What To Expect in Menopause with Dr. Pelin Batur

Podcast Transcript

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Kate Kaput: Hi, and thank you for joining us for this episode of the Health Essentials Podcast. My name is Kate Kaput and I'll be your host. Today, we're talking about menopause with Dr. Pelin Batur, a women's health specialist. Menopause is a natural part of aging that marks the end of the female reproductive years, but so many of us don't know what to expect until we're in the midst of it. Maybe you just know that you'll stop having your period or you've heard about hot flashes, but what's really happening and why? And most importantly, how can you cope? Dr. Batur is here today to explain the stages of menopause and to walk you through some of the ways that you can deal with the many changes that it brings. Dr. Batur, thanks so much for being here with us today.

Pelin Batur: Thank you for inviting me. Excited, fun.

Kate Kaput: So I know that you've been on the podcast in the past talking about menopause. We're thrilled to have you back. I like to start by having our guests tell us a little bit about themselves. So tell us about you. What kind of work do you do here at the Cleveland Clinic? What kind of patients do you typically see?

Pelin Batur: Yeah, so I have been here since 1998, a long time. Did an internal medicine residency and then a sub-specialty training in women's health, where I got all kinds of education from our osteoporosis center and endocrinology and gynecology. So I take care of all things hormonal for the Ob/Gyn department and specifically, I work day to day in a Menopause clinic, but I also helped the Ob/Gyn department create several new programs, including a female sexual health program that I lead, as well as a medically complex contraception program. So my really focus is hormonal concerns often in women who have complex medical histories such as cancer or other problems.

Kate Kaput: Perfect. So let's just jump right into it. Can you give us a brief overview of what menopause is and what is happening in our bodies when we're going through menopause?

Pelin Batur: Yeah, so menopause is defined as one year without periods in the absence of any other medical condition or medication that's impacting that period flow. And so typically, [that] happens around age 51, 52, and then, the rest of your life, you live in menopause where you're no longer ovulating and you've lost the ability to have children. Now, there's also a perimenopause, or the menopause transition, and that can be up to a decade before menopause where periods start getting a little wonky. The menstrual cycles start getting a little wonky, sometimes closer together, sometimes skipping cycles. You may or may not also be getting some of the typical menopausal symptoms during that time, but the official time is one year without periods.

Kate Kaput: So you mentioned that it normally happens around age 51. What can you tell us about when it happens sooner, about early and premature menopause or the medical conditions, like you talked about, that might induce menopause earlier?

Pelin Batur: Yeah, this is important to call out. I'm glad you bring this up. So when women go into menopausal state before age 40, that is called premature menopause. And then before age 45, is early menopause. And it's important to identify this because early loss of estrogen is associated with a lot of bad things. Estrogen has a very protective role up until menopause for women. And so especially premature menopause, losing estrogen before age 40 is associated with increased risk of death, increased risk of heart disease, lung diseases, a lot of neurological conditions, osteoporosis of bone breaks.

Pelin Batur: So really it's important to identify. So if a young woman comes in, and let's say she's 35 and she's lost periods for the last four, five months, then I do a lot more hormone testing, for example, than I might in somebody who is 53 and just is going through the natural change process. But you also want to think about other conditions. Oftentimes, thyroid problems pop up around the same time as perimenopause menopause is. So we don't want to be blaming something on just menopause and not looking at some other medical conditions, and I always like to make sure that the patient has a good primary care doctor, that they're up to date with their preventative visits, take a look at the medication list, get their history — and if it hasn't been done, check some basic labs like thyroid.

Kate Kaput: Got it. So really looking at full body health and not just saying, "It must be this," or "You're reaching this age, so it's probably this."

Pelin Batur: Absolutely.

Kate Kaput: So you mentioned perimenopause, and I feel like we don't hear as much about perimenopause, particularly the fact that it can last up to 10 years. What can you tell us about that perimenopause period and what people go through during that time? How do you know when you're in perimenopause or can you only know if you go see a doctor like you?

Pelin Batur: Yeah, no, basically, there's early menopause transition and later menopause transition. And you don't necessarily have to see a doctor like me. Basically, you are starting to get some hot flashes, especially right around the time of ... just before your period, where women notice that more, or right on their period because that's when the estrogen levels drop. That's normal, if you're just having a few days of hot flashes. Most of us again tend to gain more weight with each passing decade. So you might be noticing some weight gain, sleep might be impacted. There might be some symptoms that are occurring, but your periods are still rock solid. So if they're bothersome, you don't want to ignore them because a lot of times people will be told, "You can't be perimenopausal. You're still having periods." But if you're having some of those symptoms and they're not mild or bothersome or you can make due with lifestyle changes and maybe just getting better sleep during that time, upping your cardio, that you don't have to worry about, you don't have to necessarily come in. That's a natural phase of life.

Pelin Batur: But if they're really bothersome, come on in even if you're still having regular menstrual cycles. The late menopause transition is when you are getting a little closer. So that means that now the bleeding is actually becoming abnormal, too. Oftentimes, there is a period of time where the periods get closer together in the month, but it can also start to separate. And eventually, as you get closer and closer to menopause, you start skipping. And when you're starting to skip for prolonged periods of time — I think everybody should be seen by their doctor once a year anyway — bring that up. But if you're much younger, your early 40s, younger than that, and you're skipping periods, you definitely have to bring that up to your doctor.

Kate Kaput: So talk to us a little bit about that then. I know we said it's a normal part of life, it's a normal part of aging, but if it's starting to happen sooner, you talked about some of the risks, what are the things that people need to know about the risks of early menopause or early perimenopause to really keep themselves healthy? What do they need to talk to their doctors about? Are there any questions that you need to ask your doctor? Kind of what do you do there?

Pelin Batur: Like we talked about, there's a lot of risks that are associated with early loss of estrogen. And so it's pretty universally understood amongst menopause specialists that unless there's a real reason not to replace estrogen in that situation, you want to provide hormone replacement therapy. And I'm emphasizing replacement because in those situations, it's no different than somebody has underactive thyroid or they have their thyroid removed would we not give them thyroid replacement because we say, "Look at the packages. It says there's a lot of risks." No, we would replace it because otherwise, your risk of medical problems like heart disease and other things would be increased if we left you hypothyroid. So that's, I think, a one big message I want listeners to take away is that if you lost estrogen before age 45 or especially before age 40, it really should be replaced.

Pelin Batur: And there's very few reasons why that would not be replaced. And the way I like to think about it is, unless for a medical condition, you would actually go in and remove ovaries or give anti-estrogen treatments. There's no reason to withhold hormone replacement in those situations because the woman was meant to have that coursing through her veins. So if she is a breast cancer survivor, then of course, we're going to really be thoughtful about any kind of hormone exposure to that woman. However, if she has colon cancer, rectal cancer, I mean these individuals really need to be on hormone replacement therapy once their medical conditions have stabilized.

Kate Kaput: So let's talk a little bit about some of those hormones then, especially estrogen, which you've mentioned and I know it's a key element of menopause and in our bodies. What does estrogen typically do and what happens when those estrogen levels start to decline? Can you just walk us through the science of the estrogen itself so that we have a better understanding of kind of what's happening?

Pelin Batur: So we have estrogen receptors throughout our body and our brain and our joints. So, many women just feel better when they have adequate hormones. And it's not just estrogen. We have estrogen, we have progesterone, we have testosterone, and they have all different roles. So for example, we always like to talk about heart risks and bone health when we talk about estrogen. But when women go through menopause, many will report some increased joint aches and pains. It's important for sleep. So many women will report disruption of sleep. Estrogen is a natural mood elevator. So it doesn't necessarily work as well as an antidepressant does. However, it can really have mood elevating effects. Progesterone can be a little bit more of our chill hormone. So when we do progesterone replacement, especially the more identical types, it causes a sedating effect. It has some anti-inflammatory actions. Estrogen is good for our hair and our skin. It helps bring moisture into the skin. It's thought to have antiaging properties, and then also testosterone has important function for sexual health.

Kate Kaput: So it sounds like going back to your previous answer then, that if you are in early menopause, it's important to kind of have that treated. And then if you're kind of in menopause or in perimenopause as a normal part of aging, then it's more about lifestyle and kind of ways to cope and all of that. Is that right?

Pelin Batur: Is it? No, not always. So that's a good question. I'm glad you brought that up because I think so much ... So let's say you are a woman who's 53, you went through natural menopause, but you're having a lot of symptoms. So should you just leave it alone and cope with it? We used to tell people the symptoms are going to last somewhere three to five years. Well, it turns out it's a little longer than that for the average woman — seven to 10 years. And some women who are really miserable 12 years and some people never get rid of their symptoms. So I think just saying, “grin and bear it” and just eat healthier and lose some weight is not going to do it for a lot of women who are really suffering. And I think a big issue is that for many, many years in this country, medical care has been about stamping out disease.

Pelin Batur: Let's find the disease and treat it. And I think there's been a nice shift in the last decade to more towards wellness. And that's where hormone therapy actually has an important role. And I'm just going to digress a little bit... I think that one of the big reasons that a lot of women don't go on hormones is that we're such a risk adverse society. And clinicians, too — doctors, nurse practitioners — it's like, "Well, these hormones say that they have a lot of risks and I don't want a problem to happen on my watch."

Pelin Batur: But what about that woman's wellness? We know hormone replacement therapy reduces risk of death and women who are within a decade of menopause or who are in their 50s — the overall positives outweigh the negatives. And even the American Heart Association came out with a step — I mean most of the menopause organizations have been saying this for over a decade — but even the American Heart Association recently came out saying, "We do agree that for most women who are in natural menopause or early menopause in their 40s, 50s, there's a lot more pluses of the hormone therapy than minuses for the individual woman."

Pelin Batur: So I think we do need to shift the conversation, not just about just “grin and bear it” and I just don't want you to have a side effect with this. So I just don't want to get into that conversation … to really about fostering wellness and listening, taking a look at the big picture for that woman, what are the pluses, what are the minuses for that individual patient and not making her suffer.

Kate Kaput: That's great. I think that so many women will be happy to hear that because, like you said, for so long the narrative has been kind of, "Well, this is what happens when you get older," and that doesn't mean you're not miserable, and not everyone is, but some people are. And so I think it's really reassuring to hear that there's a shift in that approach.

So let's talk about, we've mentioned them already, but let's go through some of the symptoms of menopause, which begin to happen when we're in perimenopause. And so, as you said, one of the biggest and clearest signs is irregular periods. Why does this happen? What's literally happening inside your reproductive system when you start to have irregular periods because of perimenopause?

Pelin Batur: Yeah, so what's happening is that you are not ovulating as regularly. And so you sometimes still might have some estrogen around, but you don't have adequate progesterone from ovulation. And so you may skip a cycle but then end up having heavy bleeding because the uterine lining has thickened up from the estrogen impact. So why is this? What does mean? So what you should watch out for with your bleeding patterns, if you are having … let's say you're in your late 40s and you are having your cycle still, but they're starting to space out or they're getting lighter or you skip several months in a row, but then the one you have after that is just a nice normal period, you can just keep an eye on that. But if you're skipping — skipping months in a row — and then the one you have after is really heavy, like your body's trying to somehow compensate for that, that might be because you've thickened your uterine lining because of the estrogen and it needs to shed.

Pelin Batur: So anything that's trending towards heavier bleeding. So “my periods were always five days and now there's seven days and I'm just soaking through pads and tampons. I'm getting a lot of spotting in between or that period that I do have, it's intermittent, but it's really heavy” … You should always report that. A lot of those are hormonal, but we need to take a look and make sure you don't have a uterine polyp. And also, we always are thinking in the back of our minds [that] we never want to miss the uterine cancer. So it's always good to talk about that with your doctor if there's been a change.

Kate Kaput: Got it. A good reminder that bodies are complicated and there can be all kinds of things going on. So I think that also brings up another good point, which is that sometimes people think, "I'm going to stop having my periods or my periods won't come as often. That's great, that sounds awesome." But as you mentioned, sometimes your period symptoms can actually get worse when you're in perimenopause. Why is that? That's because of just the hormonal imbalance? Are there other period symptoms that can get worse as well, like cramps, things like that?

Pelin Batur: So I would put that on the bucket of “if you're noticing changes, I would just speak to your clinician” and that way they can ... because there's multiple reasons for cramping and heavy periods … and hormonal imbalance is only just one of them.

Kate Kaput: OK, so either way, if things start to change or you're particularly unhappy with the way things have changed, definitely time to see a doctor.

Pelin Batur: Sure, anything that's tending towards more bleeding.

Kate Kaput: One of the most well-known symptoms of menopause is hot flashes. What can you tell us about hot flashes? Why do they happen? And I guess most importantly, how do we deal with them?

Pelin Batur: OK, yeah, so that's a very good question. The honest answer is, we don't know exactly why hot flashes happen. Basically, the part of your brain that generates the temperature smack dab in the middle of your brain, the hypothalamus pituitary, it's probably somewhere in there. It's probably something related to the feedback from the hormones, but it's not exactly clear. There's a lot of active research on that area, and we might actually have some medications in the horizon that non-hormonal … that specifically impact those areas. But that's an area of active research. And frankly, there's probably a lot of contributors to hot flashes because we know stress can make it worse. Your lifestyle sometimes, if you're using a lot of caffeine and alcohol, and all those kind of things can actually trigger. So the good old-fashioned lifestyle tricks of keeping yourself healthy, getting your sleep, managing your stress — is it a surprise that it actually helps for hormonal symptoms, too?

Pelin Batur: It's not a surprise to anybody. Doing what's good for us. If you're good to your body, your body will respond and be good to you. But how to treat them. So let's say you're doing all the right things and you're still miserable with the hot flashes. You go online and you look it up, there's everybody that's trying to make a buck off of you. And you have to be so blunt about it. But it is big business because a lot of people have been suffering for a long time and because of the risks of hormone therapy, I blame us the medical community, too. A lot of people turn their back saying, "Well, just stick it out. It'll be over soon." And nobody wants to be miserable. Nobody wants to be in a board room sweating all of a sudden where surgeon patients don't want to be sweating into their mask.

Pelin Batur: I mean, there's multiple ... A busy mom of three that has to get up and function all day, doesn't want to be disrupted with night sweats and hot flashes. People care about these symptoms. So you go online and you see tons of stuff advertised. And there's another honest answer here is that the placebo effect from menopausal symptoms is really quite high. It's close to 40%. So that means that I can put together some “tictacs,” put it in a nice bottle, sell a great story, write a book about it, whatever, and promote it. And I am going to be still of benefit to half of individuals out there. And is that because we're all crazy and blah, blah, blah … I hope not because I'm perimenopausal myself and I don't get hot flashes and I don't think I'm crazy. But I think the reason is because if negative energy going to your hypothalamus pituitary can drive up hot flashes, why can't positive energy powers of wishful thinking and belief in something and having calm thoughts about your hot flashes, why wouldn't that make it better?

Pelin Batur: So why does that matter? If somebody's taking something harmless and they're getting benefit, I'm all for it. But supplements are unregulated and we have had issues, significant issues, with liver toxicity and other things and — not to mention the cost — and you're putting that through your liver. So I think we have to be thoughtful about what we put into our bodies and things that even have some of the longest safety track record or, I shouldn't say safety, longest use like black cohosh, do help some individuals. They don't seem to help better than a placebo. Studies are very mixed on that. So most of them show no benefit over placebo and there are warnings from the FDA about liver toxicity use for more than six months. So you have to make sure you're getting liver enzymes check. So all things natural don't always necessarily equate to safe or effective. So just … beware. There are some other holistic methods that if you wanted to talk about that haven't shown to be much better than placebo.

Kate Kaput: Yeah, I would love to hear that. I was just going to ask really quickly, are there any supplements that you specifically — that are dangerous — that you see people taking or trying to take or hearing about that are an absolute no go that you want to warn people about?

Pelin Batur: Yeah, there's nothing that's an absolute no go. But unfortunately, so basically, since there's no FDA oversight on the supplement market, it would take a long time to prove something is harmful. So there's a lot of people probably getting some sort of harm not realizing it because they don't see it as a FDA-approved risk or as that FDA risk because sometimes, it takes years and years of something being circulating in the market before the concerns come up about its risks.

Kate Kaput: That makes sense. So let's talk about some of those holistic methods then. I think that could be really helpful to a lot of people, including myself.

Pelin Batur: I mean, I'm a big believer in that mind-body connection. So there are several things that have been really shown to be helpful compared to sham procedures. So cognitive behavioral-based approaches, mindfulness therapies, hypnotherapy, well-designed studies, has been shown to be helpful. I used to recommend acupuncture, the data on it, recognizing that data on it is mixed. But North American Menopause Society is a great website that you can go to menopause.org. They are the main medical society for North America and they have lots of reviews. They basically review the scientific data and have nice explanations about what has data behind it, what doesn't.

Pelin Batur: And it's just hard to sometimes make time and carve out the chunk of change to follow through on these regimens. But for the acupuncture, the data on it, because it is so mixed, it's not concrete, that it's helpful. If somebody's already going to an acupuncturist for their headaches or whatnot, I talk to them, they might be able to pop a few needles in for a menopause, but the data doesn't show that it's so effective. And so I just don't want people shelling out a lot of change for acupuncture, just for menopausal symptoms.

Kate Kaput: Sure. If it's already part of your kind of lifestyle, then maybe you can ask to tackle the menopause piece, but you don't necessarily have to start seeing an acupuncturist for it. And this might be a sort of silly question, but are night sweats just hot flashes that happen while you're asleep?

Pelin Batur: Yep, exactly. But they are linked to sleep disruption. And it's interesting, we used to think that and people would say, "I get night sweats and then I wake up and I have to throw the covers off and I can't fall back asleep." And when you look at sleep studies, it's interesting, there's actually a distinct disruption in the sleep cycle first oftentimes followed by the night sweat. So it's really interesting how estrogen really impacts the sleep cycle because we know that actually happens during pregnancy, too.

Kate Kaput: Got it. And I think also worth saying that night sweats can be kind of a symptom of all kinds of other health issues as well. So if you're experiencing night sweats, important to get to a doctor to figure out what it is.

Pelin Batur: Yeah, yeah, absolutely. And I'm glad you brought that up because oftentimes, I do see young women having normal menstrual cycles. They're 25, their thyroid is fine and they're saying, "It must just be my hormones," because I think that's become a trend just to blame everything on hormones. And I think we need to sometimes take a step back from that. And yeah, we're a whole bag of hormones, our body is full of, but it's not always estrogen, progestin — there's more than 50 hormones in our body and we want to make sure it's not from serious medical conditions night sweats can be related to. So especially, I see somebody, let's say, she's 54 and I've got her in high doses of hormones because her symptoms are so bad. We check our hormone levels, she's absorbing it properly and she's still having night sweats. I will work with the primary care doctor, the endocrinologist to make sure we're not missing other hormonal problems outside of just the estrogen deficiency there.

Kate Kaput: Perfect. I think I'm going to start describing myself as a big bag of hormones. So on the continued topic of hormones, menopause can also cause vaginal dryness, which can make for uncomfortable and even painful sex. Tell us a little bit about why this happens and I suppose more importantly, again, what people can do about it.

Pelin Batur: And this is really important topic because a vaginal dryness impacts about half of women after menopause. But oftentimes, women are suffering, they think they're alone. And in fact in our breast cancer survivors and other women taking anti-estrogen treatments, it's much higher and can be much, much more severe. And so it really needs to be addressed. And there's lots that can be ... first of all, we need to talk about it. We need to normalize it. You don't have to suffer in silence. There are lots of good lubricants out there that can be really helpful. There's healthy 18 year olds that use lubricants all the time.

Pelin Batur: More women are using lubricants than not. We have to normalize that. But also, vaginal hormones are very effective. And in fact, vaginal hormones are oftentimes much more effective at treating vaginal dryness than even systemic hormones, meaning ones that you would put on your skin or take in your mouth. And so you can actually use creams, vaginal rings, suppositories to deliver the hormone right where you need it, where you're minimizing any kind of exposure to the breast or to the heart, especially if you're really nervous about being on hormones and having the hormones go through your bloodstream. You can get it straight to the vagina and you don't need to suffer.

Kate Kaput: Got it. And are those by prescription then something you have to see a doctor for?

Pelin Batur: The hormones are prescription.

Kate Kaput: What's the difference between vaginal dryness and vaginal atrophy, which also can be a part of menopause?

Pelin Batur: Yeah. Vaginal dryness is a symptom and vaginal atrophy is the medical term that is used. Vaginal atrophy is actually an older term. We changed that, not me, but it's been changed to GSM, genital urinary syndrome of menopause. And the reason it was changed to that long word is because it doesn't just affect the vagina, it can also impact the urinary structures. So where women feel like they're not just dry but they can't get a break from vaginal infections or they feel like they have that vaginal infection, they go to their doctor, nope, nope, your swabs are clear or same similar story with the urine where they feel like they're getting urinary tract infections, UTIs, but you go and yeah, you might have one or you might not even have a UTI but you feel like you have one and the vaginal hormones can be very, very helpful for those.

Kate Kaput: So another one is hair thinning or even hair loss during menopause. Why does this happen and is there any way to prevent it or to stop it?

Pelin Batur: Yeah, hair loss is a tough one and I hate to sound like a broken record, but there are lots of causes of hair loss. So you always want to take a look at your vitamin levels, your thyroid function. There's a set of labs that dermatologists and us we will do for if hair losses really bothersome. But the reality is as we age, most of us are going to have some age related thinning. So that's why when you look at grandma's picture from when she was younger, 18, she has this big head full of hair … a little waist, and when she's 60, she certainly might still look like that, but it's going to take a lot of work and effort to continue to look like that.

Pelin Batur: So if you just leave things to nature, we're going to notice change in our midriff where we're gaining more fat around our midriff and our hair thinning. So some of these things do happen and you can fight hair loss not just with hormones but lots of other topical over the counter products. So you don't necessarily have to be on hormone therapy for hair loss. But we do know estrogen has beneficial effects on hair loss, not just after menopause, but in younger women who go on birth control pills, oftentimes, that can actually help improve hormonal hair changes.

Kate Kaput: So another one that I've heard about is body hair, that actually the body hair on your legs starts to grow in lighter, but that the reverse of that is that we sometimes start to grow hair in new places like on our chins. What can you tell us about body hair?

Pelin Batur: Yeah, so those are some of the natural shifts that do happen that I was mentioning to you. So as you drop estrogen, what's happening is that some of your testosterone has a little bit more powerful effect relatively. And so some of the things that I was describing, such as some of the hair thinning, some of the weight around the waistline and some of the hairs on the chin are thought to be related to that shift. I mean your testosterone levels drop as you get older, too, but they drop much more slowly over time.

Pelin Batur: So when your estrogen levels drop abruptly, the testosterone is playing a little bit more of a dominant role during that stage. So similarly, being on hormone replacement can be helpful if the hair in the chin is pretty very disruptive. But typically, I find that that's not really a big concern for individuals unless that was a big concern for them throughout their younger years. They just want to know that, "OK, this is normal." But you will also see that pubic hair also becomes a little bit more scant and a little bit more widely distributed ... Take out the widely distributed, that sounds stupid. The pubic hair becomes more scant, so you will notice some of those shifts in the hair distribution and that is normal. Hormone therapy can offset some of that, but it doesn't need to be offset if it's not bothersome.

Kate Kaput: So if you've got a couple chin whiskers, suddenly they're normal. Pluck them out. Good to go.

Pelin Batur: You got it.

Kate Kaput: So you have mentioned this, but I know that during menopause there's also potential for issues that we can't always see, like bone loss. What can you tell us about bone loss in menopause, including what that is and why it happens and again, what needs to be done about it?

Pelin Batur: Yeah, so we know estrogen, frankly all the hormones, but estrogen in particular is very important for bone development, maintenance of bone density. So after estrogen loss, there is a pretty rapid drop in bone density. It's most rapid in the first five years. And so if, let's say, a woman is having a lot of menopausal symptoms and she has a family history of osteoporosis or she went to a healthcare and they told her the heel scan was low or she got a bone density and it was low, then that's a perfect opportunity to use some hormone therapy just to stave off that bone loss. Especially for women who are in their earlier 40s, they have then more close to a decade longer of bone loss. And that's important because osteoporosis fractures are more common than our risks of heart disease stroke combined. So people worry about their heart and cancer risks, but the reality is many more of us are at risk of having a osteoporosis related fracture that can impact not only quality of life, but in the case of hip fractures, quantity of life as well.

Kate Kaput: I think that's really important and really a little bit scary because, like you said, you can sort of manage some of the more visual elements of menopause, but you got to make sure you know what's happening inside. So talk to me a little bit more about treatments for menopause. When people come to you in, they're going through menopause, they're having all kinds of issues, what are the options?

Pelin Batur: And let's tie that in with your prior question about the bone health because that was a good one. So when I think about hormonal treatments for both menopause and bone health, a strategy that I've employed that I think works well. Let's say a woman comes in, she's 52, she's worried about her bone, she's feeling miserable and she is a good candidate for hormone replacement therapy, wants to start it. If we start hormone therapy, if she has a uterus and she needs a progesterone, too, that estrogen progesterone type of therapy, then for the breast cancer risks don't really start to increase until closer to five years of use. So for the first five years she can go on the hormone therapy not recognizing that the risks to her are minimal but help protect her bones. And let's say after that, she's worried because she develops a family history of breast cancer and now her symptoms have subsided.

Pelin Batur: She went on a vacation, she forgot her hormones and she found that, "These hot flashes aren't that bad for me anymore." Then, we actually have these designer estrogens where they have estrogen-like effects and anti-estrogen effects and I don't think we need to go into that in this conversation. We actually went into that a little bit more in detail in one of our prior podcasts with the head of the osteoporosis center. People are interested in looking that one up, if you YouTube Cleveland Clinic Osteoporosis, Dr. Diehl or Dr. Batur, it'll pop up — but you can actually intervene five years with medication that has anti breast cancer effects but still it's FDA approved for bone health. A nice little segue before you actually jump into the other osteoporosis treatments. So there's different ways to think about it and bring these up with your osteoporosis specialist and menopause specialists.

Pelin Batur: But let's talk about the hormone therapy. So if you don't have a uterus and you just need estrogen alone, that's a much more favorable pro and con where you don't increase breast cancer risks for 20 years and maybe beyond. In fact, in our studies that looked at the risks and the benefits of hormone replacement, even at 20 years out, women using that specific type of hormone replacement had a reduction in breast cancer risk if they were on estrogen only — and I always like to say that out loud — I like to scream that out loud for people in the back.

Pelin Batur: So the package insert warns you that you take hormones, you're going to get breast cancer. It's very scary package insert. But if you're using estrogen plus progestin, that risk doesn't start to increase until five years. But if you had a hysterectomy and you're out of estrogen alone, even at 20 years in the same studies that they did to guide that package insert labeling warning about risks, women had a reduction in their risk of breast cancer, not only of being diagnosed with it, but being of dying with it. So there's a much better safety track record with estrogen alone. But remember, if you have a uterus, you need that progestin, too, because otherwise you can't use estrogen alone. It can impact uterine cancer risk.

Kate Kaput: And so forgive me if this is an inelegantly worded question, but then, if you do start menopause early or if you go into early menopause and you need to be on, you do have a uterus, you need to be on estrogen and progesterone … you said your risk goes up after five years, but if you go into it early then you're probably going to need it for longer. What do you do there? How do you balance that risk?

Pelin Batur: That was very eloquently put and that's a very important question actually and I'm glad you mentioned it because I neglected to mention that. So when you go into earlier premature menopause and we replace hormone replacement in those situations, the norm is that you continue until the natural age of menopause until age about 51, 52. And then you make decisions about whether you want to start true hormone therapy. They even have different names. One is hormone replacement therapy because you're replacing something that was lost, versus hormone therapy. Is the average woman 52 and beyond coming in saying, "Hey listen, I'm having symptoms or I want this for bone protection, should I use it?" That's hormone therapy because in that case, we're giving you something extra that you weren't meant to have. So there's going to be some pros and cons, but in the other situation, we're replacing what you were supposed to have. So you're really, your clock starts at 52.

Kate Kaput: So the hormone replacement therapy is essentially, then, safer to be on until the time when you "would've hit menopause anyway." And then you shouldn't be on the hormone therapy for longer than five years.

Pelin Batur: So there's no “shouldn't,” but it really is a balance of risks and benefits.

Kate Kaput: Got it. But that makes more sense in terms of the timeframes, I think, helpful to know the difference between hormone therapy and hormone replacement therapy and the timeframes that again, where the risk balance comes into play for each of them.

Pelin Batur: And you're using the word timeframes, which is good because that's something called the timing hypothesis. And when you look at the package insert, we use the timing hypothesis to figure out does this package insert apply to this patient because most package inserts of a medication, they are very accurate. It's an antibiotic, it tells you, you can get diarrhea or you can get this. And that's true for most women regardless of their age. It's a little different with the package insert of hormone therapy. The package insert warns about risks that if a woman went through menopause for 10 years already, she's now in her mid-60s and 70s and she decides to start hormone therapy, what are her risks? So it's going to talk about, it really looks like somebody's trying to murder you, it's going to tell you…

Kate Kaput: They're scary.

Pelin Batur: They're a very scary packages. It's going to say you're going to have a heart attack, you're going to have a stroke, you're going to have breast cancer. But sure, if you want to … your hot flashes, go ahead. That's what it sounds like when I read it. OK. But most of us are not starting hormone therapy, in women in their 60s and 70s who have been without their estrogen for more than a decade. There's exceptions to that rule, but in general where ... because there's benefits, there's still the bone benefits, there's still the colon cancer reduction, there's still all the other benefits, but the risks sound scarier. So the pros and cons is not as evenly weighted versus when you're in your 50s — there's a window of opportunity where the risks are much lower and the benefits are much higher. And in fact, for women in their 50s, they do not seem to have those elevated cardiovascular risks.

Pelin Batur: And in fact women in their fifties are thought to have a reduction in their risk of heart disease, especially if they're on estrogen only and they die. And we know across the board women die less when they're on hormone therapy. It doesn't matter the age group. But that is much more powerful reduction in death as you get younger and younger and you're on hormone therapy. So what age you start hormone therapy makes a difference about whether that package insert applies to you. And like we talked about for women in premature and early menopause, it's actually you're at increased risk of all those scary things in the package insert if you don't take hormone therapy. So it's actually reversed.

Kate Kaput: So much like you shouldn't believe everything you read on the internet, the package insert is, it needs to be taken with quite a lot of context and nuance in terms of how it applies to you as an individual.

Pelin Batur: Absolutely.

Kate Kaput: Got it. So I know that we talked about supplements to be a little bit weary of, but what about supplements like calcium supplements and vitamin D? Are those things that are important to be on when you are going through this time in your life?

Pelin Batur: I think it's important to make sure that you have adequate vitamins of all types and calcium and vitamin D is important for bone health. However, for menopause in particular, besides the decrease in bone density, they're not going to help you with hot flashes or other types of symptoms.

Kate Kaput: And so are there non-hormonal treatments then for menopause or are they all hormonally based?

Pelin Batur: Yeah, good question. So no, I always think of it as three buckets. If a woman's coming in and saying, "I'm miserable, what can I do?" There's a holistic bucket that we talked about, managing stress and those kind of things. I'm sprinkling flax seeds. We have great patient education materials on our Cleveland Clinic handout. If you go into our, and maybe you guys can give the link somewhere for our patients, but the dietary approaches that don't work as well, but they don't cost anything, they don't have side effects. Then there's the hormone therapy that is a lot more complicated, individualized discussion in the office. And then there are the non-hormonal treatment options. And there's several that actually haven't shown compared to placebo in well-designed studies. They do work. A big number of them are antidepressants and it's not because we're saying, "Yeah, just take it easy, my dear."

Pelin Batur: That's not why. Because it really has been shown, especially in breast cancer survivors who sometimes have the worst symptoms, to really help — sometimes, 75% or so reduction in flashes. And then there's some seizure medications, gabapentin, Neurontin, that have been shown to help. There's a bladder medicine called oxybutynin for urinary leakage that really has been shown. They haven't been really compared to each other. So we don't know if one is much better than each other, but they have been compared to placebo and they are helpful. And those are all available also on our patient education websites.

Kate Kaput: And are there any other ways to find relief from some of these symptoms that you think are worth mentioning? I know we've talked about medication, we've talked a little bit about some of the lifestyle changes. Anything else that people should know?

Pelin Batur: Just remembering that this is really an individual thing. So I think social media is great, but to think about things that you didn't know to ask or didn't know to look up. But, I mean, we covered on most of the treatment approaches, but I really would say just social media is a double edged sword where there's a lot of wrong information steering people, whether it's with good intent or with maybe on the background, they're making money off of things because I think because the medical community wasn't very good about addressing menopausal years for many decades, especially when these hormone therapy studies first came out 20 years ago. We didn't really understand that it's just more the older population, 60s, 70s, and beyond where we're worried about the risks. So there was a flood of women coming off the hormone therapy, but they were miserable.

Pelin Batur: And so what happened is, there were well-intentioned providers that maybe were not menopause trained, but they're doing a lot of custom compounding, putting pellets in. And we do see sometimes the ricochet effects. We've had diagnosed many cancers where women were given compounded hormones where they were not balanced correctly. So it's really always important, if you're being given whatever type of estrogen, if you absorb it very well through your skin, but if you don't have an adequate progestin to protect your uterus, you don't want to do that through compound and you want an FDA-approved treatment for that. We have diagnosed many uterine cancers where that was done, mishandled at a local clinic where they were just trying to help out people with doing all this non-FDA proof stuff. So you do a little bit of buyer beware and pellets we do not recommend because women can get really sky high levels and they have to detox off.

Kate Kaput: OK then. So relatedly, one last question for you is, what is the right kind of doctor to see? Do you ask your Ob/Gyn about menopause? Do you need to see a menopause specialist? Kind of where should people start and where might they end up in terms of trying to find help?

Pelin Batur: Yeah, so there are several of us that are certified in menopausal medicine by the North American Menopause Society. It means we prove that we're going to these meetings and conferences and we've taken a test to show that we've actually passed. And so that's a good site to start with because in North America, you can find a menopause provider near you. But the reality is, there's only a handful of us. And so there are lots of great primary care doctors, Ob/Gyns, endocrinologists that are very well versed in menopausal care. I just want to make sure that … do I do some compounding? I do when I don't have an FDA-approved way or a patient has had an intolerance to FDA-approved methods, I do compound. However, you just have to be careful about somebody who is not giving you the full gamut of options and only saying, this is the only right approach.

Pelin Batur: And because you do want to do things safely when you're dealing with hormones. And also just remember if you're going to your Ob/Gyn or your primary care doctor and you say, speak up and say, "Hey listen, this is miserable. I think my hormones are going haywire." But they may ask you to come back for another visit. Because as you can see, it's very complicated and depending on what your medical history is, it might get even more complicated. So that's something that they're probably not going to be able to cover an annual visit and it's OK. Make another visit, speak up so it's being addressed, but make a dedicated time with your provider because they may be very well trained, but you may feel blown off because you've already covered so many other things. They just don't feel like they will do that justice at that visit.

Kate Kaput: So really make sure that you are advocating for yourself and getting the time to talk through all of the options, all of the possibilities.

Pelin Batur: Absolutely.

Kate Kaput: Let's see. We've covered a lot of ground. I don't want to take up too much of your time, but is there anything else that you think we haven't talked about today that's important for our listeners to know about menopause?

Pelin Batur: Be patient with us because there's so few menopause clinicians. There's oftentimes long wait times and our visits can go pretty long because as we talked about, our hormones impact so much of our body that there can be multiple different symptoms a woman is bringing up and she's not sure which one of these are hormonal. So these visits tend to be lengthy. So we're trying our best, we're seeing people from all over the world coming in because it's just an unmet need. And I hope that lots you, women will empower themselves with getting the right kind of education, will have a new line of menopause clinicians. Because as we age, there's going to be even more of an unmet need. But be patient with your clinician. They might get a little behind in clinic, they might need to squeeze you in and it might take a little longer than you expected, but it's just because we're working really hard and we're really listening, too, because women are complex.

Kate Kaput: All right. Dr. Batur, thank you so much for being here with us today to talk about such an important topic. This was really helpful to me. I hope that it was really helpful to our listeners as well. We really appreciate it.

Pelin Batur: Thank you so much.

Kate Kaput: To all of our listeners, thank you so much for tuning in. To schedule an appointment with a Women's Health specialist, please call 216.444.6601 or visit ClevelandClinic.org/women. Thanks again for listening.

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