Managing Menopause Without Hormones

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. Erican 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. Sarah Hershman, who will be talking to us about non-hormonal treatment of menopausal symptoms. Dr. Hershman, thanks so much for joining me on the podcast.

Sarah Hershman, MD:

Hi, nice to be here.

Erica Newlin, MD:

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

Sarah Hershman, MD:

Yeah, I'm a board-certified OBGYN, practicing a full range of obstetrics and gynecology, so that means I deliver babies, I do hysterectomies, I take care of you in the office, give you your birth control, but I really enjoy menopause care because I feel like this is an area where there's such a big and instant impact on people who are really suffering, so I'm really happy to be here today to talk about some of the ways to alleviate that suffering.

Erica Newlin, MD:

Yeah, thanks for joining us. In our past episodes we've discussed symptoms of menopause, but for those who may not have had the chance to listen to those, could you briefly recap what some people may experience during menopause and the perimenopausal transition?

Sarah Hershman, MD:

Yeah. So menopause often hits people by surprise with all the different symptoms they can experience, so first of all as you're approaching menopause often a lot of menstrual abnormalities, like irregular periods, really heavy periods, just unusual bleeding, people also notice hot flashes and night sweats, which I think most people know about. Mood changes, especially anger and irritability, often people are like, "I hate my husband." Sleep issues, libido issues, vaginal dryness, brain fog, which is tough when you're at the peak of your career, because you're in your late forties, early fifties, and you're supposed to be performing so well, and you just can't anymore. People also notice hair, skin, and weight changes that they find unfavorable.

Erica Newlin, MD:

For sure, when I have patients who come with a symptom and ask me if it could be due to menopause, I'm often like, "Yeah, probably." (laughs)

Sarah Hershman, MD:

It's always like, "Yes." (laughs)

Erica Newlin, MD:

(laughs) Some patients feel like they're going crazy with their symptoms, or that they're insane, and that these symptoms aren't real, but they very much are.

Sarah Hershman, MD:

And validating that is very helpful, and sometimes therapeutic in its own right.

Erica Newlin, MD:

For sure. In a past episode we broke down the pros and cons of hormone therapy, however, for some people hormone therapy may not be an option at all. Can you talk about some medical conditions that might make someone not a candidate for hormone therapy?

Sarah Hershman, MD:

Yeah, so first and foremost, anyone who has any active cancers that could be affected by estrogen therapy, most frequently this would be someone with hormone receptor-positive breast cancer, but it could also include certain ovarian cancers, and then anyone with undiagnosed uterine bleeding, which could be a sign of endometrial cancer. Of note, if you've had uterine or endometrial cancer in the past but you've been fully treated and don't have any disease, you could still be a candidate for hormone therapy. So those are like the absolute contraindications. But then there's people for whom the risks and the benefits just probably aren't favorable for starting them on hormone therapy, so that would be anyone who has a history of blood clots where they're not supposed to be, so a thrombotic stroke, a TIA, or a mini-stroke, or a blood clot such as like a DVT or a PE, so that would be a blood clot in your leg that travels to your lungs, or anyone with a strong predisposition to blood clots such as someone with Factor V Leiden disorder.

Additionally, anyone who has a history of a heart attack, or a significant risk of having a heart attack or cardiac disease in the future. And I'll often use a cardiac risk calculator-

Erica Newlin, MD:

Mm-hmm.

Sarah Hershman, MD:

... to help me stratify those patients. Chronic liver disease is a contraindication, because estrogen is metabolized in the liver. And of note, this sounds a lot like the people who also aren't candidates for hormonal birth control or estrogen containing birth control, but it's not identical to that list, because people with hypertension are still candidates for hormone therapy, migraine with aura you could also consider, it would be a slight or a relative contraindication, but you could consider someone with a migraine with aura for hormone therapy.

Erica Newlin, MD:

And we always want people to stop smoking, but ... smoking isn't necessarily-

Sarah Hershman, MD:

Right.

Erica Newlin, MD:

... a contraindication as well.

Sarah Hershman, MD:

Yeah.

Erica Newlin, MD:

But, you should stop smoking.

Sarah Hershman, MD:

(laughs)

Erica Newlin, MD:

(laughs)

Sarah Hershman, MD:

For sure.

Sarah Hershman, MD:

And don't vape either.

Erica Newlin, MD:

When someone thinks menopause, they often think of hot flashes, night sweats, kind of the stereotypical symptoms. What are some relief methods you would recommend to someone suffering prior to starting any medication?

Sarah Hershman, MD:

So I think you really got to kind of learn yourself and your body, and what are your triggers, which they're gonna be different for everyone, but common triggers for people a lot of times are stress, so that same time when you start sweating in general because you're nervous at work, or you're upset about something, that's gonna bring on a hot flash if you're in that perimenopause or menopause period. Caffeine also often becomes a trigger for people, alcohol is a really big trigger. You might notice certain foods, like spicy foods, or high in sugar foods, if that's a trigger for you, if it's not a trigger, don't avoid them if you love them. And then clothing, tight clothing and synthetic clothing can be a big trigger, and then sometimes smoking and cigarette smoking can be a trigger for people too.

Erica Newlin, MD:

And what kind of other relief methods might someone be able to use for those hot flashes, like dressing in layers, or fans?

Sarah Hershman, MD:

Yeah, so I mean controlling your environment as much as possible, especially at nighttime when you really need to rest, I mean your bedroom temperature needs to be low, and there's great data that in general we all sleep better when the bedroom is quite cool, I would say even like 65 is a nice thing to shoot for, if you can, opening the windows in the winter, a lot of times people are fighting with their significant others if they're not going through menopause at the same time with the temperature of the room, but I would say the menopausal person should win. Also make sure that you have a fan in the bedroom to help with ambient cooling. Make sure that your covers and your nightgown and stuff are natural fibers, because synthetic fibers will trap heat. Think about do you have a memory foam pad on the bed that is trapping heat? And could you get a cooling mattress topper instead?

And then in general just like other things that promote sleep hygiene are gonna be helpful, because people who are experiencing night sweats often, they'll fall asleep okay, but they'll wake frequently. So anything to help your brain stay asleep, so I love white noise machines and in general just sleep hygiene stuff, like calming environment before bedtime, you could try aromatherapy, like lavender, eucalyptus oils, things like that.

Erica Newlin, MD:

I often recommend a lot of the meditation apps too, there's a lot of great ones our there.

Sarah Hershman, MD:

Yes, meditation and calming your brain can really help.

Erica Newlin, MD:

For sure, and if those conservative or lifestyle changes aren't effective in bringing relief, what's kind of the next line or non hormonal therapy you'd recommend?

Sarah Hershman, MD:

So there are quite a few options that are helpful, that are non hormonal that are safe for addressing mostly these hot flashes, night sweats, and the mood changes. The real trigger is as I think you guys discussed last episode would be like, as your estrogen levels drop, so non hormonal things can't replace your estrogen, but they can kind of mediate the neurologic changes that are happening in response to a lack of estrogen. So there's a couple of meds that are FDA approved, and the first one that's been FDA approved for the longest is a medication called Paroxetine. It is a SSRI, which is typically thought of as an antidepressant medication, but its actually been FDA approved for those vasomotor symptoms of menopause, and its given just at a lower dose than you would give for depression. It tends to help with sleep. At this lower dose it's not gonna help with mood, but it can help with hot flashes and night sweats.

There are other medications that are in that same drug class or SSRI, or SNRI, the most common first line anti-depressant meds, but have been tests and shown to be quite effective for hot flashes too. I frequently will use in my practice venlafaxine, and it's shown to be quite safe. You start it at about half the dose you would for an antidepressant dose. All of these meds can have side effects of nausea, you can have some GI changes, changes in bowel habits, some diarrhea or constipation. Unfortunately SSRIs all have known side effect of decreasing your libido, however, if you're miserable because of the hot flashes and that is affecting your libido, you might actually find it has a neutral or positive impact on your overall sex life. And it can cause dry mouth, some people note some weight gain. But overall really well tolerated, and the side effects are usually pretty self limited, meaning they go away on their own within a couple of weeks.

There's several other SSRI or SNRI medications that are in that class that are also useful, you should talk to your doctor about. There's a couple other meds that are not antidepressant, so gabapentin has been studied. So gabapentin you might have heard of, it's an antiseizure med, but we really usually use it for nerve pain. So it makes sense that it would also help for that neurologic disruption of estrogen withdrawal. It can help with sleep, in fact gabapentin is usually very sedating. All of these meds you can sorta take their negative side effect and flip it and see the positive side in menopause-

Erica Newlin, MD:

(laughs)

Sarah Hershman, MD:

... so it makes me drowsy? Yeah, it helps you sleep. Clonidine's not very commonly used, but that's another one, it's a blood pressure medication that is pretty safe and can help with hot flashes, although it will drop your blood pressure, so you might feel dizzy.

Erica Newlin, MD:

And then what about the new drug on the market? There's been a lot of press about fezolinetant? How does that work? What's the evidence for that?

Sarah Hershman, MD:

This is a new medication that just came on the market as of May 2023 and the thing that's very interesting about this medication is that it's the first medication addressing hot flashes that targets a brand new pathway in the brain, and that is specific to vasomotor symptoms, and hot flashes, and night sweats. So we don't have any clinical data yet, other than the trials to bring it to market. So we're still, you know, waiting to see, what are all the side effects gonna be? How well is this really gonna work in practice? But it's a novel drug target, so basically what they found is when they were studying the hot flashes and night sweats phenomen in patients, they found that there was some neurons that were implicated in this called the KNDY neurons, K-N-D-Y neurons, in the brain. They are located in the hyper thalamus, and they help regulate temperature.

Throughout most of your life these neurons are sort of equal and opposite in how they're activated by both estrogen and the neural receptor called NKB. So as you go through menopause and your estrogen levels drop, these neurons are getting imbalanced input, and they're hypertrophying, or getting too big, and too active. So this drug sort of targets the NK3R antagonist, it targets those receptors that are sort of equal and opposite to estrogen, and helps just calm down and chill out that neuron.

So it sounds like the initial data is pretty promising, that it tends to work very well, and in general it's got not too bad a side effects, the side effect profile is pretty much what I just mentioned for all the SSRIs with one exception, so you can have abdominal pain, diarrhea, sleep issues, sometimes people got paradoxically more hot flashes. The only really major concern with safety is for some reason we think it can increase your liver enzyme production, there's a possibly it could cause liver damage, so they recommend testing your liver enzymes before and after. That was a pretty rare side effect, but I think so far that's the only major concern we've seen with it.

Erica Newlin, MD:

I've tried prescribing it, but it's been expensive.

Sarah Hershman, MD:

Yeah.

Erica Newlin, MD:

So far, so, looking forward to some coupons to help with affordability-

Sarah Hershman, MD:

Yeah.

Erica Newlin, MD:

... for patients.

Sarah Hershman, MD:

Right. The other thing is its only FDA approved for post menopausal patients right now-

Erica Newlin, MD:

Yes.

Sarah Hershman, MD:

... when there's no reason to think that it wouldn't work for peri menopause, but so a lot of times the insurance cover is gonna lag for that.

Erica Newlin, MD:

For sure.

Sarah Hershman, MD:

Compared to all the other non hormonals, which are gonna be very cheap, they're old meds-

Erica Newlin, MD:

Mm-hmm.

Sarah Hershman, MD:

... with the exception of that one that was FDA approved the paroxetine, the lower dose is gonna be more expensive, because they're marketing it.

Erica Newlin, MD:

Right.

Sarah Hershman, MD:

Yeah.

Erica Newlin, MD:

We briefly touched on sleep and some sleep hygiene techniques, are there any other recommendations that you make for people who are struggling with sleep?

Sarah Hershman, MD:

Yeah, so a lot of people will ask about sleep meds, and whether or not melatonin is safe or whether they should be on other sleep meds, so in general, those are always gonna be best used for a short amount of time, and in conjunction with like meticulous sleep hygiene. So we've all gotten in the habit of like being on our phones, or just rushing straight from like work to fun to bed, but in general if we can combine something like melatonin with the way our body naturally wants to fall asleep, that's what's helpful.

So melatonin itself, it's a hormone produced in your brain in the pineal gland, which is the gland the controls a lot of our circadian rhythming and response to, for instance, like light coming into the brain. So it controls your internal sleep and body clock, if you take it about two hour before you're hoping to go to sleep, and then you engage in all those pre bedtime things, so you know, relaxing, calm environment, maybe take a warm bath, go into a bedroom that is dark and is not stimulating, it can help. You want to take a low dose of melatonin, a lot of these supplements out there in the grocery story, you know, they're safe but they're like 10 milligrams, you'd really rather have like a one to three milligram dose. And try it, and if it doesn't help after a week or so, don't use it.

And then for most people, once you establish a healthy sleep pattern, and your body's sleep debt is repaid, and you're restored, you wanna store using it after about two months. So it's not really a long term solution, but it can really help people who are trying to get back on track.

Erica Newlin, MD:

And then what about other sleep medications?

Sarah Hershman, MD:

I don't generally prescribe other medications, because they can have a habit-forming potential. If you did have a need for that, I'd recommend seeing a sleep specialist, because you might actually have a sleep disorder, such as sleep apnea or something like that, and then there are other things that are over the counter and in, in general unless, for short term if you're like, "I have jet lag or something, I really need to do it," maybe? But you don't want to be taking meds like that all day, every day. There's some implication that those can be implicated in like dementia later on if you were on high doses of antihistamines and things like that in your lifetime.

Erica Newlin, MD:

And then can you talk a little bit about vaginal dryness and changes in the vagina related to menopause?

Sarah Hershman, MD:

Yes, this is a huge thing that people come to me with. So first of all, starting about like in your mid 30s, most people will notice that their natural lubrication is not what is was, and a lot of people are very confused, they wonder, "Does this mean I'm not attracted to my partner anymore? Why am I not enjoying sex anymore?" So I definitely want to let them know about all these lubricants that are available. And then the other thing to know is that many people will experience extreme vaginal dryness starting several years after menopause. So they think they're through, they think they're out of Dodge, and then they are like, now all of the sudden everything is dry.

So there are several helpful things. So no one should be afraid to use lubricant, water-based lubricant is a great first line to start with. There are other lubricants that are silicone based lubricants that have really nice slipperiness and feel, And everyone should basically be using those when they're having intercourse if they at all feel like they need them. I would generally not recommend using like food oils, like coconut oil, olive oil, because those can cause allergies, they, those can cause irritation. They're also really messy and they'll destroy your sheets. I would not recommend using baby oil.

If you are feeling like you need something more than those lubricants, there are some options that kind of offer longer term vaginal moisturization. So first of all there is hormones, vaginal estrogen which is really safe, does not have those contraindications that are associated with systemic hormone therapy, and I'm sure you'll talk about that in a different episode. But for anyone who doesn't wanna use that or doesn't feel like they're ready for that yet, these is a hyaluronic acid suppository-

Erica Newlin, MD:

Mm-hmm.

Sarah Hershman, MD:

... that is on the marketIt is FDA approved for vaginal dryness and anyone who is a skin care person, you know how important hyaluronic acid is in general, with plumping up the skin, and inspiring collagen production. And then there's some moisturizers that can be used externally or internally, and these just sort of help keep like a barrier on the skin so that you don't lose moisture through the epithelium  barrier of the skin. And patients get a lot of relief from any and all of these methods.

Erica Newlin, MD:

Yeah, I think I remember talking to another doc in our practice and she was like, "You moisturize your face, why shouldn't you moisturize your vagina." (laughs)

Sarah Hershman, MD:

Right.

Erica Newlin, MD:

If it's kind of part of your ... not exactly daily routine-

Sarah Hershman, MD:

Mm-hmm.

Erica Newlin, MD:

... but if you're experiencing dryness, there are a lot of vaginal moisturizers on the market.

Sarah Hershman, MD:

Yeah, I mean, and you think of like we know that when you go through menopause, as your estrogen leaves your body, like your skin suffers, and I think of vaginal estrogen, or vaginal hyaluronic acid as similar to the way you would use those on your skin, or similar to the way you would maybe use like tretinoin on your skin.

Erica Newlin, MD:

Mm-hmm.

Sarah Hershman, MD:

Don't use tretinoin on your vulva, but similar thing.

Erica Newlin, MD:

For sure. What about any herbal supplements that you'd recommend for the peri menopause or menopausal transition?

Sarah Hershman, MD:

Yeah, so these are tough because on the one hand there's herbs that have been around for, you know, hundreds, thousands of years, you know, and they have probably very good track records in popular use, but you don't always have, as a physician, who's a scientist, I can't always back those up with data. So in general when I approach supplements with my patients, I think, is there anything there that I think is a risk to you? So, you know, you always want to come with like an ingredient list if you're asking your doc about something. And there's, the data is always gonna be mixed.

So probably the one that we have the most data on would be black cohosh, which has been around for a long time, and it does have, in some studies, shown some safety data. It is approved in Europe. It's not approved by the FDA here, but there's studies from, a saw a study from Iran showing that it was pretty effective, studies in Germany. With all these things you don't wanna overdo it, so don't think, "Oh, it's an herbal, I can use as much as I want." Use what the package says. It's a pretty small dose of black cohosh, you take it every day, it can significantly help with hot flashes, if you use too much of it you could theoretically cause liver toxicity. So always make sure your doctor knows. There's supplements you do definitely want to avoid, like kava kava, valerian root, anything that doesn't have an ingredients listed on it. You want to look for that label on it that says US Pharmacopeia, that's not something that's FDA approved, but at least has been made in a clean facility. And then the other common herbal supplements that patients bring to me would in the category of phytoestrogens, or isoflavones, so these are supplements that are derived from soy, from a natural plant-based estrogen.

Most patients, I don't ever recommend these, but they'll come in and they'll say, "Doc, I've been using this. I feel better. Is this safe?" And to that I would say, you know, if it's just got soybus estrogen in it, I'm, I'm okay with it. You take on unknown risks when you use something that's not FDA approved, and at the same time the benefits are sort of not known. Like is there a benefit or not? So one thing to keep in mind is that all drugs, prescription drugs, over the counter drugs, they all have a placebo effect. And a placebo, it's a good effect. When we believe we are taking something that's beneficial to us, we feel better.

And if you think of something like hot flashes, those are modulated in the brain. It's not all in your head, but it's coming from the brain. And so the things that we do to neuro regulate our brain, like deep breathing, calming, sense of peace, decrease of anxiety, if taking a totally ineffective pill (laughs) that is safe from, you know, causes you to feel like anxiety in your brain, and causes you to feel like you're doing something proactive for your health, that is absolutely gonna, it's not gonna decrease the number of hot flashes, but it's gonna decrease the distress you feel with them. So keeping in mind that everyone is susceptible to placebo effect, there's no one who's too smart or too educated to not have a placebo effect, I'm okay with a lot of these.

Erica Newlin, MD:

And then you briefly mentioned phytoestrogens, what about foods that are rich in phytoestrogens?

Sarah Hershman, MD:

Yeah, so generally we found these in soy based food, and the short answer is there's really nothing that we know of that has a ton of phytoestrogens that's not soy, but so soy milk doesn't have a ton because that's pretty much been, a very small amount of soy in there. But anything that's like pure soy beans, soy flour, tofu has a decent amount, miso soup if you like that it, would be a great source of phytoestrogens for you and you could easily work that into your daily routine, a little cup of miso. And tempeh, and soybean cheese, can be helpful in getting that soy into your body. Now does it help? It's hard to say.

Erica Newlin, MD:

And then you briefly mentioned before foods that may trigger menopausal symptoms.

Sarah Hershman, MD:

Mm-hmm. Yeah, I think that's very, very personal. I would say caffeine and alcohol would be the big ones, and then other than that I think you just gotta experiment, I don't want people to like cut out all foods (laughs)-

Erica Newlin, MD:

Yeah. (laughs)

Sarah Hershman, MD:

... um, no weird restrictive diets and stuff like that, but if you notice that like after you eat this every time you feel gross ... you know, avoid it.

Erica Newlin, MD:

Yeah. Perfect. Well thanks so much for joining us, anything else you'd like to add?

Sarah Hershman, MD:

I don't think so. Thank you so much for having me on, this was great. And appreciate it.

Erica Newlin, MD:

Perfect. Well thanks so much.

Sarah Hershman, MD:

Thanks.

Erica Newlin, MD:

Thank you for listening to this episode of Ob/Gyn 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.