The perimenopause moment

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1:33So my name is Amy Sibyl. I live in Oregon. One day, Amy looked in the mirror and noticed something was different. I started getting curly hair. I had always had long, straight hair. I know. But then some very not fun things started happening. Night sweats were the most disruptive and horrible. cramps, heavy bleeding, like, oh my gosh, what is wrong with me? And then also emotional impacts, like I was clearly feeling more anxiety and dread, none of which were fun at all.

2:05Jonquilyn Hill:She had her suspicions, but she was 41, on the young side for menopause. Besides, she was still getting her period. But the symptoms kept coming. Acid reflux, really bad. and went through a whole year of like endoscopy and changing diet and not eating after 5 p.m. No red wine, no chocolate, sleeping on a slanted bed. And that was happening kind of on this side path at the same time that I was speaking with my physician. And she eventually, after about a year, put me on oral birth control. Within days, my acid reflux went away, just gone. Turns out, Amy had begun the change before the change, a nebulous period that doctors now call paramenopause.

2:57Jonquilyn Hill:It can last for years, it impacts a ton of people, and it has a wide range of symptoms. I had random, what I thought was random panic attacks. It was like being run over by a truck. Brain fog, frozen shoulder, debilitating exhaustion. kind of feeling like I was getting the flu every month, really, around my cycle. And yet, when it comes to women's health, there's a ton that modern medicine just hasn't figured out yet. Why is that? I'm John Gwynn Hill, and this week on Explain It To Me from Vox, we're going to talk about it.

3:44Jonquilyn Hill:Okay, to start, we gotta define some terms. Menopause is technically when it's been one year where a woman hasn't had periods, and perimenopause is all the time leading up to that, which can be a decade for many women. Heather Hirsch is an internist that specializes in treating women in midlife. I think it is the biggest transition a woman will go through. And we think about puberty, and this is actually puberty in reverse. the biggest physiologic change is happening which is that our sex hormones are declining and so we know that there is a lot of changes in the brain at this time the brain is changing in terms of both the sex hormones and then also the neurotransmitters and so that can change your mood it can change your ability to process at fast speeds to remember multiple things these are things that definitely frighten women when they cannot remember their neighbor's first name but it's common because all of these changes in the brain we know the skin's changing the heart and the bone so we know a lot of the physiology i.e the anatomy and things and in what's changing and how that's experienced clinically what women will say and feel you know there is a lot of things that happen to women that seem totally unrelated so for example you could get the worst headache of your life, all of a sudden in your 40s.

5:08This is a migraine, and it's sometimes triggered by the rapid loss of estrogen, palpitation. So all of a sudden you feel like your heart's skipping a beat. This is really anxiety provoking. The first time you feel your heart, you almost wish you never knew you felt it. Women will talk about a new onset of ratches, itchy ears, dry skin. You may end up in the dermatologist's office, right? Joint aches and pains? Here's a funny one. If you notice before your period, like your hips are really stiff or maybe even your fingers or your knees, and then it seems to get better once you get your period and in the first part of your cycle, perimenopause.

5:54Jonquilyn Hill:Okay. A lot of these things though could be other things. How do you know if it's perimenopause versus any other thing that makes your body do these things? There's two things you can think about. The first is it's really helpful to track them. If it's perimenopause specifically, and we're talking about perimenopause, which is when women are experiencing symptoms, but they're still menstruating or they're still ovulating, they might have a cyclic pattern. So if you notice hot flashes or night sweats or mood symptoms that seem to go on a cyclic pattern, this is one very strong indication that it could be hormonal because your hormones do have this cyclic pattern of about every four to five weeks.

6:36Although again, that will change as you get into perimenopause. The other thing is that sometimes you know it's perimenopause when we actually start menopausal hormone therapy. Because if we are to start menopausal hormone therapy in sort of a diagnostic way, sometimes that really helps women say, oh, wow, it was hormonal. So let me give you the example of palpitations or the joint aches and pains. If we start menopausal hormone therapy and my patients say, wow, Dr. Hirsch, they're gone. That's also how we know it is hormonal.

7:10Jonquilyn Hill:I think for a lot of people, this can be really isolating because, you know, you feel like something's off, you feel like maybe something's wrong, but you can't get a clear answer. Why is that? You know, I think it has so much to do with still the taboo and the shame on the topic, whether it's, you know, aging or it's just changing how culturally you're perceived. You're no longer someone who can reproduce. You're no longer getting your periods. Maybe you're no longer youthful and your body is changing so much. So for many women, when they start to experience these symptoms, they start to feel socially isolated because maybe you are exhausted.

7:53You get home from work. It took all of your energy to get through work. Now you just want to take your clothes off. Maybe you've gained weight. You want to sit on the couch. You want to go to bed and you just want to veg out. I talk with women all the time. They still say often in their friend groups or among their siblings, it's still not a topic that's easily talked about. Now, these are changing, but still slowly. We feel like we've made such a big change. And a lot of that I do believe has to do with social media. But there's a difference between talking to avoid and actually talking to one of your best friends or your partners.

8:27It can feel more vulnerable when it's someone that's very, very close to you.

8:33There is still this idea that we have to suffer through this. There's this idea that that's what our grandmothers did and our great grandmothers. And so we should just suffer through it. And I am here to say to anyone listening, that suffering not only is unnecessary, there's no metal at the end, but it will derail your health. And so what's been exciting in the last couple years is there's more and more and more acceptance of how to treat symptoms through perimenopause, that they're safe, they're effective, and they can be life-changing for the vast majority of women who start them.

9:15Jonquilyn Hill:Up next, we get into that life-changing treatment. And we bust some myths about it, too.

9:26Thank you.

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11:40Jonquilyn Hill:I'm JQ, back with more Explained It to Me. And we're talking with Dr. Heather Hirsch about the pause before the pause, perimenopause. So, Heather, to deal with their symptoms, a lot of people turn to hormone therapy. How does it work? Well, you know, essentially what you're doing is you are replacing what you're missing. So there's lots of examples of where we do this. Diabetics, specifically even type 1 diabetics, They don't have insulin, a hormone that helps them take, you know, carbohydrates, glucose, and utilize it well. And so we're kind of doing the same thing with menopause, perimenopause.

12:19Because your hormones are starting to low, get lower and drop, we're replacing them. Now we're replacing them in actually very low, low doses. And it can be extremely helpful for the places that the body is missing it. We've already talked about the brain, the heart, the bones, the pelvic floor, the skin. it can make a huge difference when we replace them.

12:41Jonquilyn Hill:I'd love a breakdown. Which hormones are we talking about and what are doctors looking for? There's sort of three big ones if we think about the trifecta. And I always explain this as sort of an ice cream cone analogy. When we think about estrogen, this is kind of if you're craving a sundae, let's say, okay? It's a hot summer day. This is like the ice cream. This is the main ingredient. This is what you want to go down to the ice cream shop for. Estrogen, when it drops, can make us feel hot and dry. So that can be the hot flashes, the night sweats, the dry skin. It can make us feel like we have low mood or anhedonia or depression because estrogen actually keeps serotonin in the brain longer.

13:27It's a natural antidepressant. Oh, okay. And it also plays a role in keeping our heart and our bones healthy. So estrogen is kind of like the main ingredient. Now, progesterone is like the ice cream cone. It keeps the estrogen safe, or really, it's also protecting a woman if she has her uterus still. Progesterone in the brain converts to allopregnenolone, which binds to GABA receptors, and it makes you feel calm and sleepy. So many women, if they've ever had a pregnancy, will remember in their first trimester, they can feel really tired. That is the effects of progesterone. It's really, really increasing in that first trimester.

14:08And then I think about testosterone as sort of the toppings of your sundae. So maybe a little sprinkles, maybe a little cherry on top. Kind of really cinches things together. Not necessary. You could absolutely have an ice cream sundae. You don't need any toppings, right? The ice cream is good enough. But some women like to have toppings. Testosterone helps with libido for sure. And it can also help with reducing brain fog. It sometimes can help with reducing joint aches and pains and helping mood. More research needs to be done on testosterone. The vast majority of research in terms of these three hormones is actually on estrogen, then progesterone, and then testosterone, which actually isn't technically FDA approved for women.

14:56Jonquilyn Hill:I would love to know more about hormone panels. I feel like I've seen more and more people bring that up online. What does it take to get a full hormone panel? Flat out say, I want a blood test. I want a full panel. Ask specifically for a full hormone panel. We are becoming data junkies. We love our Wook. We love our Apple Watch. We love our Oura Ring. And all of those are okay. They just need to be taken in context. The most important thing for women to do is really that journaling and tracking. If you can track what symptoms you're having in correlation with either when you're bleeding or maybe when you're ovulating, this is the most helpful thing because perimenopause, believe it or not, is a clinical diagnosis.

15:44And all that means is the clinician decides, which can be frustrating, right? So women are trying to sort of get support and they're looking for a diagnosis. But if their clinician doesn't know what to do, they're thinking maybe lab work will help me. But there is no lab that tells you you are in or not in perimenopause. It's all about how you're feeling over, you know, a period of time.

16:07Jonquilyn Hill:Why are we so, I don't know, prickly when we hear the word hormones? Because I've seen it when people talk about perimenopause and menopause and hormone replacement therapy. I've seen it with discussions online about birth control, just like no hormones, hormones bad. Why do we have this kind of contentious relationship with hormones? I think the word itself is very broad, right? When I hear the word hormones, I think of like, and this is sort of silly and personal, so this probably applies to no one else, but I think of like agriculture where they're injecting hormones into animals, right? They're doing it unethically and they're kind of disrupting our food supply or so they tell us.

16:50And so when we think about the word hormones, it sort of has a negative connotation to it. It just does. And I think that's part of the patriarchal and sexist society that we live in. Not that we need to go deep onto that. But again, the idea that the word hormone has become negative or has become tainted or is something bad is something that should make us sort of think like, why do I even think that, right? Interestingly, for perimenopause, we're actually very often using plant-based estrogen or plant-based progesterone in very, very, very low doses. And so when we think about it as estradiol or transhermal estradiol or prometrium or progesterone that mimics our natural progesterone, it feels different, right?

17:36A little bit than just the word hormones in general. Hormones has this idea that we're like, you know, artificially injecting things into our bodies. but we make a lot of hormones every single day. And so, you know, I think that may be why. I think it's just that our perception, the media has shaped what this word means to us.

18:01Jonquilyn Hill:And it's not just perception that shifted. Even the way we study women's health has changed. That's coming up.

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20:54The estrogen patch made the world of difference. I wish I would have had that two years ago. So why are primary care providers not being trained on that of a 40-year-old woman's body? Thanks. Bye.

21:12Jonquilyn Hill:This is Explained It to Me. I'm J. Q. Modern medicine has made so many strides when it comes to health care. Things that felt inevitably unpleasant don't have to be. But why does it sometimes feel like doctors are still playing catch up on some pretty basic aspects of women's health. Because it's true. It takes a long time for medical science to catch up with the glaring gaps in our health care system. And the gaps are not just about the obvious women's health issues. That's Elizabeth Komen. She's an oncologist and a professor at NYU. And she focuses on the gap between women and modern medicine.

21:51We focus a lot on breast cancer. We focus a lot on reproductive function or our gynecological needs. But really, the gaps also exist head to toe from our neurologic care, our gastroenterology care, how our hearts function, how our immune system functions, how our joint functions. And so the gaps are real and the experiences are real.

22:10Jonquilyn Hill:Can you walk me through some of the history? Like, what did it look like to study women's health before the 20th century? What were we dealing with? For much of history of medicine, at least in the Western world, the idea was that at best, we were small men. And at worst, there were many ridiculous diagnoses like hysteria and a long legacy of dismissing women's medical needs because we were largely not taken care of by women. And those women that were caregivers in the history of medicine, whether it was the midwives or other types of healers, were largely pushed out of medicine as it became codified.

22:49And the idea of medical science really came to rise in the late 19th century.

22:54Jonquilyn Hill:So I'm guessing they weren't really talking about menopause at the time, let alone perimenopause? Perimenopause wasn't anything that was even discussed.