Menopause information and advice is available everywhere now, and literally at your fingertips. And with a quick search with Doctor Google, you could either find some very valuable resources, or be taken down a path of misinformation. Gaining reliable advice as well as evidence-based treatments to manage your symptoms is what we are all about here at Gennev. So, we tapped into Dr. Lisa Savage, board-certified OB/GYN, to answer questions from our community about menopause, and help dispel the myths and share the facts surrounding symptoms and treatments.
Will my migraines disappear after menopause?
Headaches are very common, and what happens during menopause is highly variable. I've had plenty of patients whose migraine headaches do get better, others who got worse and many who stayed exactly the same. It’s not predictable and it’s very individual.
Some women have a cyclic component to their headaches (menstrual headaches) that come on as a prelude to menstruation, and lift after your period is over. Those types of cyclic headaches generally get better with menopause when cyclic hormones are not playing a role. Ultimately, I think it probably takes about a year after that last menstrual period to really know where your headaches have ended up - and even after that, there may be some change that can go either way.
How long does it take to feel better on HRT?
Time to symptom relief is a really gratifying part of starting HRT because it doesn't take long. It’s not delayed gratification. I always tell my patients I don't want to overpromise, but typically results can be seen anywhere from 48 hours to a couple of weeks.
How long can you take HRT?
It’s very individualized, and it depends on how old you are, when you need to start, and how long you want to take it. HRT does not need to be a long-term commitment if you don't want it to be. Some women will take it for a few years to relieve the worst of the symptoms, and some women will need it longer, especially if they started their menopause transition at a younger age. Usually when a woman is approaching 60, I'm looking to see if we can get her off HRT, assuming she was around average age for menopause…meaning she’s been on it for around 10 years. I like to describe the therapy goal as extracting the most benefit while minimizing risk. But again, it's not written in stone and there's no hard and fast stopping point. Some women have ongoing symptoms for which they need the HRT. The most recent NAMS statement on HRT has taken away some of the boundaries about duration of treatment, which allows for our favorite way to prescribe medication; that is, with a lot of individualization.
Should I fear using HRT because it can cause breast cancer?
The short answer is no, but the better answer is “it depends.” There's no doubt that some susceptible women, such as those with certain family history or genetic risk factors, may not be able to or want to take HRT because it may fertilize a propensity to develop breast cancer. It's true that with longer term use from combined (that is estrogen and progesterone…not estrogen alone) HRT, there's a small increased incidence of breast cancer. It's about 8 extra cases per 10,000 women, so the absolute risk is very low. The increased risk from two glasses of wine per night or eating red meat is higher, to put it in perspective. You do have to commit to screening mammograms and knowing your body. I put this in terms of risk benefit ratio more than cause and effect. So often the benefits are going to outweigh any potential risk. We consider the individual patient and her individual profile when it comes to HRT.
Can women start having migraines in perimenopause if they've never had them before?
I’ve seen women start having migraines in perimenopause, but headaches are so multifactorial, especially vascular headaches. And my sense is that the sleep disturbance that comes along with perimenopause transition may play a big role in headaches. We all know if we've had a restless night’s sleep, the next day we don't feel as well in our body. Maybe more headachy. I believe there's a real sleep disturbance component to these headaches.
If you are post-hysterectomy, do you need to take the progesterone with the estrogen?
The only job of the progesterone in HRT is to protect the uterus from overgrowth of the lining. So, if a woman does not have a uterus, whether or not she still has ovaries, then she doesn't need a progesterone. There’s some evidence to show that the combination of the estrogen plus the progesterone (the E + P) is what can cause some additional risk over time.
Is there a connection between autoimmune diseases and menopause?
Autoimmune is highly prevalent in women compared to men, and estrogen plays a role in autoimmune disorders and immunity in general. But immunity is also influenced by genetics, lifestyle and environment, so it's hard to carve out just the estrogen component. It definitely plays a role in some autoimmune disorders such as rheumatoid arthritis and MS – as they may get worse with menopause. Lupus sufferers may actually feel better with menopause. But this varies greatly as it’s based upon the individual patient.
Is it true that the earlier a woman starts puberty, the earlier they'll start menopause?
Not necessarily. A lot of women think if they were a late bloomer, they will not go through menopause until later. Or perhaps they started their periods when they were ten years old, and think they’re going to finish earlier. These things are not necessarily correlated. The average age of menopause across the board is 51. The normal age range is 45 to 55, and it’s independent of how old a woman was when she started puberty. Family history may actually be helpful; that is, knowing how old your mother or older sisters were at the time of menopause may be somewhat predictive.
Should I worry if I’m 59 and haven’t hit menopause yet?
This is definitely older than average (by the age of 55, 95% of women have completed the menopause transition), but as long as you’ve been getting medical care from a clinician who is familiar with these things and there is good confidence based on menstrual history and (in this case) labwork, that you are still pre-menopausal and not having post-menopausal bleeding, there are benefits to ongoing ovarian hormone production. There is a silver lining there for your bones, cognition and cardiac health.
Is weight gain a side effect of HRT?
No, HRT does not cause weight gain. But it is true that many women start HRT coincident with the onset of menopause, which does bring metabolic changes. Increased weight around your midsection is very common at this stage of life, even if you have never had it before. It’s the body’s way of compensating for the loss of ovarian estrogen production, since estrogen can also be made in fat. To a certain point (say 5-10 pounds), I usually encourage patients to be accepting of a new normal and not too go crazy trying to maintain a weight that they were five or ten years ago. Some changes in nutrition can be helpful, along with getting adequate sleep, and exercise.
What can I do about hair loss or hair thinning with menopause?
It is true that aging in both men and women can cause hair to thin. I never automatically attribute this to menopause and always encourage patients to see their dermatologist. Thyroid disorders, among a list of other things, can cause hair loss. Depending on the pattern of hair loss on a physical exam, labs and/or scalp biopsy might be indicated. Menopause absolutely can contribute to hair changes, but please see your dermatologist for an examination, blood work and investigation before assuming it’s strictly based on menopause.
Does HRT prolong menopause?
HRT does not extend or prolong menopause. This is a common concern among women considering HRT. Menopause symptoms tend to dissipate over time naturally, and so your symptoms are going to be what they are at that age, whether or not you took any HRT.
Is there a certain age that someone is going to start menopause?
It’s highly variable. I always say 45 to 55, but a lot of women will start to notice changes in their late 30s and I call those prelude symptoms. This is when symptoms tend to come and go. Certainly, into your mid 40s it is very common to start seeing some symptoms, even if they're not consistent.
Is a woman infertile because her periods have become irregular?
You may still ovulate from time to time until you have gone a year without a period. So even if your period is not regular and predictable, I always tell my patients they still need contraception until they’ve been a year without a period. Irregular periods are not a form of birth control.
Is more painful ovulation a sign or symptom of perimenopause?
It doesn't seem fair that when we're trying to end our reproductive years that we have to get more pain with it. But I’ve seen many patients that report more painful ovulation and periods, and more PMS during perimenopause compared with the earlier years of their reproductive life.
If my hormone labs are normal then I’m not in menopause or perimenopause, right?
Not necessarily. Labs indicate levels in a snapshot - a moment in time – and they may vary a lot from one day to the next. If we look at a woman at the right age with classic symptoms, the labs might still be normal, or they may be normal today and not tomorrow. So, it’s good to not to rely on them, as normal labs may not mean that it's not perimenopause.
What are your tips for relieving increased PMS during perimenopause?
There are a lot of holistic things I go back to like exercise, eating well, and adequate sleep. I have prescribed very low dose birth control pills for women in perimenopause who have a lot of PMS as women who do not ovulate do not have a lot of PMS symptoms. The pill eliminates ovulation so that that can be a nice transitional thing to do.
How do you feel about testosterone pellets as hormone treatment?
I don’t use them. Testosterone is typically prescribed for libido, and in order to make a difference on that, you have to use really high doses of testosterone. I call that trying to make a woman into a man - and there may be some cardiac risk associated with that. So, I am not a believer in the use of testosterone for women. Other doctors disagree, and I respect that, but I'm not a fan of testosterone in any form, whether it's pellets or creams, patches, etc., and I've not found it to be helpful.
If you are in menopause, should you avoid regular Pap smears or have them more frequently?
Menopause really doesn't influence our Pap recommendations for most women over the age of about 30. If you've had normal Paps, you can get one about every third annual. There are some age-based recommendations on how often to get a Pap, but typically we're going to do Paps up to the age of about 65, assuming normal results over time. Menopause doesn't influence whether or not to get a Pap smear.
Will all this extra protein in my diet make me fat?
I always promote a diet consisting of lean protein and vegetables, more specifically the Mediterranean way of eating. I think we really have to watch out for the carbs and especially refined sugars. As we age, we're losing muscle, and estrogen does play a role in maintaining lean muscle mass. So, when your estrogen is decreasing and your muscle mass is naturally decreasing, having that additional protein can help to rebuild, repair, and maintain that muscle.
Are low dose antidepressants effective for hot flashes?
Yes, I've had some good luck with this. Especially for patients who cannot take hormone replacement therapy, or don’t want to. We know that certain low dose antidepressants can help with hot flashes. Additionally, menopause frequently brings mood disorders. It can unmask depression and anxiety or make it worse. So, you may get some double coverage by using a low dose antidepressant for hot flashes and moods. But I will say that as helpful as they may be, there's nothing as effective as estrogen for relieving hot flashes.
What is your trusted advice for women going through menopause?
I always say be aware of “Doctor Google”. Getting your information from Doctor Google can be like drinking out of a firehose and you don't know what's reliable and what's not. Rely on your physician, and specifically in menopause, your OB/GYN physician. Narrow your resources to reliable ones such as gennev.com, acog.org and menopause.org.
You can listen to the “Menopause Myths & Facts” interview with Dr. Savage here.
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The information on the Gennev site is never meant to replace the care of a qualified medical professional. Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev's telemedicine doctors before beginning any new treatment or therapy.
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