Transcript

[00:00:00] Susan Russell, MD: Let's get stronger.

[00:00:03] Khalilah Gates, MD: Healthier.

[00:00:03] Michelle Prickett, MD: Calmer.

[00:00:04] Susan Russell, MD: Smarter.

[00:00:05] Khalilah Gates, MD: Better. 

[00:00:06] Susan Russell, MD: Living a healthier life is a journey, not a destination. 

[00:00:09] Khalilah Gates, MD: You can always get better. 

[00:00:11] Michelle Prickett, MD: Let's get better together. So today we're talking about menopause. I think this is a topic nobody really understands. I can tell you: I went through medical school, we've trained together. I still don't know the whole process. It's somewhat of a mystery to me, and I think it's one of those things people talk around and about, but really never hit the nitty gritty. So I'm hoping we can get some details, understand it, understand what we're looking forward to in, uh, a couple of years, uh, and, and go at it with grace, right? I think aging is a great process, but the more we know, the better we are.

[00:00:55] Susan Russell, MD: Yeah, I think just in the last generation, there's been a lot more openness discussing menarche, which is when you have your first period. But that hasn't really translated to the other end of the spectrum. So, I'm looking forward to discussing this to be informed for myself, because I don't know, I don't know what to expect. 

[00:01:16] Khalilah Gates, MD: Yeah. It's known, but unknown. When is it going to happen? What is, what's going to happen? Do I need to get tests for it? We all know that it's coming, and we're waiting for it, but that's all we can do is wait. And the biggest thing for me is the symptoms. Are there things that we can do? What are the therapies out there now? We've heard a lot about hormonal therapies and breast cancer risk. And so we all are like, ‘ugh, we just got to deal with it.’ Is that true? 

[00:01:50] Susan Russell, MD: You may know it as the stop of your monthly period, but menopause involves more than just the end of menstruation. While some people experience no symptoms, others may experience hot flashes, vaginal dryness, insomnia, mood swings, brain fog and weight gain. People today can expect to live almost 40% of their lives after menopause. So how can we live better during and after menopause? Today, we're talking to Northwestern Medicine Gynecologist Dr. Traci Kurtzer. Dr. Kurtzer has had more than 25 years of clinical experience in menopause and sexual medicine. She is also the medical director of Trauma-Informed Care and Education in the Department of Obstetrics and Gynecology at Northwestern University's Feinberg School of Medicine. And, she currently sees patients at the Northwestern Medicine Center for Sexual Medicine and Menopause, and was awarded the Menopause Practitioner of the Year Award in 2019 by the Menopause Society. Welcome.

[00:02:42] Traci Kurtzer, MD: Thank you so much. It's wonderful to be here.

[00:02:44] Susan Russell, MD: First of all, let's just get the definition out there. What is menopause? And why does this happen ?

[00:02:51] Traci Kurtzer, MD: Right. So you actually did hit upon what the actual definition of menopause is, which is the end of our menstrual periods for those of us who have ovaries and live long enough. And basically it's due to the limited number of eggs or oocytes that we're born with. And at some point, they run out or they are not as effective at releasing. And, basically that then affects production and the levels of our two primary hormones that regulate our menstrual cycles: estrogen and progesterone. So those levels start declining, and that's also what creates a lot of the symptoms that accompany menopause. If we have our ovaries surgically removed or in some cases, due to chemical interference, our ovaries may not be functioning normally. Average age is around 51, but kind of the range can be anywhere from 45 to 55 for the majority of women and then some you know, earlier 40-year-olds, plus up to even 60. Actually, my oldest patient was 62 who went through menopause. So there's quite a range of ages that it happens to us.

[00:03:57] Susan Russell, MD: Ah, so much to look forward to.

[00:03:59] Michelle Prickett, MD: We think of puberty as kind of a timeline, and it starts at kind of a lower end and can evolve over the course of years. What can you tell us about menopause and the menopause timeline?

[00:04:09] Traci Kurtzer, MD: Yeah, so it's a longer process than I think a lot of people realize. I think there's misconceptions about it just being a couple years of changes and then you're done, right? You have those hot flashes and then you're done, but we know that some of the hormonal fluctuations that can lead to symptoms, some of them subtle to start with, really happen before that cessation of the period. So the menopause transition is really those years leading up to where we're starting to have those changes in symptoms up to and including the 12 months from our last menstrual period. There's kind of an early menopause transition, late menopause transition and then we're postmenopausal. So once we've had that full year without a period or our ovaries are removed surgically, we're considered postmenopausal at that point. Symptoms really interestingly on average for American women last around seven years total, but there's some racial and ethnic differences there. So we know that Black and Latina women tend to have longer duration of symptoms, up to 10 years at times. And we definitely have handfuls of patients that have symptoms, you know, decades later.

[00:05:20] Susan Russell, MD: Wow. You mentioned hot flashes, which I think is the thing that people, when they think of menopause, commonly associate it as being the symptom, but I find it surprising the broad range of symptoms that can be included. Can you talk a little bit about what common symptoms you see when you talk to patients who have menopause or perimenopause?

[00:05:39] Traci Kurtzer, MD: Yeah, vasomotor symptoms are an experience of hot flashes, which is feeling warm, usually in the upper half of the body. They usually last for just a few minutes. They can be associated with some flushing or turning kind of red in the face or chest area, breaking out in a sweat. And then night sweats are basically hot flashes that happen at night associated with pretty significant sweats. And they can be, just kind of waking up and feeling like you're a little damp to full blown sweats where your nightgown and bedding is like soaked through and you have to change your nightgown. So we know that those vasomotor symptoms are going to affect about 80% of us going through this. So that is a really common symptom and it's a very recognizable symptom for most, and I think that's why you hear a lot more about it. But some of the more subtle symptoms that actually start even before we start having vasomotor symptoms would be sleep disturbances where we're not getting really into those deeper restorative sleep zones. So even if you're not necessarily having disrupted sleep, you may be waking up feeling really fatigued and low energy. Cognitive changes, so things like short-term memory; word retrieval; what we call executive functioning, which is, how good are we at multitasking things that we used to be able to do, are often reported. Weight gain is definitely reported. I think I hear weight gain, sleep disturbances, actually more frequently than vasomotor symptoms as complaints in our clinic. Moodiness and either depression or feeling anxious or panicky are also fairly commonly reported. And then some other physical things like feeling joint aches or pain, some of the skin changes, loss of hair, hair shedding, sexual dysfunction issues can start creeping in too.

[00:07:24] Michelle Prickett, MD: That is certainly a lot of symptoms that we found and more than I think I really expected. To build on that: what are the treatment options? 

[00:07:31] Traci Kurtzer, MD: This part of menopause and transition is so individualized. Our standard of care treatment, kind of the gold standard, is still hormone therapy. Most of the major menopause organizations in the United States and across the world still feel like that should be the primary treatment offered for patients who are dealing with vasomotor symptoms. But, you know, that's not appropriate for every person. There's medical reasons that people should not be using hormones, and then there's sometimes personal reasons that people choose not to use hormones. So it's nice that we have some other options. But the benefits, I would say, of hormones are they are covering the majority of the symptoms, and they also can help with some of the sexual dysfunction issues that come up as well. One of the physical changes that happens to our bodies after menopause is we start having less bone-building activities, and so our bone density starts to decline naturally, and hormone therapy is the one treatment that also kind of prevents some of that progression. So certainly indicated in women who've been diagnosed with osteopenia, or low bone mass, when they're in that menopause transition period. Hormones still, I would encourage people to kind of think of, primarily, am I a good candidate for that? Talk about it with your doctor, see what benefits you'll get, review some of the risks and see if that's a good choice.

[00:08:52] Michelle Prickett, MD: I just wanted to clarify, when you talk about hormone use, are you talking about pills or patches? 

[00:08:56] Traci Kurtzer, MD: Yeah, and that's a really excellent question because I think there is a lot of confusion around that. So when we're talking about hormone therapy, menopausal hormone therapy, or hormone replacement therapy, we're typically referring to systemic therapy. So those hormones that are being replaced are getting into the bloodstream one way or the other. That can be through pill form, it can be through transdermal forms like a patch, a lotion, a vaginal ring. All of those basically just directly absorb through skin surfaces into the bloodstream. Hormone therapy is either estrogen-only therapy, which is appropriate for women who've had a hysterectomy, or it can be estrogen with some type of a progestogen to protect the uterus for women that still have their uteri. And that's very different. These risks and the benefits as well, the bone health, that is only with those systemic forms of treatment. 

[00:09:51] Susan Russell, MD: I know there's a lot of information out on the internet about how hormonal treatments could be potentially harmful. And I think that's from much older research. Can you talk a little bit about how that thinking or approach has changed over time?

[00:10:04] Traci Kurtzer, MD: Definitely. So, that kind of hesitation and really disruption in hormone therapy that was more prominent when I first came out of training. Almost all menopausal women who were having symptoms were put on hormone therapy and then the WHI or Women's Health Initiative trial came out and released information that let us know that there was higher cardiovascular risks by using hormones. I would say the WHI was a good trial in some ways and that it had a lot of participants. And so it was powered to find some of these really minor differences in risks, like what we see with breast cancer, for example. But it kind of shocked all of us that the cardiovascular rates were higher because we had always felt before that there was probably cardiovascular protection for women who stayed on hormone therapy. And also we knew from prior studies that women who are on hormone therapy seem to have a survival advantage over their peers who are not on hormones. And we always thought that was from bone and heart health reasons. So when that came out, it surprised everybody, and lot of women stopped their hormones, you know, very abruptly with that release, and then you know, got very symptomatic, and we just never really recovered in our hormone therapy use since the WHI trial. And that's because the follow-up information really hasn't been promoted as equally. And that is the group of women who had those higher cardiovascular risks were women who were over the age of 60. And as I mentioned, average age of menopause is around early 50s. That's typically not the age we're generally starting new prescriptions of hormone therapy for our patients. So the data was a little skewed because of the number of participants that were older. If the cohort ages were brought down into like 50- to 59-year-olds, we actually saw a little bit lower cardiovascular disease rates, lower heart attacks and things. So, because of that some follow-up studies were done to really figure out what's going on with this. It really seems like there's what's been defined as the critical window. So if women start ideally in their 50s or under the age of 60, or within 10 years of that last menstrual period, they really are going to reap mostly benefits from hormone therapy and very few of the risks; the remaining risks being thromboembolic events, so those are blood clot, strokes and breast cancer and those are big, loaded terms. When I say cancer and, you know, blood clots and strokes, those sound really scary, but when you look again at the data that their increases are very, very small for users. So, again, appropriate age group, there's no other reason that you shouldn't be on hormones or contraindications to hormones. You really get a lot of good things and benefits, and preventative health benefits by choosing that course. And, we have to all accept a little bit of risk if we're going to choose to be on hormones. 

[00:12:59] Susan Russell, MD: Yeah, so something that can act as a bridge and maybe just get you through the toughest time period.

[00:13:00] Traci Kurtzer, MD: Absolutely. And that's what a lot of patients do, they'll use it really for those most difficult years that are the few years leading up to cessation of the period. But it's okay too. Some women elect to continue beyond that initial heavy duty years because they want to continue to maybe get some of the bone protection or help with sexual functioning from continued use of hormones, and as long as nothing develops in their personal health history that it means it's not safe anymore, then they can continue well into their 60s. We have some patients into their 70s and 80s that continue on hormone therapy. It's fewer and fewer every year because things come up like, some of us are going to develop breast cancer, high blood pressure, have blood clots for other reasons, and then we have to stop hormone use, but it certainly is okay to continue long term as well.

[00:13:52] Susan Russell, MD: So outside of hormone based therapy, what other options are there that exist that you commonly talk with patients about for treatment of menopausal symptoms? 

[00:14:01] Traci Kurtzer, MD: Yeah, there's a variety of non-hormonal options, and recently all of them were really in depth reviewed and assessed by the Menopause Society and given levels of indication for use. And what came out of that data review is a few top items to consider. Some of them might surprise you. Cognitive behavioral therapy is one. Clinical hypnosis is another. That kind of makes it sound like it's all in our heads, which it is not. But there are some benefits because of that interaction with our hormones and some of our neurotransmitters. That is why some of these other methods may work. As far as medications, kind of going back to those neurotransmitters, we know that certain class of antidepressants, what we call the SSRIs or SNRIs can be effective for vasomotor symptoms. The FDA approved choice of that is medication called paroxetine which is at the 7. 5 milligram dose. And then there's one procedural-based option, which is stellate ganglion block. That's a block often used for pain management and that's also been reported to help with vasomotor symptoms. So it really kind of goes back to that interaction between hormones in our brains and those thermoregulatory centers and different neurochemicals. And then, of course this other, most recent FDA-approved treatment is a neurokinin-3 receptor antagonist, and it's the first one in its class that we're really excited about. So basically that medication works in rebalancing some of the chemicals that get out of balance in the thermoregulatory centers in the hypothalamus. And it has a fairly low side effect profile, and it's effective really quickly. So within a week of treatment, study participants were seeing a decline in their hot flashes and night sweats both frequency and intensity. So that's our second FDA-approved non-hormonal medication for vasomotor symptoms. 

[00:16:04] Susan Russell, MD: So options for everyone, no matter what your background is. What do you think are common misconceptions about menopause that are out there that you're having to consistently break down in your clinic when you see patients?

[00:16:16] Traci Kurtzer, MD: I think the biggest one is that you just have to tough it out. I just mentioned the longevity of symptoms. But also there's just so many bigger implications for that as far as our well-being. So, minimizing it when people come to me, I just feel terrible if they, you know, say “Well, I talked to my doctor about this a couple years ago, and they said, ‘oh, you know, don't worry about it, it'll go away,’ right?" And not really listening to how it's affecting our patients. So, even though, luckily, these symptoms are not life-threatening to a significant degree, they really can be quite impactful for women going through that. So we need to offer treatment and solutions, and not gaslighting for what they're going through. There's good things, too. I always remind my patients, like, going through menopause is not all bad. The transition is a tough period. I always call it kind of the reverse puberty. But you know, at the end of the day, getting into post-menopause, there's really a freedom from not having to worry about unintended pregnancies, not having all the hormonal fluctuation types of symptoms, like premenstrual symptoms, not having periods, like all of that. There's some really awesome things that come out of getting through that transition or the light at the end of the tunnel.

[00:17:25] Susan Russell, MD: There's so many options out there now for people who are still having menstruation that can alter or control menstruation, like different forms of birth control or IUDs. Do you think people should have some sort of scheduled testing to tell if they're in menopause, or should they just do it based on when they develop symptoms that they think could be related?

[00:17:47] Traci Kurtzer, MD: So for those folks who are using some type of contraceptive method that inhibits using the menstrual period as kind of their key or monitoring for some of those other symptoms that might come up, or we know that by age 55, less than 1% of women have not gone through menopause to a significant degree. So 55, I think is always a fine time to stop. I think most people are going to have some symptoms that they are aware of, particularly if they've been informed about them, And a good opportunity for our primary care and OBGYNs when we are seeing our patients in their 40s to start counseling about some of the symptoms to be looking for and some of the proactive steps that we can take. It's a great time really honestly to maximize our fitness routines and get into healthy diet choices because it's harder to kind of pick those back up after, and if we maintain those good exercise patterns and diet choices, it's going to pay off again when we get to the postmenopausal time period.

[00:18:48] Susan Russell, MD: How has our thinking about or understanding of menopause changed over the course of your career?

[00:18:54] Traci Kurtzer, MD: I would say, you know, that, WHI trial was such a sentinel event for changing things: The majority of menopausal women were on hormone therapy at that time, to a complete shift where the majority of women were not using hormone therapy. Also it really spurred looking at alternative therapies. So, in some ways, inspired a deeper understanding of menopause and also an appreciation about how these symptoms. They affect our productivity, they can affect our career and educational advancement and development, our relationships with others. And so having that bigger picture, it's not just a night sweat and hot flash, but there is more to this, I think, is where we're at right now. And then the other piece of it is just really that individualized therapy. Everybody really should just have that discussion with how they want to proceed through menopause and particularly if they're having symptoms. I mean, again, there's so much wonderful things that come out of going through that transition and being kind of on the other end of our reproductive lives. It's a shame to be suffering through that when there's definitely treatment options available that can help.

[00:20:08] Michelle Prickett, MD: As a specialist in the area of menopause, what do you think is important for people to know about menopause as we leave here today?

[00:20:15] Traci Kurtzer, MD: Well, I think another thing that I come across a lot is patients that are told that they no longer need to have gynecologic exams because they've gone through menopause. A lot of the vulvar dermatoses that we see, some of those genital tissue changes, like atrophy, over time, can progress and can become harmful, potentially really affecting our sexual health and risky for urinary health as well. So I think it's really important to make sure your primary care physician or your gynecologist is still doing those periodic gynecologic exams, even if you don't need routine pap smear screening anymore, and I would say this also includes women who've had a hysterectomy. Oftentimes, they have not had adequate gynecologic exams for many years, and so there's really a lot of proactive steps we can take to help maintain that part of our body, keep its health up, sexual functioning can improve. If you're not getting the support from your physicians that you have right now, find another one. The Menopause Society, they have a very easy website. It's menopause.org, and there's a list of certified practitioners. So you can find anybody in your area. A lot of us are doing virtual consultations as well. Find a clinician that's going to support you, believe you and help. Keep an open mind to the option of hormone therapy. Find out if you're a candidate and if you question what you're being told, then it's okay to seek a second opinion. And, in some ways, treatment of those symptoms can be important also for our overall longevity and well-being. So, just, that perspective and open mind to seeking treatment, educating yourself and not having to suffer through.

[00:22:01] Michelle Prickett, MD: I think it's such a wonderful thing that we can talk openly about this and that we can know that there's a wide variety of symptoms and there's a wide variety of treatments and there's wonderful practitioners out there to listen and to partner with and resources that we can look up if we're not quite sure if we want to have that discussion or how to do it. So I am very grateful for this discussion. I feel like I've learned a lot and we're so thankful for having you with us today,  Dr. Kurtzer. 

[00:22:25] Traci Kurtzer, MD: Thank you so much for inviting me and for sharing this topic 

[00:22:29] Susan Russell, MD: Thanks for listening to Get Better. 

[00:22:35] Khalilah Gates, MD: We hope you leave this podcast better than when you started. 

[00:22:38] Michelle Prickett, MD: For more information, visit nm.org\healthbeat.