How to Have a Kinder Gentler Menopause with Dr Holly Thacker

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host Nada Youssef, and today we have Dr. Holly Thacker, professor and director of the Center for Specialized Women's Health at Cleveland Clinic. She's also the Executive Director for Speaking of Women's Health and today we are taking your questions regarding menopause. So make sure you send us all your questions in the comment section below.

Before we get started, please remember this is for informational purposes only and not intended to replace your own physician's advice.

Thank you so much for coming in today.

Dr. Thacker:      Thanks for having me.

Nada Youssef:   Thank you. Did you want to introduce yourself a little bit to our viewers?

Dr. Thacker:      Well, I specialize in menopause and hormone therapy and female sexual function and breast cancer survivorship and treatment of medical causes of urinary leakage. So lots of areas that are important to women across different disciplines.

Nada Youssef:   Great. Thank you.

Okay well, today again we are talking about menopause and as we all know it is not a disease, but more of a natural decline in the reproductive hormones as a woman reaches her 40's or her 50's. So basically your ovaries stop producing hormones and you start getting symptoms how early on for menopause?

Dr. Thacker:      Well it can vary quite a bit. It is a natural condition, but just like pregnancy is natural, you can die in childbirth.

Nada Youssef:   Right.

Dr. Thacker:      So we don't want people to suffer with menopause and not all women that are in menopause are low in hormones. But some are, and those that are low can have symptoms like hot flashes, trouble sleeping, vaginal dryness, bone loss, mood symptoms, maybe not thinking as clearly, word-finding difficulties. So it can be very variable. So it's a natural event, but in some women it is a hormone deficiency that needs to be treated. Not all, but certainly some.

Nada Youssef:   Okay. Great, thank you.

Well, let's start with some ... we have some pre-submitted questions from our viewers.

Dr. Thacker:      Okay.

Nada Youssef:   I'll start with Patricia.  "I've been having hot flashes for ten years now. My doctor says I will continue to have them for the rest of my life. Is this really true and why?"

Dr. Thacker:      Well not all women flash, but some women can flash their whole life. Most women just flash a few years. It isn't good to flash. There's a lot of changes in brain blood flow. So it should be treated and we have great hormonal options which are safe and effective. And Patricia, we have non-hormonal options too, so you should not suffer. And women who have hot flashes who don't get them treated, have more doctor visits, higher health cost, and lost work productivity.

Nada Youssef:   Wow. Alright. Thank you so much. We have Carol. "If you've had a hysterectomy, is there any way of knowing that you've gone through menopause? Especially if you don't experience hormonal changes like hot flashes?" That's a good one.

Dr. Thacker:      Carol that's a great question, because lots of women, up to one in three, have had hysterectomies. So they don't have a bleeding pattern. Starting in the late 40's, your physician should probably do a yearly hormone test with an SFH and an estrogen level. Because you want to know when you do go into menopause. It's not something you go through, you go into it, meaning your body doesn't make estrogen anymore. Half of women lose bone, half to up to 70-80% can have changes in the vagina and bladder. So even if you don't have hot flashes, you want to know what your hormone status is.

Nada Youssef:   Sure. So you would say that you would start checking on your hormones when you're in your 40's?

Dr. Thacker:      Probably late 40's.

Nada Youssef:   Late 40's?

Dr. Thacker:      Most of the range is between 45 and 55 that women stop their period. Some as early as 40, 1% under age 40, which is definitely premature and not normal and needs to be evaluated.

Nada Youssef:   Mm-hmm (affirmative).

Dr. Thacker:      And some women can menstruate and ovulate into their late 50's.

Nada Youssef:   Wow.

Dr. Thacker:      So until you go one whole year without a period and are diagnosed in menopause, there's still a rare chance for ovulation even into the 50's.

Nada Youssef:   Wow. Very interesting.

Dr. Thacker:      Mm-hmm (affirmative).

Nada Youssef:   Thank you for that.  And jumping on to Jane.  "Is it true that menopause can cause a change in a woman's voice?"

Dr. Thacker:      Yes Jane it can. So if you're an opera singer and you make your living on your voice, you don't want to lose that upper register and when women go into menopause and lose estrogen, they still usually make the same amount of testosterone. So the ratios change and become a little more masculine, so that's why some women have a deeper voice, a few chin whiskers, a little bit of a receding hairline. So that can be a concern and it's easily treated as long as we balance out the hormones and give you the estrogen back.

Nada Youssef:   Great. And do you want to talk about some of the treatments that we offer?

Dr. Thacker:      Yes. We've been prescribing hormone therapy for over 70 years. It's very well studied. There are so many myths and misconceptions, it's generally very safe and effective. There's a lot of fear about menopause and hormones and that's such a shame. Because women don't need to be fearful and usually estrogen is the main hormone that needs to be replaced. If you have a uterus, we balance it with Progesterone or something to protect the uterus.

Nada Youssef:   Mm-hmm (affirmative).

Dr. Thacker:      Most women don't need testosterone, but for those women who've had both their ovaries removed with bilateral oophorectomy many times do. Some women feel great and don't need any hormone replacement therapy initially. Maybe later they might. And for those women who can't or won't take hormones but have hot flashes or bone loss or sexual function symptoms, we have lots of non-hormonal options. So you don't need to suffer.

Nada Youssef:   Great. And then Wendy has kind of a follow up. "Is it good to have a little testosterone in your hormone replacement therapy mix?"

Dr. Thacker:      Well we women actually have more testosterone than estrogen on a gram for gram basis in the body.

Nada Youssef:   Wow.

Dr. Thacker:      It's not just the male hormone or the female hormone. The ratios are very important. Now men have ten times the testosterone women have and so, if you have too much testosterone over several years period, you can have abnormal hair growth, hair loss. So it's very important when using testosterone in women that the person prescribing it knows what they're doing.

Nada Youssef:   Mm-hmm (affirmative).

Dr. Thacker:      A lot of compounded, unregulated hormones in these anti-aging clinics, they may make someone transiently feel better, but I've seen a lot of disaster cases.

Nada Youssef:   Sure.

Dr. Thacker:      So you really need someone who is just not selling you something, who's truly an expert in it and knows how to assess and measure.

Nada Youssef:   Very good advice. Thank you. And then I know you talked about whiskers earlier, but Samantha's asking "Is the facial hair that is starting to grow, to be blamed on menopause?"

Dr. Thacker:      It depends. It certainly could be. It also could be genetic. Some women just tend to have more hair and luckily we have laser and we have Vanica cream and electrolysis. So there's a lot of things that can be done cosmetically.

Nada Youssef:   Sure.

Dr. Thacker:      But it could be certainly a reason to see your physician and have your adrenal hormones, testosterone, estrogen, SFH levels checked.

Nada Youssef:   Okay, great. Then we have Ellen. "Been in it for eight years. How long will/does it last? Hot flashes start in the middle of my back and up from there. I am on no meds and no hormones."

Dr. Thacker:      Well, you shouldn't be suffering. You should get some treatment. We have a wonderful free treatment guide book on menopause that anyone can download on our Speaking In Women's Health .com site. We have lots of information on non-hormonal treatments, as well as hormonal.

Nada Youssef:   Great.

Dr. Thacker:      But most women try to avoid the hormonal treatments because, they think it's so risky and that's just not this case. And most post-menopausal women, if you draw their estrogen level, it's lower than a man their own ages estrogen level.

Nada Youssef:   Wow.

Dr. Thacker:      Because men don't lose their sex hormones and testosterone gets converted to estrogen. That's why you don't see as many men with osteoporosis. Where as one in two women after age 50 will have osteoporosis.

Nada Youssef:   Wow.

Dr. Thacker:      And it's directly linked to the loss of hormones.

Nada Youssef:   Very interesting. Okay. Great, thank you. And let's see. Amanda asks "Are there any home remedies for hot flashes?"

Dr. Thacker:      Well certainly we recommend that you keep your bedroom about 65 degrees, to keep it cool.

Nada Youssef:   Mm-hmm (affirmative).

Dr. Thacker:      Avoid caffeine, spicy foods. Also, not all hot flashes are from menopause, they can be from thyroid disorders or other conditions or other medications. So it's really important to get evaluated.

Nada Youssef:   Sure, sure. Great. And Candice. "Sex is becoming unbearable due to pain and vaginal dryness. What to do?"

Dr. Thacker:      Well, when a woman enters menopause, it's kind of like reverse puberty. Losing all the hormones, the vagina kind of goes back to a pre-pubertal state. And the vagina and the external genitalia and the base of the bladder all have very high concentration of estrogen receptors. So when there's no more estrogen, those tissues tend to shrivel up. And local treatment is very safe and effective, does not have systemic effects. We have non-hormonal options by pill women can also take. We also have vaginal DHEA, which is now available, which does not have any estrogen or testosterone, but stimulates the own body's cells in the vagina to make those hormones. To get the tissue healthy.

So do not wait until things are very painful, because then if you do, even when we treat the thin lining and make it healthy again, which we can do usually within a month, sometimes the muscles of the vagina go into a spasm, because they remember the painful sexual activity.

Nada Youssef:   Interesting.

Dr. Thacker:      So it's very important to be proactive. Once your periods stop, you need to talk to your women's health physician about, how does the tissue look? Do you notice any dryness? Are you having bladder irritability or more bladder infections? That can be signs of not enough estrogen in the genital tract.

Nada Youssef:   Now if someone is on birth control and they don't get their menstrual periods, then you're saying just even at the end of your 40's to always get checked.

Dr. Thacker:      To get checked.

Nada Youssef:   Even if you don't have your period for a while.

Dr. Thacker:      If you're on birth control pills, even low dose birth control pills.

Nada Youssef:   Yes.

Dr. Thacker:      Which are a great option for peri-menopause, because who wants to bleed and have hot flashes and PMS and all that jazz.

Nada Youssef:   Sure.

Dr. Thacker:      Right? So as long as you don't smoke and you don't have blood clots or some other reason why you couldn't take a low dose of hormonal contraception, women can take that well into their 50's and then choose ... not the week before their daughter's wedding.

Nada Youssef:   Right.

Dr. Thacker:      Of when to stop the pill to see.

Nada Youssef:   I see.

Dr. Thacker:      But if you're taking a hormone pill every day, for most women not all, but most women, that's enough to keep the vagina healthy.

Nada Youssef:   Great. Thank you. Then we have questions coming in. I have Julie. "Do you think there is any natural ways to reduce or eliminate post-menopausal symptoms like hot flashes or moodiness?" I know we talked a little bit about the hot flashes.

Dr. Thacker:      You know, what I say about hormones, if you were really low in insulin, like with Type One Diabetes, you gotta take insulin or get a new pancreas. We're not in the business yet in 2017 of giving ovary transplants.

Nada Youssef:   Right.

Dr. Thacker:      So when you don't have estrogen anymore, you need to replace that or you need to use something that effects the estrogen receptor. Which by in large are prescription medications.

Now we do use low doses of medicines like Peroxitine or Brezdell, which are FDA approved to treat hot flashes, that are not hormones that reset the thermostat in the brain. So for people with estrogen-positive cancers who at the moment can't take hormones ...

Nada Youssef:   Sure.

Dr. Thacker:      That's an option. Sometimes we'll use judicious uses of sleeping medications or Gabapentin-Nuerontin and other off-label medications, to help women not have those marked flashes. But those flashes are a warning sign that you need to be evaluated.

Nada Youssef:   Sure.

Dr. Thacker:      And even if you don't have hot flashes, what's the bone status? You might need a bone density if you've been a couple years into menopause. What does the vagina look like? How is the bladder functioning? What is sexual function like? So that should be evaluated periodically.

Nada Youssef:   Okay and speaking of hot flashes, I have Patty. "Will a thyroid condition mask hot flashes?"

Dr. Thacker:      Generally a thyroid condition won't mask it, but if the thyroid is off, that certainly interacts with the other hormones in the body. Women who are on medications that are SSRI's or NSRI's, which are anti-anxiety/antidepressant medicines, sometimes we use them for pain, migraine, fibromyalgia. There's a lot of different reasons we use that class of medicine.

Nada Youssef:   Sure.

Dr. Thacker:      Many of those women on those medicines don't flash and then they think "Oh, I'm fine".

Nada Youssef:   I see.

Dr. Thacker:      But they don't realize that maybe their levels are low and they're losing bone, their skin and hair might be changing, other tissues may be effected. So that's why it's complicated.

Nada Youssef:   Sure.

Dr. Thacker:      And important to get evaluated.

Nada Youssef:   And Patty has a follow-up question. "I took estrogen for years after hysterectomy and I felt great. Now I'm off of it and I feel terrible. What else can I do?"

Dr. Thacker:      Well I would say, why are you off of it? There's no time limit. I have women in their mid-90's still want estrogen.

Nada Youssef:   Oh, interesting.

Dr. Thacker:      In fact, I'm part of a non-profit called Advancing Health After Hysterectomy, AHAH. And it's a group of physicians, researchers, health educators, wanting to get the word out to women, their doctors, the media, the press, that if you've had a hysterectomy and you're under 65, you should be on estrogen. Generally, because there's less death, there's less breast cancer, there's less heart disease.

Nada Youssef:   Wow.

Dr. Thacker:      Less Parkinson's, less dementia. So ... And if you're over 65, we just tend to use lower doses or instead of oral, which can increase the risk of stroke, one extra case per thousand women, we may use transdermal patches or gels. So just because you've lived long enough to live to your age, congratulations, but you don't need to suffer.

Nada Youssef:   So don't ever get off of it. There's no age limit where you should get off of the estrogen.

Dr. Thacker:      There's no age limit. We don't have any age limit of "Oh, you've been on blood pressure medicines for ten years".

Nada Youssef:   Yeah.

Dr. Thacker:      "Oh, you've been on your thyroid pill for eight years."

Nada Youssef:   Yeah.

Dr. Thacker:      No.

Nada Youssef:   Very good. Okay.

Dr. Thacker:      Yeah.

Nada Youssef:   Great.

Dr. Thacker:      There's this fixed thought that you have to be off at a certain ... a period of time.

Nada Youssef:   Sure.

Dr. Thacker:      And that is totally wrong and it's totally antiquated.

Nada Youssef:   Alright. Okay. Well, let's ...

Dr. Thacker:      So don't suffer.

Nada Youssef:   Don't suffer. And we have Laura. "When will I start menopause? I'm 60. What's the normal age?"

Dr. Thacker:      If you're still having your periods at 60, I would see a physician. Just because you're bleeding doesn't necessarily mean it's a period.

Nada Youssef:   It's her period, yeah.

Dr. Thacker:      So it would be pretty unusual to not be in menopause by age 60. You might be, you might have great ovaries, but I would be checked. I would be checked. Now if your periods have stopped and you don't have any symptoms, that's great. But yearly exams to look at the vagina and certainly by age 65, get a bone density.

Nada Youssef:   Okay, so speaking of no symptoms, is there actually a lot of cases of women going through menopause without any symptoms at all?

Dr. Thacker:      Well usually people who feel great and have zero symptoms, they're generally not in my practice. But I have seen certainly women, and there are some women whose ovaries still make precursor hormones and their genetics and diet are such, and they have very good adrenal glands, which sit on top of your kidneys that make precursor sex hormones. So there is a group of women who don't flash, whose bones are fine and sex life is fine.

Nada Youssef:   Wow, awesome.

Dr. Thacker:      But they generally don't come to see me.

Nada Youssef:   Yeah. Well that would make sense. Okay and we have Stacy. "Are you saying that a complete blood test is necessary to figure out what is going on? Hot flashes, hair loss, to determine if it estrogen loss or a thyroid issue."

Dr. Thacker:      Well that's really got a lot of things in it.

Nada Youssef:   Yeah.

Dr. Thacker:      We like to examine a woman, because looking at the woman, looking at her hair, listening to her heart, feeling her thyroid, looking at the vagina, getting a bone density if needed, getting selected blood work. All of that helps us look at the whole entire picture.

Nada Youssef:   Sure.

Dr. Thacker:      There's not just one single test and the FSH or blood test that is usually very high when a woman has no more eggs, still later can come down if the person still has eggs. So when you're in the peri-menopausal timeframe, sometimes the hormone test will only help you for those few minutes in time that you draw the blood.

With hair loss though, not only do we check thyroid and estrogen, but also what's your vitamin D level. Vitamin D helps hair and skin and bone. What is your iron level? What is your zinc level? Are you getting high quality protein? And we have a lot of information about hair and skin and beauty on our Speaking In Women's Health website.

Nada Youssef:   Sure. And diet contributes big time to hair loss.

Dr. Thacker:      Yes, especially having high quality protein ...

Nada Youssef:   Sure.

Dr. Thacker:       Is very important.

Nada Youssef:   Okay.

Dr. Thacker:      So you are what you eat.

Nada Youssef:   Yeah, yeah. I've heard that many times. Then I have Susan. "What about a hysterectomy with ovaries still present? How do you know when to see if you need to be checked or have hormone replacement?"

Dr. Thacker:      That's a great question because, it's good to try to keep your ovaries up to at least age 65, unless you have the [inaudible 00:15:57] gene or a family history of breast and ovarian cancer or there's something wrong with the ovaries. But when you take out the uterus and the tubes and clamp the blood flow, even though the ovaries are still in place, sometimes within a couple years they don't function as well.

Nada Youssef:   I see.

Dr. Thacker:      So, if you don't have any symptoms, starting in the late 40's by early 50's, I would start getting a blood test to see. Because you do want to date when you are in menopause.

Nada Youssef:   Yeah, when you're starting to feel the symptoms.

Dr. Thacker:      Yes. And the reason why it's important to know when you go into menopause, some women may be 40, some may be 58.

Nada Youssef:   Mm-hmm (affirmative).

Dr. Thacker:      That's a big age range ... Is because most of the benefits of the hormone therapy in terms of the brain and the vascular system, are most beneficial if you start within six years of menopause. Certainly no later than ten years.

Now the vagina and the bone, regardless of the age, get benefit.

Nada Youssef:   Okay.

Dr. Thacker:      But in women who go more than 10, 15, 20 years of being low in estrogen, their estrogen receptors change in the body and then when you give back estrogen and you're talking about somebody in their 70's or 80's who have not been exposed to estrogen, that's the group of women that can have an increased risk of heart attack and stroke or memory loss.

Nada Youssef:   I see.

Dr. Thacker:      And you read all that stuff on the package label and so you're some 40 or 50-something year old woman thinking "Oh, I don't want a heart attack, stroke, dementia", and it's really different ages. So dating yourself, not just by your chronologic age, but your hormonal age, is very important.

Nada Youssef:   So based on everybody's symptoms could be different and based on your symptoms your menopause could go for years. It could go 10, 20 years long? The actually menopause symptoms? Going through them.

Dr. Thacker:      The symptoms can be very variable and in some women can last indefinitely.

Nada Youssef:   Oh wow.

Dr. Thacker:      And once you're in menopause and you're not making eggs, that's it.

Nada Youssef:   Your body is just

Dr. Thacker:      And this thought about "Well I already went through it, now I'm out" ... You don't go to a location and drive back home.

Nada Youssef:   I see.

Dr. Thacker:      The ovaries have stopped making eggs. Stopped cycling.

Nada Youssef:   I see.

Dr. Thacker:      So it's just that period of time. But there is an early, post-menopausal phase in the first five years and a late post-menopausal phase.

Nada Youssef:   Okay.

Dr. Thacker:      And then of course the geri-pause, in people that are of advanced age.

Nada Youssef:   Okay.

Dr. Thacker:      So it's important to not just look at chronologic age, but hormonal age.

Nada Youssef:   Great, great. Thank you. And I have Mikaela.  "Most of my friends always describe their hot flashes as intense and severe. Mine is not all that bad. Is that normal?"

Dr. Thacker:      Yes. That's great. Not everybody's brains are wired to flash. So that's great if you don't have symptoms, but you still have a 50/50 chance of losing bone density when you stop your periods or lose your estrogen.

Nada Youssef:   Okay.

Dr. Thacker:      And a lot of women do have changes in the vagina and it's so much better to treat it sooner rather than later. We don't want any painful sexual sensations.

Nada Youssef:   Sure, sure. Then we have Jane. "What age can I stop drugs for menopause if I still have symptoms? I'm 72 years old."

Dr. Thacker:      Well, at any age that a woman stops hormone therapy, if that's what you're talking about, hormone therapy, there's a 50/50 chance of having symptoms. So 50% chance you will, 50% chance you won't. Nothing special about weening off or anything. If you're using non-hormonal agents for your hot flashes, we don't have as good a data on that, but we would generally recommend that you would ween off.

Nada Youssef:   Okay.

Dr. Thacker:      Over a span of a few weeks, if it's a non-hormonal agent. And again, if you're not on medications for menopause, check the bone, check the vagina.

Nada Youssef:   Mm-hmm (affirmative). Okay great.  Then jumping on to Chloe. "I went into peri-menopause at 39. My doctor had me go on birth control for five years to continue my periods. Was that necessary or could I have just gone into menopause at a younger age?"

Dr. Thacker:      Well, the younger someone goes into menopause, usually the shorter the lifespan and the higher risk of medical problems.

Nada Youssef:   Okay.

Dr. Thacker:      And especially if you're under the age of 40, it's a lot more concerning for severe osteoporosis, psychiatric problems, neurologic issues, increased cardiovascular disease. So it was good that your physician identified that you needed some treatment. Women don't have to have periods, in fact nowadays, we pretty much often times give women hormones every day continuously so there's no cycle.

Nada Youssef:   Sure.

Dr. Thacker:      So there's no bleeding.

Nada Youssef:   Sure.

Dr. Thacker:      So migraine headaches don't get worse. So women don't have to bleed on hormone regiments.

Nada Youssef:   Okay. Great. Then we have Maria. "Now that I've begun menopause, should I be concerned about birth control?"

Dr. Thacker:      Yes. Until you go a whole year without a period, preferably being over 51, the typical age or average age of menopause, there's still a rare chance for ovulation.

Nada Youssef:   Mm-hmm (affirmative).

Dr. Thacker:      So, if you were using contraception, we would recommend to continue that.

Nada Youssef:   Okay, great.

Dr. Thacker:      Until it's absolutely clear that there is no more eggs left. That is the safest thing. And after teenage women, women in their late 40's, early 50's are the next most common group to be surprised with unintended pregnancy.

Nada Youssef:   Oh.

Dr. Thacker:      So that's important.

Nada Youssef:   Very interesting.

Dr. Thacker:      Mm-hmm (affirmative).

Nada Youssef:   Very interesting.

Then Wendy is asking, "Who's the best professional to determine the right mix of hormones? Can most gynecologists handle it or does it require a specialist, and who would that specialist be?"

Dr. Thacker:      Well it depends. There's lots of OBGYN's that are very comfortable in treating menopause. Then there's others that are pretty much doing surgery or delivering babies. Just like there can be some primary care doctors that have expertise in menopause. So it really just depends and I think asking your healthcare provider, do they feel comfortable, would they be more comfortable for you to see someone else, is a good question to have with your doctor.

Nada Youssef:   Sure. Great. Then we have Paula. "Any effective and natural ways to get through menopause symptoms?"

Dr. Thacker:      Well natural is kind of a loaded word. Lots of things are natural like hurricanes, manure.

Nada Youssef:   Yeah.

Dr. Thacker:      So natural's not necessarily better.

Nada Youssef:   Yeah.

Dr. Thacker:      And replacing the hormones, estrogen, we can use bioidentical hormones.

Nada Youssef:   Okay.

Dr. Thacker:      So I think in terms of just what are good, hygienic lifestyle issues like eating right, getting regular sleep, exercising, that goes a long way to reducing health risks and helping you feel better.

Nada Youssef:   Okay, great. Thank you. And Lana. "Is hormone replacement therapy safe?"  I know we talked about that.

Dr. Thacker:      For most women, hormone therapy is safe and it's effective. The most serious side effect with hormones is the rare risk of blood clot. But if you had a baby, you've had a C-section maybe or surgeries or you've taken the birth control pill, you're probably not in that risk. Now if you do have a risk of blood clot and you've personally had one or someone in your family's had one, then we don't generally use oral estrogen. We would usually only use transdermal and we would maybe do some things differently.

Nada Youssef:   Okay. Perfect.

Dr. Thacker:      And for women that don't have hot flashes, but maybe their bones are a little bit thin or they're worried about breast cancer risk, we have a class of medications called Serms or estrogen antagonists. They're not estrogen, it's not hormone therapy, but it does act on some of the estrogen receptors and helps the bone, some help the vagina, some reduce breast cancer risk actually.

Nada Youssef:   Great.

Dr. Thacker:      So, even if you're not on standard hormone therapy, there are other options.

Nada Youssef:   Perfect.

Dr. Thacker:      And we also have designer hormones too, that help ...

Nada Youssef:   Designer hormones?

Dr. Thacker:      Designer estrogens, which help to reduce some of the common side effects like breast tenderness or abnormal bleeding. Things that tend to turn women off to hormone therapy.

Nada Youssef:   Oh, very interesting. Very good to know. Thank you. And I have Rachel. "Sex has become painful since menopause. What can I do?"

Dr. Thacker:      Well it's important to have an exam, because most likely it's from vaginal atrophy or the so called genital syndrome of menopause. But it could be caused from an infection or a skin condition, like lycan sclerosis or muscle spasm. So it's very important to get an exam by someone who can find out what the cause is. And we have local treatments, we have systemic treatments, but nobody should suffer with those symptoms.

Nada Youssef:   Now vaginal dryness is also a symptom to menopause, correct?

Dr. Thacker:      Yes.

Nada Youssef:   So something just like a lubricant would work, correct?

Dr. Thacker:      Well, you can certainly use moisturizers or lubricants and there's several. There's water based ones, in general we don't like any mineral oil, but olive oil or vitamin E or coconut oil would be fine as a moisturizer/lubricant.

Nada Youssef:   Okay.

Dr. Thacker:      And is generally inert. Sometimes these lubricants can affect the PH of the vagina, which can effect infections. But anything that you put on to just moisturize or lubricate, might temporarily make you feel better, but it doesn't change the integrity.

Nada Youssef:   Right.

Dr. Thacker:      And if women could see the dramatic changes that happen to the estrogen-sensitive tissue in the vagina, I think that they would want treatment to keep that tissue healthy.

Nada Youssef:   Sure. Great. Thank you.

Dr. Thacker:      And we can easily see that on exam and treat it.

Nada Youssef:   So get an exam. Right. It's the first thing you want to do. Alright and we have Linda. "I will be 80 in a few months ..."

Dr. Thacker:      Great!

Nada Youssef:   "I still have all my female organs. My doctor told me I no longer need to have a pap smear. What is your opinion?"

Dr. Thacker:      Well the pap smear is a screen for cervical cancer. It's one of our best cancer screens and if you have always had normal pap smears and you don't have HPV or HIV/AIDS or your mom didn't take DES hormones, then after age 65 if you've had a reproductive lifetime of normal paps, you don't need that scrape of the cervix.

Nada Youssef:   Okay.

Dr. Thacker:      But every couple of years we like to do an exam. Look at the health of the tissue, feel the organs, check your muscle strength. How do you do at kegel? Make sure there's no prolapse. Ask about leaky bladder, ask about your sexual function. So a lot of women equate the yearly pap, even though they're not necessarily getting the scrape, with a yearly check on being a female. So regardless of your age, you're always a female and need periodic checks and contact with your healthcare provider.

Nada Youssef:   Great. Then we have time for one more question. Here I have Brandy. "What about hormone pellets? Are they safe?"

Dr. Thacker:      Well pellets, putting hormone underneath the skin, is not FDA approved. A lot of places are doing it and I see problems with it, because you get elevated levels above the normal range.

Nada Youssef:   Oh.

Dr. Thacker:      So they start out low, go really, really high, sometimes too high and then start to crash. Then when they come down, the women gets withdrawal-like symptoms. So it's not really an addiction, like to nicotine or opiates or something like that, but there is this tacky phylaxis. And I see women use more and more and more hormones. So I do not recommend that. We have pills, patches, gels, sprays, vaginal rings. We have lots of different ways to give women a constant level of whatever the right hormone that they need.

Nada Youssef:   How are pellets placed in your body? You said underneath the skin?

Dr. Thacker:      Underneath the skin. And women are used to having contraceptive devices ...

Nada Youssef:   Yeah, I was gonna say that.

Dr. Thacker:      put under the skin, but I do not recommend pellets.

Nada Youssef:   Okay. Great. Thank you. Okay well, that's all the time we have for today, but before I let you go, is there anything you want to tell our viewers?

Dr. Thacker:      Don't be fearful. Don't get your menopause information from your nextdoor neighbor. They may be well intentioned. Even your own doctor may be well intentioned, but not informed. So we want you to be strong and be healthy and be in charge and get the right information. So go on our Speaking in Women's Health .com site. Download our free treatment guidebooks, ask the nurse questions, see where our latest breaking health news, our columns are.

Nada Youssef:   Sure, sure. Great. Well thank you so much for coming in and also, you guys make sure you tune in next week. Tuesday at 1pm for another Facebook Live Q&A with Dr. Rosenquest, where we'll be taking your questions regarding opioids. So do not miss it and make sure you keep following us on Facebook, Twitter, Snapchat, and Instagram at ClevelandClinic, one word, and thank you so much for watching. We'll see you next time.