Welcome to Midlife with Brooke. I am your host, Brooke Oniki. I'm a disciple of Jesus Christ, a wife, mother, grandma, and a certified life coach. On this podcast, we talk about all things mothering, health and emotional wellbeing. I share practical tools and examples from my life and from the lives of my clients to help you navigate this new season of midlife. It can feel tricky and confusing and a little bit out of our comfort zone as our children grow up and they don't really need us in the same way. These concepts and principles have changed my life and I've watched them change the lives of my clients, and I hope that they can be helpful if there are things that you wanna change in your life. So let's get started. Welcome to the podcast I'm so excited to be with Angela Jones. she is a nurse practitioner and she is actually my nurse practitioner and she is a wealth of knowledge, and so I am really excited to have her talk to us today about perimenopause, menopause, and just women's health in general. So before we start in with my questions, I'd love for you to just introduce yourself and also let us know like why you chose women's health, like why that has been your primary emphasis.

thank you for having me. I'm excited. Anytime I can talk about women, menopause. I jump on it. it's just my favorite thing to talk about. so I'm Angela Jones. I worked as a nurse in critical care in ICU for a long time. And then I was able to go back to school and there was actually a, doctoral program that is specifically in women's health. And as I started thinking about things, you know, my background being in critical care and whatnot, a nice job clinic, nine to five, no weekends, no holidays. It sounded really nice for me. I'd done the exciting er and trauma And so when I thought about it even more, the thought of doing family practice just was not for me. Even just for graduate school, I thought, I cannot do men and pediatrics. That's just not my interest, but women is what I wanted to, to go into and study. So I had this opportunity to get my doctorate in women's health and I had to go for it. A lot of my cohort at that time were also doing midwifery. Which is fantastic, but that was never my interest. I wanted to specifically, focus on women's health, the aspects of women that it's not about, pregnancy and those things are so important and there are so many good people that will. Go into that. But there's also so much more to us as women than having babies and postpartum and it's a really common, thing to hear. And in fact, my mom was the first one who, who said to me that once I was done having babies, I didn't necessarily feel like I had a place in a doctor. Like I loved my ob, they were wonderful, but that wasn't their focus anymore. They had to focus. And, and pregnancy it has to be the priority if that's what you're doing. And so for me, the opportunity to go into women's health specifically was just a dream come true. And then along that same line, my mom also said that, you know, when she started to experience some of these changes in regards to menopause or perimenopause, whatever you wanna kind of call it. Again, there was even less information out there for her. And so to be able to focus on this very, you know, everybody is going to become perimenopausal and menopausal. It happens at different times in different women's lives, but all of us are going to experience that. That's just a, a given. And there's not a lot of education. There is now it's being talked about a lot more, thank goodness. but for so long it hasn't, women have tried to get information and they've just been kind of. Dismissed by their doctor, whether it's, you know, just because it's natural and they're told, it's just part of being a woman and you just kind of grit your teeth and get through it. or, or a lot of fear about it as well. That if we do anything to treat or to help you to feel better during this, then ultimately the risks are going to be too much at the end of the day. Right. In terms of breast cancer or blood clots or strokes or dementia, I mean, there's so many different things that people have been scared away from. That in reality is much more nuanced of a discussion. Most women, Have many options available to them, not just one fit. I kind of think of it as puberty in, when we teach our daughters about puberty, we explain to them, I've got a little girl that's in that change right now. And we talk about it, what's changing in her body and, and what to expect and what happens if you, you know, are bleeding in, in the middle of the day at school. Like we try and, and prepare them. So it's not this really frightening experience. And it's also not just a one-time experience, like they're going through change for many years. That's the introduction of these reproductive hormones into their body, estrogen and progesterone. In menopause, it's the reverse. We're removing those hormones from our body. It also is over many years, but our estrogen and our progesterone is what's being removed to where once we're menopausal, we have no more of those hormones. We don't make any of them at all from our ovaries anymore. So why we. You know, educate our daughters. But then as women, we don't have any education on what that means for, you know, just even our, our sense of sanity. It can have so much change that we just feel like we don't know who we are anymore. But health-wise, it has impacts on our bodies, on our bone health and our brain health and heart health. So we need to talk about it just like we talk about puberty for young girls, it doesn't need to be, a doom and gloom situation. Menopause is okay. We don't need to avoid it. It doesn't need to be where it consumes our life either, but we need to talk about it. We need to educate and, and be aware of it. And so that's kind of where I love my job. Because I get to do that all day long and I'll have people that will wait for months to get in just because they are so desperate to get help. And they will have asked, you know, trusted people, their doctors, their primary care, their ob, and a lot of times they are either given incorrect information or just nothing Like this is just what it is. And so to be able to make movement in the opposite direction is just one of the biggest honors of my life is to be able to talk with women and, help them feel like themselves again.

Yeah. Do you feel like the change has come because there are more female doctors? What do you

think

has brought more information? In recent years,

I think for sure the more women that we have in medicine, but also social media. I mean, there's a lot of challenging things about it, but it is also a really good way to get information out there. And so a lot more women are talking about it. a lot more doctors are becoming, social media, Savvy and or that's kind of their whole platform is educating and talking about that. And I think that just as women too, we're just a little bit tired of being told that, this is just the rest of our lives. I mean, when we look at the average lifespan of women, we're not talking just the last five, 10 years of our life where we, you know, or are frail and old. We're talking 40, 50 years of women living in, in a menopausal state. And I think women just aren't okay with that anymore, of just feeling like they're just going to be getting sicker and frail or every single year until, they fracture a hip we deserve better and women's voices are being heard and being, talked about. There's good and bad aspects of that, meaning we're talking about it finally. We haven't talked about it in so many years, but we also have a lot of predatory practices that are being opened up as well, because as women, they just wanna feel better. I mean, they'll just come to you desperate in tears for a variety of different ways that they're feeling, and that also has made it so that other individuals, other providers can, take advantage of that and do a lot of unnecessary testing and expensive hormones and, and sometimes really unsafe treatments as well. But there's money involved in it. And so if somebody tells you they can help you feel better for a certain price, a lot of women do. Because again, when they go to their regular doctor, they are, are dismissed and shut down and told that, you know, it's just normal and it's just, the way that they have to feel. And I think women are not accepting that anymore. So you've got several things going on in terms of menopause being talked about more. You've got really great information out there But then there's also areas where women are being taken advantage of because of this, so it's important to be getting good information and I want to be a voice to. Simplify it more for women so that it doesn't have to feel like what should I do? And this person saying this and this person saying this. Even in social media, you'll have menopause experts that are arguing amongst each other so I like to just simplify it for women and, and women can choose what's gonna be best for them and, and kind of what, what works.

Very good. So let's start out with that very basic, like, what is perimenopause, what is menopause? And then we'll

mm-hmm.

We'll go on with some additional things.

Perimenopause is that term. So you've got your regular menstrual cycles from when you started puberty to your normal menstrual cycles. Of course, that's interfered with like pregnancy or if you're on pills or there's a lot of different things, but still your regular reproductive years. And then you have menopause, which is. Your ovaries will no longer produce any hormone specifically estrogen and progesterone. So once your menopausal is just basically ovarian failure, your ovaries will no longer produce any hormone ever again. And then in your regular menstrual years, your ovaries are these hormone making machines and they're just pumping out estrogen and progesterone. And then perimenopause is just that transition. It's not a date, it's not an event. It's not even that something that we see in blood work. It's just that transition of our ovaries. That are becoming less and less efficient. The follicles that are inside those ovaries, which is what we ovulate every month with, that's what, produces estrogen and progesterone. And we're born with as many follicles as we will ever, ever contain like that. We just are born with a certain number of follicles, and by the time we have no more follicles to mature, we're menopausal. So perimenopause, I kind of describe as like these follicles are just less quality. We're kind of scraping the, the bottom of the barrel a little bit in terms of, what quality there is. So that means that perimenopause means your periods are gonna become really irregular. There's no rhyme or reason to it. Sometimes we'll see that your period gets a little bit closer together. Initially, maybe you're a very regular every 28 day year, and then maybe you'll start notice it becoming every 26 days instead, very subtle changes. And then. There are no rules or or reason to it. You can have a period that lasts for three months and then go six months without a period and then bleed for two weeks at a time. it can be heavy bleeding, it could be light bleeding. It's just all over the place. there's just no rhyme or reason to it, and that's because your estrogen and progesterone are no longer doing this kind of cycle that your menstrual cycle is. Your estrogen is high. It's low. Your progesterone is usually low, so it's chaos. There's a lot of chaos. So we see that in our periods. But even in women who aren't having periods, maybe they have an IUD or an ablation or even a hysterectomy, they're still going to be feeling throughout their body those changes that are happening too. So perimenopause is this kind of bridge between normal menstrual periods and no menstrual periods ever again, and it's a time of chaos. Your highs are higher than usual. You're, you're bottomed out to zero in the matter of eight hours. Your body hasn't experienced this type of whiplash before, and that can last for seven years, 10 years, three years. It's really just when you start recognizing those symptoms, and so it's a long transition. The reason blood work's not helpful in that is because of the chaos that's happening. You might have an estrogen of 700. When I draw your levels, if you're in my office and then eight hours later you could have an estrogen of zero, that's the chaos that is fueling the crazy periods. But then the symptoms that can be felt in perimenopause. I mean, there are dozens and dozens you'll hear a lot about, like hot flashes, night sweats, joint pain, insomnia, mood changes, whether that's anxiety or more rage. brain fog is a huge one as well. And then you've got all of these miscellaneous weird ones, itchy ears, dry mouth, The, the list could go on and on about potential symptoms that, that perimenopause can kind of be, causing because we've got these estrogen and progesterone receptors throughout our entire body. So when we start to, have this chaos happening, it's gonna cause a lot of chaos in our body as well. So whenever I am talking to somebody for the first time, I tell 'em we've got two goals during all of this. The first goal is to help you to feel better and whatever that means, right? Maybe it's just, you know, feel like yourself. Maybe it's this long list of things. in terms of the spectrum of symptoms, And you will just feel at your wit's end, like, I don't know what to do. I cannot live like this the rest of my life. Like, I don't know who I am anymore. I'm gaining weight. I can't sleep. I, am arguing with my family or partner all the time. something has to change. And then occasionally you have people who, it really is not a big deal in any way. They'll just say like, they stopped having a period and that was it, and they were fine. So anywhere in that spectrum is where somebody will fall, right? So the first goal. Is to help you to feel better in wherever you are on that spectrum. The second goal is going to be applicable to all women, and that once we are menopausal, meaning we don't have any estrogen in our bodies anymore, that will immediately impact our bone health, our risk of osteoporosis. It impacts our heart health cardiovascular system wide, we start to see more insulin resistance because of that lack of estrogen. We'll see cholesterol changes happening again because of that lack of estrogen. And same with brain health. We start to notice, over long, periods of being in menopause, that the risk of dementia impacts women more than it does men. Not that men, you know, men absolutely can get dementia in Alzheimer's, but the rate it in which it impacts women is greater. And we think that that's largely because of that lack of, of estrogen that women are cut off from. So we want to address. Both of those when we start talking about perimenopause. And it doesn't mean that that just needs to be your new identity for the rest of your life, is that your perimenopausal or menopausal? But we just need to talk about it and have a discussion and kind of create a game plan going forward so that as those things start to pop up, you can recognize them and not feel like you're falling apart or you're losing your mind and you can say, okay, I remember this being something that might be happening. So then we address it in whatever way is going to be best.

So if you went in to see your doctor and you felt like he or she dismissed your problems, like we said, if your OB is very focused on pregnancy and doesn't know as much right, you can't be an expert in everything. Absolutely. So they don't know as much about women's health beyond pregnancy, What do you do if you feel dismissed? I had a male doctor, for many years who said, let's just keep you on birth control until you hit menopause and then you won't feel the effects. I don't know if that was the right thing to do, so I ended up doing that, till I was 50 something. Yeah. You know? Yeah.

Probably 55 or so.

Yeah. And I don't know if that's the typical way of dealing with it if you don't know anything about it, like what would you suggest to someone who feels like they go in and they feel like, I'm not really feeling like myself and their doctor just says, this is the way it is. Would you just change

doctors?

Like what would you suggest?

Yes. You just have to keep advocating for yourself and I don't have the answer to it. I have a wait list of probably six months right now, and that's not because I'm so amazing. It's because there's not enough. People to go to, to get good information. And I mean, I've had women in my office, just crying, saying, you are my fifth person. If you can't, talk to me about how I'm feeling. Then I, give up. I don't have any other avenues to go to. So there are more. People going into this. And so there are becoming more providers available. There are online companies that you can use as well. If you go to the Menopause Society, They've got a directory with different providers that are certified in, the Menopause Society and their certification. there's a lot of good online people, I could give you some references that you get Yeah. And I can put 'em in the show notes. Yeah, to be able to, get as much information you can on your own. I've had quite a few patients who, as they're waiting to get in with me, they'll say, I actually went to my doctor and I said, this is what I want to be on. And they said, I kind of ran the show a little bit and I said, I, you know, I think I wanna be on this and this. And I had to be quite forward about it. And eventually they agreed to it in some of these bare minimums. so, learning to advocate for yourself and be able to be educated so that you can be, persistent and not just be, dismissed because many women are. And so then you can just say, all right, this isn't the person for me. And Keep trying. this is the rest of our lives as women, we're gonna be perimenopause and then we'll be menopausal the rest of our lives. And again, it's not a bad thing, but it's worth finding somebody that can help you in this. So there are some online companies that you can do that, do virtual appointments. we are trying to educate. I've always got students with me that are, are so interested in this. There are people that are wanting to help and there are movements that are happening that I hope in 10, 20 years this won't be something that we're talking about like this anymore. Of it being a rare thing to be able to find a, a doctor that can do it for you. I would say on the other side of that, be wary of people who are going to, take care of you through. You know, in perimenopause, there's not a lot of labs needed. Now, general labs always meaning, I do wanna know what your cholesterol is. I wanna know if you've got insulin resistance and kidney and liver, and make sure you're not anemic. Like labs are so important, but you don't need a plethora of hormonal panels or urine testing or saliva testing to indicate that you are perimenopausal. it's a clinical diagnosis, your age, your symptoms. That tells me whether you're perimenopausal or not. if you have somebody that is, you know, offering. To help you and it's a package of $1,500 just to see them. I would be wary of that. You don't need to have these hormones compounded bioidentical hormones are are going to be the best. And that's typically true, not always, This is not exclusive to just estrogen and progesterone. Any hormone that is bioidentical, it simply means that it is identical to the hormone that our body makes. So, for instance, when it comes to estrogen, 'cause that's really at a lot of, of what's at play here in perimenopause, and then menopause, estrogen itself is kind of an umbrella term. There's not just estrogen out there. You've got estrogen that's made in nature, our body that makes three or four different types of estrogens, and then we have. Synthetic estrogens that are used in like birth control pills primarily, or to stop bleeding or or whatnot. All of those are incredibly different from each other. The main type of estrogen that our body makes, that has been your menstrual cycle for all of these years. It's what was introduced during puberty, and now it's what's being taken away is called estradiol. So if we're using estradiol, that is bioidentical, it means that your body can't tell what you're getting from a patch or a pill versus what your ovaries are making. They're binding with exactness, they're chemically identical, and in fact, when I draw your blood, if you're still perimenopausal, you'll still be making your own estradiol. I can't differentiate from that blood work, what's coming from your ovaries versus what's coming from a patch or a gel So if it's estradiol, that's bioidentical, it's exactly the same. Same with progesterone. If it is called progesterone, then that is bioidentical. That doesn't mean. Compounded, and that's sometimes a bit of a, confusion there that if you're going to be on natural or bioidentical hormones, that it has to be compounded. You don't need compounded. If it's estradiol, it is bioidentical. And we like bioidentical for a lot of purposes because it's exactly the same as what our body makes. So it's very safe, it's very effective, and there are very little side effects with it too. I mean, we're just giving your body back the same hormone that it's had during all of this time. And so a lot of times we like to use those hormones if we can. The reason we don't use them all the time is. Bioidentical does not work as contraception. There's a reason there's a different type of estrogen and birth control pills. It's called ethanol estradiol. Don't need to remember that, except that it's probably at least a hundred times more potent than what our own estradiol is. So it's very common for women to not like the way they felt on a birth control pill. It was not a good fit for them. For whatever reason, they had side effects that just were not acceptable and just made them feel terrible. But that's an entirely different hormone than what we're referring to when we're talking about hormones for perimenopause or for menopause. So it's important that you're talking to somebody who is. Talking about all of these differences, not just offering you one solution. Hormones are not the only option, and not everybody who's perimenopausal or menopausal has to be on hormones to be healthy. I think that's one thing that we're seeing the pendulum swing a little bit. In the early two thousands, a study came out, the Women's Health Initiative, and it really villainized hormones. That's where now we always associate incorrectly. It shouldn't be this way, but estrogen and breast cancer, I feel like go hand in hand for a lot of people. that's a real fear of theirs. And so in that WHI, when all of that came about, all of a sudden, hormones, so estrogen, progesterone were just very much demonized in terms because we didn't want breast cancer. so, people that were prescribing were terrified to prescribe it. Women who were taking it were. Terrified to take it anymore. And so you had this swing where nobody was giving hormones, and it's been about 20 years, 20 years of not educating, not really doing anything education wise for menopause or perimenopause. And now the pendulum has swung though in some ways to where sometimes the narrative from people is that if you don't use hormones, Your bones are gonna shrivel up into dust and your brain's gonna cannibalize itself is what I've been hearing by some people lately. if you don't choose to be on hormones, then that's just it for you and you will, get sicker and sicker every year. It's, it's in the middle right here. I mean, there are some absolute benefits to using hormone therapy for most people. They will benefit from it far more than there's any risk from it, but it's an individual conversation. And so again, there's not enough people out there doing it right now, but if you can educate yourself and then patiently try and find somebody that is, certified in their different specialties, and then they can guide you into what's gonna be right for you. I talk to patients, I say it's a bit of a trial and error process and never error in terms of safety by any means, but in what's going to be right for you? What's right for you. Brooke is gonna be very different than what's right for me versus my mom because we're all different and so we need to talk about it and, decide tell me more

about weight resistance, that kind of stuff, like for bone health.

One of the reasons that osteoporosis becomes such a concern in menopause is 'cause estrogen is very apparent. it's pivotal in this process where our bones are, are breaking down and being rebuilt. That's always what's happening, in bone health. When we lose that estrogen, it offsets that balance where we're losing much faster and we're not building in the same degree as we used to. So I tell people probably the two best things you can do for bone health, number one is talk to your doctor about estrogen, simply for the protection of their bones to prevent osteopenia. The second best thing that you can do for your bones is going to be strength training. So building muscle and having there be tension on the bones that's going to allow them to stay, structurally strong and have a good matrix within that bone to keep it from, getting what we call low bone density. So a lot of times a bone density scan or a DEXA scan we'll talk about is needed to be able to see. what is your bone health? There is a US preventative task force that puts out their recommendations for screening and their official recommendation is that at age 65 you should be getting a bone density scan. 65, is really too late to be doing a bone density scan for the first time because there is so much that we can do before then. To prevent the bone loss that happens by the time you're 65. Most women, I'm talking to them in their fifties, maybe age 55 is when I would like to have them consider getting a bone density scan. Insurance won't always pay for it because of that 65 guideline that's out there, but typically women can get a bone density scan for fairly affordable, $200 or so, And it's worth it for most women because if we can prevent. 10 years worth of bone loss before we then get that bone density scan, we're gonna be in a much better position. So definitely strength training. Just naturally our body loses muscle every year. That's just part of the aging process. And then when you throw in the lack of estrogen, that's also going to metabolically change things as well. And we're going to start to deposit more, visceral fat around the middle. Which is just this vicious cycle of insulin resistance and inflammation that's going on in the body. So we want to do whatever we can to hold onto the muscle that we have, and then if we can be building muscle from there, it's doable. But it does take very deliberate effort, right? We need to be focused on strength training. I don't mean like joint CrossFit tomorrow, like it needs to be reasonable. I don't want you getting injured, but just having that on your mind. anything is better than nothing. Some resistant bands that you can do at home, some free weights, jumping jacks, whatever. 'cause that's got that stress motion on the bones that are gonna be so healthy for it. When we talk about nutrition, same thing. We want to make sure that we're getting protein to build our muscle. I don't advocate for a protein only diet, carnivore diet, anything like that. It needs to be balanced. But we do need to be thinking about protein, healthy fats and fiber. And so typically what I tell patients, and I'm not a registered dietician, again, we can't be experts at everything. I know where my limits are in that, but in terms of like general knowledge. Something similar to a Mediterranean type diet. So plant-based is always going to give you good minerals and natural elements that we need with a focus on lean protein is going to more beneficial even than hormones. Like what we're doing on a daily basis is going to be. One of the biggest impacts on how we age and, hormones are a tool to aid in that, to amplify those benefits that we're getting from it. and so again, depending on the individual person, when we talk about weight management with individuals, I still will always be talking to them about muscle. Whether it's that we want to lose weight or we're just trying to maintain where we're at. We need to be building muscle along with that. And then when it comes to weight, I have women that will, just sob in my office that they're doing. Better than they've ever done before. women that have said I hire a personal trainer, now I have my meals delivered. Like, 'cause I'm so desperate to be able to, feel like myself again. And not only, they'll say, not only am I not losing, I'm not even maintaining. I continue to gain weight from here. And it's not about necessarily the number on the scale per se or even about being skinny, but it's okay to wanna feel confident in your body to fit in the clothes that you wanna fit in, to have energy, to have, motivation. That's another thing that a lot of women struggle with, with this kind of transition is they say, I just feel blah, I don't, they said I can't put my finger on it, they said I'm not necessarily depressed, but I'm not motivated. So. A lot of things like that contribute to weight management all of this change our bodies go through, that we're just left to manage on our own. And that's unbelievably frustrating.

Six months before I turned 58, I I hired a personal trainer and a nutritionist, and I met with my nutritionist every week and I lifted weights with my trainer three times a week. And it was costly. but I was like, this is the gift I'm giving to myself doing that. and I do think it helped me a lot. I felt like I was making a lot of progress, but one day when I was doing a pull-up, I injured my shoulder and eventually had to have rotator cuff surgery 'cause it had disconnected my superspinatus. it was hanging, I guess, by a little bit of a thread. And so then it feels like, oh, you work so hard. And then mm-hmm. All of

that.

You lose it and, the money of that And so I had to really work through that and just think I still learned a lot and I still appreciated the discipline that I exercised so then I had the surgery last year, so last May. Mm-hmm. And it took me several months. So all of last year was kind of rough as far recovery as sleep and all of those kinds of things. But now I can play pickleball again and I'm eating really well, but I've been really timid about. The strength training because of the injury. Right. And I also don't wanna spend a bunch of money this time. I feel like I've learned a lot, but I also have a lot of fear of injury because I've injured myself lifting weights many times so that is a drawback for me. I mean, there are simple things that I know I can do, but as far as like really getting stronger, it feels like you do need some supervision. and even under supervision, I got injured. so that has been rough for me.

It's hard. but as I hear you, doing pickleball and that really all of this is to. Stay healthy as we can, right? We're not trying to be 20 again and, reverse the clock. We're wanting to be healthy, to be strong, avoid injury, be able to heal when we do get injured, because that is life. There are plenty of things that are not in our control, right? And, we have to learn to adapt to that in whatever comes our way. Because illness happens. injury happens, life happens, relationships fall apart. so we're talking about things that we can do that will then help us to be maybe in our best state to continue to. Live life with all of its up and downs and bumps and whatnot. One other question that I get because I know we don't have a lot of time is because a lot of these symptoms and we didn't even talk about sleep, which is also so which we can still, I think we should still should we need to, because sleep, I mean, becomes so challenging for women and if we're not getting sleep, then our body can't. Function. It can't focus on healing if we're not getting sleep. It can't focus on weight management if we're trying to do that. it's just in the state of survival. If we're not getting consistent, good sleep and that doesn't mean that, if we're not getting consistent eight, nine hours every single night, then we might as well give up. We do need to acknowledge that if we're not, getting, for the most part well rested at night, that's going to just be this brick wall that we're hitting against constantly, with all of our efforts that we're doing. a lot of women will say, I can fall asleep pretty good, but come to three o'clock in the morning. My brain just turns on for no particular reason. And then that's just it. I'm done for the, for the night. I cannot go back to sleep. And variations of that, sometimes that'll happen. They'll be able to fall asleep, but they'll just keep waking up. And then obviously there are women who have a hard time falling asleep too. That also needs to be discussed and be able to, talk about how we can help with that. And it's. Discussion. We wanna rule out things like sleep apnea, if that's a, a concern. And actually, sleep apnea is not uncommon in menopausal women. We, a lot of times, will associate sleep apnea with maybe having gained weight, which is a risk factor. But in menopause, that lack of estrogen affects our airway and the laxity of our airway. And so it's not uncommon for women to develop sleep apnea as they get older without realizing it. And if you have undiagnosed sleep apnea or untreated sleep apnea, that's like your body dialing 9 1 1. Over and over and over again in the middle of the night, you're basically gasping for breath over and over again. And a lot of women don't know that they have it. sometimes, symptoms will be, waking up with headaches in the morning, feel exhausted, which can be from a lot of things. But that's something that we should, consider if you are told that you snore or make a lot of noise at night, we need to look into that for sure. And then sometimes it really is just this hormonal change. Progesterone, I just talk about estrogen all the time because it is so vital. But progesterone is also a hormone that has a lot of impact on our body, particularly our brain, our brain. It is very susceptible to progesterone. Sometimes for good, but sometimes for bad meaning. It can also be the cause of like PMS and PMDD and postpartum depression. Progesterone has the, potential to not be a very, well tolerated hormone. But for other women, progesterone can be an incredibly calming and soothing hormone in fact, I see a lot of menopause providers and some, do things differently just based off of, habit or experience But some people, when you go talk to them for perimenopause, when you look at the hormone fluctuations that are happening, your estrogen, like I said, is going all up and down. If over years of tracking your estrogen, even though you're gonna see it going all over the place, if we were to track it, you know, day by day, you would see it declining. Ultimately over those five years or seven years. Progesterone is more zero than it is anything at all, because we only make progesterone when we ovulate, and we're not ovulating regularly anymore In perimenopause, we don't have the follicles to ovulate as as regularly as we used to. And so for much of perimenopause, we are functioning in a state of very low progesterone and that can really impact women's. Mind their mood. So that's where we see a lot of anxiety happen in perimenopause. A lot of the mood, disruptions, whether it's that I feel angry all the time or that kind of motivation or depression. I have women talk about anxiety that pops up out of nowhere. For instance, like I, I'll have women say I fly all the time, like for work, and all of a sudden I have. Flight anxiety, like they say, it makes no sense, but yet it's this new onset anxiety that they feel. And then sleep as well is impacted by that progesterone. So some people who are, are taking care of women in perimenopause instead of starting them out with estrogen, will start out with progesterone only. And so when I say bioidentical, that means, again, progesterone, or you'll hear it called micronized progesterone. It's a pill that you have to take. Totally safe to do it as a pill. And women who take this type of progesterone, they'll fall into three camps. Either they will love it and they will talk about it just being the most beneficial. I describe it as like our own Xanax receptors in our brain, our natural ones. It's these GABA receptors that just cause a woman when she takes it to feel. Calm to feel relaxed. Her mood stabilizes, and then she'll talk about getting the best sleep of her life. So progesterone is so helpful when you fit into that camp. And that's probably about 50% of women, I would say. There's other women who are indifferent to it. It just tends to be that our bodies metabolize things differently. So plenty of women who unfortunately don't get those benefits, they don't get negative impacts from it, just nothing. They feel nothing when they take it. And then there's a few percentage of women, maybe four or 5%, who are intolerant to progesterone. This is again, that bioidentical. Mm-hmm. And in that case, it creates this opposite effect that the nice sleepy impact does. It makes them feel more anxious and more uneasy. I'll have women that will call me and say like, I'm losing my mind. I can't continue like this. That would be, that they are, intolerant to this progesterone. so when it comes to sleep, a lot of times, if you're having trouble falling asleep, progesterone is something that might help with that quite a bit. The waking up in the middle of the night, that's more seen with perimenopause for a lot of women either. We need to rule out that it's not night sweats, which is something that can definitely impact sleep. if you're waking up drenched in sweat and you've gotta change, your clothes and your sheets are drenched, that's gonna do a number on your sleep for sure. But even if it's not night sweats, and again, it's just that waking up at two, three o'clock in the morning, estrogen tends to be very helpful with that to just kind of keep that stable release of estrogen while you're sleeping and can make quite a big difference in that regard. So when somebody's struggling sleeping, we need to look at many avenues of what's doing that. If you have a snore. In your bed next to you that's going to impact your sleep and I can't give you medication to, have that be changed or, people will say, they're an elderly dog or a brand new puppy that needs to get up in the middle of the night a lot. Like, those are situational things that also need to be thought of, how can we get you sleeping because that is so vital. Nothing will fit in place if we're not getting sleep on a regular basis. a lot of women will ask me, because so many of these symptoms are, are pretty. Attributable to a lot of things. when I ask women about maybe anxiety or sleep in particular, they'll say, well, yes, I have a child that I'm really worried about. That's causing me a lot stress right now. I've got, work that's on my mind it's that my thyroid is not, being treated appropriately there's so many things beyond just perimenopause and so the question I get all the time is, How do I know what's maybe something else completely unrelated to perimenopause that's going on and really. The simplest answer is to address the perimenopause part of that. let's go over that. Let's talk about it and formulate a plan. And that helps us to see, especially in terms of health, the things that are getting better with treatment of perimenopause Then it's pretty easy to identify, hey, that was hormonally related and so we're really glad if we're still dealing with things though severe depression, anxiety or, low iron, which is not uncommon in perimenopause because at that bleeding that women will experience, we need to address those things. We don't want to just naively blame everything on our hormones either, but it definitely has a factor in all of that. Right. A good

place to start.

Yeah. and also. Life, like we said, is always gonna be life. We're always going to be dealing with really hard things that are going to, come in our way and multiple hard things at once. If anything, treating the perimenopause and the menopause, component of it helps us because I'll have plenty of women who say I just feel like myself again. Nothing has changed in terms of a divorce that I'm going through, or, at work. nothing has changed there. But I'm myself, I'm functioning the way that I used to and I don't feel like I'm drowning while trying to, Deal with everything else that's going in my life. So I think all women deserve to talk about it. I would love to get all women at 40, kind of like the maturation program my daughter just had her maturation program and I think, wow, we need to do this for women too. long before they feel like they're drowning,

So if you are going to an appointment with a doctor, what kinds of things can you do to prepare?

I think it's important to realize that if you're in a clinic that accepts insurance, I want you to have patients and grace for that clinic because when you accept insurance as the provider. My hands are tied in terms of what I'm able to do appointment wise. Insurance dictates the time that we get for each appointment. They dictate, how it needs to be coded. So have, maybe 1, 2, 3 things that are your biggest priority I wanna talk about menopause, but this in particular, I want to know about bone health. Or I wanna get rid of these hot flashes, or I need to be sleeping. Your list can be this long and that's okay. Just know that. We're probably only gonna get to this much, and that's not because the doctor doesn't care or that they're just rushing, or that they're just trying to cram in as many people as possible for the money. It's just the limitations of being able to, stay in clinic, stay in business And so If it's my first time meeting you, I try and have it be a 30 minute appointment, I wish we had an hour, even 30 minutes. There's not everything we can go over. Most follow ups from there though are 15 minutes. Again, that's not very much time at all, and that's not, because again, we're just trying to cram people in. That's what a follow up is dictated as, so we have a clear. Idea one, two things that are like, I really need to talk to you about these things. And then if we don't get to the rest of the things, then schedule another appointment. I tell people when we first start doing this, they're gonna be seeing me a lot and it's just the way it is. Because these treatments, they take time to see how you're gonna respond to them. To find the right dose, to find the right route, maybe, you know, in terms of like a patch or a pill or a cream or whatever it's going to be. And then, because there are so many things, you're gonna be seeing me a lot because we're gonna be slowly going through that list. It doesn't mean that that will always be the case. again, this doesn't have to consume your life, but as we're getting to like, get to what it is that your body needs it, except that you'll probably be having a lot of appointments just so that we can adequately address everything that needs to be. A lot of times. Hopefully you're able to do that virtually. I like to do usually in person when I see people at first. but then most of my follow-ups are virtual just because we can do that a little bit more flexibly and, you know, have that be something that you don't feel like you're having to take work off all the time to, to do it. I've done, appointments with teachers who are at recess and we've got, our 15 minutes and we stick to it and we get a lot of things done. Plenty of car appointments. Let me run out to my car while I'm on my break and we talk about it real quick. And then that's that. So just have kind of some organization and some understanding that we're not gonna be able to get through an entire list of things. And it's not because we don't care and because we don't want to. And part of it too is that all of it is working towards that goal of getting you to feel better about yourself. If we, I tell patients if I throw. Everything, get your body at once, estrogen, progesterone, testosterone, and then weight management. That's a lot for your body to sort through. We wanna do this step by step so that we can see how your body's responding. If something's gonna cause a side effect, it's helpful to know which one it is, and if we have a little bit of time in between doing these therapies so that we can see how your body responds to it, and then be able to adjust like that. So have some patience, but know that everything is heading towards getting you feeling like yourself and better again.

That's great. So I, I've been working with you for a couple of years and I feel like taking estrogen and progesterone have been really, really helpful to me. Mm-hmm. In lots of ways, I think the sleep has improved, like vaginal dryness, things like that have been way, way better. 'cause that was a big concern. I don't have any kind of hot flashes anymore. and, some of those things seem to evolve over time, As you go from perimenopause to menopause. but I've been grateful for your knowledge. And also I've never felt rushed when I've been talking to you. you act like you have all the time, and I do think you can do a lot in 15.

You

can. And so if you come prepared right, and you're doing a little bit of your own self-advocacy, then you're ready to let them know, I've tried this and I didn't really like this. like I've tried testosterone in several forms so everything you try. is information teaching you And is helping you decide what you like and what you don't like. And so rather than thinking of it as frustrating or failing, it's just more information that's leading you to something that will be most effective for you.

Exactly. Estrogen has been associated with breast cancer, since, since 2000 and, and four. in fact, even my own mom, said when she was on a perimenopausal early menopause, her doctor had offered estrogen and had said, do you wanna be on this? And she didn't have a lot of challenge when it came to perimenopause. And she thought, well, no. I don't want breast cancer and I'm not having a hard time. So, of course not. and, even now, doctors are telling women that there still is that association. And I want to be very, clear on this, that everybody. Deserves a discussion about hormone therapy. Again, not everybody is going to want to do it. Not everybody is going to be the best option for them, but nobody is truly a non candidate for any of these things. There's a lot of research that's being done. Now, we do know that estrogen. Does not equal breast cancer. And that's an important thing that we need to be able to separate those. Even estrogen receptive positive breast cancer does not indicate that estrogen was the cause of that. Breast cancer, there's a lot of nuance and that in cancer is complicated. just barely, oh gosh, what has it been maybe two months now. the FDA removed the black box warning, that was on all estrogen products. Again, estrogen being that umbrella term. So anything that contained estrogen of any sort, had a black box warning on it and it would be very frightening. And I would have to warn patients, say, ignore this warning. And it would, in that warning, say you were at risk of breast cancer if you use this, you were at risk of blood clots, at risk of stroke, and. Dementia. One of them even said probable dementia. That's the one that I can't even even fathom. You'll probably get dementia if you use this. That warning has been removed from all estrogen products and it's because you can't put a blanket statement on there. Even women who have had a blood clot or even if they attribute it to their birth control, can safely use estrogen as long as we talk about what type we're using and how we're delivering it, delivering it through the skin instead of, being digested through the liver. So it's not that everybody needs to be on on hormone therapy. It's not the only way to stay healthy, but all women should. Talk about it and should have the opportunity to talk about perimenopause and menopause with somebody who is knowledgeable and can work with you and your goals, even if it's just that you don't want that's great. Like we all have autonomy to be able to choose what's best for us, but if we don't even have the right information, then we can't choose knowledgeably what we think is best for us. We didn't even broach this, but the very, last thing that I will, say is Most women will eventually develop some sort of vaginal dryness. so dryness of the vagina, the vulva of the urethra as well. That's, at the top of the opening of the vagina, the clitoris as well. so that can cause pain just regular day-to-day living. It can cause pain, rubbing on clothing if you are trying to bike, it puts you at an incredible risk of UTIs. Menopausal women are at a high risk of UTI and that can lead to sepsis in, women who are in their seventies, eighties. So it's not just a benign thing of like, oh, you've got a little bit of dryness. It can make intercourse or sex incredibly painful. women will describe it as sandpaper sex or razor blade sex. I mean something that is just excruciating. Again, whether you're having sex or not, you're going to be probably noticing these changes eventually. That is also so. Easily treat it for every menopausal women. I wish that we could just hand out this vaginal cream to every woman who's 45 and just say, welcome to perimenopause. This is to stay with you for the rest of your life. It shouldn't even be prescription. You should just be able to pick it up over the counter, because that is so easily treated. And when we talk about, relationships or certain activities, biking or whatnot, uh, those things can become something that you can't do anymore because it's so painful. That is so easily treated with just a local estrogen of some sort. So again, no matter what your symptoms are. You need to talk to somebody about it and be able to just know. a lot of times we just live with things as women, incontinence, leaking of urine. Uh, so many things that we just kind of, Hmm, it's what happened. Think, I guess that's what it has to be now. Yeah. Having babies, pregnancy, gr you know, gravity, all of the things like, that's just what our bodies go through. But so much of it doesn't need to be that way. Just because it's common doesn't mean that it should be normal either. There's plenty that we can do to treat. our symptoms as women and we deserve that that care so that we can take care of other people. Yes. But then also feel our best as well. Again, menopause is a long time, and that's a good thing. There are a lot of benefits to being menopausal. How wonderful. Not to have to bleed anymore. Oh, I not to have to worry about being pregnant anymore. I mean, there are so many things that are just, a new life in front of you. So let's not look just, be, a fraction of ourselves after that point. women deserve so much better.

Well, I'm getting a mammogram today and a DEXA

scan.

Well done. Well done. And I'll, I'll be excited to look at that.

That's right. And it will be good. I did have a DEXA scan when I was in my forties, but I haven't had one for a long time, so I'm excited to see where I am

Yeah. we need the information. putting our head in the sands is no longer acceptable, for women's health.

Thank you Angela. you are a wealth of knowledge and I hope this will encourage people to advocate for themselves

thank you for having me, Brooke. It's just been a delight.

It was so good.

Thanks for listening to the podcast today. If you

have found my podcasts helpful.

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