How Should I Prepare For Menopause? with Dr. Susan Loeb-Zeitlin

Faith: Welcome to Health Matters, your weekly dose of the latest in health and wellness from New York Presbyterian. I’m Faith Salie.

Menopause – it’s a topic that’s been getting a lot of attention lately, and yet it can feel like we’re left with more questions than answers. This phase of life has been shown to impact everything from mental health to heart health to sleep — leaving many women in search of ways to help manage symptoms and ease this transition.

As part of Women’s Health Month, I’m joined by Dr. Susan Loeb-Zeitlin, a gynecologist at NewYork-Presbyterian and the director of the Women’s Midlife Center at Weill Cornell Medicine. We discuss how to recognize signs of perimenopause and menopause, as well as treatments and advancements, including the latest on what we know about hormone replacement therapy.

Faith: Dr. Susan Loeb-Zeitlin, thank you so much for joining us today.

Dr. Loeb-Zeitlin: Thank you for having me.

Faith: As a woman in mid life, I am excited and perhaps even breathless to talk to you because the breadth of topics that we want to touch on today — perimenopause, menopause, hot flashes, hormones, hormone replacement, each of those could be its own episode, if not its own series, so we are turning to you for a primer, to learn what 50 percent of humanity experiences.

Dr. Loeb-Zeitlin: Yeah, I’m thrilled to be here to talk about this. And as I think we know, menopause is certainly having its moment right now. And there’s a lot of information out there. It’s important to really know what’s the accurate information.

Faith: Speaking for myself, I don’t think I actually learned the medical definition of menopause ‘till I was in my late 40s. So can we start there? What exactly is menopause?

Dr. Loeb-Zeitlin: So menopause is defined by a woman’s final menstrual period after she goes a full year without a menstrual cycle. It’s when the ovaries stop producing estrogen and they are pre-programmed. We’re born with a certain number of eggs that produce our estrogen and they decide when they’re no longer going to be doing that. That’s the definition. The time leading up to that we call perimenopause, which is the time during which our hormones fluctuate. And therefore our cycles begin to fluctuate.

Faith: Right, I think peri is Greek for around, so around menopause. And perimenopause, it can change for everybody, right? There is no exact time frame for perimenopause?

Dr. Loeb-Zeitlin: So I think that’s a really important point that this whole menopause transition is so individualized and everybody goes through it differently. So the average age of menopause is about 51 and a half. That perimenopausal time leading up to that final menstrual period is variable and can start in a woman’s early 40s with some subtle changes, or even earlier than that.

Faith: Oh my gosh, okay, so this keeps your job lively. I had kids in my early 40s, so, if you’re not getting a good sleep, because you have little kids, you’re not getting enough sleep, it can also be perimenopause, it can get very confusing. So, what are the most common symptoms?

Dr. Loeb-Zeitlin: So perimenopause and menopause symptoms are not that different, except really mainly the menstrual changes. So early perimenopause, we’ll start seeing some very subtle changes in menstrual cycles, maybe a week or so in either direction, a little early, a little late. As we progress into later perimenopause, we’ll start skipping cycles, maybe 60 days or more.

And once we start skipping more than 60 days, we know that the final menstrual period might come in about 1 to 3 years. But the symptoms of perimenopause other than those menstrual changes are similar to what women experience during those early years of menopause also.

Faith: Okay, let’s go through them.

Dr. Loeb-Zeitlin: Hot flashes and night sweats. Those are the most common symptoms. They can start in a woman’s 40s. They definitely increase as we get closer to menopause. But 60 to 80 percent of women will experience those hot flashes and night sweats.

Faith: Is there a difference between hot flashes and night sweats?

Dr. Loeb-Zeitlin: Not really. Night sweats are hot flashes that occur during the night.

Faith: Okay, so we can also call hot flashes day sweats, right? They’re sweats. They’re sweaty! Um, what is actually happening in the body during a hot flash?

Dr. Loeb-Zeitlin: So what we know, and it’s been studied a lot, is that there are nerves in the brain. They’re called KNDy neurons that trigger the hot flashes and they affect the area in the brain that regulates our thermostat. So actually some newer medications are actually targeting those neurons in the brain that trigger the hot flashes.

Faith: Hot flashes are serious. My understanding is that they have been linked with heart disease, inflammation, diabetes.

Dr. Loeb-Zeitlin: They are linked to heart disease. They are linked to mood changes. They are linked to sleep trouble, which of course leads to all of those things, too. Hot flashes and night sweats are just very disruptive for women and can have health implications that are being studied more and more. But can impact cardiovascular disease, can impact mood significantly.

They can linger on average – and I hate to say this to discourage people – but hot flashes and night sweats can linger for, on average, seven years. And we do know that black women get them worse than white women do.

Faith: Other symptoms?

Dr. Loeb-Zeitlin: Hair loss is common. A lot of women do experience it. Some of it is estrogen dependent, but there are other reasons why a woman gets hair loss too. Some of it being stress related. Genetics are a big part of hair loss.

And another big one that we really have to talk about is vaginal dryness. That progresses as a woman goes through menopause, the less estrogen, the less stimulation of the vaginal tissue and the dryness can develop that can lead to change in sexual function, but it also can affect the bladder health, cause more urgency and frequency of urination, which actually is another reason why women wake up at night. At least 80 percent of women, as they go further along in menopause will experience some vaginal dryness.

Faith: You mentioned sleep problems. Surely, if you’re waking up sweating, that causes a sleep problem. Anything else linked to menopause and perimenopause that causes sleep problems?

Dr. Loeb-Zeitlin: One of the things that comes to mind is just mood changes that happen and we definitely see during this perimenopause transition an increase in depressive episodes and anxiety, especially if a woman had that previously. Maybe a postpartum depression. They’re at more risk of a depressive episode during the perimenopause menopause transition. And so that definitely can be disruptive towards sleep also.

Faith: What about cognitive issues? People talk about foggy brains, trying to search for words?

Dr. Loeb-Zeitlin: So brain fog is real too, and the good news there is oftentimes that can get better after we pass this transition time. But also relate to what we’ve been talking about.The sleep troubles, maybe the hot flashes too, they can trigger some brain fog and lack of ability to concentrate. Most of these symptoms will improve after this transition period.

Faith: Does “improve” mean go away?

Dr. Loeb-Zeitlin: For many, yes.

Faith: What about weight gain?

Dr. Loeb-Zeitlin: As with many of the things that happen with a women during this transition, some of them are menopause related and some of them are just age-related changes, and I think weight is one of those things that kind of goes both ways. We definitely see redistribution of weight occurring with a change in estrogen in our body, with more weight depositing in a woman’s midriff and maybe in her neck also.

Faith: Do you have any tips to help manage weight gain?

Dr. Loeb-Zeitlin: There’s some diet modifications that are really helpful during the menopause transition. It gets harder to metabolize carbs. Also exercise is critical. And really, I recommend strength training, resistance training, to build the muscle that our body wants to get rid of. Our body wants to build fat, we want to build muscles.

And, bone building exercises are really important. We know that the biggest decline in bone mass is occurring during the menopause transition, and so working on weight bearing exercises is a really important part of a woman’s regimen as she goes through this transition. Peak bone mass occurs at the age of 35. So focusing on bone building exercises earlier, even before the perimenopause time, is so important for a woman.

Faith: Okay, Dr. Loeb-Zeitlin, we just went through a list of a lot of things that aren’t fun. Most of which are predictable and inevitable. This feels very intimidating. Can you provide some perspective on the kind of, I’ll even say fear that many women have about going through menopause?

Dr. Loeb-Zeitlin: As with any transition, they’re challenging. And I think just doing what you’re doing and preparing women to understand what might or might not happen with their bodies is the best way to prepare for this menopause transition. So understanding what’s normal and what’s not normal, what can be treated, what to talk to your doctor about. Learning more is what we really need to do to help women get through this transition.

There is a lot of information out there about menopause right now. And I caution women to make sure they’re getting it from reliable sources. And using evidence-based practices, which I think for women is hard. It’s on all sorts of social media platforms, and there’s a lot of good and less good information.

Faith: And there are a lot of people who want to sell you things these days to deal with menopause. That’s a whole business too that should probably be looked at with some caution, yeah?

Dr. Loeb-Zeitlin: I think you make a really good point. There’s so much out there. It’s important to look for FDA approved formulations of treatments. And to really know what they’re putting in their bodies, even with supplements, not all supplements are as benign as we think they are and can have side effects.

Faith: Is it possible to delay menopause?

Dr. Loeb-Zeitlin: So we really can’t delay menopause. We can cover up the symptoms and make it easy to get through. But the actual menopause, the lack of production of estrogen from the ovaries, that we really can’t delay.

Faith: Let’s talk easy to get through. What are some of the treatment options for managing menopausal symptoms and making it easy to get through?

Dr. Loeb-Zeitlin: Sure, so we have hormonal and non hormonal treatment options. We’ll often start with non hormonal treatments, being lifestyle modifications, less alcohol, no smoking, weight loss can help with some of these symptoms, managing stress.

For women who either can’t or won’t use hormone therapy, or if hormone therapy isn’t enough, there are some FDA and also off-label medications that we can use and also non medication treatments. But FDA approves the antidepressant Paxil for the treatment of menopausal hot flashes, in treating mood, even in helping sleep, as you asked earlier.

And then there’s a new medication that was approved in May of 2023, which blocks the neurons in the brain that trigger hot flashes. It’s called Fezolinetant or Veozah. It was actually the first commercial in the Superbowl this year. So as we said, menopause is getting its moment. And this is a medication that has been shown to be about effective in reducing hot flashes by about 50 percent with very few side effects. There is some monitoring that needs to be done. Currently it’s rather expensive, but insurance companies are starting to cover it, but it is a novel therapy in the treatment of menopausal hot flashes.

Faith: And have the people who have invented that won the Nobel Prize yet?

Dr. Loeb-Zeitlin: Not yet [laughs]

Faith: Any minute, yeah. Is there any kind of non-hormonal treatment that doesn’t require a prescription?

Dr. Loeb-Zeitlin: Yes. So one of the most effective treatments, of menopausal symptoms and for insomnia is cognitive behavior therapy. Especially for insomnia, that is the most effective treatment there is. And it retrains you how to think about things and helps you sleep. But it’s also been shown to be effective for hot flashes as has hypnosis. That’s been shown also to be helpful for hot flashes. Yeah.

Faith: Wow. Okay, so let’s talk about hormonal treatments. Hormone Replacement Therapy, or HRT. I want to make sure everyone understands what we mean when we talk about HRT.

Dr. Loeb-Zeitlin: So hormone replacement therapy, or as we call it now, menopause hormone therapy, is estrogen and if you have a uterus, it’s progesterone too. So, um, estrogen is what will help with the symptom relief. Progesterone, if you have a uterus, must be taken and I stress that over and over again to my patients because estrogen alone can increase the risk of uterine cancer, but if you take estrogen with progesterone that will decrease the risk of uterine cancer.

Hormone therapy has gotten a bad reputation over the years, but now is becoming much more popular again because we understand more about it. In 2002 came this Women’s Health Initiative study, which basically put a kibosh on hormone therapy. That study was designed to look at the preventative effects of hormone therapy in preventing heart disease, and stroke. And instead, It showed an increased risk of heart disease, stroke, and breast cancer in women taking hormone therapy. So the study was cut short and we pulled hormone therapy from women. But over the 20 years that passed after that study, it’s been reanalyzed and looked at.

And what we learned is the average age of women in that initial huge study was 63 years old. That is more than 10 years past the average age of menopause. When they broke down the groups and looked at women from ages 50 to 59, they saw that those risks basically dissipated. And so based on that study, we have learned now that it is safest to start hormone therapy if you’re within the first 10 years of menopause. So in the 10 years since that final menstrual period and to start before the age of 60.

The other thing we know is prolonged use of hormones can possibly lead to an increased risk of breast cancer. So if you’re taking estrogen and progesterone, the goal is five years of use because that’s when we start to see an increased risk, but many women will stay on longer because that risk is not so great. And they balance the benefits and the risks that they are experiencing from hormone therapy.

Faith: Okay. Do you have any sort of general advice for people approaching menopause? ‘Cause if we’re lucky enough, we all will.

Dr. Loeb-Zeitlin: So it’s important to realize the menopause transition is a normal part of a woman’s reproductive life. So much of a woman’s life is spent past the reproductive years. Learning, understanding, and discussing symptoms and treating them as necessary are super important.

I talk a lot about using this time as a pause and a pause to live our lives in the way we want to live maybe the second half of our lives in a healthy and productive way. So assessing our diet, assessing our exercise, assessing our professional lives, our personal lives.

So my girlfriends and I call this time period the “silly putty generation.” So while our hormones are sort of mushy, right? They’re fluctuating, we’re being pulled and tugged in a lot of directions. Maybe we have aging parents, or we have young adult children and our careers may be at their peak. So it is a challenging time.

Faith: I think you said a lot of really important things there, including talking about it with your friends. I think it’s so affirming for us to share our experiences and our knowledge.

Dr. Loeb-Zeitlin: And understanding everybody goes through this differently. So sharing is so important, but individualized care is the most important thing. Because just like when you were pregnant and everybody tried to give you advice, that advice might not be right for you.

Faith: That’s right. Dr. Loeb-Zeitlin, I have really enjoyed pulling the silly putty with you. Thank you so much for joining us today. This is such an important conversation.

Dr. Loeb-Zeitlin: Thank you for having me and for allowing menopause to have its moment, and to really discuss the important parts of menopause.

Faith: Our many thanks to Dr. Loeb-Zeitlin.

I’m Faith Salie.

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