Thriving Through Perimenopause

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 today's episode, we're focusing on perimenopause, the transitional phase leading up to menopause that can bring unexpected changes in your body, mood, sleep, and daily life. Even though it's a normal part of aging, many women don't realize the range of symptoms that can start years before their periods stop. I'm joined by Dr. Madeline Cohn to discuss what perimenopause is, why symptoms happen, and when it's time to seek care. Thank you so much for joining me on the podcast, Dr. Cohn.

Madeline Cohn, DO:

Thank you so much for having me, Dr. Newlin.

Erica Newlin, MD:

Before we start, can you tell our listeners a little bit about your role in the Cleveland Clinic and your background?

Madeline Cohn, DO:

Yeah, so I am born and raised in Texas, came here to Cleveland Clinic a couple of years back, moved to Cleveland in 2020, so a big adjustment coming from Texas. And I work here in our specialized women's health department, seeing women in the perimenopause and menopause times. So lots of women going through this time of their life.

Erica Newlin, MD:

To start us off, let's break down what perimenopause actually is, and importantly, what it isn't. What exactly is perimenopause and how does it differ from menopause?

Madeline Cohn, DO:

Well, first, let's talk about what menopause is, so that way we can talk about what perimenopause is. So menopause is defined by 12 months without a menstrual period, and the average age is about 51, 52. Perimenopause is that transition time leading up to it, and it is caused by the hormonal fluctuations, which leads to changes in the periods and all these symptoms we hear about.

Erica Newlin, MD:

Do symptoms usually start gradually or can they come on suddenly?

Madeline Cohn, DO:

Well, it differs from person to person. So we usually hear about the brain fog and the fatigue and the insomnia, and those usually tend to come on gradually and people look backwards and they notice that they've had these symptoms going on for a long time. But those things like hot flashes, those come on suddenly. All of a sudden you have that hot flash that comes on and you remember when your first hot flash happened.

Erica Newlin, MD:

What factors might influence timing of perimenopause?

Madeline Cohn, DO:

This can be a little complicated. So the average age of menopause is about mid to late 40s, but some people it can be earlier or later. So like I mentioned, average age of menopause is about 51, 52, but because perimenopause can last anywhere from a couple of years to anywhere for about 10 years, we can do the mathematics backwards to see when perimenopause will start. But there are a couple factors that can influence this timing. Things like genetics can influence it. What time was mom when she went into menopause and kind of work that mathematics backwards to about when are my perimenopause symptoms going to start? But other things like, have you had any surgeries on your uterus or surgeries on your ovaries? How many pregnancies have you had actually can affect the time that you go into menopause or perimenopause? How old were you when you had your first period?

Madeline Cohn, DO:

If you went into what we call menarche or how old you were when you started having periods can actually affect how old you are when you go into menopause. Things like smoking can actually make you go into menopause earlier. And there's lots of other factors that go into them, but those are the big ones.

Erica Newlin, MD:

How early is considered normal and when would that be?

Madeline Cohn, DO:

Thank you so much for this question because this is something I really harp on when my patients come to see me because they think that some of these symptoms, “oh, this is just perimenopause, this is just normal.” But when somebody comes in and these symptoms are occurring at a young age, I really focus on this. So again, because these symptoms are based on the age of menopause, it is unusual when they may indicate that somebody's going into early menopause. So early menopause is defined by menopause that occurs less than age 45. So if somebody's having symptoms that may indicate that they might go into menopause less than 45, that's when it starts to become concerning to me. So in particular, when they start having abnormal periods or their periods really start spacing out and they start skipping multiple periods and they're less than 45, that's when I start getting concerned because that may be showing me that they may be at risk for going into early menopause.

Erica Newlin, MD:

What kind of hormonal changes are happening during perimenopause?

Madeline Cohn, DO:

So erratic fluctuations in the hormones, estradiol and progesterone, as well as follicle stimulating hormone or FSH for short, causes this hormonal rollercoaster, these dramatic ups and downs. And to simplify it a little, whenever we have these hormonal ups and downs, this causes erratic changes in our ovulation. This causes our periods to become irregular, sporadic. They start to space out. Because they start to space out, our ovulation is what releases progesterone. Whenever we start to release less and less progesterone because we're not ovulating as much, now we're not having as much progesterone as we are releasing estrogen. This is what causes things like heavier periods, longer periods. It also is what causes things like hot flashes, difficulty sleeping, the mood swings, all of this causes all of these symptoms that we see quite commonly.

Erica Newlin, MD:

Now that we've laid the foundation, let's talk about what perimenopause can actually feel like, including some symptoms women may not realize are connected to hormonal changes. What are the most common symptoms women experience in perimenopause?

Madeline Cohn, DO:

So I've kind of mentioned a lot of them here in some of the questions we've already said, but the most common ones are hot flashes, night sweats, vaginal dryness, discomfort, pain with intercourse, changes to the periods, brain fog, difficulty sleeping, fatigue, mood swings, weight gain, and low libido.

Erica Newlin, MD:

Can you focus a little on the fatigue and brain fog? Because I feel like that's one of the kind of vague symptoms, and it can be difficult to say, "Is this life or is this perimenopause?"

Madeline Cohn, DO:

That's such a great question. So yes, you're exactly right. Especially with these women, patients that I see coming in to see me, there's a lot of life stress going on at this time, right? They're taking care of their families, they're in busy jobs and careers and maybe they're not sleeping well. And is it just perimenopause or am I having fatigue because of perimenopause or is it because I'm not sleeping well? Is it because I'm stressed? I think it's the difference between that kind of insidious onset of all of this other stuff that's going on and this unexplained fatigue that I'm working on all of this other stuff that's going on. I'm managing my stressors. I am starting to sleep better or I'm working on my sleep and it won't go away. The fatigue won't go away. Or the patients who come to me and they say, "I was sharp as a tack. I'm a lawyer. I'm a teacher. I'm doing very well in my career, but I just can't find the words. I can't remember everyday things. I'm going through my life and I just can't focus anymore." Those are the patients who are experiencing the typical brain fog type symptoms.

Erica Newlin, MD:

Many women are reporting kind of "weird" symptoms that they didn't expect. So things like burning mouth or itchy skin or heart palpitations or joint pain. Itchy ears are ones that I've been hearing a lot more. Can these be related to low estrogen?

Madeline Cohn, DO:

They can actually. So I hear these a lot. The short answer, which is probably going to sound a little obvious, but also like that's kind of a boring answer is we have estrogen receptors all over our entire bodies. And when I tell this to patients, they kind of just scratch their heads and go, "Okay, that doesn't really explain anything." But it's true. We have estrogen receptors almost in every single tissue of our body and that is why it's related to low estrogen. We have estrogen receptors in our skin, we have estrogen receptors in our hearts, although I'll talk about the palpitations in just a second. We have estrogen receptors all over our brain and that is why these very weird symptoms can be related to perimenopause and they sometimes get better with hormonal treatments. The most common kind of quote unquote weird ones I see is joint pain.

Madeline Cohn, DO:

Almost every patient complains of joint pain. I do get ear ringing a lot, itchy ears I get quite common. Heart palpitations can sometimes be a presentation similar to hot flashes, but I always emphasize to my patients if they're having heart symptoms, we always, always get that evaluated with a cardiologist. We don't just ever chalk it up to perimenopause.

Erica Newlin, MD:

For sure. And I think in our general workup of hot flashes and heart issues, we want to make sure that we're not missing anything.

Madeline Cohn, DO:

Oh, a hundred percent.

Erica Newlin, MD:

That would be something in addition to perimenopause.

Madeline Cohn, DO:

Yeah.

Erica Newlin, MD:

But I know you're the same when a patient comes to me with symptoms and they're like, "Is this perimenopause or is this menopause?" I'm like, "Well, it could be. " It causes all sorts of things under the sun.

Madeline Cohn, DO:

Yep, definitely.

Erica Newlin, MD:

Sleep changes and mood shifts are often talked about. How do hormone fluctuations specifically contribute to these?

Madeline Cohn, DO:

So a lot of these are related to perimenopause, mostly due to the actual ups and downs themselves. So I kind of differentiate to my patients when they come to me, the low hormone symptoms, the high hormone symptoms versus the actual roller coaster itself. So these particular symptoms, the sleep changes and the mood shifts are usually due to progesterone. So progesterone I describe as like our chill hormone. It's our relaxation hormone. So low progesterone due to kind of what I described earlier, the spacing out of the periods that can lead to mood swings and can lead to sleep difficulties, but the actual ups and downs are what can cause these hormonal changes in these symptoms.

Erica Newlin, MD:

Understanding symptoms is essential, but knowing what to do about them is equally crucial. It's important to remember that there's no one size fits all approach to perimenopause, but there are many tools that can help. What treatment options are available for managing perimenopause symptoms?

Madeline Cohn, DO:

Yeah, so we have our hormonal medications. We have, of course, our non-hormone medications, of which there are a few. And then of course, things like lifestyle modifications we talked about earlier focusing on stress and sleep and diet, exercise. And then there are some behavioral options that have pretty good data behind them. So this includes things like meditation and cognitive behavioral therapy, and then our natural options that people lean or gravitate towards. So supplements and certain food groups. So whenever I talk to my patients, I'm a hormone therapy specialist, so I do tend to educate my patients a lot about that because most of the time when patients come to me, that's what they're looking for, but I do give them a lot of education about these other options as well.

Erica Newlin, MD:

I think many patients are surprised when we talk about perimenopause and treatments and birth control comes up. Can you talk about the role of birth control versus hormone therapy and how they might serve a similar purpose?

Madeline Cohn, DO:

Yes, absolutely. It goes back to the roller coaster. So whenever I talk to my patients, I say I'm like a detective. I have to figure out what your symptoms are and I have to see are they due to the highs, the lows or the ups and downs. And if they're due to the rollercoaster, my job is to stop the roller coaster and birth control plays a role because it stops the rollercoaster. Hormone therapy, while it's wonderful, it does not stop the rollercoaster and because birth control stops the rollercoaster, that's where it can play a really nice job in helping some of these perimenopause symptoms, whereas traditional types of hormone therapy that are sometimes used in patients that are in menopause doesn't always play that role and doesn't always help all of the perimenopausal symptoms.

Erica Newlin, MD:

How can lifestyle habits like sleep routines, nutrition, stress management, support women during perimenopause?

Madeline Cohn, DO:

They are hugely important. So I usually tell my patients, this is a 360 degree treatment here. So if I'm just giving you one very small piece of the puzzle, the medication management, but we're not addressing the other 360 degrees, you may only notice one tiny improvement in your symptoms. So we have to focus on how is your diet? Are you doing meaningful movement at home? How is your stress levels at work? How are things outside of the home? If we're not addressing these other 360 degree things, then maybe I'm only addressing one tiny piece of the puzzle here.

Erica Newlin, MD:

When should someone seek medical care for their symptoms?

Madeline Cohn, DO:

This is also a really great question. So a couple things that I focus on here are our red flag symptoms. So red flag symptoms include things like heavier periods, longer periods, periods that are longer than seven days, bleeding through pads or tampons in one hour, passing large clots, having periods that are much more different than your periods you had before. Those are red flag symptoms. But for patients that are just asking, when do I seek treatment for perimenopause in general? I'm not having red flag symptoms, but when should I seek care for my perimenopause symptoms? It's all about quality of life. It's all about when do my symptoms become so bothersome to me that I can't manage anymore? When is it becoming something that is affecting my ability to go about my day-to-day life? And that is whenever you should come in and you should talk to us.

Madeline Cohn, DO:

So it's kind of two prongs here, the red flags and the quality of life treatments.

Erica Newlin, MD:

Great. And I think we're in an era too where hopefully patients are feeling more empowered to talk about their symptoms and how much it's impacting their life. And I always encourage patients and listeners that if they're not getting the answers that they feel like they need, then have another visit or another physician. Hopefully everyone feels like they're being listened to and that their concerns are being met for sure.

Madeline Cohn, DO:

Yes, 100%.

Erica Newlin, MD:

We've talked about symptoms and treatments. Now let's look at how women can stay empowered, informed, and supported throughout this transition. How can women advocate for themselves when talking with their provider about perimenopause?

Madeline Cohn, DO:

So we touched on this, but schedule a non-annual exam appointment to focus on this. Go to your appointment prepared, track your periods, track your symptoms, especially symptoms and how they relate to your periods. Know your medical history, know your family history, and then go into that appointment saying, "This is my goal. I'm having these symptoms. These symptoms are affecting my life and I want to talk about options for management." Be informed if you want to take information from reputable sources. Good sources include things like the Menopause Society, bring in a support person, whether that is a family member or a trusted friend. And then if you feel like you're still not being heard, like I mentioned, the Menopause Society does have a database of people that are menopause society certified. So these are people who have extra education and training in menopause and perimenopause.

Erica Newlin, MD:

Great. And I want to reiterate that you said a non-annual appointment because I think that it's nice to make sure that you're really allotting that time since during the annual visit we're doing a lot of screening exams and making sure we get through certain things on that. But this can be a very nuanced discussion and really providing that time and consideration is really valuable.

Madeline Cohn, DO:

Yes, absolutely.

Erica Newlin, MD:

What role does emotional or mental health support play during this transition?

Madeline Cohn, DO:

Yes. There's actually a lot of data regarding this in perimenopause. So the term is like window of vulnerability during perimenopause. And so patients that have history of mental health are at increased risk for things like depression and anxiety during the perimenopause transition. So we just need to remember that there can be a huge role for support from other people that are going through the same thing that we're going through during this transition time, because it can feel very isolating if we're not talking to others. We don't live in a bubble, thankfully. So seek help from others. If you feel like you need to seek help from your clinician, reach out to your clinician. If you feel like you need to seek care in regards to like therapy or even medication management, there is no shame in that. I think it can be very empowering and understanding that there is an increased risk for things like depression and anxiety during this transition period.

Erica Newlin, MD:

What should women know about staying healthy long term as they transition toward menopause?

Madeline Cohn, DO:

So I think that what a lot of women don't realize is that there should be a focus on things like chronic disease management. I think that as we age, we kind of forget some of the basics. So things like managing diabetes and high blood pressure and high cholesterol, focusing on our heart health. There is a significant jump in the risk for heart disease as women go into menopause. So focusing on diet and physical activity, limiting your alcohol intake, avoiding smoking if you smoke, focusing on sleeping well and stress reduction. You can see that there's a theme here, making sure you're doing your preventative screenings, your pap smears, your mammograms, colon cancer screening. That's particularly important right now as we've seen, unfortunately, and then making sure you're getting your calcium and your vitamin D.

Erica Newlin, MD:

This has been such a helpful discussion, but before we wrap up, what is the one thing you want our listeners to remember about perimenopause?

Madeline Cohn, DO:

It's different for every single woman. It's very, very different. What your friend is going through may not be what you go through, and so it is a very individualized journey.

Erica Newlin, MD:

What's one practical step someone could take today to feel more in control?

Madeline Cohn, DO:

I am a huge advocate for education and empowerment. So there are lots of different resources you can use to obviously gain knowledge. So the Ob/Gyn Time Podcast, we have lots of resources on our Cleveland Clinic website. So yeah, absolutely. Educate yourself, teach your friends. I think knowledge is power.

Erica Newlin, MD:

Well, Dr. Cohn, thank you so much for joining me on the podcast today. For more information on perimenopause, visit clevelandclinic.org/perimenopause. That's clevelandclinic.org/perimenopause. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding your body during this transition is one of the strongest steps you can take towards supporting your long-term health and wellbeing.

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.