Navigating Digestive Issues During Menopause

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, president of Main Campus here at Cleveland Clinic in beautiful Cleveland, Ohio.

And today, we're going to talk a little bit about navigating digestive issues during menopause. And I'm super pleased to welcome a first-time guest, Dr. Catherine Caponero, who's a staff physician in the Department of Obstetrics and Gynecology here at the Cleveland Clinic. She's also a clinical assistant professor of reproductive biology, obstetrics and gynecology here at the Cleveland Clinic, Lerner College of Medicine of Case Western University, and also serves as the specialty quality and safety officer for the Obstetrics and Gynecology Institute. So Catherine, thanks for joining us here on Butts & Guts.

Dr. Catherine Caponero: Thank you so much for having me.

Dr. Scott Steele: So as you know, I always like to start a little bit about you and where are you from, where'd you train, and how'd it come to the point that you're here at the Cleveland Clinic?

Dr. Catherine Caponero: So I'm a lifelong Clevelander. I've been here since I was born. I love being at the Cleveland Clinic. It's been one of those almost a childlike dream to get here, so it's a pretty cool experience. I went to Case Western for undergrad and then I trained in Dayton, Ohio for my residency, and now I'm really excited to be back here as staff. And then I also, in regards to my background here, I am a full spectrum OBGYN and I'm certified through the Menopause Society. I love empowering women to help make thoughtful decisions about their health.

Dr. Scott Steele: That's fantastic. And so today we're going to talk about something, honestly, I don't think we've talked about here on Butts & Guts, and we're going to be navigating digestive issues during menopause. And so to start, Dr. Caponero, what do doctors mean when they say menopause and when does this typically occur?

Dr. Catherine Caponero: Yeah. So when doctors refer to menopause, they mean that natural biological transition marking the end of a woman's menstrual cycle and reproductive years. It's officially diagnosed when a woman has gone 12 consecutive months without a period with no other medical cause. So menopause is not a gradual transition, but it's a single point in time. So that time is, again, 12 months after your final period. You don't know you're through it until it's been those 12 full months. And then everything leading up to that point is called perimenopause and everything after that point is called post menopause.

Dr. Scott Steele: Okay. So let's break down that a little bit for this perimenopause thing. What is this and how long does it last?

Dr. Catherine Caponero: So perimenopause can actually last for four to 10 years. It begins as the estrogen and progesterone levels start to fluctuate. And those symptoms include irregular periods, hot flashes, mood swings, and digestive changes. And fertility does decline during this period, but it's still possible.

Dr. Scott Steele: So what causes the drop in hormonal levels? Is it just natural part of us aging or what is it?

Dr. Catherine Caponero: So it's a natural change in a woman's reproductive life, and those hormonal changes can happen just due to those declining levels of estrogen and progesterone. And the symptoms associated with them definitely overlap throughout this process, which is really challenging for a lot of women. It's almost like puberty in reverse. It happens to all people with reproductive organs that identify as female. And if you're lucky, you go through it.

Dr. Scott Steele: Fantastic. And so let's delve a little bit deeper into these. What are some of the common signs and symptoms of both perimenopause as well as menopause?

Dr. Catherine Caponero: So for perimenopause, we have irregular periods, and those periods become shorter, longer, heavier, lighter, even skipped. But with menopause, again, those periods do stop, like we said, completely for those 12 consecutive months. You can also sometimes experience hot flashes or hot flushes, which are those sudden waves of heat usually in the upper body. And those can be accompanied by flushing and sweating. Night sweats are also very common, which are those intense sweating episodes during sleep, often waking the person up. You can also have sleep disturbances because of this, which is the difficulty falling or staying asleep. And those can be linked to those hot flashes, anxiety, or hormonal changes.

Mood changes are also really common. So you can have increased irritability, anxiety, or depression, and mood swings are really common as well. Vaginal dryness and discomfort can happen, which is the thinning of the vaginal walls, which can lead to dryness, itching, and painful intercourse, or what we call vaginal atrophy. There's also decreased libido. So women have a lower sexual desire due to hormonal shifts and physical changes. Memory problems or brain fogs, so difficulty concentrating or forgetfulness. Fatigue. So persistent tiredness or lack of energy. Weight gain or changes in their body composition. So slower metabolism, redistribution of fat, often to the abdomen. Urinary changes. So increased frequency or urgency of urination, higher risk of urinary tract infections as well, like UTIs. Breast tenderness is also really common and that can fluctuate, especially during perimenopause with those hormonal changes, along with hair and skin changes. So thinning hair, dry skin, and increased facial hair.

Dr. Scott Steele: So there's a lot there. So we're going to focus today a little bit more on the digestive system. So what are some digestive issues that might occur during menopause?

Dr. Catherine Caponero: So some of the common digestive issues during menopause are bloating. So that can be caused by slower digestion, fluid retention, or increased gas. And estrogen fluctuations can contribute to this. There's also gas and flatulence. So hormonal shifts can affect those gut bacteria, which can lead to more gas production. Constipation is also really common, as declining progesterone slows down bowel movements. And it's often worsened by reduced physical activity and lower fiber intake. Diarrhea and loose stools is less common, but some women do report alternating bowel patterns, especially during perimenopause.

Abdominal cramps or discomfort can also be common, and that can be due to that slower digestion that we talked about, or heightened gut sensitivity. Nausea is also not universal, but some women do experience mild nausea during hormonal fluctuations. And then heartburn or acid reflux can also happen. This is because the drop in estrogen can weaken the lower esophageal sphincter, which causes acid to rise, and this can worsen if menopause is accompanied by weight gain or stress. Food sensitivities or intolerances can also occur. And that might also just be because women are more aware of their sensitivities, so they figure out that they're more prone having issues with dairy, gluten, or caffeine. And then IBS or irritable bowel syndrome flare-ups can also happen just due to those erratic hormonal instabilities.

Dr. Scott Steele: Hold up. So are you saying that hormones are the driving factor for these digestive issues? And if so, how so?

Dr. Catherine Caponero: Yeah, so during menopause and perimenopause, hormonal changes, especially the decline in estrogen and progesterone, can affect gut function, and that can lead to a range of digestive issues. These symptoms may be new or may worsen if you already have digestive conditions like IBS. And estrogen and progesterone do influence that gut-brain axis, gut motility, and microbiome balance. And those lower hormone levels can slow down or even speed up digestion, increase bloating, and affect how your body absorbs nutrients.

Dr. Scott Steele: So you mentioned a little bit about IBS and IBD. How is this mistaken, if you will, or even misdiagnosed as a digestive condition?

Dr. Catherine Caponero: Yeah, so menopausal digestive issues can sometimes be mistaken for or misdiagnosed as more serious conditions like inflammatory bowel disease or irritable bowel syndrome and vice versa. This because many symptoms overlap. And menopause can also worsen pre-existing digestive disorders, which make the diagnosis much more complex. Hormonal changes in menopause can cause, again, those bloating, abdominal pain, or cramping, constipation or diarrhea, gas, and those changes in bowel habits. But these are also those core symptoms of IBS and IBD, which includes things, as you know, like Crohn's disease and ulcerative colitis.

Dr. Scott Steele: So I don't want people to miss something. You said a lot so far in this podcast. And so can we go back to something you mentioned about maybe the role of having increased acid reflux or heartburn? What causes that during menopause?

Dr. Catherine Caponero: So many women do experience heartburn or acid reflux more frequently during menopause, and it's largely due to hormonal shifts, especially the drop in estrogen and progesterone. These changes can affect the entire digestive system, including the lower esophageal sphincter, the muscle that keeps the stomach acid from flowing back into the esophagus. So this can happen because of that decline in estrogen. So estrogen helps to maintain muscle tone, including that lower esophageal sphincter. And when estrogen level drop, the lower esophageal sphincter can become weaker or more relaxed, allowing acid to backflow more easily into the esophagus. Progesterone also has a natural muscle relaxing effect, and in perimenopause and early menopause, fluctuating levels can lead to inconsistent function of that lower esophageal sphincter causing those symptoms to come and go.

There's also hormonal shifts that can slow down gastric emptying. Meaning food and acid stay in the stomach longer, increasing the chance of reflux. And that weight gain that can also occur is really common during and after menopause due to metabolic changes. There's also extra abdominal fat which can put pressure on the stomach, which pushes the acid up into the esophagus. There's also changes in the gut microbiome. So estrogen helps to support a healthy balance of gut bacteria, and hormonal changes can disrupt this balance, contributing to inflammation and acid sensitivity. Many women also report higher stress levels during menopause, which can increase stomach acid production, worsen perception of reflux symptoms, and affect eating habits. So stress eating or skipping meals.

Dr. Scott Steele: Catherine, you also mentioned that there can be either maybe constipation or even diarrhea as well as affecting other food movement through the digestive tract. How does menopause affect that?

Dr. Catherine Caponero: Menopause can significantly affect bowel movements, and the overall movement of food through the digestive tract known as gut motility through hormonal changes, particularly the decline in estrogen and progesterone. So as we discussed, estrogen supports the gut lining, microbial balance, and the muscle tone in the digestive tract. And progesterone has a relaxing effect on smooth muscle, which slows gut motility.

So when these hormone levels drop or fluctuate during the menopause and perimenopause, it can lead to slower digestion, irregular bowel patterns, and discomfort. So when we talk about constipation, that's our most common change that can happen during menopause. And that's caused by that slower gut motility, dehydration, sometimes reduced physical activity or fiber intake. And that stool may be hard, dry, and difficult to pass.

In regards to bloating and gas, we can have slower digestion, which gives bacteria more time to ferment undigested foods. Hormonal changes can also disrupt that gut microbiome, which can lead to increased gas production and bloating. Some women also experience constipation and diarrhea, particularly if they're prone to IBS. This fluctuation may result from erratic hormone levels during perimenopause. And diarrhea is a little less common, but some women do have looser stools or urgency, possibly tied to stress, dietary triggers, or increased gut sensitivity.

Dr. Scott Steele: So I've heard through the years that, a woman becomes pregnant, that you can have cravings for some things. Does this happen with changes in appetite, or maybe some craving of different foods during menopause or perimenopause?

Dr. Catherine Caponero: Yes. Menopause can absolutely change a woman's appetite, both in terms of how hungry she feels and what kinds of food she craves. These changes are tied to hormonal fluctuations, particularly the decline in estrogen and progesterone, which play key roles in regulating hunger, metabolism, mood, and even food preferences. So menopause does cause that increased appetite. So lower estrogen can reduce the effect of leptin, or the hormone that signals fullness. Higher ghrelin, which is the hunger hormone, can also make you feel hungrier than usual. And emotional stress and poor sleep, which is really unfortunately common in menopause, can also increase appetite. However, some women do have a decreased appetite as well. And they can experience nausea, digestive discomfort, or bloating that can make eating less appealing. And mood changes like depression or anxiety can also blunt appetite.

Dr. Scott Steele: So I can just turn on a television, it seems like any given time, and find some role of probiotics or some supplement that is the end-all the be-all. Does it have a role in any of these things that we're talking about here today?

Dr. Catherine Caponero: There is some role. And I do think it's so important to make sure that we're looking at our sources. There are definitely several supplements and functional foods that can help ease menopause digestive-related issues. And these primarily revolve around probiotics, prebiotics, fiber, and magnesium. While research is ongoing, many women find relief through targeted use. So if we're going to talk about these, so when we talk about prebiotics, probiotics, and symbiotics, these matter because gut bacteria can help metabolize estrogen, regulate inflammation, support digestion, and even influence mood and bone health during menopause.

And then magnesium can also be really helpful as well because it is pretty well absorbed and can help relieve constipation by attracting water into the intestines. Other magnesium formulations can help with relaxation and sleep, which are very important during menopause. But the biggest thing is that we need to make sure that we're exercising good caution with all of these just because a lot of times they haven't been FDA approved. And we want to make sure that we're using medications that are safe and effective. And so it's really important that you check with your healthcare provider before you start using supplements.

Dr. Scott Steele: So outside of supplements, what about just nutrition itself or lifestyle changes? Can this, on one hand, ease some of these digestive issues during menopause, or are there foods that actually can worsen some of these symptoms?

Dr. Catherine Caponero: For sure. So dietary adjustments are really valuable. So we want to make sure that we're including more fiber, probiotics and water in our diet. We want to try and reduce processed foods and trigger items. So a lot of these trigger items include things like caffeine, alcohol, and high-fat meals. Exercise is so important as regular movement helps digestion and reduces bloating and constipation. There's also a lot of benefit to stress reduction. So meditation, yoga and deep breathing can really help to calm that gut-brain connection. Hydration is also essential for healthy bowel movements. And medical support. So sometimes things like hormone replacement therapy, digestive aids, or medications can be appropriate if the symptoms are severe or persistent.

Dr. Scott Steele: So if this is a natural process of aging, when should someone see a healthcare provider about menopause-related issues or digestive issues?

Dr. Catherine Caponero: Yeah. So you should see a healthcare provider about these issues if any of the following applies. So if you have a red flag symptom, you definitely want to see your doctor promptly. So these include things that could indicate something more serious than hormonal changes. So blood in stool, so bright red or black and tarry, unexplained weight loss, persistent or severe abdominal pain, difficulty swallowing, frequent vomiting or nausea, new or worsening acid reflux symptoms that wake you up or affect your daily life. Sudden or significant changes in bowel habits. So diarrhea or constipation lasting for weeks. Or fatigue that doesn't improve with rest, especially if it's paired with GI symptoms.

Something to consider, and even if it's not super alarming, you should still see your provider if you experience bloating, gas or cramping that persists for more than a few weeks. Constipation or diarrhea that's frequent, chronic, or worsening, heartburn or reflux that occurs more than twice a week, a loss of appetite or feeling full quickly. Food intolerances that are new or increasing, or emotional distress or anxiety linked to gut issues. So that gut-brain connection is real.

This is really important because, as we discussed, menopause symptoms can mimic or mask other conditions like IBS, IBD, celiac's disease, Crohn's disease, hernias, reflux. And providers can help recommend different tests that might be indicated. So blood tests like iron, thyroid, or inflammatory markers, stool tests, colonoscopies or imaging, or hormonal evaluations.

Dr. Scott Steele: So now it's time for our quick hitters, a chance to get to know you a little bit better. So first of all, salt or sweet.

Dr. Catherine Caponero: Sweet.

Dr. Scott Steele: What was your first car?

Dr. Catherine Caponero: An Acura Legend.

Dr. Scott Steele: If you had the ability to have a superhero power, which one would you choose?

Dr. Catherine Caponero: Invisibility.

Dr. Scott Steele: Now you are to go back to your 17-year-old self and you are to give her a piece of advice. What would you say all these years later?

Dr. Catherine Caponero: The most important thing in life is developing a strong community. I don't know if you've ever seen the TV show Blue Zones, we talk about how people live to be 100. And one of the biggest parts of that is making sure that you have people that you love around you. And this is so important, both at work, honestly, but then in the rest of our lives, knowing that we're surrounded by great people and people that love and care about you. And to developing that community however you can be really valuable.

Dr. Scott Steele: That's fantastic. And so give us the final take home message for our listeners out here.

Dr. Catherine Caponero: It is so important to speak up. If something doesn't feel right or you are concerned, definitely speak with your physician or your healthcare provider about what symptoms you're having. A lot of times people feel like they're unheard, and sometimes it takes a little bit of time to find the right provider. But once you do, it can be really beneficial for your overall health. And when we talk about menopause and perimenopause, eight to 10 years is a lot of our lives. So making sure that we're getting the care and the help that we need so that people can transition successfully into postmenopausal state is so valuable. And knowing that there are resources out there can really help to change our world.

Dr. Scott Steele: Fantastic. And so to connect with OBGYN and Women's Health Institute here at the Cleveland Clinic, please call 216.444.6601. That's 216.444.6601. You can also visit our website at clevelandclinic.org/womenshealth. That's clevelandclinic.org/womenshealth. Dr. Caponero, thanks so much for joining us on Butts & Guts.

Dr. Catherine Caponero: Thank you so much for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.