The Perimenopause Guide: Navigating This Transition with Dr. Susan

Despite the numerous well known benefits of menopausal hormone therapy, it's important to talk about some common side effects. The most common frustrating side effect that we seen our practice is a new onset of bleeding, which affects about 5% of patients. The good news this is very rarely anything to worry about. It is certainly a major annoyance that needs to be addressed. Today I'll discuss why this happens in both menopausal and perimenopausal patients, how to evaluate it and most importantly how to make it stop!

During the last decades of confusion about menopausal hormone therapy, many well-meaning solutions were offered to patients claiming to be safer than the feared traditional HRT. These include combinations of estrogens, progesterone and testosterone in the form of topical creams and sublingual preparations. Now that we are emerging from this fog of confusion, and understand that estradiol, progesterone and testosterone are not only safe, but also provide numerous health benefits for women, it's important to reevaluate whether compounded estrogen products still have a place. Today I’m discussing the different types of estrogen that are available in compounded form, why progesterone cream is not a safe solution for patients who have a uterus, and why at the current time we need to rely on testosterone in compounded form, and how to ensure that we're getting the safe and most beneficial dose.

Managing the time leading up to menopause, known as "peri-menopause," can be particularly challenging due to fluctuating hormone levels and their often unpleasant side effects. These years can feel like an unpredictable roller coaster, making it difficult for both patients and providers to find balance. However, understanding what's happening in your body during this period is key. With the right knowledge, we can develop a treatment plan that includes effective options to alleviate symptoms and bring your life back into balance, helping you navigate through these challenging years with greater ease.

As science progresses, it's so important to recognize when we got something wrong and tell patients that we have learned something new and better. Too often, doctors are stuck in their old ways and are not up-to-date in the latest science, and are continuing to practice out-of-date medicine without recognizing that they were wrong. Today I'm addressing the top five things that I personally got wrong, and I told patients these things for years before learning that there was a better way based on modern science. Even what we tell patients today no doubt will change as our understanding progresses, so it's important to see medicine (and science in general) as an ever-changing growing body of knowledge. As patients it's so important for us to stay educated and advocate for ourselves if we hear that our providers are giving information that is out-of-date or incorrect. If we learned anything at all from the debacle about menopausal hormone therapy, it's that we get things wrong sometimes, and we need to accept that, learn from it and move forward with a better way of practicing to take great care of our patients.

With metabolic dysfunction on the rise (including everything on the insulin resistance/pre-diabetes and diabetes spectrum) it's critical to understand how we are metabolizing glucose and carbohydrates. When you come to the doctor's office, we typically check glucose, insulin and other markers in a fasting state, but we have no idea what happens later in the day. Until recently, continuous glucose monitors have only been approved by insurance for diabetic patients and have required a prescription. Recently Dexcom released an over-the-counter continuous glucose monitor called Stelo, which measure is your glucose every 15 minutes, 24 hours a day. Today I'm talking about my experience with Stelo and why it might be something to consider, especially if you're struggling with weight gain or if you simply want to be educated about how different foods affect your metabolism.

Now that we are all aware of the multiple health benefits of taking menopausal hormone therapy, let's dig into some of the questions regarding timing, particularly for estrogen. There's no doubt that starting estradiol as soon as possible after menopause helps keep our blood vessels healthy, and reduces the risk of cardiovascular disease as well as multiple other diseases, including Alzheimer's. But what if you were not offered hormones and you are now more than 10 years past menopause? Today I'll be talking about what studies have shown regarding the possible risks of starting estrogen later in life, and why these risks may have been overblown and don't apply to everybody. I'll also talk about the myth that hormones should be stopped at some point, and discuss why this idea ever became popular.

This has been an exciting year with much more attention being paid to midlife women's hormonal health. Finally perimenopause/menopause is getting a voice, and the use of MHT (menopausal hormone therapy) is becoming widely accepted. Once we have decided to take menopausal hormone therapy, there are multiple options of products and routes of administration. Today I'll be discussing the different options for bioidentical menopausal hormone therapy, and the pros and cons of each. It's also important to understand why the doses are vastly different for the various different products, and why it's important to have your blood drawn to make sure that you are reaching optimal levels, because absorption is highly variable between patients. In the end, reaching the appropriate blood levels is much more important than the route of administration, which is really just a matter of personal choice and lifestyle. While the vital hormone testosterone continues to be controversial, in my practice we consider "optimal" for female testosterone to be in the upper range of what is physiologic for women (restoring levels to the high end of what they were when we were younger). Multiple studies have shown that these levels safely provide benefits for sexual wellness as well as muscle and bone conservation, sleep and mood. We recognize that long-term very high levels of testosterone put patients at risk of not only nuisance symptoms, but also irreversible masculinizing effects, which is why we never dose at that level, and why we have developed a novel dosing protocol which has proven to be safe and effective. Unfortunately, the practice of "Supra-physiologic dosing" continues elsewhere in the community, and is at the root of many people's misunderstanding about the safety of testosterone . We set ourselves apart from others who put their patients at risk with levels that are too high, and we pay the utmost attention to making sure we keep hormone levels optimal, without elevating risk.

Vitamin D is the subject of a lot of controversy right now after the Endocrine Society made new recommendations in June 2024 suggesting that routine screening for vitamin D was not necessary, and routine supplementation was not beneficial for the average person. Today I'm looking into how they came up with this recommendation and what hundreds of studies have shown over the years, to put this recommendation in context. Everyone agrees that vitamin D is critical for life and no one is suggesting that we don't need it, but questions remain around whether we need to take a supplement or if we can find it naturally, and if so, whether we need to measure blood levels and what the optimal blood level should be.

Creatine is a naturally occurring peptide consistent of 3 amino acids, and has been widely studied for its numerous benefits and low side effect profile. In fact creatine is the most studied supplement in the world. Well known to improve muscle mass and sports performance, creatine is particularly relevant in midlife when losing muscle and bone accelerate, and gaining muscle can be more challenging. As well as the numerous health benefits related to muscle and bone, creatine also has important implications for brain health including improving memory, dementia risk and recovery from brain injury. In short, creatine is one supplement that I recommend for just about everyone!

Most of us have heard a lot about insulin resistance but many of us still don't understand why it should be considered a disease in and of itself, separate from diabetes. Insulin resistance affects more than 50% of our patients and causes weight gain around the middle, as well as increasing heart disease, Alzheimer's disease and of course, diabetes and its related complications. My hope is that with a better understanding of how this process works we can each get more involved in doing the things that are necessary to cure insulin resistance. This can almost always be cured with nutrition and exercise alone, without medications. Once we truly understand how the process works, we can become internally motivated with a clear reason WHY to stick to our healthy nutrition and exercise program.