Chapters Transcript Video Rethinking menopause care for midlife women Not every woman in midlife is going to experience these menopausal symptoms that can be potentially really bothersome for quality of life. But a lot of women will have really, really bothersome symptoms, and for too long, women have been told, like, this is just menopause. This is natural. Everyone goes through this, whether it's, um, you know, from a medical provider or whether it's from, you know, culture, family, friends. Women have just kind of sucked it up for too long. Yeah, accepted it for, but there's treatments for this. But we have treatment options. So it's really looking at the whole host of symptoms that women are experiencing and also setting expectations on what different medical therapies or what other lifestyle or behavioral changes can provide. Hi, I'm Lindsay Carrillo, director of business development at UCI Health. Hi, I'm Doctor Sunil Verma, Associate Chief Medical Officer for ambulatory at UCI Health and an otolaryngologist, head and neck surgeon. Welcome to Physician Huddle by UCI Health. Today we are joined by Doctor Rebecca Sauer, associate professor in obstetrics and gynecology at UCI Health. Welcome, Doctor Sauer. Thanks for having me. So, Doctor Sauer, tell us about, take us through your career here at UCI Health. What brought you here and what do you enjoy doing? So I think it actually starts that I started my medical school here. So when I, I, I live in Orange County, I went to medical school here. I did my residency up at UCLA, so not too far away. And eventually came back to UCI due to a combination of family and just really loving the institution and academics and what I was raised in. The whole reason I went into OBGYN was through my medical experience and the OBGYN clerkship in my 3rd year of medical school here. So I came back, um, as a general OBGYN initially with kind of a more broad practice, taking care of obstetrics, doing surgery, taking labor delivery calls. Seeing patients in the clinic. Um, and then I've kind of narrowed that down over the past couple of years. I am seeing a lot of perimenopausal patients. I am seeing a lot of patients who are wanting more information about midlife care. And, um, I think, you know, whether by word of mouth or by, um, by certifications and menopause, uh, society as being a practitioner in menopause. Um, I, I'm just kind of getting that population in my practice now. So it is kind of self-evolved in a lot of ways, um, and I've learned a lot over the past, you know, 5 to 10 years regarding midlife care, and that's where I find myself now, um, in the process of trying to really advance menopause care here at UCI. So you mentioned your training here at UCI. Tell us a little bit about the training that was offered to you for menopause care, midlife care, and is that changing now, or are you hoping it will change? There's been a lot of talk about sort of the lack of training for physicians in that area. Yeah, for me, at least in my, in my rotation in obstetrics and gynecology. We didn't talk about this subject at all, so I'm personally fascinated to learn, like, is, was this a for you, you alluded to this being a formal training. Yeah, absolutely. So when I was training, I also, like you did not hear about menopause. Um, I think a lot of the focus in medical school and in residency is very much inpatient, going to be obstetric. It's going to be gynecologic surgery, high level gyne cancers, um, really, you know, acute critical issues. We're spending probably 60 to 70% of our time at least managing that in residency, and a smaller portion of that is in ambulatory care. And then you get a whole breadth of ambulatory care. But again, menopause is not a huge part of it. In my training, at least, a lot of my patient population was more reproductive age, so a lot of contraception, um, a lot of reproductive rights, obstetrics in the ambulatory setting, but we're not seeing a lot of our, I didn't see a lot of midlife patients. So, um, through clinical exposure and even formal didactics, really, really very minimal, if any, exposure to menopause. I do believe that is changing. There's a lot of work that needs to be done in terms of education, in terms of our medical students and our residents, not only in OBGYN but really broader to everyone's, anyone who takes care of midlife women, which is many, many specialties, um, and knowing how this may impact their life and how their subspecialty may play a role in midlife care. Um. But, you know, at UCI for instance, our residents have a lot of interest in learning about it. They're excited to practice menopause care and be comfortable with prescriptions, hormone therapy and understanding how to counsel patients and identify who's a good candidate for X, Y, Z. So there's a lot of interest and passion, and I think they feel like they don't have enough education. So, It's a combination of kind of figuring out what's the best way to address this. There's no formal necessarily curriculum that's set on a broader level, um, in terms of like a fellowship in menopause or anything like that. But I think with the amount of information that we're getting in the research studies and, um, just the change in clinical practice that Who knows that might happen in the future, because midlife women is a huge population with a very special um amount of needs, and we need providers who are specialized in that care to be able to provide that. Yeah, absolutely. So, you know, you mentioned some of these subspecialties that could potentially be taking care of these women or some of these symptoms. So beyond sort of the typical hot flash conversation, what are some of these symptoms or things that come up that, you know, if you didn't get training on it, you wouldn't necessarily know is tied to menopause or perimenopause. I've heard things about like frozen shoulder and Sleep deprivation, like all these things, can you kind of just give us a little rundown for our physician friends out there who maybe haven't, they don't know that this is the connection. Yeah, absolutely. So when we look at these broader studies, the most common symptoms of menopause and perimenopause are going to be our vasomotor symptoms like hot flashes and night sweats, sleep disturbances, mood changes, urogenital symptoms, um, whether it's urinary frequency, incontinence, vaginal dryness, um, And um Those are really our top common symptoms that we see with perimenopause. But that being said, there's a lot of research that is showing different things that are associated during the midlife time, and whether it's directly related with menopause, I think some of these um correlations have to be figured out more directly, but we are seeing, um, joint issues like frozen shoulder, and in the orthopedic literature, they are noticing a correlation of perimenopause with things like frozen shoulder. I know and ENT, some tinnitus and um uh other ear symptoms have been associated in the perimenopausal time. And again, whether these are completely linked with the hormonal fluctuations, I think still really needs to be fleshed out. We're not sure if it's like correlative or causation or just a random coincidence. But women can experience a whole host of symptoms, whether it's more like headache symptoms, um, metabolism symptoms, weight changes. We do know that there are cardiovascular changes that can happen in midlife that may affect women. There's cognitive changes, um, women may experience. Subjective cognitive fog where they're just having a more difficult time with word finding, short-term memory. This has been really hard to, um, quantify in studies, but many women report these symptoms, and we do know that dementia does predominantly affect women as well. So, um, there are a lot of things that may also have consequences later in life too. So, midlife care is really an opportunity to Kind of address these and hopefully make a change for the better. So what is the, that's a whole host of symptoms you just mentioned. So what is the workup for a patient with, with these symptoms? How much do you rely on testing hormones and, and then tell us a little bit how you, how you manage patients both with and without hormone therapy. Yeah, absolutely. That's a great question. So, In a sense, the symptoms of perimenopause are somewhat of a diagnosis of exclusion, since we don't have any objective data, whether it's blood work or imaging that can confirm that your symptoms are a result of perimenopause. Um, you know, for like the, the Menopause Society and OBGYN Society's expert opinion is that there isn't any lab testing that's necessary in order to test for perimenopause. But that being said, it's important to exclude other underlying medical conditions. For instance, 1 in 10 women who present with perimenopausal symptoms actually have a thyroid disorder. We also see rheumatologic conditions and autoimmune conditions rise in midlife women. They predominantly affect women. So evaluating for those, if someone is complaining predominantly of joint pain, um, they're having swollen nodules, family history of autoimmune disease, working that up with a specialist first before saying, oh, this is all perimenopause. Um, Look, sir, um, regarding the mood disorders, we do see, you know, depression and anxiety peak in, uh, midlife. Care. Um, it's considered a window of vulnerability in the reproductive axis for women, and whether it's like a perimenopausal link or just, you know, happens at the same time due to hormonal fluctuations, um, you want to kind of work that up with other vitamin deficiencies, potentially folic acid, B12, um, ferritin, because they can sometimes manifest symptoms of mood disorder. So, Um, there's no, I think, standard that needs to be done if someone has been, you know, in the care of a primary care and you already have this objective data, but depending on their symptomatology, if there's a possible other medical cause, important to rule that out before attributing it to perimenopause. So that being said, um, then we kind of have to really individualize the care. Because not every woman in midlife is going to experience these menopausal symptoms that can be potentially really bothersome for quality of life. But a lot of women will have really, really bothersome symptoms, and for too long women have been told like, this is just menopause, this is natural. Everyone goes through this, whether it's, um, you know, from a medical provider or whether it's from, you know, culture, family, friends. Women have just kind of sucked it up for too long, accepted it for, but there's treatments for this. But we have treatment options. So it's really looking at the whole host of symptoms that women are experiencing and also setting expectations on what different medical therapy. Or what other lifestyle or behavioral changes can provide. Oftentimes, you know, I think what's best for a woman is a multidisciplinary approach. So what's, I think, really hot right now is things like hormone therapy, which is standard of care for your common menopausal symptoms, like, um, hot flashes, night sweats, sleep disturbances. And there's certainly some studies that show benefit to some of the mood disturbances women may experience, and depending on the hormone therapy, um, benefit to the eurogenital symptoms women may experience as well. We have a lot of non-hormonal medical options as well. Um, generally, they're not as effective in terms of treating symptoms based on, uh, compared to menopausal hormone therapy. However, they may carry, you know, a safer profile or for women who it's medically not safe. To have hormones, then this can be a very good class of options for them. Or if someone has like a really targeted symptom, they're in midlife and they're only experiencing like depression and anxiety, sometimes using something that's more along the antidepressant route may be more effective than menopausal hormone therapy for that individual. So part of it is like kind of assessing their whole health history, their risks, also their symptomatology to kind of set expectations on what may get better or not. Um, for instance, I think like weight gain is a very common complaint in midlife, and we see it both in men and women in the 40s and 50s. So it's not something that's strictly due to perimenopause, but likely a combination of cellular aging, metabolism, and so forth. So we can't really expect hormone therapy to reverse. All those metabolic changes that are associated with aging, we do see potentially some benefits, but to think that this is going to be like a dramatic impact on weight gain, I think not, um, realistic. So, kind of making sure that we're setting expectations on what hormone therapy can do or may not do for the patient. Yeah, I'd like to know a little bit about, you didn't mention osteoporosis, muscle loss, bone loss. And there's a big movement for women and men in this age group to start really thinking not so much about cardio, but more about weightlifting and resistance training. How does that play into the advice that you give patients, or what does the literature show? Yeah, absolutely. So I think what's critical here is that also multidisciplinary approach, that hormone therapy and medical therapies that we have prescriptions helpful, but probably not the whole piece of the pie. Um, in addition to being FDA approved for treating vasomotor symptoms, menopausal hormone therapy with estrogen. can help prevent osteoporosis. So for women who have low bone density or normal bone density with a family history of osteoporosis, risk factors for osteoporosis, this is a very good option for them. So, even in light of just bone health, hormone therapy can be an option. I think it's underutilized for that purpose because of concerns about the potential risks of hormone therapy, but it is FDA approved for that indication. Um, In terms of um The lifestyle modifications, really important. I think with cellular aging and metabolism, we have to know that there has to be lifestyle modifications from both a dietary standpoint and an exercise standpoint. And that weightlifting is very critical in order to preserve that bone and muscle mass for women, which does rapidly decline with the onset. I mean, studies are showing that it starts even earlier in life, potentially in the mid-thirties for women. But we certainly know its impact accelerates in perimenopause and more so after menopause. Currently, the guidelines for bone density screening in women who are low risk is to start at 65, and this is really, we've already missed the boat for a lot of these women. So This is just a whole host of the things that needs to be done with midlife care, but advocacy, changing policy, getting the research to support what is the best to really prevent osteoporosis, because once someone is diagnosed with osteoporosis, it is challenging in terms of treatment. There's no great long-term treatment. Oftentimes women are trying multiple medications to preserve their bone density, to prevent those really catastrophic. Um, like hip fractures that can really affect women with osteoporosis. Can we go back to HRT for just one minute because it It feels like for so long there were, there were a lot of fears about breast cancer, and it wasn't just patients. There were a lot of physicians who were just too scared. The data was unclear, and so they really didn't know how to counsel their own patients. Even primary care doctors were like, Hey, I get it. If you're worried about cancer, then we won't even go there. And it feels like we're in a moment right now where that might be shifting. Can you kind of tell us? How we've turned the corner. Well, I hope we have. Yeah, absolutely. I'm glad you asked that, Lindsay, because I was scared to actually ask that myself. I was like, oh we're terrified. Yeah, what's truth and what's rumor? And I think this is so confusing for patients because the pendulum really has swung so far. You know, I think back in the 70s and 80s, we saw all the benefits hormone therapy was having for preservation of bone health and really symptomatically helping women. Then the Women's Health Initiative, which was such a large number of patients enrolled in that study, was initiated with the use of hormone therapy. Um, to be specific, they did use synthetic hormones, which was available at that time, which for the estrogen estrogen was a conjugated estrogen. What this means is that um, Chemically, the hormone is not exactly identical to the estrogen in our bloodstream. It binds to the same receptors, so it's going to have an impact, but not chemically the same. And then the progesterones are also synthetic, so similar. They have the potential to be more potent than they need to be with these synthetic compounds. For instance, like in birth control, we use synthetic compounds because we need it to be more powerful than a physiologic estrogen will be in someone's bloodstream. So this study just looked at women of all, you know, post only postmenopause, um, and starting hormone therapy to potentially have some cardiovascular benefit because we were seeing that cardiovascular disease and heart attacks were happening in women in midlife. Maybe hormone therapy can reduce that or prevent that. So when they started that study, they did see an unacceptably high risk of breast cancer in a group of women who was taking estrogen and progesterone. Um, so the study was stopped, and then basically the number of prescriptions for hormone therapy declined dramatically. But I think when we start to parse out some of the details of the study, what we're seeing is that the women who were enrolled in the study, the average age was 65 or above, which is again, Far beyond women experiencing the average woman nowadays experiencing perimenopause or menopause, it's kind of beyond the transition point. A lot of these women were also asymptomatic as well, so likely have already undergone the menopausal transition. So maybe not our ideal group of patients to be looking at. Um, additionally, we are more commonly using bioidentical hormones now, and that is also a term that I feel like is very confusing. It's out there. It's in social media. What does it mean exactly? And bioidentical just means that the chemical compound of the prescription is similar to the one in our bloodstream. So for estrogen, it's 17 beta estradiol. That's what's in our bloodstream. The micronized prometrium or micronized progesterone. is an oral capsule that's like bioidentical to the progesterone in our bloodstream. So we are using these more, which are FDA approved and regulated because I think there's also a concept that these have to be like specialty formulated or compounded only, which is not accurate. It is FDA approved and available at your CVS. It's regulated, tested for purity, etc. But studies are showing with these compounds that overall risks that we did associate with menopause hormone therapy really extrapolated from the Women's Health Initiative are not that, not as high. We haven't had a study as large as the Women's Health Initiative looking at the bioidentical compounds alone, and there's a lot of heterogeneity in studies, um, because some will use like Uh, synthetic progesterone and the bioidentical estrogens. So it's hard to kind of do a direct comparison, but we're also seeing that it probably is a lower risk of breast cancer than we thought. And then when you do even a, you know, deeper analysis of the Women's Health Initiative. Some people are finding that that placebo group had like a very extraordinarily low rate of breast cancer. So when you do the comparison of the placebo group that compared to an average, you know, population, that um it was unrealistically low, so the comparison seems more dramatic. So. Now that we see some of the flaws of this study are, um, I guess, relevance to the patient population that we're treating now, I think people are understanding the benefits of hormone therapy and the risks are not as impactful as we historically thought. Now, they're not zero. I think it's very important to counsel a patient regarding the potential risks, and the really most dramatic health risk would be the potential risk of breast cancer, which is slightly increased, but again, not to the point of the Women's Health Initiative. And um there is a risk of blood clot for any kind of estrogen that's given in the body that can increase the risk of blood clot. But when we look at, um, kind of the transdermal approach that's available for women, It avoids needing to be metabolized by the liver, which can cause a lot of the inflammatory reactions that predispose women to blood clots and stroke. That risk is also lower too. So we have safer alternatives nowadays that would be preferred to start with for hormone therapy. So in balancing this out and counseling patients, The benefits are symptomatic. A lot of the symptoms that you mentioned should be reduced. Are there, is a reduction in any type of cancer from taking, from being on HRT or cardiac benefits, um, other than perhaps just, uh, yeah, so like perhaps you can review the, the benefits of being on this. Absolutely, um, so primary the indication is symptom alleviation or osteoporosis prevention. Um, the studies did show a small reduction in colon cancer, and if you look at some other different studies, potentially a slight decreased risk in lung cancer and why that is unclear, but, um, potentially some benefits there. These benefits are not so impactful that we should be prescribing hormone therapy for these indications, but again, it's like not all bad, but the osteoporosis is one that you should be prescribing it for, OK. Um, and it's the osteoporosis prevention. So once someone has osteoporosis, not a really great treatment option, but for the prevention of it, it certainly can be utilized. Um, And in terms of cardiovascular, yes, this has always been really controversial, um, because we are seeing heart disease happen in women at menopause, and we do know that there's estrogen receptors in the vascular and probably to have some of my colleagues in the cardiovascular women's health, they probably have much more up to-date information on this, but from my understanding in terms of the larger studies that they've been controversial. So some studies have shown a benefit in terms of reducing cardiovascular disease for women. And some have been equivocal, but overall, there's a small trend for women who are close to menopause. So usually less than 5 years from the last menstrual period. So from that perimenopause to like right after menopause, where you still may have a benefit for cardiovascular health by initiating hormone therapy in that window. But once you've gone 5 years past your last menstrual period, or certainly more than 10 years, then potentially the effects of estrogen may be negative on cardiovascular health. So there's this timing hypothesis that may be in play on when to initiate hormone therapy to have those cardiovascular benefits. Very interesting. Yeah, so to sort of close the loop, I mean, you've been doing this for a long time. Tell us, what are the impacts you're seeing in your clinic among your patients who decide, yeah, I want to try this like. Life changing, right? Yeah, yeah. It's been so gratifying to see how just listening to a patient and having them feel heard that they're just not, you know, it's not just natural or they're crazy for thinking this. Um, they're not, you know, it's, it's hard for women. A lot of the women I see in this position are not only dealing With the symptoms of menopause, but they're oftentimes like in a high level position at work. You know, they're usually just at the top of their career, in their late 40s, early 50s, mid-50s, managing their children, managing their children. They're usually the director of their household, taking care of sick parents or other family members. So they are juggling so many hats. And a lot of times it's like, oh, you're just stressed, you know, this is life is hard, and it's not, that's not the case. You really are experiencing menopause, and um to make them feel more like themselves, so that they can handle the things that they cannot control changing. It is extremely gratifying. And I think, um, it's just important for us, like all, as all providers, but especially in women's health to be just really attuned to listening to patients and their bodies because menopause is so individualized. Someone's menopause is not going to look the same as somebody else. And um we may not have a lot of information regarding certain symptoms. But to not dismiss them, I think is really important. Um, I, I think it's really impactful. I think because I have word of mouth, you know, um, I see a patient that are like, oh, you know, you saw my sister, you saw my mom, that you saw my coworker, and like they're really happy now, so I want the same. So I think that's just reflects like what a small thing of even not, not necessarily like prescribing hormone therapy, but just like listening to provide support and validation and Um, possible options to improve quality of life can make a big difference for women. Absolutely. So I know you are working to build some things here at UCI Health, um, some comprehensive programming. So tell us what is, yeah, what's your dream here? Yes, so we are so fortunate that the state of California is supportive of advancing really care in midlife women. So, um, actually there's been an assembly bill that provides funds to building comprehensive menopause programs for the UCs, and I've been very fortunate to be a part of that. In collaborating with all the UC campuses to kind of create a more standardized evidence-based approach to addressing menopause cares. There's a huge need in the community. You can see it. It's on social media. You see a lot of these like online consumers that are targeting midlife women because we are not meeting the needs as an institution, as a women's health, you know, specialist, we are not meeting the needs of our patients. So we need to do that. Um. So our vision here is we are creating like a core group of certified menopause providers. So the Menopause Society is kind of the evidence-based expert opinion society for menopause, and they have a certification process. So you know what's evidence-based, you know what's up to date, you know what's safe, what's not. Um, because there's a lot, there's a lot out there in the community, some things that are even potentially harmful, frankly, that is being provided in the community. So we're trying to provide something that is evidence-based. We're an academic institution, we're cutting edge research, we can provide that, um. But right now, I think there's a lot of heterogeneity in the advice that we're providing to our patients, because some people are a little bit more comfortable, some people are a little bit more aware of what's happening in menopause care, and some are not. And it's a lot easier to say, I don't know, see somebody else than Provide the care that we can. So we're trying to bring up in our primary care, family medicine, internal medicine, OBGYN to be all on the same page here, to provide that access for patients. And then also networking with a great network of sub-specialists we have in UCI. to make sure these patients are getting connected to appropriate care. We have our endocrinologists who specialize in bone health, particularly in midlife women. That's a huge need. Our breast health, making sure they're getting their adequate screening and prevention for breast cancer, and our cardiovascular, you know, Women's heart disease is so different than men's heart disease, and midlife plays a big role in that. So having our cardiovascular team as well, our behavioral health and psychiatrists, our pelvic floor physical therapists, and our urogynecologists, urologists. So we have um our subspecialized physicians who are up to date on the menopause literature to be able to take care of those patients for the individualized concerns that may be associated in midlife. That's so cool. Yeah, love it. Yes, this is so exciting. I've learned so much today. So thank you so much for being on with us, Doctor Soer. Oh, it's my pleasure. This has been Physician Huddle by UCI Health. Thank you for joining us. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shahen, Angelica Yagubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, view the show notes or visit clinical connection. UCIhealth.org. Created by
