In this episode of PodMD, Specialist Menopause and Menstruation Wellness Coach, Dr Baljit Kaur Rana will be discussing the topic of the Stages and Symptoms of Menopause.
- Transcript
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*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.
Today I’d like to welcome to the PodMd studio Dr Baljit Kaur Rana.
Baljit has a background in Psychology, teaching and working as a Psychologist. She currently teaches at Monash College. Baljit is a passionate professional dedicated to providing specialist holistic coaching support for young girls going through challenging and sensitive hormonal issues during menstruation such as Endometriosis, PCOS, and for women transitioning through the menopause stage of peri menopause, menopause and post-menopause in their lives. She is the founder of MenoBloom based at the Clynden Avenue Specialist Centre in Malvern East Melbourne.
Today, we’ll be discussing the topic of the stages and symptoms of menopause.*We do hope you enjoy this podcast but please 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, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Baljit, thanks for talking with us on Pod MD today.
Baljit: Thank you for having me, Portia.
The topic of today’s discussion is the stages and symptoms of menopause and how these have an impact on women’s physical health and emotional well being. Can you describe for our listeners what menopause is?
Baljit: Thank you for inviting me here to talk about this very important topic, PodMD and team. Menopause actually affects about 51% of the population directly and it’s estimated that about 1.3 billion women around the world are currently experiencing menopause. However, only approximately 5% of these women will take up evidence-based treatments and a lot of healthcare professionals have had limited or no menopause training. Just to define what menopause is, it’s a hormone deficiency and it’s a stage of life that affects women for the rest of their lives. This is where the levels of oestrogen, progesterone and testosterone decline. We have hormones that are produced in the brain, these are powerful chemical messengers, they tell the body what to do and when, they influence the growth, development and metabolism, emotions, sexual and reproductive functioning, sleep, brain functioning and blood pressure. This typically results in them experiencing many symptoms during menopause, so if these are not managed appropriately, these can have other implications or links to different health risks.
For women it’s very important to understand that there are different stages or what we refer to as transitions of menopause. This is where a lot of people don’t realise, they just think it just happens when menopause goes on; but there’s different stages. The first one is perimenopause, which is where this starts at the reproductive age, this is also referred to as the monarch or menstruation stage. Next stage is perimenopause, this can last several years and is marked by reproductive hormones fluctuating downwards, resulting in menstrual cycle disruptions and other hormonal shifts. The menopause stage is where women have their final menstrual period as their ovaries no longer produce the eggs, so this signals the end of reproductive capabilities, and it’s officially confirmed 12 months after the last period, which also marks the end of the perimenopause stage. Post menopause is everything that comes after menopause and continues until the end of life.
Question 1
Baljit, how would a patient with menopause typically present?Baljit: Women are typically about 40 years plus who have entered the paramount perimenopause stage typically present with the different symptoms. These can include regular bleeding, what’s being referred to medically as vasomotor, which is heart thrushes or night sweats, poor sleep which could be disturbed sleep or insomnia, joint pains, anxiety or feeling of having low moods, cognitive concerns, which are also referred to as brain fog, which is the lack of focus and concentration, urogenital symptoms, such as vaginal dryness or soreness, bladder or urinary infections, loss of interest in sex and weight gain, which is around sort of the mid regions or central weight gain this is referred to. But typically these are some of the symptoms that can be presented.
Question 2
Okay Baljit what are the risks or efficacy of this condition?Baljit: The risks of this condition and for medical specialists and practitioners to be aware of is the exact age that women are going to enter into menopause. This is going to be based on various factors such as genetic, physiological and lifestyle factors like smoking, alcohol consumption and whether they’ve taken hormonal contraception or not. The average age for women to go through to enter this stage is about 51 years. The normal age range is between 45 and 55. Every woman is going to be different and unique, and menopause can arrive early for other reasons too. Early menopause can be before the age of 45 could be simply a normal biological variation, or it could be related to other physiological and environmental factors such as stress or another health issue.
Surgical menopause is where the ovaries are removed and this can result in a sudden and complete loss of oestrogen and progesterone. Menopause symptoms can be quite severe as there is no gradual leading up to or tapering down at the hormone levels. A hysterectomy without the removal of ovaries does not cause menopause but any pelvic surgery can trigger menopause. By the way, I’m not a medic here, but this is from knowing the research and the medical resources, these are the things that medical specialists will be aware of.
Primary ovarian insufficiency (POI) is where the ovarian production sharply declines before the age of 40 and about 1 to 3% of women are affected. Possible causes could be autoimmune disorders, thyroid disease, diabetes, chemotherapy, radiation therapy, pelvic surgery, but in most cases we don’t know the cause. Functional hypothalamic amenorrhea (FHA) is where there isn’t any menstruation happening which could be due to overexercising under or disordered eating and high levels of stress. This then results in a disruption of the hormone or rhythms, so unlike menopause, FHA can often be reversed with effective nutrition, stress management changes and body fat levels and so on.
In addition to these other ways or factors or reasons where menopause can arrive early, there are other elevated health risks of early menopause that GPs and medical practitioners and female health specialists need to be aware of. These are higher chances of later life, osteoporosis, cardiovascular disease, cognitive decline and obviously these can all have an impact on mortality.
In terms of understanding more about the condition and the risks and efficacy of it, there’s been some research all across the world around this, and like I mentioned, some of the you know, health and long term health issues that can happen because of the decline in the hormone levels. There’s a recent study by Doctor Louise Newson, 2024, so last year, she’s from the UK. Specialists in menopause and she looked directly at the she did research on the women on the experiences of women going through perimenopause and menopause, and she highlighted in her report that a lot of the symptoms are not linked to changing or low hormone levels and women can go under unnecessary investigations that for their symptoms, that would improve with effective treatment.
Sometimes there is some misdiagnosis of the conditions where they can be confused with you know, they actually could be underlying menopause symptoms, but the practitioners could be picking up on the depression, anxiety, arthritis, other conditions like fibromyalgia, overactive bladder symptoms, irritable bowel syndrome (IBS), chronic fatigue syndrome and other psychological conditions. When in fact they are perimenopause or menopause or symptoms that they’re experiencing.
This can then result actually in women being inappropriately medicalised with antidepressants, painkillers, sleeping tablets, antibiotics, and antipsychotics, as clinicians are treating individual symptoms instead of addressing the actual cause of the problems, which is low hormones, a reduction in those. Or these women may not be given any treatment at all.
Her report also details chronic diseases, such as the ones I mentioned earlier, cardiovascular disease, dementia, osteoporosis and diabetes, if they’re left untreated, then this can place a huge-because of the menopause that they’re probably experiencing these in the long term-his could place a huge financial stress on the healthcare systems around the world. She also said that if perimenopausal and menopausal women were treated properly, in time with hormone therapy, this could result in a reduction in costs, financial savings and also obviously a reduction, which is obviously ultimately what women are concerned about in the instance of these diseases.
It’s very clear that we need to be aware of the huge impact on hormonal imbalances and that these can result in physical and mental and psychological effects, and they can also exacerbate pre existing conditions. Women who are presenting with medical symptoms or concerns could be osteoporosis, a kind of vascular risk, dementia, diabetes and obesity. There are some proactive measures like DEXA scans where you can measure the bone density, primarily in the hip and spine of menopausal women and then you can get what we call what the score is the T score, which will indicate possible risks or fractures and broken bones. Obviously at that stage before the official diagnosis of osteoporosis, it could be osteopenia or before that stage and then obviously measures can be taken to overcome those and to try and obviously do what you need to with diet and supplements.
Other research across the world in America particularly, there’s doctor Lisa Masconi. She’s a leading neuroscientist and women’s brain specialist. She’s done a lot of really, really interesting research on the brains of women, and particularly the important role of the brain during hormonal changes, so obviously going through menopause. She’s recognised that there is a decrease in oestrogen which can influence body temperature, mood and memory. And it could lead to cognitive decline later in life.
Another American specialist, doctor Sharon Malone and obstetrician, she’s also acknowledged that during parent perimenopause, women’s brains are wired to be receptive to oestrogen. We have a lot of oestrogen receptors in the hippocampus area of the brain and prefrontal cortex parts of the brain that are responsible for membrane cognitive functions. As these increase and decrease because of the hormonal shifts during PMS symptoms, which is before you get the period, premenstrual syndrome, postpartum, obviously, after you’ve had a baby, you’ve got symptoms of that, of depression, perhaps, or affecting your memory and perimenopause. These can all result in women feeling like their brain is scrambled, which is also referred to as brain fog.
I’ve just given a bit of a summary on what we need to be aware of as practitioners, not only are there certain conditions where you know things can happen earlier or proactive measures that we need to be aware of and educate women about this. But also obviously there are cultural differences where certain cultures do experience menopause earlier, but also overall to make sure that women are receiving prompt and appropriate treatment to manage their menopause symptoms so that they obviously have an improved quality of life and to prevent those diseases, the long term ones that I’ve mentioned.
Question 3
That’s all really interesting Baljit, and in terms of treatment options available, what is out there for them?Baljit: This will vary depending on the route that you know women would like to go through. Perhaps the most effective and the evidence there now is increasing which is reassuring for women, is to replace the missing hormones that used to be called HRT, but now it’s referred to commonly as menopause hormone therapy, so MHT. This is where oestrogen levels are replaced, with or without progesterone to treat the symptoms of menopause like hot flashes. Obviously these options need to be discussed for the qualified healthcare professional who has experience with menopause and different types of MHT, that could be metrologist, gynaecologist or a GP.
It is a complex medical decision that the woman would need to make and monitor with her specialist, depending on her age, symptoms, risk factors and any contraindications and obviously their specialists would be aware of all of that and they’ll be able to track that as well. Another option is non-hormonal prescription treatments, supporting general health and hormonal health with health and wellness practices such as good nutrition, regular exercise, and managing stress. Women who have contracted contraindications to MHT or those who prefer not to use hormones may choose to use non hormonal medicines to relieve, say for example, the hot flushes, the motor symptoms. These perhaps may not be as effective as MHT, but some women have a clinically significant reduction symptoms, so these could include serotonin, noradrenaline, reuptake inhibitors, (SNRI), antidepressants and selective serotonin reuptake inhibitor inhibitors. SSRI’s and they all have proven to have some evidence of benefit too, but it obviously does vary from each woman to each woman and the medical practitioner needs to be aware of the full history of the patient, what their clinical history is and their family history, if any other conditions? It has to be very complex in terms of looking at all of that before anything is prescribed by the medical practitioners. There are other treatment options such as alternative and complementary remedies such as acupuncture or naturopathic medicines. These could be functional medicine practitioners such as cognitive behaviour therapy which has also been found to be effective clinical hypnosis and mindfulness.
Question 4
Ok, have there been any developments in treatment in the last years or are there any in trials or development at the moment?Baljit: Over the past few years, there have been a lot of developments, fortunately, in clinical trials across the world for MHT, particularly after the first sort of trial that was done, and by the Women’s Health Initiative (WHI) that was reported in 2002 which unfortunately resulted in lots of concerns and risks about the developing breast cancer through hormones and then that did affect obviously the perceptions of MHT and the risks amongst clinicians and the general public, quite rightly so.
However, since then, that’s been since 2002, they obviously did at that time report that there could be increased breast cancer, cardiovascular disease and VTE in people who used MHT. Fortunately, developing on from those studies, further studies have reanalysed the WHR data, and they’ve done other undermined trials and observational studies and this has resulted in our change in our understanding of the benefits and risks of MHT and also national and international menopause organisations have acknowledged that the risks of harm associated with MHT were perhaps overstated.
Question 5
Are there any warning signs that a GP or their patient could look out for?Baljit: Yeah, so women really should be proactive. This is where the the education piece comes in, if they know about this recognising symptoms, but they are menopause rather than anything else or perimenopause entering into that stage, then obviously there can be proactive about getting help in a timely manner, consorting with the GP about any physical and or psychological symptoms that they can receive an advice and intervention in a timely manner.
A big concern and warning sign to look out for the practitioners and the patients are possible perimenopausal symptoms that could be misunderstood for other symptoms that I mentioned earlier. This could be like physical pain and stiffness in their joints, heart palpitations and anxiety and depression.
Question 6
What is the likelihood of recurrence of the condition?Baljit: As I mentioned earlier, the transitions obviously when you reach menopause then you go into post menopause for the rest of your life. But you know, leading up to that, there are different stages of menopause that need to be carefully monitored and tracked with the patients because they are likely to exhibit different and present with different physical and psychological symptoms during these stages and each stage, because depending on how much is bothering them and affecting them and the quality of life, they may require different interventions and treatments.
Question 7
When should a GP refer?Baljit: A GP should typically refer the patients to a multi disciplinary team of women’s healthcare providers for mental health, heart health, bone health, at the stage of menopause, obviously they themselves can support them with providing them with the support and medications that they need, and they could refer them to a gynaecologist or endocrinologist as well. Whatever symptoms they’re presenting with could require specialist intervention and monitoring. This is something that’s very important because it’s not all going to come from the GP there could, you know, there are other specialists that then work together to provide them with the different support that they need. In with the MENA bloom that I have launched recently and through the experience there, so as a certified menopause coach and specialist, where I can help women with their menopausal symptoms through the different stages is to provide them with holistic support to their women themselves and their families because it affects them too, particularly partners and husbands, navigating through the different stages of menopause.
Question 8
Baljit, what role does the GP play in the treatment of the condition?Baljit: They play a very, very important role. GP’s are the first line of contact so they play a very important role in the diagnosis and treatment of the different stages of menopause, because they should come to them first, they can carry out relevant screenings of their symptoms. They can also provide education to the patients about what symptoms they should pay attention to that indicates that they could be entering the different stages of menopause and they can also prescribe MHT if and when they feel it’s an appropriate treatment for their patients.
Question 9
Baljit, thanks for your time here today in the Pod MD studio. To sum up for us, could you please identify the three key take-home messages from today’s podcast on menopause?Baljit: Thank you so much for having me here to talk about this topic that I’m very, very passionate about, that I, you know, very an advocate and I want to support as many women as possible in the community and raise the awareness. I do appreciate you inviting me and having this really good, important discussion. I guess there’s a lot of messages but I will just to try and pick up on three.
I’d say is firstly, it’s very important for women to recognise their physical and psychological symptoms that can indicate that they are at the different transitions of menopause. For also for them to feel confident and empowered to speak about these with their GP’s and healthcare providers in a very proactive way. Secondly, the range of treatment and intervention options which I did describe and and you know and and I chat the there are obviously ranging from prescriptive and alternative therapies, they’re all very holistic too, so it could be a bit of this bit of that going on that are available to women who are experiencing menopausal symptoms and and it is really important, as I mentioned as well earlier, is that to have a multiple multidisciplinary team of women’s healthcare providers who can provide that support with the the different physical and psychological symptoms that can be associated with menopause. Finally, it is really reassuring to see that there have been a lot of developments ongoing as well, and the continuing all around the world that we are learning from in the research and clinical trials on MHT, that has obviously definitely made women and professionals, healthcare practitioners feel a bit more confident about these taking these and they are very much again you could be replacing the like for like hormones, you know, so body identical and they that women should feel reassured that this is an effective option for them to take and consider at different stages of menopause and not feel that it’s that they, you know, in any way, they’re not coping well or they there there could be some side effects it’s just be proactive and knowing that they don’t have to suffer in silence that that there are treatment options out there and these are supported by evidence based clinical and research.
Thanks again for your time and the insight’s you’ve provided.
Baljit: Thank you so much for having me here to talk about this important topic. Like I said, it’s very, very important to educate and raise awareness across the practitioners and also women who are going through this to know that there is a lot of support out there. Thank you so much.
