Well Wisconsin Radio

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Interviewer: Hello and welcome to Well Wisconsin Radio, a podcast discussing health and wellbeing topics with experts from all over the state of Wisconsin. I’m your host, Jennifer Schmidt, and today’s episode is part of a series called Strong and Steady through Perimenopause and Menopause. This is part one of our two-part series, where we’re focusing on perimenopause, a major life change and stage that affects nearly every woman, yet often doesn’t get the attention or conversation it deserves.

I’m joined today by Dr. Melissa Emmerich from Sanford Health Marshall Clinic’s Health System, Eau Claire, who will be my guest expert for both episodes in this series. In part two, we’ll continue the conversation by shifting our focus to menopause, building on what we discuss today and exploring what women can ex- expect, and how to stay strong and steady through this next phase. Dr. Emmerich, thank you for being here today.

Guest:Thank you, Jen. I’m really excited because this is an area of special interest for me, and I see women with concerns about perimenopause and menopause on a daily basis in my practice. So, I really, um, feel I need to stay on top of things, and I’m happy to share the scientific information about perimenopause and menopause. Um, I’ve been practicing OBGYN for 34 years. I initially started in the, the Navy, where I did my training, and then after I completed my Navy obligation, I’ve been practicing with the Marshall Clinic in Eau Claire, and that would be for 26 years now. Um, and my practice has evolved. You know, when I was younger, I was interested in the OB and, you know, young women’s issues, and I found as I aged that my interests also aged with me and, and right now I see a lot of the older women, not so much of the OB patients anymore, and very many perimenopausal and many menopausal women. So again, it’s a, definitely an area of interest for me that I keep up to date on.

Interviewer: Um, can you explain exactly what is perimenopause?

Guest: So, perimenopause is the in-between time. It’s the, the time when you first start experiencing some menopause or perimenopausal-type symptoms, like some vasomotor symptoms, which could be even in, um, for some women in their 30s and 40s. So, they start to experience some of the symptoms, and then they might, might start to experience some menstrual irregularities And then that perimenopause extends until a woman has actually gone a full year without a period, then she actually enters menopause. So from the first symptom until a full year without a menstrual cycle would be the perimenopause, and that on average is about seven years, but can be even as many as 10 years. And for some women, it’s very abrupt. They just stop having cycles, and it’s over. So, it’s very– it’s quite variable.

Interviewer: Sounds like it. So, it’s not exactly a, a switch, uh, you flip overnight. It’s definitely a process. So, what are the most common symptoms that women notice or that you see? You know, them coming into the office and discussing with you.

Guest: Well, most of the, the symptoms tend to be in that perimenopause time because of fluctuating hormone levels. So rather than having organized hormone cycles like we do when we’re younger, there’s a lot more fluctuation and irregularity, um, until gradually the ovaries stop producing estrogen. So, we believe especially the most common symptoms, which, which are the vasomotor symptoms, and that includes the hot flashes and night sweats, are probably related to those hormonal ups and downs. And data shows that about eighty percent of women will experience some hot flashes and/or night sweats during the perimenopause. Um, gradually, as women get, um, deeper into menopause, those symptoms tend to spontaneously resolve because they’re no longer getting the fluctuating hormones. Other symptoms that are, you know, pretty common in the perimenopause, of course, the menstrual changes, just less predictability of the menstrual cycles, generally farther apart, sometimes lighter.

Also, mood swings. We do know that women who have the vulnerability to depression or anxiety, for instance, maybe they had postpartum depression, perimenopause becomes another time of vulnerability where they’re more likely to have either exacerbation or recurrence of some anxiety or depression they have experienced in the past. The other thing that I’m hearing more and more of from women is joint aches and sometimes even muscle pain. But I think more the joint aches. Um, brain fog is another term woman will come in and describe to me. And I think what, you know, that includes is trouble with memory and even some cognitive changes, like feeling like it’s harder to be focused.

Um, and you, you wonder, you know, some of this may be due to the hormone fluctuations. But also, if they’re having vasomotor symptoms and they’re not getting good sleep, that could be affecting their memory and, their clear– you know, how clear is their mind during the day if they’re sleep deprived. Also, if they’re struggling with mood swings, that can affect cognition and memory. So, there’s a lot of different things come into play. It’s not all just, well, fluctuating hormone levels cause, you know, joint or the brain fog. Another thing that many women will report is weight gain, and that is not necessarily true for everyone, but a lot of women really feel like they are gaining weight or it’s really hard to lose weight when they enter the perimenopause. And of course, women also come in with sexual changes.

Interviewer: Wow. Well, there’s no shortage of symptoms. Um, and I can see where there could be a lot of confusion too on, like, what’s going on. Mm-hmm. Uh, why, you know, especially having, uh, just the broad mix or array of symptoms that a woman can have, and it clearly can also vary women to woman to woman. Um, but all that comes back to those hormone shifts. So, what specifically, um, related to hormones, like, what hormones are kind of fluctuating a lot at this stage?

Guest: Most specifically, it’s estrogen. So, our ovaries start to produce less estrogen, um, but I think even more important than the hormone production themselves is the disorganized pattern. So when we’re having regular menstrual cycles, there’s a very organized pattern of release of, of, first of all, the hormones from our brain that stimulate the ovaries to produce estrogen, and then in the second half of the cycle, there’s a surge in progesterone. And what happens in perimenopause is there’s no longer that organized hormone release.

So, there’s the ups and the downs. There’s less ovulation you know, so women are less able to get pregnant because they’re not ovulating regularly each cycle also because of the changes in the hormone fluctuation. So, it’s really not… You know, women are hopeful that, oh, we can just check some hormone levels and tell me what’s going on, and it’s really not true because the whole problem is it’s the fluctuation and the disorganized hormonal pattern.

So on one day, we can check your estrogen and your progesterone and your FSH, and they may be normal, but then you skip a couple of cycles, and we check them, and the estrogen’s low and the FSH is high. So it, it’s really the variability in the hormone levels. Um, so it’s not really helpful to check hormone levels. It’s helpful to listen to symptoms and address them.

Interviewer: That’s a great point, uh, because I think a lot of women out there might think, “Oh, let me just go get my hormone levels checked,” and, um, think that that’s going to show, um, what’s going on. So, uh, thank you for, uh, explaining, you know, how those shifts can change from day to day. So beyond day-to-day symptoms, how does perimenopause affect l- like, more long-term health?

Guest: Yeah. I’m so glad you asked that because it’s so important to recognize the unseen Things that happen in our body at the time of perimenopause and then into menopause. And very clearly, as we’re transitioning through the perimenopause, there is a decrease in muscle mass, there’s an, a decrease in bone density. We have an increase in our cardiovascular disease risk. So, I think most of us know that younger women are not as high risk for cardiovascular events as men are. So, men in their 40s are higher risk for cardiovascular disease than women in their 40s. Well, once we are approaching menopause and go through menopause, our cardiovascular disease quickly catches up to that of men.

And cardiovascular disease is actually what causes most fatalities in women, even though w- women worry about breast cancer and all these other things, it’s actually cardiovascular disease that we really need to be thinking about, even in the perimenopause. And what happens also in, you know, as we go through this transition, is it’s been clearly shown now that there is a bump in our cholesterol levels, which increases atherosclerosis, which is thickening of the walls of our blood vessels, so that increases our risk of blood clots, stroke, high blood pressure.

So all of those are kind of unseen things that are hap- happening, and it makes us… it even more important for us to really focus on healthy lifestyle changes that we can incorporate so that as we go through the perimenopause, we don’t end up falling victim to those higher risks. Um, the other thing that does happen, and women will notice this too along with the weight gain, they say, “It’s in my s- it’s my stomach I keep gaining weight in my stomach.” And that it’s called visceral fat, and that is actually the highest risk place to carry extra fat mass.

Interviewer: Wow. So yes, so clearly going through this, um, this change, uh, affects long-term health. What about, um, also bone health? Um, cause I’m sure the fluctuation in hormones can cause a, you know, risk of osteopenia, osteoporosis.

Guest: Correct. Yeah, so the, um, as we, as our estrogen levels get lower, so estrogen is actually protective for bone density. It is true that we will start to lose bone density until… unless we very specifically work to keep our bones strong. And the two things that are so essential to that is, first of all, in our diet, to make sure we’re getting adequate calcium and vitamin D, which unfortunately many women don’t anymore. They’re… For whatever reason, um, dairy products have gotten sidelined i- in recent decades. A lot fewer people are consuming adequate dairy, and that’s where the vast majority of us are getting our calcium and vitamin D. It’s very hard to get it from other dietary sources and we do know that dietary sources are better ways to get it than through a supplement.

So, it’s, it’s partly making sure we get that adequate calcium and vitamin D. And how I simplify that for women is it’s three servings of dairy daily, and very few women get that. The other way is we have to strengthen our bones with some type of strengthening or weightbearing activity, and that needs to be at least two or three days a week where we’re doing some type of strengthening, weightlifting, um, body resistance exercises. That, by the way, also will help us to preserve muscle mass. So really, really important to focus on that strengthening activity, which I think is something that’s come out more recently and less women are doing, but hopefully more women will hear about and start doing regularly.

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And now we’ll head back to the Well Wisconsin radio interview

Interviewer: Yeah. So there’s a lot women can be doing proactively, um, during perimenopause, um, like you were saying, especially around nutrition and then yes, exercise, very important to include that strength training and cardio to help, you know, with bones, heart, mood as well. Yeah. Um, are there any specific, um, foods that you recommend that can– women, you know, should aim for to get in their diet? Or if, you know, they simply can’t get that, um, from the food they eat or drink, you know, is supplementation, um, with vitamins or something over the counter helpful as well?

Guest: Um, very clearly studies have shown that dietary, um, absorption of calcium, vitamin D, all of our nutrients, it, it’s going to be best absorbed through the diet. There’s even been some concern about calcium supplementation causing calcium deposits on the carotid arteries. So, um, always try to get it through diet. And there are other types of milk that are– or other types of drinks that are called milk that are fortified with calcium, which would be a better absorbed way of getting it than say from a pill.

But if necessary, you know, there are calcium supplements that come with vitamin D. The preferred one would be calcium citrate with vitamin D just because the, the citric acid helps with the absorption of the calcium. Um, but keep in mind that that’s only one serving, and again, we have to have three servings a day.

So, one supplement equals one serving. So, it really does take very conscientious effort. The other thing as far as, well, what is a healthy diet in the perimenopause and menopause, it’s really the Mediterranean diet. So, if you look at the Mediterranean diet, it’s also an anti-inflammatory diet, so it’s high in fruits and vegetables, um, lean proteins.That, that would be for cardiovascular health, for anti-inflammation, um, for bone health. The Mediterranean diet really is the winner.

Interviewer: Yeah. That’s– And that’s been a popular diet and a, a diet that’s been established for many, many years. Um, so another good thing to look into. Uh, there’s lots of resources out there for anybody that’s interested in that, that diet. Also, um, you know, if people are, I’m sure, interested, they can work with a registered dietician as well.

Guest: I agree.

Interviewer: Yes Um, how about other, um, things that we can proactively as women work on? Uh, we talked about, you know, nutrition, exercise. Um, what about, like things like sleep hygiene, um, stress management? Mm-hmm. I also think of like other lifestyle choices like, you know, tobacco, alcohol use, um, and then also just staying on top of those preventative screenings.

Guest: Yeah. Yeah. So particularly for, um, avoidance of the cardiovascular disease, you know, the risk factors for cardiovascular disease, a lot of them really are things we can control. You know, absolutely not smoking, you know, um, sedentary lifestyle works against us. So, you know, I already talked about the import- the importance of strengthening activities, but in addition, all of us for cardiovascular health should have at, at least 30 minutes of cardiovascular activity, you know, most days of the week.

Ideally, five days a week, and better yet, seven days a week. So that’s getting your heart rate up. When you talk about cardiovascular activity, people say, “Well, yeah, I walk around the house, I clean, I, you know, I don’t sit down.” That’s not enough. It actually takes something that you, you conscientiously do something extra to get your heart rate up for 30 minutes. And, you know, if you’re not doing it now, you gradually build up to that. But eventually, you want to get to that recommendation of 30 minutes, you know, at least five days a week. Um, the other thing is if we have excess body weight, you know, working on getting that weight down to a healthier level definitely will help with cardiovascular disease risk and, and avoidance of metabolic syndrome.

So metabolic syndrome is something too that women are more prone to as they go through perimenopause, and that’s a combination of insulin resistance, high blood pressure, high waist circumference, which is a measure of that visceral fat. So, you know, again, maintaining that healthy lifestyle, which is really the Mediterranean diet, strength training two or three days a week, the cardiovascular disease or the cardiovascular activity five days a week, those are just essential for so many things.

And you mentioned moods. It, it’s true that getting out and being active, people will eventually notice, “Oh, that I feel better,” like it generates positive chemicals in my brain. It also has been shown to help with the cognitive changes, so being regularly physically active and socially active helps our memory, m- you know, less risk of that, that brain fog if we stay active. Um, so that social network is so important. The other thing, I guess, when I, when I talk about dietary things, like there are actually some very essential things in the diet like the omega-3 fatty acids. And when you go– when you follow a Mediterranean diet, you’re actually getting those, the healthy fatty acids like in olive oil, walnuts, fatty fish like tuna and salmon.

So that’s another important part of our, our brain health Our medical health is getting the essential fatty acids and the healthy ones. Um, oh, alcohol. I didn’t mention alcohol. As far as alcohol goes, that can incur some extra risk too. So, the, the recommendation is moderate or no alcohol. Definitely not a reason to start using alcohol if you don’t. Moderate for women would be no more than one drink per day.

Interviewer: So, if somebody is listening and thinking, “Wow, this is me,” uh, what should they know about seeking care?

Guest: Yeah. I, you know, I, I think that you can start with your primary care provider, but there’s a lot of variability in how comfortable primary care providers are in helping women with perimenopausal and menopausal symptoms. I find in my experience that many of the primary care providers will refer women to me for ongoing management and evaluation, and especially if a woman is very clearly interested in hormone therapy. I think our primary care providers are a little bit… Some of them are willing to prescribe, but most of them are not.

They want them to come to a gynecologist, someone who maybe has more experience and stays up to date with recommendations as far as what medical therapies could help. Um, so definitely, you know, go to your primary care provider, get a referral to a gynecologist who has interest in, and most of us do, with managing perimenopause and menopause. Some other things to consider would be, like, a lifestyle coach. You know, if you recognize, “Boy, I am kind of gaining weight. I’m concerned about my bones and my muscles,” get a, a lifestyle coach, a personal trainer can be helpful. And I think you mentioned also that registered dietician can help with the dietary recommendations.

Um, if there’s a lot of, you know, more cognitive symptoms and behavioral or mood swing symptoms, you know, maybe behavioral health would be a good place to go to discuss that further too. So, there’s a lot of professionals out there who can help. Um, but again, I think the first, the first place to start with your primary care provider.

Interviewer: Yeah. Yeah. There’s a lot of different, um, you know, medical professionals, um, and people you can work for so that, work with, excuse me, so that nobody has to, you know, kind of suffer in silence, that there’s lots of, of support available out there for women. If they were referred to an OBGYN, w- um, what is, you know, some of the treatment options that you kind of discuss as a first, you know, first start when you meet with a patient?

Guest: Well, first it’s, you know, getting to know her history, cause not everyone is going to be eligible for every type of health, health management options, and always focusing on lifestyle change first, cause that’s really everybody… Everybody’s got to do the lifestyle change. Um- Unless they’re al-already perfect, which I, I would venture that probably none of us are. Uh, all of us could probably improve. But then after that, you know, first evaluating their medical risks. So, there are some women who want hormones because hormones can be very beneficial for many of the perimenopausal symptoms, but they’re not eligible for various reasons. So, it’s really important to be with a, a provider who understands, well, what are the risks, what are the benefits, and helping them to, to weigh that.

So, when it comes to therapy, it’s got to be very personalized. So, it’s that one-on-one, I have to get to know the patient, their history, um, listen to the symptoms. Right now, hormone therapy is seeing a surge of interest because the FDA just here in January removed the black box warning off of estrogen and progesterone products, so we’re seeing a lot more interest. But we still have to be cautious and really personalize who’s appropriate for which hormones and the different ways of administering them, how long to continue. So, it’s a really a personalized discussion. Um, there are some women who won’t be eligible for hormone therapy, so other options, there are some, um, brand name medications and some of the things that we’ve thought of in the past is either antidepressants and mood stimulator– uh, I’m sorry, mood stabilizers that have been shown to help, like, say with the vasomotor symptoms or if it is depression or anxiety. So, there are other medications besides hormone therapy that can be helpful, but really if you’re looking at for most women who are having clearly perimenopausal vasomotor symptoms particularly, hormone therapy is going to be the most effective option for most. But again, in a personalized fashion, so…

Interviewer: Good to know. Are there any, uh, Dr. Emmerich, are there any resources that you would recommend for women? I think, you know, any educational support websites, reading materials, maybe even apps or tools that exist now?

Guest: I am so glad you asked because there’s so much out there, and unfortunately, a lot of it is misinformation. So, the reliable site to go on, and I explored this completely over the past week to make sure I was telling you the truth, is The Menopause Society. This, the, The Menopause Society, it used to be called, um, oh, the American Menopause Association or, yeah. And now it’s the… Oh, it was the North American Menopause Association, um, NAMS. Now it is just The Menopause Society. They have a wonderful website with patient information, provider information, links to reliable scientific-based information, also links to where you can find providers who specifically are menopause cert-certified care providers. So, I would, that would be the site I would recommend.

Interviewer: Perfect. Thank you so much for sharing that resource. I want to thank you for joining me today and, you know, sharing all of these insights, um, and education for women out there that are, you know, maybe approaching this transition, um, or going through this transition in life. Yes. So, thank you for breaking this down for us.

Guest: Thank you. Thanks, Jen.

Interviewer: Perimenopause can feel overwhelming, but with the right knowledge, lifestyle strategies, and clinical care, you can stay strong and steady through the transition.

Thanks for listening to Well Wisconsin Radio. I hope you enjoyed the show. We love hearing from our community, so please take a moment to visit the Well Wisconsin radio card under the Benefits tab in your Well Wisconsin portal to share your feedback or suggest a guest for future episodes. You can find our transcripts and previous episodes all at www.webmdhealthservices.com/wellwisconsinradio. If you’re listening to this podcast on your platform of choice, be sure to subscribe so you never miss an episode.

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