Menopause: The Next Thirty Years

E4 The Next 30 Years: From Mamaya Health, this is It's Never Just Hormones. I'm Amy Green. I'm a therapist. I've spent two decades in the chairs sitting with women who had been told that it was stress or hormones or just what motherhood feels like, and watching them fall through the cracks of a system that kept answering a different question than the one that they were asking. Eventually, I stopped waiting for that system to fix itself. And built the one I wish I could have had to refer them to. This show works the same way that room did. Every episode starts with a woman's story told on her terms. Then someone who knows this territory helps me trace it back to what was actually happening in her body, in her mind, and in the system around her.

She knew the date because she had it written down. Twelve months and one day after her last period. That one had come in March and had been unremarkable. Lighter than usual, two days. Nothing that she normally would have noticed if she hadn't been counting. So the following March, she made a note on her phone. Done. She's fifty six now. That was three years ago. She still wakes at three. She's not drenched. She's just warm and completely awake. And her heart feels like it's racing. She lies there until 4 30 AM. Sometimes she just gets up. At our physical last year, she said, I'm still not sleeping. Her doctor said, Well, you're through the worst of it.

And he meant that generously. He meant the hard part is behind you. She went out to her car afterward and sat there for a minute before she drove home. Because she isn't asking to go back. She doesn't want to be forty again, but she wants somebody to tell her what this is. The thing that didn't end when she was told it would. This woman is a composite of stories. She isn't just one, but the sentence she heard in that exam room, it gets said thousands of times, and it's just not quite true. Today, I want you to meet Dr. Michelle Monfo. She's a gynecologist, and she spends her days on exactly this perimenopause, menopause, and the part afterwards that almost nobody talks about out loud.

What actually happens after you're told you're through? What a lot of people find surprising is that the symptoms can continue for a long time. So, I think a lot of people think that once you've been through like that twelve months without a period, that all of a sudden you've graduated, it's over, you've made it through and you know, carry on business as usual. But the truth is that symptoms can actually continue for several years. And It's not unusual for women to continue to have menopausal symptoms into their sixties. About fifteen to twenty percent of women can have persistent hot flashes, night sweats and and those symptoms. And I think, you know, they're also surprised that that menopause is a permanent state, right?

So our ovaries, once they stop producing estrogen and they stop functioning, they they persist in that state forever. So we're actually postmenopausal for the remainder of our lives. So we live in an estrogen deficient state forever. We say you go through menopause through. It's like a doorway or a tunnel, but where we actually arrive is at a different state. And it's a permanent one. You're postmenopausal for the rest of your life. And so with that, you know, what we really want to focus on is yes, symptom relief and you know, making sure that women can have quality of life with treatment and other tools, but we also want to shift our focus to what's happening.

To someone metabolically when their ovaries stop functioning. You know, what's happening in our our heart health, our metabolic health, our bone health, our brain health, those are really the places where we want to put a lot of energy and focus to make sure that we're addressing the changes in our risk to develop issues long term. Heart, bone, brain, metabolism. We've heard those words before from Dr. Yun, and here they are again. They are, according to the clinicians who do this all day, the four that matter most once our periods stop. So what symptoms don't end at the transition? And then which new fun ones arrive that nobody has warned her about? Well, the truth is that you can start having all of these symptoms even before menopause and they persist through the transition and past.

So it's like you can start having menopausal symptoms even when you're having periods. They're estrogen receptors over our entire bodies. So that means that there can be we can experience symptoms of menopause in every single organ system. And so women may start saying, like, hey, I'm I'm starting to get like sleep disruption. My mood is I'm really irritable. I'm losing desire. I'm not interested in sex, or maybe sex is becoming uncomfortable. Or I feel much more urgency to go to the bathroom. And that's something that people miss all the time is those symptoms of genital urinary syndrome of menopause, which is like that loss of estrogen impacts the bladder, the vaginal tissue. And as the ovary stops producing estrogen and follicles as reliably, then women's periods start spacing up apart more.

You start skipping them. And that's really when I find that those low estrogen symptoms or those menopausal symptoms become really pronounced. So like hot flashes, night sweats, hair thinning, weight gain. What's kind of challenging about all this is that it's unpredictable. But once you're in menopause, then it's pretty simple. Basically your ovaries are always low. Your your hormones are always low. There's no fluctuation. They're just predictably low. So and it doesn't go back. Talk to me. You mentioned the pain with sex or the like vanishing libido. How many women bring this up naturally on their own? And what is treatable that women are just silently kind of suffering around? You know, what's kind of skews my perception of this is that I'm a gynecologist.

And so I think it comes up a lot more often in my visits with patients than maybe in a different setting. What are some of the way that women name it to you? Well, really, like the the the the phrase is I have no interest in sex or my libido is really low. and I think it's really important to make sure we understand the distinction between desire or libido. Those two are words are used interchangeably and arousal. So libido or desire is the interest. It's like it occurs to you. Like You're like, it's a thought. It's like, that's a good idea. He looks cute today. She looks cute today. It pops in your head. The arousal is what happens in your body in response to those stimulus or that idea or physical stimulus.

And the arousal piece can have a lot to do with lack of estrogen because arousal really depends on physical stimulation, the blood flow to the vulvar tissues and the clitoris and the vagina. And so with loss of estrogen, there can be issues there with like, you know, I can't get to orgasm or the orgasms aren't as strong, you know. So those are all the arousal pieces and that can be impacted. But what I find is more people find that they've lost the interest. And when we talk about that, what the science shows is not the actual loss of estrogen and progesterone that is causing the low desire. There's lots of factors that go into why. desire changes, especially in long-term relationships. so it's not just menopause here, but it plays a big piece in it because if you're not sleeping well, if you're irritable, you're stressed, you don't feel like yourself, you don't feel like you look you know, you like what you're seeing in the mirror because you know, you're gaining weight, like mental load, relationship issues, worry, anxiety.

Physical discomfort, all of these things are the breaks. And what we need is gas. We need the gas to like, you know, give a little momentum and and like feel like that is something you wanna engage in. Gas and breaks. I think that's the most useful thing that has been said on the subject, because it takes something women experience as a personal failure, and it makes it a system that you can actually work on. The brakes are the mental load. That's the worry, the not sleeping, the pain if there's pain, the not recognizing yourself in the mirror. And the gas, well, that's the part that we forget to ask all about. What are all the things that might put gas in the tank?

Right? Like managing stress, improving sleep, working on your relationship and communication, making sure there's no pain. Right? Like if you're having pain with sex and dryness, like making sure you're addressing those things. You know, the quality of the sexual connection, the emotional connection, those are all like that all puts gas in the tank. So making sure that, you know, when we're in this phase of life, we can't control all of it, right? But being able to put things in buckets, I'm like, okay, these are definitely breaks. This is gas. How do I change the balance so that I can restore some of that spontaneous desire? what I find in my conversations with women is that it's very important to them.

And not because it's just important to their partner, but actually it's really important. to the woman for herself. How they feel connected and and and sexy and all the ways that they identify with themselves too. Exactly. Like for them, it's like this is who I am and this is I feel like part of that has been lost. What does menopause do to identity and mood? So we're talking about, you know, how we identify with our sexual identity and our sexual sense of self. But beyond that, to the woman who feels invisible or unneeded or unrecognizable, where maybe even like The world just stops looking at her or noticing her, right? Where she used to feel desire, have attention or, you know, get compliments and those things feel good too.

But now I'm a little bit older and I've gone through some changes and transitions and it's just not the same. Yeah. I mean, you know, the the truth of the matter is we live in a society that puts so much value on youth and external beauty and and all those things. And so that's the world we live in. And and that's part you know, obviously I'm preaching in the choir here, but that's particularly true for women. First and foremost is identifying it, owning it. being like, Yeah, this is it's coming for everybody. Like I I mean, it's not something nobody can fly unscathed. You live long enough, you're gonna go through menopause. So it's not like a personal failure.

I mean, I I see it's like, wow, I I have the privilege of growing old enough that I am aging, I am going through menopause, like I'm healthy, I'm strong. Like it's a privilege to be able to get to these stages of life. The story that you're telling yourself is so important around how you transition and through the season. And there's also grief in it too, right? There's a lot of grief. It's all these things and all they're they're all valid. But at the same time, you know, I I kind of look at it this way. We could either let this stage of our life bring us to our knees. Right. And it can. Yeah.

But it also can be an empowering moment where it actually forces you to stop, take stock of your life, and evaluate what works, what doesn't, what serves you, what doesn't, and make decisions about what you're going to do. A client I was talking to, Michelle, we were talking about some of the sacredness that comes with some of the like even just like some of the irritability or shortness, right? Like it's impossible sometimes to deal with or it feels really, really jarring. But there's also such a sacredness to it because I think that as women, we for so long have been supporting, serving, caregiving, taking care of, and not necessarily honoring our boundaries or not necessarily naming the things that we need.

And then all of a sudden perimenopause and menopause come and it's like, no, you're absolutely going to pick up your towel. I'm not do like I'm not. I just I'm not doing that anymore. And Those yeses and no's become what feel like, just much more fierce and embodied. It feels sacred in that way to me because it's also just like what a what a calling of us into our truth. Exactly. We don't have to like sugarcoat things. I'm done with this nonsense. I'm done with the tolerating, yeah. The tolerating and the suffering and silence and bending over backwards for everybody else. Or feeling invisible or not seen because I'm not speaking my needs. Yeah. Exactly.

And so when you know, for my experience as a perimenopausal woman is again like it really forced me because physically I could not keep up with the demands of family and work and my health and no sleep and this and that. So like I had to stop and be like now I'm going to actually take stock of what's serving me, what's not serving me. Say no, like it's a complete sentence. Put some boundaries and invest in my own health and my own self. And and I think I can do that more successfully when I involve the closest people around me into what I'm doing. You know, my husband, my kids, my kids know a lot about Venopause now.

It was just like for Venic or Worse, here we are. For better for worse. I'm like Here's here are the rules. Mom goes to bed. This is my bedtime. No interruptions. We're gonna keep the room cold. Like everybody is aware that these are the things that I'm doing to invest in myself. And it's non-negotiable. And there's sweatshirts you can put on if you're too cold. You're welcome. That's why they make them. Now I wanna go to this part of the conversation that I think is really important and maybe the least known. Because everything so far has been about how you feel. The next part, it's about what is happening, whether or not you feel anything at all.

So you're talking a little bit before about like our metabolic health, about our gaining of weight. You mentioned heart, bones, brain. Why is it evidence to start treatment even sooner so that we can be supported? And how does that impact our longevity? Yeah. So this is really critical for us to understand that the menopause transition and changes our risk profile for everyone, even if you're having symptoms or not. So if someone is just like, I breathed through menopause and nothing nothing burger. I didn't have symptoms. That woman is still experiencing the same impact on her wrists that someone that's having that may or may not be having symptoms. So it's really important for us to all understand that.

The second part of that is for us to all understand that it's not just one thing that we need to do or put in our toolbox to be able to mitigate some of these changes in our health. So it's not just gonna be hormotherapy, right? Which we'll talk about, but everyone has to do something to invest in their long term health to account for what's going on. And so what happens is with that loss of estrogen. The point I really want to drive home is our change in our cardiometrobiotic health because heart disease is still the number one killer of women. Not breast cancer, heart disease. So your lipid profile might change. LDL could be going up.

Your HDL may be going down. other cardiometabolic markers like APOB or inflammatory markers, those are all can't are modulated by estrogen, we lose muscle density, not just because of aging, but because estrogen and testosterone impact our muscle density. And our skeletal muscle is a really important metabolic organ. So so as we start to lose that density muscle density over time, our metabolism changes. So our ability to manage weight is impacted. Our bone health is impacted. Estrogen impacts the bone density directly. So when we lose that, over the course of that transition, we've lost a huge percentage of our bone density in the first two years after menopause. And then our brain health as well. Menopausal hormone therapy is the gold standard for treating symptoms.

Menopausal hormone therapy has the evidence to support prevention of osteoporosis and bone health. So the key is to start menopause estrogen therapy before heart disease has set in. Right? Before your blood vessels have, you know, have plaque in them, or you know, in your brain or around your heart. That is really the key. And again, it's like, well, you'll you could have the argument that like, well, menopausal hormone therapy does not have an indication to prevent heart disease, right? So the FDA does not does not has not approved us saying that we we provide estrogen therapy to prevent heart disease. The reason for that's because the study's not been done. We don't have a randomized controlled trial that looked at, okay, this woman is on hormone therapy, this one's not In twenty years, does this woman have prevention of heart disease?

That was not. Right? But the studies have been done that look at women who are on estrogen therapy that started younger. Those women have less plaque buildup in their carotides. Those women have better lipid markers. Those women have, you know, improvements in their metabolic health. And we do have observational studies with millions of women that show that women who have Been on menopausal hormone therapy, especially starting within the transition, their overall mortality risk is lower. I want to make sure nobody misses what just happened there because it's the reason I trust her so much. She told you what the evidence supports. And then she told you exactly where it stops. Hormone therapy is the most effective treatment that we have for the symptoms.

And the evidence on bone is solid. On heart and brain, there's a real body of observational data, large, consistent, pointing in the same direction. And there is not the randomized control trial that would settle it. So anyone who tells you it is proven is going past the evidence. Anyone who tells you it's dangerous is going past it in the other direction. The other thing that you know we all need to do is how considers how we exercise. So I talked about how, you know, when you lose estrogen, you lose muscle density. and so we really need to shift our focus from we're not trying to be small anymore, we're trying to be strong. So we're trying to build as much muscle as we can, maintain, and build.

So in order to build muscle, we got to give it protein to build muscle cells and hype, you know, get hypertrophy, but we also have to give it work. And we do that through resistance training. So picking up heavy things, moving and lifting heavy things, and doing that regularly. Right. So, like, yes, cardio is still important for our overall health and our cardiovascular resistance and health, but we really need to make sure that all of us are doing some form of resistance training to maintain our muscle because remember, important for bone. Important for our metabolism, important for insulin resistance and our body composition. The other thing that I love to talk about is sleep. Right?

So like I talk about hormotherapy, I talk about strength training, and I never miss an opportunity to talk about sleep. because without sleep we can't function. We can't exercise care of ourselves. No. Our mood is terrible. My kids know that I am extra grumpy and I have been told that I am less grumpy when I when I actually get some good sleep. Yeah, my ten year old told me that since starting HRT treatment, that I have been less grumpy. Everyone benefits. Everyone benefits from them feeling better. It's true. One thing you should know about me, I'm on hormone therapy. I started it this year. I'm not telling you to, and nothing in this episode is a recommendation about your body.

The conversation genuinely belongs to you and a clinician who knows your history and the timing and the risks that are individual. If you asked me like, okay, doctor Mottville, I know you told me to do all these things, but realistically my life is so chaotic and hectic that I can only do one of them. Which one do I focus on first? Sleep. My answer is always sleep. If you don't have sleep, you can't get good workouts in. Right? If you don't get good sleep, if you're if you're functioning at the your minimum, it becomes r a struggle to focus on your nutrition and your protein and your intake and your relationships and all that stuff.

So like if I if if when somebody asks me where do I begin? Usually it's like, well, let's put you on some estrogen. But okay, lifestyle wise, if I had to say where do I begin, I always say sleep. It's like, make it your job. It's a foundational building block. That's it. Like that's where you begin. If you had to start somewhere, start there. And what I want to say is for a lot of women who are perimenopause and menopause, for a lot of women where this is new, these sleep disruptions or they're getting acutely worse, it's because of loss of estrogen. And progesterone to an extent. So when I talk about sleep, if somebody tells me like that, how do I make sure I get the best sleep?

A big part of that conversation is going to be hormone therapy. Yeah. So as we wrap up, what would you say to the woman who's been told you're through the worst of it, but she still feels like she lost herself somewhere in the middle and really want to feel like herself again? I mean, I think a huge part of this is investing in your physical health. Right? Like how where are you investing your time and and effort to make sure that you're you're living out that second half of your life in good health? It's not just enough to s you want to live a long time. You want to live that life healthfully. When you start investing in these things, sleep, exercise, right?

We're I really want to reframe exercise. It's not just for body composition, how your body looks, but it actually improves your mood. It is very likely to get you out of the house and make new connections, new friends, new social circles. Like it really gets you out and connected to your community when you find a form of exercise or activity that you like. You're making me think of those those videos of a bunch of women who are enjoying the exercise of prancing. Have you seen those videos? No. Okay. Well I'm gonna have to send it to you afterwards. But it's like something I would love. you're gonna adore it. They're in great aerobics outfits, like early nineties.

And yeah, they're prancing and they're prancing together. I'm I'm gonna have to find where this prancing community is near me. So, I mean, I feel like finding social connection right is really an important way of people finding their place in this world and Bringing attention and having conversations about what you're going through with people that understand it, you know, makes you feel seen, heard, validated. That's why we're doing this podcast and you know, finding friends or people that you know that can commiserate with you and and understand this experience and not have to figure this out all on your own is really powerful for women who who are doing this and and honestly you know I just keep coming back to like how do I invest in myself and I'm not gonna let culture dictate you know how I get to live out that life like I'm gonna set that standard.

Menopause just presents this opportunity for us to really take the reins. Thanks so much for the conversation today. Thanks, Amy. Super fun. Anytime I get to talk about perimenopause and menopause for me is a good day. I wanna go back to that woman in the car. She has about 30 years in front of her. Longer, probably. And what she was never told is that the twelve month mark wasn't the end of anything. It was the beginning of the stretch where what she does most matters. And the window where some of it matters most is open right now. The tools strength instead of smallness, protein. Picking up heavy things, sleep, and a conversation about hormone therapy that you get to actually have with the evidence and the gaps laid out instead of inheriting somebody's leftover fear from two thousand two.

If you've been told that you are fine and you don't feel fine, you're allowed to go back. You're allowed to ask what my heart numbers are doing. You're allowed to ask about your bones. You're allowed to ask, what are we doing about my sleep? And you're allowed to find somebody else if that answer is that you're just through the worst of it. If something in this found you where you live, here's what I want you to know. What you're carrying is real, it has a name, and it is more treatable than anyone has told you. At Mamaya, we measure every woman's progress, every single session, because the only way to know care is working is to actually check.

Most women who come to us in the clinical range finish below it, and most of that change lands inside twelve weeks. Finding care built for your season takes one step. Visit us today at memayahealth.com or visit the resources in our show notes. If you're in a crisis, call or text 988. If you're pregnant or postpartum, postpartum Support International is a great resource. And if there's a story you've never told about this season or any season nobody warned you about, the form is in our show notes. Anonymous is fine. Nothing airs without your okay. I confirm it with you first, every time. It's never just hormones is from Amaya Health. Our senior producer is Emily Seiner.

New episodes twice a month. I'm Amy Green.