Functional Medicine and Menopause

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob-Gyn Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Hi everyone, I'm your host, Dr. Erica Newlin. Welcome to Ob-Gyn Time. During this season we are focusing on topics related to menopause. On this episode, I'd like to welcome Dr. Sobia Khan, who will be talking to us about functional medicine and its role in alleviating menopause symptoms and other ways functional medicine can impact your life. Dr. Khan, thanks so much for joining me on the podcast.

Sobia Khan, MD:

Thank you for having me.

Erica Newlin, MD:

Can you tell us a little about your role in the Cleveland Clinic and a little about your background?

Sobia Khan, MD:

Sure. So I hold a primary board certification in internal medicine and completed women's health fellowship training at Cleveland Clinic in 2012. I also specialize in menopause and functional medicine. After serving as director at Women's Comprehensive Care Center at Baylor College of Medicine in Houston, Texas for 10 years, I returned to Cleveland Clinic in February 2022 to establish a consultation program focused on women's health functional medicine.

Currently at the Center of Specialized Women's Health, we offer functional and integrative approach in conjunction with the hormone replacement therapy, menopause care, perimenopause, hormonal imbalances, insulin resistance, and treating inflammation in general.

Erica Newlin, MD:

Great, and can you go a little more in to what is functional medicine? I think even a lot of physicians don't know exactly what that means as a field.

Sobia Khan, MD:

So functional medicine is more of an upstream approach to identify the root cause of the disease or the symptom that patients are experiencing. It is not just focused on a single organ system, it is more of a holistic approach and looking at the patients as a whole and how my approach in women's health functional medicine is kind of different is because I am combining the scientific and medical perspective with the holistic lifestyle education to restore the physical, mental, emotional, and spiritual health and harmony.

Erica Newlin, MD:

Great. What kind of conditions would you say are best served by functional medicine? Who would you usually see as a general patient population?

Sobia Khan, MD:

This is a very good question and I'll tell you that even someone who is not a patient and who is absolutely healthy needs a functional medicine consultation. I think that it is so important for everyone to understand the preventative care and how they can have a more structured approach to their health and the resources that are around to maximize their health span.

Erica Newlin, MD:

So what might someone expect at their first appointment?

Sobia Khan, MD:

So typically in Women's Health Center, you know I'm receiving quite a bit of referrals on all different kind of presentations and conditions such as PCOS, endometriosis, perimenopause, menopause, simple weight management, hormonal dysregulation.

So it is very comprehensive and when a referral is made, usually when the patient comes to see me for the very first time, it is an opportunity to set some goals. It is opportunity to build confidence and communication with them because it is a very comprehensive field and it is work in progress.

It's not like one visit where we will be accomplishing everything that are a concern to them or what is affecting them throughout their health span. So we try to streamline their goals and then we try to make a plan according to it. We try to meet the patients wherever they would like us to meet them. Let's say if they would like to just be more detailed in their history, we share questionnaires with them. We try to collect as much data as possible.

The first visit will also order some specific labs pertaining to their conditions. We'll share some resources that will help them with their diet, exercise, in general whole lifestyle and will give them the confidence to accomplish some of it over the next two weeks. Because if a patient comes back and they have not even read those resources, this is their time to then ask more questions to inquire about ideas, the what works for them, what challenges them.

So if they have not even accomplished this much to read the material and the resources we share with them, then the next visit we kind of reinforce that because it's also to identify the readiness of the patient. This is, as I mentioned, not a conventional medicine. So we are not talking about the treatments from the first visit, but more trying to get to know them, try to get as much as objective data through labs, through testings, through their history, and then tailor a very personalized approach for their lifestyle and their general health.

Erica Newlin, MD:

What kinds of things are you usually looking for in the history? Is it primarily diet, exercise or are there other things patients should be prepared for as well?

Sobia Khan, MD:

It's a very interesting question. You know, at times, because patients have been referred, so they'll be just focused on hormones or they'll be just focused on the PCOS component of it or maybe facial acne or anxiety that they're experiencing. So when we start asking questions in more detail, just trying to evaluate their gut health and their physical health, they're very surprised at why we are having this deep dive. But this is all very connected and we try to just like get to know them and see that what are the triggers, what are the mediators, what are the certain circumstances that have led to this condition?

And this helps us a lot to then refer back to the root cause and targeted. And that's where they really start feeling good. They start feeling like they have been validated, they have been heard, and now they are moving in the right direction to actually have their own self-motivation and their self-care geared towards their own health goals.

So we empower them. We do not hold them indefinitely. We give them the tools to work with that so they're able to then identify their own challenges and deal with them better.

Erica Newlin, MD:

What kinds of things might someone do to prepare for their first appointment?

Sobia Khan, MD:

So at first appointment, if they can prepare a timeline for us, which is like, you know, any kind of health related incidents preceeding to the visit, sometimes we even are interested in how were the things when their mother was pregnant with them, how was the delivery like during their early years of life? Were they exposed to too many antibiotics or they were constantly in the hospital for certain conditions?

So timeline is the key. If they can do a brief synopsis of their health history, they can bring a timeline for us where they have really a very structured kind of detailed history telling me that, you know, 2010 this event happened, 2011 I used an antibiotic or had colitis or this will help me connect the dots so much efficiently that we'll be able to make the best out of that visit.

Secondly, if there are any data available like labs or any imaging studies or any consultations that they had locally or nationally they can bring with them, then we can sort through and prioritize that what is relevant to that particular condition.

Erica Newlin, MD:

I'm sure this may be too general of a question, but are there any specific labs or anything that someone should have before coming to see you that might help expedite things?

Sobia Khan, MD:

We don't expect that because really it will be tailored to their history and their condition. So it is best that they come with their timeline, with the goals they would like us to help them accomplish and we can then work around it and try to figure out a plan for them.

Erica Newlin, MD:

Is there anything generally that you would recommend as lifestyle interventions even before someone were to come to see you?

Sobia Khan, MD:

This is a loaded question. You know,

Erica Newlin, MD:

(laughs).

Sobia Khan, MD:

(laughs). Yeah, I would like to make those recommendations, but then everyone is so different and of course functional medicine has this philosophy of using food as medicine and everyone has a certain emotional and social connection with the food and you cannot tell them ahead of time that they should be eliminating gluten or dairy or sugar without identifying that you know, what is their relationship with the food.

We can certainly, you know, encourage them to have more activity, moving more, having more steps, not using the word exercise all the time because it gets very intimidating for some people. So trying to optimize their diet and their movement are the two things that if that could be just like initiated before the appointment, we can certainly build upon it during the visit as well.

Erica Newlin, MD:

What about any other environmental exposures that people may come across? Like any specific cleaners or soaps or things like that people should avoid generally or is that also very individualized?

Sobia Khan, MD:

It is individualized and it is also in today's world, very much generalized as well. We all know that there are various environmental triggers and there are toxins in air, there are toxins in water, there are toxins in food. So detox is the main idea behind addressing some of these conditions. So when a patient comes to me for the very first time and we do not know that what kind of a diet plan will be best tailored to this condition until we meet the next time, we usually advise them to go on a detox diet, more like cleanse, trying to just like avoid toxins that they can inhale or they can ingest.

Therefore, we share with them some diet resources where of course everyone cannot buy everything organic. We try to limit them to buy some organic produce. That is very much important because otherwise they're loaded with pesticides.

So first visit I share with them those resources, I try to detox them as much as possible and try to bring them back with the confidence that now they have an idea of moving forward. You know, if there are some deficiencies in their vitamins and minerals, we'll replenish those stores, we'll restore the gut and we'll get the hormones in balance. So yeah, I mean this is really a world where we are surrounded by toxins and exposures.

In fact, it is now called expo zones that is exposing us to certain allergens and certain toxins that we certainly cannot avoid all the time.

Erica Newlin, MD:

Let's focus a little more on functional medicine and menopause and perimenopause also. I have a lot of patients that come to me in perimenopause and they just describe a myriad of symptoms. So loss of energy in addition to the hot flashes. They just feel like a different person. Can you talk a little more about the role of functional medicine in managing perimenopausal and menopausal symptoms?

Sobia Khan, MD:

That is my passion and that is really my goal to help women through perimenopause and menopause. And I think that perimenopause is actually more of an important domain to focus on because once menopause has manifested, really women are surprised. They do not know what they could have done differently to avoid some of those symptoms. So the education should be initiated five years prior to their menopause age and at times we can calculate it by asking about their family history and their general wellbeing and try to implement some of those changes ahead of time.

So the symptoms that women typically start experiencing at the time of perimenopause are of course hot flashes, night sweats, that could be random, that can come and go, and anxiety, brain fog, fatigue, all of this makes them feel like, you know, is it real? Is it really just something that they are feeling or is it happening in a real sense? And there is a treatment around it.

So first and foremost, we have to validate them that this is real, their hormones are fluctuating, things are changing in the body and we have to do something about it. The most complicated time is perimenopause because they're still menstruating. So we cannot use the best treatment that we have available - hormone therapy, very effectively because that can create other hormonal and menstrual irregularities if we are not being very cognizant of their whole health picture.

So we have to make sure that we start with their lifestyle changes, we'll see that what we can adjust as far as the triggers around them, toxins around them, try to get them to be more self connected and focused and also stay in touch with them as their different symptoms begin to evolve. Then treat them according to those symptoms.

At the time of menopause though, when they're having really no periods and they're feeling like you know, they really have no hormones left and their mental health and their physical health is taking a toll, hormone therapy by far is the best treatment available.

So at Center of Specialized Women's Health, we effectively risk stratify them for their hormone therapy. We actually individualize and personalize the care and if patients are really not interested in hormone therapy and they would like to maybe start other modalities then functional approach and then integrative medicine plays a vital role.

So the same sequence, we try to get their history, we try to get their timeline, we try to get the basic lab work for them and try to tailor the supplements according to their needs. We try to work on the restoration of their circadian rhythm, try to nurture a healthy gut microbiomes and find and eliminate the endocrine disruptors for them.

And lot of work is done by the patient themselves. So it's empowering them, it's keeping them engaged in their own care and they come back very much just happy and healthy and just more transparent sharing their challenges with us and trying to just guide us how we can help them better.

Erica Newlin, MD:

Can you talk a little bit about what supplements you often recommend?

Sobia Khan, MD:

So, ideally I try to run a very comprehensive panel before I make certain recommendations. Supplements are very costly and, (laughs), we all know that that you know, they are derived from food as well. So my approach is slightly different. I try to work on the gut first. You know, instead of putting the cart in front of the horse, I try to make it in a very strategic way and try to work on the gut health so they can absorb the nutrients better from their own diet.

So first detoxing the diet and then improving and restoring the gut health and the microbiomes helps them a lot to just extract all these minerals and vitamins better from their own diet. But of course there are some deficiencies that have accumulated over time. So once we do the comprehensive panels, we see that if they are deficient in zinc or if they're deficient excessively in vitamin D and B12, so we supplement them with those vitamins and minerals.

But if I have to pick a few that we should be recommending it. If patients can't even afford to do certain labs, then vitamin D is the best one and we are recommending that it should be taken with the food because it's a fat-soluble vitamin so it can get absorbed better. And now we have formulations available which are vitamin D with K and it enhances its absorption and helps with the bone health.

In addition to it, magnesium is an excellent one because majority of the time patients are not even moving their bowels well. So magnesium not only helps them relax and unwind if it's taken at night and helps them overcome some of that muscle stiffness, it also supports their gut health and helps them move the bowels better. And a good multivitamin - making sure that you know it's a good brand for women. I sometimes even recommend a good quality prenatal vitamin.

Erica Newlin, MD:

Mm-hmm.

Sobia Khan, MD:

And they're surprised and they're thinking that they do not want to have babies.

Erica Newlin, MD:

Right. (laughs).

Sobia Khan, MD:

And why are we recommending it? But this is D vitamin, even if they take it once a day or every other day, it will replenish some of the stores of iron and vitamins that are commonly getting depleted in the body.

Erica Newlin, MD:

And you've mentioned a detox diet a few times and briefly kind of alluded to organic fruits and vegetables. What else is a component of a detox diet?

Sobia Khan, MD:

Cruciferous vegetables. The vegetables like broccoli and cabbage, so they have tons of polyphenols in it and these are the main vitamins that help us a lot to detox the body. These are going to detox the gut better, they're going to bind to the toxins and help them excrete. They are loaded with fiber and help with the natural bowel movements so we can have a natural detox.

Majority of the time, even if you ask patients about their bowel movements, they just say regular. And when you ask the definition of regular for them they'll say like every other day or twice a week.

Erica Newlin, MD:

Mm-hmm.

Sobia Khan, MD:

So everyone is so different and that's why it's so important to go back and take a good history and timeline and then tailor the treatments and make sure that, you know, we don't overwhelm patients. And again, I would emphasize that my practice is different in that way that we are doing it in small chunks. We are not just doing two-hour visit where we are loading the patient with all this information, sending them home, feeling overwhelmed and just not ready to do all of it.

Erica Newlin, MD:

Mm-hmm.

Sobia Khan, MD:

So you have to build their confidence, get them involved in their care, and then start the treatment process and then they're vested to do changes in their diet, to buy those supplements and then they also get a sense of it that the physician cares for them.

Erica Newlin, MD:

Mm-hmm.

Sobia Khan, MD:

They're caring for their pocket and their health and their family as well.

Erica Newlin, MD:

And then on the realm of gut health, a lot of patients ask me about probiotics. Would you say that generally probiotics are helpful for everyone or is that also a very generalized or individual?

Sobia Khan, MD:

It is a very good question. You know, what are we using the probiotics for? We are trying to restore the gut microbiomes. We can do it very much naturally as well by having more healthy foods and of course it means more fresh fruits and vegetables because this is what is going to replenish our gut with the healthy microbiomes and microbiomes are like our pets. They live in our-

Erica Newlin, MD:

(laughs).

Sobia Khan, MD:

... gut and they are making byproducts that are actually the hormones and enzymes and and neurotransmitters that affect our general wellbeing. And that's why there's so much emphasis on pre and probiotics at this time because we think that by taking a probiotic in a form of a pill is going to just like rejuvenate the gut health and we will automatically be feeling good.

It is functional to some extent, but if we have not worked on the natural gut restoration yet any pill that we are going to take is not gonna get absorbed and function appropriately. So probiotics are very helpful if they are targeted to a certain condition and once we are confident that the gut health has been restored.

Erica Newlin, MD:

Let's talk more about different symptoms specifically. Let's talk about hot flashes. And, (laughs), I know we talked a little bit about how hormones are really the best treatment for things, but in someone who's perimenopausal going through hot flashes, what generally kind of lifestyle recommendations do you make or food recommendations?

Sobia Khan, MD:

So hot flashes and night sweats are very debilitating and it's a condition that we really have to be just personalizing to a patient's presentation. Some of them are having few of them, some cannot sleep at night. So we start with hormone therapy really when they are suffering a lot. But if they're just getting into that stage of perimenopause at that time, typically what I offer them is a detox diet. I try to cleanse their gut, I try to get them optimized on certain supplements and also the supplements that are targeted towards increasing the response to the estrogen.

And we do have certain formulations available that are having some of the soy in it and also rhubarb root in it. And then we have altheine, we have a combination of ashwagandha. So all of them basically help them relax their nervous system so that they are not having those flares too frequently.

But as I mentioned, if the gut is not working well, all these supplements will be redundant. So trying to first get them to relax, focus on their gut, and then advise them to just be on some of these targeted supplements that will help dampen these hot flashes and night sweats to some extent is usually very helpful.

Magnesium, vitamin B6, vitamin B12 combination of some of these minerals and vitamins are helping as well. And then some of the targeted probiotics that we use in functional medicine to help them relax and improve their sleep and have flashes. Stress is the main denominator in this big picture.

So sometimes teaching them techniques to calm down the vagus nerve, you know how to improve the quality of the sleep. It all plays a vital role.

Erica Newlin, MD:

And then I imagine that it also comes down to gut health, but also with weight loss in the perimenopausal stage. I have a lot of patients who are like, I exercise, I'm eating well, but there are body composition changes. It's just difficult to lose weight. Is there anything specifically that you'd recommend in patients who are having difficulty with weight loss in the perimenopausal period?

Sobia Khan, MD:

So you know, this is so challenging because at the same time they're experiencing different changes, hormonal changes, weight changes, mental health changes. So if we just focus on everything in isolation, we are never able to accomplish great results. But when we are doing more of a holistic approach, we are able to get them where they want to be with their ideal weight.

Of course the detox and the elimination diet helps a lot to reduce the inflammation to help with the weight, but majority of the time it's the rhythm of the body as well that affects the hormones. So we focus so much on estrogen and progesterone, but cortisol is the key player-

Erica Newlin, MD:

Mm-hmm.

Sobia Khan, MD:

... when we talk about the weight management. And cortisol is at its max in the mornings and that is a time actually to work out. And if they're really geared towards losing weight, then working out empty stomach is the best way to do it, which is impossible. I've tried it myself-

Erica Newlin, MD:

(laughs).

Sobia Khan, MD:

... (laughs), it doesn't work. And I have narrowed it down to a healthy broth that you know, instead of having something like an energy drink or coffee prior to it, maybe just have a very healthy vegetable or a bone broth and this will help them with the energy to get through those workout routines in the morning. So that's the time to do cardio. And then making sure that they are doing time and calorie restricted eating.

This is so important again because we are connecting things also to the cortisol and melatonin. So if they are not working out in the morning and more in the evening, then the high cortisol levels in the evening will resist the weight loss. In the evening, they can adapt to more relaxation techniques, more yoga, meditation, stretching walks with the nature and this will help them unwind better and set the melatonin in action so they can sleep better and their circadian rhythm is improved.

So yes, they are doing fantastic with the diet, with their cardios, with their workouts, but it's the timing and the sequence in which they're doing some of these activities also leads to the results.

Erica Newlin, MD:

Is there anything that you would recommend for patients who are experiencing that brain fog or increased anxiety that come with the perimenopausal period?

Sobia Khan, MD:

So you know, this is very, very important for our patients to focus on the sleep and de-stressing themselves during this time of perimenopause. This is very critical time in their lives when they are maybe in leadership positions, maybe they are just like, you know, having other responsibilities from their families and friends, but also there's more responsibility on them for their own health. And multitasking actually just drains the ability of the brain and especially at the time of perimenopause when they should be conserving their energy and their potentials.

If they are just exhausting it, they will feel depleted and the brain fog will be more pronounced. So making sure that that they get adequate sleep, they're on the right kind of supplements like vitamin B12 and magnesium and they're eating healthy and we have brain foods that help enhance the brain health.

So this will help them a lot to get clear mindset. And once they're more focused, they will actually make the right decisions. But if there are multiple stressors or the multiple tasks that they're dealing with and body is already going through those changes and we have to validate and accept it and then prioritize our responsibilities so we can be present in the moment and can address the vital components of our life rather than, just like during our teenage or 30s, we are doing everything and we-

Erica Newlin, MD:

Mm-hmm.

Sobia Khan, MD:

... we have time and energy for that, it's not gonna be the same. So first trying to understand that it's going to be that time in our lives that hormones are fading and we are limited. And once you know they have this acceptance, they actually do better with the meditation and being present in the moment and overcome the brain fog.

Erica Newlin, MD:

Lastly, I've found that many of my postmenopausal patients are dealing a lot with vaginal dryness, vaginal vulvar irritation. Is there anything that you'd recommend for those patients who don't have any sort of infection but have it chronic?

Sobia Khan, MD:

Absolutely. I mean, that's why I'm saying I'm so passionate about women's health and menopause and perimenopause because we have toolkit that we can utilize to help women with all of these symptoms and we can even start at the earlier stages of dryness and definitely we have FDA approved treatments for that. But at Cleveland Clinic we also compound vaginal DHEA and we share it with patients at different ages and age groups and try to help them with the vaginal dryness and irritation.

Basically trying to restore the pH of the vagina as well as the healthy microbiomes in the vagina so that they are able to prevent infections, prevent dryness, and then they can have like improved collagen and elasticity in their vaginal tissues.

Erica Newlin, MD:

Great. Anything else you'd like patients to take away from our talk today?

Sobia Khan, MD:

I think that patients should be an advocate for themselves and they should be just like involved in their care and bring all of these smart questions to us so we can help them understand their health better and improve their health span.

Erica Newlin, MD:

Perfect. Well thanks so much for talking with us today, Dr. Khan.

Sobia Khan, MD:

You are very welcome. Thank you for having me.

Erica Newlin, MD:

Thank you for listening to this episode of Ob/Gy Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.