Navigating Menopausal Stages and Treatment

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On this episode, I'm joined by Dr. Rachel Novik to discuss a topic that grabs the attention of many people: Menopause. Menopause affects about 1.3 million people every year in the US. And the good news is updated research and guidelines are opening the door for better conversations to help people make informed decisions. Since menopause care isn't one size fits all, it's about individualized care and shared decision making. And yes, there are plenty of treatment options from hormone therapy to non-hormonal approaches. Thank you so much for joining me on the podcast, Dr. Novik.

Rachel Novik, DO:

Thank you for having me.

Erica Newlin, MD:

Before we start, can you tell our listeners a little about your role at the Cleveland Clinic and what drew you to focus on menopause care?

Rachel Novik, DO:

Of course. So I am a specialized women's health physician here at the Clinic. I did a two-year fellowship in specialized women's health, which is a menopause-focused fellowship, specifically for, you know, women's health and looking more so at complex menopausal care. So the women or the people who have history of blood clots, people who have other like high-risk comorbidities or autoimmune disorders, things that might make them other physicians or clinicians a little less comfortable prescribing hormone therapy.

Erica Newlin, MD:

Let's start with the basics. What are the most common symptoms of menopause and when should someone think about talking to their doctor?

Rachel Novik, DO:

So the common symptoms we think about are periods spacing out during menopause, hot flashes, brain fog. Some women's cycles actually shorten first, so some have changes in their flow, both heavier and lighter flow, night sweats, or the opposite cold chills, anxiety, depression and mood changes, vaginal dryness, painful intercourse, difficulty with concentration or word finding and, you know, simple tasks like walking into a room and not remembering why you walked in there. Things like, there's something on the tip of my tongue, but I can't remember what it is. Dry skin, dry eyes, hair thinning, changes in body composition like fat distribution. So it's not just those stereotypical hot flashes and night sweats.

Erica Newlin, MD:

So it sounds like when I have patients who come to me and they're like, "Is this due to menopause?" My answer to almost anything is like, "Well, maybe."

Rachel Novik, DO:

Yeah. That's pretty much what I say. We'll see.

Erica Newlin, MD:

A lot of social media from TikTok to Facebook and everything in between has been talking a lot about perimenopause. Can you explain what perimenopause is? Because that term has been thrown around about everything under the sun.

Rachel Novik, DO:

So perimenopause is a vague term to describe someone who has some of the symptoms that we just talked about, but is not 12 months without a period. And that's the true definition of being in menopause is 12 months with no period. So generally, I say if you have a symptom, whether it's hot flashes, fatigue, joint pain, whatever it is, period changes, but you are still having a period and it hasn't been 12 months, and it's significant enough that it's affecting your life and you're coming to see me, then you're probably in perimenopause.

Erica Newlin, MD:

What about people in their 20s, 30s who might have a little bit of irregularity in their periods? A lot come and they ask me, "Is this perimenopause?"

Rachel Novik, DO:

And the true answer is perhaps it could be, but it, on less likely there's, that's not to say we don't see women who, or people who are in their 20s that have early onset menopause, but generally speaking, if you have fairly regular periods, I would not necessarily consider you perimenopausal. Regardless, the approach to treatment can be very similar.

Erica Newlin, MD:

What about people who still have regular periods, but maybe are starting to get into that mid-age difficulty losing weight, symptoms here and there. Can you tell me whether or not it's helpful to do hormone level testing or when that may be beneficial?

Rachel Novik, DO:

Yeah, so the true answer is we don't need blood work to answer these questions, right? Your body is telling us what's going on. If you're having irregular periods, if you're having symptoms, we can say, “yes, you're probably in perimenopause.” However, some people like to have those numbers, and I understand that we're in a very data-driven society. Do we need it? No, not necessarily. I typically check, if I do check hormone levels, an estrogen level and an FSH, a follicle stimulating hormone level, to look at ovarian function. Other labs that I commonly check though would be like a thyroid level, B12, ferritin, which is an iron storage level, vitamin D, because these are other things that cause very similar symptoms, whether it's your hot flashes, night sweats, brain fog, fatigue, things like that. So blood testing specifically for your hormones, not necessarily, but other things that could mimic similar symptoms, yes, I definitely check those.

Erica Newlin, MD:

For sure. And as we've alluded to in these long lists of symptoms, those symptoms can really impact daily life. So once someone recognizes them, what's next, that brings us to treatment options. We keep hearing about hormone replacement therapy, HRT. Can you break down what it actually is and how it works?

Rachel Novik, DO:

Of course. So hormone therapy replaces estrogen and progesterone if the person has a uterus. So menopause hormone therapy is a little bit different than hormone replacement therapy on our side of things, right? Because we're not necessarily trying to get you back to that premenopausal hormone level, replacing the hormones rather more so enough to get rid of your symptoms, but not necessarily enough to get you back to a premenopausal range. So hormone menopausal therapy supplements estrogen and progesterone through oral, transdermal, which would be through the skin or vaginal treatments. Estrogen is what helps get rid of your symptoms. Progesterone is what helps protect the uterine lining. So estrogen can make that endometrial tissue that lines the uterus that you shed each month with a period thickened, and if we don't shed that period, whether it's every month or with a medication to help keep it thin, the tissue can sit there and become abnormal and put you at higher risk of uterine cancer.

So progesterone helps keep that lining thin and, and protect us.

Erica Newlin, MD:

And you've alluded to different types, so systemic versus local. Why does that delivery method matter?

Rachel Novik, DO:

So we have hormones in pill form, patch form, gel form, there's a spray. We have all sorts of options, which is great. And systemic hormones are what is circulating in your bloodstream. Really what helps get rid of those hot flashes, night sweats, but helps with the brain fog, the fatigue. It can help with vaginal symptoms, but sometimes that's not enough. Systemic hormone therapy is where we see a lot of the data on the cardiovascular protection, the bone protection. And again, that's what really is concentrated to help with the hot flashes and the night sweats, those things that people tend to think of. Local hormone therapy is vaginal therapy. That's vaginal estrogen cream, vaginal estrogen tablets, suppositories, rings, as well as vaginal DHEA creams and suppositories to help with the genital urinary symptoms associated with menopause. So that can be vaginal dryness, pain with intercourse, urinary frequency, urgency, frequent UTIs, recurrent yeast or BV infections.

So sometimes one is enough, depending on your symptoms, sometimes you need both.

Erica Newlin, MD:

We get a lot of questions about testosterone therapy. Can you provide any insights on this therapy? Is it effective? And who could be a candidate for it?

Rachel Novik, DO:

We do offer testosterone therapy for a subset of women here at the Clinic, but it's multifactorial. There's only current evidence-based indications for testosterone therapy in hypoactive sexual desire disorder in post-menopausal women. And that's after we've already reviewed, you know, other potential causes or treatment options. There's no true FDA approved testosterone product for women in the US, the Endocrine Society, American College of OB/GYN and the Global Consensus Position Statement recommend using a fractionated dose of male approved transdermal testosterone, commonly dosed at one 10th of the 1% formula for men. Compound testosterone is also a consideration if commercial options are not available. There's an oral option called esterified estrogen methyl testosterone or EEMT, and this is also not an FDA approved medication.

Now, what do we use testosterone for really is low libido, that hypoactive sexual desire disorder, and we can see that it can help with blood flow back to the vaginal tissue, tends to be local vaginal treatment and can help with blood flow back, help with sensation and help with getting some of that more spontaneous desire.

Erica Newlin, MD:

So it sounds like testosterone therapy isn't helping as much with the menopausal symptoms as for specifically hypoactive sexual desire?

Rachel Novik, DO:

Generally, no. I mean, you will hear a lot of women feel better on testosterone and there are, you know, people who report there's additional bone protection, but the reason that testosterone protects the bones is because it converts to estrogen. And generally, if you're having hot flashes, night sweats, all of those symptoms that are associated with menopause, we can control those symptoms pretty well with estrogen and progesterone as opposed to adding in testosterone, which can have additional side effects.

Erica Newlin, MD:

What about things like testosterone pellets?

Rachel Novik, DO:

We do not recommend testosterone pellets because number one, this is not an FDA approved treatment option. Number two, testosterone pellets can give you unregulated hormone levels. So more recently, I just had a person come in who had a testosterone level of 800. This was a 50-some year-old female who, you know, had an initial testosterone level less than 12, so very low, and came back within male range is what we would say.

And there's really nothing we can do about it except wait for the, you know, three plus months that this pellet needs to wear off.

Erica Newlin, MD:

Now that we know what hormone replacement therapy is, what does the research say about whether it's safe and effective?

Rachel Novik, DO:

There is more and more research coming in about hormone therapy and its safety as well as its indications. There's a most recent study on vaginal estrogen that was just published in breast cancer patients, and it shows that there is no evidence of increased breast cancer recurrence or mortality with vaginal estrogen use in breast cancer survivors. The largest study that I know of was a 2024 meta-analysis, which involved 24,000 patients who found that vaginal estrogen use in those patients who had a history of breast cancer was not associated with any risk of recurrence, as well as no increased risk of specific mortality or overall mortality.

Generally speaking, we know that when started within 10 years of menopause and under the age of 60, there is cardiovascular protection, there is bone protection. We obviously help with the hot flashes and the night sweats, which can correlate to the way you're sleeping, which can then correlate to additional cardiovascular long-term effects.

Erica Newlin, MD:

So I've always found it a little confusing the way we explain it to patients, and patients find this confusing too, because we're saying that this helps with the cardiovascular risk factors that come after menopause, but then we're counseling them that it increases their risk for heart attack, stroke, blood clots, and you alluded to it a little bit, but can you expound upon why those two conflicting issues exist?

Rachel Novik, DO:

The WHI trials ended in 2002 early because part of the study showed that there was an increased cardiovascular event seen in women who were on treatment. The analysis of the WHI results by age group, as well as the randomized control studies like KEEPS, the Kronos Early Estrogen and Prevention Study, and then the Early versus Late Intervention Trial, the ELIT trial, showed that the risk of adverse cardiovascular events for hormone therapy are low for women under the age of 60 or within 10 years of menopause. So the WHI study showed the average person in that study was around age 63. This was a subset of people who were probably 10, 15 years from menopause, and we were seeing increased cardiovascular VTE risk, right? So VTE is venous thromboembolism, so increased risk of strokes.

So when we counsel patients who are over the age of 60, we like them to know that there is that increased risk, but it's still there's a different health subset for that age group where you have to say, let's look at your risk factors and if the, your symptoms are significant enough and your other health comorbidities are otherwise well controlled, perhaps this is a conversation we have and you go in knowing that you may be at this risk, but you have that conversation and you work with your physician or your clinician to make the right choice that's for you.

Erica Newlin, MD:

So in summary, when we're starting hormone therapy in patients who are early in their menopausal transition, it may have benefits or cardioprotective effects, but then once they're getting more than 10 years past that menopausal transition, we need to continue to have those risk benefit discussions.

Rachel Novik, DO:

Exactly. And I think that there's still the conversation, no matter what, if you are at higher risk for cardiovascular disease, you have a strong family history of heart attacks or strokes. You still counsel on all of these risks, but we also say, "Hey, we see this, there's all this good prevention data as well."

Erica Newlin, MD:

So on that note, not everyone is a candidate for HRT, right? Let's talk about who should avoid it.

Rachel Novik, DO:

So there are only a small subset of people that I would say I will truly say absolutely not. Everything else I generally say is a conversation, but the big things that I think about are if you have a certain type of estrogen sensitive cancer. So women who have had hormone sensitive cancers are generally not ideal candidates for hormone therapy, but again, there's much more conversation about the risks versus the benefits factoring in the type of cancer, what the treatment was. Are they on a sort of medication that can block hormones and how long has it been since the diagnosis and treatment? Another person that needs to be evaluated would be someone who has unexplained vaginal bleeding. So when a postmenopausal woman has vaginal bleeding, we recommend evaluation, right? We want to make sure that there's no uterine cancer or others cause of this bleeding. So if that bleeding has been evaluated and treated and the bleeding is thus controlled, then there's not necessarily a reason to. But that unexplained, unevaluated bleeding, definitely I would hold off on giving hormone therapy.

Another person that again is conversation is significant cardiovascular disease, especially people who have ischemic disease or risk of blood clots and stroke. But again, depending on the degree of the disease and the time that person is from menopause, it's a risk verse benefit conversation. Other things I think about, active liver and gallbladder disease, because estrogen can increase that risk of gallbladder disease through bile formation and slowing gallbladder motility, it could increase risk of gallstones and can induce intrahepatic cholestasis. So basically if someone has known liver or gallbladder issues, potentially we're thinking maybe we don't give you some oral, but we give you a patch or something like that. But again, it just depends on the disease process because there's other liver pathologies that can be very much hormone fed.

Another group that I think about is blood clot history, stroke history. So as we talked about, estrogen can have this prothrombotic effect on blood weaning that it can increase that risk of blood clots, but we need to know the whole story. So if I've seen someone who has a history of a blood clot, there's a difference in that story. Did they have that blood clot after they started smoking or while they were pregnant or while they went on a long plane ride or car trip? Because those might be outliers. There are a few blood clotting genetic disorders where we generally try to avoid hormone therapy because that risk of blood clots is also significantly increased. But if someone has a history of a clot, they've had an evaluation and they do not carry a genetic elevated risk, or we discuss what that risk is, potentially we think about a transdermal versus an oral option, and if someone is on blood thinners and this is going to be a lifelong thing, again, maybe there's more to the conversation of, can we give you hormones and do we keep that risk lower by giving you a patch while you're still on your blood thinner?

Erica Newlin, MD:

Can you expound upon the difference between the patch versus the pill? So we kind of refer to transdermal, so being some of the patches, the gels, the things we think about putting on the skin versus what we would take by mouth and how the risk might be different between those options.

Rachel Novik, DO:

So the patch, the gel, anything that goes through the skin is going to have a slightly lower risk of clot because your liver does not metabolize that. It just, it's kind of absorbed into the bloodstream versus a pill is metabolized by the liver and that first pass metabolism is what increases the blood clot risk. Patches, gels, sprays, all of these things are still systemic. They're still being absorbed into the bloodstream, just like a pill is still systemic, as opposed to a vaginal treatment that would be more, again, localized. So that might not get rid of your hot flashes, but everyone absorbs a little differently. So every once in a while, I have someone come in and they say, "Well, I'm sleeping a lot better with my vaginal estrogen cream," and I'm guessing they have maybe a little bit of absorption versus a little bit of placebo effect, who knows?

Erica Newlin, MD:

For sure. And we focused a lot on the risk that comes from the different estrogen therapies, but we've also mentioned that there has to be progesterone to balance that out in someone who has a uterus. Is there risk that comes from the progesterone side of hormone therapy?

Rachel Novik, DO:

So generally speaking, progesterone is a fairly safe option, right? The WHI study was conducted with a specific estrogen, conjugated equine estrogen and medroxyprogesterone. And in that study, there was a very, to most physicians, a small incidence of increased breast cancer diagnosis, but no increase in mortality, but we don't typically use those progesterones anymore. So it is thought to be that the common progesterones used today, norethyndrone and prometrium or micronized progesterone have less breast absorption, micronized progesterone being the most so thought to be less breast stimulating. So generally speaking, pretty safe.

Erica Newlin, MD:

For sure.

Rachel Novik, DO:

And if someone has a clot history and let's say they're in perimenopause with symptoms, sometimes just needing a little bit of progesterone kind of eases the symptoms and there's no clot risk that we see increased with that.

Erica Newlin, MD:

So let's say someone has a consultation with their physician and turns out hormones are not an option or someone just doesn't want hormone therapy. What else can help? What are some of the best non-hormonal options for managing symptoms?

Rachel Novik, DO:

Yeah. So we have a lot of options, which is fantastic nowadays. The common things that you may have heard of are what we call selective serotonin re-uptake inhibitors, SSRIs, or selective norepinephrine reuptake inhibitors, SNRIs. And these are medications such as paroxetine, venlafaxine. So these are technically quote unquote mood medications, but at lower dose, they can help with vasomotor symptoms, the hot flashes, the night sweats. So they're specifically, you know, that's typically where I'm prescribing them, but if you also are coming and complaining of mood symptoms, they can also help even them out, right? And help with sleep depending on why you're having sleep issues. There are newer medications, neurokinin inhibitors that work on the hypothalamic area in the brain, and this is our temperature regulatory center, and these are fisolinetant and a linzenetant, and the linzenetant just came out, I guess, in November, and these work more so on like the brain connection, the brain source of the hot flash, what is triggering the hot flash.

And so they're very effective when it comes to temperature regulation. These are great options for when you can't have hormone therapy or don't want it. The other plus side to these medications is that they can help with sleep.

Erica Newlin, MD:

What about different supplements? I see a lot of ads online about the supplement that can cure your menopausal symptoms.

Rachel Novik, DO:

So generally I'm not a huge fan of supplements. I think a lot of menopause supplements that we all, myself included being in this field and being a female, we get targeted advertisements on social media. So the short answer is no, I don't generally recommend any of those supplements, but I do check vitamin D, vitamin B12, I check your iron typically, I check zinc levels because that can be associated with mood. Depending on the person, sometimes I start adding in some other levels like omega levels because that can also be associated with hot flashes, with mood, with all of those things. So it really depends on the person and what your specific symptoms are and, and a more in-depth conversation about why I'm picking what I'm picking and what I'm picking. There is some data behind magnesium to help with sleep, magnesium glycinate, but also althionine and L3N8. Magnesium three and eight can be a combination of that, which can help a bit with cognition, sleep even to some degree some vasomotor.

Erica Newlin, MD:

Yeah. I find what's so tricky about some of these supplements is that they're not well regulated and it's not well studied. I wish that we had more data to go off of.

Rachel Novik, DO:

Exactly. And with all of these supplements, we don't, you know, things like, for example, biotin, turmeric, these can affect your lab work if you're still on them. So you can get inaccurate lab results. And so then we don't know, are you truly absorbing things or they can affect your liver function or something like that. And I think we're in a time where supplements and like being proactive and anti-aging is hip and that's great, but we also need to remember that like all of these things that are potentially health beneficial can also have negative impacts on our health.

Erica Newlin, MD:

Yeah. It's hard because just because it's a supplement and over the counter doesn't mean it's completely benign and can interact with other medications and cause untoward side effects as well.

Rachel Novik, DO:

Exactly. And I won't lie to anyone. I always tell my patients, like I've fallen into the traps too where I'm like, "Oh, you know what, maybe I'll feel better and try this." And usually I, after a month I'm like, "Yeah, this was not, this was a waste of my time and money." But we're not perfect.

Erica Newlin, MD:

For sure. It's interesting, I've seen a couple supplements on the market now that have certain plant derived estrogens and have had a couple patients come in with abnormal bleeding after taking those.

Rachel Novik, DO:

Yeah, yeah. I mean, we see a lot of it. And there's some new birth control that is with the plant derived E4 estrogen. So I offer that one as well because it can be kind of a more natural option. There's also a newer birth control that has estradiol valorate, I believe it is. So that's also another option for someone when I'm thinking about, do you want something that's more closer mimicking a hormone therapy regimen, but is still going to control your heavier periods or someone who maybe is having a little bit of symptom but doesn't necessarily need menopause dosing and potentially needs contraception.

Erica Newlin, MD:

Interesting. What about lifestyle changes or mind body approaches?

Rachel Novik, DO:

So I don't think that anything lifestyle-change-wise that I'm going to mention is going to be news to anyone listening to this or just, you know, we, we all kind of know these things, right? We should all strive to eat a balanced diet, high in fiber, higher protein, get our mainly plant-based when we can, vegetables, beans, legumes, that kind of stuff, and regular exercise.

But we see that a well-balanced diet and regular exercise can be beneficial for symptom control. The counter of that is that we can see that too much exercise can also trigger hot flashes. So it's a balance. Alcohol and tobacco are common triggers for hot flashes. So if you notice that maybe the nights where you're drinking a glass or two of wine and then you have bad night sweats or insomnia, perhaps there is a menopause component, but also perhaps it's that your alcohol is triggering your symptoms. Spicy foods are another one. Again, kind of common sense, but if you notice that you tend to get hot flashes after spicy food or blow drying your hair in the morning after you take a hot shower, you know, those things, there's only so much we can do about some of it, especially if that's part of your routine or you just love spicy food.

We live with it, but knowing your triggers can help. Paced breathing, CBT, cognitive behavioral therapy, mindfulness all have shown to improve symptoms, so there is benefit there.

Erica Newlin, MD:

So we've gone over a lot of different options, but sometimes the hardest part is starting the conversation with your doctor. What's the best way for someone to start the conversation with their provider?

Rachel Novik, DO:

I think the moment you get this idea in your brain, it's worth a conversation because most of us know a little bit, but not a lot, right? We remember maybe our parents who complained of significant hot flashes, right? But that's a lot of times burdens. So just knowing that sometimes that change in mood or the worsening anxiety can be something that's related. The changes in bleeding, it doesn't always have to be that your periods space out. It's that they can get closer together or they can just change and flow. And if there's ever a question, it's worth a conversation, but track your symptoms, have an idea of what you think is related and come in to have that conversation. If you have significant family history, whether it's cancer history, cardiac history, let us know so that way we can, again, try to tailor things to you.

And if there's potential additional genetic testing, like that is something that I talk about a lot with my patients of, "Oh, you have this huge family history of cancer, let's make sure that you're optimized on that side, especially if someone has children, I would want to know to pass that information forward."

Erica Newlin, MD:

Yeah, and I think a lot of these things come up at annual GYN visits, but it's also nice to have a dedicated menopause visit, and I respect patients' time, and I know it can be hard to have multiple visits, but that way we truly are able to set aside time for a conversation.

Rachel Novik, DO:

Yeah, I agree. And I think, you know, when people see me for that initial menopause visit, they see that it ends up being like a true 30-minute visit because I get so much history. I'm going through all of that cardiac and family history, getting their pregnancy history, looking at their blood pressures, their labs all, and their inflammatory markers, whatever it is, and so it takes time. It's not something I can just throw into my annual visit because I'm not giving you the level of care that I want to, but I do understand why it can be frustrating.

Erica Newlin, MD:

And two, I always want people to know that if you didn't feel listened to in a visit, if you feel like your symptoms are being brushed off, that's a good time to see a different provider or really make that, that space because we're past a time when you can just be like, "Ah, just the hot flashes, you can deal with it".

Rachel Novik, DO:

Right. And I think that that is something that's nice about the current generation going through menopause is that we, we're really adopting this like, we don't need to grin and bear it. It's okay to do things that can make our lives easier and not like I'm going to just coast through things, but like these impact our daily lives, they impact our function, they impact our relationships with our friends, our family, our coworkers, our ability to do our jobs. And if we can make that more bearable and get us back to where we were, then why are we not doing it? And protect our heart and our bones.

Erica Newlin, MD:

Any tips for preparing questions or tracking symptoms so patients feel confident going in?

Rachel Novik, DO:

I think you start off with making a list of the symptoms you think are related and keep an eye on, you know, "Oh, I do notice these are worse at night or I notice that this is worse with these foods or drinks." Anything that you can think of if it's new, just jot it down and we can always look at it. I know the way I tend to approach things, I just ask you everything I can think of and then I say, "What did I miss?" And usually people have a handful of things that they're like, "Oh yeah, I associate these with menopause." And I jot them down and we see if they improve. Whether I think they're related or not, every person's different and we, we can't, just like we said, we can't always say, "Yes, this is because of menopause or no, it's not." We just, we can see if it improves.

Erica Newlin, MD:

Before we wrap up, do you have any final thoughts for our listeners?

Rachel Novik, DO:

The best things that we can do are have conversations, be open to all options and if you are considering hormones or you'd like to discuss more and learn more we have those Cleveland Clinic shared medical visits with some of our clinicians who can talk to you about common signs, symptoms and treatment options. We have specific ones related to brain fog, weight, worsening like cognitive changes. So we have a lot of different options there. Dense breast tissue would be another one and how does hormone therapy impact the mammogram and breast density. So if you have questions, we probably have a place where we can get you an answer. We just need you to ask it.

Erica Newlin, MD:

Great advice. Like we've discussed, menopause care is personal. There's no one size fits all approach, and the good news is we have more safe options than ever. So talk to your provider, ask questions, and make decisions together.

Dr. Novik, thank you so much for joining me on the podcast today.

Rachel Novik, DO:

Thanks for having me.

Erica Newlin, MD:

For more resources on menopause, visit clevelandclinic.org/menopause-care. If you found this episode helpful, subscribe and share it with a friend. Also, check out season two of our podcast where we have more episodes devoted to all things menopause. Remember, your health matters and understanding your body's signals is the first step to living your best.

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.