we're going to talk about menopause so menopause is something that every female is going to go through and it's a significant transition where women will have a noticeable change in their health their mood and potentially their overall quality of life when does this start so typically the average age is about 51 and per menopause is the time around menopause which is around about four years before so typically that four to 10 window around menopause is par menopause and then prior to that is what's called premenopause and after that is called postmenopause so how do you know you've gone through menopause so menopause is essentially 12 months after you've stopped having menes or having a period but there's sort of a whole host of symptoms that occur prior to then around perimenopause and so the early stage of perimenopause occurs when your periods are delayed for more than 7 days than they used to be so there's some irregularity and then late early per menopause is when the delay is more than 30 days but the interesting thing to know is that vasomotor symptoms or what we commonly call hot flashes start even before you go through menopause so you can see them and they will continue for up to a decade for some people there's a whole host of other symptoms that women can experience during menopause and this can include those vasom motor symptoms we talked about like hot flashes or night sweats you can see genital urinary symptoms like irritation dryness or pain with sex sleep disturbances and even mood disturbances and I think even as equally important you may see change in your bone loss as well as in your lipid profile and so when you think about the symptoms of menopause they occur because estrogen receptors are all over the body including the brain so sometimes people can have inability to concentrate poor memory they can have mood swings they may notice some changes in their skin because receptors on the skin causing decreased collagen and you know even crepey skin you can see joint pain or even frozen shoulder you can see changes of course as we mentioned in the vagina but also urinary symptoms so more urgency got to go got to go maybe even having leakage or recurrent urinary tract infections so when you think about what happens is you go from having a relatively normal amount of estrogen to going very low in terms of estrogen levels so in the beginning phases you will have some short-term symptoms and this will include the hot flashes the Sleep disturbances and the mood issues which typically tend to get better with time however those urogenital symptoms like having vaginal dryness or urinary incontinence or overactive bladder those tend to last and may even progress with time the other big change that happens is your bones get weaker so you get osteoporosis and that is again another long-term consequence of having estrogen loss so let's talk about hot flashes hot flashes will occur in up to 80% of women and it's basically a sudden sensation of heat that you feel maybe on the upper chest or the face that rapidly becomes giz me you feel it all over it typically lasts for about 2 to 4 minutes you can sometimes have palpitations with it or anxiety and sometimes you may not even have the heat sensation but you may just notice that you're feeling very irritable but it goes away and this occurs periodically you know repeatedly over the course of the day you'll also see that because of these hot flashes you may see problems with sleep with concentration with mood with energy and sexual activity now other symptoms that sort of alluded to already but brain fog and change of memory is very often seen the genitor urinary syndrome of menopause which includes things like vaginal dryness discomfort with sex urinary urgency urinary frequency urinary incontinence and recurrent urinary tract infections are all symptoms of the genitor urinary syndrome of menopause now as I mentioned there are long-term consequences including bone loss cardiovascular changes skin changes and even balance has been seen as a a concern with these hormonal changes when should you get treated for menopausal symptoms so typically very strictly it is indicated for vasom motor symptoms like hot flashes and for the prevention of osteoporosis but I would argue that if you're having other symptoms like sleep disturbances mood disturbances joint problems or you're having concerns about the risks of cardiovascular disease dementia diabetes or obesity that are correlated with having low levels of estrogen that's an indicator to at least discuss it with your doctor now when should you avoid treatment with traditional hormones so if you have a history of breast cancer and again this is relative and we'll discuss this a little more in detail if you have congestive heart failure if you have previous Strokes or or blood clots this is typically for oral treatment options if you have active liver disease unexplained vaginal bleeding or high-risk endometrial carcinoma then doing any sort of hormonal option is not recommended now you may have heard of a lot of sort of things that people tout on the internet of being effective but based on randomized control trials and very rigorously clinical data many of these things have been deemed not effective so things like acupuncture evening primrose oil flax seed exercise unfortunately you can't exercise your way out of menopause Jin sing danai wild lamb progesterone creams which are ubiquitously prescribed or given to women they actually don't are not effective Chinese herbs reflexology or magnetic devices are not going to fix the hormonal abnormalities that are associated with menopause and this is is a list and this is just to show you the wide variety of options that we have available to you for menopausal hormonal replacement therapy and this is really just to show you that we can find something that works for you as an individual if you're suffering from menopause there's a whole host of options and you don't have to settle for just one standard treatment option particularly if you're having side effects or you're not feeling good on that particular option so let's go over in terms of estrogen what are the options estrogen is predominantly the main hormone that is causing a lot of the consequences associated with these hot flashes with the symptoms of brain fog of muscular skeletal joint conditions and a whole host of things so there's transdermal options which are gels and sprays and these are essentially nice and often used because they have a lower risk of blood clot or stroke in fact probably unlikely to get one so if you've had a history of these things transdermal options are usually a good option for you now absorption of any transdermal product is variable so some people will need more and some people will need less and some people may not absorb it as well as others in which case you may consider other options so another option is oral and oral is not a bad option although there are some other risks with it so the advantages are you see an improvement in some of your lipid parameters so it actually improves your HDL which is the good cholesterol and decreases your LDL however it can affect your cortisol um your sex hormone binding globulin which can affect your levels of testosterone and maybe affect libido although we haven't seen that and it may cause uh problems with your thyroid binding globulin uh if you're already having thyroid issues it may not be the best option for you there are some contraindications generally speaking with oral so if you have high triglycerides if you have gallbladder disease if you have a known clotting disorder like Factor 5 Li in or a personal history of Venus thrombo embolisms now there are Depot injections which you which are available they're not used quite as often and there's also vaginal Rings which are systemic dosing or high dosing so they're placed in the vagina about every 3 months and they release slow release estrogen over the course of those months and so the advantages are that you don't have to think about it too often and there however the disadvantage that is something that is placed in the vagina now the one thing I I want you to realize Is bioidentical means that estrogen is plant-based meaning that it's not made synthetically it does not mean that it has to be compounded which is what a lot of people tend to Market as we offer bioidentical hormones meaning they're compounded from a pharmacy now compounding Is Not a Bad Thing inherently but ideally we recommend using FDA approved estra dials or 17 beta estrel which is available at your regular Pharmacy via prescription and is also bioidentical now side effects most commonly are things like breast tenderness and often times that first 6 months while you're figuring out your dosing you may see some vaginal bleeding and that's okay and not unexpected if it persists after 6 months then we need to evaluate further in terms of risks and benefits of menopausal hormonal therapy I wanted to touch on this because I think a lot of people have heard a lot of misinformation and the Women's Health Initiative was sort of this large study that sort of changed the way people prescribed estrogen progesterone for women during menopause and this was because they found some risks now the important thing to realize is that this study looked at types of medications the types of estrogen progesterone that we don't really used it used something called conjugate acine estrogen which is from a horse and also a synthetic progesterone called MPA also it was not used on people who were necessarily symptomatic and needed therapy it was just used on a whole host of women who tended to be a little bit older and have a whole host of other sort of comorbidities but what they found was that when you had estrogen and progestin together they saw a higher risk of cornic artery disease so about 2.5 cases out of a thousand they saw three additional breast cancer cases out of a thousand about 2 and 1 half additional Strokes out of a thousand and three additional blood clots in the lung out of a th000 but they saw a lot of benefits and that was fewer choral cancer cases fewer endometrial cancers fewer hip fractures and most importantly a reduction in all cause mortality and when they look at estrogen alone they actually saw no risk of increase in breast cancer they saw an improvement in cardiovascular heart disease they saw an improvement in invasive breast cancer and stroke and coloral cancer and all cause mortality and so the question then is is it the progesterone that's causing it well we don't really use MPA anymore and so is this still relevant if you have a uterus then in order to protect your uterus from developing endometrial carcinoma you need to use progesterone with the estrogen to prevent the uterine lining from building up and then putting you at risk for developing a cancer if you don't have a uterus then estrogen alone is just fine you don't need a progesterone however there are benefits some people derive benefits with sleep as well as um mood with the progesterone as well so what are the options for progesterone so the one that's most favored is micronized progesterone it's a very small dose it's bioidentical and it does not appear to increase the risk of breast cancer or cardiovascular disase like MPA however some people do have difficulties tolerating progesterones because they get some bloating and they get sort of tearful or mood changes and so that is sort of the disadvantage any progesterone option and you could take it daily or if you are on perimenopausal and still bleeding you can take it about 12 to 14 days a month around the time you're having your period so the bleeding will coincide there's also the mpa which is well studied however it does have these increased risks that I showed you and does tend to have an unfavorable effect on your lipids also if you have an IUD that will work also to specifically a Le Leone or gestolen containing IUD will also help with preventing this risk of uterine lining buildup the good part about this is it has lower systemic concentrations it mostly C it mostly focuses effect on the uterus so if you're having difficulty with side effects related to Progesterone then um this may be a good option for you disadvantage are is this minor procedure to get an IUD placed there are some alternative options as well so there's du of V is the brand name it's called Bas basado Dophin and conjugated estrogen and this avoid voids progesterone but still allows you to get the benefits of preventing uterine lining buildup and so it is an option it does use conjugated estrogen which is not bad but it's certainly not considered bioidentical um it's good for people who develop sort of breast tenderness with estrogen um or have difficulty tolerating progesterone there's also combination therapy so if you don't want to take two separate things you can get estrogen and progesterone combined in either oral or transdermal preparations it can also use to transdermal testosterone now its benefit is primarily noted in the libido area but there's also some benefits for bone health and other issues other things so maybe something to consider if you are struggling with sexual dysfunction there's also tibolone which I won't spend too much time on because it's not available in the United States it is available in Europe essentially it's a synthetic steroid where there the metabolites of it have both estrogen androgenic and progesterone genic properties there's also options that if you don't want to take any hormones at all or you can't take hormones and that can be using ssris or snris which are essentially anti-depressants the most studied one is venlafaxine in or in terms of improving hot flashes there's another medication called fol lant also brand name is vioa and that works on the brain receptors that cause hot flashes and so that can be helpful gabop pentin can also be used and then there are some promising Therapies which are not fully proven in evidence but may have some benefit including cognitive behavioral therapy hypnosis and other mindbody therapies like mindfulness and something called a stellate gangling block which you need to be referred to a specialist for which can sometimes help as well