Menopause: What to Expect & How to Prepare

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Katie: Hello and welcome to the ”Wellness Mama” podcast. I’m Katie from wellnessmama.com. And I’m here today with Dr. Lyla Blake-Gumbs, who is a board certified family medicine physician with 22 years of clinical training and experience in functional medicine and urgent care from the Cleveland clinic. Her practice is focused on listening to her patient’s needs first, then keeping them involved in every decision along the way. As a mother of three and a Yogi, she loves to travel in her free time. She’s accepting a limited number of patients across the country through SteadyMD where she’s a personal online concierge doctor. You can find out more about that in the show notes at wellnessmama.fm or by going to steadymd.com/wellnessmama. And in this episode we tackle peri-menopause, hormones, menopause if you are in that phase of life, how to get through it with the least discomfort possible, what you need to know about hormone replacement, how everything else can come into play during that time of life. So if you are in that phase or close to that phase, stay tuned. This episode is going to be a great one for you.

Dr. Lyla, welcome. And thanks for being here.

Dr. Lyla: Thank you so much for having me, Katie. I’m glad to be here.

Katie: I’m so glad to have you here because you are an expert on a topic that I get a lot of questions about that I don’t know how to answer, which is perimenopause and menopause and how to navigate that in the best way possible with the least discomfort possible. And I know that’s something that you are very much an expert on. So to start broad, can you explain exactly what perimenopause is and why there’s such a wide range of ages in which women experience that?

Dr. Lyla: Right. It’s kind of an interesting concept because we talk about menopause like it’s this really long period during life when in actuality perimenopause probably takes up more time. A woman can become peri-menopausal, which means around the time of menopause, as early as her, you know, early to mid-40s. And this can go on until, depending on how late she stops having her periods for up to 12 months, which is the definition of menopause. She might go till 52, 53, 54. So it can take quite a long period of time that you’ve actually fit into that category. And it really depends on the woman and a whole host of factors. Like when did she start menstruating? How many pregnancies, if any, did she experience? How long did she breastfeed?

And so it’s a very interesting time and the symptoms can be confusing. The height of the symptoms where, that we’ll get into a little bit, I’m sure, itself may only last a couple of years though. But women will start to notice some changes in their periods mostly as early as their mid-40s moving forward. So this wide range of ages leads a lot of women… I’ve even heard women in their late 30s describe themselves as feeling like they’re in the perimenopausal period. Sometimes we can tell with hormone testing where people are, but most of the time these are clinical kind of diagnoses based on symptoms that people come in with.

Katie: Got it. So when it comes to like technically defining peri-menopause, it’s not like there’s an age cutoff or even like a hormone test that defines it, but it’s more symptom based. Is that, am I understanding? So like how would one know that they might be in perimenopause and might need to like keep an eye on these things or address things?

Dr. Lyla: Yeah, exactly. That’s a really good question because menopause is a little bit easier to define. It’s the definition of menopause is not having had a cycle for a full year. If you don’t have a period for 12 months, you’re considered menopausal regardless of what your FSH is, which stands for follicle stimulating hormone. However, with peri-menopause, it is true that there’s really no lab test that can diagnose that and there’s no specific age for it. Like I mentioned earlier, you can begin to have some erratic periods, you can have breast tenderness, you can start having some weight gain and some mood changes when you start entering the perimenopausal period of time. You might even have a little bit of hot flashes because this is a period when estrogen levels are fluctuating from high to low, high to low. But progesterone is often quite low. Progesterone starts reducing much earlier than estrogen levels, maybe about 10 years earlier. Maybe in the early 40s, progesterone levels start going down. So that kind of heralds the onset of perimenopausal symptoms.

Katie: That makes sense. So I’m curious, just like to understand biochemically what is happening during perimenopause with regarding hormones and physiologically? Like I get the overall idea that the body’s preparing to stop menstruating and to go through menopause, but what hormones are changing and tend to go up or down?

Dr. Lyla: So initially, like I said, you’re gonna get a reduction in your production of progesterone. Progesterone is produced primarily by what we call the Corpus luteum within the ovary. And this happens after ovulation every month. As you become peri-menopausal, you have more cycles where you don’t actually ovulate and so you’re not secreting as much progesterone as you were earlier in life. So you’ll start seeing a steady decline of progesterone. Your estrogen levels can be great and they can continue at pretty high levels up until the time you stop having periods. And this leads to a problem called estrogen dominance and we’ll talk about that I’m sure during the course of this podcast. So you’re gonna see decline in progesterone, steady or normal estrogen. As you approach closer and closer to the menopause itself, you will also see a sharp reduction in progesterone beginning.

In addition, you’ll start seeing testosterone levels going down. And that also plays a role in some of the symptomatology, especially libido issues and energy issues. But we’re not gonna talk a whole lot about testosterone today, but do know that that is one of the three major hormones that are affecting or bringing about some of the symptoms we see.

Katie: That makes sense. And I would guess based on my understanding of hormones more just from me, the pregnancy and just monthly cycle side, it’s like they are so interdependent. Like if one goes up or down, it typically has an effect on the others in some ways. Is that true also in perimenopause?

Dr. Lyla: Yes, that is absolutely true. And, you know, other things like body weight can kind of impact the severity of symptoms during the perimenopausal and menopausal period of time because remember, fat cells will make estrogen in the body. And so, you know, one of the ways that you can keep your estrogen levels a little bit more steady and try to avoid some of the estrogen dominance that’s at least preventable is by trying to maintain a healthy body weight.

Katie: That’s good to know. And I know that applies to hormones, like for people with PCOS or other hormonal-related issues that can be really beneficial as well. To circle back to something you said at the beginning, just sheerly out of my own curiosity, you mentioned that like pregnancy and nursing and how many babies and how long can affect potentially that the age at which someone starts to enter this period. So I’m just curious to understand for my own benefit how that works and whether that makes you more or less likely to go through it at an earlier age. Because I’ve had six babies and I started having kids pretty young, so I’m just curious for my own sake.

Dr. Lyla: Yeah. So the number of pregnancies and how long you’ve nursed is important because remember we were born with a certain number of follicles in our ovaries. And whenever you’re pregnant, obviously, you’re no longer ovulating and having monthly cycles during the pregnancy. In most, you know, in 99% of cases you’re not ovulating or having a period during a pregnancy. And then for most of the time where at least if you’re nursing enough, you know, there’s that window where if you go below a certain amount of minutes per day nursing, you also won’t ovulate. That’s why women don’t get their periods immediately. And they can often go up to a year without having a period. The lucky ones, can go up to a year without having a period if they’re nursing sufficiently.

So those two things, pregnancies and nursing, help reduce the amount of actual periods that you have, the amounts of time that you actually ovulate. So then you can go longer into your lifetime, if that makes sense, having more periods. So if you never had a pregnancy, obviously you probably didn’t nurse. If you never had a pregnancy and you started your period relatively early, you’re probably gonna enter menopause a little bit earlier and vice versa. It doesn’t always follow that rule book, okay? But these are just kind of generalizations and that’s how those two things can affect the time at which somebody might enter perimenopause and then menopause. Does that make sense?

Katie: Yeah. That does, that makes perfect sense. And yeah, good to know that those factors would be really could influence that. You mentioned estrogen dominance a minute ago, and I know this is a word I know in the context of like PCOS for instance. So I’m curious, can you, for anyone who doesn’t know, define technically what estrogen dominance is and then how this affects women in that perimenopausal menopausal period and like what’s going on there?

Dr. Lyla: Well, remember I mentioned earlier that progesterone levels start going down and estrogen pretty much stays the same. And in some women, their estrogen levels may be higher than normal. So there’s a few scenarios that can lead to estrogen dominance. One of those is you’re not producing enough progesterone, but you’ve got normal amounts of estrogen. When you look at that ratio, even though your estrogen levels look normal because the progesterone is low, it throws the ratio off and so you have too much estrogen. Another scenario is when you have high estrogen and either normal or low progesterone, again, that will lead to a picture of estrogen dominance. And then the third scenario is if even if you’re almost menopausal or you’re in the midst of being, say you’ve not had a period for nine to 18 months and your estrogens already become low, you can still be estrogen dominant with a low estrogen because your progesterone is even lower. It might even be almost non-detectable because you don’t have any more Corpus luteum being produced. And so you’re still gonna be estrogen dominant.

And it’s interesting because now the more I’ve studied about this, the more patients I’ve seen in this period of their lifetime, the more I’m finding that that’s the predominant picture that we see is women with estrogen dominance. And the symptoms that you’re gonna see are, you know, those tender breasts, fiber cystic breasts, those irregular menstrual cycles., mood swings. You can see a lot of mood swings because these rapidly swinging estrogen levels. We call them basal motor symptoms. These are your hot flashes and hot flushes, weight gain, especially around the abdomen. Sometimes the hips as well can be involved. And also we can see an increase in uterine fibroids. Those typically tend to get a little bit better as estrogen levels completely go down because they’re sort of, for lack of a better word, fed by the estrogen. So these are all the symptoms and there’s several more, but these are the main symptoms that people will come in. Sometimes low libido. A lot of women complain of brain fog during this time period.

Katie: Okay. So if I’m understanding estrogen dominance is actually all about the ratio. It’s not like men can just take a test and have an estrogen number in a vacuum and a doctor say, “Okay, you have estrogen dominance.” It’s about in relation to progesterone.

Dr. Lyla: That’s correct. So you can get estrogen levels as well as progesterone levels drawn. And you know, there’s debate out there about whether saliva, blood spot or serum levels are best. I typically use blood levels. You know, I send someone to the lab and I’m gonna get an estradiol level and I’m gonna get a progesterone level and I can do the math to figure these out. And it’s easy to find if a woman is… especially if you see that her progesterone comes back really, really low. Ideally you want a ratio of about a hundred to 200. And I’ll be honest, most women that come in that are in this period of time typically do not have a ratio of 100 to 200, and they’re usually pretty symptomatic by the time they see me. So that’s probably why we’re seeing this.

Katie: Gotcha. So then if it’s about the ratio, is it as simple as raising progesterone or is it more complicated than that?

Dr. Lyla: Well, that’s a good question. And I think you’ve kind of hit the nail on the head. And there’s a lot of ways we can do that. It doesn’t automatically mean giving somebody progesterone, but in many cases that is what we do. There are some other things that you can do to reduce the estrogen dominance. You can give oral micronized progesterone. Typically we use, the studies have shown about 200 milligrams per day. In women that are still menstruating, you can give it during the last half of their cycle. So usually it’s day 12 or 14 until they begin menstruating. And women that aren’t menstruating, we can give it throughout the cycle. We can give it daily. But some other things before going to progesterone, especially in women that are concerned about taking any hormones, these are for sure bioidentical hormones. However and it’s the correct form of progesterone. It’s not the same progesterone you find in oral contraceptives. But some women still wanna try other things first.

So one of the biggest things that I like to encourage are dietary changes to start with. Things like increasing your fiber intake because fiber is going to help remove some of the excess estrogen that’s recirculating through our intestinal tract. If you have very low fiber intake, what will happen oftentimes is you’ll reabsorb some of the estrogen that would otherwise pass out through your stool. So increasing fiber will help bind some of those estrogen molecules up and carry them out. Cruciferous vegetables, one to two servings a day, I highly recommend. And one of the reasons is because they contain nutrients. One in particular called Indole-3-Carbinol, helps to detoxify estrogen. And so, especially for women that have what we call a ICOM T mutation, it’s a type of a genetic mutation that some women have that can make it more difficult for them to detoxify their estrogen.

And we won’t go into a whole lot of the forms of estrogen that are toxic versus non-toxic, but cruciferous vegetables and certain supplements like DIM, Diindolylmethane will help detoxify estrogen and also allow it to pass out through the stool. Also, exercise and stress reduction. I can’t talk more strongly about the importance of stress reduction. Things like yoga and meditation and breath work. All of these can help reduce or eliminate excessive estrogen and what we call Pregnenolone Steal, which is kind of a siphoning off of the components that you need to make progesterone where it is due to stress, kind of shuttled over to make cortisol as opposed to making progesterone and then therefore resulting in a reduction in your circulating progesterone levels.

Acupuncture is also helpful and can help with a lot of the basal motor symptoms that women suffer from. Which by the way I haven’t mentioned tends to be the biggest complaint that women come in with but not necessarily the most dangerous aspect of menopause. And, you know, those would be cardiovascular, risk of bone loss. And I’ll just leave it there. Bone loss and cardiovascular risk factors. Also, changes and alterations in the cholesterol profile. We’ll see that happen with reductions in estrogen levels.

Katie: I love that you addressed some of the food based ways because that’s my background in nutrition and it’s like as if any of us needed even more reasons to eat green vegetables. But they’re so beneficial in so many ways. And I’ve also read that green vegetables are high in magnesium, which I personally found and I think a lot of women find helps lessen symptoms of like even like PMS or cramps for me. And so I would guess there’s maybe like a beneficial effect there as well. And I also love that you brought up the cardio and boneless side because you’re right, I think hot flashes are what we stereotypically associate with menopause. But from what I’ve read, at menopause, women’s risk of cardiovascular disease rises almost to the rate of men. And I’d love to explore a little bit of why that’s the case and if maybe like is iron an aspect there because women are losing iron each month by bleeding. Are there other factors involved and how can we counteract that? Because obviously that’s a huge problem in our society and it’s on the rise. So what can women do knowing that going into this to help protect themselves?

Dr. Lyla: Right. Well, we know that cardiovascular disease is the number one killer in the United States and it’s rapidly becoming the number one killer throughout the world. As we explore our food habits and fast food chains to other parts of the world, we’re seeing just everybody catching up with us. That being said, estrogen is protective for women. And so premenopausal women have a much lower risk of developing heart disease than men do. And so what ends up happening is when we no longer have that protective factor circulating in our blood to the levels that we had as premenopausal women, then we began to look like men to some degree as it relates to our cholesterol profile and our propensity to develop heart disease.

The interesting thing about that is that estrogen, what we found in the Women’s Health Initiative, which was a study back in the very early 2000s, I believe, 2001 was when it was published, caused the panic in the medical community because, you know, at that point in time, almost every menopausal woman had been put on some form of hormone replacement. They were synthetic hormone. Well, let me put it this way. The estrogen component was Premarin which is derived from mare’s urine, horses urine, pregnant horses urine and a synthetic progestin. What that study showed was that women’s risk for what we call VTE or Venous Thrombosis Events went up drastically as did their cardiovascular events. And so it did not protect them against the things that we thought they should be protected against by giving them those components. However, and this is a big caveat to that study and to the interpretation of that data, there were a lot of women in this cohort that were more than 10 years out of menopause. So they were over age 60.

They were naive to estrogen for that entire time. Many of them, or most of them, hadn’t been on any estrogen during those interceding 10 years or so. And also the third piece of it was these were not the same type of products that we are gravitating to now in terms of, you know, using Estradiol as opposed to conjugated estrogens from horses urine. And the progestins I mentioned were different than the oral micronized progesterone that we use now, which is more bio-identical. And so the interpretation of that study really scared a lot of people off from using either if you can call it hormone replacement therapy or menopausal hormone treatment because they were interpreting the results appropriately, but the patient that were in the clinical trials were not the patients that we’re trying to target now that are the most symptomatic and that are within 10 years of starting or having been in menopause.

So I can clarify that a little bit more if you have specific questions, but just know that those…it can get very muddy, right? Because we’re saying, “Okay, you’re gonna treat cardiovascular risk by replacing someone’s estrogen, but wait a minute estrogen and progesterone or progestins caused more heart attacks and clotting events. Where’s the disconnect?” That’s the disconnect. We’re using different forms now of these products and we’re trying to start women earlier.

Katie: Got it. That makes sense. Okay. So I’d love to go deeper on hormone replacement therapy because I know that there are several different kinds. You’ve mentioned a couple of them. And that’s an option that’s often presented to women at that age. And I know that there’s also like the functional medicine approach differs a little bit than maybe the straight conventional medicine approach. So I’m curious for when a patient comes to you who’s in this phase, who’s maybe having some symptoms what are the options available to her and how do you evaluate which one’s best?

Dr. Lyla: At the outset I’d like to say that, you know, women, we’re all individual. And so the nice thing with this is that you can really sit down and talk to a woman and find out what’s bothering you, what are your symptoms. And that’s really what I try to gear my treatment at is what’s interfering with your quality of life. And then in most cases, like we talked about earlier, it’s a lot of the time it’s basal motor symptoms, the hot flashes, the night sweats, etc. So for somebody like that, we do know that as long as the woman is within the first 10 years of her menopause and she’s under the age of 60, the risk benefit ratio is gonna be in her favor to do some form of estrogen replacement. Also, remember that if you have an intact uterus, in other words, you’ve not had a hysterectomy for whatever reason, then you must take progesterone if you’re taking estrogen.

So what we typically will do is offer what we call transdermal estrogen. And that is a patch. And, you know, historically the, you know, there’s been…we’ve had patches for a long time, but the technology that’s around now that allows us to provide very, you know, reasonable amounts of estrogen absorbed through the skin so that it doesn’t have to pass through the liver, makes it a much safer form and also a very effective form. That’s gonna be the most effective for those hot flashes. And then progesterone would be delivered in a tablet or a capsule, typically. Other options are vaginal estrogen in a cream form. That’s gonna be great for some of the vaginal dryness and thinning of the vaginal tissue, but it’s not gonna help so much typically with the hot flashes. You need something a little bit more systemic to help with hot flashes.

For women that have any contra-indication to estrogen therapy, will start again with some of those things I mentioned. With diet, you know, increase in fiber, increasing cruciferous vegetables, acupuncture, starting somebody on DIM also was very helpful, can sometimes help with those symptoms. If a woman is not having significant hot flashes yet, but she’s having maybe the really heavy bleeding, irregular bleeding that some women get, maybe earlier in the perimenopausal period, sometimes we can do things like chasteberry which is a capsule that you take every day. It’s another name for it is Vitex, V- I-T-E-X. Sometimes that will help regulate periods in women, help make them more reliable. You know, they might come a little bit more frequently and they might be a little bit less heavy. That buys you a little bit of time before you need to start some other type of hormone.

Again, weight loss is important because estrogen production that takes place in the fat cells can contribute to these swings. And other things like evening Primrose oil has been used. Agnus castus, this is another herb that some people use. So there’s a lot in our armamentarium and really what most of us are gonna do is look at the particular woman sitting in front of us and we’re gonna say, “Okay, what are your symptoms? What bothers you the most?” And try to gear our treatment at that. That might mean that we’re gonna do several different things over a period of five to 10 years. So the therapy may change from when she’s in her mid-40s or late 40s to when she’s in her early to mid-50s. A few other things that might be helpful is we do some caffeine intake also abstaining or reducing the amount of alcohol that you drink because alcohol we know can increase Estradiol levels and also decrease progesterone levels. And so that’s gonna exacerbate any estrogen dominance that we’re already seeing at baseline.

And lastly, I would say avoiding plastics and other Xenoestrogens like that. Everybody’s probably heard about bisphosphonate A that’s BPA. So avoiding the use of plastics whenever you can, not just, you know, using them in the microwave but trying not to store food in plastics and trying to drink your water out of stainless steel containers and things like that. Looking at your cosmetics and any Xenoestrogens that might be present in those, avoiding foods with pesticides, so eating organic and non-GMO foods, all of these things can help treat those symptoms before even moving on to giving somebody progesterone and or estrogen.

Katie: Yeah, I love that and I think it’s so important what you said about taking that whole body approach and looking at the woman’s sitting in front of you. And I am so glad for functional medicine and for this like really this rise and understanding about functional medicine. Because I think when you’re talking about any life change or health condition, it’s so much more effective to work with a doctor who’s taking everything into account and just like in this how hormones, you know they all affect each other and if one goes up or down it can influence the others. There’s also, at least from my own experience, things like thyroid function and how that can influence perimenopause or any hormone aspect or if there’s gut stuff going on. You know, if people have other conditions instead of just trying to look at estrogen in a vacuum and is it too high or too low, it’s taking the whole body approach and testing all of those things and then working with the patient to figure out how can you as the person where you are right now, change your lifestyle, your diet and is there a need for things like hormone replacement so that it’s a whole body approach.

And that just, I found that was the key for me with thyroid disease and with so much else. An you work with SteadyMD, which is a company I love and my doctor is also a SteadyMD. So I just wanted to mention that for anyone looking for a functional medicine approach who may or may not have a local doctor this is a great way that people can connect with doctors like you, including you and work through all of these things, not just be looked at as a symptom in a vacuum. I also love that you brought up plastic because that is one of those topics I love to write about and educate about and I think is so important. I write about it especially from the kids’ perspective and when they’re young and they’re still, they haven’t even gone through puberty yet, how important it is to minimize plastic, but you’re so right. I think we also have to think of that for ourselves and especially when we’re going through any hormonal period. It’s so, so important. And I think people often discount just how important that could be.

I know for myself when it comes to hormone changes, and again, I haven’t been through perimenopause, but I have worked on balancing my own hormones, I’ve also found that things like sleep is drastic. If I don’t get enough sleep, my hormones will be off. And also for me, sunlight. And I’m curious if this is something that you found as well, but if I get up and go outside in the morning and drink tea or water or just be outside early in the morning, I find that it not only gives me more energy and helps my sleep at night, but that over time my hormones including cortisol, but also estrogen and progesterone have all seemed to get into better ranges. And I’ve done other things as well. But I’m curious if that’s something that you look at with your patients as well.

Dr. Lyla: Oh, absolutely. And thank you for bringing up just the intertwined nature of our organ systems and our hormones because you’re right that all of these hormones are important to understand your thyroid. You know, you can’t do this in a vacuum. You can’t treat someone in menopause and ignore what’s going on with their thyroid. It doesn’t always mean that something’s wrong with their thyroid, but we really need to rule that out as a contributing factor. As it relates to the last thing that you said surrounding the importance of sunlight and sleep, absolutely. So you know that not getting enough sleep causes in and of itself just that alone can cause stressors on the body, which are gonna increase cortisol. And remember I mentioned earlier in the podcast that when the need for cortisol production goes up because of chronic stress, including sleep deprivation, that you’re gonna be pulling away from the hormone cascade that makes progesterone. And so that’s gonna cause a problem right there.

So minimum, ideally of six, ideally more like seven to nine hours of sleep. And what we know is that DNA changes occur after just one night of getting less than six hours of sleep. And these DNA changes lead to an upregulation of your inflammatory what we call cytokines or inflammatory chemicals in your body and downregulation of the anti-inflammatory cytokines. And so what ends up happening is you have an inflammatory picture going on when these genes change. So you’ve gotta get enough sleep first and foremost. And then also the stress piece. We talked about that a little while ago. You really have to keep stress under control. And that means different things to different people. Sometimes it’s meditating. And I recommend all my patients to meditate. We could do a whole podcast on meditation. Sometimes it’s breath work. Sometimes it’s, you know, a walking type meditation, something that’s gonna calm your nervous system. So anything that brings you calm and comfort, you should do that every day for at least 20 minutes.

Sunlight, you brought up. I’m sitting here in front of my light right now because even though it’s still sunny and the weather is still not too bad in Ohio right now, I wanna get ahead of the game in terms of it’s gonna get dark here really soon. It’s gonna start getting dark early. It’s gonna be dark when I wake up. And so trying to get exposure to the sunlight if you can, that would be ideal because if you’re out and you’re walking, you’re getting exercise and you’re getting sunlight. However, for people that live in areas where it’s not as amenable to that type of activity every day, you can get yourself a light that provides at least 10,000 Lux, that’s L-U-X. And use that 20 to 30 minutes sometime shortly upon awakening. If you can get it in within the first four hours upon awakening, that would be great. And that will also help not only your mood, I don’t know that there’s any studies that will prove that lights like this will or sunlight, it in fact helps with hormone levels, but I think you’re onto something when you say that this has helped you because if it helps your mood and it helps your stress levels, then it’s by definition going to help balance your hormones.

Katie: That makes sense. And like you said, if it helps your sleep as well, like sleep is so, so key for, I find that more and more for every aspect of health. And also the stress component you mentioned. That was the one I ignored for a lot of years because I just thought I could power through and as long as I ate really clean and exercise and did all of that, I could just kind of power through the stress and the emotional side of things. And it wasn’t until I really dove in and addressed those things that I really started seeing those internal shifts and then also the physiological shifts that come with them. A few kind of a followup questions related to things we’ve talked about. So, so many of the things you’ve mentioned related to perimenopause sound like things I also hear from women with PCOS and I’m curious if there is any type of connection there and if people who have PCOS are more or less likely to experience symptoms more in perimenopause or to go through menopause earlier.

Dr. Lyla: So women with PCOS have a little bit of a different milled of symptoms. A lot of them, have because of the fact that they have so many it’s called polycystic ovarian syndrome because they have an increase in the number of cysts. They’re producing more testosterone. And so that testosterone is what kind of monkeys up, monkeys with their hormone kind of picture. I don’t know, honestly whether or not women with PCOS tend to have more symptomatic or less symptomatic perimenopausal periods. My gut instinct would tell me that they probably do only because most people with PCOS have spent decades with hormonal aberrations. And so why should it be any different during the perimenopausal and menopausal period of time? They also tend to have problems with blood sugars. And when you have blood sugar issues, that tends to lead to you know, weight discrepancies or having too much weight on board, which as we already talked about, can lead to increased production of estrogen and that estrogen dominance becoming again a problem.

So yes, the symptoms can sound very similar. And, you know, let’s face it, a lot of the symptoms that we’re talking about are sometimes sort of vague symptoms that a lot of us complain about. Fatigue and moodiness and, you know, acne and these kinds of things. So, you know, we’re gonna see them across the board in women with different reproductive type conditions. We can treat them very similarly. People that come in with PCOS though I’m gonna have probably a different mindset as it relates to, “Okay, which hormones do we wanna treat here?” And it’s also gonna depend a lot on their age.

Katie: Gotcha. And then as another followup to that I’m curious about different methods of birth control and how they might impact people and their experience in peri-menopause and just hormonally overall. Because I know there’s a lot of options out there and I get a lot of questions from women about this and I have no idea, and I’m not a doctor, so I don’t answer them. But I’m curious how, if they do come into play, how they come into play?

Dr. Lyla: Well, so the interesting thing is what we often see is that women that enter this period because they’re having these irregular periods, oftentimes very heavy periods because of the high levels of estrogen and the anovulatory cycles that they might experience because of the low progesterone or as a result of low progesterone. We’ll see them get recommended to have, say a Mirena, which is a progesterone eluding IUD placed. Because that will help provides for a local installation of progesterone in the area of the uterus. It can help reduce bleeding and oftentimes just stops periods altogether which can by women a few years before they actually enter menopause. So it can really reduce the amount of bleeding and blood loss that women experience.

Some women are treated with low dose oral contraceptives. Because remember when you’re perimenopausal, you’re still capable of becoming pregnant because you do ovulate sometimes and if you ovulate and you have intercourse, you can become pregnant. So some doctors will use various types of oral contraceptive, usually combination contraception. However, women that are over 40 and or women that smoke may be more at risk for blood clots if they’re on oral contraceptives. So that’s less and less common. We see that less and less commonly nowadays. And that’s certainly nothing that somebody in functional or integrative medicine probably would recommend.

I think it’s definitely worth, especially for the women out there that don’t tend to go to the doctor a lot. If you’re on an oral contraceptive, you may not really see a lot of these changes because you’re gonna be getting a pretty constant dose of estrogen and progesterone throughout, you know, the days that you’re taking your tablets. So you may not get as much of the hot flashes and your periods are gonna be regulated. However, it might be worth for sure a visit at age 48, 49 to start discussing how to manage these symptoms or how long you should continue to be on the oral contraceptive therapy. And I say that because of what I mentioned a minute ago about the risk for blood clots, especially if you have a family history of blood clots. It may be advisable to come off of that and to choose another course of therapy.

You definitely wanna wait until you’ve been off of your oral contraceptives for a period of time, at least four to six weeks before checking hormone levels because clearly if you’re checking them while you’re on those types of hormones, it’s gonna throw off the results. So having an appointment 48, 49, no later than 50 to discuss, “Okay, I’m entering this age range where most likely I’m gonna be entering menopause.” And the average age in the US is 51 for women becoming menopausal. And so while there is a range of typically four to five years on either side of that, I think going to the doctor no later than age 48 would be advisable to see if there are some other ways to manage this period of life in the safest way possible.

Katie: That’s, yeah, great advice.

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Katie: For me personally, I’ve never been on any form of hormonal contraceptives at all, but I track my cycle using several apps actually in NFP and body temperature. I hope I still have quite a bit of time before peri-menopause. But I’m curious for those of us who do track our cycles, you mentioned that like cycles can space out. Are there other changes that we would begin to notice if we were actually like watching for fertile signs? Would like a certain phase of the cycle tend to lengthen? Would it be like the luteal phase or what would we see there?

Dr. Lyla: Yeah, so typically your cycles are gonna get the time between your cycles, say your typical period might be every 28, every 29 days. They tend to get a little bit shorter. And that variation tends to be the luteal phase where that’s actually shortening. And that’s what accounts for the change in the overall cycle length. More often than not, you’re gonna see women that have heavier bleeding maybe more clots. And it can be a little off putting. Women often will come in iron deficient at this point in time because they’re having such heavy periods.

You know, it’s interesting to know that the average woman should typically only lose about 35 MLs of blood per cycle, and that would equate to about 70 spoons of blood. Women that are in the perimenopausal period can lose that in a day or in two days of their cycle or even shorter than that. So you’ll find that maybe you’re going through more tampons or you’re going through more pads, or if you use a menstrual cup, it’s filling up within a few hours as opposed to the 12 hours they say that it’s supposed to last you. Those are indications that you’re probably beginning to have lower progesterone levels and entering perimenopausal time. Another symptom would be of course the hot flashes and sometimes they’ll only happen at night. You might just wake up a little warmer than you typically would. So those are probably the main kind of alerting symptoms that you’re gonna see. So, you know, watching those cycle lengths on your apps can be the first tip off before you’ve even gotten any breast tenderness or anything like that.

Katie: Okay. Awesome. That’s great to know. And as we start to get towards the end, I’m curious, we’ve talked about a lot of these symptoms and what to look for. Is and I know that the understanding is that women think they’re gonna have these symptoms, especially in menopause, are the symptoms avoidable to some degree or completely if women are willing to kind of take this broader functional medicine approach that you talked about and address diet and lifestyle as well as hormones? Have you seen women go through perimenopause and menopause much more easily by doing that?

Dr. Lyla: You know, it’s interesting because you’ve talked to women I’m sure that have said, “You know, I hardly had any hot flashes. I had the easiest menopause known to mankind.” And they’re not always women that are seeing functional medicine doctors. You know, sometimes it just really depends on the person, their family history, their, you know, obviously diet and things like that. I would say this, I would say that in the vast majority of women that are really symptomatic, seeing the right, you know, practitioner can really, really make a difference. Making these dietary changes, losing weight, sometimes it’s putting on weight. If you’re underweight, sometimes putting on weight will help a little bit. Exercise. Can’t stress enough the stress reduction. All of these things can definitely ameliorate the symptoms of menopause.

And when all else fails, you know, we know that estrogen combined with progesterone will help symptoms. And more and more information actually has come out that even progesterone alone, micronized progesterone, like I said, 200 milligrams daily in a postmenopausal woman sometimes is enough. Sometimes they don’t even need to resort to using an estrodiol. It just is gonna be so individual. And so I really urge people to have that conversation with somebody that they trust. Read, read, read. There are all kinds of… Well there’s lots of things out there that you probably don’t wanna read, but there are really good Christiane Northrup’s book ”The Wisdom of Menopause.” It’s an older book, but there’s really a lot of good information in that book. And I think just really getting to know A, your body and B, paying really close attention to when an intervention is tried taking good notes and really being able to document how did that intervention work for you because it’s not always gonna work the same for every individual. And talk to your physician about the results of any interventions that are tried because if it’s not working, working together, the two of you can figure out something that will work. It may take some trial and error and it may take a little bit of time to get it right, but that’s so important. And don’t hesitate if something’s not working to bring it up and just keep plugging away at it because you can get relief.

Katie: Absolutely. And I mentioned SteadyMD kind of in the middle of the episode and there’s gonna be links to both SteadyMD and to you directly on steadyMD in the show notes at wellnessmama.fm. So if any of you guys are listening and you are in this phase of life you can definitely find and work with Dr. Lyla or any of the doctors at SteadyMD. But anything you wanna say about SteadyMD or how people can find and work with you.

Dr. Lyla: Well, the great thing about SteadyMD really is, you know, I’ve found in my past 19 years of practice that one of the biggest complaints of people is that they can’t get in when they need to get in. They don’t have the access that they want or that they need. People are busy nowadays and they really need, if they have an issue, they need to be able to get into their doctor. And sometimes two, three, four weeks isn’t fast enough. So with SteadyMD, you have access to somebody that is aligned with your thought process and your philosophy for health and you have access to them and they’re gonna get back to you. The app is great. The video chat is to me as good as being there in person. And so I feel like I can really help improve access. I can see people from all around the country.

Another piece of it is that, you know, if there’s issues with these types of symptoms, I can order labs and you can take them to your local lab. You don’t have to fly to Cleveland, Ohio to see me. And so I really like the convenience of it. The piece about, you know, they typically, when you sign up for SteadyMD, you take this quiz and this quiz will kind of match you with the doctor that has the most similar outlook or philosophy to yours. And so you’re gonna end up with somebody that you didn’t just pick out of a book because they were on your insurance. You’re finding somebody that’s very aligned with the way you look at the world. And I think there’s nothing better than sitting and talking with somebody that thinks the same way you do. You don’t spend a lot of your visit trying to convince the doctor that this is how things should be or this is what you’re experiencing. So that I think it also makes it a very efficient service.

Katie: I agree. And I think a link to find the quiz is steadymd.com/wellnessmama. So if you guys are listening, it’s really quick, easy quiz and like Dr. Lyla said, it connects you with the doctor who’s gonna agree with you. You’re not gonna have to fight your doctor about nutrition or the fact that you want to take a natural approach. They’re amazing. I love my SteadyMD doctor and I think this was a super, super helpful podcast episode. Like I said, this is an area I don’t have experience with and I love that you jumped in and answered all these questions and provided so much value. So Dr. Lyla, thank you so much for being here today.

Dr. Lyla: Thank you, Katie. I look forward to talking with you again and I hope this has been helpful to your listeners.

Katie: It absolutely has. And thanks as always to all of you for listening and sharing your valuable resource, your time with both of us. We’re so grateful that you did and that you are here today. And I hope that you will join me again on the next episode of the ”Wellness Mama” podcast.

If you’re enjoying these interviews, would you please take two minutes to leave a rating or review on iTunes for me? Doing this helps more people to find the podcast, which means even more moms and families could benefit from the information. I really appreciate your time, and thanks as always for listening.