Weighing the benefits and risks of hormone replacement therapy (HRT) related to menopause can be one of the most confusing decisions a woman will make over the age of 50.  There is no one-size-fits-all recommendation that can make the choice simple, or standardized chart to reference “if this, then that” scenarios.  Every decision about HRT should be individual, and best when made between a patient and her health care provider.  

Additionally, the care and treatment of menopausal women is complicated by the varied level of training and specialized experience of health care providers related to menopause. Not all OB/GYN’s or other health care providers have studied the latest research related to the potential benefits and risks of HRT in accordance with personal and family health history – research that increasingly demonstrates a window of time where HRT can provide both symptom relief and, in some cases, delay or ward off disease.  

Most problematic is the legacy effect of how providers understand and interpret the seminal research that has been the basis for standardized care for HRT””a study completed two decades ago””called the Women’s Health Initiative (WHI). The 2002 study was conducted with women at an average age of 64- 65, and cited health risks associated with HRT around cancer, blood clots, and heart disease. Many healthcare providers have not kept up with subsequent publications on this data that showed that in women who were younger when they started, the risks are fewer and benefits greater. This has come at a cost to menopausal women suffering from sleepless nights, brain fog, painful sex, and hot flashes.  

Thankfully, attitudes are shifting as new research surfaces.  Both the Endocrine Society and the North American Menopause Society state that for symptom relief, the benefits of FDA-approved hormone therapy outweigh the risks in women younger than 60 or within 10 years of their last period, absent health issues such as a high risk of breast cancer or heart disease. The menopause society position statement adds that there are also benefits of HRT for women at high risk of bone loss or fracture.

With a bit of education, and having an informed conversation with a doctor, OB/GYN, or a menopause specialist, women are moving beyond the decades-old stigma of the HRT health concerns.  They are creating personalized preparedness plans with their doctors as to when hormone therapy, if used as directed, might deliver more benefits than risks.  

3 questions to ask your doctor about HRT

To evaluate with your doctor whether hormone therapy could be right for you, at what age, for how long, and what type, see the below set of questions and considerations to review in advance of your appointment, or to guide conversations with your doctor.  

Based on the severity of how my menopause symptoms are impacting my quality of life and daily routine, would HRT potentially deliver relief?  

• There are 40+ symptoms associated with menopause.  The most common include hot flashes, vaginal dryness, painful sex, insomnia, fatigue, headaches, joint pain, anxiety, mood swings, memory lapses, digestive problems, and brittle nails.
• It is up to each individual woman to decide when and how her symptoms are impacting her quality of life and need addressing to provide relief.
• As some of the above symptoms can be related to other health issues, it is helpful to discuss which tests and screenings could be done to rule out other health concerns.

How might my health history, and that of my family, such as heart disease, strokes, dementia, osteoporosis, etc. factor into the benefits or risks of HRT?  

• HRT may be especially beneficial if you have a family history of”¯osteoporosis, high”¯cholesterol, and”¯heart disease. On the other hand, it may not be best if you have”¯gynecologic cancer,”¯ or a blood clotting disorder.
• There is increasing evidence that starting HRT at the transition to Menopause can reduce the risk of Alzheimer’s, as discovered in studies by Dr. Lisa Mosconi.
• Research on cardiovascular health shows increasing evidence that starting HRT in the early years of menopause can provide cardiovascular benefit with reduced risk of cardiovascular disease. This benefit changes with age, and HRT may become riskier as you get further into menopause.  
• There is evidence that HRT can help prevent osteoporosis.  
• If you still have a uterus, Progesterone is recommended along with Estrogen to avoid the risk of uterine cancer. However, progesterone does slightly impact the incidence of breast cancer. The increase in risk is actually very low.  
• If you have a family history of breast cancer, hormone therapy will not impact your risk (which is based on family history and genetics), and may be a valid choice for you.

Given my symptoms and family history, why type of HRT is best and for how long?  

• Some of the options for HRT include topical, vaginal, oral pills, and patches””all with pros and cons and are described here.
• FDA regulated forms are always safest, and your doctor should be recommending these.
• Length of use of HRT is based on your symptoms and benefits from HRT, and varies woman to woman. There is no set stop date or number of years after which you must stop.  

As research continues to emerge that demonstrates the benefits of hormone therapy for short term symptom relief and long-term risks related to heart, bone, and brain disease, there is no doubt decision making will become easier and standards will shift. Until that time, women at the age of 45 can have a conversation with a Gennev OB/GYN or their physician about how HRT might be considered as they move through menopause, and under what scenarios.  This can set a valuable benchmark to inform treatment, if needed, in line with their own personal and family health history, and their individual health goals.    

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The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.

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Joanna Wasmuth has always juggled a variety of roles and responsibilities, producing impressive results in her career while lovingly taking care of family and friends. Like so many women, Joanna has spent so much time and attention on others that she neglected herself – until now. Joanna has taken her strong work ethic, care, compassion, and business savvy and applied it to a new, and probably the most important job of her life””CEO of her health. “I need to be responsible for my own health,” Joanna says. “Your doctor doesn’t live in your shoes. While they’re wise and have great input, we also have to trust our intuition.” And with all the varying symptoms that accompany menopause, advocating for yourself and seeking the care you deserve is more important than ever.

Today, Joanna’s prioritizing herself, her health, and finding peace and joy. But just a few years ago, she was driven to produce, often putting herself last. Joanna was on a plane several times a week, flying around the world for her job as a strategy consultant, commuting between her home in Miami and office in New York City.  She was also making cross-country trips to Seattle to care for her mom and sister, who were both ill. There were early mornings, late nights, and lots of stress. “I was running myself into the ground,” she says.

Everything changed when, at age 44, Joanna had a hysterectomy that included the removal of her ovaries. “I was told that I’d just be put on an estrogen patch, and life would be normal, no big deal,” she recalls. Four day slater, Joanna had three life-threatening pulmonary emboli (blood clots in the lungs) and landed in the ICU. She not only faced months of recovery from that emergency, but she was plunged into surgical menopause with intense symptoms like debilitating joint pain, hot flashes that felt like she was “claustrophobic, suffocating, and burning from the inside out,” sleep problems, weight gain, and memory issues. And because of the pulmonary emboli, hormone replacement therapy was no longer an option.

“I realized that now my body is different, and I couldn’t just keep doing the things I used to do,” says the now-46-year-old. Thanks in part to the pandemic, she’s doing more Zoom meetings and traveling less, which has reduced her stress. “I’ve been given a second chance at life, and having beautiful moments every day is what I’m looking for now.”

As the CEO of her health, Joanna has employed some of her business systems and management skills, starting with a spreadsheet of non-negotiables. “What gets measured gets done,” she explained as she shared her list of 28 “things that I do to be well.” Some are daily practices like drinking 100 ounces of water, walking four miles (she uses the Conqueror virtual challenges to stay motivated and keep it fun), cooking plant-based meals, painting, and meditation using sound bowls (“It’s just a few minutes of peace and resets my energy”). Others are weekly rituals, for instance, meeting with her Gennev health coach to stay on track, sessions in an infrared sauna, sound and light therapy, and strength training (three times a week). And monthly, she gets a massage, has acupuncture, and meets with a Gennev menopause-certified doctor. She marks off each goal in the spreadsheet as she goes, to help her stay on track.

She’s also adjusted her day to have breaks between meetings instead of scheduling them back-to-back. And when she has a stressful presentation or appointment, she rejuvenates by doing something that brings her joy, like walking on the beach or spending time in a favorite place. “As we do hard things, we can do them in a way that supports our wellness and our health,” Joanna says.

Joanna’s return on her investment has surpassed expectations, as her doctors frequently express amazement with how well she’s recovering. She’s a perfect example that no matter how bad the symptoms are, you can find a way to thrive. “This is a season of life where it’s not the end, it’s a new chapter,” Joanna says. “And it can be an exciting one.”

If you connected with Joanna’s story, and need support in taking charge of your own health in menopause, book a virtual visit with a Gennev menopause specialist.

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The information on the Gennev site is never meant to replace the care of aqualified medical professional.  Hormonalshifts throughout menopause can prompt a lot of changes in your body, andsimply assuming something is “just menopause” can leave you vulnerable to otherpossible causes. Always consult with your physician or schedule an appointmentwith one of Gennev’stelemedicine doctors before beginning any new treatment or therapy.

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The Mediterranean diet is more of an eating style than a diet. It incorporates a variety of whole, nutrient-rich foods that provide the nourishment important for promoting heart health, reducing inflammation, stabilizing blood sugar, managing weight, and more. There are no strict rules for the Mediterranean diet, as it is based on the traditional foods and eating style that people eat in countries bordering the Mediterranean Sea (including France, Spain, Greece, and Italy).  Since many people find themselves unsure of how to get started with the Mediterranean diet, we’ve broken down the basics below. One key to keep in mind is that the less processed and more whole a food is, the more likely it is to fit into the Mediterranean style of eating.  

The basics of the Mediterranean diet

Create a colorful plate. Brightly colored vegetables and fruits provide many of the benefits found in the Mediterranean diet.  We also eat with our eyes, so see what you can do to have at least five bright colors as the main part of your meal.  

Choose fish more often as your animal protein source. Chicken, turkey, eggs, cheese and yogurt are also excellent sources of lean protein, but most of us don’t consume an optimal amount of omega-3s from our food which is what fish can provide. .

Include plant-based proteins. Lentils and beans are fabulous sources of protein and fiber. Enjoy hummus made from chickpeas or a lentil soup a few times per week.  

Prioritize healthy fats. Unsaturated fats from fresh salmon, nuts, and seeds provide nutrients that can support the body’s ability to manage inflammation. In addition, these foods are also a good protein source. Olive oil is a main staple in the Mediterranean diet. Use this to prepare salad dressings, marinades, and to cook with.

Go for whole grain. Whole grains such as quinoa and brown rice provide more nutrients, fiber, and protein compared to simple and refined grains. These can also be prepared easily in a large batch and added to meals throughout the week such as a salad for lunch to bring to work or a way to round out a dinner.  

Don’t skimp on flavor. Use fresh herbs, garlic, lemon juice, salt, and pepper for flavor. These simple, fresh, and nutrient-rich ingredients can really pack a pop of flavor and offer anti-inflammatory benefits that often go unrecognized.

Eat more of these foods when following the Mediterranean diet

Vegetables and Fruits as Aim for half of your plate to be filled with fruits and vegetables

• Arugula  
• Kale
• Spinach
• Romaine lettuce
• Red peppers
• Carrots
• Cabbage
• Radicchio
• Blueberries
• Apples  
• Bananas
• Oranges
• Pears
• Strawberries
• Grapes
• Dates
• Figs
• Melons
• Peaches”¯

Whole Grainsas ¼ of your plate should consists of whole grains

• Oats
• Brown rice
• Quinoa
• Farro
• Bulgur
• Whole wheat pasta, bread, crackers
• Rye
• Barley

Lean Proteins (animal or plant) as ¼ of your plate should consist of healthy protein

Animal Protein as strive to eat fish or seafood at least twice per week, and include a protein source with all meals and snacks

• Wild caught salmon, tuna, trout, mackerel, herring
• Canned tuna, salmon, sardines, anchovies
• Chicken
• Eggs
• Turkey

Plant protein

• Nuts/nut butter (almonds, walnuts, pistachios, peanuts, pecans)
• Beans (black, kidney, garbanzo)
• Peas
• Lentils
• Tempeh
• Tofu

Healthy fats as add the following as a condiment to meals as or as part of the preparation

• Olives and extra virgin olive oil
• Avocados and avocado oil
• Nut oils (almond, walnut)
• Chia seeds
• Hemp seeds and oil
• Flax seeds and oil

Dairy as if tolerable, aim for 2-3 servings per day

• Low fat plain Greek or regular yogurt
• Cheese (small amounts)
• Low fat cottage cheese
• Plant-based dairy alternative beverages and yogurts

Healthy snack options

• Apple slices with almond butter
• Carrots with hummus
• Guacamole with sliced bell peppers
• A piece of fruit or bowl of fresh berries
• Greek yogurt or cottage cheese with fresh fruit
• Hard-boiled egg with salt and pepper

Eat less of these foods with the Mediterranean diet

• Refined carbohydrates (white flour, sugar, soda)
• Saturated fat (butter, full fat dairy)
• Fried foods
• Red meat

Get started with healthy food swaps

You can start eating Mediterranean by swapping in foods that better align with this pattern for foods that don’t with your meals each day, and before you know it, it will become a healthy way of life.  

• At breakfast as add some spinach to your eggs each morning with aside of whole wheat toast, or try oatmeal with fruit and nuts instead of pancakes
• For lunch as create a mixed greens salad with quinoa and chicken, dressed with a drizzle of olive oil, avocado and fresh herbs
• At dinner as roast seasonal vegetables to pair with grilled salmon and fresh fruit

Remember to drink plenty of water throughout the day (aim for half your body weight in ounces). And while red wine is an acceptable part of the Mediterranean diet (only one glass per day), we recommend considering imbibing less frequently.

The Mediterranean diet offers a no-nonsense way to nourish your body as well as protect your health for the long-term.  And best of all, once you know the principles of the Mediterranean diet, you can modify your eating in a way that works for you, and focus on the foods you love.  

Creating healthy eating habits can seem daunting. But don’t let that stop you. Access the expertise of our integrated care team who are specially trained to help you make lifestyle modifications that support your body in menopause. They will create a personalized wellness plan based upon your needs, as well as be your companion on following through.  

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_{The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “œjust menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.}

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With all of the knowledge, self-awareness, and confidence that we gain as we age “”about ourselves, our bodies, our turn ons and turn offs “” sex after 50 can be some the best sex of our lives. I know that can be hard to believe. We’ve all heard the negative messaging around menopause as the period of time when we lose our libido as well as our physical ability to enjoy sex. As a physical therapist who helps patients maintain their pelvic health, at every stage of life, I can tell you that it doesn’t have to be true for you.

Yes, menopause brings about significant changes as your ovaries stop producing estrogen. But, by focusing on your pelvic health, you can not only prevent and improve pelvic floor issues that put a damper on sex, you can also connect with your body in new and pleasurable ways.

Low Estrogen & Sexual Functioning

Several menopause-related changes can impact the way your body feels and functions during sex. As estrogen levels decrease, blood flow to the tissues of the vulva decreases, which can affect the size of the clitoris and its sensitivity to stimulation. The tissue of the vagina can become thinner and less flexible, and you may produce less natural lubrication which can lead to pain during sex. The same dryness that affects the tissues of the vagina can also affect the tissues in your mouth, which can make oral sex and even kissing a challenge.

These changes also tend to coincide with age-related muscle and sensory shifts, which can pose even more challenges to maintaining and enhancing one’s sex life. For many people, weakness in the muscles that surround the vagina, bladder and bowel can lead to urinary leakage, constipation, sexual dysfunction and pelvic organ prolapse. All of these things can contribute to how we feel about, and how we experience sex.

But changes in your body are nothing new. Through every menstrual cycle since puberty, your body has changed. If you were ever pregnant, your body has changed. If you’ve dealt with major illnesses or injuries, your body has changed. This is not to say that going through menopause is easy or to minimize the impact that these changes can have on your life, but you’ve experienced major physical changes before “” and both you and your body are incredibly resilient.

There’s clear evidence showing that addressing pelvic floor muscle function, in conjunction with improving overall muscle strength and physical wellbeing, can help to reduce and even prevent many of these symptoms related to menopause. Which brings me to the power of your pelvic floor.

Tap into the Power of Your Pelvic Floor

The pelvic floor refers to the multi-tasking group of muscles and connective tissues that make up the bottom of the pelvis. These muscles run from your pubic bone to your tailbone and wrap around the vaginal and anal openings. They also support and bring blood flow to the clitoris, vulva, and vaginal walls; and they are critical to maintaining and elevating your sexual function!

It’s important to keep all of your muscles strong and healthy as we age, and the pelvic floor muscles are no exception. During penetrative sex, the muscles that wrap around the anal and vaginal entrances, lengthen and open for pain free penetration and stretch, but they can also be squeezed for increased friction and sensation. Your pelvic floor is also important in orgasm with research showing that, during orgasm, the pelvic floor muscles will actually contract involuntarily.

Strong, healthy muscles have better blood flow, and during arousal, your pelvic floor helps to prepare your genitals for sex by bringing blood flow into your tissues, helping with tissue engorgement, and increasing nervous system activity and sensitivity in all of your pelvic erogenous zones (your clitoris, labia, vagina, anus, cervix, and lower abdominals for example).

This is why one of the most physically important things you can do for your sex life is maintain your pelvic floor health. If you are unsure of where to start, try these tips below.

Make sex a habit. The “use it or lose it” principle is particularly important after menopause. While it’s not uncommon for sex frequency to slow down, it’s important to consider that if you aren’t having sex, or if it’s less frequent, the vagina may begin to narrow with less flexibility and increased atrophy of the tissues, which can lead to more pain and dysfunction during penetrative intercourse. If partnered sex isn’t an option or isn’t something that interests you, this is a great time for solo sex. Masturbation with a penetrative sex toy can be a great way to encourage blood flow to your vulvovaginal tissues.

Explore different kinds of touch. You may also choose to focus on outercourse, if your vaginal tissues feel pain during penetration. As your nervous system, and tissues of the pelvic floor change, what may have felt pleasurable before could start to feel irritating and unwanted. By focusing on touch and sexual activity that is pain free and pleasurable for you now, you can avoid taking part in the pain cycle that so commonly surfaces in menopause. Consider reaching out to a sex counselor, if you are looking for further guidance on how to explore different kinds of sex.  

Maximize your pelvic floor muscle health. Even as we age, research shows that people who are sexually active and able to achieve orgasm tend to have healthier pelvic floor muscles. Since healthy pelvic floor muscles can encourage blood flow to where you need it most, you may consider learning strategies to improve your pelvic floor health, such as strengthening your pelvic floor or increasing the pain free flexibility of those muscles by using dilators or beginning a stretching program to address overactive and irritable muscles. It may even mean working on your ability to properly coordinate these muscles during sex.

To learn more about your pelvic floor and how it can improve your sex life, ask your gynecologist or primary care physician for a referral to a pelvic floor physical therapist. Your therapist will evaluate your pelvic floor muscle functioning and create a personalized treatment plan to address and prevent symptoms “” and help you feel good in your body right now, which may be the biggest sexual turn on of all.  

Celestine Compton, PT, DPT is a doctor of physical therapy at Origin with a board-certified specialization in women’s and pelvic health. She continues to expand her knowledge and capabilities within the field of women’s health PT to provide her patients and community with the best care, advocate for her profession on local and national levels, and support the advancement of women’s health through contributions to research, public awareness, and education. As part of the Origin team, she hopes to do her part to raise the standard of care that all women receive at every stage of life and to improve patient access to quality care so that no individual, regardless of location, race, identity, education, sexuality, or economic status is left behind.

The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.

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Menopause information and advice is available everywhere now, and literally at your fingertips. And with a quick search with Doctor Google, you could either find some very valuable resources, or be taken down a path of misinformation.  Gaining reliable advice as well as evidence-based treatments to manage your symptoms is what we are all about here at Gennev. So, we tapped into Dr. Lisa Savage, board-certified OB/GYN, to answer questions from our community about menopause, and help dispel the myths and share the facts surrounding symptoms and treatments. 

Will my migraines disappear after menopause?

Headaches are very common, and what happens during menopause is highly variable. I’ve had plenty of patients whose migraine headaches do get better, others who got worse and many who stayed exactly the same. It’s not predictable and it’s very individual.

Some women have a cyclic component to their headaches (menstrual headaches) that come on as a prelude to menstruation, and lift after your period is over. Those types of cyclic headaches generally get better with menopause when cyclic hormones are not playing a role. Ultimately, I think it probably takes about a year after that last menstrual period to really know where your headaches have ended up – and even after that, there may be some change that can go either way.

How long does it take to feel better on HRT?

Time to symptom relief is a really gratifying part of starting HRT because it doesn’t take long. It’s not delayed gratification. I always tell my patients I don’t want to overpromise, but typically results can be seen anywhere from 48 hours to a couple of weeks.  

How long can you take HRT?

It’s very individualized, and it depends on how old you are, when you need to start, and how long you want to take it. HRT does not need to be a long-term commitment if you don’t want it to be. Some women will take it for a few years to relieve the worst of the symptoms, and some women will need it longer, especially if they started their menopause transition at a younger age. Usually when a woman is approaching 60, I’m looking to see if we can get her off HRT, assuming she was around average age for menopause”¦meaning she’s been on it for around 10 years. I like to describe the therapy goal as extracting the most benefit while minimizing risk.  But again, it’s not written in stone and there’s no hard and fast stopping point. Some women have ongoing symptoms for which they need the HRT. The most recent NAMS statement on HRT has taken away some of the boundaries about duration of treatment, which allows for our favorite way to prescribe medication; that is, with a lot of individualization.

Should I fear using HRT because it can cause breast cancer?

The short answer is no, but the better answer is “it depends.” There’s no doubt that some susceptible women, such as those with certain family history or genetic risk factors, may not be able to or want to  take HRT because it may fertilize a propensity to develop breast cancer. It’s true that with longer term use from combined (that is estrogen and progesterone”¦not estrogen alone) HRT, there’s a small increased incidence of breast cancer. It’s about 8 extra cases per 10,000 women, so the absolute risk is very low. The increased risk from two glasses of wine per night or eating red meat is higher, to put it in perspective.  You do have to commit to screening mammograms and knowing your body. I put this in terms of risk benefit ratio more than cause and effect. So often the benefits are going to outweigh any potential risk.  We consider the individual patient and her individual profile when it comes to HRT.

Can women start having migraines in perimenopause if they’ve never had them before?

I’ve seen women start having migraines in perimenopause, but headaches are so multifactorial, especially vascular headaches. And my sense is that the sleep disturbance that comes along with perimenopause transition may play a big role in headaches. We all know if we’ve had a restless night’s sleep, the next day we don’t feel as well in our body. Maybe more headachy. I believe there’s a real sleep disturbance component to these headaches.

If you are post-hysterectomy, do you need to take the progesterone with the estrogen?

The only job of the progesterone in HRT is to protect the uterus from overgrowth of the lining. So, if a woman does not have a uterus, whether or not she still has ovaries, then she doesn’t need a progesterone. There’s some evidence to show that the combination of the estrogen plus the progesterone (the E + P) is what can cause some additional risk over time.   

Is there a connection between autoimmune diseases and menopause?

Autoimmune is highly prevalent in women compared to men, and estrogen plays a role in autoimmune disorders and immunity in general. But immunity is also influenced by genetics, lifestyle and environment, so it’s hard to carve out just the estrogen component. It definitely plays a role in some autoimmune disorders such as rheumatoid arthritis and MS as as they may get worse with menopause. Lupus sufferers may actually feel better with menopause. But this varies greatly as it’s based upon the individual patient.  

Is it true that the earlier a woman starts puberty, the earlier they’ll start menopause?

Not necessarily. A lot of women think if they were a late bloomer, they will not go through menopause until later. Or perhaps they started their periods when they were ten years old, and think they’re going to finish earlier. These things are not necessarily correlated. The average age of menopause across the board is 51. The normal age range is 45 to 55, and it’s independent of how old a woman was when she started puberty. Family history may actually be helpful; that is, knowing how old your mother or older sisters were at the time of menopause may be somewhat predictive.

Should I worry if I’m 59 and haven’t hit menopause yet?    

This is definitely older than average (by the age of 55, 95% of women have completed the menopause transition), but as long as you’ve been getting medical care from a clinician who is familiar with these things and there is good confidence based on menstrual history and (in this case) labwork, that you are still pre-menopausal and not having post-menopausal bleeding, there are benefits to ongoing ovarian hormone production. There is a silver lining there for your bones, cognition and cardiac health. 

Is weight gain a side effect of HRT?

No, HRT does not cause weight gain. But it is true that many women start HRT coincident with the onset of menopause, which does bring metabolic changes. Increased weight around your midsection is very common at this stage of life, even if you have never had it before. It’s the body’s way of compensating for the loss of ovarian estrogen production, since estrogen can also be made in fat. To a certain point (say 5-10 pounds), I usually encourage patients to be accepting of a new normal and not too go crazy trying to maintain a weight that they were five or ten years ago. Some changes in nutrition can be helpful, along with getting adequate sleep, and exercise.

What can I do about hair loss or hair thinning with menopause?

It is true that aging in both men and women can cause hair to thin. I never automatically attribute this to menopause and always encourage patients to see their dermatologist. Thyroid disorders, among a list of other things, can cause hair loss. Depending on the pattern of hair loss on a physical exam, labs and/or scalp biopsy might be indicated. Menopause absolutely can contribute to hair changes, but please see your dermatologist for an examination, blood work and investigation before assuming it’s strictly based on menopause. 

Does HRT prolong menopause?

HRT does not extend or prolong menopause. This is a common concern among women considering HRT. Menopause symptoms tend to dissipate over time naturally, and so your symptoms are going to be what they are at that age, whether or not you took any HRT.  

Is there a certain age that someone is going to start menopause?

It’s highly variable. I always say 45 to 55, but a lot of women will start to notice changes in their late 30s and I call those prelude symptoms. This is when symptoms tend to come and go. Certainly, into your mid 40s it is very common to start seeing some symptoms, even if they’re not consistent.

Is a woman infertile because her periods have become irregular?

You may still ovulate from time to time until you have gone a year without a period. So even if your period is not regular and predictable, I always tell my patients they still need contraception until they’ve been a year without a period. Irregular periods are not a form of birth control.

Is more painful ovulation a sign or symptom of perimenopause?

It doesn’t seem fair that when we’re trying to end our reproductive years that we have to get more pain with it.  But I’ve seen many patients that report more painful ovulation and periods, and more PMS during perimenopause compared with the earlier years of their reproductive life. 

If my hormone labs are normal then I’m not in menopause or perimenopause, right?

Not necessarily. Labs indicate levels in a snapshot – a moment in time as and they may vary a lot from one day to the next. If we look at a woman at the right age with classic symptoms, the labs might still be normal, or they may be normal today and not tomorrow.  So, it’s good to not to rely on them, as normal labs may not mean that it’s not perimenopause. 

What are your tips for relieving increased PMS during perimenopause?

There are a lot of holistic things I go back to like exercise, eating well, and adequate sleep. I have prescribed very low dose birth control pills for women in perimenopause who have a lot of PMS as women who do not ovulate do not have a lot of PMS symptoms. The pill eliminates ovulation so that that can be a nice transitional thing to do.

How do you feel about testosterone pellets as hormone treatment?  

I don’t use them. Testosterone is typically prescribed for libido, and in order to make a difference on that, you have to use really high doses of testosterone. I call that trying to make a woman into a man – and there may be some cardiac risk associated with that. So,  I am not a believer in the use of testosterone for women. Other doctors disagree, and I respect that, but I’m not a fan of testosterone in any form, whether it’s pellets or creams, patches, etc., and I’ve not found it to be helpful.

If you are in menopause, should you avoid regular Pap smears or have them more frequently?

Menopause really doesn’t influence our Pap recommendations for most women over the age of about 30. If you’ve had normal Paps, you can get one about every third annual. There are some age-based recommendations on how often to get a Pap, but typically we’re going to do Paps up to the age of about 65, assuming normal results over time. Menopause doesn’t influence whether or not to get a Pap smear.

Will all this extra protein in my diet make me fat?

I always promote a diet consisting of lean protein and vegetables, more specifically the Mediterranean way of eating. I think we really have to watch out for the carbs and especially refined sugars. As we age, we’re losing muscle, and estrogen does play a role in maintaining lean muscle mass. So, when your estrogen is decreasing and your muscle mass is naturally decreasing, having that additional protein can help to rebuild, repair, and maintain that muscle.

Are low dose antidepressants effective for hot flashes?

Yes, I’ve had some good luck with this. Especially for patients who cannot take hormone replacement therapy, or don’t want to. We know that certain  low dose antidepressants can help with hot flashes. Additionally, menopause frequently brings mood disorders. It can unmask depression and anxiety or make it worse. So, you may get some double coverage by using a low dose antidepressant for hot flashes and moods. But I will say that as helpful as they may be, there’s nothing as effective as estrogen for relieving hot flashes.  

What is your trusted advice for women going through menopause?

I always say be aware of “Doctor Google”. Getting your information from Doctor Google can be like drinking out of a firehose and you don’t know what’s reliable and what’s not. Rely on your physician, and specifically in menopause, your OB/GYN physician. Narrow your resources to reliable ones such as gennev.com, acog.org and menopause.org.

You can listen to the “Menopause Myths & Facts” interview with Dr. Savage here.

We can help relieve your menopause symptoms

You deserve the support, education and specialized menopause care that will help you start feeling better now. Learn more about Gennev’s Integrated Menopause Care by clicking here.

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^{The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.}

The changes women experience during menopause don’t just affect their insides. Skin and hair also go through a transition.  If you’re seeing noticeable changes in the health, texture and appearance of your hair and skin, chances are you can blame declining levels of the hormone estrogen. These unwanted and often unexpected changes can be frustrating, but there are things you can do to protect your skin and hair throughout the menopause transition.

Since estrogen is linked to hair growth, density and fullness, as hormone levels decrease, head hair can become dryer, more brittle, and thinner. And due to a greater proportion of androgens (male hormones), you may begin to notice some hair on your face that’s more like male facial hair, particularly on the jaw line. You may also notice a decrease in body hair, including the pubic area.

Declining estrogen also means skin gets thinner and less elastic due to a decrease in collagen. Without their usual supply of estrogen, our bodies produce less of the oil that both softens skin and helps it retain moisture. Menopausal skin loses elasticity and hydration and becomes thinner, dryer, and loose. Many women find they have acne again for the first time since puberty. Skin becomes more prone to rashes and bruising and may heal more slowly during this time.

There are many causes for changes in hair and skin as you age. It’s best to visit with a dermatologist for diagnosis and treatment, as well as to rule out any underlying conditions that may be attributed to what you are experiencing.

Medical interventions for unwanted menopausal hair

If you are dealing with unwanted facial hair in menopause, there are a few options to consider, although they can come with some downside:

• Topical treatments as these can be expensive and require continued use or the hair grows back.
• Depilatory creams can be bought over the counter, but they may be a bit stringent for the face, particularly as skin gets more sensitive with age.
• Lasers shoot beams of light over the skin, overheating the hair follicles and destroying them so the hair doesn’t regrow, but this can take several treatments to become permanent, and it doesn’t work on fine or light-colored hairs.
• Zapping hair with electrical current in electrolysis is expensive and slow because it can only destroy one hair at a time. It’s permanent, but can take a long time to complete, hurts, and can potentially scar.

Medical interventions for hair loss

The signs of hair loss in women may include an increase in hair falling out each day, noticing patches of thinner or missing hair, a widening part at the top of your head, or even noticeably smaller ponytails.

Before pursuing hair loss treatment, it’s important to talk with your doctor or dermatologist to learn the cause of your hair loss, as well as treatment options that are right for you . Your healthcare provider will do a thorough history as well as order relevant tests to help diagnose your hair loss:

• Blood tests to evaluate ferritin levels, vitamin and mineral levels
• Blood tests to evaluate hormone levels including your thyroid and sex hormones
• Scalp biopsy or Trichoscopy (non-invasive dermoscopic imaging of hair and scalp)
• Hair pull – doctor gently pulls on your hair to see how many hairs come out

If it’s thinning head hair you are experiencing, unfortunately, there are few solutions. The good news is, the loss generally slows as hormones level out.

• Minoxidil (Rogaine) can help you regrow some hair, though you have to keep using it. “
• Anti-androgens may work for some women for whom Minoxidil is a non-starter.
• For some women, an iron deficiency may be partly responsible, so an iron supplement can be helpful. Be sure to consult with your doctor before starting any new supplement regimen.
• Hair transplants have come a long way since hair plugs and can be quite effective in filling in patches where hair has thinned.

Medical interventions for changing skin

Before you do anything to aid your age-related skin changes, we recommend locating a dermatologist who has experience with women in menopause, as all skin is different and should be treated with real care. Note that some procedures work best on skin that’s aged from sunlight rather from estrogen loss. Some options include:

• Prescription-level retinoid skin creams, made from vitamin A extract.
• “Peptide creams use amino acids (though these are likely less effective than retinoids).
• “Microdermabrasion encourages new skin growth by removing the top layeras it is time consuming and expensive and the effects only last about 4 weeks.
• “Laser resurfacing of the skin uses high-intensity light to tighten loose skin, improving the look of wrinkles.
• Newer non-ablative laser resurfacing doesn’t cause wounds to the skin, so recovery is quicker. The heat generated by the laser promotes collagen production which causes the skin to tighten and look younger and healthy.“
• Chemical peels remove the upper layer of the skin and encourage new growth.

Lifestyle modifications for healthy skin and hair

Probably the best thing you can do for your skin and hair, no matter what your age, is protect what you have.

• Reduce sun exposure, and use SPF every day.
• Use gentle products that don’t strip away the remaining moisture.
• Hydration is key. Drink plenty of good, nutritious water to hydrate your body from the inside out.
• Don’t smoke.
• Shower with cooler water for less drying of your skin.
• Moisturize skin and condition hair. Replacing the moisture you’ve lost isn’t entirely possible, but every bit helps.

When it comes to skin, we strongly advise getting to know your skin very well. Checking your skin every month for changes can perhaps mean catching a potentially serious problem like skin cancer while still in its early and more treatable stages.

Natural remedies for skin and hair

For unwanted facial hair, sugaring, tweezing, waxing, and threading may be slow and tedious, but they can be less expensive, less potentially damaging to skin, and reasonably effective, if a bit painful.

To preserve head hair, use gentle styling techniques that require less heat and pulling. Shampoo with zinc or selenium might help with a dry and itchy scalp. A shorter hair style might help make hair appear fuller.

Some say eating estrogenic foods such as soy, dried fruits, and flaxseed can help, though there’s no research to back that up. Others take collagen supplements, though currently there’s little evidence to prove the impact on menopausal hair and skin.

The effect of changing hormones on your hair and skin may seem out of your control, but when you prioritize your wellness during this stage of life, you will support your body and your beauty from the inside out. Keep feeling and looking your best in menopause and beyond by maximizing your nutrition with a healthy and balanced diet, staying hydrated as well as exercising each day. And please visit with your doctor or a dermatologist when it comes to concerning hair and skin changes, no matter what your age.

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^{The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “œjust menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.}

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Many women in menopause find their standard eat-and-exercise routine no longer works for maintaining weight. The reality is, in menopause, you’ve probably lost some muscle mass, and with it the higher metabolism that burns more calories faster. On average, midlife women gain 1.5 pounds (0.7 kg) per year. Managing your weight in menopause is simply more difficult.

Metabolism and weight gain in menopause

Body fat produces estrogen, so a little extra of the former means more of the latter to ease your transition and help protect your bones, brain, and heart. That said, menopause also directs your body to put more of the excess weight on your belly, rather than it landing on your hips, thighs, and buttocks, as it did in your reproductive years. Belly fat is more problematic, because it can contribute to heart disease and metabolic syndrome. So, if you find you’re gaining more than you’re comfortable with, there are things you can do to re-rev metabolism and maintain a healthy weight.

A smart first step we always recommend is talking with a doctor or a Registered Dietitian to find out what is truly a healthy weight for you. Talk about any risk factors you have for exercise and ask if any of your medications may be contributing to weight gain and could be safely swapped out for another without that side effect. Generally, doctors won’t prescribe medications or procedures for moderate weight gain, as better lifestyle choices and acceptance of your post-menopausal body are the healthiest paths (hard as we know those can be!) A weight gain of 10-15 pounds during the menopause transition is typical. And if you are lean going into post-menopause, weight gain may actually be protective.

Lifestyle modifications for weight management

At this stage of life, your body requires fewer calories to function – so if you eat the same amount that you did in pre-menopause, you’re likely to gain weight. Also, perimenopause can suppress leptin (the satiety hormone), and ramp up ghrelin (the hunger hormone), making you feel hungrier. We’ve rounded up the eight lifestyle changes that have proven effective in supporting weight management for the Gennev community.

Embrace your changing body. The biggest lifestyle tip we suggest is to embrace and accept your changing body. It may be a little softer and rounder in spots, and that’s perfectly normal and OK. It’s important to first focus on health. Looking good is great; feeling good is even better.  

Optimize your diet. Obviously, this is a biggie. Now is the time to really pay attention to nutrients first and foremost to support brain, bone, and heart health in the years ahead. Fortunately, good food and beverage choices for those tend also to be good choices for minimizing menopause symptoms, including weight gain. Not so much a “diet” as an eating pattern, the Mediterranean diet is the most healthful for women in menopause. It focuses on lots of veggies, plus fruits, whole grains and lean proteins. This style emphasizes eating things closer to their natural state (minimally processed) for the highest nutrient density and ease/efficiency of absorption.

The DASH diet has similar advantages to your body; in fact, it was devised specifically to help treat or prevent hypertension. In addition to many of the same foods advocated under the Mediterranean diet, DASH also advocates limiting salt. Protein, healthy fats, and fiber are how your body reaches satiation and stays there longer, so be sure you include enough of each.

Food journaling. If you eat the same amount that you did in pre-menopause, you’re likely to gain weight. When we’re stressed or our hormones are doing strange things, it can be difficult to have a real idea of what we’ve consumed during a day. Keeping a journal helps us get a clearer picture of our eating (and snacking) habits. BONUS: Journaling may also be a way to uncover food sensitivities that didn’t exist previously and that cause other issues like gas or inflammation.

Hydration. Believe it or not, what we think is hunger is often dehydration. Remember, you should be drinking half your body weight (in ounces) every day, so before you have a snack or seconds, drink some water and see if you’re still hungry. If you are, eat! Hydration is so good for us, and you may need more of it if you’re dealing with night sweats and hot flashes.

Sleep. There is a very strong association between not getting enough sleep and weight gain. And yes, sleep is a bear to get during perimenopause and menopause, so do the very best you can to practice smart sleep hygiene and maximize your chances of a good night’s sleep.  

Exercise. Even if you’ve been a dedicated exerciser, you may find that your usual routine no longer has the effects it once did when it comes to controlling weight. Changing up the balance of cardio vs strength training can help in lots of ways, to help you manage weight, sleep better, manage stress, and put some healthy demands on your bones. It’s important to keep moving in menopause and beyond for both the emotional as well as physical health benefits.

Mindfulness. “Mindfulness” is the art and science of being fully present and in the moment, and when it applies to eating, it can really help you eat better and less. Being mindful when menu planning and grocery shopping adds to the bounty of goodness this practice delivers because you won’t get home to discover some bags of empty calories, salt, sugar, chemicals, and saturated fat mysteriously ended up in your cart. Mindful eating means not doing other things while eating”” no TV, no Internet, no phone calls or emails. Instead, be aware of the now:the smell of your food, the colors, the sizzle of heat, the shine of glaze. As you eat, note not just the taste but the mouthfeel and texture. Try to experience the component flavors: is there a hint of thyme? The more aware you are, the slower you’ll eat and the better you’ll recognize when you’re satiated.

Try Green Tea. Green tea has helped many women with menopause symptoms, including weight gain. Possibly the catechins in green tea accelerate metabolism ever-so-slightly or boost the burning of calories. There isn’t sufficient research to say how or even if green tea works its magic, but it might be worth adding a cup to the early half of your day (it’s caffeinated, so maybe drink before noon and stick to no more than one or two cups per day).

If weight gain continues to trouble you, it’s important to speak with your doctor before it becomes a serious health risk. They can advise of medical interventions that may be right for you based upon your individual weight management goals.

Menopause, body weight and shape changes

Gennev recognizes that the body weight and shape changes which occur with aging and the menopause transition often leave women feeling uncomfortable in their bodies and concerned for their long-term health. Based on current research we know diets work, but with caveats. Most diets leave most women feeling deprived and frustrated to only gain back the weight they lost (and sometimes more). Through our team’s experience working with countless women and accounting for the physiological and metabolic changes that occur during menopause, we have developed the following approach to address these three important components.

Start with YOU – understanding you as the individual, your place in the menopause transition, your current habits, concerns, and goals is our starting point. Our Integrated Care team meets you where you are and supports you along the way to feeling better in your body:

• Assess current and past nutrition habits and relationship with food and body
• Listen to your health worries and questions
• Account for your lifestyle, resources, time, and energy available
• Address where you are in the  menopause transition and the influence that has on recommendations

Cater to menopause physiology – the changing hormones during peri and post menopause result in a physiological and metabolic state which is different from pre-menopause. Strategies that work with rather than against these changes offer greater benefit and long-term sustainability. They include:

• Meeting protein needs
• Assessing carbohydrate intake and adjusting to account for blood sugar response
• Incorporating anti-inflammatory foods/Mediterranean-style nutrition
• Movement that feels good (and ideally includes resistance training)
• Rest/recovery/rejuvenation/mobility

Activate the Gennev menopause mindset – a proprietary combination of cognitive behavioral therapy, abundance mindset, and motivational interviewing that supports women in embracing what can be rather than wishing for what was.

• Empower with knowledge
• Self-compassion
• Mindful/intuitive eating
• Living forward with more peace and confidence, and less resistance

With this approach some women will lose weight, and some women will find that they are exactly where they are supposed to be. All women will gain the health benefits of implementing habits supportive of metabolic and physical health as this stage of life.  

We understand how frustrating it feels to not get the results you want when you have been working so hard. We invite you to try a different approach and learn how Gennev’s Integrated Care Team can support you with your weight loss goals.

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^{The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.}

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Perimenopause (the time leading up to menopause) typically begins for women sometime in their 40s. This is when you may begin noticing menopause symptoms including hot flashes, interrupted sleep, lower energy, and mood swings. And as women arrive at menopause (defined as when a woman has gone 12 consecutive months without a period), they may also be impacted by a slowing metabolism. Menopause brings with it many bodily changes, but a well-balanced diet and nutrition can help support you on your journey.

Through the menopause transition, hormones (primarily estrogen and progesterone) are fluctuating as they slowly decline. These changes create a new physiological environment for the body which has metabolic effects that influence how the body metabolizes food. Consuming a well-balanced diet is key for optimizing health throughout all stages of life, but during menopause it becomes even more important.  

“The changing hormones of the menopause transition create stress on the body, albeit a normal natural stress, it is stress nonetheless. Being intentional about optimizing your nutrition during this time can support your body through managing the stress of the hormone changes. By giving your body this support, a reduction in symptoms can occur in the short-term and overall health can be supported in the long-term.” –Stasi Kasianchuk, Registered Dietitian Nutritionist, Exercise Physiologist, and Certified Specialist in Sports Dietetics 

Key nutrition recommendations for menopause

Stasi Kasianchuk, a registered dietitian nutritionist, and Gennev’s Director of Health Coaching, shared with us key nutrition recommendations for women in menopause that will support the body through the transition and optimize health outcomes now and into the future. Stasi suggests that first, it’s necessary to examine our relationship with food. “At times in our life when our bodies change in ways that feel outside of our control it can be tempting to see food as the enemy and want to restrict or limit your intake.” Stasi recommends, “During the menopause transition, when your body is already managing the stress of changing hormones, restricting calories can further exacerbate the stress response resulting in undesirable consequences. Establishing a positive relationship with food by focusing on nourishment and support, can be helpful to get the most out of the following recommendations.”

Rather than low carb or no carb, focus on strategic carb. Estrogen influences carbohydrate metabolism, so as estrogen levels change during the menopause transition, so does the way the body uses carbohydrate. The body’s ability to respond to insulin secreted in response to carbohydrate consumed also decreases and can lead to increased blood sugar levels. This does not mean you need to eliminate all carbohydrates, in fact that will have the opposite effect and typically exacerbates undesirable blood sugar spikes. Strategically approaching your carbohydrate intake with the majority of these coming from fruits, vegetables, and wholegrain sources can help to meet your carbohydrate needs and support an optimal blood sugar response. Refined or simple carbohydrates can certainly be enjoyed, as this is part of having a positive relationship with food, and also make a great fuel source prior to exercise, especially high intensity training.

Prioritize protein. Most women are not aware that protein needs increase during peri and post-menopause. Having adequate protein from food is important to provide the body with the building blocks to support muscle mass which naturally declines during this phase of life. Aiming for 20-25g of protein with each meal and especially after resistance training and high intensity interval training (HIIT) can help to mitigate muscle loss. While all foods containing protein are beneficial, protein foods which contain the amino acid leucine are particularly helpful for stimulating muscle growth. These foods include eggs, beans, legumes, chicken, salmon, brown rice, and chia seeds.

Fats are your friend. The hormonal shifts during peri and post menopause allow the body to better utilize fatty acids. The key here is to prioritize fats from unsaturated sources, especially those containing omega-3s such as salmon, sardines, walnuts, and flax, hemp, and chia seeds. These support brain and heart health and help the body manage inflammation.

Think in color. Focusing on eating a variety of colorful foods typically results in eating more fruits and vegetables which offer fiber and nutrients to help the body better manage inflammation which can increase with the changes in estrogen and progesterone. The hormonal changes during peri and post menopause can also influence the gut microbiome. Women may experience changes in digestion as a result. Supporting the gut with a variety of plant sources of fiber not only supports optimal digestion, but also promotes satiety, lower levels of blood cholesterol, and stabilize blood sugar. All of which are also altered when hormone levels start to shift.

Bone support. While dairy foods can certainly support bone health, they aren’t the only foods that provide bone building nutrients at a time when bone formation is no longer occurring. A combination of foods containing calcium, vitamin K, magnesium, vitamin D, and protein synergistically can support maintaining bone. These foods include dairy products, tofu, nuts, seeds, leafy greens, and plant and animal sources of protein. If you have limited exposure to the sun, you may benefit from supplementing with at least 2000 IU of vitamin D per day (check with your doctor to confirm your needs).

Take note of symptom exacerbators. Perimenopausal symptoms such as hot flashes, night sweats, sleep disturbances, anxiety, and mood swings are some of the symptoms that can be exacerbated by certain foods. These include refined carbohydrates/simple sugars, caffeine, and alcohol. Pay attention to your symptoms when you consume these foods or beverages. If you notice your symptoms getting worse it doesn’t mean you have to eliminate these items, but a modification to your intake may help you to feel better.

Implementing these nutritional strategies along with making time for daily physical activity will not only help relieve symptoms, but will support your overall health throughout the menopause transition and beyond. If you need additional guidance in developing a healthy diet in this stage of life,  our menopause specialists can be a great resource for creating a personalized plan that supports your body’s changing nutritional needs, relieves symptoms, and optimizes your health for the long term.

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^{The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.}

In part five, the final transcript in our 5-part series featuring Dr. Rebecca Dunsmoor-Su’s interview with David Steward on the SuperAge podcast, “HRT, Estrogen and Menopause, New Scientific Findings”, we’ll learn Dr. Rebecca’s take on whether intermittent fasting is beneficial, why strength training is key for women, and why it’s so important to support your bones starting in your 30s.  Plus, Dr. Rebecca shares what she wants every patient to know about hormone replacement therapy. You can listen to the full podcast by visiting SuperAge.com.  

Is intermittent fasting beneficial for women?

David: I’ve had some questions from some of the people in our community about intermittent fasting, stress, and women, how they may react differently to this. And then, does that change with changes in estrogen levels or do we not know anything about that?

Dr.Rebecca: We do have some data on that. Remember, when we were talking about sleep and that metabolic rate change? Part of that discussion was that, when you’re not sleeping and your cortisol is not dropping to its lowest point in the middle of the night like it’s supposed to, then you end up putting yourself into a state of somewhat insulin resistance. So, not fully pre-diabetic, but there’s just a little more insulin resistance, which means you don’t process sugar as well. So, we know that happens. Step one is not so much hormone therapy directly changing that resistance, although, there is probably some interaction between estrogen and cortisol that we don’t fully understand, and so that is contributing, so estrogen can help. But the biggest thing is, when I start someone on hormone therapy and they start sleeping again, then we’re improving their metabolism. Does it mean that when we start hormone therapy and the weight drops off? No. Unfortunately, not. One thing we know from all of our studies is that, women who are perimenopausal or menopausal can lose weight, but it takes a lot longer and a lot more work. Unfortunately, some of these metabolic changes that occur are permanent.

I think intermittent fasting can be very helpful for people who are insulin resistant. For some women in menopause, intermittent fasting is a structure that can work for them. What I tell all of my patients however is what you need to do long term is make changes that you’re going to be able to sustain. So, if this is something that feels good to you, and natural, and normal, and it’s something you can sustain long term, great. That’s a great thing to try. But if you are struggling through each morning to not eat until 11, then, this is probably not the right pathway for you. There’s another way for you and everybody is different, as there is no one diet plan that works for everybody. People need to find what works for their body, and their lifestyle, and their system, and understand the underpinnings of their eating. A lot of what I do in my clinical practice is talk to them about this. What are you eating and why are you eating? Is this emotional eating? Is this bored eating? What are the things that we need to maybe think about and how do we substitute those things out?

David: I just want to go back to that the relationship between the cortisol question. So, does intermittent fasting in women cause a cortisol response that doesn’t happen in men?

Dr.Rebecca: We don’t know – that is my answer. I don’t know. I think, we haven’t studied it well enough yet to really understand how that might differ between women and men. I think that a lot more depends on other impacts on cortisol. So, whether it be sleep or the drop in estrogen, which also impacts cortisol levels, probably, more than the intermittent fasting itself.

The thing is cortisol is not a simple thing. The way our whole endocrine system is interrelated is very complex and not always all that well understood. We think of the endocrine system as multiple different systems. Think of the thyroid, the adrenals, the ovaries, but these are one big system that all interrelates in a way that we haven’t fully defined.

Strength training is key for women in midlife and beyond 

David: I’m a big proponent of strength training. But especially for women, there seems to be this delusion that they’re going to turn ArnoldSchwarzenegger without anabolics. I don’t think that’s going to happen. 

Dr.Rebecca: No. Although, if you get testosterone pellets that may.

David: Yeah, that’s an anabolic. Right. If you’re not doing that, so talk tome about is there any counter indication to strength training for women?

Dr.Rebecca: No. Strength training is key for women for a multitude of reasons. One of the things that the drop in estrogen also does is it makes it harder for women to maintain their lean muscle mass. As we all know, lean muscle mass burns calories. So, you have to build that muscle mass back. Even if we put you on estrogen, you still have to build it back and maintain it. That’s just basic health. The second reason is strength training in the big muscles supports your bone. So, as women go through menopause, and they head towards osteoporosis, strength training in the core muscles, the upper body, the lower body, it’s key for maintaining bone health and bone strength and it also helps with balance and strength long term, so that even if you do get into a region of osteopenia or osteoporosis, if you have strong muscles and good balance, you’re going to be better off and less likely to fall unbreakable.

Support your bones starting in your 30s

David: Are you having your patients do bone density scans, DEXA scans?

Dr.Rebecca: Oh, yes. In my patients, I do DEXA scans. The current national recommendations are to do a DEXA at 65. I often do it much earlier than that because I feel like by 65, they kind of miss the boat. So, I often will use them in my newly menopausal women who have a strong family history and who want to use that information to help them decide about hormone replacement therapy. So, that’s a good point to do it. I certainly use it anytime someone has fragility fracture, so, like a wrist fracture or refraction. And then, in general, I tend to get one somewhere in a woman’s 50s, just so we know where she is in the pathway to osteoporosis, and so she can start to make excellent changes early on. The recommendation to do it at 65 is really more about the medications, so the bisphosphonates and the MADs, and the medications that can rebuild them, but if we can prevent that bone loss, even better.

David: What’s the delta, what’s the change? That’s important thing, right?

Dr.Rebecca: Right, exactly. I tell my patients that I don’t care what your bone mass is, you should be taking vitamin D and getting enough calcium in your diet or between diet and supplement – and magnesium. Support those bones, we should be starting that in our 30s, because women build bone until they’re 30s, and then they start to lose.

What I tell all my patients about hormone replacement therapy

When the Women’s Health Initiative came out in 2002 and everybody got scared away from hormones, it left this huge vacuum in the market where all of us physicians were saying, “Nope, we don’t do that anymore.”  So, people stepped up and stepped into the breach, and started promoting things they called safer, or better, or more natural compounds, what they call bioidenticals. These are not safer, they’re not more natural, they’re made from the same synthetic hormone from the same pharmaceutical companies, just ground up and mixed into new bases that are unregulated. Therefore, unregulated in dose. This is not a safe pathway.

Please come talk to us. There are plenty of us out there who are North American Menopause Certified. We will happily talk to you about hormones. We were not afraid of them. But we use FDA regulated products which are safe and body identical.

The more we can get information out to women that this is a pathway they can explore safely with their physician, the better. A lot of physicians are still stuck back in 2002. They don’t understand all the data that’s come since. Find yourself a doctor who has actually read it all.

Don’t miss the entire series of Dr. Rebecca’s interview with SuperAge on HRT:

• Part 1: Learn about the hormonal journey, and why hormone testing is not always helpful.
• Part 2: Learn about the benefits of estrogen, and why some women are not good candidates for HRT.
• Part 3: Learn about the need for quality sleep, and what you need to know about testosterone therapy in menopause.
• Part 4: Learn about HRT risks, and why Alzheimer’s disease affects women more than men.

And be sure to listen to the full podcast episode at SuperAge.com.

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^{The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.}

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In part four of our five-part series featuring Dr. Rebecca’s interview with David Stewart on the SuperAge podcast, “HRT, Estrogen and Menopause, New Scientific Findings with Dr. Rebecca Dunsmoor-Su”, she shares the three typical usage patterns of hormone replacement therapy, dispels the risks of HRT as they relate to breast cancer and cardiovascular disease and discusses why the risk of Alzheimer’s disease is so much higher for women.

What are the risks of HRT and is there a limit to using it?

David: Is there a time limit that one can be on HRT, or is it a lifetime?

Dr.Rebecca: Interestingly enough, we talked over the years about risks of HRT. So, a lot of women believe that HRT is going to cause them breast cancer or give them heart attacks. These are the two risks that we tend to talk about. I like to dispel those risks.

First of all, the breast cancer risk. I like to talk about the two hormones separately. Estrogen replacement does not cause breast cancer and I shout that from the rooftops. We have many studies that tell us that estrogen replacement does not cause breast cancer, it does not increase the incidence. The Women’s Health Initiative, that big study that came out in 2002 that scared everybody away from hormones – they continued their estrogen only arm and then they actually published the results of the 18-year follow up last year, and they showed no increased risk in breast cancer in the women taking estrogen alone.

Now, obviously, we talked about the fact that women who have a uterus also need progesterone. The Women’s Health Initiative showed that there was a slight increased incidence of breast cancer in progesterone users as or progestin users. They used Provera and they stopped to study for that. They also followed it up last year, 18 years later, and they can still see that slight incidence bump, and I’m talking slight, one additional cases of breast cancer in about a thousand-woman years which is how we study it, but they saw no increased risk in breast cancer mortality. So, the good news is this is low grade. But again, that was Provera. It’s not what we tend to use now. Nowadays, we tend to use micronized progesterone, which is a little more body identical as we like to call it. I use those words because that separates it from the marketing of bioidentical which is generally the marketing of compounds which are less safe. I talked about body identical, which are estradiol and micronized progesterone, which are the molecules that the body used to make, but FDA regulated.

When we use micronized progesterone, we don’t tend to see that bump in breast cancer risk. We have one big study out of France that has looked at 40,000 women on a micronized progesterone prescription up to five years and they saw no increased risk in breast cancer rates on that particular compound. I tell my patients, I can’t say for sure. It doesn’t increase your breast cancer risk. I think there’s more study to be done on this progesterone, but I certainly don’t think it increases significantly. One in eight women get breast cancer-that’s our baseline rate. Some women on hormone replacement therapy are going to get breast cancer. There’s nothing we do about that. If you get it, you have to stop. But I tell people, there’s a difference between association and causation. I think, we’ve assumed a causation that really isn’t there for many years.

Then, we talk about cardiovascular risk. The Women’s Health Initiative also made us worry about cardiovascular risk of stroke and heart attack. What we know from that in other studies is that, the risks of estrogen and progesterone are based on when you start, not how long you use it. So, if you start within five years of that last period, you can use your hormone replacement fairly indefinitely without increasing your risk. The risk of heart attack, stroke, all those things are based on when you start. And women who start hormone replacement therapy within five years of their last period actually reduce their cardiovascular risk, we talked about that. They also slightly reduce their colon cancer risk and they reduce their all-cause mortality over time. The North American Menopause Society is really clear – there is no set stop date for hormone therapy. You can use it as long as it’s functional for you.  

Three typical use patterns of HRT  

Dr.Rebecca: In my practice, I see three different patterns really. Small group of my patients use it just to manage symptoms rather transition to menopause. Two to five years, they taper off, they feel fine, we’re good. Another subset, use it through the age of retirement. They’re very functional women, they don’t like what it does to their brain when they come off their estrogen, they don’t like the hot flashes in the workplace, they want nothing to do with it, they sleep better on it. So, we use it until they’re 65, 70, 75 and then, we taper off and they do fine. And then, I have a small subset of women who feel better on hormone, and they’re going to die with that hormone in their hands, and that’s fine, too. [laughs] I’m happy to continue that journey with them as long as they don’t have any other risk factors. They haven’t developed breast cancer, they haven’t developed heart disease, or anything else that would mean that they need to come off.

Women and increased Alzheimer’s risk

David: Do you have an opinion about why Alzheimer’s risk is so much higher with women than with men?

Dr.Rebecca: I have a lot of opinions. I don’t know how based on science they are. I can tell you what we know from the data and what we suspect. I don’t know if we have the full story yet. We mentioned Dr. Mosconi. She’s working on this at Weill Cornell Medical School, and I think, she’s probably on the pathway of discovering exactly what’s going on in the brain. But I think, there are a couple things about estrogen that we need to think about. Like I said, estrogen is an anti-inflammatory molecule, and it’s anti-inflammatory everywhere including in the brain. So, I think, there’s a certain amount of that anti-inflammatory effect that is beneficial for women.I think that sleep has a lot to do with it. When women are transitioning through menopause, we’re talking about five, ten years of disrupted sleep. That’s a lot of impact in the brain and I think that has a lot to do with it.

David: Wow, okay. So, I’m going to paraphrase here and tell me if I got this wrong. But it seems like with HRT, unless you fall into one of these groups where you have a preexisting condition, and you can’t do it – this seems like a really good thing all around. If for nothing else, just the sleep. Like not sleeping for ten years like, oh, my gosh, that’s going to cause all kinds of problems.

Dr.Rebecca: Right. I don’t disagree with you. I think, we have been told a scary story of hormone replacement therapy. Before the Women’sHealth Initiative published, that was not the story we were telling. We were telling women it was great for them. Those of us who’ve been working in this space a long time have gone back to that story for the most part. I think that was the Women’s Health Initiative, and the way it was published, and the way it was recorded was a bit of a blip in that story. The way I’d like to think about it is that, menopause probably had a function when it started. Very few species go through menopause. It’s us and a couple of great whales. That’s pretty much it. There’s a whole sort of grandmother theory about why we would do this. And the theory is that, the grandmothers are the repository of knowledge within these societies, and risking them in childbirth as they age doesn’t make sense, so they stopped being able to reproduce, so they can continue to pass on knowledge. That’s a great theory. There’s no way to prove that. But sounds good. I like it.

But the one thing I do think about is, when menopause is fine and functional, if you’re going to live to be 65, you got 10 years to survive your menopause, you’re going to be okay. We live to 95, 100, 105 now. And that’s a long time. That’s almost half your life without the hormones that sort of keep things going. So, I think that we need to adjust like, I think people have been fed this line that, it’s better to just go through this natural and normal transition. Well, it’s natural normal, but so is dying by 65. We’re in a different place now. So, we need to think about our long-term health, and estrogen may actually help with that long-term health. Not everybody needs it. People do live to 85, 90, 95 without hormone replacement therapy, but it can be beneficial for many women.

David: So, if somebody comes to you and they’re non-symptomatic, they’re not having any of the sort of sleep disorders, mood stuff, weight gain, but they come to you and they say, “Huh, I’ve read this stuff about hormones and long-term brain health. Should I be doing this? Not so much my current status but my longevity, essentially? 

Dr.Rebecca: The answer if they’re just talking about brain health is, I don’t know if we know for sure. We have some studies that point at increased exposure to hormone over a woman’s lifetime being protective of her brain and reducing the risk of dementia and Alzheimer’s dementia specifically. In that, we’re talking about a couple of studies. There’s an observational study called The Cache County Study out of Utah, where they just looked at this county and watched everybody age, and one of the publications that they did was they counted up women’s years on estrogen, they counted their pregnancies, their breastfeeding, their hormone use, all those things, and showed that women with more estrogen exposure had a reduced risk of Alzheimer’s disease.

Then, there’s Dr. Mosconi’s study, which was recently published, which looks at women who’ve had exposure to contraceptives, or hormone replacement therapy, things like that, and more exposure showed decreased risk. There are other studies that show that HRT increased the risk of dementia. The Women’s Health Initiative showed an increased risk of dementia. Now, there are some issues with how that study was designed, a lot of those women were 10 or more years into menopause when they were started on hormones, there’s the whole idea of blood clotting and could there be small strokes in the brain, there are a lot of issues. But I have to be honest with these patients and say, there’s data on both sides.

Some data says that, it’s harmful, some data that says, it’s helpful. My take on all that data is, I think, there’s more help than harm if we use it correctly. If you start within five years of that menopause, if you take it continuously, if we use it through the skin rather than orally, because through the skin, there’s a lower risk of blood clots. There are ways that we can do it safely and I am happy to prescribe someone hormone therapy for health benefit as long as they understand that is actually what we consider an off-label use. Hormone therapy is FDA approved to treat hot flashes and protect your bones. That’s it. We know all these other things. So, we can have that conversation and do the prescribing based on that, but definitely, we’re in a somewhat of a gray area.

The menopause journey is different for everyone, but you don’t have to go it alone.  Learn more about whether HRT is right for you by tapping into the expertise of our integrated care team.  You will access both natural and prescription therapies approved by physicians who specializes in menopause.

Continue to part 5 for Dr. Rebecca’s take on whether intermittent fasting is beneficial, why strength training is key for women, and the importance of supporting your bones starting in your 30s.

Don’t miss the entire series of Dr. Rebecca’s interview with SuperAge on HRT:

• Part 1: Learn about the hormonal journey and why hormone testing is not always helpful.
• Part 2: Learn about the benefits of estrogen, and why some women are not good candidates for HRT.
• Part 3: Learn about the need for quality sleep, and what you need to know about testosterone therapy in menopause.

And be sure to listen to the full podcast episode at SuperAge.com.

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In part three of five transcripts from Dr.Rebecca Dunsmoor-Su’s interview with David Stewart on the SuperAge podcast, “HRT, Estrogen and Menopause, New Scientific Findings with Dr. Rebecca Dunsmoor-Su”, she reviews the need for quality sleep, and what you need to know about testosterone therapy in menopause.  Please listen to the full podcast by visiting SuperAge.com.  

The need for quality sleep  

David: I know that if you’re not getting deep sleep, your brain’s not being cleared out, and your chances of Alzheimer’s dementia goes through the roof.  So, how are you addressing that?

Dr.Rebecca: Sleep is really key for women, especially, as we age. It’s not just the Alzheimer’s dementia risk, which is higher in women as we know. But it’s also the fact that if you’re not getting deep sleep, you’re reducing your basal metabolic rate. All women tend to start gaining weight during this time in this transition. It probably has a lot to do with their lack of sleep. You can lose about 400 kilocalories a day in your basal metabolic rate if you’re not sleeping well. It tends to generate a little bit of an insulin resistance from that lack of deep sleep. Your cortisol never really goes all the way down. You don’t get to that really restful place. So, sleep is really key.

How do we address it? Well, I address it in a couple of different ways. I address it with the one proven therapy for sleep that’s been shown in studies to actually work which is cognitive behavioral therapy for insomnia, either using an app, or an online system, or they can even work in person with someone. But the apps in the online versions are actually quite good, and can really help people track their sleep habits, and make changes that helps them to sleep more deeply. Then, sometimes, I address it with hormone therapy, if that’s one of their big symptoms, and they want to try hormone therapy for it.

David: What is cognitive behavioral sleep therapy?

Dr.Rebecca: Cognitive behavioral therapy is a style of therapy that works on behaviors-recognizing behaviors, and changing them is basically the tenant of cognitive behavioral therapy. There’s a specific subset called cognitive behavioral therapy for insomnia. And what that does is, it very specifically tracks behaviors around sleep, about when you go to bed, what you do when you wake in the middle of the night, what things you include in your bedtime ritual, what do you do when you wake in the morning, all these types of things. And then, it works with you on how to adjust those to improve your sleep.  And there’s a great app that people can get for free called CBT-I trainer, I believe. It was made at the VA for veterans with PTSD. So, it’s free to everybody. It’s in your app store. You can just download it and give it a try.

 David: In my world, I would call this good sleep hygiene.

Dr. Rebecca: It’s a bit more structured than good sleep hygiene. They’re actually things that it recommends in terms of like, if you wake in the middle of the night, you actually get out of bed, don’t check the time, go to a quiet place and actually sit up. It’s a little bit more, but yeah, it starts with good sleep hygiene. 

About testosterone therapy

David: So, let’s talk about this other hormone that you mentioned, testosterone. Is it ever a good idea for a woman to be supplementing testosterone?

Dr.Rebecca: I’m glad you’re bringing it up because there’s a lot of what I like to call predatory practice out there – when people are selling women testosterone as a fountain of youth. Testosterone is anabolic steroid. It will make you feel great – and then, it’ll wear off, and you’ll need more, and then, you’ll feel great for a little while, and it’ll wear off, and you need more. So, we end up seeing as women getting into really high levels of testosterone, basically male levels of testosterone, and getting all the joy that comes with that including facial hair and acne. Their voices can deepen, they can grow an Adam’s apple, they can actually grow a small penis from their clitoris. But also on the inside, they’re getting cardiovascular disease on the level of men.

Testosterone is an important female hormone. As I mentioned before, it doesn’t really go down with menopause. It goes at a slow drift throughout our lifetimes, but you haven’t suddenly lost it. People assume as we go through menopause, and there’s often a change in libido, that its testosterone causing that change. In fact, it’s probably a much more complex thing that has to do with psychological factors, how we feel about our bodies, how we feel about our aging, how we feel about our relationships and all those things that are causing that drift down in libido. But there are some small studies that have shown that replacing testosterone at very low female physiologic levels can give a slight boost to libido in women. So, you can increase their sexual satisfying events by about two per month over time. 

David: I know you don’t like to say numbers, but can we put a number on that? What’s the dosage?

Dr.Rebecca: We’re having to use male-dosed products at female levels. Because there is no female-dosed testosterone product available in the US that’s FDA approved. So, we’re just struggling with that as physicians. A lot of people are given like compounds or pellets, these are dangerous, very hard to manage, and you can get really high testosterone levels. Those of us who practice in this space typically take a male-dosed product – it comes in little packets of five milligrams each, and for a man, that five milligrams would be a one daily dose. We have women use 1/10th of that a day. So, about 1/10th of five milligrams, 500 micrograms. We’re taking it down and trying to keep it in the female physiologic range. It’s hard for us to do. It’s something that those of us who work in the sexual function space really struggle with because we think there’s some decent data for this, but it’s really hard to safely replace in women. This is not something that should be routinely replaced in women because it is hard to manage, you have to get blood tests regularly to make sure we’re not bumping you too high to the male range, and it’s just something that has a role, but a very restricted role. 

Whether you suffer from sleep issues, hot flashes or changes in sexual function, finding the therapies that fit your needs can seem daunting.  Skip the endless searches for information, and tap into the proven therapies of our integrated care team.  You will access both evidence-based lifestyle strategies and treatments approved by our CBT-trained health coaches and physicians who specialize in menopause.

Continue to part 4 to learn about the three typical usage patterns of HRT, the risks of HRT, plus why the risk of Alzheimer’s disease is so much higher for women.

Did you miss part 1 of this series? Learn about the hormonal journey and why hormone testing is not always helpful.

“In part 2, you’ll learn about the benefits of estrogen, and why some women are not good candidates for HRT.

And be sure to listen to the full podcast episode at SuperAge.com.

Gennev Chief Medical Officer, Dr. Rebecca Dunsmoor-Su was interviewed by David Stewart of the SuperAge podcast for the women’s health episode “HRT, Estrogen and Menopause, New Scientific Findings”.

In part two of five transcripts from the session, Dr. Rebecca shares estrogen’s impact on heart and brain health, as well as why some women are not good candidates for hormone replacement therapy. If you have wondered if hormone replacement therapy is right for you, read on. And please listen to the full podcast by visiting SuperAge.com.  

Estrogen’s impact on cardiovascular and brain health 

David: As progesterone goes to zero, estrogen goes very, very low, what are the other effects on the body from this? 

Dr.Rebecca: That’s a really good question because I think we have lost sight of talking about the benefits of estrogen for a woman over the years with all the fear mongering around cancer, which we should also discuss separately. But estrogen is actually a really healthy hormone for women. So, we know that estrogen is active in basically every part of the body. It’s active in the brain, in the cardiovascular system, the bones, it’s active in the genital region, obviously. And losing estrogen has significant impacts on women as they age. For example, let’s start with the cardiovascular system. So, we for years knew that women didn’t really start having their heart attacks until after menopause. There were a lot of theories by this was, there was this big Framingham nurses’ study that came out looking at many, many nurses, and we’re tracking their progress over the years, and we were seeing that, those women who started hormones, when they went into menopause were also not getting heart attacks. So, it was obviously protecting their hearts. We asked the question, what’s happening there?

What it seems is that, estrogen is an anti-inflammatory molecule. So, at the cardiovascular system in the blood vessels, it’s increasing pliability, reducing plaque. So, it’s keeping those things healthier and younger in that sense, but it also alters the HDL, LDL ratio a little bit. So, women’s HDL is a little bit higher before they go through menopause and actually goes down, and their LDL rises with menopause. So, we switch our lipid profile a little bit to look a little more masculine when we go through menopause. So, it’s a heart healthy hormone if it’s something you’ve had all along and continued. There is some datas showing that if you go through menopause, and then, wait 10 years, and then start estrogen, it’s actually unhealthy for the heart. So, the big important thing there is that you’ve already been made those cardiovascular changes. Your vessels have become less flexible, you’ve built plaque in your vessels, and then, estrogen has the opposite effect because it also slightly increases blood clot risk. So, you can put clots on top of plaques and actually have strokes and heart attacks.

A lot of the benefit of estrogen is continuous estrogen. It doesn’t work, you can’t start later on. At the bone, estrogen helps us keep calcium in our bones. It helps prevent osteoporosis for women. It’s actually a really, really good bone medicine. It’s actually one of the things that the FDA has approved it for is for maintenance of bone health. In terms of the brain, there are a couple of different pathways to go down with brain health. One is just the general symptoms of menopause. A lot of women experience what we call brain fog. So, they just have some word searching difficulty and some memory changes as they start to transition through menopause, that does not last forever.  

David: I want to know, why is that? What’s happening there?

Dr.Rebecca: I don’t know that we fully know. There are actually trackable changes in brain function that you can see. Dr. Lisa Mosconi, who’s the head of the Weill Cornell Alzheimer’s research group did a brain function study, which I think they published in the last year. What they did was, they can actually track brain function changes in women going through menopause. The nice thing is they also checked on them a couple years later, and they recovered those brain functions with or without hormone. So, it’s just something about the brain transitioning how it functions. Estrogen is active in the serotonin system, in the norepinephrine system, in the dopamine system, it’s active in the memory centers, it’s active everywhere in the brain. So, there’s something that’s going on as we transition out of the state. Our brain comes to a new steady state. But there’s definitely a lot of women really noticed that.

The other thing that happens during this time is because of the effect on the brain is sleep gets disturbed. So, women get disturbed sleep as they transition through menopause. Usually, what they come to me and tell me is not that they can’t fall asleep, they can all fall asleep. But at 2 or 3 o’clock in the morning, they wake up, they’re up for two or three hours, their minds are racing, and they’re just getting this very scattered sleep. We think that has a little bit more to do with progesterone. Progesterone is a bit of a calming hormone level of the brain. But estrogen, too, because when we’re often waking with hot flashes, and then, they’re up, and they can’t get back to sleep. Sleep has tons of downstream complications including brain health, but also weight, and energy, and all sorts of things.Then, I lost bit for a minute there. Oh, yes. We’ve talked about the brain, we’ve talked about the cardiovascular system and the bones. What else is estrogen good for, what’s good for our skin. It’s good for our hair. It keeps our vaginal tissues young and healthy. There’s a lot of just general benefit for the female body.

Why are some women not good candidates for HRT?

David: I’ve interviewed people who’ve said, “Well, I’m not a good candidate for HRT,” or, “It doesn’t work for me.” Because everything you’re telling me is, this seems like a really good thing to do. Why not?

Dr.Rebecca: There are a couple of categories of people for whom hormone replacement therapy is not a good choice. Category number one, women who’ve had breast cancer. So, if you’ve had breast cancer, and that breast cancer often is hormone sensitive, then, we are increasing your risk of recurrence by adding estrogen or progesterone back into the system. So, we just don’t do that. Another category is, people who already have cardiovascular disease.So, if you already have known cardiovascular disease, and then we have this blood clot risk that we add on top, we can actually increase your risk of cardiovascular events. Then, the third category are often women who’ve had ac lotting disorder, or had a blood clot in the past, or have a strong family history, or a genetic reason why they might clot their blood. We’re very hesitant to add estrogen to that system because it does slightly increase blood clot risk.

David: When you’re doing HRT, are you adding both estrogen and progesterone or just estrogen?

Dr.Rebecca: That depends on whether or not a woman still has a uterus. So, as I said back in the beginning, progesterone’s role in the cycling woman is to stabilize the uterine lining to get ready to implant a pregnancy. In hormone replacement therapy, its role is to keep that uterine lining from growing under the influence of estrogen. If you give estrogen alone to a woman with the uterus, her lining will grow and grow and grow, she’ll have a ton of bleeding, but eventually, will also grow into endometrial cancer or uterine lining cancer. Progesterone stops that from happening. So, if a woman has a uterus, we give both. If a woman doesn’t have a uterus, she doesn’t actually need the progesterone arm. We usually start with just the estrogen. In rare cases, I might add progesterone if sleep is a huge issue for her, and we want to try it to see if it really calms the brain. But in general, we start with estrogen and then see if it’s needed.

To find out if hormone replacement therapy is right for you, speak with a physician who specializes in menopause.  Together, they can help you weigh the risk versus the benefits, and prescribe the therapies that are right for you.

Continue to part 3 to learn about the need for quality sleep, and what you need to know about testosterone therapy in menopause.

Did you miss part 1? Learn about the hormonal journey and why hormone testing is not always helpful. And be sure to listen to the full podcast episode at SuperAge.com.

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