Demystifying
Perimenopause
Perimenopause and Menopause are not the same. Dr. Watson explains the difference between the two terms, the changes occurring in the body during Perimenopause, and the different approaches used by professionals to ease symptoms.
With Dr. Polly Watson, MA, FACOG, NCMP
Cindi Michaelson:
Hi, I’m Cindi Michaelson with HER Health Collective, Co-Founder. I’m sitting here with Dr. Polly Watson. Dr. Watson is the founder of Hormone Wellness MD. She’s a Board Certified Gynecologist, North American Society Certified Practitioner and Institute for Functional Medicine Certified Practitioner.
I’m so excited to be here with you right now!
Dr. Watson:
Thank you so much for having me! I appreciate being here.
Cindi:
We’re going to start with a topic today that I’m very interested in. I’m a mom over 40, so I would love to hear what you have to say about Perimenopause.
Dr. Watson:
So, Perimenopause is sort of like Puberty in reverse and it’s kind of nature’s cruel joke. I wasn’t a young mom myself. When we begin to see these hormonal changes as our reproductive life is coming to an end, our kids are often going through their puberty changes. Under one roof we’ve got two folks that are having a lot of changes.
It’s the five years before menopause which is not having a period for a year. Just like when a young person is starting their reproductive life, if you will, they may have irregular cycles, mood changes, put on some weight and may have some sleep disruption, we experience all of those things on the back end as well.
Cindi:
On average, what do you find the average age is that most people enter menopause?
Dr. Watson:
In the United States, the average age for not having a period for a whole year is 52, so we are going to say 51 was the last period, which means 5 years before that. So, mid 40’s is usually when we are seeing it.
Just like not everyone started their period at 12, not everybody goes through menopause at 52. My mom went through menopause in her late 30’s. I started making changes in my late 30’s and so that was a huge driver for me to go into medicine because of the way my mom navigated the healthcare exchange, or healthcare community. Everyone told her she was too young and that she was crazy but she wasn’t, she was having really big physiologic changes and she needed some education and some support. It’s not always exactly when we think and it’s important to determine, “Is this really menopause, or a thyroid problem, or something else.” Just get some more information about it.
Just like when a young person is starting their reproductive life, if you will, they may have irregular cycles, mood changes, put on some weight and may have some sleep disruption, we experience all of those things on the back end as well.
Common Symptoms
Cindi:
What are some of the common symptoms that we need to look for with Perimenopause and do genetics play a role?
Dr. Watson:
You tend to do what your mom did, not always. If you’re not sure when your mom went through menopause, it’s a good time to talk about it. Our generation is talking about these things a whole lot more than my mom’s generation did.
Things to look for:
- The cycles get irregular. Folks will start missing cycles or as their progesterone is going down, they will start having a cycle every two weeks. It could be a combination of those two things.
- Some women will start to have hot flashes and night sweats. Usually it starts during their period. They make enough hormone, and when their horomone’s drop to have their period, they are having some night sweats and hot flashes.
- Many women will come in and their chief complaint is that they gain weight around their middle. They say that they aren’t doing anything different. They are still going to the gym, eating the same things but out of nowhere, they say they’ve put on about 12 pounds and it’s all around their middle. They want to know what’s going on! Weight gain around the middle is caused by insulin resistance.
- As we are going through these irregular cycles it is a proinflammatory time. We may feel pro-inflammatory in our mood, sleep disruption, and have a harder time processing carbohydrates ending up with weight gain in the middle.
Cindi:
Just out of curiosity, a woman that would have gone through a partial hysterectomy, meaning the removal of the uterus & cervix but leaving the ovaries, she wouldn’t be able to monitor Perimenopause through her blood flow. How would she know? Would she experience the same symptoms, night sweats etc?
Dr. Watson:
You could get some blood testing and see where you are. Sometimes we can get an FSH level, which is the brain telling the ovaries to work harder. It stands for Follicle Stimulating Hormone, “Hey brain, tell those ovaries to work harder.” FSH will start rising as the ovaries are not able to work as hard. It is important to realize that when we get hormone levels that we are checking a moment in time. It isn’t going to tell us what happened two weeks ago or what will happen two months from now.
If someone is concerned about early Menopausal changes, which in the scientific community is considered before 40, you would want to make sure you got that value and checked it several times just to make sure that you’re not giving someone the advice, “You can’t get pregnant” when they actually could because you checked it one time. You can check blood work.
The other things to look for would be weight gain, mood swings, sleep disruption, hot flashes, night sweats.
Conventional Approaches
Cindi:
So interesting. What are the conventional approaches to Perimenopause?
Dr. Watson:
A lot of times in Gynecology we were often taught, “Just give people birth control pills. Take the body’s hormonal changes and level them out.”
When someone is having hormonal fluctuations, I give them birth control pills, their body says that it has all the hormones it needs so the brain tells the ovaries to turn off and the birth control pills take over the system so there aren’t all of the fluctuations.
One of the concerns that I have with being on birth control pills as people get into their late 40’s early 50’s is that birth control pills contain estrogen which thickens our blood and increases our risk of having a heart attack or a stroke. This is also a time in life when maybe our blood pressure is going up or our cholesterol is going up, and maybe those other cardiovascular risk factors are also going up, so we are adding fuel to that, so you want to be careful. Make sure you’re on a low dose. Make sure that you’re at a lower risk of those other cardiovascular conditions so they’re not adding on risk.
The other thing that women are often offered in the conventional space is antidepressants. We don’t want to demonize conventional medicine or demonize women who that is the correct choice for at all. I want to be really respectful of that. I wish that we could have more time and take more time with women regarding what the withdrawal symptoms are going to be like when getting off these medicines and what are the side effects.
A lot of my Perimenopausal women who may be struggling with the weight that came up around their middle, then go on antidepressants which often cause more weight gain, can cause pretty significant sexual dysfunction, loss of libido and loss of the ability to orgasm. This is often a time in our lives when we aren’t rockin’ our libidos. It’s already hard and then we make it harder.
We need to have a nuanced discussion so that if we are going to make the decision, we are going to make the decision with our eyes wide open. That can be the right decision for some women. Again, we don’t want to demonize the decision but if there are natural things we can do, we want to make sure that those options are available to women, and maybe those options are a nice first line.
Cindi:
That’s a great lead into my next question. You’ve mentioned it a little bit already, but what are some of the challenges women face using the conventional methods?
Dr. Watson:
This is interesting, when your body is dealing with hormones, most of the hormones in your body are bound up by a binding protein. For sex hormones its called Sex Hormone Binding Globulin.
I think about this as a bus driving around your bloodstream. Your body feels free available hormone. If the hormones are on the bus, you don’t really feel it. When you take oral estrogen in a birth control pill, your body says, “Oh man, I’ve got too many hormones on board. I’m going to jack up my sex hormone binding globulin (putting more buses in the bloodstream) all the hormones are going to get on the buses. Guess who else gets on the bus…testosterone.
Can you feel bound up testosterone on the bus? NO! When you go on oral estrogen, you’re jacking up your sex hormone binding globulin which is binding up your free available testosterone so you’re going to feel a relative drop in testosterone. That’s one of the reasons birth control pills work so well to clear up acne, they’re dropping testosterone.
Cindi:
What does testosterone do?
Dr. Watson:
Some women will notice a difference in their libido based on their level of testosterone, but not always. Testosterone levels don’t always have a one to one ratio with libido. I think libido in women is extremely complicated and nuanced. There are some women that will notice some sexual dysfunction when they go on oral birth control, and that’s why…because the sex hormone binding globulin goes up.
When you go off of birth control, it takes about six months for sex hormone binding globulin levels to go down and get everybody off the bus.
It’s important to communicate all of this to women. Letting them know that this could provide benefit and this risk. We are having a nuanced discussion with women so they make decisions with all the information.
Cindi:
That’s great that you give them all of that information! I think some people enter into a decision without it and make their choices not knowing all the details.
Holistic Alternatives
Cindi:
What are some holistic alternatives?
Dr. Watson:
It’s important to me that people understand that this is not a hormone clinic, that is actually a whole person clinic.
We aren’t trying to just fix your hormones, we are trying to fix all of those downstream effects because it’s like a concert, everything works together. We can’t just have a drum section. We need the horns and woodwinds etc.
When someone is going through Perimenopause their hormones are going up & down and their progesterone levels are going down. They have estrogen dominance. This stimulates inflammation in the system. We really need to push the anti-inflammatory diet. It’s complicated and it’s not. Just eat whole foods including fruits, vegetables, clean sources of protein, grass fed beef, wild caught fish, chicken’s that got to walk around and be free range.
It doesn’t include eating a lot of processed things that come out of boxes, items with refined sugar, and drinking a lot of alcohol.
With a patient that has insulin resistance and the weight is coming around her middle, timed eating can be such a game changer in trying to reverse the insulin resistance. The other way that we talk about timed eating is Intermittent Fasting.
The idea is that we are often told to eat six times a day, little meals to keep our blood sugar up throughout the day. The pancreas that is making the insulin gets tired because it’s working all the time. What we are trying to do is give the pancreas a rest and give the body a rest to get away from some of the blood sugar and insulin, so that when it comes around again, it can actually respond to it.
We are trying to shrink our eating window to about 8 hours a day. Start simple, for example maybe you don’t eat after 7pm and you eat from 7am-7pm, then stop from 7pm-7am. You start with 12 hours.
Next step may include making it to 9am before you have breakfast. Or some decaffeinated coffee with some MCT oil in it. Putting fat into your coffee which is insulin neutral but gives your brain some fuel to make it through your morning and eat lunch and dinner.
I wouldn’t recommend someone go to the gym alone and lift weights with no food in their stomach. We want to use caution.
Building up slowly in the number of fasting hours could potentially be a game changer in terms of reducing the insulin resistance and helping the weight around the middle.
Cindi:
This has been so interesting and is certainly a topic for another time for us to talk about. I know that many people have questions about intermittent fasting.
Finding A Practitioner
Cindi:
How do I find a practitioner who can help? Well, you right (laughing)?
Dr. Watson:
If you are looking for alternative methods, there are some really great organizations that certify individuals. I was trained through the Institute of Functional Medicine, which probably many of your audience has heard of Dr. Mark Hyman and the Cleveland Clinic. Dr. Hyman is one of the teachers at IFM. www.ifm.org is a great place to look for a practitioner and that way you know that you’re getting someone who is certified. There is a really big test that we have to take, so you can make sure that individuals have all graduated with a certain basic skill set.
Cindi:
So much great information! Thank you so much!
Dr. Polly Watson is a board certified OBGYN who has been refining her practice of women’s medicine for almost 20 years. In 2007, she chose to focus solely on gynecology. Early in her career, she found that many women felt underserved in busy OBGYN practices which focused on delivering babies. Seeking to serve these women better, she concentrated her practice on menopausal medicine and became a North American Menopause Society Certified Practitioner in 2009. She sought to broaden her skills and attended training from International Society for the Study of Women’s Sexual Health in 2011. Dr. Watson completed the Institute for Functional Medicine Certificate Program (IFMCP) in 2019. She is one of about 1000 providers in the US who has obtained this certification.
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