The future of menopause

0:00Dr. Karen Adams:This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. Since we started this show eight years ago, it's become an archive of amazing and impactful work by my Stanford colleagues. Research is not something that just happens in the lab, and as you'll hear on this show, the research at Stanford can impact areas like health, technology, law, and business, and many other topics that can affect everyday life. We hope you'll tune in to learn more about how research has the potential to help your life and to help the lives of people you care about in your family and your community.

0:32Women's health is the most under-researched, under-educated, over-legislated area of health in this country. And we only get 10 % of NIH funding. And it really has been shameful for a long time. And so we really, really have some catching up to do. Women are educating themselves. physicians are looking and other providers are looking for education. So it's very exciting to me. I think that for our daughters and our granddaughters, we're going to know so much more.

1:09Dr. Karen Adams:This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. Thanks for listening. If you want to support the show, telling your friends, neighbors, loved ones, colleagues about the show is a great way to support it and to spread the news about the future of everything. Today, Karen Adams will tell us that the symptoms that women can get five to seven years before their menopause can be extremely alarming and disabling. So you need to know about these symptoms ahead of time for you or your loved ones, and you need to get treatment so that you don't have to experience unnecessary symptoms around the time of your menopause.

1:43Dr. Karen Adams:It's the future of menopause. Today, we're continuing our feature, The Future in a Minute. At the end of our conversation, I will ask Karen a bunch of quick questions. She'll give me a bunch of quick answers, and that'll be the future in a minute. Also, before we get started, a reminder to share the show with your friends and loved ones and colleagues and neighbors so that we can spread the news about the future of everything.

2:11Dr. Karen Adams:When we think about menopause, a lot of us have a lot of questions. This is the time when a women's period stops around the age of 50, 51. But in the five to seven years before then, an alarming set of symptoms, irritability, bone aches, and a bunch of other things can happen that are very disabling and can be of unknown cause unless the woman has been told to expect these symptoms and seek medical help because there are treatments. In addition, after the menstruation period stop, then that's the menopausal period when And there are also treatments for the symptoms that can occur, like hot flashes and other things that people have heard about.

2:49Dr. Karen Adams:Karen Adams is a professor of obstetrics and gynecology at Stanford University, and she's an expert on perimenopause and menopause and the management of these physiological changes to optimize women's health and women's life. Karen, thanks for being here. Obviously, you're committed to women's health as an OBGYN doctor, but what made you focus on the particular challenges in managing and women dealing with menopause? Well, it's interesting. First of all, thank you so much for having me, Russ. You know, I could talk about this all day and I have. So I was residency program director for 14 years at a large academic center.

3:32And one of the things that our residents were required to learn about was what they called geriatric care. And by that, they meant women over 40.

3:43Dr. Karen Adams:Oh, my goodness. I would like to register an objection. Oh, my goodness. And so, right. And all of our residents were learning everything about contraception and about delivering babies and doing surgery. But we didn't have a clinic focused on the needs of women over 40. And this was a good 20, 25 years ago. And as a good program director would do, I said, okay, I'm going to create that. So I created it, I staffed it, and that was how I started really digging into this area of medicine, and it's been my career ever since. Great. So let's start out with a little tutorial about what everybody should know about menopause.

4:26Dr. Karen Adams:Some people know a lot about it, but some people, especially men, might not even want to hear about it, but I think it's time for everybody to know the basics. So what do we need to know about menopause? When does it happen? Why does it happen? And what are the health effects? Okay. And I love that, that you brought in the partners, because, you know, I always think this is so important for women and the people who love them. Exactly. And that's basically everyone. And I also want to say that I know a lot of people with ovaries do not identify as women. So I'm going to be saying women, but what I really mean is people with ovaries.

5:02And so that I and I will try to say persons as much as I can. So the definition of menopause is no period for a year. And on average, that happens around age 51. But that doesn't happen like flipping a light switch, right? It's not like people are having periods every month, and then all of a sudden, they just go away. So that the we call this the menopausal transition. And it starts at the beginning of perimenopause. Perimenopause are those years leading up to that final menstrual period. And perimenopause can last four to seven years. And so can be starting kind of in the mid 40s. It's the time when women are the most symptomatic and often they're still having periods.

5:52And so it can be very confusing because they're all of a sudden having mood disorders or difficulty sleeping or hot flushes. And they go to their clinician and the clinician says, are you having periods? And they say, yeah. And the clinician says, well, I don't know. Then we need to we need to send you to the sleep center or put you on an antidepressant. And what we're really trying to get the message out there is that sometimes we need to connect those dots and say, wow, this could be hormonal. This could be perimenopause.

6:26Dr. Karen Adams:So if I can just interrupt for a second, I'm sorry, because I did. I'm not sure I fully appreciate this. Do you mean that not only do the periods continue, but they may even continue at the same frequency and regularity as when the woman was in her 30s? It can. It can be that way. The symptoms can precede the changes in the cycle. Eventually, the cycles will change because what we know when a woman is having a period every month, what that means is that her brain is sending that signal to her ovary every month and the brain is talking to the ovary and the ovaries responding and the ovary is making estrogen, goes up, comes down.

7:07She ovulates, makes an egg. The progesterone goes up, comes down. She has a period. The whole thing starts over again every month. It's cyclic. It's predictable. It's very regular. What happens in perimenopause is the brain is still sending that signal to the ovary the way it always has. But the ovary is aging. And as the ovary ages, it responds less and less consistently to the signals that the brain is sending. So basically, it just sits there and goes, yeah, no, I'm not doing it. And then it wakes up and it makes a big surge of hormones and that it's completely unpredictable. You never know.

7:48And eventually the periods start changing. But that's what drives those symptoms is all that crazy dysregulation of the hormone cycling.

7:57Dr. Karen Adams:Gotcha. And just to cross our T's and dot our I's, during that period, it is possible to become pregnant. When you are having these periods in the perimenopausal period, you can get pregnant. Super important point. Thank you for bringing that up. Absolutely. And until they've gone an entire year without a period, they need to be thinking about contraception. Okay. So now you hinted at some of the symptoms, but I think it's worth discussing the symptoms because especially people who are listening, as you said, who are either experiencing this or love somebody who's experiencing this. What are the kinds of subtle changes that might be indications that this is a normal beginning of the perimenopausal period and then what should they do about it other than go to clueless physicians who might not realize what's happening.

8:47And I say that with a lot of love for

8:49Dr. Karen Adams:my fellow physicians. And we're working on that. We are really out there trying to educate clinicians and we can talk about that. And not always so subtle symptoms either. You know, That's the part that can be so distressing for women in their 40s, and again, on average in their 40s, because they're still having periods. They're kind of firing on all cylinders. They've got kids. Maybe they've got teenagers. Maybe their parents are aging. Maybe they're really coming into their own at work, and they're taking on more responsibility. And all of a sudden, they start feeling depressed or irritable, more commonly irritability or anxiousness.

9:32There's a thing called perimenopausal mood instability, PMI, that is more common than PMS, but nobody's ever heard of it. You know, I mean, we know about PMS, right? We all know about it. We talk about it. We know what it is. PMI, perimenopausal mood instability, is more common than PMS. But women don't know that that's what's going on. All of a sudden, they are so irritated with their kids or their boss. And they're just kind of watching themselves be anxious or having a really short fuse. And they don't know what's going on. They think they maybe need to get divorced or something. Yeah, yeah, yeah.

10:12And really, it's perimenopause.

10:15Dr. Karen Adams:Do these symptoms tend to co-vary with the period? Because that might give somebody a clue that this is related to the menstruation. because, oh, during the time that I'm bleeding, I'm also feeling irritable, or are these disconnected? Such an important point, because with PMS, at least you know the week before your period, you're gonna feel crummy. And you can predict that and you can prepare for it. Because the cycles and the hormone fluctuations are so erratic and profound in perimenopause, and you never know from day to day to day if your hormones are going to be up or down or whatever, your symptoms are completely unpredictable as well.

10:57And that's why it's so distressing because they get up in the morning and they have no idea how they're going to feel. Are they going to feel good or not good? Because there's no cyclicity to it.

11:09Dr. Karen Adams:So is it the case that we should be treating these women who are starting to have these symptoms? And what are the treatments? We should be. And I will say, I, you know, when people are going through this process, 100 % of people have cycle changes. Their periods begin to change. We know that will happen. 80 % of people get hot flushes and night sweats. About 70 % of people get this perimenopausal mood instability. About 50 to 60 % of people start having sleep disturbance, which is hugely bothersome for them because then they have brain fog, you know, during the day and, you know, are irritable and it makes the mood issues worse.

11:52And then about 50 % of women begin to get vaginal symptoms. So you can get vaginal dryness, you can get pain with sexual activity. So that's kind of the whole gamut. And then there's also joint pain. There's a thing called musculoskeletal syndrome of menopause. And about 50 % of women just start having aches and pains when they never have had that before. And then there can be a lot of a gamut of strange symptoms that are less common, like ringing in the ears or burning mouth or, you know, tingling in your fingers. So there's really a lot.

12:29Dr. Karen Adams:That's an amazing list of symptoms. And you can imagine somebody who's paying attention saying, oh, do I have cancer? Am I out of shape physically? Am I doing something wrong in my lifestyle? Am I eating the wrong foods? So I can imagine that being very disruptive. And as you said, this could be at a very challenging and exciting time in their lives. Exactly. So they've just got so much going on and they think they are losing their minds. You know, it's like, you know, I have gone through puberty and I had my kids and I kind of had it all dialed in. And what in the world is happening to me right now?

13:04So the good news is this is 100 % treatable. Nobody needs to suffer. and it's treatable with hormone therapy. And so we treat with hormone therapy, we see what gets better and what doesn't get better. So for example, joint pain, say I put someone on hormones and the joint pain improves, then I figure, you know, that probably was musculoskeletal syndrome of menopause. If the joint pain doesn't improve, then I need to think, okay, should this person go see a rheumatologist? Maybe they're dealing with arthritis or something else.

13:39Dr. Karen Adams:It's a really interesting point that you can't just blame everything on the menopause because there might be other underlying diseases and you don't want to miss those. Correct. But it's going to be hard to it's hard to know until you treat the present menopause. And then, as you said, you can triage which symptoms get better and which ones don't. So that's really fascinating. Now, let's just pause at hormone therapy because in my career, hormone therapy has had quite a roller coaster ride. and so and i'm sure that people who are who have paid attention are are aware that there were these trials that like you know 30 40 years ago we were putting all the women on um on hormone replacement therapy then there were studies that made things very confusing we were we were expecting some results and then got different results so could you take us through what the current understanding and whatever history you think is important but the current understanding of how we should use hormones and their safety.

14:32Okay. So I do want to emphasize that the treatment for perimenopause is different from the treatment for postmenopause. So those are two different things because in perimenopause, people need three things. They need cycle control because their periods are all over the place and their hormones are all over the place. They need contraception, to your point earlier, and they need symptom management. So we need to get the symptoms improved. We need to make sure they don't have an unwanted pregnancy, and we need to make sure that their periods are not just erratic and goofy. So that requires a certain amount of hormone that postmenopausal women do not need.

15:18In postmenopause, we use those traditional hormones that you were just talking about in the big trials, they are about a quarter of the strength of the lowest birth control pill. So they're a very, very small amount of hormone, and that's really all women need for bone protection, long-term heart health, symptom management, et cetera. And we can talk about that research. But in the perimenopause, before we move on and away from perimenopause, it's really important to know that to get those three things, you're not going to be giving or receiving traditional, what we used to call HRT, we now call it hormone therapy.

15:57You're going to be looking at either a birth control pill, maybe an IUD, or, you know, some other type of stronger hormonal therapy to treat you in that transition. But once you hit that final menstrual period, age 51 on average, then we're talking HRT. And I'll just use that term because that's what people are familiar with. And yes, HRT has had a long and storied history, right? And if your age and my age, we have kind of seen that. And back in the early, oh, you know, in the 90s and 2000s, a lot of people were on hormone therapy. And then the Women's Health Initiative data came out in the early 2000s, and it was an earthquake in menopause medicine.

16:46It really surprised us because we had a bunch of observational data up until that point saying that hormone therapy was really beneficial, particularly for women's cardiac risk. And that's what the Women's Health Initiative was designed to do. It was never designed to assess symptom management or quality of life or anything like that. It was designed to look at the impact of hormone therapy on chronic conditions, primarily heart health, you know, heart attack, stroke, things like that. They also looked at breast cancer risk, other types of cancers. So I get sad when people criticize it and say that it was a terrible study, it was flawed and all that.

17:33It wasn't a terrible study. It was not flawed. It did exactly what it was designed to do. And that was to tell us the long-term risk or benefits of being on hormones. And surprisingly enough, the people that were on hormones didn't behave exactly in the way that we thought they would. So the thing that's important to know about the study is that they enrolled women between the ages of 50 and 79 on hormones, people who had never been on hormones before. And we found that the women who were older, over age 65, really responded differently to the younger women. So that's really important data that we have now.

18:14And we can talk more about it. But, you know, what ultimately happened was that everybody went off their hormones because everybody got scared. And, you know, the headlines hit Good Morning America and the New York Times and hormones caused breast cancer, hormones caused stroke and heart attack. But what got lost in the messaging was that that was in those women over 65 who were really having the heart attacks and strokes. And if you start on hormone therapy under the age of 60 or within 10 years of the final menstrual period, those women actually got benefits. So the data is nuanced and we have to have that discussion with people so that they understand, you know, it's not it's not one size fits all medicine.

19:03Dr. Karen Adams:This is the Future of Everything. I'm Russ Altman. I'm speaking with Karen Adams. We've been discussing perimenopause, getting into menopause and some of the treatments. we ended our last part of our discussion with the women's health initiative. And it was a confusing time for many people because a treatment that was universal and was really seemed to be doing well, all of a sudden came into question. So to kind of put a bow a little bit on those issues, what do you tell women, both perimenopausal and postmenopausal about the risk and benefits of a hormone replacement or hormone therapy these days?

19:37Yes. I first talk about the benefits. I say, I can take your hot flushes away in about three weeks. You'll get a decent night's sleep. It's going to be very stabilizing for your mood. Your joint pain is going to get better. Over time, probably your brain fog will lift and your vagina will get happier because the vagina loves estrogen. So those are all the benefits. And that all sounds quite good, right?

20:02Dr. Karen Adams:That's quite a sales pitch. Right, well, yeah, if you want to call it a sales pitch, I'm just laying it out there. My words, not yours, not yours. I'm just laying it out there. And so all of those things, not only that, 15 years from now, you'll have better bones. You'll have fewer bone fractures, better bone density. We know that. Estrogen increases bone density by about 5 % to 6%. So, of course, we talk about strength training. We talk about other things that people need to do for healthy bones. But estrogen really is good for the bones. Also, if you're under 60 or less than 10 years out from your final menstrual period, you will get cardiac benefits as well.

20:45So we're all depositing calcium in the coronary arteries in our hearts. But that process slows down in younger women who take hormones.

20:54Dr. Karen Adams:And the calcium is bad, just to state the obvious. The calcium deposition in your coronary arteries is not good. Right. We don't want that. And so if you're under age 60 or within 10 years of your final period, you're going to get that benefit in the heart. In women over that time frame, it doesn't harm them, but they don't have any benefit over and above placebo. So it didn't seem to have that same benefit in the older women. So that's part of the reason why we think it's best to start in that window of opportunity under age 60 or within 10 years of the final period. So those are all good things.

21:31What are the downsides? The downsides are that in the Women's Health Initiative, we saw an increased risk of breast cancer in the women who were taking both estrogen and progesterone. And it was only about eight extra cases per 10 ,000 women per year, which is not much. It's greater with a sedentary lifestyle or if you drink one glass of wine a night, obesity increases the risk of breast cancer by ninefold. So there are many other things that increase the risk of breast cancer more than hormone therapy. We also think that that was an overestimate because that data came from synthetic hormone use.

22:14And we are now using bioidentical, meaning your body recognizes it. We think those hormones are much less inflammatory and much more breast neutral. So we don't worry too much about the breast cancer risk, but that's an individual discussion that we talk about with an individual patient.

22:35Dr. Karen Adams:Would a family history, if a woman has a mom or an aunt or a sister who has a history of breast cancer, does that come into the calculation? It does, but it's not a contraindication to being on hormones. Even if a woman has a BRCA gene, even if she's BRCA positive, she can still consider being on hormones. And that's a discussion. that we have. The only people who really should not take hormone therapy are people who have breast cancer themselves. And even that's a little nuanced because it depends on the type and how long it's been and all that. People who have had a heart attack or a stroke, or people who've had a blood clot in their leg or their lung or their brain, again, with some nuance there.