- [Narrator] "Your Fantastic Mind," brought to you in part by Dennis Lockhart, in memory of Mary Rose Taylor.

And by... (upbeat electronic music) (upbeat electronic music continues) - Welcome to "Your Fantastic Mind."

I'm Jaye Watson.

This week we are focusing on menopause, a natural, inevitable part of aging.

85% of women report that menopause symptoms impact their lives, sometimes dramatically, but most of those women never receive help for their symptoms.

So this week we are looking at the science of menopause, what is happening in our brains and our bodies, and how it can impact our health and our day-to-day lives.

We're going to examine the safety of hormone treatment and non-hormone treatments that can address menopause symptoms, and will provide resources, so that you can get connected to expert help.

And as you're about to meet them, thank you to the women willing to share their menopause journeys with us for this episode.

(upbeat electronic music) (soft music) Four women at different ages and stages in perimenopause and menopause, what they have in common?

Symptoms that have disrupted their lives, that have impacted their jobs.

- I've always been, like, hyper functioning, and now I just... (chuckles) I just don't.

- [Jaye] Their marriages.

- It's gone.

The drive is, like, no libido.

It's like (clicks tongue), like, plunged.

(hisses) - [Jaye] Their self-esteem.

- I've lived for the past 10 years in heavy sweats and leggings.

- [Jaye] Their mental health.

- Is this the next 10 years of my life?

Am I ever gonna feel, like, normal again?

(soft music) - [Jaye] The National Institute on Aging defines menopause as, "A point in time 12 months after a woman's last period."

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

The years leading up to that point are called the menopausal transition or perimenopause.

Perimenopause most often begins when women are in their 40s, and can last anywhere from a few years to 14 years.

During perimenopause, the body's production of estrogen and progesterone, two hormones made by the ovaries, fluctuates greatly.

- The perimenopause and menopause transition, we call, is kind of the estrogen stock market really.

You've got estrogen fluctuating up and down, and that can also be accompanied by symptoms.

- [Jaye] There are dozens of symptoms related to menopause, and a lot of what happens is playing out in women's brains, which have been bathed in estrogen since puberty.

When estrogen levels begin dropping, a constellation of symptoms can appear.

(soft music) Some of them: hot flashes, night sweats, weight gain, sleep problems, depression, anxiety, vaginal dryness, painful intercourse, joint and muscle pain, heart discomfort, forgetfulness, brain fog, decrease in sexual desire, bladder problems.

Many of the symptoms have been distilled into the Menopause Rating Scale, a standardized globally used tool to assess menopausal symptoms.

We read the scale to the women in this episode, and each of them discovered symptoms they assumed were part of getting older, not thinking they could be connected to menopause.

Sleep problems?

- Yes.

- [Jaye] Feeling down, sad, on the verge of tears?

- Yes.

- [Jaye] Feeling nervous, inner tension, feeling aggressive?

- Yes.

- Anxiety?

- Oh, yes.

- [Jaye] Inner restlessness, feeling panicky?

- Yes.

- [Jaye] Decrease in concentration, forgetfulness?

- Yes.

- [Jaye] Sexual problems?

- Yes, yes.

- Change in sexual desire and sexual activity- - Yes.

And satisfaction?

- Yes.

Bladder problems?

- Yes.

- [Jaye] Difficulty urinating, increased need to urinate, bladder incontinence?

- Yes.

- [Jaye] Dryness of vagina, sensation of dryness, or burning of the vagina, difficulty with sexual intercourse.

- Yes.

- I didn't know that there was anything other than hot flashes and missed periods.

- [Jaye] Joint and muscular discomfort, pain in the joints.

rheumatoid complaints.

- Yeah, yeah.

- [Jaye] Hot flashes, sweating, episodes of sweating.

- Yes.

- [Jaye] Heart skipping, heart racing, tightness.

- Yes, and I had no idea that was related.

(cupboard door thumps) - [Harriett] My cycle was so bad it started to interfere with my life.

(water sloshing) - [Jaye] Harriet Hall's menstrual cycles were so difficult during perimenopause in her 40s that she couldn't leave the house, even for work.

- I had to literally stay by the bathroom, because I couldn't.

Every month at work, I had to take two days every month.

The first two days I had to be off work.

I couldn't even go to work because it was just that bad.

- [Jaye] Hot flashes and night sweats became the norm.

- [Harriett] I was like, "Okay," but then I was like, "Is anybody hot in here?

Am I the only one?"

- [Jaye] There's something called the Menopause Scale.

- Mm-hmm.

- [Jaye] When we read the Menopause Rating Scale to Harriett, it was the first time she learned anxiety was a symptom.

- Oh my God.

I'm blown away.

So if I look a little distorted... - [Jaye] Harriett says her anxiety appeared out of the blue at 45 years old, the height of her perimenopause.

She said doctors never told her it was a common perimenopause symptom.

- Mm, I couldn't point to a reason.

Still to this day, sometimes I sit and I try to think about, "Did I do something?

What happened?"

- [Jaye] At 52 years old and now in menopause, symptoms continue, including hot flashes, decreased sexual desire, and painful intercourse.

- And it does affect the marriage and the relation...

It does, 'cause I'm like, I know...

I mean, I used to be a fireball, and now I'm like a little cold little... A cold little snowball (laughs).

(soft music) - [Jaye] Research shows women of color tend to enter the menopausal transition earlier, and that it can last longer, and they can experience more intense symptoms.

It's been estimated anywhere from 27 to 84% of postmenopausal women experience urogenital symptoms.

Less estrogen makes your vaginal tissues thinner, drier, less elastic, and more fragile.

This can lead to vaginal dryness, vaginal atrophy, decline in sexual desire, and painful intercourse.

Low-dose vaginal estrogen can help, as can various lubricants and moisturizers.

(soft music) One survey of over 3000 women found that vaginal atrophy symptoms led to loss of intimacy for 85% of women.

59% said it interfered with their relationship, and 27% said it adversely affected general enjoyment of life.

(soft music continues) As for Harriett's out of the blue anxiety, 45% of women experienced psychological symptoms.

These include anger, irritability, anxiety, tension, depression, sleep disturbance, loss of concentration, and loss of self-esteem or confidence.

The cause, once again, declining estrogen levels.

Psychiatrist Dr. Toby Goldsmith is the Director of Emory Women's Mental Health Program.

- Estrogen has antidepressant benefits.

It works as a monoamine oxidase inhibitor.

We have a whole class of medications called monoamine oxidase inhibitors, and what they do is they increase the availability of neurotransmitters.

Estrogen decreases, and then the next thing you know, an individual's neurotransmitters are decreasing.

(soft music) - [Jaye] In the brain, estrogen has an effect on different neurotransmitters, such as serotonin, a mood regulator known as the happy chemical, and dopamine, known as the feel good hormone.

So when estrogen declines, it loses its regulating effect on the brain and central nervous system.

A German study reports the amygdala and hippocampus have more receptors for estrogen and progesterone, so those areas are impacted by their absence.

Researchers say these two areas of the brain are most actively involved with anxiety.

The artistry of a beautifully decorated cake given as a gift brings happiness to 52-year-old Lisa Laposata.

In her busy life as a wife and mother, she has hidden from most a decade-long struggle.

- That was my outward thing that said things aren't okay, and that's why I had such a hard time with that, because all my life I've been, you know, I work out in the gym, and try to eat healthily, and those things didn't work anymore.

And that was very, very hard for me.

- [Jaye] An avid exerciser and healthy eater, Lisa gained weight in her 40s during perimenopause, the majority of it in her breast.

- All done.

When I went to my doctor and discussed that, and they had just sort of said, you know, "It's just the process.

It'll be fine."

They didn't have any solutions for how to stop it or to make it better.

Oh, absolutely.

- [Jaye] No matter what she did, nothing worked.

She hid in baggy clothing.

- I've lived for the past 10 years in heavy sweatshirts and leggings.

(soft music) - [Jaye] Approximately 20% of women experience an increase in breast size after menopause.

As estrogen levels drop, breast go through a process called involution, where milk glands shut down and the tissue is replaced by fat.

Excess fat tissue from other parts of the body can be redistributed to the breast.

One study found larger breasts have a significant impact on a woman's body image and satisfaction.

In Lisa's case, the impact on her life led her to make a decision.

- It got so out of hand for me that, actually, last fall, I had a breast reduction.

- [Jaye] Lisa says the surgery was the best decision she made.

Just at the one year mark without a period newly in menopause, Lisa is hoping the symptoms subside.

- I always was thinking it's the perimenopause that was really the hard part, you know, it started slow, it got worse, worse, worse, worse, and then you come to this peak, and then it's like, okay (puffs), you know?

And I'm hoping for this (puffs).

- [Dr. Taniqua So tell me what's bringing you in today?

- [Jaye] Weight gain is one of the most common complaints among women in menopausal transition.

Muscle mass typically diminishes as we age, while fat increases.

Losing muscle slows the rate at which your body uses calories.

Gynecologist, Dr. Taniqua Miller.

- As we go through menopause and those estrogen levels decline, we start actually seeing more of, kind of like a male form body, where we start getting a little bit more fat deposition in the belly.

Why is that significant?

It makes us more insulin resistant.

(upbeat music) - [Jaye] During perimenopause, your muscle, liver, and fat cells slow insulin processing, sending your pancreas into overdrive to get enough glucose to your cells.

This can make us feel hungrier.

And when we eat, we are more likely to store the carbohydrates as fat, because our bodies don't break down carbs and sugars at the same metabolic rate that they used to.

- Increased abdominal circumference definitely is linked to something called the metabolic syndrome.

Increases your risk for cardiovascular and cerebral vascular disease.

- [Jaye] In addition to a healthy diet, the Department of Health and Human Services recommends 150 minutes of aerobic activity each week, and that menopausal women strength train twice a week.

This will help to build bone and muscle strength, burn fat, and up your metabolism.

- We're gonna do cheese.

You've gotta have some protein.

It's Parmesan, buddy.

Gray is the joy of my life, and he is such a gift, and, you know, I'm just so lucky to be his mommy, but he's also a lot.

He has a lot of energy.

He's nonstop.

- Look at all the papers!

- I was shocked when I found out I was pregnant at 43.

We're gonna be leaving pretty soon.

- [Jaye] Now, 49- - Climb up in.

- [Jaye] Jennifer Felton is juggling some massive life changes.

She is going through a divorce and dealing with debilitating symptoms from perimenopause, all while parenting a very active five-year-old.

- Frankly, today is one of, like...

It is on...

It's like blinking today.

I have all the symptoms times 10.

(car engine roaring) A lot of brain fog.

I feel anxious today, and it's just that.

I mean, I can tell it's not...

This doesn't make me nervous.

It's just anxiety just kind of just hanging out there with no explanation.

- [Jaye] As the oldest mom in her son's preschool class, Jennifer does not talk about her symptoms with younger mothers, and in discussing it with us, one of her struggles, finding words, shows up.

- It's like it gets the...

It's that, you know...

There's that word thing, it's...

I can't even think of the word.

I honestly cannot even think of the word.

Yeah, stigma.

That's what it is.

You can't talk about it.

I try to think of ways I can say it, like, "I'm just, oh, I'm having a... You know, it's just kind of a crazy day or whatever."

But I think it just comes out as, for me, and I'm very self-aware of it, it comes across as, like, just, you know, ditzy, or flighty, or flaky, or any of that, you know, disorganized, and all those things.

- [Jaye] Jennifer has worried if her cognitive issues were more serious.

- So significant that I actually was, like, concerned, "Do I have early Alzheimer's?"

(upbeat music) - [Jaye] It's normal for declining estrogen levels to impact memory and concentration, and the various symptoms usually improve once the menopause transition is complete.

(upbeat music continues) Alzheimer's disease is the only neurodegenerative condition that affects women more than men.

For a long time, it was assumed it was because women live longer.

But a study from Weill Cornell published in neurology found that the hormonal shifts with menopause can increase the risk of brain changes associated with Alzheimer's disease.

The study found that women in midlife had 30% more Alzheimer's related plaques than men of the same age.

Women also had 22% lower brain glucose metabolism, meaning lower energy levels in the brain, and about 11% brain shrinkage.

These brain biomarkers were associated with menopause.

The studies showed women who took hormone therapy had fewer negative brain changes than those not taking hormones.

And researchers said larger studies are needed to understand the influence of hormone therapy on the brain.

(feet patter) - I had such bad, horrific menstrual cycles my whole life that it was a relief, and so I didn't bother googling anything, 'cause I was just happy to be done with that.

- [Jaye] What 58-year-old Kimberly Krautter didn't realize is what would replace her difficult menstrual cycles would be just as unwelcome.

The grocery store is where she had her first hot flash.

- It just all of a sudden, from head to toe, it felt like I was radiating heat, and I was sweating.

I was flop sweating.

It was so miserable that I literally went down the frozen food aisle, and I opened every single door, and I was like, "Do I need frozen peas?

No.

How about lima beans?

No.

What about frozen pizza?"

Now it's, you know, the five phases of death just to get out of bed, and it's the slow sort of ambling about, and feeling like, "Okay, where am I?

What do I need to do?

Who do I need to call?"

Even though I have it written down, it's almost like the brain cells aren't connecting.

- [Jaye] A longtime strategic communications consultant, Kimberly talk to her doctor about her night sweats and hot flashes and brain fog.

- But she was just like, "Well, you're just going through menopause."

There was nothing other than, "Well, that's what's happening.

You know, get a lollipop on the way out the door."

- It was the same when Kimberly's mom was going through menopause.

- Your doctors didn't talk to you about it, and they didn't talk to me about it.

- It's really kinda sad.

- It is sad.

(soft music) - [Jaye] Approximately 75% of women experience vasomotor symptoms, which include palpitations, hot flashes, and night sweats, which are also known as nighttime hot flashes.

Hot flashes happen when decreased estrogen levels cause your body's thermostat, the hypothalamus, to become more sensitive to tiny changes in body temperature.

When the hypothalamus thinks your body is too warm, it sets off an exaggerated response to cool you down.

The hot flash.

In those with moderate to severe symptoms, hot flashes can persist for a decade or longer.

- You can't sleep, you're embarrassed, you know, a lot of women are kind of at the height of their career.

They're already going through all these other changes.

You know, they may be becoming empty nesters, they're taking care of aging parents, they're kind of that sandwich generation, and then their body is going out of control and it's scary and it's depressing.

- [Jaye] Menopause is impacting the workplace.

A 2014 review of health insurance claims for more than half a million women found that untreated hot flashes cost patients and their employers $340 million a year.

Women with hot flashes made one and a half million more outpatient visits.

A study out of the UK found that nearly half of over 4,000 women, 45 to 55, surveyed, said menopause symptoms made their jobs more difficult.

41% said it was treated as a joke by people at work.

14% said they reduced their hours, while another 14% went part-time.

8% did not apply for a promotion.

Another survey of 3,800 women found 59% had taken time off work because of symptoms.

(soft music) - I think the biggest misunderstanding is that there's nothing you can do about it.

That you just have to kind of suffer through it.

(soft music continues) - [Jaye] Gynecologist Dr. Mary Segars Dolan opened the midlife and menopausal women's clinic at Emory in 2016.

- And are you sleeping okay, or?

- [Jaye] Every day she sees patients who have been living with symptoms that have impacted their lives for years.

- I think a lot of people come to me that have been either told there's nothing they can do, they need to suffer through it.

They've been given, you know, treatments that were not helpful, and I think they kind of felt like they've been dismissed.

- Have no had one- - [Jaye] Indeed, the women in our episode were never offered any treatment or help for their symptoms.

- I remember almost being in tears in front of my gynecologist, and saying, "There has to be something else that can help me.

You know, this is just too much.

It's overwhelming.

And there was...

I mean, there was...

It was not only the lack of answer, but it was the flippant attitude about it.

And I just felt just ignored.

- Mm-hmm.

- One of Dr. Dolan's frontline treatments, when appropriate, is hormone replacement therapy.

Something none of the women we spoke to were ever offered.

(soft music) Estrogen hormone therapy started in the 1960s, and by 2002, a third of all women, 50 to 74 years old in the United States, 14 million were on hormone therapy.

Today only a small percentage of US women take hormone replacement therapy.

And the reason can be traced back to 2002 and the release of the Women's Health Initiative, the WHIA, a billion dollar study to see if hormone therapy prevented heart disease, the risk of which goes up after menopause and is the leading cause of death for women.

The study was stopped prematurely after the Safety Monitoring Committee found breast cancer and stroke incidents was higher in women using estrogen and progesterone after five years of use.

Women who'd had hysterectomies and were on estrogen only did not have increased incidents at five years.

The result, women on hormone therapy plummeted, doctors stopped prescribing it.

In the 20-plus years since its release, the WHI has been repeatedly examined, debated, and analyzed, and what emerged added context to a study that frightened millions of women.

The average age of women in the study was 63.

Most were more than a decade past menopause when they were put on hormones for the study.

- [Jaye] There was another cohort in that study called the Young Cohort.

These were women that were within the first five to 10 years of their menopause, and they too were started on it, and what they found in that group between the 50 and the 55-year-olds, they actually had long-term cardiovascular benefits, as well as some neurocognitive benefits.

(soft music) - [Jaye] Basically there's a timing hypothesis that there is a window of time in which your body will take the hormones and stay and be healthy and not have issues.

But once you age and your body changes, because it's not getting hormones, it becomes more risky.

The North American Menopause Society says, "For women aged younger than 60 years, or who are within 10 years of menopause onset and have no contraindications, the benefit risk ratio is favorable for treatment of bothersome vasomotor symptoms and prevention of bone loss.

Beginning hormone therapy more than 10 years from menopause presents greater risk, like those found in the study.

A Harvard study, 15 years after the release of WHI, found no increased risk of death from all causes associated with hormone use.

(soft music) Today, hormones are formulated differently and there are new methods of delivery like transdermal patches and gels.

As with any medication, there is still a risk.

Dr. Stephanie Faubion, the Chief Medical Officer of the North American Menopause Society puts that risk into perspective.

- The risk of breast cancer is less than one case per thousand per year and about three cases per thousand after about five years.

So it's considered a very rare thing, and it's about the same as somewhere between one and two glasses of wine a night, being inactive, or being overweight.

- [Jaye] Women at highest risk for hormone use- - History of blood clot or pulmonary embolism, current history of heart disease, history of estrogen-sensitive cancer, things like uterine cancer, breast cancer.

You know, you've gotta look at the whole person.

- [Jaye] Hormones are FDA-approved to prevent osteoporosis to treat vasomotor symptoms and for genitourinary syndrome, that cluster of vaginal and sexual symptoms.

- We also, believe it or not, have some patients who may have had a history of breast cancer, but have debilitating vaginal dryness.

And with working with their oncologists, we as a collective make a decision to potentially give them back a little bit of vaginal estrogen.

Now, vaginal estrogen is exclusive to the vagina.

It is not a systemic treatment.

And believe it or not, when you measure blood counts of estrogen in these patients, they are very similar to postmenopausal patients who are no therapy.

- [Jaye] Hormones are not the only option for women in menopausal transition.

Physicians use SSRIs and SNRIs, two types of antidepressants to treat mood and even vasomotor symptoms.

Paroxetine, brand name Paxil, is FDA-approved for vasomotor symptoms.

Gabapentin is also used off-label to treat them.

For painful intercourse and vaginal dryness, there are lubricants and moisturizers and vaginal dilators.

For decreased sexual desire, there are Viagra-like drugs, Bremelanotide and Flibanserin, both-FDA approved for women with hypoactive, low sexual desire disorder, which is estimated to impact one out of 10 women.

Other things that can help, cognitive behavioral therapy, mindfulness-based stress reduction, exercise, and weight loss.

- Hey, everybody, it's Angie, and welcome to HotandFlashy.

- [Jaye] Menopause is becoming an industry with wellness companies virtually prescribing hormones or selling non-hormone alternatives, some with little to no sign to support the claims, but it's already a $600-billion industry growing by the day.

- I am not a doctor.

I'm not telling you what to do.

- The perception of hormone therapy persist.

- It's scary, like, it could make it worse.

That's all I know about it, and then when I ask, you know, experts about it, no one has offered that, so I just kind of don't think about it anymore.

- This seems quite irresponsible as a clinician to ignore some pretty devastating, debilitating symptoms.

- [Jaye] And women are not being educated by their doctors, many of whom are hesitant to prescribe them.

- We have a gap in education now for both women and their providers, and we actually did a survey and published it a couple of years ago, looking at family medicine residents, internal medicine residents, and OB/GYN residents, and the fact is that they were telling us they get no more than one to two hours of a lecture on menopause.

This is even OB/GYN residents, and they feel completely unprepared to manage menopause when they get out.

- [Jaye] Half of all practicing gynecologists are under 50, and did their residencies around the time of the WHI release.

In a 2008 survey, 40% of University of Connecticut med students in their third year of OB/GYN studies reported zero menopause training.

A 2017 Mayo Clinic survey of postgraduate residents across the country found that 20% had not heard a single lecture on the subject of menopause, and a third said they would not prescribe hormone therapy to a symptomatic woman even if she had no medical risk.

- [Presenter] So Level One evidence is consistent- - [Jaye] All the experts in this episode are members of the North American Menopause Society, a nonprofit organization with 2,900 members around the country.

Their mission to promote the health and quality of life of all women during midlife and beyond.

This includes educating healthcare providers and providing scientifically accurate information so women can make educated decisions about their health.

(soft music) You can go to their website at menopause.org and click on "Find a Menopause Practitioner" to find an expert in your area.

Dr. Faubion's latest book on menopause comes out soon.

What she discovered in writing it is that the younger generation is not willing to suffer in silence or to be told it is what it is.

- And I can tell you millennials are not gonna put up with this.

And so I think it's going to take women getting incredibly frustrated and saying, "It's not good enough."

(soft music) - [Jaye] It is real, and for millions of women, the impacts of menopause are profound.

Information matters, because if we're lucky, our best years are still ahead.

(soft music continues) - I don't think that it's an insignificant amount of time to live in a menopausal space if you're 30 years postmenopausal.

That is a full lifetime, a lifetime where you wanna enjoy your life, where you wanna make sure your bone health is great, where you still wanna be able to do the things that you wanna do.

You still wanna have healthy sex life, you still wanna be able to, you know, live.

(soft music continues) - To learn more about menopause, go to menopause.org.

There you'll find links to articles and research and frequently discussed topics, along with a link to find a provider in your area.

That's gonna do it for us this week.

See you next time on "Your Fantastic Mind."

(upbeat electronic music) (upbeat electronic music continues) - [Narrator] "Your Fantastic Mind," brought to you in part by Dennis Lockhart, in memory of Mary Rose Taylor.

And by...