Navigating 'The Change': What Every Woman Should Know About Menopause with Dr. Pelin Batur

Podcast Transcript

Nada Youssef:    Hi. Thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today, we're broadcasting from Cleveland Clinic Main Campus here in Cleveland, Ohio, and we're here with Dr. Pelin Batur. Thank you so much for being here.

Pelin Batur:   Absolutely. Thank you for inviting me.

Nada Youssef:    Dr. Batur is a women's health specialist, practicing in the Center for Specialized Women's Health, and is an associate professor for ob/gyn and reproductive biology. And today, we're here to talk about menopause. Please remember, this is for informational purposes only, and it's not intended to replace your own physician's advice. To kick off our discussion of the transition that is menopause, can you give us a quick recap of stages of menopause?

Pelin Batur:    Sure. Menopause by definition is 12 months of no periods, and that's really the only way we can truly diagnose menopause. Now, menopause starts with a menopause transition, and there's the early menopause transition, where you might be having some screwed-up cycles a little bit, or you might actually be having some symptoms like hot flashes, but for the most part, you're still having once a month, regular periods. Late menopause transition is where you're really starting to skip months and months at a time. And we know sometimes around the corner, but really, all these stages have different time spans for different people, and it's hard to make the diagnosis until you actually go through, so it's what we call a retrospective diagnosis. You look back, and over the last 12 months, I haven't had a bleed, so that's one of the main ways that we use to diagnose menopause.

Now, people always ask about hormone testing, and menopausal hormones can be helpful to aid in the diagnosis to figure out what's happening with the cycles, but it only gives us one snapshot in time. So again, you can go six months without a period, have hormonal blood tests that look like you're in menopause, but if you ovulate and have a period after, your clock starts back at zero.

Nada Youssef:    The first thing I think of when you say 12 months no period, what about people that are on birth control that maybe even stops it completely? How would they then know?

Pelin Batur:   Yeah, so that's a great question. When you are on any kind of hormones that are affecting your cycles, you can't use that as... So it really is 12 months off of any hormones that can affect your cycles, and also in the absence of any medical conditions. So, assuming that your thyroid isn't off, or that you don't have any other hormonal problems like a prolactinoma, which is when elevated... It's a brain hormone that when elevated can actually cause cessation of menses. So, depending on what age you are when you're coming into our office, we're usually going to look at your medical health to make sure we're not missing something else that may be causing the lack of periods. And especially if you're younger, we do usually do some blood testing to make sure we're barking up the right tree and not misdiagnosing you as menopausal.

Nada Youssef:    Great, thank you. So, let's talk about perimenopause, what that is, and when is it normal for a woman to start going through it?

Pelin Batur:   Perimenopause, it can actually start a decade before, where you're starting to get some hot flashes, and for most women, it isn't, it's usually within the few years prior to the last menstrual cycle. But perimenopause is oftentimes a time of transition where women may experience screwed-up menstrual cycles. And what's important to mention to your doctor, well, I always say if you're skipping months and months at a time, and you're close to the age of menopause, which is about age 51, 52, and you're skipping months and months at a time, and the one you have after that is pretty normal, then you can just keep an eye on it. But what you do want to let your doctor know about is if you're skipping months and months at a time, and then the one you have after is really heavy, like your body's trying to compensate for that, or you're having a lot of spotting in between your cycles, or there's lots more cramping or blood clots. Any of that, you really should talk to your doctor, make sure that you get a checkup.

Nada Youssef:    Great, thank you. So, how do you diagnose menopause, and should you get your hormones checked?

Pelin Batur:   Right, so women... If it walks like a duck and quacks like a duck, most likely it's a duck. What do I mean by that? So, if you're 51, and you've been skipping for the last two years, and now you've stopped your cycles, and you're having hot flashes, and you haven't had a bleed for the last year, it's likely that you're in menopause. Now, we still probably want to check thyroid and some basics to make sure that we're not missing anything else. We're going to definitely look at your medical history, make sure you're not on any medications that might affect. So, in those women where it's a little bit more of the typical story, you don't need tons of expensive lab tests. I mean, sometimes we do, there's always exceptions to the rule, but usually we talk to you and we try to sort things out that way.

It's a little different if you're coming in at a younger age. Early menopause is defined as between ages 40 and 45, and then premature menopause is what we used to call it, now we call it premature ovarian insufficiency or primary ovarian insufficiency, POI. That's looking like you're menopausal before the age of 40, and those, almost always we're going to do some investigation, some hormone testing to make sure we're not missing anything.

Nada Youssef:    All right. So that is called premature menopause, then? Is that the term for it?

Pelin Batur:   So yeah, we've kind of moved away from the term premature menopause. If you're less than age 40, and you're looking like you are menopausal, you haven't bled for many months, it's really important to talk to your doctor, because even if you've gone the whole 12 months, and then it looks like you have the hormone testing that looks like you're in menopause, so that would be an elevated FSH, follicle-stimulating hormone, the brain hormone that regulates the ovary production of hormones, and also the low estradiol levels, so that's your estrogen, dominant estrogen. So, if the estrogen's low and the FSH is real high, and you're in your 30s and your 40s, we're going to really do some investigation. If it's before age 40 and you're looking like you're menopausal, we call that POI, premature or primary ovarian insufficiency.

Why the name change? Because we see many, many women that are diagnosed with premature menopause, and we know 5% to 10% of these women can actually even become pregnant, because they can still ovulate. They may ovulate and not bleed; they may bleed and not ovulate. So, only way we know she's in menopause when she's younger is if she had her ovaries removed. If it's based on hormones, again, those hormones are telling us one snapshot in time, and hormones may change over time, so to allow for that understanding of that flexibility, that's why we call it ovarian insufficiency.

Nada Youssef:    Okay. So, POI, not premature menopause.

Pelin Batur:   Mm-hmm (affirmative).

Nada Youssef:    All right. So, how can you tell if you've gone through menopause after a hysterectomy, and why do you need to know?

Pelin Batur:   Yeah, so that's a lot more difficult, and this same goes true if they've had an ablation, if a woman's had an ablation and she's no longer having cycles. So there, depending on what our goals are, so, if you had a hysterectomy at age 50, it's probably not so critical that we do a bunch of hormone testing, because it's really not going to change how we manage you, so if you're having terrible symptoms, we're going to talk to you about hormone therapy options and non-hormonal options. But if you are 40 and you had a hysterectomy, then it does make a difference, because we also want to know... If you had your ovaries left in place, and you had your uterus removed, now you're not bleeding, but we don't know if, when you're going through the transition.

So not that you have to have your hormones checked every three to six months, right? That'd be very expensive, time-consuming, and it's only giving us a snapshot in time. But we do want to have a rough idea of how much estrogen your body's producing, because I want to know, all right, when do I have to start worrying about osteoporosis, osteopenia, bone thinning? If you are 42 and you've lost your hormones, then we know that there's a lot more medical risks to that woman, and oftentimes we will start hormone therapy until the natural age of menopause.

Nada Youssef:    So we want to know when we're going through menopause because there's a lot of risks and a lot of diseases that come after the fact that we have to be on the lookout for?

Pelin Batur:   Mm-hmm (affirmative), especially with premature menopause, or premature ovarian insufficiency. So, what are some of the things that we worry about? Well, we worry about increased, elevated risks of cardiovascular disease, increased risks of stroke, increased risks of dementia, earlier bone aging. So, if you go through menopause at age... or premature ovarian insufficiency, you're 35, you have an additional 15 years of heart, bone aging, brain aging, and not to mention other symptoms like increased risks of anxiety and depression, increased arthritis risks, even lung diseases like chronic obstructive pulmonary disease, COPD, risks as my risks are increased. So, there's lots that comes with earlier cessation of menses, and it turns out that the use of hormone therapy in these women can help negate or minimize some of these risks.

Nada Youssef:    Excellent. Well, let's talk about just the symptoms of menopause.

Pelin Batur:   Mm-hmm (affirmative).

Nada Youssef:    What can most women expect?

Pelin Batur:   Well, it's hard to say "most women." The experience is varied for every woman. So, some women are lucky, they go through it gracefully with very minimal symptoms, and lucky for them, right? And there are other women, it's not so graceful, it's a little bit more clunky, where they may be experiencing lots of hot flashes or night sweats. Hot flashes are the sudden sensation of heat, and may or may not be associated with flushing and sweating, and then night sweats can actually be very disruptive to the sleep cycle, where women feel like they can't get through the night as well as they usually could with sleeping.

Vaginal dryness, the vagina's quite sensitive to the lack of estrogen, and about 50% of patients, so about a half of women, do get some vaginal dryness that may get in the way of intercourse, and that tends to get worse over time. So, hot flashes and some of the other symptoms, within a decade, many women find that they're actually feeling better, but the vaginal dryness type of symptoms do get worse and worse. So, speak up and talk to your doctor about it if you're... You're not alone, and there are multiple therapies that we can offer. But we also worry about mood changes, so...

Nada Youssef:    Now, is depression a part of menopause?

Pelin Batur:   It's interesting, so depression and anxiety seem to really be an issue during the menopause transition, the perimenopause period. So, what we do know is that women who didn't even have a history of any kind of postpartum depression or hormonal sensitivity, or PMS/PMDD type of symptoms, that actually, they can develop new onset of anxiety and depression. For many women, that seems to get better after menopause, but that is something that we should, women, again, should speak up about, because it's happening to a lot more women than is really discussed.

And other things that are affected by hormones, so for example, menstrual migraines, women who suffer from a lot of migraine headaches may see a worsening during the menopause transition. Many patients will see some relief, luckily, after menopause, but not necessarily.

Nada Youssef:    So when you say "menopause transition," how long are we talking, usually, estimate?

Pelin Batur:   It really varies.

Nada Youssef:    Yeah.

Pelin Batur:   Okay, so we were bad about quoting how long menopausal symptoms will even last. We used to say about five years, and now it turns out menopausal symptoms after the final menstrual period, many women have seven years to 12 years of symptoms, and some women still have problems into their 80s. So we're just now understanding even the basics about menopause, but menopause transition is less understood. Why does it happen? How long does it take? And realistically, lifestyle changes, lifestyle factors likely have a role, genetics likely have a role, but it's not fully understood, and every woman's experience is a little different. But typically, the few years leading up to the final period.

Nada Youssef:    So, if I look at my mom, should I expect to have similar symptoms, similar age when I go through menopause? Because I know everybody's different, but is mom a good one to look at?

Pelin Batur:   I don't have a good scientific answer for that, because that's still being looked at and researched. We know in some families, there seems to be some similarity, but it's a lot more than just genetics. And remember, genetics is not just your mom, right? Genetics comes from, you know, Uncle Carl's side of the family, and Aunt Molly, so it's... Genetics is complex. Plus, how we live our life seems to have a role. Women, for example, with autoimmune conditions, so thyroid problems, rheumatoid arthritis, any of those inflammatory type of conditions, are likely to have their menopause a little earlier. So a lot goes into it, and if I could predict when you're going to go through menopause, I would be retired on some Caribbean island, but we really don't have that tool. No hormone test is going to tell you when you're going to go through menopause; it just tells us what your hormones are doing right now. So it really is a matter of talking to the patient and sorting things out.

Nada Youssef:    Let's talk about some of the physical changes. I've heard that menopause can cause more growth of facial hair.

Pelin Batur:   Mm-hmm (affirmative).

Nada Youssef:    Is that correct?

Pelin Batur:   Yeah, so when you lose estrogen after menopause, you start to have a little bit more dominance of your testosterone. So, what do we associate with testosterone? Thinning hair, some increased hair growth on the chin, and yeah, that can happen, and we have some women who actually opt for hormone therapy just because of their thinning hair, for example. So that can happen, but there is a plus side to it. Women who go through menopause tend to have to shave their legs a lot less. There's thinning of the hair down there, so... The extra minute of plucking, you know, you save on the shaving.

Nada Youssef:    Very good. So, does menopause really cause weight gain? Is it slowing down your metabolism? Sounds like everything's just declining, correct?

Pelin Batur:   No, and I wish I had some good news for that, but I'm just a hop and a skip away from menopause myself, so I'm not looking forward to it. It's almost universal that women report weight gain, so it's not in your mind, it's nothing that's screwed up with you. That is something, whether you're a size zero, a size 5,000, it really doesn't matter. Every woman comes in complaining about it.

And we don't really know why, so it probably is partly slowing of metabolism, it might be hormonal. The good news is that if you need to go on menopausal hormone therapy, it does not contribute to weight gain, but the bad news is all women going through menopause, whether they're going through it naturally or through taking medications, seem to experience some weight gain. In fact, studies that we do have suggest that menopausal hormones may be a little protective from that weight gain, but it's a time where we really have to watch, make some changes.

Nada Youssef:    All right, sure.

Pelin Batur:   Yeah.

Nada Youssef:    Now, going back to hot flashes, I know that usually kind of seems like the most common symptom that you hear from women. Is this ever bad for your health? Should it be treated? I mean, if it's messing with your sleep cycle, maybe, but is it something to look at and worry about?

Pelin Batur:   So, two things. Before we go into that, I just want to also touch on a question I always get about the weight, I forgot to mention.

Nada Youssef:    Yes.

Pelin Batur:   So, the weight gain is a little bit more in the central region, and that's thinking of it like a testosterone effect, right? Where do men carry their weight? They carry it centrally. So that's also a common question that I want to make sure I'm addressing, that even if you might be the same weight, women are noticing it more around the waistline. So, minimizing sugars and really upping your exercise can help with that.

Now, as far as hot flashes, hot flashes, they're not dangerous on their own. They're certainly a nuisance. There are some data about whether women who hot flash more, are they more at increased risk of cardiovascular disease, but on its own, hot flashes don't indicate a heart problem or anything like that. Do they need to be treated? This is where we actually talk to the woman and see what she's thinking. You know, if you're having one or two hot flashes a day, and you dress in layers, and you can get through it just fine, no big deal, right? But if you are plagued with them, you can't sit through a meeting at work, you're constantly flushing and sweating, you're not getting through your nighttime with your sleep because of night sweats, then it really becomes a quality of life issue, a nuisance.

Nada Youssef:    Do you have any tips for dealing with hot flashes?

Pelin Batur:   Yeah, so I think of it in a three-pronged approach: natural approaches, medicine approaches that are non-hormonal, and hormonal approaches. Clearly, our hormonal approaches are the most effective, okay? But I always encourage women to start with non-hormonal, just some of the holistic approaches, and what are they? You know, dressing in layers. There are some data that increased intake of sugar, stress, caffeine may be contributors. The data for all of this is very weak, but certainly it makes sense to try to minimize your stress, practice mindfulness, do some deep breathing.

There are lots of products over the counter that are touted as aids. You do want to exercise a little bit of caution when reaching for them. Most of them, if we look at our well-designed studies, don't show much benefit over placebo, placebo being I give you a Tic Tac and say this is a medication that's going to really help you. About 30% of the time, somebody's going to feel the benefits. It's not because anybody thinks you're crazy, it's because, you know, mind over matter. And we do know that cognitive behavioral therapies, where you focus on your thoughts about hot flashes, those have been shown to be helpful, actually, in well-designed studies. So, when you're reaching for something over the counter, if it's reasonably safe, I'm not too worried about it, but sometimes I worry about the safety and purity of the products that we have in the United States, so you have to choose your products carefully.

So, I would encourage people to check out our Cleveland Clinic website. We have a pretty rich menopause section. I've been working on updating those handouts over the last six years, and really making sure that... I've written most of them, actually. So if you Google, or go onto Bing, or whatever's your search engine, and put in "Cleveland Clinic, non-hormonal ways to combat hot flashes," you should pull it up. If you go to clevelandclinic.org and hit that search button, that should be pulling it up too. And it kind of goes through all the different products that are available. We talk about diet, for example, soy products. It lists different types of foods and how much soy, that's plant-based estrogen, it has in them.

So if you're getting it through your diet, that's okay, like flaxseed and soy and tofu. Now, when you start to get into manmade products, the phytoestrogens, as they say, the plant-based estrogens, you essentially have an unregulated... It's an unregulated field, right? So you have a businessperson putting together a plant estrogen, sometimes in powerful form, and we just don't know, we don't have good long-term data for how that affects us. We don't have good long-term data for effect on breast safety. Because plant estrogens are found in nature, but they're actually unnatural to our body chemistry, so it doesn't look like our own estrogen, so when you're putting it into man-made forms, then you're starting to get into, essentially, a chemical that you're putting into your body. But if you're doing it naturally from foods, that's safe.

Nada Youssef:    So, are these supplements that you're talking about-

Pelin Batur:   Mm-hmm (affirmative).

Nada Youssef:    ... or is it kind of like preservatives in food, or...

Pelin Batur:   No, supplements.

Nada Youssef:    Okay, supplements.

Pelin Batur:   So if you go to your typical health food store, you'll find tons of supplements, and some women... We do know many women try them, and it's okay. Long-term safety, we don't know. Black cohosh, for example, there are some concerns. That's a supplement over the counter. There are some concerns about liver safety, there's been reports of liver failure, so the FDA has cautioned about no more than six months of use for that. So just because you're getting it at the health food store doesn't necessarily mean it's safer.

And you'd have to be careful. There are lots of estrogen and progestin creams that, especially if you have... you survived breast cancer, for example, I would discourage you from using those, because you do absorb estrogen through creams very readily, but you don't absorb progesterone through your skin easily, and so we do see a lot of women who have been lathering on a lot of estrogen products, and lathering on some progesterone thinking they're balancing, and they're not, and we've seen problems with uterine cancer and precancer with that. Yeah.

Nada Youssef:    So, for the over-the-counter medications, you said some of them you would have to kind of use with caution, some of them are safe?

Pelin Batur:   Mm-hmm (affirmative).

Nada Youssef:    How can we tell what's okay to use and what's not to use? Are there ingredients we should be looking for or anything like that?

Pelin Batur:   Yeah, so there are some studies looking at some plant-based estrogens, coming out of Japan and Europe, where there's actually some benefit over placebo. But when you look at the data overall, there's really not much benefit over placebo with most of these products. So, I hate in my practice to encourage use of something that actually is quite pricey, where I don't know the long-term safety and the suspicion for whether it's really going to help or not. But I think if you want to try something on your own for a month or two and see if it helps you, I think that's okay, but I don't think it's something to be using for five, six years for your main treatment of menopausal symptoms.

So that's the first branch. There's also hypnosis and acupuncture, so there's some data for hypnosis, and again, cognitive behavioral therapy. Data for acupunture's been very mixed, so most studies suggest not much benefit over sham procedures. But frankly, I like hypnotherapy and acupuncture, I do think it helps a lot of women, so if they want to do that, I have no objections. I think the safety profile is just fine. It's just a cost, you know, it's a time and cost investment for many women, so I hate to feel them towards products that are going to be questionable or not going to help so much, especially if they're paying a lot of money out of pocket.

We also have the second option, right, the non-hormonal option, so we have several medications that are... And that's all listed in that non-hormonal ways to combat hot flashes insert... Not insert, the patient education materials I recommended, that lists all the different types of products out there that we do use. These are FDA-approved medications, but they're FDA-approved for other reasons, but they also happen to work for hot flashes. And we do have good data that they work better than placebo, and so we've listed all the ones where they've actually been shown to be beneficial.

The SSRIs and SNRIs, these are a group of antidepressants that have been shown to be beneficial. And in fact, these are some of our go-tos for women, for example, are breast cancer survivors, who sometimes have the worst symptoms. And in those women, obviously, we can't easily use hormonal options, so these are some of our go-to medications, and they can help. So, when women come in and we offer them, some women come back and they say, "Oh my gosh, you should offer this to everybody. It helped me with so many of my symptoms." And I always say, "We do, but not every woman takes us up on it." And everybody's results do vary. And then there's also anti-seizure medication called gabapentin, it can help with sleep and with hot flashes.

And they come with their different array of pros and cons, with their side effects that we have to talk out, so we usually review all these options with women, and whatever she feels the most comfortable with, recognizing that you can always try one, and if it didn't work well for you, it's not like once you walk through the store, you can never walk back. You're not going to do any irreparable damage. If it doesn't work for you, we can try something different.

Nada Youssef:    If we have any of our viewers or listeners listening, and... You know, you just said the hypnosis, the acupuncture. If they do want to try something like that, do we offer that here at Cleveland Clinic? Do they go through you? How-

Pelin Batur:   We do.

Nada Youssef:    Okay.

Pelin Batur:   And so they can ask their primary care doctor or their gynecologist to get them pointed in the right direction. But if you want... What the science shows us now, if you want to pin me down for what's most likely to help, I would say cognitive behavioral therapy, I would say hypnotherapy, and then a shout-out for acupuncture, which may help, especially if you have other things like migraines or aches and pains, they can work on more than one thing. And then the non-hormonal medication options for women who don't... or absolutely said they don't want to do hormones. But the prescription options are going to be the most effective.

Nada Youssef:    And speaking of hormones, what is the latest on hormone replacement therapy, and how does a woman decide if we should do it?

Pelin Batur:   Right. So this is where I like to really spend some time on, because hormone therapy is a very confusing field of risks and benefits. That's why it is important to make sure that the doctor that you're seeing feels comfortable with them. In fact, many of us are certified in menopausal medicine by the North American Menopause Society, so if you go to their website, it'll give you a list of people in your town who are certified. Because it really gets very confusing, the data.

There's something called the timing hypothesis that says that depending on how old you are when you start hormone therapy, your risks and benefits are going to be vastly different. So what does that mean? Most of the package insert in hormone therapy and why people are afraid of it, it literally looks like we're trying to kill you. It tells you we're going to give you breast cancer and a heart attack, you know. And the reality is, there are some risks that we can talk about, but this package insert is written for women who've cleared menopause for 10, 15 years. They're now in their mid-60s and 70s, and they're deciding to whether they want to go on hormone therapy to prevent disease. And that's not the typical situation. The typical situation that we're seeing in the office is somebody who's newly menopausal. She's typically late 40s, early 50s, and she's having terrible symptoms. It turns out the risks and the benefits for the woman in her 50s is much, much more favorable as opposed to a woman who is in her 60s and 70s who's deciding to start hormone therapy now.

And taking this timing hypothesis a little further, if you go to women who are prematurely losing their ovarian function, so the POI, before age 40, the early menopause between age 40 to 45, in these women, we typically start... Unless there's a reason not to, we typically start hormone therapy to minimize the risks of all those things that you're going to read about in the package insert. Okay? And so, almost all of the menopause and endocrine medical societies do recommend, in those situations when you're in earlier menopause, a POI, to actually start hormone therapy and continue it, as long as you're medically fit to do so, until the natural age of menopause, which is 50 to 51 to 52.

Nada Youssef:    So it's safe.

Pelin Batur:   Mm-hmm (affirmative).

Nada Youssef:    Because you do hear a lot of things about it, it seems to be controversial, but it is safe, and if you're, you said, over the age of 65 or 66, no longer menopausal, that's when the side effects could harm us.

Pelin Batur:   There's no woman where we say, "Absolutely you can't be on hormone therapy," okay? It's all about balancing risks and benefits. So, for the average patient who's going to choose to drive to the doctor's appointment, they took on their greatest risk of death, right, by choosing to drive. So there are pros and cons to driving, right? I mean, you can choose not to drive, and negate that risk of having serious injury, but you'd probably be stuck at home feeling depressed, you're not going to get good nutrition. You know, so there's a pro and a con to everything, and it's the same discussion with the hormone therapy, so there are risks and there are benefits.

So, the risks and benefits seem to be very different depending on not just your age, but whether you need the estrogen plus progestin or estrogen alone. The only time we really are using progestin is if a woman has a uterus, because if that woman has a uterus, we can't just use estrogen alone, we will increase her risk of uterine cancer. If we add the progestin, we're not going to increase her risk of uterine cancer. But if a woman has had a hysterectomy, then she only needs estrogen. And it turns out the progesterone steals a little bit from some of the benefits of the estrogen, so some of the cardiovascular benefits on the arteries, the cholesterol benefits, and then breast cancer risk is not significantly increased in estrogen-only users. In fact, there's no increased risk in estrogen until maybe 15, 20 years of use with estrogen, and women in their 50s who were using estrogen had actually less breast cancer when they took estrogen alone. So it seems to be the progesterone or the progestin that is the culprit for that.

Breast cancer risks is the biggest thing, I think, that women worry about, and if you're taking estrogen alone, you really have plenty of time to not worry about it. You know, you may have an increased risk after 15 to 20 years, and even that's debatable. But if you're taking estrogen plus progestin, you're probably going to have increased risk of breast cancer, which is in the rare category, and that risk seems to start years after starting it, so anywhere from three to five years. So, if you want to try hormone therapy for a year or two, just to see if you're going to get some quality-of-life benefits, that's reasonable. All these risks and benefits we're talking about are really with long-term use, okay?

And people worry about cardiovascular risks, that's one thing that's written in the package insert. Again, that's really for women in their 60s and 70s. It turns out that, again, the timing hypothesis, if you're starting your hormone therapy when the blood vessels are healthier, you don't significantly increase your risk of cardiovascular disease. But there's some benefits, you know, the reduction in osteoporosis fractures, especially hip fractures, which a lot of the fancier new medications haven't even been shown to help with benefit of hip fractures, and also a decrease, reduction in colon cancer risk in estrogen-progestin users by 20%. So it really is mixing the pros and the cons, and it really, just like anything else, is an individualized decision for each woman.

Nada Youssef:    Great, thank you. Now, how long can you safely stay on hormone therapy?

Pelin Batur:   There's really no time limit for hormone therapy. We do know that after three to... around the three to five year mark, that's when you start to increase your risk of breast cancer. And when I said it was in the rare category, I'd have to write about a thousand prescriptions of the estrogen plus progestin to potentially increase one woman's risk. And that risk is comparable to other lifestyle changes, it's comparable to... You know, if you have a few extra pounds to lose, that increases your risk of breast cancer. If you consume alcoholic beverages every week, that increases your risk of breast cancer. So it's actually comparable to that.

Nada Youssef:    And what if a woman has a family history of breast cancer? What are her options?

Pelin Batur:   So, a family history of... This is something that I really want to spend some time on, because most women are coming in worried about risk of breast cancer, okay? So, if you have a very small family history, for example, you have a grandmother that had breast cancer at a later age, we're... I mean, yeah, we worry about any kind of family history, but that's a lower risk, and so I'm not as worried about the risks of hormones. After breast cancer, we rarely use hormone therapy, so that's the other extreme, where a woman's highest risk, because she's already had cancer before. Now, there are exceptions to that rule, too. There are certain situations where we do, especially if a woman has terrible quality-of-life symptoms.

But there's that in-between, where there are women who have some family history, or they carry the gene for the breast cancer, the BRCA gene. In those situations, we really individualize. For example, what we do know, we see a lot of patients who have... who carry the gene, the BRCA gene for breast and ovarian cancer, and many of these women opt to have their ovaries removed early. So, now they are in premature menopause, so we know there's all the premature menopause risks, and she may be having terrible quality-of-life symptoms, you know, vaginal pain with intercourse, not being able to sleep, terrible hot flashes, mood, hair falling out. So this woman may decide that she's going to use hormone therapy.

And we're really working hard to streamline our program between us, the Breast Center, and our gynecologic oncology colleagues so that we're giving a consistent message, because we do oftentimes, in these younger women, use hormone therapy. And the studies that we do have suggest that in our patients, even at the highest risk who carry this gene, do not seem to get increased risk from hormone therapy or even oral contraceptives, which are higher dose. So it's important to really individualize, and we want to make sure that we're not making women suffer with dogmatic rules, and that we are really weighing the risks and the benefits for the individual woman standing in front of us.

Nada Youssef:    Very good, thank you for that. So, after researching and talking to people, seems like there's a lot of confusion with hormone therapy. Is there anything else you wanted to add?

Pelin Batur:   Yeah, you know, everybody means well. You're going to get a lot of advice from hormone therapy, but you go to... Even if you come to somebody certified in menopausal medicine like us, we sit and have an hour session, you're going to go back home, and a well-intentioned doctor, a friend, a well-intentioned neighbor is going to say, "Oh my gosh, hormone therapy, haven't you heard that stuff is so dangerous?"

So there are a few things that we really... I do like to highlight. Hormone therapy, consistently in studies, has been associated with a decreased risk of dying. So we talk about a lot of risks of this, and a little risk of that, and this benefit, but in the big picture, I mean, we want to live a long, healthy life, right? So we talk a lot about the breast cancer risk, but we know that if women, the breast cancer... the increased risk of breast cancer comes with more easy-to-treat breast cancers. But consistently, there are not many medications in history that have actually consistently been shown to decrease risk of death, and hormone therapy is actually one of them, so women... In fact, there was increased death rate throughout the nation, in mortality, as we say, in women, after the release of controversial hormone therapy risks and benefits where many women came off. You started to see an increase in the death rate of women, as opposed to a drop in the death rate in men, and the only main difference at that time was that there was actually this huge stopping of hormone therapy.

We do know cardiovascular risks are increased immediately when women... the time period immediately after stopping hormone therapy. So it's really quite... Hormone therapy is quite complex. You do need to talk about your individual risks versus benefits with somebody who really knows the data, because it's not as simple as what the package insert makes it sound to be.

Nada Youssef:    And this question comes up with everything. Hormones, do they cause weight gain?

Pelin Batur:   Yeah, so weight, hormones and weight, again, weight gain seems to be universal throughout the menopause transition and into menopause, and so the data that we have so far doesn't suggest that hormones cause any weight gain. In fact, if anything, if you look at populations of women, women on hormone therapy seem to gain less weight than women who try to struggle through menopausal symptoms on their own.

Nada Youssef:    So, since menopause is a natural change for a woman, when or why should I see a doctor?

Pelin Batur:    Well, you should see your doctor when you're going through menopause because you should make sure that there's no other reasons why you may have stopped having your period, such as a thyroid problem. Plus, you know, if you're the average age, 51, 52, that's a time of change where now the cholesterol may... You're starting to lose some of the protective benefits of the estrogen, so you're starting to increase your cardiovascular risks, the cholesterol isn't looking as good, so your doctor wants to talk to you about other preventative things. Now, if you are younger and you're going through menopause, you definitely need to seek guidance from your physician, because we need to explore a little further, make sure your medical health is okay, make sure we're not missing other reasons, and to talk about the pros and cons of hormone therapy specifically.

Nada Youssef:    All right, one last question for you.

Pelin Batur:    Mm-hmm (affirmative).

Nada Youssef:    What is the best way to maintain a healthy lifestyle after menopause? I just want to hear your recommendation to our audience.

Pelin Batur:    Yeah, I mean, the tried and true things that you hear everybody preaching really do make the biggest difference. I mean, getting your regular aerobic exercise, minimizing your intake of processed foods. Minimizing carbs I think is important to bring down insulin levels with our typical American way of life, especially after menopause. Not smoking, making sure your blood pressure's... Because it's really the... Making sure your blood pressure's good, that you know your cholesterol numbers, because really, in the end, watching these risk factors is going to help you minimize cardiovascular risks. You do want to make sure that if you're in menopause and you're opting to not take hormone therapy, that your doctor is assessing your vaginal symptoms, in case you're having pain or intercourse, sometimes urinary symptoms can be accompanied with the lack of estrogen, and also following your bone health to make sure that osteopenia, osteoporosis is being prevented.

There is one thing that I always try to tell my patients. You really have to be an advocate for your health. When I look at, listen to people who have been frustrated with their health care thus far, or feel like they got blown off or misdiagnosed, I always almost hear an element of broken-down communication between the doctor, the health care provider, and the patient. So, if you're going to see your doctor, or your nurse practitioner, or your physician assistant, and you're bringing up something at the annual, they may want you to come back, but bring it up, speak up. Say, you know, "I'm having pain with intercourse. My hot flashes are terrible. My mood stinks." They may not be able to address it as part of a preventive, but they may ask you to come back. Bring it up.

And then, keep in mind also that if you're not feeling better, if we don't hear back from you, we assume you're feeling great, okay? And I think this is where a lot people get disgruntled with the medical community. Because when you come into the office, you talk to me about something, I have a plan A, B, and C in my mind, but typically, I'm going through plan A, because it's either simpler for you, or cheaper, or most likely to help you. But if you never reach out to me saying, "Hey, this is not working for me," I never get an opportunity to talk about plan B or plan C or do more investigating to make sure you're not that one in a hundred that's presenting differently.

So, what I see a lot is people get disgruntled and they say, "Oh, that doctor just recommended this. Let me go try somebody else. Let me go..." And they're seeing three different people, four different people, and they're all starting with plan A. So I think this is being your own advocate, speaking up, and recognizing that, you know, your doctor may want to see you back to talk more, and that's okay. But take those next steps.

Nada Youssef:    I love that. That's a very good point, because sometimes you go to the doctor and you're like, "She knows what to ask me, I'll tell her when she asks," and sometimes you just keep your things inside, but... It's a very, very good point. And I appreciate your time today, Dr. Batur, it's been a pleasure speaking with you.

Pelin Batur:    Yes, absolutely.

Nada Youssef:    Thank you so much. And to schedule an appointment with a women's health specialist, make sure you can call... And to schedule an appointment with a women's health specialist, please call (216)444-6601, and to listen to more of our Health Essentials podcast, you can go to clevelandclinic.org/hepodcast. And for the latest Cleveland Clinic news and health tips, make sure you're following us on Facebook, Twitter, and Instagram, @clevelandclinic, just one word. Thank you, we'll see you again soon.