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The Dose Transcript for January 25, 2023

Host: Dr. Brian Goldman

STORIES FROM THIS EPISODE

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to tThe Dose on our sister show White Coat Black Art. We have a two part series on menopause. And as part of that series, we asked for your questions about menopause and perimenopause and got a ton of responses. So this week we're asking, how can I manage the symptoms of perimenopause and menopause? Hi, Shafeena. Welcome to The Dose.

SHAFEENA PREMJI: Hi. Thank you for having me.

BRIAN GOLDMAN: So I'm sure you get lots of questions. What's the number one thing you're asked about when it comes to menopause or perimenopause?

SHAFEENA PREMJI: I think the number one question that women ask when it comes to perimenopause and or menopause is whether or not their symptoms are actually related to this transition in life, or is this a a symptom that might be more concerning for maybe another chronic medical condition? And women are finding that they don't know where to start when it comes to figuring out how to get help through this time of their life.

BRIAN GOLDMAN: Okay. So you're the right person to ask these questions to. And so we're going to do just that. But before we begin, can you give us a. Hi, my name is. Tell us what you do and where you do it.

SHAFEENA PREMJI: Thank you so much. My name is Dr. Shafeena Premji. I live in Calgary, Alberta. I've been practicing family medicine for over ten years. I opened up my own practice Mahogany Medical Clinic.

BRIAN GOLDMAN: Okay, that's great. Here's an obvious first question. How do you know if you've started perimenopause?

SHAFEENA PREMJI: Well, I think that's a fantastic first question to begin with, because I think a woman really needs to understand the terminology. There's a lot of question about am I in perimenopause? Is this menopause? What is post menopause? And I believe that if a woman really understands her own reproductive status, she will have more confidence in opening up a conversation with her health care provider. So let's go to first what is menopause? So menopause is defined as the single one day where a woman has had no menstrual bleeding for 12 consecutive months. So it's literally the one one year anniversary of her last menstrual period. And anything prior to that is what we would call perimenopause. This encompasses the years where women will start to have symptoms. Some of them they will recognize and some of them they may not recognize. And also they will notice changes in their menstrual patterns. So this is how we define perimenopause. And then menopause or post-menopausal is really the first day after that one year anniversary and for the rest of your life.

BRIAN GOLDMAN: Okay. So you know that you've you've entered menopause when you've gone 12 consecutive months without a period. Perimenopause is a little bit more insidious. What are the most common symptoms of perimenopause?

SHAFEENA PREMJI: So we all know about those raging hot flushes and night sweats that many women will experience. Not all, but many. And I would say 80% of women are aware of those symptoms. But with the 2022 landmark report from the Menopause Foundation of Canada, they have identified 30 other symptoms. So symptoms that will often be presented by women to myself would be mood disturbances, sleep issues, insomnia, weight gain. They may also talk about sexual dysfunction. Women will tell me it feels like razor blades. They may have recurrent bladder infections, the vagina feeling dry or irritated. Women will also talk about hair loss, sometimes headaches, palpitations. The list just goes on. There are so many more symptoms as well.

BRIAN GOLDMAN: Is there a blood test or some objective way of confirming that a woman has entered perimenopause?

SHAFEENA PREMJI: That's an excellent question. And the answer is unfortunately, no. This is a clinical diagnosis. We don't use any formal salivary gland testing. We don't use any kind of hormonal testing to identify women in her reproductive stage. Because when women are in perimenopause day to day, their hormonal levels are fluctuating. So if we were to do any kind of blood test, it would really only be indicative of that single one day. So no, menopause is a is a clinical diagnosis, and we don't have any formal blood test to confirm that.

BRIAN GOLDMAN: I think that, you know, certainly some of the women that I've that I've known who've talked about perimenopause have said they they didn't feel like it was worth it to bother their health care provider about it. But when do you think a woman should talk to her doctor or a health care provider about symptoms of perimenopause?

SHAFEENA PREMJI: I think that's a very excellent question, because women may feel that, oh, this might be just something I have to go through or experience. And there really is nothing that my family doctor can do for me. And I'm going to have to suffer through this. And, you know, as a maternity doctor, obviously, I see women who go through many physical, emotional and mental mental changes with their bodies and their health through that transition. They have the responsibility of raising their children, taking care of their families, continuing on with their careers and taking care of their parents as well who may be elderly and all of a sudden they hit their forties and they just say, oh my gosh, what's happened to me? And they realize that there might be something that's changed within themselves that happened without them even realizing it. And so really, I think the woman, a woman who is experiencing this, should present to their family doctor. And as a family doctor, this is an amazing opportunity for me to help a woman bring her power back to herself and make her own health a priority at this point.

BRIAN GOLDMAN: If we only had time for one question, it would be What's the most effective way to deal with night sweats and hot flashes? The first question before I ask about that are the two symptoms related to one another, or are they different?

SHAFEENA PREMJI: So really, the hypothalamus is where we control our thermal regulatory centers. And women, some women will go through menopause and have a hot flash or two, and that's about it. And then there are a subset of women who will experience this much more intensely. It can be paralyzing and and disabling. I have a patient who told me that she would leave her bedroom in the middle of the night in her underwear and run out into the backyard to cool off because it was so disabling for her. When we talk about treatment, we break it down into lifestyle modification. And of course, therapy is both hormonal and non-hormonal for hormonal therapy. This is a first line therapy for women who are experiencing these days vasomotor symptoms.The hot flushes and night sweats. In general, the consensus with the Society of Obstetricians, Gynecologists of Canada advocating menopause society, we recommend for all women who are under the age of 60 or within ten years of their menopause if they are an average risk woman with no contraindications menopausal hormone therapy is first line therapy for management of their symptoms.

BRIAN GOLDMAN: That's good. I know that women who are going through perimenopause and menopause can have disrupted sleep. Are night sweats the main reason for disrupted sleep?

SHAFEENA PREMJI: That is one of the many reasons why women will have issues with their sleep. The other symptom could be related to sleep apnea. And so a woman who has sleep issues, I always do recommend a screen for sleep apnea and even a sleep study. The other reason women may experience sleep disturbances could be related to their bladder. The other thing also could be just related to depression or anxiety. If a woman is experiencing either of these conditions, then that can also affect and worsen her sleep.

BRIAN GOLDMAN: You mentioned weight gain. We heard from some women who are concerned about that in particular, especially around the abdominal area. Any tips on how to prevent or lose that weight?

SHAFEENA PREMJI: Women who are in menopause do in general gain around 2.5 kilograms during the transition. And really what happens is that there is a change in the body composition. So there is a loss of lean mass and fat gets redistributed and oftentimes it gets redistributed into the central abdominal area. So women will talk about an increase in their waist circumference. What can we do to help these women when it comes to hormone therapy? We know that menopausal hormone therapy doesn't necessarily lead to weight loss, but it can help with body fat distribution. And the key to managing weight in this time of life is really exercise. The SOC guidelines recommend 150 minutes per week of regular physical activity, but in particular, body weight training 2 to 3 times a week should be part of that exercise routine. We know that muscle utilizes more calories more efficiently, and so that would really help a woman to maintain her weight during this transition. Of course, we talk about diet and healthy lifestyle choices from a dietary perspective. And for a woman, I tell her this is not about going on a diet. This is really an opportunity for making positive health changes and changing one's eating habits for the rest of their life.

BRIAN GOLDMAN: Fatigue is another common symptom. How can women improve their energy levels?

SHAFEENA PREMJI: Again, it comes really back down to their their overall lifestyle choices. So women in this time of life feel a lot of stress. They may have young children or teenagers. They may be also caring for their elderly parents and or trying to maintain their career. So stress reduction is a big part of keeping up those energy levels. You know, if a woman is feeling like there's no purpose for her anymore, being more engaged socially, keeping active really does absolutely help with that with energy levels as well.

BRIAN GOLDMAN: Got it. We also got a lot of questions around headaches, specifically migraine headaches. If you suffer from migraines, how do they typically change as women go through perimenopause and menopause?

SHAFEENA PREMJI: There is definitely a clear connection between headaches and menstrual cycles. Women who are in the pre menopause so, you know, in their twenties and thirties, they may discuss having menstrual migraines or migraines that are associated with the changes in their cycles. And any research that really focuses on women with migraines finds that those who have a fast decline in estrogen levels during that perimenopause and menopause are the ones that are most affected compared to other women. We don't have any Health Canada approved hormone product to prevent or treat migraines, but sometimes we can use hormone therapy to help minimize those huge fluctuations in the hormones, which is what is causing the migraines. Something to keep in mind for women that migraines with aura are considered a contraindication to the low dose birth control pill, which we sometimes do use in perimenopausal women who are in the menopausal transition and having menopausal symptoms and also menopausal hormone therapy itself can have a side effect of headaches as well.

BRIAN GOLDMAN: Women have told us that brain fog was a common symptom. What may be causing that?

SHAFEENA PREMJI: Women tell me a lot that, you know, they feel like they're going crazy. They say to me, oh, I can't remember anything. Or my husband thinks that I am not as sharp as I used to be, or they go to work and they feel like they're having word loss or word finding difficulties. And this can be very disabling for a woman when she's otherwise been very high functioning. The good news is that oftentimes the brain fog that women do experience in the perimenopause and menopause is transient and does not lead to dementia that most women are worried about. And really, the management of brain fog in the perimenopause and menopause is really focusing on cognitive health and screening for any modifiable risk factors. So as I mentioned during my menopause consultations with my patients, I was screened for hypertension, high cholesterol and diabetes. We also talk about those lifestyle changes with respect to smoking, caffeine and alcohol and in particular, one thing that definitely may help a woman who is experiencing brain fog is really trying to engage socially in a new or different way. So whether that means volunteering at a community center, learning a new skill, perhaps a new language. These are some of the changes that they can work towards which may help ease that transition for them and make them feel like it's less of a burden.

BRIAN GOLDMAN: I've got another question here for you. One woman asked about how this natural change may affect women's bladders and could it lead to more yeast infections.

SHAFEENA PREMJI: When I talk about what happens in menopause, I draw a little stigma for my patients during the appointment, and I point to them all the different places in the body where there are estrogen receptors. And women do not realize this, but we have estrogen receptors in our bladder, in our vulva, vagina and the urethra. And so when a woman is going into menopause, the estrogen deficiency can lead to changes in bladder function. Women may present with recurrent bladder infections. They might tell me that they have burning when they go to the bathroom. They have experience, they experience urgency and feeling like they need to run to the bathroom very quickly. They may also present with dryness, burning and even abnormal discharge. So really, the estrogen deficiency is what is leading to many of these what we call GSM genital urinary syndrome of menopause, which comprises vulvovaginal bladder and sexual dysfunction related to menopause. And so what can we do about this? Well, there is absolutely treatments available, both nonhormonal and hormonal. We have many different types of lubricants, moisturizers and Health Canada approved vaginal topical estrogen therapy. So I would encourage all women and patients to bring this up to their family doctor or health care provider, because there are many, many things we can do to help you through this.

BRIAN GOLDMAN: As I mentioned on Waco Black Art in the emergency department, I've seen women who were dealing with heart palpitations while going through perimenopause. What do we know about that?

SHAFEENA PREMJI: Many women may actually experience a 7 to 15 beat increase per minute when they are having a hot flush. This can be very distressing for a woman. And in your other podcast, one of your presenters did mention that she was worried that she was having a heart attack. And so I think when a woman presents with heart palpitations, it's very important that she does bring this up to her health care provider because most of the time it is benign and is not worrisome, but it can be associated with other conditions that we need to rule out. Perhaps she's got a thyroid disorder, maybe she has an arethmia, or maybe she's got some anemia that needs to be worked up. Perhaps she has an anxiety disorder or maybe this is a side effect of a medication. So when a woman presents with heart palpitations, it has to be something that should be brought up to their health care provider and all the other symptoms. Sorry, all the other conditions need to be ruled out.

BRIAN GOLDMAN: We've been talking around the subject of hormone therapy. You know, it's come up a number of times, but I want to make sure we talk about it all at once, because we had a lot of questions around menopause hormone therapy. So what is it actually what do we mean by menopause hormone therapy?

SHAFEENA PREMJI: So menopausal hormone therapy is really a combination of hormone therapies, which generally include an estrogen and progesterone. So a combined oral contraceptive pill is a combination of a form of estrogen and a form of progesterone. When we talk about menopausal hormone therapy, it also is estrogen and progesterone as a two primary hormones that we are using for a woman who's had a hysterectomy and she does not require progesterone, we use estrogen only. Let me explain this. So the estrogen is the hormone that we are using to help manage many of those symptoms that women are experiencing. So the brain fog, the the hot flushes, the night sweats, the vaginal symptoms, the mood changes. The progesterone is really there to protect the uterus. So when a woman is taking estrogen, it leads to a thickening of the lining of the uterus. And so I explain to women that this is like the fertilizer to the uterus. And then we add the progesterone to act as the lawnmower. So it really helps protect that uterus from that lining to become thickened. And it prevents them from developing uterine cancer. Now, in the last five years are also a few other new hormonal therapies on the market, which are Health Canada approved. They are what we call an estrogen antagonist and agonist so that the molecule itself actually has different roles on different tissues within them, within the body. So really, when it comes to hormone therapy, there is no one size fits all. A woman has to be assessed by somebody who is well trained and understands the role and how hormones are used to help manage their symptoms.

BRIAN GOLDMAN: Okay, so who should go on hormone therapy and when?

SHAFEENA PREMJI: So menopausal hormone therapy is a safe option for any woman who is perimenopausal or menopausal if they are under the age of 60 or within ten years of menopause. It doesn't mean that every woman needs to go on hormone therapy. But if they have symptoms which would be improved with hormone therapy, then it is actually a safe option. Now, we do break that down into ages as well. So for a woman who is in early menopause, which is before the age of 45, or women who are under the age of 40, which we call premature menopause for these women, we are also recommending menopausal hormone therapy, not just to treat their symptoms, but to actually use hormone therapy to prevent osteoporosis, to prevent cardiovascular disease, and also to prevent the progression of genital urinary syndrome of menopause, which we talked about earlier.

BRIAN GOLDMAN: Women wanted to know about the safety of hormone therapy. What is the research show?

SHAFEENA PREMJI: We have to go back 20 years, more than 20 years to answer that question. So in 2002, the Women's Health Initiative, which is the largest study looking at hormone therapy. And when the data was published, it was published because there was findings from that study where they stopped the study earlier because there had been findings that there was an increase in breast cancer and heart attacks. So women and health care providers across the nation became fearful of hormone therapy and were worried about the the risks of being on this regimen. What we realized later on was that the data was incorrectly published, and really the study was focusing on women over the age of 5060. Sorry, but the results actually were being generalized to younger women. And so it's taken us over, you know, 10 to 20 years to backtrack and to be able to fix what that Women's Health Initiative initial release has done for many women and health care providers. The research now is showing that hormone therapy is a very safe option. There are some women who cannot be on hormone therapy. There are some absolute contraindications. But overall, hormone therapy has many benefits. It provides relief of hot flushes, night sweats. It can improve a woman's mood, her sleep, her overall quality of life. It can protect her bones from osteoporosis and allow her to have better health outcomes in terms of her heart health as well. When it comes to the age at which we need to discontinue hormone therapy, there is really no magic age limit. Really what happens is when a woman is entering into her sixties, there has to be a conversation with her health care provider to review a risk assessment, making sure that she doesn't have any changes to her health that might increase risks of complications for her. And really, it's a it's a it's a conversation to have with her and her and her doctor. But we don't have any hard, fast rule about an age limit. And I do have patients into their seventies who are still well managed and well stable on their hormone therapy.

BRIAN GOLDMAN: What are the we call them contraindications? What are the situations or the medical conditions for which. Women should not be on hormone therapy.

SHAFEENA PREMJI: So if she has had a personal history of breast cancer, if she has ever had a blood clot in her lung or her deep veins of her legs, which we call AP or a DVT, if she's ever had a stroke, if she has a history of any active liver disease or if a woman is experiencing undiagnosed vaginal bleeding, that requires a workup before we were to consider hormone therapy.

BRIAN GOLDMAN: Got it. We've been talking about pharmaceuticals. You've talked about life. Lifestyle management. Are there any natural remedies that are worth checking out?

SHAFEENA PREMJI: There is a subset of natural health products. Many women will lead to the natural fruit health food stores and will look at black cohosh or evening primrose oil as they have been marketed to help manage some of these vasomotor symptoms. However, most of the studies that are being done on these natural health products are limited and very small. And at this time we don't have enough data to support the evidence or the recommendation for using them to manage vasomotor symptoms in menopause.

BRIAN GOLDMAN: Menopause perimenopause is something that most women are going to have symptoms about. And and I you spend a lot of time with your with your patients talking to them about the symptoms, talking to them not only about therapies, but lifestyle management. What are the symptoms or the duration of symptoms or the conditions for which you're thinking? You know what? We better we better look further and not just attribute it to perimenopause or menopause.

SHAFEENA PREMJI: That's an excellent question. The symptoms that, you know, sometimes women actually don't even realize that they're having some of these symptoms. But if a woman presents with chest pain, shortness of breath, a rapid change in her weight, these are some of the symptoms that may be definitely related to something cardiac in nature. And, you know, when we look at screening, when a woman comes in for her periodic health exam, we are screening routinely for diabetes, high cholesterol. And as you know, these are silent killers. Many women will not present with any symptoms and they may not even recognize it. You know, you're coming in for your annual appointment, your annual physical. We're going to check your blood pressure as well. Just like osteoporosis, we don't know we have it until we break a bone. And similar to a heart attack or a stroke, we may not necessarily realize that we've got blockages in our arteries that is going to lead us to that event. And so I think, you know, when we have a woman who's coming in in the perimenopause in her forties and her fifties, of course we're asking her about all of these symptoms. But at the same time, screening is a very, very important part of what we're doing. You know, women at this time of life, they are very busy with their lives and they don't prioritize their own health. And, you know, this is a very important part of them allowing themselves to progress into the next stage of their life with being empowered and feeling strong and feeling healthy and feeling like they own and have good control of their overall life and quality of life.

BRIAN GOLDMAN: Well, Dr. Shafeena Premji, I want to thank you. You've answered a lot of questions and you've answered them very well. And you've been a fountain of information. And and thanks for coming on the dose to talk about perimenopause and menopause.

SHAFEENA PREMJI: It's been a pleasure, Dr. Goldman, and thank you for this opportunity. And I wish every woman listening to this podcast, the empowerment, to go and look deep within and find those answers for yourselves. And please, please bring up these conversations with your with your health care provider.

BRIAN GOLDMAN: Dr. Safina Premji is a family physician and medical director of the Mahogany Clinic in Calgary. She's also a North American menopause Society certified menopause practitioner. Here's your dose of smart advice. Menopause begins 12 months after a woman's last menstrual period. The years leading up to that point are known as perimenopause or the menopause transition. Perimenopause, which most often begins between the ages of 45 and 55, has 30 possible symptoms. There is no blood test for perimenopause. The most common symptoms include hot flashes, fatigue, mood swings and menstrual changes. Sleep disruption may be caused by night sweats, hot flashes, bladder problems, and sleep apnea. On average, women gain 2.5 kg and may notice increased abdominal girth. Your health care provider can assess you for symptoms of perimenopause and lifestyle factors such as diet, exercise, smoking and alcohol use. This is also a good opportunity to check bone density, blood pressure, cholesterol and diabetes. Adopting healthy habits like exercising 150 minutes per week can help control symptoms. Hormone therapy is a mainstay of treatment. Estrogen is the most effective option for relieving hot flashes and can also help relieve bladder and vaginal symptoms. Progesterone therapy is added to estrogen to protect the uterus. In general, hormone therapy is considered safe for women aged 60 and under who have had menopausal symptoms for less than ten years after age 60. Check with your health care provider about whether to discontinue hormone treatment. You should not take hormone therapy if you have a history of breast cancer, blood clots in the legs or lungs, stroke, or if you have active liver disease. Women who have few symptoms or none at all should also talk to their health care provider for a checkup. And don't assume that every symptom is due to the menopause transition. If in doubt, see your health care provider. If you have topics you'd like discussed or questions answered, our email address is the dose at cbc.ca. You can find the dose wherever you get your podcasts. If you like this episode, please rate us five stars so more people can find us. This edition of the Dose was produced by Stephanie Dewar. Our senior producer is Colleen Ross. The dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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How can I manage the symptoms of perimenopause and menopause? - Transcript

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