A Discussion About Menopause and Hormones

with Dr. Jason B. Wilson  and Dr. Brooke Kalanick

article by Meredith McKinnie

Menopause and hormones are often associated with the dreaded conversations women avoid as long as possible. Approaching menopause means getting older, and hormones are often the culprit of erratic behavior and dramatic mood swings. We talked to local OB-GYN Jason Wilson and Functional Medicine Specialist Brooke Kalanick about these topics. Wilson breaks down the facts about menopause and hormone replacement. Kalanick provides an in-depth understanding of our hormones and how they affect perimenopausal and menopausal symptoms. The conversations show, regardless of a woman’s stage in life, that educating ourselves about our bodies is essential to a healthy and productive life.

Dr. Jason B. Wilson

UNDERSTANDING MENOPAUSE

Menopause is a natural lifecycle that all women will experience with differing levels of severity. Menopause is the permanent cessation of menstruation for one year. However, symptoms including vasomotor instability (hot flashes, night sweats), vaginal symptoms (dryness, discharge, itching, painful intercourse) and menstrual irregularities may pre-date menopause by several years. The average age of menopause is 51. The median duration of symptoms is usually 3 to 5 years. Only about 1% of women will experience premature menopause or loss of ovarian function prior to age 40. With that being said, I believe women in their mid-40s should begin educating themselves on the common signs and symptoms of menopause and seek treatment if any become bothersome.

QUESTIONS ABOUT MENOPAUSE

I think that most women should seek guidance from whom they most feel comfortable speaking about such important health issues. With that being said, an OB/GYN is an excellent choice and resource for information about menopause. OB/GYNs have eight years of training including months of rotations in reproductive endocrinology. Most OB/GYNs have years of experience in their own practices diagnosing, treating and monitoring therapy.

MISCONCEPTIONS ABOUT HORMONES

Systemic hormone replacement therapy (oral estrogen, topical estrogen) is the most effective therapy for treatment of vasomotor symptoms. Multiple studies have shown their effectiveness and therefore they have received FDA approval. The only other FDA approved medication for hot flashes is paroxetine (Paxil), an SSRI used by many in the past for depression. Many other hormones including progesterone-only formulations, testosterone and bio identical hormones have been marketed for relief in the past but there is no evidence of benefit and they are not FDA approved. Research indicates that many other treatments including Phytoestrogens (soy products), herbal remedies, exercise, acupuncture, and reflexology have been used and studied in the past but have no proven benefit and are not FDA approved.

COMMON HORMONAL ISSUES

Hormone replacement therapy is a common transitional issue that most patients will have to deal with at some point in their lifetime. In my practice, I commonly see women who transition from a hormonal contraceptive to a post-menopausal hormonal regimen. With a multitude of hormone replacement therapy options, choosing the right mode of delivery and dose may require a few months to determine the best regimen. The important thing to remember is these are no longer lifelong medications as prescribed in the past. They are now given for the treatment of symptomatic patients for the initial years of menopause until the severity lessens and abates. Using the lowest dose that prevents symptoms will lessen side effects and risks. Each individual’s health risks must be kept in mind.

HORMONAL HEALTH AND SIGNS OF MENOPAUSE

When approaching menopause each woman will experience signs and symptoms of menopause differently. Some may experience vasomotor symptoms more severely than others; some may have only vaginal symptoms and may be better treated with the local topical therapy. Patient’s risk for breast cancer and cardiovascular risk must be considered when prescribing these medications. Women with a uterus will need progestins added to their regimen for protection against endometrial cancer. Therefore, each individual patient’s hormone replacement therapy regimen must be customized not only to their symptoms but also based on each’s own health conditions and risk for harmful effects. 

Dr. Brooke Kalanick

IMPORTANT FACTS ABOUT MENOPAUSE

When women think about menopause and perimenopause, they immediately think about estrogen and progesterone. They think, “I’m not going to be making as much of my own hormones,” and worry about hormone replacement and symptoms like hot flashes. But what’s really important for women to know is that from a diet and lifestyle perspective, a couple of things happen. When you lose estrogen, as it starts to wane during perimenopause and then after, you become more carbohydrate sensitive, maybe more insulin resistant, so sometimes we need to change the way we’re eating a little bit. 

Women often find the same diet doesn’t work or they don’t feel as good as they used to. The waning estrogen means we need to think about our nutrition differently, perhaps consuming more protein and less starchy carbs. When women’s hormones start to fluctuate, progesterone levels drop, and we become more stress sensitive. Progesterone is a nice tempering hormone that keeps estrogen and cortisol in check. That means the lifestyle choices become more important, like sleep patterns, eating patterns, emotional stress, blood sugar fluctuation, too intense or too little exercise. Many bigger conversations need to be had rather than the knee-jerk “Do I need to take hormones?” Women have a lot of control over lifestyle choices, so that’s good news. 

EDUCATING OURSELVES ABOUT PERIMENOPAUSE AND MENOPAUSE

Perimenopause can last for up to ten years for some women. Most women start to notice hormone shifts and declines by the ages of 35-40. Perimenopausal symptoms include changes in the length of your cycle, hot flashes, brain fog, weight gain, changes in where you hold weight, loss of muscle mass, and disrupted sleep. After 40, it’s not a five-year gap in symptom shifts; it starts becoming more noticeable every year. I call it the 40 Fix because we don’t want to wait until we’re in the throes of menopause to learn how to manage our stress, to learn why we’re not sleeping, to learn how to eat in a way that works for us. 

Late 30s is probably the time to make sure we’re thinking about hormone health and the big picture like stress levels and blood
sugar, to get a better understanding of how our hormones work.
Our hormones are talking to us all day. Women, especially, are really good at ignoring symptoms because we are often tending to work and families and think there will be more time for me later. It’s not that we have to be planning for a bad menopause, but the healthier our hormones are and the healthier our adrenals are by the time we get to menopause, the better we’re going to do. 

MISCONCEPTIONS ABOUT HORMONES

One misconception is that there is nothing to talk about besides estrogen and progesterone. When women hear the word menopause, they immediately think of those two female hormones and they forget how important the other hormones are. For example, thyroid can take a real dive during perimenopause, so it’s really important to get a thorough evaluation during that time. Women used to fear hormones, so many question whether bioidentical hormones are safe. Many women question whether to take hormones. There’s a big art to this. And there are many things you can do to ensure that if you do decide that you are a good candidate for bioidentical hormones, there are a lot of things you can do to make sure you are being safe. 

Working with a Functional Medicine practitioner, like myself, can help you understand how you are metabolizing a hormone and what other things are getting in the way. Inflammation is a really huge one that will impact how a hormone works, as will stress. Many times, women are told the only answer to lessening effects of taking hormones is to up the dose, when in reality if we cleaned up nutrition, lifestyle, and stress, we could have continued to do better on that lower dose. It’s so much more nuanced than just taking a hormone replacement. 

ADJUNCTIVE CARE WITH OBGYNS

OBGYNs generally have limited tools including whether to prescribe hormones or not.  A functional medicine doctor will ask how you’re eating, how you’re sleeping, how’s your digestion, are you having any joint pain or headaches or other  signs of inflammation? Where do we need to look to get your whole system healthier? Testing hormones can be dicey because they’re all over the place. Tests one week apart can look totally different. 

If you want something in addition to the option provided by your OBGYN or if you want a more holistic approach, you should seek out a functional medicine doctor. You may want to know how to optimize your health or your response to any other prescribed treatments, or you may want an alternative to those options. Adjunctive care is important because a team approach is usually the way to go. During perimenopause, herbs do work great and can be an option for some women. And many women want to try that before they try hormones or in addition to them.

UNDERSTANDING OUR HORMONES

Hormones are a big web. Knowing other hormones are in the mix along with estrogen and progesterone is imperative. When one hormone goes low, it impacts another one. As a result, women start to hate their hormones, and especially going through perimenopause because symptoms are so extreme. They feel like they’re bodies are betraying them. 

UNDERSTANDING OUR HORMONES

Your hormones are trying their best to keep you going in your crazy lifestyle. If you can learn how to eat and exercise in a way that supports your hormones, and figure out stress management and causes of inflammation, you’ll be much happier and healthier. And you can use your symptoms as a guide to what will work best for you.. Diets for menopause are easily googled, but no one diet or plan works for everyone. It is important to understand how your hormones are responding to what you’re doing so you can adjust and not just follow some rote plan. 

Some telltale signs of metabolic hormone (blood sugar and stress) imbalance are appetite cravings, lack of energy, and lack of sleep. Those symptoms are specific to insulin and cortisol. Other symptoms can signal issues with estrogen and progesterone such as changes in your cycle and hot flashes. 

You need to understand the signals and what they mean, and learn in real time what you can do to effect some change in that hormone. Most of us would much rather have a plan handed to us, but it rarely works that way. When estrogen and progesterone are on the decline, it makes other hormones super sensitive, so that’s where what you eat, how often you eat, how you’re exercising, etc. becomes much more important. It can be annoying to have to do detective work, but it is also really freeing to know what works for you and cultivate a plan that’s better for you.

THE IMPORTANCE OF STRENGTH TRAINING

Strength training becomes more important for overall bone and metabolic health. Women are not always in love with strength training, though I believe that’s starting to change. When we go through perimenopausal changes and we start to lose that hourglass, feminine shape, we begin to see more weight in the middle. We experience changes in insulin sensitivity and cortisol sensitivity. Perhaps we begin not tolerating carbs from lack of estrogen and/or tolerating stress worse from lack of progesterone. Strength training is a great way to keep insulin and cortisol more in check, especially insulin. Muscle is your reserve of insulin sensitivity. It’s where you want all the food you eat to go, feeding muscles instead of storing more body fat.  

As far as metabolism, one of the best things a woman can do is to put as much muscle on as possible. You’re not going to put on a ton of muscle during perimenopause. You’re actually going to struggle to put on muscle because your testosterone is also going down. Muscle is a really important tissue for longevity. Your bones and metabolism need it and it’s important for anti-aging.

IMPORTANCE OF DAILY MANTRAS

Mantras are one tool for stress management. Sometimes we need to take stuff off our plate, leave a relationship, leave a job, hire help, or let some things go. We encourage meditating, even if only for a couple of minutes a day to tap into the more relaxing side of your nervous system. Mantras are good ways to change a pattern of thinking, to set the stage for your day. “Thank you” is a good gratitude mantra. Another is “Everything is going to be okay.” Just say the opposite of what you don’t want to be feeling to disrupt a negative thought pattern.

THE IMPORTANCE OF FOOD TO HORMONAL BALANCE AND MENTAL HEALTH

I can’t stress this enough. Food is often overlooked in the menopause conversation. Two of your biggest metabolic drivers are insulin and cortisol, and they’re going to be profoundly impacted by how well your blood sugar is regulated and how much inflammation and stress you have. A woman with low cortisol is not going to do well with fasting or keto for example, whereas a woman with just insulin issues may do great with it. As well, many women don’t get enough protein which supports metabolic health and muscle mass. Women also need a lot of vegetables to balance blood sugar and keep their gut healthy, a key part of hormone metabolism.  

Don’t forget about those big metabolic movers, the insulin and the cortisol. When it comes to estrogen, not only is it waning during menopause, your estrogen metabolism becomes more pronounced in terms of symptoms. A lot of women will notice going through perimenopause that their boobs are tender, their cycle gets heavy or shorter, and they’re breaking out or having weight gain. 

Food can also be a source of inflammation which disrupts hormones. Some foods like grain, dairy, sugar, and processed food may be causing inflammation. Are you noticing digestive upsets, skin issues, headaches, joint pain, or water retention? Food is a huge foundation, and isn’t talked about enough relating to women’s hormones, it’s about so much more than weight loss.