that is - if hot flashes are a marker of that or if they're part of the process. But that's now one of the risk factors that we would look at in terms of screening women for long-term health risk.

Mary Masson:

Okay. When you talk about the life-altering, right, I would suspect that a lot of people, you know, try to live with things. Are there things that you tell your patients, you don't have to live with that?

You know, let's do something about that. 

And I'm curious, too, the hot flashes, it interrupts your sleep, and we know that the sleep is crucial to your health, right? 

John Randolph, M.D.:

Sleep problems are a really, really common midlife concern. It's that's a they have a complicated relationship with hot flashes uh and it's clear that in women who have lots and lots of vasomotor symptoms that does affect their sleep and there's now some suggestion that poor sleep may be one of the risk factors for long-term cognitive issues and so it's a lot of interest in looking into that and so sometimes treatment for hot flashes can help with sleep. Not always, but frequently. 

And so that would be one of the places to start. But other kinds of things. Women whose sexual function has changed because their vaginas are a problem. That's a big issue in women who have stopped having intercourse because it just hurts or it doesn't feel right. And that can generally be managed very effectively with local estrogen. And so then there's a number of different options for that. And so clearly that's something that you know, somebody should bring up and pursue. And the hardest part, I think now, is most of the research has looked at women who have stopped bleeding and mostly for hot flashes and for vaginal dryness. And so for a lot of those other less well-defined symptoms, especially in perimenopause, the earlier changes when... even bleeding hasn't changed or hasn't changed very much we really don't know because we haven't had any clinical trials of what to do, so in somebody who's starting to have some variation in her bleeding pattern, and maybe she's having hot flashes, but maybe she's just having problems because her joints hurt and running's becoming difficult because she can't do that or her skin has changed or she's having trouble thinking Um, you know, I work here with all of you and with professors, and I've had women say, I can't lecture at this point because I can't think of the words and what can I do about that. And so that's absolutely real. But we don't know exactly what the best thing to do at that pointbecause we don't have the research. But there are certainly things that we can try.

Mary Masson:

So, is there an age? What age can this start for women? Does it vary a lot? 

John Randolph, M.D.:

Absolutely. Good worldwide data, average age of last period is about 51 and a half, and that seems to cross all populations. But it's considered normal anywhere from age 40 to age 60 - so there's a really, really big difference. 

Interestingly, a lot of women tend to have a very similar pattern to their moms. I was asked that question, when did your mom go through menopause? And that's assuming we can define that because... somebody who's had a hysterectomy or is taking hormones, you can't really count that in terms of their last bleeding episode. And so there's lots and lots of variability. And it's really hard to figure out when it starts to happen because there isn't any good clinical measure for that. 

So there's no test to say, yep, this is happening. So typically we'll make the decision based on the symptoms that you have and what presents. And it's a... kind of a discontinuous process.

You know, ovaries are designed to cycle and to change all the time. And so when they start to change more irregularly, it gets really tricky in predicting when things are going to happen. And so one of the things to remember is this is a time of change, and where you're at right now may be very different than where you're going to be in six months or a year, because your body is changing.

Mary Masson:

Yeah, and we were talking earlier about how... they can start and stop, right? Absolutely. As symptoms, you may feel like, oh, I'm done with those hot flashes, and they can come back. 

John Randolph, M.D.:

Absolutely. And that can be really frustrating. Yeah, absolutely. 

Mary Masson:

I was a good person to have do these questions because we're living it in real time here. So something that's been very popular on social media right now is the testing of your hormones.

So can you tell us a little bit about what that is and is there any benefit from that? Do doctors want us to do that? 

John Randolph, M.D.:

That's a great question. Kind of - I'll give you my perspective. We are - Michigan is one of the seven clinical sites for the biggest and longest running study of the menopause process, called the SWAN study, the study of women's health across the nation. So we've been studying, started with over 3,300 women back in 1996, and are now just got some funding to take it into the seventh funding grant. Thank you, finally, NIH. 

And so we've looked a lot at that, including we've measured thousands and thousands and thousands of data points with hormone levels, and what is abundantly clear because it's such a variable time is that the hormones don't really correlate very well with symptoms. And since the primary goal of treatment is to help with the symptoms, hormone testing hasn't proven to be terribly helpful. And so chasing a hormone level and trying to use that to figure out what... appropriate thing to do is certainly hasn't been shown any kind of good clinical trials to be helpful. A lot of people will recommend doing that. I haven't found that to be terribly helpful. It's better to talk to somebody and figure out what's the best option for her in terms of managing what her particular constellation of symptoms are.

Mary Masson:

So can you actually do this at home? Are people recommending that you do this on your own? Test your hormones?

John Randolph, M.D.:

With modern technology, if there is a possibility, yes, it will be out there. The tricky part is trying to interpret what the numbers are. 

Again, because ovaries are designed to be variable in what they do, and then when they become even more variable, and so changing - change is really hard to interpret. You know, just doing it scientifically, trying to describe change is really tricky. And so on an individual basis, it's tough. And so, again, I haven’t found that to be terribly useful. 

There are an increasing number of online resources, a number of national practices where women can go to and get consultations and actually get therapy. And a variety of different companies. And so that is kind of a growing option that's available if there's not a provider in your area that can answer your questions, basically. 

Mary Masson:

Yeah. Yeah. Okay. So what do you do if you want to find an expert? What do you recommend women? How do you start finding someone who can help you with these symptoms? And maybe you just start with your primary care doctor?

John Randolph, M.D.:

Start close to home because it may turn out that your PCP, your gynecologist is comfortable and knowledgeable and can do that. And if they're not, and you'll know pretty quickly if that's the case, ask them if they know someone that you could talk to. And if that doesn't work, then seek out a provider. 

The Menopause Society, which was formerly called the North American Menopause Society, which is the North American group of experts, actually has a certification program. It's actually a course and an exam. And so you can look for a certified menopause provider, and they will have knowledge and can give you balanced information on the therapeutic options that you have. 

And so I would specifically ask a provider if they're NAMS certified. We have a number of faculty and professionals here who are certified and can provide that kind of care.

Mary Masson:

So, I’m curious about why you think research in this area is important. And obviously, we've demonstrated that a bit by just talking about it's 20 years of some women's lives. But what made you decide to, you know, make this a big part of your practice? 

John Randolph, M.D.:

Ovarian aging - I'm interested in that from both fertility and a life-altering perspective - and you know now what we're looking at is, what are the end results? You know, does the experience of going through this transition help predict healthcare issues later on things like cognition, you know. Is there something about how a process do we does it change the trajectory of somebody's capacity to think. We're looking into things like cancer risk and cardiovascular risk. 

And part of that is if there is a difference and could we potentially intervene, and there are actually kind of evolving data to suggest that, yes, maybe there is a significant benefit on a medical basis with cardiovascular and cognitive function. So, again, that... research is in progress and it kind of comes and fits and starts. 

We'll never have another WHI. It was really expensive and lots and lots of controversy. And so I don't think the NIH is going to go down that pathway again. But there'll be a whole series of smaller studies that are learning things all the time. 

Mary Masson:

You're telling me that you're going to celebrate your 40th year on faculty is that right? Yeah, next month. 

So tell me a little bit about what you remember from when you first started practicing about the way we treated patients with menopause or the way we you know approached menopause then and how we approach it now.

John Randolph, M.D.:

Yeah uh dramatically different uh back 40 years ago uh we only had pills. And so, in fact, we prescribed hormone therapy a lot. In fact, we had pre-printed paper prescriptions in the clinic. 

They were stamped already, and we just signed them and hand them out. So, as I say,

it was very, very popular until WHI. And what has changed is WHI changed a lot. And also, we learned a lot more about the biology of menopause and about the biology of how to prescribe hormones. 

We have very good data now that if we give estrogen not as a pill, where it goes to the stomach and then the liver, and that's where it seems the issues are, and especially with estrogen patches, those clot risks don't seem to be there.

And so how we give hormones... has been, and the safety of being able to give hormones and has really, really changed a lot. And certainly we know, especially when it started, when symptoms tend to be their most significant. So in those years before and after somebody has their last bleeding episode, that the safety profile seems to be quite high in terms of with healthy, healthy midlife women. 

Mary Masson:

I wanted to also ask you a little bit about portrayal in popular culture. We were talking about this - there's a show out called Friends and Neighbors - and there is a woman in there who is going through menopausal symptoms or perimenopausal symptoms. She has crazy hot flashes. But it was interesting, because when I brought this up to you, you said there's some concern about that portrayal as well. Maybe you could talk a little bit about the risks that you see to essentially women being portrayed as being crazy. 

John Randolph, M.D.:

And I mentioned that WHI had a lot of interesting sociological components, and that was one of them. Again, think about the 90s and early aughts and what was going on socially with women and how they were viewed in society.

And one of the concerns about, and again, a criticism of big pharma in pushing hormone therapy was that menopause could be portrayed as a time where women became unstable and untrustworthy and could not be placed in positions of importance or decision making because they might make bad decisions because their hormones were raging. 

And, you know, frankly, there is an element that persists with that. And so that's one of the things that is absolutely...have to counteract, because that's not true. People don't go crazy, and they have issues in terms of symptoms, but they are fine. And we just have to be really, really careful we don't allow that, especially given the current social circumstances and with the crazy manosphere and all the things that people say online.

And so I will put the plug in. Women are absolutely capable of doing anything, and they're not subject to their raging hormones. 

Mary Masson:

Here, here. I think that's a good way to end it. Johanna, can I see if there's a question from the audience? Does anybody have a question they'd like to ask before we wrap up? Okay, I think I heard the question. You probably heard it better than me. Sure. Go ahead. 

John Randolph, M.D.:

The question was, if a woman has a hysterectomy and has a uterus removed so she can't bleed, but maintains her ovaries, does that mean the ovaries will no longer work and she'll go through menopause? 

The answer is no. 

If they maintain the ovaries, the ovaries continue to function. They may stop a little bit earlier, but not really very much. And so, in fact, that's a big decision in a woman who's still having regular periods. Should she keep her ovaries or not? 

And in general, unless there's a specific reason to remove them, the consensus now is to leave them in place so that she will have her endogenous hormones, and will go through menopause at the time she usually would. And so that's pretty much what the recommendation would be, certainly in our department here.

Mary Masson:

Was there another one? Okay, go ahead up there.

John Randolph, M.D.:

Yeah, the question is, are there positive changes with pre-menopause? [laugher in room] Yeah, because, you know, at that point, women don't have to worry about contraception. Now, the tricky part is during that early transition, seriously, during that early, early transition part, you know, as fertility is declining and, you know, that can be a little bit unpredictable, and so we still recommend using contraception. But at some point, certainly when the periods stop, that's marvelous. You don't have to worry about that. 

And a lot of women, you know, we did - we've done focus groups on midlife women, and a lot of women feel a sense of liberation at that time, and actually say, this is a time for me. I can now focus on my career and my wants. And so for many, many women, it's a sense of empowerment. 

So, yeah. Unfortunately, there's a lot more negative than positive.

Mary Masson:

I'm so glad you asked that because we really didn't focus on that for sure. Well, I just want to say thank you so much for taking the time to speak with us. I learned a lot. I'm sure all of us learned a lot. Is there anything before we end, any key takeaways that you would like to stress? 

John Randolph, M.D.:

Yeah, absolutely. One thing to keep in mind is this is a time of change. So as I mentioned earlier, how you are right now may not be how you are a year from now and how you end up may be very different. And so it's, again, think of that analogy to puberty when things are going to change and then stabilize at some point. 

Secondly, if you have issues, seek out care and ask. Be your own advocate and ask and seek to find somebody that can get your answers. 

And then finally, if you do have very significant bleeding leading up to that final period, seek medical attention to make sure that you're okay.

Johanna Younghans-Baker:

All right, wonderful. Thank you so much, Dr. Randolph and Mary. Thank you all for joining us.

That concludes our event for this session.

Host:

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