Women Have Many Options to Manage Menopause

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Hot flashes, night sweats, difficulty sleeping, mood changes, brain fog, dry skin, joint pain, weight gain – these are just some of what women experience during menopause. Can anything be done to treat or lessen those symptoms? Can diet or medication help? And when is it time to see a clinician for advice? Jean Marino, CNP, a menopause and women’s health expert, comprehensively answers these and other questions she gets on a daily basis.

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Pete Kenworthy
So, my wife was pushed into menopause due to the drug she took following breast cancer surgery a few years ago. She was 48 years old, and my guess is menopause would’ve been delayed a few years without the drug. But either way, I didn’t really know how to help her.

Macie Jepson
You know, in a lot of ways, families go through menopause together, the fighting over the thermostat, the covers during hot flashes, sometimes the arguments that go with mood swings. And Pete, did you know that your wife’s age at menopause is really normal in America? It is just one of the many menopause misconceptions that we’re tackling today. Hi, I’m Macie Jepson.

Pete Kenworthy
And I’m Pete Kenworthy, and this is the Science of Health. Now, part of me says I should just sit back and stay quiet for this one, but you’re right, Macie. It would be nice if I knew more about what my wife is going through. Joining us today is Jean Marino, Certified Nurse Practitioner at University Hospitals. She specializes in both menopause and women’s sexual health. Thanks for being with us.

Jean Marino, CNP
Thanks for having me.

Pete Kenworthy
So, every journey is different. Right? But some things are always the same as women go through menopause. So first, can we break down perimenopause, menopause and post menopause? And when does it usually begin if there is an age for that?

Jean Marino, CNP
Sure. So, actually I would start with premenopausal women. Those are women having regular monthly cycles, ovulating on a regular basis. And then when women enter into perimenopause, that’s the transition to menopause and on average lasts for about four years, and that’s when the hormones really start to fluctuate and ovulation isn’t necessarily occurring on a regular basis. And then when someone is menopause, we diagnose that retrospectively. So, it’s not more sophisticated than counting periods. So, you’re looking for 12 months in a row without a period, and that woman should no longer be having cycles, ovulating or bleeding, and then that’s just where she stays. So, menopause, post menopause can be used similarly.

Macie Jepson
What determines when a woman will begin menopause?

Jean Marino, CNP
So, that’s a wonderful question and people ask me that all the time, and it’s really hard to predict. Lots of people ask me, well, this is when my mother went into menopause, this is what my older sister did. And sometimes it’s similar, but often we’re just our own unique people. There’s really no way at this point to predict when someone’s going to go into menopause. They’ve looked into looking at different lab values to see if we could figure that out. But so far that that’s not a practice.

Macie Jepson
Alright, so not necessarily genetics, but what about when a young woman begins her cycle? If she begins that early, will menopause start earlier for her?

Jean Marino, CNP
No, not necessarily. No. No. It’s really unpredictable.

Pete Kenworthy
So, let’s go into symptoms here. What are the common symptoms, then, of menopause? Because it’s so much more than what we talked about at the beginning, the hot flashes, mood changes, and then how long do those symptoms last? And I realize that’s a range, too.

Jean Marino, CNP
Sure. So, symptoms can start in perimenopause, so I just want to make that clear and then continue throughout menopause. So, we’re looking at about four years in perimenopause. And then the most common symptom of menopause are hot flashes, or we call them vasomotor symptoms or sometimes night sweats. And on average those last for seven years, but it can run the gamut. So, I always like to remind people that women have estrogen receptors everywhere, so everything is affected by that significant drop off of estrogen. So, tons of changes in the brain, hot flashes, night sweats, difficulty sleeping, mood changes, brain fog, difficulty concentrating, having trouble remembering a word. You can also start to have drier skin, drier hair, drier fingernails. Joint pain I think is something that usually catches people off guard. And then you can start to have more vaginal dryness, troubles with arousal, lubrication, orgasm, a little bit more frequency, urgency with having to empty your bladder.

Macie Jepson
We’re a hot mess.

Pete Kenworthy
Whoa. And she did that without a list in front of her, too. Holy smokes. So, as I mentioned at the beginning, my wife was pushed into menopause, so I imagine her journey was different, but any advice for women who are in that same situation or another reason like hysterectomy, what else might cause this? And does it only happen when you’ve already started perimenopause? Does it shorten that period?

Jean Marino, CNP
So, not necessarily. Again, and I wish I had more clear-cut answers. I get asked this every day. We just really have to just see what happens for that individual woman. So, the symptoms, like I said, can go on for years. They can start quite early. And I think the big takeaway message is that there’s tons of different treatment options. You mentioned with treatment for breast cancer. If someone goes into menopause because of damage to her ovaries or they’ve been surgically removed, that’s a pretty deep dark dive into menopause, and those symptoms can be much more severe because instead of this gradual kind of decrease in your ovulation, lowering of those estrogen levels, it’s a pretty quick, abrupt drop off of hormones.

Pete Kenworthy
Yeah. And you talked about treatment. We’re going to get to treatment here in just a minute. But before we get there, one other question I have about this impact for my wife was tamoxifen. Does birth control impact anything. Like being on birth control for a long time, does that lessen symptoms, increase symptoms? Is it, again, just different for every woman?

Jean Marino, CNP
So, it doesn’t change your course for menopause. What it does is that it can take away those perimenopausal symptoms. So, lots of women are on birth control through their 40s into their 50s. If they’re really healthy, they can be on it till about 55 is usually when we recommend that you can stop, cause you have a really good chance of being in menopause and no longer being able to have an unplanned pregnancy. So basically, depending on the birth control, but let’s just say she’s on the pill, so it’s an estrogen and a progesterone combined pill, she’s essentially on hormone therapy. So, she’s not going to have those symptoms. And sometimes I meet women who they’ve had a tubal ligation or they don’t need contraception and they’re in their 40s and they’re wondering what is going on? My friends don’t have these symptoms. And usually that’s because their friends are on birth control, so they’re not noticing these symptoms.

Macie Jepson
You mentioned going without a period for a year. And I want to get back to that because, I mean, I’ve heard this and I know you have, a lot of women go literally a week shy of a year and then all of a sudden, surprise, their period shows up again. What’s happening with your body that makes that happen? And are you truly not in menopause if that happens?

Jean Marino, CNP
Yes. You’re truly not in menopause. So, when we make it to that 11th hour, get a period and then we reset the clock. So, we’re looking for 12 months in a row without a period. And again, there’s no way to predict when that’s going to happen. And the hormones are still fluctuating throughout perimenopause until they finally really drop off in menopause. So, you could all of a sudden ovulate and have a cycle.

Macie Jepson
And to be clear, you could get pregnant.

Jean Marino, CNP
Correct.

Macie Jepson
So, for that following year, what do you need to do or not do?

Jean Marino, CNP
The chance is really low for women in their late 40s and 50s, but it is not zero until you’re in menopause. So, that is a very good point to bring up.

Macie Jepson
And you mentioned late 40s and 50s. I wanted to get back to the fact that I honestly thought that menopause started in the 50s for women and was surprised to hear that it was younger. Is it getting younger and younger, and is it because of our environment, what we eat? Why is it getting younger?

Jean Marino, CNP
I don’t, I have not seen research saying that it’s getting younger. So, the average age is 51 here in the United States, but it could be anywhere between 40 and 60. If someone goes into menopause between the ages of 40 and 45, that would be considered an early menopause, and they should very seriously look at some hormone therapy, which we can talk about. But again, the average age is 51, but if we’re saying someone could be in menopause in their early 40s, then you’re looking at symptoms potentially starting in your late 30s.

Macie Jepson
That’s sad, though. And a lot of women go through that. Right?

Jean Marino, CNP
Right. And the other issue that we have to consider, too, is that a lot of women are delaying having children because of careers or choice or whatever they decide. And so, when a woman goes into menopause on the earlier side, that can be somewhat catastrophic. That’s where we’re kind of looking at some labs to see, could we predict when someone’s going to go into menopause so that she can plan whether or not she wants to have a pregnancy. And we’re not quite there yet.

Macie Jepson
That’s good. That’s a good start.

Pete Kenworthy
That’s what I was going to ask you. I realize you’ve said now twice that the way to know when you’re in menopause is 12 months without a period. There’s no tests or anything to prove that you’re in menopause or to check to see if you’re there. It sounds like we’re working on that.

Jean Marino, CNP
Well, we’re working on that test is looking more at ovarian reserve, which they use a lot in when they’re working with women for fertility. But there’s tons and tons of online, different advertisements for it, get your hormones tested. We can get you a hormone therapy that’s directly in line with what your labs show us and whatnot. And the truth of the matter is there is no research to back up any of that. There’s no reason to be checking your hormone levels. If you are of certain age and having certain symptoms, you do not need hormone levels. No hormone’s going to tell you how much longer you have to go, when you’re going to be in menopause. And you don’t need it to know what kind of therapy you need or the doses. You can kind of think of it like puberty. You have a child of a certain age, certain symptoms. We don’t check labs. We just kind of know what’s happening. So, it’s the same as we transition to menopause.

Pete Kenworthy
What about diet? Is there anything you can change that impacts any stage along the way?

Jean Marino, CNP
So, I would say diet’s really important because of, I mentioned earlier about our risk of heart disease going up once you go into menopause. So, that’s really important. Weight gain is also a very common symptom. So, working on a really healthy plant-based diet is also fantastic for that. As far as making symptoms better, some women do have what’s called triggering foods. And it’s unique for everyone. The most common ones are caffeine, sweets, sugar, sometimes spicy foods or alcohol. And if that’s a trigger for you, that’s a relatively easy thing to avoid. But otherwise, as far as eating certain foods, there’s a little bit of data on soy, and some women have the right enzymes in their gut to help work like an estrogen in their body. So, sometimes the food foods that are high in soy might be helpful, too.

Macie Jepson
All right. Let’s dive into hormone therapy. Boy, there’s so many questions. And I was going to ask you how long you have to stay on it, but I feel like we need to ask other questions first, like what kinds are there and what do you need to know about your body that might put you at risk for being on that or even not being on hormone therapy? That can put women at risk as well. Right?

Jean Marino, CNP
Correct. Yeah. So, hormone therapy gets a really bad reputation. We started off giving hormones way before the infamous WHI study of 2002, and it was at one point almost thought of as the newest Fountain of Youth. One particular provider even famously said, women, you need to be on hormones to keep your looks and your husband. And then we had that infamous WHI study of 2002, just trying to see, can we give hormone therapy to older women? Would that prevent heart disease? Because we know women’s risk of heart disease goes up when she enters menopause. And of course, the answer to that is no. But what happened was this huge negative publicity on that study and really didn’t get into the fact that the hormone therapy is a really safe option for the majority of women in perimenopause, the first 10 years of menopause. That really has not been publicized as much. So, a lot of people are still holding on to that negative publicity from that WHI study and assuming hormone therapy can cause breast cancer, heart disease, stroke, heart attacks, dementia.

Macie Jepson
And you mentioned when women start their menopause in their 30s that they might actually need to hop onto a therapy. Why is that?

Jean Marino, CNP
So, if a woman goes into menopause before the age of 40, that’s considered primary ovarian insufficiency. And that woman is at an increased risk for heart disease and weaker bones, so osteoporosis, for example, if she doesn’t go on hormone therapy. And the recommendation is to stay on it till the average age of menopause right around 51. And then that recommendation for women who go into menopause between the ages of 40 and 45, again, they’re on the younger side so hormone therapy should be pretty strongly considered because, again, just the risk for going a long time because women on average are living into their 80s. So, you’re looking at a whole second half of a lifetime without hormones.

Macie Jepson
And so, for everyone else, how long do they need to stay on?

Jean Marino, CNP
So, that’s the million dollar question. We used to tell women, you had to be on the shortest dose for the shortest amount of time. You absolutely had to stop at 65. All of that has been updated. So, now for women who start hormone therapy within 10 years of menopause or less than 60 years old, the benefits almost always outweigh the risks. And again, on average, women are going to have hot flashes for seven years. So, every year you should be talking to your provider, share decision making, looking at that individual woman’s health and risk. And then you make a decision every year how long you’re going to need it. No one knows how long you’re going to have these symptoms.

Macie Jepson
See a lot of stuff out there about bioidentical hormone therapy, also compound therapy. Could you touch on that a little bit?

Jean Marino, CNP
Sure. So, everyone should be aware that the term bioidentical started as a made-up marketing term. We have since adopted it into our everyday language, but we should all be aware of that because again, you went from everyone being on hormones to the WHI and everyone stopped being on hormones. Women still needed help with these symptoms. And so, you had these different people and companies starting with what they call bioidentical and saying that it was safer. So, when we’re talking about bioidentical, usually what we mean is something chemically similar to what the ovary is producing, and that’s estradiol and micronized progesterone. And there are studies showing that it probably is safer. And I like estradiol a lot because we have some data showing it helps with moods better than the other type of estrogen. So, compounded bioidentical therapy means it’s made in a compounding pharmacy. There’s never been a head-to-head study that compared the compounded bioidentical with what is commercially available because you can still get your estradiol and your micronized progesterone at your commercially available pharmacies, your Walgreens, your CVSs, et cetera, and they’ve never compared the two to show that one was safer than another.

Pete Kenworthy
What about non-hormonal options? What’s out there?

Jean Marino, CNP
So, we have several options that are non-hormonal, and that’s either for women who aren’t a good candidate for hormone therapy or just choose to not use hormone therapy. The first one that we had approved was called Brisdelle. It’s a really low dose of Paxil, or the other name is Paroxetine. At that really low dose, it does not treat moods, but it works really well for hot flashes and has a nice side effect for helping women sleep. At that really low dose, it also doesn’t have the more common side effects of weight gain, decreasing sex drive, making orgasm more difficult that the Paxil or that Paroxetine at the regular dose would. And we could use any of those medications that we normally use for mood changes. So, those are called the SSRIs, the SNRIs. Those work really well for hot flashes. They also work really well for moods.

So, we talked about moods also being a common side effect. So, anyone with a previous history of anxiety or depression is at risk for a worsening of those moods during perimenopause and menopause. So, it might be a fantastic option to go back on, say, your Lexapro because it might help with those mood changes and your hot flashes. The side effects of weight gain, decreasing sex drive, making orgasm more difficult are things to consider. I would argue if you aren’t sleeping well, aren’t feeling well, your moods are changing, you’re also going to have weight gain, decrease in sex drive and maybe trouble reaching orgasms. So, there’s risk and benefits to everything, including not doing anything. We also have a medication, another medication that’s FDA approved called Veozah. This is a medication that works with the neurons in your brain. It actually helps block the receptors for this neuron that goes into that internal thermostat within your brain. And that works really well for hot flashes, too. We can also use gabapentin, which can help with sleep and hot flashes and oxybutynin, which can also help with hot flashes.

Macie Jepson
Speaking of mood swings and mood change, your partner’s going to have a little bit of a mood swing, too, if your sexual desire is decreasing. So, can we talk a little more about that? I mean, are there options out there for women who, because of menopause… we know there are other reasons for low sexual desire because of menopause… what are those options?

Jean Marino, CNP
Sure. So, I’ll just start by saying that sometimes the low desire is because someone is not feeling well, so they are hot and not sleeping and having mood changes. And I always tell them, of course, your desire is low. You have other more important things that you are worried about. So, often if I can help someone feel better, that desire will follow. Sometimes it’s that vaginal dryness. So. if I can treat that, the desire may follow when sex is no longer painful and they get something positive out of it. But there’s also medications for low desire. Testosterone is one of them. We have the most data on it for low desire in menopausal women. It’s not FDA approved, but we do have research to back it up. And so that’s a really nice option to use for low desire. Our other medications that are FDA approved, Addyi and Vyleesi. They are not approved for menopausal women. They were approved for premenopausal women. We do have some studies though on menopausal women, but it would be an off-label use.

Macie Jepson
As we said a moment ago, I said, after you listed all these symptoms, we are complicated human beings. And I know that women sit around and they talk about all of these things and they think they know, but the bottom line is everybody is different. So, as we kind of wrap up, if you were sitting with that group of women talking about it, what would you want them to know? What would you say to them to kind of put them at ease and let them know, hey, it’s going to be okay?

Jean Marino, CNP
So, I would tell them menopause is completely normal and natural in what’s supposed to happen. Your body is not betraying you. It’s doing what it’s supposed to. That doesn’t mean you have to suffer, put up with anything. You have so many treatment options available. And there might be a woman sitting at that table, all of her friends are having a very easy transition. And if you are the one not having an easy transition, that doesn’t mean anything negative about you. It’s just your own journey. So, what I always would want women to know is that it’s normal, it’s natural. You can get help for everything. I also like to remind women that menopause is a privilege. Not everyone gets to this point. So, if you’re there, that’s fantastic.

Pete Kenworthy
Jean Marino, Certified Nurse Practitioner at University Hospitals, thanks so much for joining us.

Jean Marino, CNP
Thank you for having me.