Episode 51: What’s Happening in Perimenopause? Symptoms, Hormones, and Real Solutions with Dr. Elizabeth Elkinson

Perimenopause is often the most confusing stage of the menopause transition, with shifting hormones, irregular cycles, and a mix of symptoms that can feel unpredictable. In this episode, board-certified OBGYN and Menopause Society–certified physician Dr. Elizabeth Elkinson breaks down what really happens during perimenopause. We discuss the most common symptoms, how oral contraceptives and IUDs can change your experience, and who may benefit from starting hormone therapy early.

This episode really goes into the details of what’s happening with your hormones—and why those changes cause the symptoms so many women experience. Dr. Elkinson also explains the different routes of hormone administration, the role of testosterone, and clears up common hormone misconceptions.

If you want to truly understand what’s happening in your body and feel more confident advocating for yourself with your healthcare providers, this is a must-listen episode.

Find Dr. Elkinson:

Bluegrass Gynecology and Wellness

For more information on Menopause:

The Menopause Society and MenoNotes

thestartinggatepodcast.com

Email us with questions and topics you want us to cover at
contact@thestartinggatepodcast.com

Follow us on social media @thestartinggatepodcast




The content in this podcast is for general reference and educational purposes only. It is not meant to be complete or exhaustive, or to be applicable to any
specific individual’s medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis or treatment. This podcast does not create a physician- patient relationship and is not a substitute for professional medical advice, diagnosis or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different so make sure you consult your own healthcare professional before seeking any new treatment and before you alter, suspend, or initiate a new change in your routine.

Transcript

What’s Happening in Perimenopause? Symptoms, Hormones, and Real Solutions with Dr. Elizabeth Elkinson

[00:00:00] Before we start today's episode, I would like to quickly read you our podcast disclaimer. The content in this podcast is for general reference and educational purposes only. It is not meant to be complete or exhaustive or to be applicable to any specific individual's medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis, or treatment.

This podcast does not create a physician patient relationship, and it's not a substitute for professional medical advice, diagnosis, or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different, so make sure you consult your own healthcare professional before seeking any new treatment, and before you alter, suspend, or initiate a new change in your routine.

Welcome to the starting day. We're your host, Dr. Kitty Dotson and Dr. Sarah Schuetz. Two internal medicine doctors who spent years practicing traditional primary care. Over time, we realized something was missing from modern healthcare, a [00:01:00] real understanding of how everyday lifestyle choices impact overall health.

We'll help you cut through the noise of the countless health influencers and their conflicting opinions because no matter who you follow, the basics of lifestyle medicine are at the heart of it all.

Welcome back to the starting gate. We're your host, Dr. Kitty Dotson, and Dr. Sarah Schuetz. Well, hopefully you're enjoying this menopause series. As much as Sarah and I are, I think last week's episode with Dr. Degler was really great to just talk about all the mood changes that may be happening in midlife.

And I love how she talked about having the right mindset as you're going through this stage of life. So today we're gonna kind of go back to the beginning of when this happens and really dive in and talk about perimenopause. So if you haven't listened to our episode back last winter with Dr. Deidra Beshear, it was episode 20.

That's a great one, explaining how we got here with the controversy around hormones and some of the common symptoms and basics of [00:02:00] menopause. But today we're really wanting to focus on perimenopause and those years leading up to menopause where it may be more confusing. 

And today we have a special guest to help us.

Understand this better because I know it's really tricky and Kitty and I both did not get a lot of training in understanding perimenopause. So we brought on Dr. Elizabeth Elkinson. She's actually a return guest. She was on our show earlier this year talking about PCOS, but we brought her back on because she is board certified O-B-G-Y-N, as well as certified through the Menopause Society and is helping women navigate this time of life every single day.

She has her own concierge practice here in Lexington called Bluegrass Gynecology, and we just wanna welcome her and thank her for coming back. Thank you all so much for having me back. I'm excited to talk to you all today. To get us started, I think it's best to understand what is going on in a woman's body in perimenopause.

Like how do we explain to [00:03:00] women what that is? 

So I think in order to understand perimenopause, you have to understand what menopause is. And menopause is the loss of the ability of the ovary to ovulate. And that is defined as. 12 months from your last menstrual period. Perimenopause is defined as the time around that transition. It includes an early perimenopause stage and a late perimenopause stage.

Then you have this final period. . You don't realize it's your final menstrual period, and then 12 months later you get to look back and now you've finished perimenopause. You haven't had a period in 12 months. So that transition , is variable depending upon women to women.

And it can last for years. 

And I think because it is so variable is why it is such a struggle for women to understand if it's happening.

Yes. And some of the. Earliest [00:04:00] symptoms of perimenopause even occur before the technical start of perimenopause. So if you look at these, long-term prospective studies that, investigate hormone levels and symptoms that women have like the SWAN study.

Those studies show that the first hormonal change that we experience in perimenopause is actually occurring while our period pattern is still really regular. And that is the result of some decrease in quality of our oocytes and our eggs and our ovary that result in a drop in a important hormone inhibin B.

And that results in an increase in FSH. And so our periods are still really regular because the follicles as they develop, are still producing estrogen. They're ovulating, then they [00:05:00] produce progesterone. But in order for that to happen, there's a need for a little more follicular stimulating hormone. So I think before we get too much in the weeds of what are the hormone changes that cause symptoms of perimenopause, I think we have to back up and look at how does the ovary work to produce hormones, because that is an extremely well orchestrated hormonal pathway that is very important to the way our bodies work and our brains work.

And it's well understood that the changes in that pathway result in symptoms that are really interesting to talk about. But we have to understand how the ovary works first. The ovary produces estrogen and progesterone in a very cyclic fashion.

In order to produce an egg each month when the ovary is in premenopausal [00:06:00] mode, this path is extremely well coordinated with the pituitary hormone, FSH or follicular stimulating hormone telling our ovary to start the production of a follicle. The follicle, develops over about two weeks, and it produces the estradiol.

That prepares the uterine lining to have fertilized egg implant. So the first two weeks of the follicular phase of your menstrual cycle, you're producing estradiol, then you ovulate, and that follicle converts to a corpus luteum And the corpus luteum then produces two weeks of progesterone and.

That progesterone is produced and then drops that results if there's not a fertilized egg that implants in the lining of the uterus sloughing off [00:07:00] and becoming your period. And so every month in this extremely well orchestrated pattern that when you look at textbooks, it looks like little waves in the ocean producing this rise of estrogen, ovulation, rise of progesterone, drop of progesterone, period.

And it's just beautiful and our brains get really used to that. And we know that a woman's brain really likes this regular pattern. And so as we age the pool of follicles that listen to the , follicular stimulating hormone get less. Able to respond to that stimulation.

 Every month that pattern is not as well orchestrated and organized. And one of the changes that happens is you actually have a shortening of the follicular phase. So the phase that the egg is developing because there's [00:08:00] more FSH being produced, that phase is shorter and

as a consequence, the luteal phase of the cycle or the phase after ovulation is relatively longer, and that's one of the reasons they think that mood symptoms occur in women because you have this relative shortening of the follicular phase compared to the luteal phase. So why would that make your mood different?

One of the things we know about the rise and fall of estrogen is that when estrogen drops after ovulation, that withdrawal of estrogen. Can be a trigger for the change in the way our brain produces serotonin. And that can result in a relative decrease in serotonin. And so for women, for example, that have really bad PMS or even the clinical diagnosis of premenstrual [00:09:00] dysphoric disorder, we understand that those mood symptoms are caused by the drop of estrogen.

 I think another time, and another example of when this happens in a women's life is postpartum because in pregnancy your estrogen levels are really high, and then you deliver and those estrogen levels drop. That's another time when women are really susceptible to mood changes. Because this drop in estrogen affects the serotonin levels in our brain.

And so one of the earliest, signs of perimenopause can be this increased anxiety or this increased sort of feeling of mood symptoms. Not feeling quite like yourself, I think is a really classic way that people come in. And that can be caused by the effects of the shortened follicular phase in early perimenopause.

[00:10:00] Another hormonal phenomenon that occurs in up to 30% of cycles in perimenopause is, a wildly fluctuating hormonal pattern, called a loop phase. And that is a luteal. Out of phase cycle. And that occurs when you start to look at the patterns of ovulation being very regular.

Two weeks of secretory phase, two weeks of luteal phase. So two weeks of estrogen, two weeks of progesterone in this beautiful cyclic pattern. when we ovulate monthly, one of the goals of the ovary is to create one great egg each month.

And that is caused by a really important ovarian hormone called anti mullerian hormone. And so in perimenopause. That [00:11:00] anti mullerian hormone starts to decrease. And so the mechanism that our ovary has to just produce one egg a month is not as good. And so when the FSH is recruiting a follicle, AMH is usually the hormone in charge of just saying, Hey, we're just doing this one follicle a month.

So we have a very regulated hormone pattern. And instead in perimenopause is that drops. Even though you've started ovulating and you have a path where one egg is producing a follicle, another primordial follicle will escape the downregulation and the atresia where it usually dissolves and goes away.

And so you'll have a second phase right on its tail. And so that results in these ovulatory events that are really close together [00:12:00] and when that happens, the actual amount of estrogen in each cycle for a period of time that a woman has in their body is actually much higher. And so a loop event can result in two cycles that are almost back to back.

So sometimes patients will come in and they're like, my period is now every 14 days, or every 16 days or something, because the anti mullerian hormone, that usually allows us just one event a month because it's dropping, there is an extra follicular event that's happening right behind the first one.

Sometimes that disrupts the ovulation of the first follicular event. And so you end up with a relatively higher amount of estrogen, but then you don't ovulate until the second. So you have these big gaps in your cycle. And so that results in a high [00:13:00] estrogen followed by a real drop in estrogen and that larger peak to trough of the level of estrogen.

That also causes some of the really significant symptoms that we see in perimenopause, like mood symptoms. 

is someone who experienced say, worse mood changes after pregnancy or had really bad PMS symptoms, are they gonna be more susceptible to having. Worse mood symptoms in perimenopause. Is that something that a woman should mentally prepare for?

Absolutely. 

That is a really important component of assessing someone who comes in with mood symptoms in perimenopause the hormonal changes that are caused by perimenopause can cause one of the first symptoms of perimenopause, which is hot flashes. And [00:14:00] that can disrupt sleep causing insomnia and that disrupted sleep can cause worsening mood symptoms like irritability and then also some increased mood symptoms that feel like depressed or down mood as a consequence of insomnia.

And so when I have a patient who comes in with mood symptoms, one of the most important questions I think we look at is what is your history of mood symptoms throughout these hormonal events in your life? Where you affected by premenstrual dysphoric disorder? Has it gotten worse as you've gotten into your forties?

That's a really common symptom. Did you have postpartum depression and did it need medication? , Did you ever have depression that needed medication? Because , some of the mood symptoms of menopause really overlap with some of the mood symptoms of depression.[00:15:00] 

And sometimes it's difficult to detangle those. so that's whenever you get to the question of how do you treat those mood symptoms? When a person comes in perimenopause and they're having worsening hot flashes, anxiety, insomnia, irritability, like how do you treat that problem? 

if someone is still having their period regularly Can they still be having these abnormal cycles where they're not ovulating or they're double ovulating? Or would that definitely show up with changes in bleeding as well? 

I think that the definition of perimenopause is defined by. Changes in bleeding pattern. And with early perimenopause, we define that phase as the change in menstrual cycles.

There's at least seven days difference in your menstrual cycle. [00:16:00] So that phase of perimenopause is very commonly associated with the loop events that I just described. But even before that phase, people start to have symptoms of perimenopause even before they perceive. These period pattern changes, and I see that a lot in women.

As young as late thirties and early forties that come into my practice. And they really have had either a few months of hot flashes and then all of a sudden they're like, and now I can't sleep anymore. Like I, my sleep pattern is totally disrupted. And that's a really interesting phenomenon. That is caused by a change in egg quality or oocyte quality that results in a decreased [00:17:00] inhibin B, which is an important hormone that helps regulate the follicular stimulating hormone.

And when that happens, you have an increase in the follicular stimulating hormone and that increase in follicular stimulating hormone, which happens in a part of our brain called the hypothalamus. Also affects our sleep wake cycle, and it increases the production of this hormone called orexin, which is the hormone that's a counter to melatonin instead of being the sleep hormone.

It's the arousal hormone, it's the awake hormone. And so a rise in FSH actually results in this rise in this hormone that kind of makes you alert. And so I think that it's being understood more and more that's that pathway of this 40-year-old disrupted sleep. All of a sudden. Remember when you're in your thirties and used to [00:18:00] sleep all the way through the night, and then you get into your forties and it becomes totally normal.

To wake up in the middle of the night and you're like, if you're lucky, you go back to sleep. And if you're hot flashing, you don't, but at some point it was normal to sleep through the night. But because of hormone changes, they think that stimulation or that rise in FSH stimulates the increased production of orexin.

So I wanna make sure I'm understanding this correctly. For our listeners early on, we're seeing the mood and then slowly right behind it is this new insomnia that just pops up, which is gonna exacerbate the mood. 

Heck yes, I totally agree. So.

What trails right behind that 

then I think you see period pattern irregularities.

And I would also like to emphasize everybody's path through this phase in their life is unique. And I think that's one of the hardest things about treating perimenopause [00:19:00] is everybody's experience is different and tolerance of these changes is different. And when they look at these big population studies, it's really interesting.

Like childhood trauma increases , the severity of menopause hormone changes. Life events affect the wiring of our brain also affect the way we perceive these changes as we transition hormonally through perimenopause and menopause.

 We see a lot of people that come in with worsening PMS then changes in menstrual patterns that are the kind of heralding feature of early perimenopause. So I look at those two groups as a group that have. Wildly fluctuating hormones or ovarian dysregulation [00:20:00] as the source of their hormonal symptoms.

Because then as you progress into late perimenopause, which is the two to four years before your final menstrual period, those are the people that start skipping cycles. And so in the two to four years , early peri to late perimenopause, you go from this. Wildly dysregulated, estrogen and progesterone production to skipped periods a lot of times caused by lack of ovulation.

And you can see the rate of ovulation per menstrual cycle really drops in those years from about 50% of ovulatory cycles at three years before the final menstrual period, then about 30% at two years before the final menstrual period, then 20%. And so in those women, you're [00:21:00] gonna have all of these skipped periods, and those women have the symptoms of menopause because of lack of hormone.

And so they feel really crummy because they're having hot flashes. We start to see. Some pattern changes in where we gain weight , in those phases of menopause because of the dropping levels of estrogen. The higher levels of estrogen when we were younger allowed for our fat distribution to be what we call gynacoid fat, which is around our hips and thighs and butt.

And that distribution of fat is a healthier distribution of fat compared to Android distribution of fat, which is that central. Location where all of a sudden we notice belly fat and increasing abdominal girth because of this accumulation of fat. And [00:22:00] it's really interesting because that pathway is understood to be caused by this dropping level of estradiol as our ovary doesn't ovulate as frequently.

And then our ovary continues to make testosterone and androgens and other androgens in its normal level at this phase in our life. And so this change in ratio of estradiol to androgens results in, the change in the location of where we accumulate fat and that change in location can really impact health characteristics because as we know, the increase in central obesity or central.

Fat distribution really impacts our lipid metabolism and our risk of problems like fat accumulation in the liver, fatty liver disease, and also in the [00:23:00] pericardial distribution. And so those are important changes that have cardiometabolic implications of decreased health in perimenopause.

So what about if you have an IUD or you've been on birth control, how do you figure out where you are in this 

phase? That's a great question because I think patients who come in feeling so symptomatic in perimenopause really want a lab test to define what's going on.

And so a lot of patients come in and they want some lab assessment to tell them that they're in perimenopause. And the reality of perimenopause is it's a clinical diagnosis, and so the hormone levels of perimenopause can look. Frustratingly normal. And so when we look at FSH and estradiol and [00:24:00] perimenopause, and I do order it when people ask me for it because I like to help people understand what's going on with their body because ultimately that's gonna help us get to a treatment.

And so when I can show people and I tell them before we get the lab, these labs might look completely normal. And in fact. Most likely they're gonna look really normal and , it doesn't mean that your symptoms are any less, and it doesn't mean that you're not in perimenopause. The other labs that I look at to help characterize what's going on is I look at a thyroid stimulating hormone, and I often take the opportunity to get a hemoglobin A1C, which is a screening test for pre-diabetes and diabetes.

And I do that because thyroid abnormalities can also cause menstrual pattern changes and hormones that can mimic perimenopause and menopause. So I, and it's a common endocrine problem that women struggle with. So I [00:25:00] always exclude that. Or rule it in sometimes. And then I always take the opportunity to get a screening exam in while we can.

'cause I think that actually is really important in the management of some of the problems that we run into in perimenopause. The question of , how do we diagnose this problem in a person who has either a Mirena IUD or an endometrial ablation where we've burned out the inside lining of the uterus in an attempt to treat abnormal bleeding so they don't even have a period anymore.

I do continue to use clinical signs and symptoms. So are they having the mood changes, hot flashes, insomnia, joint pain? Are they having change in interest in sex? Are they having the other symptoms that, that women in perimenopause experience? And then I'll order labs to help see

is she got postmenopausal hormone levels or is she still perimenopause and has premenopausal hormone levels? So [00:26:00] when I give a person their results and we talk about their results, I often won't say Your postmenopausal or your premenopausal. I'll say, Hey, your hormone pattern today when we checked your labs, show me a level of a premenopausal woman.

And that doesn't mean you're not perimenopausal, but that just means you're one of those people that still have wildly fluctuating hormone levels. And that is important. And I try to define it as an ovarian dysregulation because the ovary is still trying really hard. And as when I say the ovaries trying really hard, it's trying to ovulate.

And in order to do that, the pituitary hormone, follicular stimulating hormone or FSH is getting higher and higher. And so when the ovary can respond, it will make loop events. It will have , especially in early perimenopause, [00:27:00] more estrogen than you had when you were in your premenopausal years.

And so that phenomenon of this more estrogen than your body is used to. I think leads to one of those terms that we talked about or this estrogen excess, like what is that? Is that a real thing? And I don't know about you guys, but it's not in medical textbook. They don't define anything as estrogen, excess and medical textbooks.

But we do know that as women are in early perimenopause, their estrogen levels are higher on average, and those higher estrogen levels are causing lots of symptoms. And so I think that's where the term estrogen excess comes into play for people because they'll notice problems like breast tenderness like way more severe than they had [00:28:00] before, or their cyclic migraines are way more severe , or common than they are before.

And that. Phenomenon is definitely an early perimenopause phenomenon and how to treat that really sometimes surprises people. Should we talk about that? Yeah. 

I mean I feel like you just, let's led us right, let's go ahead because 

I will tell you, this is Kitty and I are really excited to hear some of the things you have to say on managing perimenopause because this is just a challenging, I don't know, it's challenging because you don't have labs specifically to help you.

You're doing it all based off symptoms. Everyone is experiencing different symptoms at that. How do you help women in this situation when it's seems like it's so different for everyone. 

I think to get to the, decision about what to use to treat a person's symptoms. You really have to go back to their [00:29:00] medical history and their needs.

And so one of the common phenomenon of perimenopause is this changing menstrual cycle and some of the changes from the extra estrogen that we get in early perimenopause can contribute to bleeding pattern abnormalities. And so when I talk to a patient, I try to really, get to the bottom of what other symptoms, if they're having any are they experiencing.

I also look at the fact that perimenopausal women have the second highest rates of unintended pregnancy of women, behind teenagers women in their late forties have the highest rate of unintended or unplanned pregnancy. And so I look at the need for contraception. And then I also ask [00:30:00] about their experiences in the past using hormones and hormonal contraception, because as I described, early perimenopause is a dysregulated ovary.

It is an ovary that's producing hormones all over the place. You can have excess or extra estradiol. It's not a low estradiol. So really what you want to do is you wanna gain control of the situation because otherwise it's going to be really hard to treat a patient's symptoms. And so in early perimenopause, and even in those years leading up to early perimenopause where the FSH is high and that's what's causing the problem, if you can talk to a patient about a really amazing treatment that we have available for the management of [00:31:00] perimenopause and it.

is a hormonal treatment that can help regulate their hormones and at the same time decrease their risk of cancer. And you can describe this amazing product that is conveniently packaged in a month long pack that has four rows of seven with a little inactive pill at the end. You might be able to describe to this woman this incredible pill that they might be willing to try.

 I say it that way because I feel like one of the most important treatments, and I would say first line evidence. The most recommended management of perimenopause is the use of low dose combined oral contraceptive pills. And if I just [00:32:00] say that to a woman, they often will be like, I don't want the low dose version.

I want to treat my symptoms. And I do a lot of explaining that low dose combined oral contraceptive pills and some progestin only pills have the power to suppress ovulation. And when you have a dysregulated ovary that is producing sometimes more estrogen than you need, and then crashing down into low levels this dysregulated production of estrogen if you

don't suppress the ovulation, then you're really never gonna fix the source of the symptoms of early perimenopause. And when I describe the use of these products, I say we've got the power to suppress ovulation, and then you also have the low dose conjugated, ethinyl, estradiol

that is in most birth control pills, is actually about four or [00:33:00] five times more potent than the hormone levels we use in menopausal women when we're supplementing hormone levels to treat lack of hormone. So it's a much harder job to m anage an dysregulated ovary than it is to just supplement an ovary that doesn't make estrogen anymore.

So here's my counter argument on this. Yes. 'cause I've heard it many times. Anytime I take OCPs, I feel horrible. Like they don't make me feel well. So how would it help me now? It never helped me when I was younger and making mood symptoms better, or I just never felt well on it. What about that patient? 

I like to get into the details of what pill they took importantly because there are many different contraceptive options.

And when you look at the active hormonal ingredient in contraceptives, they [00:34:00] vary based on which estrogen is in the contraception and which progestin is in the contraception. And we also know some of the progestins by themselves have the power to suppress ovulation. So I get into the details of which pills did you take.

I write it down, we call the pharmacy sometimes and go back eight years and find out what they were on. That's the beauty of electronic records in your pharmacy. And I try to talk to them about the use of a product that. Doesn't contain any hormone that they used before, because at this phase we have a new pill that has a unique estrogen that's a bioidentical estrogen.

A trol, which is the newest estrogen on the market. That pill has only been on the market and that estrogen has only been on the market for a couple of years. So if somebody had a bad experience a [00:35:00] decade ago or 20 years ago on a pill, it wasn't that one. And so I will talk to them about that.

Sometimes I'll use a progestin only pill, so I say, okay, let's use one of the progestin only pills. That's, that has the power to suppress ovulation. It doesn't have an estrogen. So if we're gonna do this, we're gonna just do it with one hormone at a time. We're gonna just see if this hormone is tolerable.

And. Then I really do shared decision making. I think that's the first line approach. But if they don't like that approach, I talk to them about the fact that we can use menopausal type hormone supplementation. And when we do that, the addition of that estrogen is really there to put a floor on this peak of estrogen, and then it drops down into a trough.

If you supplement the estrogen, [00:36:00] maybe you make that difference between the peak and trough a little less, and maybe someone has a little fewer symptoms. Because of that. And then another really important hormone treatment in early perimenopause that is really helpful and I use it all the time in really early perimenopause, is the supplementation of just progesterone.

And I typically will use that cyclically from ovulation, so mid cycle to the onset of menses. And that sometimes can really help bridge the gap for someone who doesn't wanna be on a combined oral contraceptive pill, but their periods are coming closer together and they're having lots of PMS and PMDD like the depression and dysphoria or symptoms of perimenopause and that cyclic progesterone we think works because [00:37:00] we understand that when progesterone is metabolized, it turns into hormones that affect the GABAergic system in our brain. That system helps promote calm and so supplementation of cyclic progesterone, especially in the early phase of perimenopause, I do that all the time for patients who are I would say weary of using combination oral contraceptive pills or if they have a contra, like a medical contraindication to a combined oral contraceptive pill.

And what about the patients that we mentioned earlier that have a IUD. Oh, 

I love an IUD. I love, I do, I love a progesterone IUD. How do you 

manage those patients? 

I keep the IUD in. I think there are very few reasons.

Unless the person is having pain or a problem with the IUD to take the [00:38:00] IUD out at the perimenopause, there is the benefit of having this consistent contraceptive that's very reliable. And then also the progestin in the IUD is very effective at fixing bleeding problems. So then that's a person who you could either choose to do the transdermal estradiol, or you could even add in addition to the IUD, you could do a contraceptive pill that helps suppress ovulation.

Okay, that is using it off label and it would really depend on the patient. I would really wanna make sure I had a patient that had no additional cardiovascular risks before I did that. But I've done that before. 

I wanna simplify this a little bit and you tell me if I'm oversimplifying or getting it wrong, but in the early stages of perimenopause, when your hormones are up and down and all over the place, basically [00:39:00] taking the oral contraceptive birth control type pill shuts the ovary down from doing the up and down, it takes over and is guiding the show.

But if you do like a menopause hormone. Level patch or something like that. Mm-hmm. You're not giving it enough hormone to shut down the show, so you still may have times where your estrogen's really high, so you're still gonna get a lot of fluctuation. You're just not gonna drop so low. So I guess you're limiting the size of the fluctuation, but you're still gonna have a lot more fluctuation than if you were taking the pill where you're consistent every day.

And then , later when you're at the end of perimenopause and you're really not producing much hormone or after menopause because you're not having that fluctuation anymore, you can do these lower doses, like the lower dose patch because you're still gonna be consistent , really it's, a lot of times it's the fluctuation that's making you feel 

bad.

That is an [00:40:00] appropriate understanding. That is absolutely the reason that perimenopause is really hard to treat and I. Will treat patients. I think patient autonomy and working with patients to meet them where they are is really important. But I tell my patients who are using menopause hormone therapy and perimenopause, you may feel great now, but when you don't feel well in two or three months, call me.

'cause we may have to modify and adjust. And so I think that the use of a birth control pill, combined oral contraceptive pill in perimenopause has been described as taking a person off a rollercoaster of hormone change and putting them on a merry-go-round where everything goes back to being smooth sailing cyclic.

You know exactly what's coming. And so that [00:41:00] feels really good to our brains. And then when you have the people who are in perimenopause who don't wanna get on the merry-go-round, and they're willing to stay on the rollercoaster, they need to be ready to ride the wave, which means as things change, you might have to change what you're on.

And so it's a much more labor intensive way of dealing with perimenopause, but you can do it. You just really need to have a, I think a situation where you have someone you can work with that will change your medicines around. 

No, I think that's very important because it's not something that. In a scenario where it takes six months to get in to see your provider, is gonna work well doing that. 

 , I hope today people understand that the birth control pill is just packaged as the pill. If you understand why you're being prescribed this pill and that it [00:42:00] addresses the reason you're having your symptoms, it's not meant to mask the reasons you're having your symptoms.

People will be like, oh, I don't wanna mask it with a pill. I'm like it actually is because we completely understand the physiology of why these symptoms happen, that we can say this pill is a good idea. It's definitely not intended to mask anything. It's really meant to resolve the reasons you're having those symptoms.

Question for this, 'cause I know this would always come up in primary care for women who are on the pill a low dose OCP, when do they know that they need to switch to lower dose hormone replacement therapy? 'cause they've hit menopause. Like when do you start questioning that? 

Oh, I think that, that's such a great question.

And the guidelines for the use of low dose combined oral contraceptive pills actually say that you can continue in, in a, low risk patient. You can continue [00:43:00] using low dose, combined oral contraceptive pills up to age 55 because at the age 55, 95% of women are in menopause. And so stopping the pill at that point means that you've transitioned everybody.

I start around 51 or 52 depending on patient's medical history, I find it really hard to have a totally low risk patient at 52 or 53. If you look 

and you mentioned I, let's pause here because I think clarifying. What do we mean by low risk versus high risk patient in this age range? What are things are we looking at and we're talking about when we're talking about risk?

I think that's such a good question because we're talking about cardiovascular risk and risk of thromboembolic events and not really talking about breast cancer risk. And so I think women, when they're high risk, it's almost always skews breast cancer. But really the number one cause [00:44:00] of death in women is still cardiovascular disease by a lot.

And cardiovascular risk is really what's affected by hormonal contraceptive pills. a low risk person would be a person that does not have additional cardiovascular risk like smoking or diagnosed hypertension cholesterol problems diabetes. Those are all considered risk factors where you would want to judiciously choose a pill if if you're gonna use a hormonal contraception in a woman over age 35.

 Let me jump on the breast cancer topic for a minute, Uhhuh, because this really shocked me when I looked into this in the last two years because I have a first degree relative that has had breast cancer, and so I had thought. I need to get off oral contraceptives, which I was on after after my son.

And [00:45:00] so then I decided well, I'll do an IUD instead for birth control. And then lo and behold, I start doing the research and find actually taking the low dose oral contraceptive during this particular time of perimenopause because your estrogen is going up and down. Leveling that off seems to give you a lower estrogen over time and seems to reduce breast cancer risk.

I agree with that theoretical reason and I think. There is a population based study that was published in 2021, and I can't it, it's out of England. It is a gigantic population based study. It's like tens of thousands of women. And they looked at risks of combined oral contraception users with today's doses of contraceptives.

'cause a lot of the studies of women on combined oral contraceptives were done in the fifties and sixties and seventies when the doses were way higher than what we use [00:46:00] now in pills. And that study showed that women on combined oral contraceptive. Pill users had a 50% risk reduction in ovarian cancer, or it was more than that, and then 40% risk reduction in colon cancer and then a 20% risk reduction in breast cancer.

And so I have patients all the time that don't want to take combined oral contraceptive pills and I feel like I should put that study like on the wall in the bathroom or something and be like, it's okay. It's risk reduction. And that's why I was joking when I started like talking about the therapy, because I think that I think it was Malcolm Gladwell that said that , the pharmaceutical industry did a terrible job of packaging combined , oral contraceptive pills.

They should have , called it like a cancer reducing tablet instead of a oral contraceptive pill. 'cause it, it just has [00:47:00] different weight and have different, social meanings to different people. And just because it's packaged and it was marketed originally as an oral contraceptive pill, it is really effective therapy for perimenopause.

So all of that 

to say. Just go talk with someone who's well educated at this and really go through your personal concerns. Your, you may have some misconceptions about risks of birth control, just like I had the misconception of my breast cancer risk with birth control, and make sure you're going through all the things you're worried about and going through the pros and cons of each treatment and that you're talking with someone that can actually.

Tell you the pros and cons of each treatment, and it's not someone that's just giving the same thing to everyone. 

And I'll add one other thing that is very well versed in understanding your cardiovascular risk as well, because that's really important. And I know many women may be receiving hormone replacement therapy [00:48:00] over a long period of time or at older ages, , but no one's sitting down and talking about the cardiovascular risk and what are we doing to make sure we're keeping that as low as possible?

In order to be able to continue the hormone therapy as well. So it's, it is just really important to have educated providers helping you with these decisions because there's more to it than just taking a pill or not. 

Absolutely. And I think importantly we know from some of these population studies that the 20% of women that have the earliest onset hot flashes and most severe and long duration of menopause symptoms also have the highest increase in cardiovascular risk factors. And those. Changes that occur because of the menopausal transition or the perimenopausal transition include a change [00:49:00] in the vessels called medial intimal thickness.

And that's a risk factor for cardiovascular disease. They have a change in their lipid profiles increasing total cholesterol and dangerous qualities of LDL apo, lipoprotein B and increased centripetal weight gain resulting in these other metabolic risk factors that we talked about.

And so addressing the symptoms of perimenopause hormonally, I think is ultimately the decision that is associated. With preventing these cardiovascular risk factor changes. We're still not allowed to say to reduce cardiovascular disease, but it does show to reduce the changes that we know are risk factors for cardiovascular disease.

 So there was one symptom that we didn't really touch on, and it's probably the one that women may even [00:50:00] feel most uncomfortable to bring up at the doctor's office. But when do women in this transition start experiencing low libido?

I think that a change in interest in sex or libido occurs often in women even before the perimenopause transition.

It's can happen really early on where people have this kind of diminished interest. In studies the testosterone or the androgen levels stabilize. And the ovary continues to produce testosterone and androgens throughout the perimenopausal period. And then in post menopause is where you see the depletion of androgens.

And I think that it's an important and more complicated diagnosis in perimenopause and in menopause. That needs to be flushed out because [00:51:00] when you assess someone's low desire, there are multiple components including. Biological components like vaginal dryness that can occur in perimenopause other illnesses that can affect sex drive.

There's psychological components. And then there's social components. And so using that bio-psychosocial model to look at libido is really important. And it shouldn't just be, oh, you have low libido and perimenopause, here's your testosterone supplementation. In fact in perimenopause for low libido, there are a couple of agents that are FDA approved for the treatment of low libido.

And I think that I often try to get to. The source of the decreased interest. Is there a problem with pelvic pain? This age is an age [00:52:00] where endometriosis really has its final throes with people and so often they can have a lot of pain with sex that's causing a change in interest or new onset vaginal dryness or new onset change in sensation where they have diminished sexual response and diminished orgasm.

And so these sort of, the reward mechanism of sex is affected. And so it really is important to get a full history and I think that's such an, like an important topic. 

Yeah, I'm excited 'cause we are gonna talk more about this with Dr. Juliana Hauser and also really getting into all the other factors that affect that because there are so many things that go into that one component.

Yes. So I use and sometimes will offer perimenopausal patients a trial of testosterone therapy and a lot of times I choose that one because the patient will also have like [00:53:00] that feeling of brain fog or decreased energy because testosterone is a hormone isn't just like a hormone that is about increasing your libido or making, like a sex hormone.

 It really is a hormone that has receptors all over our brains. And pelvic floor. And so I think that when you're using testosterone in a premenopausal woman, I sometimes will use it and say, we're gonna use it for a trial period to see if it makes an effect on either energy or focus and concentration.

Like some of these things that to me feel a little bit nebulous, but they're definitely affected in perimenopause 

 . All right. This is a lifestyle medicine podcast, so we have to ask this question. What are some of those specific lifestyle habits that you always recommend to women during this stage of life that's gonna have the biggest benefit for them?

I think that there are definite lifestyle, factors to focus on in perimenopause. [00:54:00] if your sleep is disrupted get help with that. I constantly review patient's sleep hygiene and try to review things that a patient can do at home to improve the quality of their sleep, including some diet modifications and behavioral things that can help.

I really try to encourage patients to stay active and become more active because people like to blame perimenopause hormone changes on weight gain, but when they look at weight gain, it really is a phenomenon of aging and a decreased, activity in their lifestyle. It's really important to encourage patients to stay active to help maintain their weight and manage some of those weight gain that we see almost universally in women as they age.

Not necessarily as they have the hormone change, but as they age. [00:55:00] And then I also really encourage patients to care about their bone health. So some characteristics like excess alcohol intake or no activity that is weight bearing. I really encourage patients to lift weights and do something that has weight bearing because of the, impact on bone density.

 And I am gonna throw one more in there. And that is social connection because I think that's the one we tend to leave out sometimes with our lifestyle medicine pillars. But during this time when you feel not yourself knowing that other people are going through that, being able to talk to your friends about it is really important.

So make sure you are having your network of people that, that you can talk to about it.

And do you have any recommendations on, there's just so much information coming out about menopause and perimenopause now. Lots of studies being cited. Lots of facts and one thing I do wanna encourage you listeners out there, when you are [00:56:00] looking at all of this, really try to actually look at this study.

You can throw some relative risk reduction numbers out there and it can seem like it's making a huge difference. I just wanna give you an example. So you can have this in your head. You can say something reduces your risk of something by 50%, but if your risk to begin with was only 2%, you've gone from 2% risk of this happening to a 1% risk of this happening.

And when I say it like that, you probably don't think it's that big of a deal. But if I say to you, do this or this supplement, or this hormone, or this can reduce your risk by 50%, that sounds much more impressive. So when people are putting these things out there, they're gonna phrase it in the impressive way.

Do your homework. Look at it. Know where you stand and know how much is that actually affecting you before you go spending money on a supplement or spending money on something else just because you see this wild claim. So really try to [00:57:00] make sure you're looking for the evidence. Is there anywhere you recommend women go to for accurate evidence on this that's coming 

out?

I think the Menopause Society website has some fantastic patient information that is produced by people who have created the studies and who are ongoing lead authors of. Studies that help us understand what's going on in perimenopause and menopause. And on the website they have something called Meno notes and that's accessible to patients and they're one or two page handouts that you can print out and they have them on all the topics and it is so helpful.

I print them out and give them to patients. Sometimes when you have a conversation about something and you're like, and read this that is just the information there is is very helpful and not financially motivated. 'cause I do think a lot of the information [00:58:00] especially in perimenopause ultimately if you get to the bottom of the website and there's a product to buy be very suspicious of the information you read in that website.

Yeah. 

Now. If someone that is listening would love to come see you because they are wanting help in navigating this time of life, how can they make an appointment to see you? 

My practice is called Bluegrass, gynecology and Wellness, and I am in here in Lexington and you can look me up. I have a website and I also am still taking patients.

And so I'm happy to see people that have questions about this phase of life. I really enjoy taking care of patients in this challenging phase of life. 

That's great. And we're so glad we have you in our community. 

We are. And as we came in today to record, it's storming. It's been beautifully sunny here for like forever months.

It was storming as we came in. I was like, this [00:59:00] is perfectly appropriate for talking about perimenopause, which is just like a storm going on in your body. Get ready. Hopefully you guys got a lot out of this. Join us next week. We are going to be talking with a breast cancer surgeon from University of Kentucky, Dr.

Veronica Jones. So we touched on breast cancer risks today, but we're really going to dive into that with her and really go in depth on what is your risk for breast cancer? What do we need to be looking at? What kind of screening do you need to do, what treatments are available? And hopefully you can walk away feeling like you know how to minimize your own risk.

So we look forward to talking to you next week. If you have time, please click on that follow button or you can send us a text and let us know anything else you wanna hear about. But it really helps us when you give us that feedback. Have a great week. See you next time.