Front Burner - Weekend Listen: The Dose

Episode Date: August 19, 2023

The Dose is a weekly look at the health news that matters to you. Dr. Brian Goldman brings you the best science from top experts in plain language. This episode answers listener questions about perimenopause and menopause symptoms and treatments. Dr. Shafeena Premji, a family doctor and medical director of Mahogany Clinic in Calgary, shares her best advice on how to manage symptoms and when to speak to a health-care provider. More episodes are available at: https://link.chtbl.com/mOAbEQfT

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, Tamara Kandaker here. We have a special bonus episode for FrontBurner subscribers from the CBC podcast, The Dose. The Dose is a weekly look at the health news that matters most to you. Dr. Brian Goldman brings you the best advice from top experts in plain language. He cuts through the confusion to give you a dose of smart advice that you just won't find anywhere else.

In this episode, how can I manage the symptoms of perimenopause and menopause, Dr. Goldman teams up with Dr. Shafina Premji, a family doctor and medical director of Mahogany Clinic in Calgary, to share her best advice on how to manage symptoms and when to speak to a healthcare provider. Have a listen. to speak to a healthcare provider. Have a listen. Hi, I'm Dr. Brian Goldman. Welcome to The Dose. On our sister show, White Coat Blackheart, we have a two-part series on menopause. And as part of that series, we asked for your questions about menopause and perimenopause and got a ton of responses. So this week we're asking, how can I manage the symptoms of perimenopause and menopause? Hi, Shefina, welcome to The Dose. Hi, well, thank you for having me.

So I'm sure you get lots of questions. What's the number one thing you're asked about when it comes to menopause or perimenopause? I think the number one question that women ask when it comes to perimenopause and or menopause is whether or not their symptoms are actually related to this transition in life, or is this a symptom that might be more concerning for maybe another chronic medical condition? And women are finding that they don't know where to start when it comes to figuring out how to get help through this time of their life. Okay, so you're the right person to ask these questions to. And so we're going to do just that. But before we begin, can you give us a hi, my name is, tell us what you do and where you do it.

Thank you so much. My name is Dr. Shafina Premji. I live in Calgary, Alberta. I've been practicing family medicine for over 10 years. I opened up my own practice, Mahogany Medical Clinic. Okay, that's great. Here's an obvious first question. How do you know if you've started perimenopause? Well, I think that's a fantastic first question to begin with, because I think a woman really needs to understand the terminology. There's a lot of question about, am I in perimenopause? Is this menopause? What is postmenopause? And I believe that if a woman really understands her own reproductive status, she will have more confidence in opening up a conversation with her healthcare provider. So let's go to first, what is menopause? So menopause

is defined as the single one day where a woman has had no menstrual bleeding for 12 consecutive months. So it's literally the one year anniversary of her last menstrual period. And anything prior to that is what we would call perimenopause. This encompasses the years where women will start to have symptoms. Some of them they will recognize and some of them they may not recognize. And also they will notice changes in their menstrual patterns. So this is how we define perimenopause. And then menopause, or postmenopausal, is really the first day after that one-year anniversary and for the rest of your life. Okay, so you know that you've entered menopause when you've gone 12 consecutive months

without a period. Perimenopause is a little bit more insidious. What are the most common symptoms of perimenopause? So we all know about those raging hot flushes and night sweats that many women will experience, not all, but many. And I would say 80% of women are aware of those symptoms. But with the 2022 landmark report from the Menopause Foundation of Canada, they have identified 30 other symptoms. So symptoms that will often be presented by women to myself would be mood disturbances, sleep issues, insomnia, weight gain. They may also talk about sexual dysfunction. Women will tell me it feels like razor blades.

They may have recurrent bladder infections, the vagina feeling dry or irritated. Women will also talk about hair loss sometimes, headaches, palpitations. The list just goes on. There's so many more symptoms as well. Is there a blood test or some objective way of confirming that a woman has entered perimenopause? That's an excellent question. And the answer is unfortunately, no, this is a clinical diagnosis. We don't use any formal salivary gland testing. We don't use any kind of hormonal testing to

identify a woman in her reproductive stage because when women are in perimenopause, day to day, their hormonal levels are fluctuating. So if we were to do any kind of blood test, it would really only be indicative of that single one day. So no, menopause is a clinical diagnosis, and we don't have any formal blood test to confirm that. I think that, you know, certainly some of the women that I've known who've talked about perimenopause have said they didn't feel like it was worth it to bother their healthcare provider about it. But when do you think a woman should talk to her doctor or a healthcare provider about symptoms of perimenopause? I think that's a very excellent question because women may feel that, oh, this might be just

something I have to go through or experience. And there really is nothing that my family doctor can do for me. And I'm going to have to suffer through this. And, you know, as a maternity doctor, obviously, I see women who go through many physical, emotional and mental changes with their bodies and their health through that transition. They have the responsibility of raising their children, taking care of their families, continuing on with their careers and taking care of their parents as well, who may be elderly. And all of a sudden they hit their 40s and they just say, Oh, my gosh, what's happened to me. And they realize that there might be something that's changed within themselves that happened without them even realizing it. And so really, I think the woman, a woman who is experiencing this should present to their family doctor. And as a family doctor, this is an amazing opportunity for me their family doctor. And as a family doctor, this is an amazing opportunity for me to help a woman bring her power back to herself and make her own health a priority at this point.

If we only had time for one question, it would be what's the most effective way to deal with night sweats and hot flashes? First question, before I ask about that, are the two symptoms related to one another or are they different? So really, the hypothalamus is where we control our thermoregulatory centers. And some women will go through menopause and have a hot flush or two, and that's about it. And then there are a subset of women who will experience this much more intensely. It can be paralyzing and disabling. much more intensely. It can be paralyzing and disabling. I have a patient who told me that she would leave her bedroom in the middle of the night in her underwear and run out into the backyard to cool off because it was so disabling for her. When we talk about treatment,

we break it down into lifestyle modification and of course therapies, both hormonal and non-hormonal. For hormonal therapy, this is a first-line therapy for women who are experiencing vasomotor symptoms, the hot flushes and night sweats. In general, the consensus with the SOGC, Society of Obstetricians and Gynecologists of Canada, and the Canadian Menopause Society, we recommend for all women who are under the age of 60 or within 10 years of their menopause. If they are an average risk woman with no contraindications, menopausal hormone therapy is first-line therapy for management of their symptoms. That's good. I know that women who are going through perimenopause

and menopause can have disrupted sleep. Are night sweats the main reason for disrupted sleep? That is one of the many reasons why women will have issues with their sleep. The other symptom could be related to sleep apnea. And so a woman who has sleep issues, I always do recommend a screen for sleep apnea and even a sleep study. The other reason women may experience sleep disturbances could be related to their bladder. The other thing also could be just related to depression or anxiety. If a woman is experiencing either of these conditions, then that can also affect and worsen her sleep. You mentioned weight gain. We heard from some women who are concerned about that in particular, especially around the abdominal area. Any tips

on how to prevent or lose that weight? Women who are in menopause do, in general, gain around 2.5 kilograms during the transition. And really what happens is that there is a change in the body composition. So there is a loss of lean mass and fat gets redistributed. And oftentimes it gets redistributed into the central abdominal area. So women will talk about an increase in their waist circumference. What can we do to help these women? When it comes to hormone therapy, we know that menopausal hormone therapy doesn't necessarily lead to weight loss, but it can help with body fat distribution. And the key to managing weight in this time of life is really exercise. The SOGC guidelines recommend

150 minutes per week of regular physical activity, but in particular, body weight training two to three times a week should be part of that exercise routine. We know that muscle utilizes more calories more efficiently, and so that will really help a woman to maintain her weight during this transition. Of course, we talk about diet and healthy lifestyle choices from a dietary perspective. And for women, I tell her this is not about going on a diet. This is really an opportunity for making positive health changes and changing one's eating habits for the rest of their life. Fatigue is another common symptom. How can women improve their energy levels? Again, it comes really back down to their overall lifestyle choices. So women

in this time of life feel a lot of stress. They may have young children or teenagers. They may be also caring for their elderly parents and or trying to maintain their careers. So stress reduction is a big part of keeping up those energy levels. You know, if a woman is feeling like there's no purpose for her anymore, being more engaged socially, keeping active really does absolutely help with with energy levels as well. Got it. We also got a lot of questions around headaches, specifically migraine headaches. If you suffer from migraines, how do they typically change as women go through perimenopause and menopause? There is definitely a clear connection between headaches and menstrual cycles. Women who are in the premenopause, so in their 20s and 30s they may discuss having menstrual migraines or migraines that are

associated with the changes in their cycles and any research that really focuses on women with migraines finds that those who have a fast decline in estrogen levels during that perimenopause and menopause are the ones that are most affected compared to other women. We don't have any Health Canada approved hormone product to prevent or treat migraines, but sometimes we can use hormone therapy to help minimize those huge fluctuations in the hormones, which is what is causing the migraines. Something to keep in mind for women, that migraines with aura are considered a contraindication to the low-dose birth control pill, which we sometimes do use in perimenopausal women who are in the menopausal transition and having menopausal symptoms. And also, menopausal hormone therapy itself can have a side effect of

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Women have told us that brain fog was a common symptom. What may be causing that? Women tell me a lot that, you know, they feel like they're going crazy. They say to me, oh, I can't remember anything, or my husband thinks that I am not as sharp as I used to be, or they go to work and they feel like they're having word loss or word-finding difficulties. And this can be very disabling for a woman when she has otherwise been very high-functioning. The good news is that oftentimes the brain fog that women do experience in the perimenopause and menopause is transient and does not lead to dementia that most women are worried about. And really the management of brain fog in the perimenopause and menopause is really focusing on cognitive health and screening for

any modifiable risk factors. So as I mentioned during my menopause consultations with my patients, I will screen for hypertension, high cholesterol and diabetes. We also talk about those lifestyle changes with respect to smoking, caffeine and alcohol. And in particular, one thing that definitely may help a woman who is experiencing brain fog is really trying to engage socially in a new or different way. So whether that means volunteering at a community center, learning a new skill, perhaps a new language, these are some of the changes that they can work towards, which may help ease that transition for them and make them feel like it's less of a burden. I've got another question here for you. One woman asked about how this natural change may affect women's bladders and could it lead to more yeast infections?

When I talk about what happens in menopause, I draw a little stick man for my patients during the appointment. And I point to them all the different places in the body where there are estrogen receptors. And women do not realize this, but we have estrogen receptors in our bladder, in our vulva, vagina, and their urethra. And so when a woman is going into menopause, the estrogen deficiency can lead to changes in bladder function. Women may present with recurrent bladder infections. They might tell me that they have burning when they go to the bathroom. They experience urgency and feeling like they need they go to the bathroom, they experience urgency and feeling

like they need to run to the bathroom very quickly. They may also present with dryness, burning, and even abnormal discharge. So really the estrogen deficiency is what is leading to many of these what we call GSM, genitourinary syndrome of menopause, which comprises vulval vaginal bladder and sexual dysfunction related to menopause. And so what can we do about this? Well, there is absolutely treatments available, both non-hormonal and hormonal. We have many different types of lubricants, moisturizers, and Health Canada approved vaginal topical estrogen therapy. So I would encourage all women and patients to bring this up to their family doctor or health care provider because there are many, many things we can do to help you through

this. As I mentioned on White Coat Black Art, in the emergency department, I've seen women who were dealing with heart palpitations while going through perimenopause. What do we know about that? Many women may actually experience a 7 to 15 beat increase per minute when they are having a hot flush. This can be very distressing for a woman. And in your other podcast, one of your presenters did mention that she was worried that she was having a heart attack. And so I think when a woman presents with heart palpitations,

it's very important that she does bring this up to her health care provider. Because most of the time it is benign and is not worrisome, but it can be associated with other conditions that we need to rule out. Perhaps she's got a thyroid disorder. Maybe she has an arrhythmia or maybe she's got some anemia that needs to be worked up. Perhaps she has an anxiety disorder or maybe this is a side effect of a medication. So when a woman presents with heart palpitations, it has to be something that should be brought up to their healthcare provider. And all the other symptoms, sorry, all the other conditions need to be ruled out. We've been talking around the subject of hormone therapy, you know, it's come up a number of times, but I wanted to make sure we talk about it all at once because we had a lot of questions around menopause hormone

therapy. So what is it actually? What do we mean by menopause hormone therapy? So menopausal hormone therapy is really a combination of hormone therapies, which generally include an estrogen and a progesterone. So a combined oral contraceptive pill is a combination of a form of estrogen and a form of progesterone. When we talk about menopausal hormone therapy, it also is estrogen and progesterone as the two primary hormones that we are using. For a woman who's had a hysterectomy, she does not require progesterone, we use estrogen only. And let me explain this. So the estrogen is the hormone that we are using to help manage many of those symptoms that women are experiencing. So the brain fog, the hot flushes, the night sweats, the vaginal symptoms,

the mood changes. The progesterone is really there to protect the uterus. So when a woman is taking estrogen, it leads to thickening of the lining of the uterus. And so I explain to women that this is like the fertilizer to the uterus. And then we add the progesterone to act as the lawnmower. fertilizer to the uterus. And then we add the progesterone to act as the lawnmower. So it really helps protect that uterus from that lining to become thickened, and it prevents them from developing uterine cancer. Now in the last five years are also a few other new hormonal therapies on the market, which are Health Canada approved, they are what we call estrogen antagonists and agonists. So the molecule itself actually has different roles on different tissues within the body. So really, when it comes to hormone therapy, there is no one size fits all. A woman has to be assessed by somebody who is well trained and understands the role

and how hormones are used to help manage their symptoms. Okay, so who should go on hormone therapy and when? So menopausal hormone therapy is a safe option for any woman who is perimenopausal or menopausal if they are under the age of 60 or within 10 years of menopause. It doesn't mean that every woman needs to go on hormone therapy, but if they have symptoms which would be improved with hormone therapy, then it is absolutely a safe option. Now we do break it down into ages as well. So for a woman who is in early menopause, which is before the age of 45, or women who are under the age of 40, which we call premature menopause, for these women, we are also recommending menopausal hormone therapy, not just to treat their symptoms, but to actually use hormone therapy to prevent osteoporosis, to prevent cardiovascular disease, and also to prevent the progression of

genital urinary syndrome of menopause, which we talked about earlier. Women wanted to know about the safety of hormone therapy. What does the research show? We have to go back 20 years, more than 20 years to answer that question. So in 2002, the Women's Health Initiative, which is the largest study looking at hormone therapy, and when the data was published, it was published because there was findings from that study where they stopped the study earlier because there had been findings that there was an increase in breast cancer and heart attacks. So women and healthcare providers across the nation became

fearful of hormone therapy and were worried about the risks of being on this regimen. What we realized later on was that the data was incorrectly published. And really, the study was focusing on women over the age of 60, sorry, but the results actually were being generalized to younger women. And so it's taken us over, you know, 10 to 20 years to backtrack and to be able to fix what that Women's Health Initiative initial release has done for many women and health care providers. The research now is showing that hormone therapy is a very safe option. There are some women who cannot be on hormone therapy. There are some absolute contraindications.

But overall, hormone therapy has many benefits. It provides relief of hot flushes, night sweats. It can improve a woman's mood, her sleep, her overall quality of life. It can protect her bones from osteoporosis and allow her to have better health outcomes in terms of her heart health as well. When it comes to the age at which we need to discontinue hormone therapy, there is really no magic age limit, really. What happens is when a woman is, you know, entering into her 60s, there has to be a conversation with her healthcare provider to review a risk assessment, making sure that she doesn't have any changes to her health that might increase risks of complications for her.

doesn't have any changes to her health that might increase risks of complications for her. And really, it's a conversation to have with her and her and her doctor. But we don't have any hard, fast rule about an age limit. And I do have patients into their 70s who are still well managed and well stable on their hormone therapy. We call them contraindications. What are the situations or the medical conditions for which women should not be on hormone therapy? So if she has had a personal history of breast cancer, if she has ever had a blood clot in her lung or her deep veins of her legs, which we call a PE or a DVT, if she's ever had a stroke, if she has a history of any active liver disease, or if a woman is experiencing undiagnosed

vaginal bleeding, that requires a workup before we were to consider hormone therapy. Got it. We've been talking about pharmaceuticals. You've talked about lifestyle management. Are there any natural remedies that are worth checking out? There is a subset of natural health products. Many women will lean to the natural health food stores and will look at black cohosh or evening primrose oil as know, been marketed to help manage some of these vasomotor symptoms. However, most of the studies that are being done on these natural health

products are limited and very small. And at this time, we don't have enough data to support the evidence or the recommendation for using them to manage vasomotor symptoms in menopause. Menopause, perimenopause is something that most women are going to have symptoms about. And you spend a lot of time with your patients, talking to them about the symptoms, talking to them not only about therapies, but lifestyle management. What are the symptoms or the duration of symptoms or the conditions for which you're thinking, you know what, we better look further and not just attribute it to perimenopause or menopause? That's an excellent question. The symptoms that, you know, sometimes women actually don't even

realize that they're having some of these symptoms. But if a woman presents with chest pain, shortness of breath, rapid change in her weight. These are some of the symptoms that may be definitely related to something cardiac in nature. And, you know, when we look at screening, when a woman comes in for her periodic health exam, we are screening routinely for diabetes, high cholesterol. And as you know, these are silent killers. Many women will not present with any symptoms, and they may not even recognize it. You know, you're coming in for your annual appointment, your annual physical, we're going to check your blood pressure as well. Just like osteoporosis, we don't know we have it until we break a bone. And similar to a heart

attack or a stroke, we may not necessarily realize that we've got blockages in our arteries that is going to lead us to that event. And so I think, you know, when we have a woman who's coming in, in the perimenopause in her 40s and her 50s, of course, we're asking her about all of these symptoms. But at the same time, screening is a very, very important part of what we're doing. You know, women at this time of life, they are very busy with their lives, and they don't prioritize their own health. And, you know, this is a very important part of them allowing themselves to progress into the next stage of their life with being empowered and feeling strong and feeling healthy and feeling like they own and have good

control of their overall life and quality of life. Well, Dr. Shafina Premji, I want to thank you. You've answered a lot of questions and you've answered them very well. And you've been a fountain of information. And thanks for coming on The Dose to talk about perimenopause and menopause. It's been a pleasure, Dr. Goldman, and thank you for this opportunity. And I wish every woman listening to this podcast the empowerment to go and look deep within and find those answers for yourselves. And please, please bring up these conversations with your health care provider. Dr. Shafina Premji is a family physician and medical director of the Mahogany Clinic in

Calgary. She's also a North American Menopause Society certified menopause practitioner. Here's your dose of smart advice. Menopause begins 12 months after a woman's last menstrual period. The years leading up to that point are known as perimenopause or the menopause transition. Perimenopause, which most often begins between the ages of 45 and 55, has 30 possible symptoms. There is no blood test for perimenopause. The most common symptoms include hot flashes, fatigue, mood swings, and menstrual changes.

Sleep disruption may be caused by night sweats, hot flashes, bladder problems, and sleep apnea. On average, women gain 2.5 kilograms and may notice increased abdominal girth. Your healthcare provider can assess you for symptoms of perimenopause and lifestyle factors such as diet, exercise, smoking, and alcohol use. This is also a good opportunity to check bone density, blood pressure, cholesterol, and diabetes. Adopting healthy habits like exercising 150 minutes per week can help control symptoms. Hormone therapy is a mainstay of treatment. Estrogen is the most effective option for relieving hot flashes and can also help relieve bladder and vaginal symptoms. Progesterone therapy is added to estrogen to protect the uterus.

In general, hormone therapy is considered safe for women age 60 and under who have had menopausal symptoms for less than 10 years. After age 60, check with your health care provider about whether to discontinue hormone treatment. You should not take hormone therapy if you have a history of breast cancer, blood clots in the legs or lungs, stroke, or if you have active liver disease. Women who have few symptoms or none at all should also talk to their health care provider for a checkup.

And don't assume that every symptom is due to the menopause transition. If in doubt, see your health care provider. If you have topics you'd like discussed or questions answered, our email address is thedoseatcbc.ca. You can find The Dose wherever you get your podcasts. If you liked this episode, please rate us 5 stars so. You can find The Dose wherever you get your podcasts. If you liked this episode, please rate us five stars so more people can find us.

This edition of The Dose was produced by Stephanie Dubois. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your healthcare provider. I'm Dr. Brian Goldman.

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