Speaker 1: 0:01

Welcome to the Healthy Matters podcast with Dr. David Hilden , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health healthcare and what matters to you. And now here's our host, Dr. David Hilden .

Speaker 2: 0:18

Hey everybody. Dr. David Hilden here, your host of the Healthy Matters podcast. And welcome to episode 13. You know, if there was something that affected over half of the population for decades of their lives, that's something we should be talking about. Well, today we're gonna talk about it and that subject is menopause. Joining me is Dr. Heather Lag . Agree . She is a pharmacist at Hennepin Healthcare in downtown Minneapolis and Lisa Lagrande , she is a clinical psychologist also at Hennepin Healthcare, and the two of them are experts in the care of people experiencing menopause. Welcome to the show.

Speaker 3: 0:51

Nice to be here. Yes,

Speaker 4: 0:52

Thank you so much for having us.

Speaker 2: 0:53

So before we jump into this, I understand that both of you are Menopause Society certified practitioners, just what is that?

Speaker 3: 1:01

That is an additional certification that one can obtain that is administrated by the Menopause Society and it involves taking a two hour exam. Is that right, Lisa? That demonstrates, number one, an interest in the field, and number two, a basic level of competence, not only in menopause care or what many people think of as one of the main treatments hormone therapy, but it actually encompasses a wide array of health issues that midlife women experience. Well, I credit

Speaker 4: 1:31

Heather with finding this force and getting us both interested in obtaining this certification. And as a psychologist I should say that when I was studying for the exam, there were points where I thought I could see why there's not a lot of psychologists doing this because it's really, it's really health focused . So I had to learn a lot of stuff from scratch, medical things from scratch, but I'm so , so glad I did. And I did wanna bring up that the Menopause Society, if you go to their website, they do have a search mechanism where you can search by city , state zip code to find somebody in your area that focuses on treating menopause.

Speaker 2: 2:06

Okay. So we have a psychologist, we have a pharmacist or experts in menopause, but what exactly is it? Uh, could you tell us what defines menopause?

Speaker 3: 2:15

Well, menopause is a retrospective diagnosis and it's defined as 12 months without a period. And so that is easier to define in some women than others. Of course, not all women are having periods. One may have had their ovaries removed, in which case that's sort of instant surgical menopause. One may have an IUD and be period free or have minimal bleeding for that reason. But in the absence of things that suppress menses or menstruation, menopause is defined as the mark in time when you've been 12 months without a period. And it's a continuum of leading up to menopause. When hormone levels fluctuate, it's not a smooth ride by any means. And in the years leading up to menopause, progesterone and estrogen fluctuate a fair bit. And as you lead up towards menopause, estrogen can spike up and down in erratic fashion, which can result in several different symptoms. But the gradual trajectory of the curve of estrogen is on the downward slope.

Speaker 4: 3:18

I was thinking, I , you might imagine a slide on a playground where at the beginning you're , it's pre menopause. At the end of the slide you're a post menopause. But instead what you wanna imagine is the giant yellow slide at the state fair. Except with even bigger bumps up and down, it's really can be a rollercoaster ride. Some women manage that time no problem. But for some women it's a, it's a very difficult time. It depends on how sensitive an individual woman is to fluctuations in hormones.

Speaker 2: 3:45

You know, I really like your analogy of the slide and for those of you who aren't in Minnesota at the state fair, the world's best state fair, I might add, there's a giant slide that's several stories high and you sit on a burlap bag is a big yellow thing and you go from the top to the bottom, but it's like a rollercoaster on the way down. I think that is a fantastic metaphor for menopause. So there are phases of menopause. Can you clarify the difference for our listeners between menopause, perimenopause and post menopause? What are those phases? What's happening in the body or maybe more importantly , uh, what isn't

Speaker 3: 4:19

Perimenopause is defined as the period of time which can encompass really up to 10 years, but on average four to seven years and is the time when symptoms are first noticeable leading up to the time of menopause. And so the very initial symptoms of perimenopause can be quite subtle and such things as a shortening of the menstrual cycle, a lengthening erratic bleeding and other early symptoms can include changes in thinking and cognition. Sometimes we term that brain fog and there's a whole host of other symptoms. And of course what one might experience varies greatly between women

Speaker 4: 4:54

And sometimes women will say, I'm done with menopause. But I think Heather and I would argue you're never really done with menopause. You might be done with the hot flashes portion, the downward slope of the slide, but you continue to have symptoms of estrogen deprivation that are cumulative over time. And there are a number of symptoms that do worsen over time. I actually would like to tell a personal story, which is it that in 2020 I was diagnosed with an estrogen positive breast cancer and invasive breast cancer. And after the initial treatment, I , like most people with an estrogen positive breast cancer, were prescribed endocrine therapy for five to 10 years. And so I had the experience of becoming quite suddenly very acutely aware of what estrogen does within the body and the symptoms of reduced estrogen. And because I take a pill every morning that I link the symptoms to, I think I took a much more problem solving approach to the symptoms than one otherwise might if you just attributed it to aging. I was kind of the right age also, but it was, I was really linking it to this pill that I was taking it . The medication is a very important medication to take and it does give these unpleasant symptoms. And so , um, part of the message I also wanna have today is if it's a , you know, surgical or chemical menopause or a natural menopause, you don't wanna suffer in silence. Advocate for yourself. There are treatments, there are ways to mitigate these symptoms.

Speaker 2: 6:18

Thank you for sharing your personal experience with your breast cancer because , uh, first of all, that's courageous, but second of all, you have an a unique personal perspective on everything we're talking about today. So thanks for that. So you've talked a little bit about some of the symptoms people have and what is the first one? Is it, is it a missed period?

Speaker 3: 6:38

Yes, that's often one of the symptoms either missed period , uh, yeah, length and cycle between periods. Also very common as I mentioned already, changes in thinking brain fog and of course the classic what we call vasomotor symptoms are hot flashes. Temperature regulation in the body is regulated by what we call the thermo regulatory center in the brain. It's actually the, in the hypothalamus and it's responsible for regulating body temperature and it is dependent on estrogen. So as estrogen levels decline or fluctuate, that part of your brain does not work as well. And sometimes a small rise in body temperature can result in a misinterpretation by your brain. And so you have your blood vessels dilate, you feel very warm. And then alternatively, you can also feel cold the next minute. And so overall the whole temperature control is kind of not regulated properly.

Speaker 2: 7:28

That makes sense. Everybody's different. But generally speaking, how long do these symptoms last?

Speaker 3: 7:33

Every woman is different. So I can't give just one answer to that. But on average those symptoms last between four and seven years. And there are some variations for some women they can last up to 10 years and there are some, a subset of women and we call the super flashers that may have hot flashes for the rest of their lives.

Speaker 2: 7:53

Okay. So there are a whole bunch of 40-year-old women listening right now and their eyes are getting bigger. And I do promise you we're gonna talk about some of the things you can do about these symptoms because I'll, joking aside, that sounds like a lot.

Speaker 3: 8:05

It is definitely a lot. And yeah , you're right. All joking aside, often these hot flashes are sort of looked at as a sort of comedic trope in our society and they are not funny and in fact , um, really can impair quality of life for many women. And interestingly, there is some sort of new data coming out that has shown an association between the women that have the worst hot flashes and increase incidences of cardiovascular disease later in life. And we can't say that it that there's a direct cause one to the other, but there is an association and clearly this is an area that requires further research.

Speaker 4: 8:41

And I think that's why the menopause symptoms can be so easily missed. Is that the age of onset, again, it's the perimenopause, it's the time before your reg, your periods might still be regular. Um, the time of onset can vary so much between women and there's so many different symptoms that two women could have completely un overlapping symptoms and have the onset at completely different time periods in their life. Somebody could be in their late thirties, somebody else could be in their late fifties. And so I again, I think that's partly why they can get missed.

Speaker 2: 9:12

Such a good point. I think that's super important to mention too, that every woman is different, every woman's body is different, but it's all still part of that natural, albeit very long , uh, variable range I guess. That said, when might the average age be for menopause?

Speaker 3: 9:27

The average age in our country for menopause is 51 and 90% of women go through menopause between the ages of 45 and 55.

Speaker 2: 9:37

Sounds like there's a lot of variety in menopause, but that gives us a bedrock for today's conversation with Dr. Heather Lagree , a pharmacist and Dr. Lisa Lagrande , a psychologist, both of whom are here at Hennepin Healthcare in downtown Minneapolis and both of whom are menopause society certified practitioners. So let's take a quick break now and when we come back we're gonna look a little bit deeper into the help available for those going through menopause, the therapies and the treatment options, as well as general tips on how to manage symptoms. So stick around, we'll continue the conversation right after this.

Speaker 5: 10:09

When Hennepin Healthcare says we are here for life, they mean here for you, your life and all that it brings. Hennepin Healthcare has a hospital HCMC and a network of clinics both downtown and across the west metro. They provide all the primary care and specialty care you would expect to find, but did you know they also have services like acupuncture and chiropractic care available at many of their primary care clinics and at their integrative health clinic in downtown Minneapolis? Learn more@hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

Speaker 2: 10:47

And we're back with our two guests from Hennepin Healthcare, Dr. Heather Lagree , who is a pharmacist, and Dr. Lisa Lag Grant who is a psychologist and both are experts on menopause. So let's get into therapies. What can be done about symptoms of menopause? I'd like to start out with medications, so maybe I'll look to you, Heather , uh, to talk us through what medications are available including hormone replacement therapy and other medications as well.

Speaker 3: 11:10

Absolutely. Well, there's a wide array of options available, thankfully, and how we choose what might be appropriate for a given person depends on many different factors including their baseline health risks and what symptoms they're looking to address as well as affordability, convenience, all of those things. And so I'll start by dividing hormonal options into two categories. We have local therapy, which includes hormones that are used just locally in the vagina to treat local issues there. And then we have systemic hormone therapy and for the vaginal therapies that can address the common complaints of dryness, painful sex, increased urinary symptoms that one can see in the perimenopause and menopause timeframe , um, which includes urgency that gotta go feeling when you need to feel like you have to pee all the time, as well as an increased risk of urinary tract infections. Local vaginal estrogen can be extremely helpful for all those issues. And it comes in multiple forms. There's creams, tablets, suppositories, even a vaginal ring that goes in and stays in for three months and has changed every three months.

Speaker 2: 12:22

Before we move on from that, I'd like to focus on that for just a second. If you are listening to this and you're having these symptoms, please do bring them up with whomever you're seeing because you are not alone. I think sometimes we don't address that adequately and it's a very real thing. So listeners, if you are having these symptoms, dryness and the other symptoms that , uh, Heather's been talking about, bring that up with whoever you see in the clinic because these topical therapies really are quite effective

Speaker 4: 12:47

And that's why it's so, I feel like it's so important to talk about menopause because I think people are , there is an element of sort of embarrassment with a lack of understanding of how exceptionally common these symptoms are.

Speaker 3: 12:57

Right? We joke that every woman should receive a tube of vaginal estrogen cream at her 50th birthday <laugh> . But yeah, the local vaginal estrogens can be used in almost all women. If women are on aromatase inhibitors, the recommendation is that there's a shared decision making conversation between the doctor, the oncologist, and the woman to make a decision. And these local therapies can be complimentary with over the counter options like moisturizers and lubricants. And by the way, those are two different things. Moisturizers are meant to be used on a regular basis to help with , uh, moisture and lubricants are used in anticipation of sexual activity. Two different things

Speaker 4: 13:37

And they can help the women who have been diagnosed with breast cancer continue with the recommended therapy. You know, they help reduce bothersome symptoms, does help people follow the recommendations of the medication for five to 10 years.

Speaker 2: 13:50

Thanks for that, Lisa. So to preface the conversation about hormone replacement therapy, the systemic kind now not the topical kind, I'll start with a story from medical school. When I was in med school in the late nineties, it was pretty much every single solitary woman was put on hormones. And if you didn't put people on hormones at the first sign of menopause, oh boy, you weren't practicing medicine right? Then. Fast forward like 10 years, it was the opposite. If you have a single woman on hormones, oh my goodness, you're not practicing adequately there. So the pendulum swung a little bit too far. So now let's talk about HRT for whom is it the right thing and why would you consider it and how does it work?

Speaker 3: 14:28

I , I think I come from your era, Dave. When late 1990s I was doing my pharmacy training at the University of Washington, I was a young pharmacist and checking medications that were being sent up to people in the hospital and 90% of the women and I was sending up estrogen, right? And then most people have probably heard of the Women's Healthy Initiative where results from a very large trial that was designed to look at the cardiac safety of these hormones. Um, it was abruptly stopped in 2002 due to a increased signal of , uh, cardiac events and breast cancer. And there are a number of problems of of applying the results of that study to all women in all phases of their lives. And I will say that the results of that study have been reanalyzed and it's important to know that that data , um, the average age of women was 63, which is more than 10 years past the average age of menopause. And they were asymptomatic. And so the generalizability is not there as far as the women that tend to come in asking for hormone therapy , uh, we tend to use , um, what we call bioidentical hormones now, which is estradiol, which is the same as the estrogen that our own body makes and progesterone and the older data. What didn't get broadcast was that in that study there were two groups of women, women with a uterus, women without a uterus. The women with a uterus were randomized to estrogen plus a progesterone, which the progesterone piece is necessary if we have a uterus to protect the lining of the uterus from building up too much and causing problems. And so then there was the estrogen progestin group and the estrogen alone group. And what didn't get broadcast widely was that the estrogen alone group women had a lower incidence of breast cancer risk. So we have had a lot of great data come out since then. Pretty much all of which consistently shows that the closer one is to the age of menopause, the more the benefit tends to outweigh the risk of hormone therapy. And we have what's called the timing window now that has been consistently supported that in general, if a woman is within 10 years of menopause or before age 60, for most women, benefit of hormone therapy outweighs risk, of course not all. And every woman needs to be looked at individually and needs to have a shared decision making conversation, taking into account all her individual risk factors and medical conditions that she may have. The

Speaker 4: 16:56

The statistic is even in the estrogen plus progesterone group, it was one extra case of breast cancer per 1000 women per year. So if you are a breast cancer oncologist, that's a very high number to you. But if you are a woman having debilitating brain fog and you're worried that you're gonna lose your job and lose your livelihood because of your symptoms, I think women should be allowed to be part of the shared decision making and whether they're , they're willing to take that risk. And the risk is the same as drinking two glasses of wine per night. It's less than being overweight and it can be reduced by regular exercise. So as I understand it, it's not just pills we're talking about here,

Speaker 3: 17:37

Right? It's not just pills. We often use estrogen in the form of a patch. Um, and it comes in various different patch formulations. One, you change twice a week. One you change once a week. It also comes in a spray and a gel. And the reason we tend to favor what we call transdermal formulations, in other words, estrogen through your skin versus a pill that you take, is that there's quite a bit of data that's suggestive that taking estrogen via the skin route is safer from a blood clot standpoint. And I guess the complexity of all these different products just illustrates that it's really important to find a clinician that's familiar with the whole array of treatment options so that they can help you find what might be the best product for you.

Speaker 2: 18:20

I really like that. Find a doctor that A, listens to you B knows a thing or two about your options and see includes you in the conversation. There are options, especially if you are newly into the menopause period and are having symptoms. There are people and there are treatments that can help. So non-hormonal treatments, let's shift to those now what are we looking at here? There

Speaker 3: 18:43

Are many options there thankfully because not every woman is the , a good candidate for hormones. So,

Speaker 2: 18:49

But before we get into them, are they as good?

Speaker 3: 18:51

Well let me say maybe we do have a new medication that is on par with estrogen as far as relieving hot flashes. Estrogens are the gold standard and they are, if we were in the United Kingdom, they have guidelines that say women should be offered in the absence of a contraindication or a reason that they can't take e estrogen. Women should be offered estrogen as first line therapy if they're within 10 years of menopause. So other non-hormonal medications include , uh, sometimes we use very low doses of antidepressants like the, what we call the SSRIs medications like venlafaxine, citalopram, peroxetine. Those can be effective for hot flashes. In some women we sometimes use a medication called gabapentin that can be effective if taken, especially at bedtime for nocturnal hot flashes, which we call night sweats. And let me talk about the new medication we have that's called Fein. The brand name is za , it's a medication that works earlier we were talking about the thermo regulatory center in the brain. The center that regulates temperature. It works directly on that part of the brain to help regulate temperature. And it's only been out year and a half maybe and it's an easy pill. You just take one, takes once a day and is quite effective for hot flashes. It hasn't been studied head to head with estrogen to my knowledge, but it is quite effective and a nice option for women for whom the other non-hormonal therapies aren't cutting it and who can't take estrogen. Of course the downside is it's exorbitantly expensive and one must fight with their insurance company to get it covered. But here, here at Hennepin we're pretty good at getting it covered. Not always successful but we can help with that often.

Speaker 2: 20:29

So I'm gonna come back to you Heather, because I do wanna talk a little bit more about things people can buy just in the store , um, that might help their symptoms. But for now I wanna talk to you Lisa, about the psychological and support systems that are available.

Speaker 4: 20:40

And it's not just social support, there's actually cognitive behavioral therapy for managing hot flashes as best you can. There's cognitive behavioral therapy for sleeping as best you can despite the night sweats and there's cognitive behavioral therapy for gaining control of urinary urgency. Unfortunately or fortunately, I have had ample opportunity to practice these myself and I have found that they are helpful. Just because the psychological treatment is helpful doesn't mean it's all in your head. These symptoms are real. They are, they are real and they're helpful. You know, it's education, it's putting tools in your toolbox. It's learning to understand your own triggers, how, how to manage them. I'd also like to say that I think some women, there's symptoms are so severe that the cognitive behavioral therapy would be insufficient. And so everyone should have the option of having a discussion about medication. You wouldn't want to put a barrier to medication saying you had to do therapy first. Therapy is for people who choose that they would like to learn those skills.

Speaker 2: 21:40

So I do hear this often that women who are struggling with effects of menopause, particularly things like hot flashes or getting all sweaty or feeling warm, they have these experiences minimized like so what you had a hot flash, you know, get over it. How do you communicate to them that their symptoms are real and that they're not alone? Well they

Speaker 4: 21:58

Are, they are real and they can be debilitating. And also I think we should, we we're focusing on the symptoms also that women are experiencing. There's also the silent symptoms that really have consequences for health that I think are important, such as, well I tend to think of osteoporosis bones are actually a living tissue. We're constantly , um, being reformed, rebuilt and it's estrogen that keeps that in homeostasis. And so when people start to go through the menopause transition and lose estrogen, you start losing bone more quickly than you're gaining bone. And you know, that's 80% of the people diagnosed with osteoporosis are women. I mean these are important health things we that should be discussed.

Speaker 3: 22:40

And 50% of women who live long enough will have an osteoporotic fracture. So a fracture due to low bone mass and in addition to the bone issues, another silent symptom can be the accelerated cardiovascular risk that's seen with the dip in estrogen. And that's been looked at and it's not due to aging alone. The drop in estrogen can greatly accelerate cardiovascular risk as an example. Um, and there's some various reasons behind that. But one illustrative example is that for many women, if you take their lipid profile, their cholesterol profile and look at it when they were 40 to when they just after menopause, there can be a dramatic rise in LDL cholesterol with menopause.

Speaker 4: 23:21

And there is something that I just wanted to not forget to mention, which that is, that anybody with ovaries can experience the symptoms of menopause. So an individual whose who is intersex or non-binary or trans man can also experience the symptoms of menopause. I would have the same general advice, which is don't suffer in silence. Advocate for yourself. There are treatments, you know, get yourself to Heather and me and we'll do everything we can to do to help you. And so we've been using the term woman , but it's much broader than that of

Speaker 2: 23:49

Course. Right, right, right. That is so important to mention. It's the presence of ovaries. Yes. That's what we're talking about. And

Speaker 4: 23:56

So we've been using the term woman , but it's much broader than that of

Speaker 2: 23:59

Course. Thank, thank you for bringing that up. That's a significant and a key point . Okay, so switching to things people can buy in a store, you go to a grocery store, your drug store, your health food store, and there's a load of things on the shelves that are available and it's hard to know what's what, what do we know about those? Yeah,

Speaker 3: 24:15

And there's also numerous products being hoked on social media feeds at vulnerable women. Uh, where do I even start? Yes, there are many over the counter and herbal type options that are being marketed to midlife women. And I will say at your local drugstore, there are a couple of options that are recommended and tried and tested and those are vaginal moisturizer. A brand name of that is Replens moisturizer and lubricants. We already talked a little bit about that. There are also all kinds of herbal supplements and talking about all of those is probably beyond the scope of this podcast. But I will say that some of them on an individual level may be helpful for women. But broadly speaking, we don't have a lot of scientific data to show that they're effective at a population level, not enough to actually recommend them in most cases. And with any supplement as a pharmacist I have to say, it's always sort of buyer beware . Since they're not regulated the same way that prescription medications are, one can never really be certain exactly what's in them.

Speaker 2: 25:15

Okay. Lisa and Heather, we could easily keep talking about this for hours as there's so much to discuss and we probably should talk about it for hours, but we are bumping up against our showtime. So to close us off, I'd like to ask you if you could leave us with any bit of advice, what would you leave us with? Heather, you start.

Speaker 3: 25:33

Well, I'd like to leave you with, even though we've talked quite a bit about medications, medications are only one tool in the toolbox. Also equally or even more important of course are lifestyle things that one can do that can mitigate some of these health risks and overall make women feel better. Those things include a healthy diet, exercise, strength training, and the , all of those things ideally need to be done together. Uh, plus or minus medications that can help. The other thing I'd like to mention is that midlife women that are perimenopausal, menopausal are often have sort of phased out of seeing their ob gyn. They may be done having children if they did have children and they may not yet be fully engaged with a primary care provider. So I just like to encourage women that it's a very important time to start to build a relationship with a medical provider. Ideally someone that can help you address some of these issues as well as help you take care of your health in the long run. That's

Speaker 2: 26:29

Really great advice, Heather. Thank you. Okay, Lisa, you get the last word.

Speaker 4: 26:33

So I do wanna do a shout out to the physical therapist here at HCMC or at Hennepin Healthcare. We have some really great physical therapists that have expertise in pelvic floor so they can do sexual health, also the urinary incontinence. Um , I also think it's just really important that this is something that we talk about and that we not be embarrassed

Speaker 2: 26:52

To talk about. Absolutely. Thank you both for talking with me and with our listeners about this topic. It's essential and something we definitely don't talk about enough. We've been talking with Dr. Lisa Lagrande , she's a psychologist, and Dr. Heather Lagree , a pharmacist in both of them, our experts and certified specialists in menopause care here at Hennepin Healthcare in downtown Minneapolis. I feel really lucky to have had them on the show today. It's been a great conversation. Thank you both.

Speaker 4: 27:18

Thank you. Thank

Speaker 3: 27:20

You for inviting us. We really appreciate being able to talk about this

Speaker 2: 27:23

Listeners and to anyone who even knows a woman, this is a really important topic and one that goes overlooked all too often. I hope you've picked up a few things on today's show, as I certainly did, and I hope you'll join us again in two weeks time for our next episode. In the meantime, be healthy and be well.

Speaker 1: 27:42

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden . To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. Got a question or a comment for the show, email us at Healthy matters@hcme.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive Producers are Jonathan, CTO and Christine Hill . Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well .