The changes that come for women as we get older.

Perimenopause beginning in our 40s and menopause following in our 50s, not being talked about enough.

And that really should chang because many women don't realize there are options that can help with the brain fog the anxiety, sleep disruption, weight gain, night sweats, mood changes, all of tha that come with hormonal shifts.

So often we chalk it up t stress or simply getting older.

But doctors say these symptoms are treatable and women do not simply have to tough it out.

And one of those doctors is Doctor Katie Rust DC, who is a senior director with Intermountain Health and Reproductive Health in all things.

Thankfully, menopause.

Thank you for coming on and joining us because this is an important conversation.

I should mention that the two of us have actually had this conversation before and ever since.

I've told all my friend and my mahjong group about what I learned from, Doctor Katie here because, like I said, women are not talking about this.

Why is that?

Yes.

Thank you so much for having me today.

This is one of my most favorite topics to discuss and it's exactly what you said.

We have for many, many years been downplaying the impact of perimenopause and menopause, as a health care system.

And it is time for us really to start talking about something that has such a tremendous impact for women throughout their 40s and 50s, and sometimes even later.

Women really deserve to have an opportunity to talk about these things and more importantly, if they're having symptoms that can be treated, we absolutely owe it to them to make sure they're informed and can opt into those treatments.

I think for women, you know, we go to an ObGyn at the beginning for reproductive health care, and then we enter this area that we don't really know much about.

There's a spectrum.

Let's talk about the differences not only in age but in symptoms between perimenopause and then menopause that follows.

Yeah, such a such a great topic.

So the average age of menopause in the United States is 51.

Okay.

But that's an average, right.

So there can be women who go through menopause, as defined by a yea from your last menstrual period much earlie or sometimes even in their 30s.

And wome who go through this much later, sometimes in their 50 and even into their early 60s.

So it really is a spectrum.

And I think that's part of the reason why women don't they don't come in very quickly because they don't necessarily know what's going on.

Right.

It's not like you can say at 45, this is the day you're going to start experiencing these symptoms.

It really can be so highly variable.

Perry, menopause can last up to ten years before that final menstrual period can.

Which that's another piece of this.

Where in your 40s, when this is statistically most likely to be happening.

There are a lot of women who are going through, career changes, high stress jobs, children who are getting older, right, having to fund college, you know, change in relationships, friendships, things like that, that can all add stress and I think can make it a lot harder to recogniz what these symptoms really are.

So it's very hard to identify the symptoms and necessarily know that you even need to go in and be seen.

Okay.

So that what are some of the symptoms in that first phase of perimenopause.

Because there are two right.

Yes.

Yes.

Yeah.

So there's two kind o distinct parts of perimenopause.

There is the, the part toward the end where women are starting to skip periods and having those hot flashes and night sweats.

And I think that's what we all consider it to be more traditional perimenopause.

But the earlier phase of perimenopause really can be characterized by feeling like you're almost a teenager again.

So a lot of the same symptoms, your hormones, when you're going through your teens are really up and down, and that's designed to hel to get your ovaries to ovulate.

Healthy eggs.

And the same thing is happening in your 40s.

Your hormones are going crazy trying to get the ovary to ovulate a healthy egg.

So it's a very similar typ of symptoms that we see so often heavier, more painful periods, periods that are irregular but maybe even getting a little closer together.

Acne, mood changes, bloating, weight gain, feeling all of those PMS type symptoms is really characteristic and classic for that early phase of perimenopause, and that can feel really frustrating, right?

You've gone through your whole reproductive life and you're pretty used to what your cycles are like, and then you get into this period of time where it almost feels like you don't have control over your body anymore.

It's just doin all of these crazy things.

So.

So yeah, it can be very frustrating.

So I would think like when the periods change, the second phase of perimenopause is when you should really alert your doctor.

But do most women say, hey, I have acne.

Like, is there anything you can do to help with that?

Yeah.

Or the really, really good question.

And I would say that the majority of the tim when women are coming into us, to talk about menopause, it's really more of those hot flashes and night sweats that are driving those conversations.

Right?

Those are the things that really are so impactful in your life that you can't go to work.

You're calling out sick.

You can't do your activity.

Your normal activity is you can't travel with your family, right?

So those are the things that that really kind of push people to come in.

But what I think is really important in this conversation is understanding that there are things we can do about those symptoms earlier in the transition.

Yes, we can treat acne, w can treat perimenopausal acne, we can treat some of these cyclic mood, symptoms that women have.

We can treat some of the menstrual irregularities.

So I do think it's worth coming in to discuss those symptoms, particularly if they are having a significant impact on your life.

We have I think, told women for a long time that there's not muc we can do about those symptoms.

And what we have learned over the past 15 or 20 years is that actually, there are things we can do, as a really hearing our patients, understanding what they're going through and then helping to offer solutions, I think is so important.

Okay.

So when does the hormone replacement therapy conversation happen in perimenopause or after that ten years when the menopause sits in a menopause means you're no longer having any periods, right?

Correct.

Incorrect.

So historically, and I would say maybe 20, 25 years ago, our approach was to say that women really should be considered candidates for hormone replacement therapy as their periods are ending.

So really that, that early phase of I'm done having periods, I'm really debilitated with hot flashes and night sweats, and I need something to kind of bridge bridge me until those go away.

Over the last 20 years or so, our understanding of what hormone replacement therapy can offer for women in the earlier phase of perimenopause, when they're still having periods, really has expanded quite a bit.

And we now recognize that some of these hormones really can hav a tremendous impact for women, even if they are still having the spontaneous periods.

So definitely something to conside and talk with your doctor about because there are treatment options.

You know, I it I don't want to say it's controversial, but either you do or you don't go that route and you have a firm belief on either side.

Why is there such confusion over over what hormone replacement therapy is?

And some people just stay away and some people cal as soon as they can.

Yeah, yeah.

So, this really is a historic, historical conversation.

Related to what we've known about hormone replacement therapy over the years.

So back in the 1980s, 1990s, hormone replacement therapy was pretty common.

So women were being started on this, these medications, they were kind of deemed the fountain of youth.

So a lot of women would go on them just because their doctor said, this is going to make you feel really good.

And then a study came out, in 2002 called The Eye Study.

It actually was a study that was started and, ended early because of so much concern related to cardiovascular disease risk for women and breast cancer risk for women.

This study had included a broad range of patients, from their 40s, all the way up into their 60s and even their 70s, who had been started on hormones.

Importantly these were synthetic hormones.

These were not bioidentical hormones.

And at the time that that study came out, doctors said enough, we're stopping this.

There's too much risk.

And everyone was taken off their hormones.

So a lot of the concern around hormones really stems from that study that came out and really kind of turned the table on how we were treating women with hormones.

Unfortunately it turns out, on reevaluation of that data that came from that study.

That wasn't the whole story.

So because we were using synthetic hormones and because we were starting women on them much later in life, that really skewed the data.

So women, we found that the women who were getting these cardiovascular issues, and some of the increase in breast cance really stemmed from being older.

So these were women in their 60s and 70s, and it doesn't really make sense to start women on hormones in their 60s and 70s, because that's not when they'r going through menopause.

Right?

Right.

So subsequent data really showed that if we were starting women on hormones around their late 40s, early 50s, in fact, that got rid of all of the cardiovascular increased risk, if we were using bioidentical hormones especially applied transdermal.

So as a skin patch, we could get rid of all of the blood clotting risk.

All of a sudden it became much more favorable to be considering starting women on these on these hormones.

We also understand that there are some, some good, longevit benefits for women on hormones.

And this has been newer research, research showing, reduced risk of, of colon cancer, reduced risk of osteoporosis, potentially reduce risk of cardiovascular disease, and potential cognitive benefits long term.

And so we really have kind of flipped our thinking on this and are much more readily offering hormones to women.

That really, though, explains wh we have two subsets of patients, some that that really feel lik these hormones are pretty risky and some that are like, you know, based on newer data, we should we should be off.

So talk to your doctor.

Right.

If you do have a history of cardiovascular or any breast cancer, talk with your doctor.

Everyone is so different.

I want to talk about what is showing these are positive impacts.

Estrogen is the big thing that we're losing right as we age.

And estrogen has a really important protective factor for many different areas of our body.

Let's talk abou when you're taking the estrogen, part as part of your home, replacement therapy.

What it does to help you.

Yes.

Yes, absolutely.

So, estrogen, as you are going through that perimenopause and menopause time frame is just kind of gradually dropping here.

And as you get to your your last menstrual period, it kind of plummets.

And then it's going to stay pretty low for the rest of your life.

Estrogen does have protective effects throughout your body.

There are, demonstrated protective effect on the cardio vascular system, on th the brain and neurologic system, certainly on your bones.

We know that that estrogen plays a tremendous role in maintaining bone health.

There's there's dat about reduction in colon cancer, which would indicate that there is some improvement in, in, GI health as well.

Your musculoskeletal system.

So being able to maintain lean muscle mass and your metabolism, those type of things are all really impacted by estrogen.

So there is really a significant benefit to considering replacing this estrogen that is going down here with, with estrogen that we are delivering throug generally a transdermal patch.

Important to note that we are now using bioidentical, hormones for virtually everyone.

Does that mean.

Yeah So they're plant based hormones.

Okay.

That synthetic estrogen that they used in that study that that showed all of that concerning data initially, is a synthetic estrogen, it's conjugated equine estrogen, meaning meaning that it comes from pregnant cow or sorry, pregnant horse's urine.

Which is kind of a strange source, right?

I think, yeah.

It doesn't feel good for people to be taking that.

But, bioidentical estradiol, which is plant based estrogen is what we use now.

So this is this is the estradiol.

It's very similar to the estradiol that is circulating through your body, and seems to be better tolerate.

And it uses patch, not a pill, not a pill.

So we can treat women wit bioidentical pills, but they're.

Because the pills have to be metabolized through the liver, it increases your risk of blood clots.

So in every woman that can tolerate the patch, they don't have any issue with with the adhesive or anything like that.

We try to use the patch.

Okay.

So is there any risk to our heart if we don't take estrogen?

I mean, could it is there.

We are just creating problems for ourselves.

Great.

Great question.

So the data on cardiovascular protection is not there yet okay.

You're just not at a place where we can say faster, gene is going to reduce your risk of cardiovascular events.

There's some pretty compelling data out there to suggest that that might be the case, but we're not really at a place where we're using hormone replacemen therapy as primary prevention.

Got it.

And we start you on it wit the intent to reduce that risk.

I'm curious too, about there are so many products.

So people who don't want hormones, bu they want some kind of balance.

And you go online and you scroll and you see the quizzes you can take, and you can see the creams and the powders and the diets and also certain times of a day to exercise.

It will help your hormone imbalances.

What do you take from away from.

Those are disease patients.

Let come let me talk with you.

Yeah.

This has been a really challenging piece of it being a menopause provider.

In the age of social media, right?

Yes.

I would be everyone claims to be an expert, and there's reall no way for women to confirm that what the information that they're getting is accurate.

And it can be pretty frustrating, right?

This is a population of patients, of women who are pretty desperate.

They are feeling bad.

They want to feel better.

This ad is claiming that it's going to help them to feel better.

And so they they are willing to to purchase that product and try it out.

The problem is is that most of those products do not have reliable data.

The any data that they are putting out there is data tha they have produced themselves.

This is not, you know, journal publications and FDA approval and all the rigorous process that goes with that.

It doesn't mean that some of these products can't make you feel better.

And certainly there is a significant placebo effect.

But I think it's important to know that they are not a replacement for the conversation with the provider and the and the, review of options that are clinically shown to improve your symptoms.

The other thing that I think is really interesting, a study was done not too long ago looking at marketing and what's out there for women, for menopause, you know, on online and on social media.

And u to 66% of everything that is out there is actually non evidence based.

It's predatory.

And it's designed to make a profit.

So women are getting information up to 66% of the time.

That really is not giving them what they want, which is actual meaningful information and solutions.

And we're all clicking on it.

Yes, all of us are.

Oh my gosh.

Okay.

So we need to have more information, right.

And you have a doctor that you can go to, you know, once a year or call on.

But something great with Intermountain Health is you have now expanded care to have menopause specialists who can meet one on one with patients.

Why, how how do you find these people?

Yeah.

Great question.

So we realized at Intermountain, maybe about five years ago or so, that we had a disconnect in what we could offer women for menopause care.

Many of u who trained in the era that post II study, which again came out in 2002, really were training in and in an environment where we were saying no to hormones, right?

We were saying, unless you're really, really debilitated with these symptoms, you're safer not taking them.

And so as the data has shifted and we've got these, these physicians and, and apps out there who are very well-meaning are telling patients what they learned.

And it turns out that the data has has really evolved.

And so being able to keep pace with that and have providers that are really well versed in what the data shows today, not what it showed 10 or 15 years ago, but what does it show today so that we can meet patients where they are?

It's really important.

And I think many women out there can identify with going in to see doctor or nurs practitioner, a Pas or a midwife who they really like and respect, but who just seems like they don't have the training or the backgroun to be able to tackle this topic.

Again, not those providers faults.

They trained in a time where we didn't get that information, and there are other areas in the practice that they have to focus on.

Exactly, exactly.

But how can we meet the needs of that patient population without having them go to click on social media and getting their their information?

There.

So we really took an innovative approach to this to say, let's get providers certifie through the Menopause Society, which really is the gold standard for for training and education to tackle perimenopause and menopause.

Let's get those folks certified.

Let's get, a certified practitioner in every one of our Women's health clinics so that when a patient calls and says, I'd like to talk to my provider about menopause, we have a place to put that patient where we kno they are going to get good, high quality evidence.

It also takes the pressure off the providers that maybe don't do as much menopause.

And so they don't feel, you know, so, so, challenged and frustrated with these patients coming in asking questions that they don't know the answers to.

So it has been lovely because we have got, patients that are able to come in, they feel like, right off the bat, this is someone that understands exactly what they're going through.

We take longer time for those appointments.

So this is another thin that I think is super important.

When you go in to see your doctor to talk about these concerns, if you only have 15 minutes to get through this whole thing, forget it.

It's going to take 15 minutes to tell them all the symptoms you've been having.

Right.

And so and you really want to understand, right?

I think it's important for patients to really dive into these questions around what are the risks.

Right What are my long term benefits?

Is this something I'm going to take forever?

Is this something that I can take short term?

What's the impact of the different dosages?

Right.

Lane.

What's the impact of something like testosterone or wha if I'm struggling with weight?

What do I do about that?

There's just so many question that come as part of this topic that we really want to make sure patients have time to, to have those conversations.

So that's good.

We, we allocate 45 minute for that initial consultation, which makes patients really feel feel seen and heard, and they leave feeling like they have learned a lot.

And that's great because like what your experiences and what your friends experience.

Absolutely.

My mother says nothing happened to her so she doesn't remember.

So it's just hard.

You need to talk with somebody who gets it.

Yes, that really gets it.

You mentioned how long you could be on this therapy.

Is it for the rest of your life?

You know, because you worry about like, you know, aside from, you know, that I guess you won't have acne anymore after menopause.

But if you're if you're worried about the energy, if you go outside.

But yeah, how do you wean off it or do you win off the hormone appeasement.

Yeah.

The answer is it depends.

Hormone replacemen therapy is a really personalized conversation, and it's going to look really different for each individual patient.

What I personally d when I'm working with patients is to understand what their priorities are, what are their symptoms, what are their risk factors?

For example, do they have a family history of significant cardiovascular disease, a family history of breast cancer?

Do they have a personal history of cardiovascular disease?

So understanding all of those nuances about the individual person and then having this conversation about next steps, there is some data that staying on these hormones long term.

Is is a reasonable choice.

For som it can have a protective effect, as we said, o multiple different body systems.

And so for a patient who doesn't have any of those risk factors and who has been counseled about the pros and cons, absolutely.

They can choose to stay on these medications.

I have some women in their in their 90s still on hormone replacement therapy.

And every year they say you can pry these hormones out of my cold, dead hands.

I'm going to keep taking them because I feel great.

Right?

And we should not to deny tha from patients who who really are feeling great and doing well on their hormones.

On the flip side, if we have someone who is who does have those risk factors or who does have concerns around staying on these hormones long term, the conversation can look different.

Those hot flashes are night sweats that are most debilitating, usually last 3 to 5 years.

And so for a patient who is who is struggling with those, we can keep them on the hormone for a shorter duration of time and then trail them off.

And if the hot flashes and night sweats have gone away and they feel pretty good that's fine to stop the hormone.

So it really depends.

And is is a personalized decision based on understanding the patient's risk factors, their goals and then offering them options.

So there's some trial and error just trying to figure out what works best.

Yep.

But on the most part you're going through these hormonal changes for ten years.

Yes okay.

All right.

As I'm you know.

But at least now we're talking about it.

At least you're explaining that there are treatments and there are very different kinds of.

True.

We talked about estrogen.

There are other hormones too, that come into play depending on a certain pregnant woman's, you know, knees or what she wants to accomplish.

Yeah, absolutely.

I think the message really should be one of hope.

We've got so many options to treat women, and we spent a lot of time talking today about hormones.

But there is a whole host o non-hormonal treatment options.

So if we've got patients who maybe have breast cancer or who have had a cardiovascular event and they really still want treatment for these things, absolutely come in.

We have got options that are hormones.

We've got options that are not hormones.

There's actually some really good options nowadays that are then non-hormonal.

And so really everyone should have an opportunity to talk about their symptoms, understand what the treatment options are and then have access to those options.

Okay.

And one thing that we can do as women, you know I have the weight gain is hard for a lot of people.

And there is something we can do that evidence shows that if you're going through menopause, do what?

What is best for exercise?

Lifting heavy weights, right?

Not so much treadmill or elliptical anymore.

Yep.

Yeah.

The data really shows that.

In fact, if you are going all out with cardio, that is going to rev your appetite and it's going to make you crave carbs and you're going to eat those carbs and you're going to maybe und the hard work that you just did.

So as wome who grew up in the 80s and 90s where the mantra was cardio, cardio, cardio, right?

This is takes a little bit of of a mind shift change to say, maybe it's not cardio, maybe it is weight lifting and lifting heavy weights to help build that lean muscle mass.

The other thing that I think is really interesting is back in the 80s and 90s, right?

We all remember hearin don't lift heavy weights, right?

No one wants to bulk up.

You don't want to look like a big old bodybuilder.

It turns out women do not have the hormone composition to even look like that.

If you lift heavy weights so it is okay to lift heavy weights, it's going to make you look lean and toned.

But more importantly, it's going to drive that building of lean muscle mass, which is going to help metabolically so that your, your body is, is burning a many calories as it can for you so that you're not having that weight gain.

And that helps with the bones, too, which are already, you know, you have to worry abou because you're losing estrogen.

So yeah.

Okay.

So ever since I first met you, I've been like trying to lift more.

Okay.

So what have we not touched on?

Because I feel like you've thrown a lot of information about the symptoms, but not to be scary to inform us and to let us know that there are now resources.

There are people.

Okay, I have a question.

What?

How do I make an appointment to see somebody?

One of the certified menopause specialist.

Yeah.

So it's separate from a regular annual visit.

Yep, yep.

Exactly.

So, a couple of things.

Number one, obviously, if you're in the Intermountain system, this is pretty easy.

You call any of our women's health clinics and they're going to have a menopause specialist available to book U.S, for women outside of the Intermountain system or for folks who maybe are watching from a place that is not right here in Denver.

There is a website through the Menopause Society where you can search for menopause certified practitioners in your area or through your insurance.

So, this is a database where they keep tabs on all the people who have passed the certification exam and who have this additional expertise finding someone on that list to see specifically for these symptoms is my best advice.

It will get around that problem of showing up for your appointment, thinking that you're seeing someone who really can help with these problems, and maybe speaking to someone that just doesn' have that additional education.

So starting with that list and finding a practitioner there is really the best advice.

That's good.

I did do some research before I met with you today, and there are other people you know that are I don't know if they'r with the Menopause Society, so we just have to do our research.

You do.

Right.

And then we're going to find that right person that's going to help us through this.

Yep.

I feel like you have offered some help.

We were not we're not in a tunnel going downward.

There is definitely things that are going to not only help us feel better, but also maybe help our body in general.

Yes, I am really optimistic about where we are in women's health right now.

I think 20 years ago this was a little bit more hopeless, right?

It was we can't treat you with hormones because they're dangerous.

And so you're just going to have to live through this.

This is a new day, right?

We have really come around to understand so much more about the impact of hormones and their ability to help treat women through this midlife period of time.

They're in their 40s, their 50s, their 60s.

And so I'm really, really excited about where we are.

Right now.

And I would jus absolutely offer hope to women if you're having symptoms, if you're struggling, make an appointment, come in, let us help you.

Okay, doctor.

Katie, thank you very, very much for joining us.

So we appreciate it.

Yeah, absolutely.