In this episode of PodMD, Endocrinologist A/Prof Dr Kevin Lee will be discussing the topic of Peri-Menopause with Dr Pritinesh Singh and Host Caroline Chaplin. They discuss what peri-menopause is, common presentations and case scenarios, how GPs can provide support for their patients, and more.
Resource:
A Practitioner’s Toolkit for Managing Menopause (source: Monash University)
- Transcript
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Caroline: Welcome to the PodMD studio. This podcast is sponsored by DPM Financial Group. Today, I’d like to welcome to the studio Associate Professor, Doctor Kevin Lee – Kevin, welcome – and Doctor Pritinesh Singh. Welcome to you too, Nesh.
Both: Thank you.
Caroline: Kevin’s an endocrinologist and medical researcher. He’s very interested in hormone dysregulation and the study of weight management, particularly in perimenopause. Joining Kevin, as we said, is Nesh who’s an experienced GP and she has a very holistic approach and a strong interest in Wellness and Women’s Health. She’s been through perimenopause herself and realises there’s definitely a need for education in this space and to look at the condition holistically. So in this episode, we’ll explore the perspective on that and the whole-person care, clinical education and we’ll also look at some management of complex health issues.
Now this is episode one of a perimenopause series with both Dr Lee and Dr Singh, so we do hope you enjoy this podcast, but do remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor and not PodMD and if you do have a patient on whom you require specific advice, then please seek this advice from a colleague with the appropriate expertise in that area.
So, Nesh over to you, what will we be covering today in the podcast?
Nesh: So today we will be covering episode one of our perimenopause series. Kevin, perimenopause is something that we’ve both discussed many times and is an area that many GPs like myself frequently encounter. Can you give us an overview of what we’ll be discussing today?
Kevin: Yes, Nesh. I think we’ll discover what perimenopause actually is and the common signs and symptoms. Then we’ll also look at how GPs can intervene and provide support for their patients. As well as providing some advice and guidance as to when a patient may have to be referred to an endocrinologist.
Nesh: Kevin, to start this conversation off, can you describe for our listeners what perimenopause is?
Kevin: Yes. Perimenopause is a time that can vary from a few years to many years, when hormonal fluctuations are occurring and the menstrual cycle becomes erratic and eventually completely stops permanently. It is associated often with symptoms like hot flashes, mood changes and other things like fatigue, head fog, memory disturbance, even musculoskeletal problems like joint pain start to emerge, and I suppose some of the more challenging things are also vaginal dryness and loss of libido.
Nesh: So in other words, it seems to include so many varying symptoms that can be so confusing as it overlaps with many other common conditions. Talk about common presentations and case scenarios.
So for example I found myself, as a busy mother, juggling commitments and there are lots of other women out there who go “I’m tired”, “I’m fatigued”, but everybody says “you’ve got three kids and managing theirs”, “you’re running the house”, and you go “I’ve got brain fog I can’t remember what I came to the kitchen for” and then I’m going back again, or that you find yourself repeating things and what used to come so easily to you previously wouldn’t come as easily to you now.
And then you go, “I’m tossing and turning at night”, “I’m putting the blankets on and I’m throwing them off”, “I’m restlessly kicking my legs” or you know what “I’m getting these aches and pains” and all these other things are going on as though all of a sudden my life is falling apart and I’m now 45. Is this just another transition in life?
Kevin: Often, many women don’t talk about this with their peers or even their GP. So they think that it’s just something that is to do with ageing and it often goes untreated so it’s a shame that it often is a condition where many women suffer in silence.
Nesh: So how can we tell if it’s just normal busy day-to-day life as we live now, or is there more going on? Is it the hormones causing the mental and emotional changes that we experience?
Kevin: It can be quite difficult even for specialists, to discern the difference between mental and emotional changes you mentioned being part of perimenopause or to distinguish it from a mood disorder or related to life circumstances. What makes it easier is if these mental and emotional changes are associated with symptoms like hot flashes or hot flushes, those terms are interchangeable, or other menopausal symptoms we talked about earlier, like vaginal dryness or joint aches and pains.
Typically, the emotional disturbance, mood swings and brain fog can be misinterpreted, as I said, as a mood disorder, and unfortunately some women get prescribed antidepressants inappropriately rather than potentially a more beneficial hormone therapy. The common complaint with brain fog and memory disturbance can vary. They can be mild to severe, with some women thinking that they’re getting dementia even or having something sinister going on needing some sort of scan of their brain because they’re forgetting simple things like names, as you mentioned, word finding difficulties, unable to complete tasks without feeling overwhelmed or just feeling depleted generally.
Do you find that these symptoms are quite varied and range in severity in your practice?
Nesh: Absolutely. So what I’m starting to see in my practice is I’ll have a woman that usually comes in and says, “I’m just tired, I’m fatigued, can I get a blood test, doctor, please?” Is what they usually say. Or “I’ve been to the naturopath and she’s asked me to do some iron, some zinc, some vitamins”, and she’s also asked me to add some hormones while I’m there. Or “I’ve been reading an article and a friend of mine thinks that I’ve got ADHD because I’m overwhelmed and I’m tired”.
So, because it’s so varied sometimes I as a GP am lost as to where do I start with this person? So that’s when our holistic care comes in. Looking at the whole biopsychosocial environment and finding a starting point, trying to understand what their life is, what is going on, but also from where their life cycle is, what phase of their life they’re in and what are the changes that they may potentially be going through.
Caroline: Potentially a whole lot of miscommunication on TikTok and the like as well to throw into the mix.
Kevin: Oh that confuses the matters a lot.
Nesh: Absolutely, everything on social media these days and you click one thing and suddenly a whole heap of algorithms show up on your phone and so you go from one to the other to the other and they will come in with this. So I think it does get quite confusing, but most times it is just starting with a point to start from and then working your way through it.
Caroline: Do you look at the most severe symptom, or what’s most troublesome to the patient?
Nesh: Yes, absolutely. Now usually it comes with, “I’m feeling anxious, I don’t know what’s going on with my body”, “these are changes which I haven’t experienced before”. Or it may even be as simple as my cycles have become longer or they’ve become shorter, the periods are heavier than they used to be, or “I used to be clockwork on 28 days but now it’s 35”. It’s just those subtle things but it’s starting to impact them, especially if you’re someone who’s been routine in many ways, and then those subtle things are now starting or the temperature variances and things like that that are now starting to impact.
Kevin: Just to make it harder, if your patient comes to you with those symptoms and they don’t present at the typical age of perimenopause like late 40s or early 50s, then it becomes even harder if they have those symptoms and they’re in their early 40s or even late 30s even.
Nesh: Correct, and that’s the other thing that we find challenging is depending on where they are and how they are because most people go it “it can’t be menopause or perimenopause I’m still 38 or 35 or the age that typically we don’t expect it because there’s a stereotype associated with when perimenopause takes place, is there a magic number Kevin?
Kevin: No, we typically just define whether it’s a typical age of late 40s or early 50s as being what we would expect to be so called ‘normal’ but if you have these symptoms and you’re going through perimenopause before 45, we say it’s early and if it’s before 40, it’s premature.
Nesh: Well, just to share my experience in this, I actually started experiencing this when I was 37. So it was just the hot flashes, the temperature and sensitivity, the mood changes, the aches and pains and everything else that started. But I had a little bit more in terms of an IVF journey, so it was more that the fertility specialists actually said “I think you’re in premature or early menopause”, but then we went back on to family history and things and that’s where I suppose I became a bit more passionate about wanting to increase my own knowledge around this because I went “if it’s happening to me, this is a GP who’s going through this”, there are lay people out there who don’t understand what’s happening to their body and it’s more about empowering the women out there, as in it’s not all in your head and that there are some reasons and explanations about what’s going on.
Caroline: I think it’s associated a little bit with success or failure too, and if you’ve got this somehow you’re failing.
Nesh: That’s correct.
Caroline: And the earlier the more of a failure you are. So, I think in my own journey, it was more about just ignoring those things and that was part of life or shutting up and putting up and not mentioning anything until later. When symptoms became worse, and for me it was particularly hot flashes that got me to seek out medical support and to know more because life wasn’t doable with that many hot flashes a day. So, it forced me to seek that support.
Nesh: Absolutely. With that also comes the social anxiety or the embarrassing situations that you find yourself in or avoiding certain places and people and things including food choices because you know that it’s going to exacerbate and aggravate how you feel.
So, Kevin, how can GPs intervene and provide support for their patients during this stage of their lives?
Kevin: So, as you’ve already alluded to, the biopsychosocial model is important to not just pay lip service to it, but all the lifestyle interventions from healthy eating to exercise to managing weight and all these things are important to be reviewed. But as clinicians, we also have the option of looking into medications or hormone therapy. So, it really depends on the severity and predominance of symptoms experienced by your patient, as to which option you go down and you have to carefully weigh the risk and benefit of these various medication options.
The most common is of course oestrogen therapy in menopause hormone therapy. Oestrogen is a hormone that alleviates the majority of symptoms that we’ve already mentioned and it can be delivered in a variety of forms. The commonly used ones though are topical and oral preparations. It is important to acknowledge that hormone therapy also includes a progestogen if your patient has an intact uterus or has had moderate or severe endometriosis in the past. This is to prevent endometrial hyperplasia from unopposed oestrogen and thus reducing the risk of uterine cancer.
Coming back to the oestrogen, at the moment topical preparations are usually the go-to because topical estrogens are less thrombogenic than oral preparations generally, and are most beneficial if we can use it in the form of patches or gels. The patches can be ‘patchy’ to get sometimes from the pharmacist, pardon the pun. But if you can get it, it’s a good starting point to start at 50 micrograms and then to titrate and dose according to response. One of the most common questions I get is the risk of breast cancer in the use of hormone therapy.
Nesh: So, Kevin, what are some of the risks of starting menopause hormone therapy?
Kevin: Other than the thrombogenic risk mentioned before, I think this is a great question and often women want to know about breast cancer risk. The risk of breast cancer is now known to be a lot lower than what we initially thought when the Women’s Health Initiative studies came out. This is partly because since then, there’s also been the advent of body identical progestogens such as prometrium, that reduce that risk even further. With these new hormone therapy options, the increase in breast cancer risk that I typically quote to patients is from not using hormone therapy, around 23 cases per thousand women over 5 years to 27 cases per thousand women over 5 years. Just to put it into context, that is actually less than an increase risk for perimenopausal woman who drinks 2 standard drinks a day.
Nesh: So, a question that I have for you then is should women be getting mammograms prior to commencing menopause hormone therapy? Do you get them to do a baseline?
Kevin: We typically don’t do that unless there’s a strong indication in family history or past history of dense breast tissue. Usually following the typical guidelines in terms of breast screening is all we recommend.
Nesh: So, going back to the intact uterus. We’re talking about oestrogen, so if a woman has an intact uterus, you’ve said that we should be using the body identical progestogen. How do we do that to prevent endometrial hyperplasia or endometrial cancer?
Kevin: So typically, if we are using say prometrium or the body identical progesterone as the tablet form, we would be using it at night and we would use a higher dose of 200 milligrams every night for two weeks and then for two weeks we would then stop it, just to mimic the ovarian cycle such that when you stop the progestogen there is actually the potential for any buildup of uterine tissue to result in some spotting or bleeding, and this keeps the uterine tissue healthy. If however, bleeding is a concern and some women don’t want to have that bleed, they can either reduce the times in which they have that progestogen withdrawal, but the better option is to use the progestogen IUD like the Mirena. This is perhaps a bit more effort from the patient’s perspective initially to have it inserted, but it’s a practical consideration to take into account. After about 12 months of not having a period, the option then becomes to use the prometrium nightly rather than using it cyclically, and you can drop the dose from 200 milligrams down to 100 milligrams at night.
Nesh: So I’ve heard, and have seen some gynaecologists prescribe the progestogen orally that can be inserted vaginally is that a thing?
Kevin: Yeah, that is also something that can be done and it would be also possible to not have to insert it every day. It can be also done every few days as well.
Nesh: Yeah, I did find that fascinating when a patient actually said that to me that “I’m actually putting in vaginally” and I was like “ohh okay, that can be done”.
Kevin: Yeah, there are also oral options for the progestogen to be combined with the oestrogen. So, in case it is a bit too much work or effort to apply a gel every day, you can combine the prometrium with oestrogen in the form called by Bijuva and it is commonly used, and you can use it at night. As I mentioned before any oral oestrogen will have a slight increase in thrombone disease. So, DVTs are more common when you use oral forms of estrogens.
Nesh: Can oral contraceptives be used as hormone therapy? I’ve seen certain specialists also use things like Zoely.
Kevin: So, in the perimenopause period, if you want contraception then you should use oral contraceptive pill as a form of contraception as well as relieving of all the different symptoms that we’ve mentioned before. However, if you want the lower doses of oestrogen, you can still use the oestrogens we’ve mentioned, like the gels and the patches. If you want contraception on top of that, then you would use something like say cylinder for example.
Sure. All right, moving on. So, for example, some women come in and they go, “intercourse is very painful, there’s vaginal dryness or I’ve got frequent and urgent itching and I can’t sit still”. What are options for them, and I really don’t like taking tablets, doctor.
Kevin: Well, there’s there are plenty of medical options available for what you’re referring to as the urogenital symptoms. So, I would say that topical preparations like topical oestrogen should be considered like Ovestin. Lubricants also shouldn’t be avoided, they have a role. Also to mention what happens commonly in this period is a loss of libido as well, which testosterone preparations like Androfeme can help restore. The symptoms you mentioned are important to mention proactively to women because oftentimes they are not comfortable mentioning it at the onset of the consultation and they can feel a bit embarrassed to bring it up, so it is important to proactively ask that.
Nesh: Kevin, finally, can you give us some guidance on what a patient may have to be referred on to an endocrinologist like yourself?
Kevin: This is a difficult question to answer because it depends highly on how comfortable the General Practitioner is at managing perimenopausal symptoms, balancing the risks versus benefits. So, I would say if in doubt just refer. However, there are a few scenarios where it is a good idea to share responsibility in managing the woman going through perimenopause and this is usually in women that have a personal or family history of breast cancer or increased risk of DVTs or Pes. It is worthwhile getting a second opinion to reinforce the message to the patient and to work out how to improve the safety of symptom control, which we must remember goes beyond medication but also involves the lifestyle options that we started off talking about like exercise, nutrition and weight management. Another common reason to refer patients is if patients are having challenges getting on top of their symptoms despite using adequate hormone therapy dosing or if patients are not responding as the way you would expect. For example, having spontaneous bleeds postmenopausally, which you can’t really quite explain.
Nesh: Wow, now that was pretty insightful into perimenopause like a crash 101 course.
Kevin, before we finish up today, could you please identify the three key take-home messages from episode one of our perimenopause series?Kevin: Great Nesh, I would say if I had three take home messages it would be: 1, recognise the symptoms of perimenopause being diverse and that it can range from psychological to physical symptoms that can mimic many other conditions.
The second one would be once you’ve identified that this is what’s causing the symptoms that your patient has come to you to know the many options that will help them safely manage their symptoms, which will range from hormone therapy but also there is a role for other non-hormone therapy options like neurokinin blockers and antidepressants as well.
The third is to think beyond the symptom management, but to also manage some of the longer-term risks that are going to increase when a patient enters into menopause, like cardiovascular disease, bone health, as well as managing the psychological transition in the patient’s life. This is a time when roles of a woman often change from being a caregiver to one of potentially moving beyond that role, and sometimes it can feel like it’s a period when the shift needs to happen and they can feel a bit lost and so many options should be explored.
There’s also a very useful online toolkit which I should mention, and that’s the menopausal toolkit designed by the doyen of perimenopause and menopause management by Professor Sue Davis, and so I’d recommend that as a guide to complement what we have discussed today.
A Practitioner’s Toolkit for Managing Menopause (source: Monash University)
Nesh: Amazing. Kevin, thanks for joining me on the podcast today. I really appreciate your time and the insights you’ve provided, in the next episode of our perimenopause series we’ll be examining the important aspect of weight change in perimenopause and how to manage this, as it is perhaps one of the more distressing issues for women that they find hard to raise themselves.
Kevin: That’s exactly right and I find that often towards the end of your consult, looking at the hormone therapy options and when you mention weight to your patients, suddenly their eyes light up and go “Yes, I’ve always wanted to get some help with this”. Unfortunately, because of the way our consults are structured, we then have to schedule another appointment to talk about it but I can almost guarantee you they will always come back to talk about it because it really is very distressing.
Nesh: Absolutely. Indeed, and it’s always about the central weight around the abdomen. They’ve tried everything, but nothing is shifting.
Kevin: Yeah, the same things that many women would have tried before to shift their weight before menopause doesn’t quite work after the onset of menopause.
So, thanks Nesh it was a pleasure. I look forward to being back in the studio soon.Nesh: Thank you.
Caroline: Thank you both for coming in today. It’s been delightful to hear about this perimenopause condition, and we’ll hear more in your next episode. Look forward to that.
Nesh: Thank you for having us.
Kevin: Thank you.
