October 7, 2025 • 39 mins
Menopause is a significant phase in a woman's life, yet it is often surrounded by misconceptions and misinformation. Join our conversation with Dr. Karen Adams, Clinical Professor of Obstetrics and Gynecology at Stanford University, as she unpacks the complexities of menopause and hormone therapy. Discover the impact of the Women’s Health Initiative and how it shaped the conversation around hormone use, leading to a dramatic decline in its adoption. Dr. Adams will also address common myths, explore effective non-hormonal treatment options, and share insights on managing symptoms through lifestyle changes. This discussion will provide you with practical tools and a deeper understanding of menopause, helping to demystify this important life transition.
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Episode Transcript
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(00:00):
(lively music)
(00:06):
- Welcome to "Stanford Medcast,"
the podcast from Stanford CME
that brings you the latest insights
from the world's leadingphysicians and scientists.
If you're joining us for the first time,
be sure to subscribe on Apple Podcast,
Amazon Music, Spotify or YouTube
to stay updated with our newest episode.
I am your host, Dr. Ruth Adewuya.
(00:29):
Today I will be joined by Dr. Karen Adams
who is a clinical professor of obstetrics
and gynecology here atStanford University School
of Medicine and the director
of the Stanford Program inMenopause and Healthy Aging.
She is board certified in both OB-GYN
and lifestyle medicine, acertified menopause specialist
by the Menopause Society
(00:50):
and a fellow of the International Society
for the Study of Women's Sexual Health.
Dr. Adams is a nationallyrecognized expert on menopause,
sexual health and midlife medicine
with a particular focus onintegrative preventive approaches
that support brain, bone, cardiovascular,
and sexual health acrossthe menopausal transition.
(01:12):
Dr. Adams, thanks for being here today.
- I am so happy to be here.
- I'm thrilled to havethis conversation with you
and talk about menopause.
Despite the fact thatwomen spend up to 1/3
of their lives in post-menopause,
most never receive evidence-based care.
Why do you think menopause continues
to remain so underdiagnosed,untreated and misunderstood
(01:34):
in clinical practice?
- With longevity, womenare gonna be living half
of their lives post-menopause.
We're gonna live to be 100
and average age of menopause is 50,
and why are we not talking more about it?
Most of us, if we'relucky, our mother sat down
with us when we were eight or 10 or 12
and talked to us aboutyour period's gonna start.
(01:56):
We don't get that talk
on the opposite end of that journey.
For generations, women have been left
to wander in the wilderness,
wondering what in the world is going on
and really thinking it's their new normal
and being resigned to it.
There was some discussionback in the '60s and '70s
about it, but it wasconsidered very shocking
(02:18):
and edgy to put it on "Allin the Family," for example,
and have Edith hot flushing.
It's a generational thing now.
I think women are tired ofhaving their issues marginalized.
Science always marches on
and we have more knowledgenow than 20 years ago
that informs our care as well.
But still, there are a lot of care deserts
(02:40):
and women who are seeking that care.
So I'm just really happy to be here
to have this chat with you today.
- That's a great point
and I love that vivid framing
of women wandering in the wilderness
because it's never openlynamed or normalized,
and I think this raisesan important question
of how does care change
when we stop treating menopauselike a hidden pathology
(03:02):
and we start framing itas a natural transition?
- I wanna just be as inclusive
with our conversation as we can be.
When we're talking about women,
we're talking about people with ovaries,
and anyone who has ovaries isgonna go through menopause.
I will try to say menopausal people.
If I say women, please know
that I'm talking aboutpeople with ovaries.
(03:24):
It is a natural transition.
And if we live long enough,we'll go through it,
but that doesn't mean thatwe just have to accept it
and just say, "Those were good years."
No longer.
I think we can treat it, acknowledge it,
and maximize our healthwithout overmedicalizing it.
There's a difference between acknowledging
(03:45):
and treating and pathologizing,
and so it's very important
that we look at everyone'sexperience individually
and think about what'sgoing on for that person
and figure out the best path forward.
- A lot of that tensiontraces back to the legacy
of the Women's HealthInitiative, which reshaped
how patients and cliniciansthought about hormone therapy.
(04:06):
Can we talk about that history
and where the evidence stands now?
- When the Women's HealthInitiative came out,
it changed everything.
The Women's Health Initiative
was the largest randomizedcontrolled trial
of hormone therapy thathad ever been undertaken.
165,000 women.
(04:27):
Average age was 64,
and in order to enroll in the trial,
people couldn't be having symptoms.
So that's a really important thing
because if they were having symptoms,
they would know if they werein the treatment group or not
because their hot flushes would go away.
To have a well done trial,
anybody symptomatic was not enrolled.
(04:49):
What that means is it was never designed
to evaluate symptoms
and the use of hormonesfor relief of symptoms.
What it was designed to dowas to look at the impact
of hormones on long-termhealth, primarily cardiac risk,
heart attack, stroke.
They enrolled women betweenthe ages of 50 and 79.
(05:12):
The average age of menopause is 51,
but they were putting womenin their 70s on hormones
who had never been on hormones before,
thinking that it wasgonna benefit their hearts
for a lot of good reason
because we had a lot ofobservational data prior to that
saying that it seemed to bereally beneficial for hearts.
(05:33):
What happened was they hadto stop the trial early.
It had planned to gomuch further than that,
but they stopped it five years in
because of an increasedrisk of heart attack, stroke
and breast cancer, and thosenumbers hit The New York Times.
"Good Morning America" madethe phone ring off the wall
in my clinic that day, likehuge increases in heart attack,
(05:56):
stroke and breast cancer.
For example, 26% increasedrisk of breast cancer
with hormone therapy.
Now, that sounds like onein four, right? It's not.
It's eight extra casesper 10,000 women per year.
Eight extra cases per 10,000 women.
(06:17):
So 26% increase in breastcancer sounds like one in four.
It's not. It's eight per 10,000.
So that was one thing that kind
of freaked everybody out was like, "Ah,
I have a one in four chanceof getting breast cancer."
Not at all true.
The other thing that got lost in the noise
is that the younger women
(06:37):
in that trial responded differently
to hormones than the older women.
It was women 70 and abovehaving heart attacks
and the strokes and theincreased risk of breast cancer.
Women who were under age 60 in the trial,
so between the ages of 50 and 60
or within 10 years of theirlast period did better.
(07:01):
It's nuanced.
There's a lot to unpack about that,
but the take-home message
is younger women behavedifferently on hormones
than older women, and therisks aren't as enormous
and scary as they really weremade out to be and sounded.
And now we have 20-year follow up,
so we can talk about that too,
(07:21):
but it scared everyone off hormones
and we're still dealing with the fallout.
- Exactly, because it led
to about a 79% drop in HRTprescriptions after 2002.
More recent data clarifies the risk
when you are talking about HRTbeing started before age 60
or within 10 years of menopause.
(07:42):
What is one myth about HRT
that you hope clinicians can abandon?
- As an aside, we callit hormone therapy now
rather than HRT 'causewe're not replacing,
we're using it as a therapeutic strategy.
One myth I spend so muchtime in the clinic unpacking
is that hormone therapycauses breast cancer.
(08:03):
People are worried about breast cancer.
We die of heart disease.
So even though the fearis around breast cancer,
we want to improve people's longevity
by improving heart health.
But women continue to be convinced
that hormone therapy causes breast cancer
and that is a myth,and this comes directly
(08:23):
from the Women's Health Initiative trial.
When women are on estrogenalone, they have lower rates
of breast cancer thanpeople not on hormones.
So it seems to be protective.
Now, who gets to take estrogen alone?
Those are women who've had a hysterectomy.
If you have a uterus, you takeestrogen plus progesterone
(08:44):
because progesterone protects the uterus.
If you've had a hysterectomy though,
you're on estrogen alone.
Those people had protectionagainst breast cancer.
So that's one aspect.
And then the group who had estrogen
and progesterone together,
that was eight extracases per 10,000 women,
(09:04):
and the risk of breast cancer is greater
with a sedentary lifestyle,alcohol intake or obesity.
Obesity increases the riskof breast cancer by ninefold.
There are so many other things
that impact our breast cancer risks
so much more than hormone therapy.
If I could erase a thought out
(09:25):
of everyone's mind, it would be that.
- Such an important myth to call out
and highlights how riskperception can be different
from actual risk.
We know that not everypatient is a candidate
for hormone therapy andsome simply don't want it,
even knowing all of the data.
Let's shift to what'savailable beyond hormones,
(09:46):
what's credible and what'smore hype than help?
What is the current state of evidence
for non-hormonaltreatments for hot flashes
and genitourinary syndrome of menopause?
It's such an important myth to call out
and it highlights how riskperception can be different
from actual risk.
Not every patient is acandidate for hormonal therapy
(10:08):
and some simply don't want it,
even knowing all of the data.
Let's shift to what'savailable beyond hormones,
what's credible and what'smore hype than help.
And so if you could talk to us
about what is thecurrent state of evidence
for non-hormonal treatmentsfor all the symptoms,
hot flashes and genitourinarysyndromes of menopause,
and what's worth clinicians' attention
(10:30):
and which are more hype than help?
- When we're talking about prosand cons of hormone therapy,
there's a small group ofpeople who should not take it.
Contraindications are if people
have active breast cancer themselves,
if people have had ablood clot in their leg
or their lung or their brain,
if people have had a heart attack
or a stroke, those are people in general
(10:52):
we wouldn't recommend hormones for,
but everybody else we consider it.
And we also have to factorin not just symptom relief
but long-term health, risk and benefits,
and the risk of not treating.
What does it mean if you'regonna hot flush for 10 years
and just wait it out?
What is the downside of that?
(11:12):
So we also have to thinkabout what would the impact
of not treating be?
That's how we think aboutthat risk-benefit discussion.
If we're going to say,"Yeah, based on all of that,
we're not gonna recommendhormone therapy for you,"
then there are somevery good pharmacologic
and non-pharmacologic approaches.
We unpack it based on symptoms.
(11:34):
80% of women get hotflushes and night sweats.
That's the primary symptom
and that can be incredibly bothersome
and impactful to our brains.
There's interesting data thatwhen hot flushes are treated,
verbal memory improves.
When we go throughmenopause, we get brain fog
(11:55):
and people are like, "I came in this room,
I can't remember why I am here."
When people are hot flushing,those symptoms are worse.
And when their hot flushes are treated,
those symptoms get better,
even if it's not a hormonal treatment.
So even if it is some othernon-hormonal treatment,
(12:16):
the brain fog lifts.
There's something about hot flushing
that's triggering brain fog, not hormones.
So when thinking aboutnon-hormonal treatment
of hot flushes, there's a new drug
that has come out in the past year or so.
It's really been a game changer.
It's a non-hormonaltreatment for hot flushes.
It's called Tant
(12:36):
and it works on the brain a step back
from the hormone receptors.
It's just a pill thatpeople take every day
and it takes hot flushesand night sweats away
in a couple weeks.
Other drug options, there'sa drug called gabapentin,
which can help with sleep.
There's a drug called paroxetine.
It's an antidepressant
(12:56):
and it also has been shownto help for hot flushes.
So those are the top threepharmacologic approaches.
The non-pharmacologicapproaches that really work,
cognitive behavior therapy issuper interesting how it helps
to decrease the bother of hot flushes.
Clinical hypnosis helps with hot flushing,
(13:17):
which is a little bit harder to access.
Soy is a phytoestrogen,plant-based estrogen.
And there's some research
that's been published in thepast year that half a cup
of soy every day, likesoybeans, decrease hot flushes.
And so we're watching that.
There's not enough consistencyin the studies for us
to really be able to say for sure,
(13:40):
but we don't think it's harmful.
We don't think it'sgonna increase your risk
of breast cancer or anything like that
because it's such a tiny impact.
But for some people,
it might improve hot flushes a little bit.
Weight loss helps with hot flushing,
stellate ganglion block,which is a procedure
where you're having somethinginjected into one part
(14:00):
of the nerve plexus in your neck,
the uptake of that, pretty poor.
But things like yoga,acupuncture, paced respiration,
deep breathing, things like that,
there really isn't muchevidence to support them
above and beyond placebo.
There's good reasons to do yoga
and paced breathing for stress management
(14:23):
and things like that,but are they really going
to make your hot flushes worse or better?
Probably not.
- That's such a helpfulway to break it down.
Tailoring options by symptom profile
and weighing the risks oftreatment and non-treatment.
It's helpful for all of us to hear some
of the pharmacologic options
and non-pharmacologic strategies.
(14:44):
And what it reinforces
is that clinicians have moretools than they may realize.
- Yes, there absolutely are options,
and we didn't even talkabout genitourinary syndrome
of menopause or GSM.
That's the thing that 50%of menopausal people get
and it's vaginal dryness,it's vaginal irritation,
(15:06):
it's pain with penetration.
So with sexual activity, things can start
to get really ouchy.
It can also be thatfeeling like you have a UTI
all the time, but youactually really don't
or that kind of frequency or urgency.
So it can be bladder symptoms
and it can be vaginal symptoms.
(15:27):
And there are both hormonal
and non-hormonal treatmentsfor those things as well.
So vaginal moisturizers,using the right kind
of lubricant when you're having sex.
Coconut oil is my favorite by far.
Just grocery store coconut oil.
And then local estrogentreatments, which are tablets
(15:47):
or creams or rings that go in the vagina
and don't circulate into the bloodstream.
- It also strikes me thatwhile these therapies help
with quality of life,
they also tie into bigger outcomes.
What do you see as the mostimpactful interventions
that clinicians should prioritize
to support long-term brain, bone
(16:09):
and cardiovascular health duringthe menopausal transition?
- Now we're walking into a minefield
because this is controversial.
The US Preventive Services Task Force
has given hormone therapyfor the prevention
of chronic conditions, a grade of D,
meaning no evidence ofbenefit or potential harm.
(16:33):
As the data is evolving,
that actually is turningout not to be true.
We do see long-term health benefits.
And hormone therapy is FDAapproved for prevention
of osteoporosis in high-risk women.
It's not approved totreat osteoporosis per se.
(16:54):
It is approved for that in Australia
and some other countries,
and it may ultimately getthere in this country,
but it is FDA approved forprevention in high-risk people.
We know when you're on hormone therapy,
your bone density goes up by five to 6%,
which is great.
In the first five yearsafter that last period,
(17:15):
women can lose up to 20% of bone density.
It drops so dramatically.
And when you start on hormonetherapy, it arrests that loss,
it stops it wherever it isand even bumps it a little.
For bone health, hormonetherapy is indicated.
Also, strength training.
As much as we love ouraerobics, that's great
(17:37):
for our heart and our bones,
the real benefit for bonesis strength training.
It's lifting heavy andincreasing it all the time.
Squats, hinges from yourhips, pushes and pulls.
That's what we should beadvising our patients do.
Yoga and Pilates are greatfor balance and flexibility
(17:57):
and core strength, butthey don't give us a lot
of bone benefit.
So bone benefit is aboutresistance training.
That's how I talk aboutbones with my patients.
Heart health and brain healthare inextricably linked
and everything for heart healthis promoting brain health.
So not smoking, decreasing alcohol intake,
(18:19):
trying to eat a whole food,plant-based diet to the extent
that we can, prioritizingsleep, managing any kind
of long-term health issues.
If you have high bloodpressure, get it under control.
If you have diabetes, get yourblood sugar under control,
manage those things.
And then finally, staying connected
to family and friends and community.
(18:40):
Connection is superimportant for protection
for our hearts and our brains.
- I really appreciate
how you laid out both thecontroversy around this,
but also some really practicalstrategies for everyone.
Another area where lifestyle
and hormonal changesintersect is mental health,
especially depression and anxiety
(19:00):
during the perimenopausal years.
How do you adviseclinicians to better screen
and intervene here?
- Mood, sleep and cognitive issues
can show up in the perimenopause
before hot flushes and beforeperiods start to change.
Mood and sleep disturbance inparticular often are happening
(19:22):
when people are still having periods
and patients get told, "Oh,this isn't about hormones,
this isn't aboutmenopause or perimenopause
'cause you're still having periods."
So that's a really key pointfor people is to recognize
that mood in particular affects people.
In the perimenopause,
there is a thing called
perimenopausal mood instability, PMI.
(19:47):
It's more common than PMS,
but nobody's ever heard of it, right?
PMI, perimenopausal mood instability,
can affect up to 60 to 65%of perimenopausal people.
And the thing that's so key about it
is that it is unpredictable.
When you have PMS, okay,the week before my period,
(20:07):
okay, I'm not gonna feel great.
I can expect that's gonnahappen. I can prepare for it.
PMI is completelyunpredictable from day to day
because the hormone cyclingis becoming unpredictable.
A woman gets up every day having no idea.
Is she gonna feel irritated, anxious,
is she gonna feel normal?
And so that's a really important thing
(20:29):
that people should be looking for
when they're seeingpatients in their early 40s.
People with a history of majordepression earlier in life
are also much more at risk
around perimenopause and menopause.
So we have to keep our antenna up
for both it being hormonally driven
but also a recurrence ofprior major depression,
(20:51):
which can be life-threatening.
- This podcast is generallygeared towards clinicians,
but we may also have patientslistening in as well.
How do patients approachclinicians to be able
to have these conversationsand to get those antennas up?
Especially when it comes to perimenopause
where you're not reallyhaving the skipped periods,
(21:12):
but you're having some of the mood, sleep
and cognitive issues.
- People think they're losing their mind.
- Exactly.
- They're like, "What's wrong with me?
Why am I feeling soirritated with everyone?"
So I think women are educating themselves.
Often they know more aboutthis than their providers
because they've soughtout the information.
(21:33):
And on average, people have to go
to about five different providers
in order to find someone who can help.
At Stanford, we are doingour best to train providers
because I cannot see all thepeople who need to be seen.
It is really important
that we raise awarenessacross primary care,
endocrinologists, womenneed to arm themselves
(21:55):
with this information,listen to webinars like this,
seek out good sources, whichin and of itself can be hard
'cause there's so muchmisinformation and noise out there.
So really looking formedical center-based,
evidence-based sources.
Like we're starting a podcast in October,
"Stanford Conversations inMenopause and Healthy Aging."
(22:18):
So I refer people to thatfor an evidence-based source.
What you're doing here, super important
for getting the word out ina really evidence-based way.
But once you know aboutwhat you're dealing with
and how it connects tothe menopausal transition
that you're experiencing,then what you do is you go
to the Menopause Societywebsite, put in your zip code,
(22:42):
and a whole bunch of certifiedmenopause practitioners
will come up in your area,
and you can find someone who is certified,
has actually studied up,taken a multi-hour exam
and knows how to guideyou through the process.
- You are so right becausethis is such a hot topic.
We have social influencers
(23:02):
that talk about this fromall different perspectives
and it's hard to siftthrough all of that noise.
So I'm glad you've leftus with a practical place
to go to for evidence-based information.
- Probably the most common question I get
after we've dealt withall the hormone stuff
and the symptoms and everything
is what supplements should I be taking
(23:23):
for perimenopause and menopause?
If you eat the rainbow,
if you eat a whole food, plant-based diet,
if you move your body,
chances are you're notgonna need health in a pill.
I just really caution people about that
because supplements are not always safe.
They're not always the right thing to do.
And so really find someone
(23:44):
who can help guide you through this.
- So how do you approach the topic
of supplements in menopause care?
Are there any evidence-based options
that you routinely recommend
or do you prefer toindividualize those decisions
based on each patient'ssymptoms and health profile?
- I do think there are somethings that are worthwhile
for most perimenopausaland menopausal people.
(24:07):
Calcium intake is super important.
You wanna make sure thatyou're getting about 1,000
to 1,200 milligrams of calcium every day,
ideally in your diet,no more than about 500
to 600 in a supplement
because any more than that will tend
to deposit in the coronaryarteries in your heart,
which we do not want.
(24:28):
Things like beans, peas, legumes,
chickpeas are just apowerhouse full of calcium,
full of protein.
Dark green leafies alsohave calcium in them.
Along with that, vitaminD also for bone health
because vitamin D absorption from the sun
really decreases as we get older.
And so we're just not makingit from the sun the way we did
(24:51):
when we were 20.
And so I generally recommendabout 2,000 international units
of vitamin D
and that sometimes I willfollow a blood level for that
because you can push peopleup a little bit to about 50
to 55, that level,
and it will really help ifthey're dealing with joint pain
and muscle aches and things.
(25:12):
Coenzyme Q 10 can behelpful for heart health.
And so my colleaguesin the cardiology world
will often suggest that for folks.
I don't recommend that routinely.
People pay attentionto their protein intake
and rightly it should be 1.2 grams
per kilogram of body weight.
Again, getting it in your diet is ideal.
(25:33):
People ask me about creatine all the time
for muscle strength andwhen we think about muscle
and bone health, which Ireally want perimenopausal
and menopausal people to thinkabout, you wanna be strong,
you don't want your bones to be crumbling.
You want to have strongmuscles and strong bones.
- I'd like to go backto when we were talking
(25:53):
about mood, sleep and cognitivechanges in perimenopause.
One of the things that youmentioned is sleep disturbances
and how it's often one
of the earliestunder-recognized manifestations.
In your research, you'veshown that sleep problems
are among the most prevalentsymptoms of menopause.
What are the earliestsigns that sleep disruption
(26:15):
is tied to hormonal change andhow can clinicians spot this?
- What's interesting, when you ask women
what bothers them the most in this period
of time when they're going through it,
even if they're hot flushing like crazy,
if they have sleepdisturbance, they rate that
as their most bothersome problem
because, "Oh gosh, Ijust treasure my sleep
(26:37):
and I get so crabby if I've had one night
where I'm not sleeping well."
And if you go on andon and not sleep well,
it impacts you in so many different ways.
You get more brain fog,you get more irritable,
more mood disturbance,your sex drive drops.
It's harder to lose weightif you have insomnia.
There's ripple effectsof the sleep disturbance
(27:00):
in so many differentareas and it can manifest
before hot flushes or skipping periods.
If you have preexisting sleep problems,
they will tend to worsenin the perimenopause.
And that's a very different kind
of situation than somebody who's,
"I used to be a great sleeperand now I just can't."
(27:22):
And so that's one ofthe questions clinicians
should ask, "Is this new?
Or have you been a crummy sleeper
since you were 15 years old?"
Because those are twodifferent conditions.
But if people say, "Wow,I've always slept really well
and now this is happening,"that should be a tip off
that this is something that'sprobably hormonally mediated.
(27:42):
And then you wanna ask people,
"Are you having trouble falling asleep?
Are you having troublestaying asleep or both?"
Because those are also different kind
of manifestations of things.
The sleep scientists callthat sleep initiation
or sleep maintenance.
The most common thing
that we see in our menopausal population
(28:03):
is that early morning wakening,
that 3 AM kind of thing where you wake up.
Now, we think it's normal towake up twice a night to pee.
You get up, pee, getback in bed, then what?
Can you fall asleep?
If you can fall asleep within15 minutes, that's normal.
True insomnia is three timesa week or more you wake up
(28:25):
and you're up for an hour or more
and that goes on for months.
That's the person thatneeds to get referred
to sleep scientists tohave a sleep study done.
Obstructive sleep apneabecomes more common
in women after age 50.
Restless legs keeps people awake.
You want the sleep scientiststo be looking for those things
(28:46):
and helping diagnoseand treat your patient.
So that's how I would think
through the presentation as a clinician.
The good news is progesterone,
part of our hormone therapy regimen,
hits the sleep centers of the brain.
We have people take progesterone at night
because the side effect is drowsiness.
I had one patient and shecalled our office one day
(29:08):
and she said, "I forgot totake my progesterone last night
and I took it this morning
and I am canceling all my meetings
'cause I am literallyfalling asleep at my desk.
Is that the progesterone?"
And we were like, "Yeah, call Uber.
Don't try to drive homebecause you might fall asleep."
So hormone therapy can help with sleep,
(29:28):
but knowing when to refer is important.
- And since sleep and mood
are often intertwined with intimacy,
another sensitive area
that can be overlooked is sexual health.
How do you approach sexualdysfunction in midlife
and menopausal patientscompared to younger individuals?
- When I talk with my patientsabout sexual function,
(29:49):
I always acknowledgeI'm not curing cancer,
but it is super importantfor our quality of life.
There's a thing called the Living Index.
The two most predictivethings about wellbeing
are good sleep and good sex.
That's what my TED Talk is about,
"Sleep, sex, and menopausal zest."
Because if you havegood sleep and good sex,
(30:11):
you have a pretty good quality of life.
Sexual dysfunction in women,
it is a little different inyounger versus older women.
Younger women, it doesn'ttypically involve pain
with insertion ofsomething into the vagina.
And again, I'm gonna try notto be too heteronormative here.
So some people have same-sex partners,
(30:33):
some people are having sex by themselves,
so I'm talking aboutfingers, a vibrator, a penis,
anything you insert into the vagina
is not supposed to be painful.
When you go through menopause,
about half of women experience pain,
actual true pain with penetration.
It's not 100% sure that'sgonna happen with you,
(30:53):
but if it does, it is treatable.
And 50 is way too youngto stop having sex.
That's my message topeople who are listening.
If it's painful, we shouldbe able to treat that.
That can be either related
to the effective estrogenat the opening of the vagina
where we need a little estrogen there.
Sometimes it's pelvic floor pain
(31:14):
where there's a spasm on the pelvic floor
and it feels like you goabout halfway up the vagina
and you're hitting a walland you can't get past.
Then there's the wholeelephant in the room,
which is, "Gosh, I don't wantit and I wish I wanted it."
That low libido, it can berelated to all sorts of things.
It can be related tophysical pain, back pain,
(31:38):
chronic illness, chronicmedical conditions.
It can be related to drugs,alcohol, recreational drug use.
It can be related to medications, stress.
If you're running fromthe saber tooth tiger,
Mother Nature does not wantyou to stop and have sex
because you will die.
Libido is complicated
and we spend a lot of time unpacking that,
(31:59):
and those factors canbe involved at any age.
But the thing that makesolder women different
from younger women is that risk of pain.
About 50% of people have it,
even if they've never had pain before.
- It's valuable to hearhow you individualize care
for sexual health and midlife,
especially since many patients are unsure
how to initiate thoseconversations with clinicians.
(32:21):
But clinicians also still feel unsure
about how to even startthose conversations.
Your dual training in OB-GYN
and lifestyle medicinegives you a broader toolkit
for looking at this issue.
How has that dual lens
reshaped the way youapproach menopause care,
particularly from a preventative
and systemic perspective?
(32:42):
- I really wanna do a shoutout to the American College
of Lifestyle Medicine
and the American Boardof Lifestyle Medicine.
You can get board certified, in addition,
in lifestyle medicine.
I found that essential inhaving these conversations
with patients becausemenopause and hormone therapy
isn't just about symptom management,
(33:03):
it's about long-term health.
People are motivated
to start looking at their health habits,
and this is when thechickens come home to roost.
You can get away witha lot when you're 20,
but when you're 60,
your lifestyle choices arereally starting to add up
and people are motivated.
They're realizing that.
So this is a real opportunity.
(33:24):
Many of my patients say,
"I am in the best shapeof my life now at age 65
because I'm paying somuch more attention."
I wanted to get boardcertified in lifestyle medicine
so that I could say, "Here,
let me give you an exercise prescription.
This is what the science tells us
(33:44):
is gonna help you age in a healthy way.
Here's your nutrition prescription,
here's your sleep prescription."
So the pillars of lifestylemedicine are sleep, exercise,
physical activity, healthy eating,
avoidance of toxicsubstances, stress management
and connections to community.
(34:04):
Those are the pillars ofaging in a healthy way.
- That is such a helpful framework.
It really grounds sleepin the bigger picture
of overall health.
And as you mentioned,
many patients are alreadymotivated at this stage in life
to make the change thatwill serve them for decades,
but that opportunity is sometimesnot distributed equally.
(34:26):
We know from research that Black, Hispanic
and LGBTQ+ individuals are less likely
to receive adequate menopause treatment.
From your perspective,
what are the most urgent changes needed
to make menopause care moreinclusive and equitable?
- We have a study called
the Study of Women's HealthAcross the Nation, SWAN,
(34:47):
that was one of the few that looked
at the experience of menopause
broken down by race and ethnicity.
What we found is that Black women
have more severe hot flushesfor longer periods of time
than any of the othergroups in that study.
Almost half experiencedsevere hot flushes,
and they on average last for 10 years.
(35:10):
And Hispanic people are a close second,
Caucasians are in the middle,
and then Asians lessfrequently and less severe
and for a shorter period of time.
We don't know why that is,
but we need so much more data than we have
about the experience of menopause
in different race and ethnic groups.
We really need more research.
(35:31):
And if anybody out there is a researcher
and you wanna contribute towellbeing of women worldwide,
please look into thismore, it's essential.
Having cultural competencearound this discussion
is something we all need to focus on
and do better on becausewe're all on that journey.
Nobody does it perfectly.
We're all trying to increase our awareness
(35:53):
and there's a wonderful article.
Makeba Williams is aresearcher doing a lot
of work in this realm, andshe's written an article
about cultural competencyin menopause care
that I highly recommendto anyone who's listening
and is in a provider role.
And she talks about therebeing three steps of that.
And it starts with cultural curiosity.
(36:15):
You know, we often don't wantto come across as not knowing.
Research shows if you come across humble
and wanting to learn, peopledon't judge you for that.
Your patients are notgonna judge you for that.
In fact, they're gonna be grateful.
And so if you say,
"I really don't know alot about your experience,
but I want to learn
(36:36):
and if you're willing to tellme what it's like for you,
I can provide better care for you."
So having that curiosity and saying,
"Just tell me what it's been like for you
and would it be okay ifwe talked about this?"
So the first part is being curious.
The second step is therespectful query where you say,
(36:56):
"If it's okay with you, I would like
to ask you some questionsabout what your experience is."
And then you dip your toein that water together.
The final portion of it isconnected care where you partner
with that patient in front of you
and you say, recognizing, for example,
you say something like, "Iunderstand you've told me
(37:17):
that you're not interestedin talking about hormones.
All you wanna do is talkabout non-hormonal approaches.
I hear that and I respect that.
To me, it's important
that all my patients have the knowledge.
Would it be okay with you
if we talked about the hormonesjust for your knowledge?"
And then if they say, "No, Idon't wanna hear about it,"
(37:39):
then you say, "Okay, you respect that."
They drive the conversation.
So Dr. Williams, thankyou for that article.
It was really impactful for me,
and I know for many providers,the steps are curiosity,
respectful query, and partnership
in developing the treatment plan.
(37:59):
People feel lonely in theirmenopause transition already,
even if they're highly resourced,
a member of a majority group,
and I can only imagine how lonely it feels
to be navigating it ifyou're not in that group.
- Thank you for walkingus through that article
and highlighting such an important point
that equitable care is truly at the core
(38:20):
of good menopause medicine.
It's such a meaningful wayto close this conversation.
Dr. Adams, I appreciateyou sharing your expertise
and helping us see menopauseas an opportunity for health,
for connection and empowermentrather than just an endpoint.
I know our listeners willwalk away with practical tools
(38:41):
and a broader perspective tobetter support their patients.
Thank you again for sharingyour time and expertise with us.
- Thank you for theopportunity. It was my pleasure.
- Thanks for tuning in.
This episode was broughtto you by Stanford CME.
To claim CME forlistening to this episode,
click on the Claim CME link below
or visit medcast.stanford.edu.
(39:04):
Check back for new episodes by subscribing
to "Stanford Medcast" whereveryou listen to podcasts.
(tranquil music)
(lively music)
(00:06):
- Welcome to "Stanford Medcast,"
the podcast from Stanford CME
that brings you the latest insights
from the world's leadingphysicians and scientists.
If you're joining us for the first time,
be sure to subscribe on Apple Podcast,
Amazon Music, Spotify or YouTube
to stay updated with our newest episode.
I am your host, Dr. Ruth Adewuya.
(00:29):
Today I will be joined by Dr. Karen Adams
who is a clinical professor of obstetrics
and gynecology here atStanford University School
of Medicine and the director
of the Stanford Program inMenopause and Healthy Aging.
She is board certified in both OB-GYN
and lifestyle medicine, acertified menopause specialist
by the Menopause Society
(00:50):
and a fellow of the International Society
for the Study of Women's Sexual Health.
Dr. Adams is a nationallyrecognized expert on menopause,
sexual health and midlife medicine
with a particular focus onintegrative preventive approaches
that support brain, bone, cardiovascular,
and sexual health acrossthe menopausal transition.
(01:12):
Dr. Adams, thanks for being here today.
- I am so happy to be here.
- I'm thrilled to havethis conversation with you
and talk about menopause.
Despite the fact thatwomen spend up to 1/3
of their lives in post-menopause,
most never receive evidence-based care.
Why do you think menopause continues
to remain so underdiagnosed,untreated and misunderstood
(01:34):
in clinical practice?
- With longevity, womenare gonna be living half
of their lives post-menopause.
We're gonna live to be 100
and average age of menopause is 50,
and why are we not talking more about it?
Most of us, if we'relucky, our mother sat down
with us when we were eight or 10 or 12
and talked to us aboutyour period's gonna start.
(01:56):
We don't get that talk
on the opposite end of that journey.
For generations, women have been left
to wander in the wilderness,
wondering what in the world is going on
and really thinking it's their new normal
and being resigned to it.
There was some discussionback in the '60s and '70s
about it, but it wasconsidered very shocking
(02:18):
and edgy to put it on "Allin the Family," for example,
and have Edith hot flushing.
It's a generational thing now.
I think women are tired ofhaving their issues marginalized.
Science always marches on
and we have more knowledgenow than 20 years ago
that informs our care as well.
But still, there are a lot of care deserts
(02:40):
and women who are seeking that care.
So I'm just really happy to be here
to have this chat with you today.
- That's a great point
and I love that vivid framing
of women wandering in the wilderness
because it's never openlynamed or normalized,
and I think this raisesan important question
of how does care change
when we stop treating menopauselike a hidden pathology
(03:02):
and we start framing itas a natural transition?
- I wanna just be as inclusive
with our conversation as we can be.
When we're talking about women,
we're talking about people with ovaries,
and anyone who has ovaries isgonna go through menopause.
I will try to say menopausal people.
If I say women, please know
that I'm talking aboutpeople with ovaries.
(03:24):
It is a natural transition.
And if we live long enough,we'll go through it,
but that doesn't mean thatwe just have to accept it
and just say, "Those were good years."
No longer.
I think we can treat it, acknowledge it,
and maximize our healthwithout overmedicalizing it.
There's a difference between acknowledging
(03:45):
and treating and pathologizing,
and so it's very important
that we look at everyone'sexperience individually
and think about what'sgoing on for that person
and figure out the best path forward.
- A lot of that tensiontraces back to the legacy
of the Women's HealthInitiative, which reshaped
how patients and cliniciansthought about hormone therapy.
(04:06):
Can we talk about that history
and where the evidence stands now?
- When the Women's HealthInitiative came out,
it changed everything.
The Women's Health Initiative
was the largest randomizedcontrolled trial
of hormone therapy thathad ever been undertaken.
165,000 women.
(04:27):
Average age was 64,
and in order to enroll in the trial,
people couldn't be having symptoms.
So that's a really important thing
because if they were having symptoms,
they would know if they werein the treatment group or not
because their hot flushes would go away.
To have a well done trial,
anybody symptomatic was not enrolled.
(04:49):
What that means is it was never designed
to evaluate symptoms
and the use of hormonesfor relief of symptoms.
What it was designed to dowas to look at the impact
of hormones on long-termhealth, primarily cardiac risk,
heart attack, stroke.
They enrolled women betweenthe ages of 50 and 79.
(05:12):
The average age of menopause is 51,
but they were putting womenin their 70s on hormones
who had never been on hormones before,
thinking that it wasgonna benefit their hearts
for a lot of good reason
because we had a lot ofobservational data prior to that
saying that it seemed to bereally beneficial for hearts.
(05:33):
What happened was they hadto stop the trial early.
It had planned to gomuch further than that,
but they stopped it five years in
because of an increasedrisk of heart attack, stroke
and breast cancer, and thosenumbers hit The New York Times.
"Good Morning America" madethe phone ring off the wall
in my clinic that day, likehuge increases in heart attack,
(05:56):
stroke and breast cancer.
For example, 26% increasedrisk of breast cancer
with hormone therapy.
Now, that sounds like onein four, right? It's not.
It's eight extra casesper 10,000 women per year.
Eight extra cases per 10,000 women.
(06:17):
So 26% increase in breastcancer sounds like one in four.
It's not. It's eight per 10,000.
So that was one thing that kind
of freaked everybody out was like, "Ah,
I have a one in four chanceof getting breast cancer."
Not at all true.
The other thing that got lost in the noise
is that the younger women
(06:37):
in that trial responded differently
to hormones than the older women.
It was women 70 and abovehaving heart attacks
and the strokes and theincreased risk of breast cancer.
Women who were under age 60 in the trial,
so between the ages of 50 and 60
or within 10 years of theirlast period did better.
(07:01):
It's nuanced.
There's a lot to unpack about that,
but the take-home message
is younger women behavedifferently on hormones
than older women, and therisks aren't as enormous
and scary as they really weremade out to be and sounded.
And now we have 20-year follow up,
so we can talk about that too,
(07:21):
but it scared everyone off hormones
and we're still dealing with the fallout.
- Exactly, because it led
to about a 79% drop in HRTprescriptions after 2002.
More recent data clarifies the risk
when you are talking about HRTbeing started before age 60
or within 10 years of menopause.
(07:42):
What is one myth about HRT
that you hope clinicians can abandon?
- As an aside, we callit hormone therapy now
rather than HRT 'causewe're not replacing,
we're using it as a therapeutic strategy.
One myth I spend so muchtime in the clinic unpacking
is that hormone therapycauses breast cancer.
(08:03):
People are worried about breast cancer.
We die of heart disease.
So even though the fearis around breast cancer,
we want to improve people's longevity
by improving heart health.
But women continue to be convinced
that hormone therapy causes breast cancer
and that is a myth,and this comes directly
(08:23):
from the Women's Health Initiative trial.
When women are on estrogenalone, they have lower rates
of breast cancer thanpeople not on hormones.
So it seems to be protective.
Now, who gets to take estrogen alone?
Those are women who've had a hysterectomy.
If you have a uterus, you takeestrogen plus progesterone
(08:44):
because progesterone protects the uterus.
If you've had a hysterectomy though,
you're on estrogen alone.
Those people had protectionagainst breast cancer.
So that's one aspect.
And then the group who had estrogen
and progesterone together,
that was eight extracases per 10,000 women,
(09:04):
and the risk of breast cancer is greater
with a sedentary lifestyle,alcohol intake or obesity.
Obesity increases the riskof breast cancer by ninefold.
There are so many other things
that impact our breast cancer risks
so much more than hormone therapy.
If I could erase a thought out
(09:25):
of everyone's mind, it would be that.
- Such an important myth to call out
and highlights how riskperception can be different
from actual risk.
We know that not everypatient is a candidate
for hormone therapy andsome simply don't want it,
even knowing all of the data.
Let's shift to what'savailable beyond hormones,
(09:46):
what's credible and what'smore hype than help?
What is the current state of evidence
for non-hormonaltreatments for hot flashes
and genitourinary syndrome of menopause?
It's such an important myth to call out
and it highlights how riskperception can be different
from actual risk.
Not every patient is acandidate for hormonal therapy
(10:08):
and some simply don't want it,
even knowing all of the data.
Let's shift to what'savailable beyond hormones,
what's credible and what'smore hype than help.
And so if you could talk to us
about what is thecurrent state of evidence
for non-hormonal treatmentsfor all the symptoms,
hot flashes and genitourinarysyndromes of menopause,
and what's worth clinicians' attention
(10:30):
and which are more hype than help?
- When we're talking about prosand cons of hormone therapy,
there's a small group ofpeople who should not take it.
Contraindications are if people
have active breast cancer themselves,
if people have had ablood clot in their leg
or their lung or their brain,
if people have had a heart attack
or a stroke, those are people in general
(10:52):
we wouldn't recommend hormones for,
but everybody else we consider it.
And we also have to factorin not just symptom relief
but long-term health, risk and benefits,
and the risk of not treating.
What does it mean if you'regonna hot flush for 10 years
and just wait it out?
What is the downside of that?
(11:12):
So we also have to thinkabout what would the impact
of not treating be?
That's how we think aboutthat risk-benefit discussion.
If we're going to say,"Yeah, based on all of that,
we're not gonna recommendhormone therapy for you,"
then there are somevery good pharmacologic
and non-pharmacologic approaches.
We unpack it based on symptoms.
(11:34):
80% of women get hotflushes and night sweats.
That's the primary symptom
and that can be incredibly bothersome
and impactful to our brains.
There's interesting data thatwhen hot flushes are treated,
verbal memory improves.
When we go throughmenopause, we get brain fog
(11:55):
and people are like, "I came in this room,
I can't remember why I am here."
When people are hot flushing,those symptoms are worse.
And when their hot flushes are treated,
those symptoms get better,
even if it's not a hormonal treatment.
So even if it is some othernon-hormonal treatment,
(12:16):
the brain fog lifts.
There's something about hot flushing
that's triggering brain fog, not hormones.
So when thinking aboutnon-hormonal treatment
of hot flushes, there's a new drug
that has come out in the past year or so.
It's really been a game changer.
It's a non-hormonaltreatment for hot flushes.
It's called Tant
(12:36):
and it works on the brain a step back
from the hormone receptors.
It's just a pill thatpeople take every day
and it takes hot flushesand night sweats away
in a couple weeks.
Other drug options, there'sa drug called gabapentin,
which can help with sleep.
There's a drug called paroxetine.
It's an antidepressant
(12:56):
and it also has been shownto help for hot flushes.
So those are the top threepharmacologic approaches.
The non-pharmacologicapproaches that really work,
cognitive behavior therapy issuper interesting how it helps
to decrease the bother of hot flushes.
Clinical hypnosis helps with hot flushing,
(13:17):
which is a little bit harder to access.
Soy is a phytoestrogen,plant-based estrogen.
And there's some research
that's been published in thepast year that half a cup
of soy every day, likesoybeans, decrease hot flushes.
And so we're watching that.
There's not enough consistencyin the studies for us
to really be able to say for sure,
(13:40):
but we don't think it's harmful.
We don't think it'sgonna increase your risk
of breast cancer or anything like that
because it's such a tiny impact.
But for some people,
it might improve hot flushes a little bit.
Weight loss helps with hot flushing,
stellate ganglion block,which is a procedure
where you're having somethinginjected into one part
(14:00):
of the nerve plexus in your neck,
the uptake of that, pretty poor.
But things like yoga,acupuncture, paced respiration,
deep breathing, things like that,
there really isn't muchevidence to support them
above and beyond placebo.
There's good reasons to do yoga
and paced breathing for stress management
(14:23):
and things like that,but are they really going
to make your hot flushes worse or better?
Probably not.
- That's such a helpfulway to break it down.
Tailoring options by symptom profile
and weighing the risks oftreatment and non-treatment.
It's helpful for all of us to hear some
of the pharmacologic options
and non-pharmacologic strategies.
(14:44):
And what it reinforces
is that clinicians have moretools than they may realize.
- Yes, there absolutely are options,
and we didn't even talkabout genitourinary syndrome
of menopause or GSM.
That's the thing that 50%of menopausal people get
and it's vaginal dryness,it's vaginal irritation,
(15:06):
it's pain with penetration.
So with sexual activity, things can start
to get really ouchy.
It can also be thatfeeling like you have a UTI
all the time, but youactually really don't
or that kind of frequency or urgency.
So it can be bladder symptoms
and it can be vaginal symptoms.
(15:27):
And there are both hormonal
and non-hormonal treatmentsfor those things as well.
So vaginal moisturizers,using the right kind
of lubricant when you're having sex.
Coconut oil is my favorite by far.
Just grocery store coconut oil.
And then local estrogentreatments, which are tablets
(15:47):
or creams or rings that go in the vagina
and don't circulate into the bloodstream.
- It also strikes me thatwhile these therapies help
with quality of life,
they also tie into bigger outcomes.
What do you see as the mostimpactful interventions
that clinicians should prioritize
to support long-term brain, bone
(16:09):
and cardiovascular health duringthe menopausal transition?
- Now we're walking into a minefield
because this is controversial.
The US Preventive Services Task Force
has given hormone therapyfor the prevention
of chronic conditions, a grade of D,
meaning no evidence ofbenefit or potential harm.
(16:33):
As the data is evolving,
that actually is turningout not to be true.
We do see long-term health benefits.
And hormone therapy is FDAapproved for prevention
of osteoporosis in high-risk women.
It's not approved totreat osteoporosis per se.
(16:54):
It is approved for that in Australia
and some other countries,
and it may ultimately getthere in this country,
but it is FDA approved forprevention in high-risk people.
We know when you're on hormone therapy,
your bone density goes up by five to 6%,
which is great.
In the first five yearsafter that last period,
(17:15):
women can lose up to 20% of bone density.
It drops so dramatically.
And when you start on hormonetherapy, it arrests that loss,
it stops it wherever it isand even bumps it a little.
For bone health, hormonetherapy is indicated.
Also, strength training.
As much as we love ouraerobics, that's great
(17:37):
for our heart and our bones,
the real benefit for bonesis strength training.
It's lifting heavy andincreasing it all the time.
Squats, hinges from yourhips, pushes and pulls.
That's what we should beadvising our patients do.
Yoga and Pilates are greatfor balance and flexibility
(17:57):
and core strength, butthey don't give us a lot
of bone benefit.
So bone benefit is aboutresistance training.
That's how I talk aboutbones with my patients.
Heart health and brain healthare inextricably linked
and everything for heart healthis promoting brain health.
So not smoking, decreasing alcohol intake,
(18:19):
trying to eat a whole food,plant-based diet to the extent
that we can, prioritizingsleep, managing any kind
of long-term health issues.
If you have high bloodpressure, get it under control.
If you have diabetes, get yourblood sugar under control,
manage those things.
And then finally, staying connected
to family and friends and community.
(18:40):
Connection is superimportant for protection
for our hearts and our brains.
- I really appreciate
how you laid out both thecontroversy around this,
but also some really practicalstrategies for everyone.
Another area where lifestyle
and hormonal changesintersect is mental health,
especially depression and anxiety
(19:00):
during the perimenopausal years.
How do you adviseclinicians to better screen
and intervene here?
- Mood, sleep and cognitive issues
can show up in the perimenopause
before hot flushes and beforeperiods start to change.
Mood and sleep disturbance inparticular often are happening
(19:22):
when people are still having periods
and patients get told, "Oh,this isn't about hormones,
this isn't aboutmenopause or perimenopause
'cause you're still having periods."
So that's a really key pointfor people is to recognize
that mood in particular affects people.
In the perimenopause,
there is a thing called
perimenopausal mood instability, PMI.
(19:47):
It's more common than PMS,
but nobody's ever heard of it, right?
PMI, perimenopausal mood instability,
can affect up to 60 to 65%of perimenopausal people.
And the thing that's so key about it
is that it is unpredictable.
When you have PMS, okay,the week before my period,
(20:07):
okay, I'm not gonna feel great.
I can expect that's gonnahappen. I can prepare for it.
PMI is completelyunpredictable from day to day
because the hormone cyclingis becoming unpredictable.
A woman gets up every day having no idea.
Is she gonna feel irritated, anxious,
is she gonna feel normal?
And so that's a really important thing
(20:29):
that people should be looking for
when they're seeingpatients in their early 40s.
People with a history of majordepression earlier in life
are also much more at risk
around perimenopause and menopause.
So we have to keep our antenna up
for both it being hormonally driven
but also a recurrence ofprior major depression,
(20:51):
which can be life-threatening.
- This podcast is generallygeared towards clinicians,
but we may also have patientslistening in as well.
How do patients approachclinicians to be able
to have these conversationsand to get those antennas up?
Especially when it comes to perimenopause
where you're not reallyhaving the skipped periods,
(21:12):
but you're having some of the mood, sleep
and cognitive issues.
- People think they're losing their mind.
- Exactly.
- They're like, "What's wrong with me?
Why am I feeling soirritated with everyone?"
So I think women are educating themselves.
Often they know more aboutthis than their providers
because they've soughtout the information.
(21:33):
And on average, people have to go
to about five different providers
in order to find someone who can help.
At Stanford, we are doingour best to train providers
because I cannot see all thepeople who need to be seen.
It is really important
that we raise awarenessacross primary care,
endocrinologists, womenneed to arm themselves
(21:55):
with this information,listen to webinars like this,
seek out good sources, whichin and of itself can be hard
'cause there's so muchmisinformation and noise out there.
So really looking formedical center-based,
evidence-based sources.
Like we're starting a podcast in October,
"Stanford Conversations inMenopause and Healthy Aging."
(22:18):
So I refer people to thatfor an evidence-based source.
What you're doing here, super important
for getting the word out ina really evidence-based way.
But once you know aboutwhat you're dealing with
and how it connects tothe menopausal transition
that you're experiencing,then what you do is you go
to the Menopause Societywebsite, put in your zip code,
(22:42):
and a whole bunch of certifiedmenopause practitioners
will come up in your area,
and you can find someone who is certified,
has actually studied up,taken a multi-hour exam
and knows how to guideyou through the process.
- You are so right becausethis is such a hot topic.
We have social influencers
(23:02):
that talk about this fromall different perspectives
and it's hard to siftthrough all of that noise.
So I'm glad you've leftus with a practical place
to go to for evidence-based information.
- Probably the most common question I get
after we've dealt withall the hormone stuff
and the symptoms and everything
is what supplements should I be taking
(23:23):
for perimenopause and menopause?
If you eat the rainbow,
if you eat a whole food, plant-based diet,
if you move your body,
chances are you're notgonna need health in a pill.
I just really caution people about that
because supplements are not always safe.
They're not always the right thing to do.
And so really find someone
(23:44):
who can help guide you through this.
- So how do you approach the topic
of supplements in menopause care?
Are there any evidence-based options
that you routinely recommend
or do you prefer toindividualize those decisions
based on each patient'ssymptoms and health profile?
- I do think there are somethings that are worthwhile
for most perimenopausaland menopausal people.
(24:07):
Calcium intake is super important.
You wanna make sure thatyou're getting about 1,000
to 1,200 milligrams of calcium every day,
ideally in your diet,no more than about 500
to 600 in a supplement
because any more than that will tend
to deposit in the coronaryarteries in your heart,
which we do not want.
(24:28):
Things like beans, peas, legumes,
chickpeas are just apowerhouse full of calcium,
full of protein.
Dark green leafies alsohave calcium in them.
Along with that, vitaminD also for bone health
because vitamin D absorption from the sun
really decreases as we get older.
And so we're just not makingit from the sun the way we did
(24:51):
when we were 20.
And so I generally recommendabout 2,000 international units
of vitamin D
and that sometimes I willfollow a blood level for that
because you can push peopleup a little bit to about 50
to 55, that level,
and it will really help ifthey're dealing with joint pain
and muscle aches and things.
(25:12):
Coenzyme Q 10 can behelpful for heart health.
And so my colleaguesin the cardiology world
will often suggest that for folks.
I don't recommend that routinely.
People pay attentionto their protein intake
and rightly it should be 1.2 grams
per kilogram of body weight.
Again, getting it in your diet is ideal.
(25:33):
People ask me about creatine all the time
for muscle strength andwhen we think about muscle
and bone health, which Ireally want perimenopausal
and menopausal people to thinkabout, you wanna be strong,
you don't want your bones to be crumbling.
You want to have strongmuscles and strong bones.
- I'd like to go backto when we were talking
(25:53):
about mood, sleep and cognitivechanges in perimenopause.
One of the things that youmentioned is sleep disturbances
and how it's often one
of the earliestunder-recognized manifestations.
In your research, you'veshown that sleep problems
are among the most prevalentsymptoms of menopause.
What are the earliestsigns that sleep disruption
(26:15):
is tied to hormonal change andhow can clinicians spot this?
- What's interesting, when you ask women
what bothers them the most in this period
of time when they're going through it,
even if they're hot flushing like crazy,
if they have sleepdisturbance, they rate that
as their most bothersome problem
because, "Oh gosh, Ijust treasure my sleep
(26:37):
and I get so crabby if I've had one night
where I'm not sleeping well."
And if you go on andon and not sleep well,
it impacts you in so many different ways.
You get more brain fog,you get more irritable,
more mood disturbance,your sex drive drops.
It's harder to lose weightif you have insomnia.
There's ripple effectsof the sleep disturbance
(27:00):
in so many differentareas and it can manifest
before hot flushes or skipping periods.
If you have preexisting sleep problems,
they will tend to worsenin the perimenopause.
And that's a very different kind
of situation than somebody who's,
"I used to be a great sleeperand now I just can't."
(27:22):
And so that's one ofthe questions clinicians
should ask, "Is this new?
Or have you been a crummy sleeper
since you were 15 years old?"
Because those are twodifferent conditions.
But if people say, "Wow,I've always slept really well
and now this is happening,"that should be a tip off
that this is something that'sprobably hormonally mediated.
(27:42):
And then you wanna ask people,
"Are you having trouble falling asleep?
Are you having troublestaying asleep or both?"
Because those are also different kind
of manifestations of things.
The sleep scientists callthat sleep initiation
or sleep maintenance.
The most common thing
that we see in our menopausal population
(28:03):
is that early morning wakening,
that 3 AM kind of thing where you wake up.
Now, we think it's normal towake up twice a night to pee.
You get up, pee, getback in bed, then what?
Can you fall asleep?
If you can fall asleep within15 minutes, that's normal.
True insomnia is three timesa week or more you wake up
(28:25):
and you're up for an hour or more
and that goes on for months.
That's the person thatneeds to get referred
to sleep scientists tohave a sleep study done.
Obstructive sleep apneabecomes more common
in women after age 50.
Restless legs keeps people awake.
You want the sleep scientiststo be looking for those things
(28:46):
and helping diagnoseand treat your patient.
So that's how I would think
through the presentation as a clinician.
The good news is progesterone,
part of our hormone therapy regimen,
hits the sleep centers of the brain.
We have people take progesterone at night
because the side effect is drowsiness.
I had one patient and shecalled our office one day
(29:08):
and she said, "I forgot totake my progesterone last night
and I took it this morning
and I am canceling all my meetings
'cause I am literallyfalling asleep at my desk.
Is that the progesterone?"
And we were like, "Yeah, call Uber.
Don't try to drive homebecause you might fall asleep."
So hormone therapy can help with sleep,
(29:28):
but knowing when to refer is important.
- And since sleep and mood
are often intertwined with intimacy,
another sensitive area
that can be overlooked is sexual health.
How do you approach sexualdysfunction in midlife
and menopausal patientscompared to younger individuals?
- When I talk with my patientsabout sexual function,
(29:49):
I always acknowledgeI'm not curing cancer,
but it is super importantfor our quality of life.
There's a thing called the Living Index.
The two most predictivethings about wellbeing
are good sleep and good sex.
That's what my TED Talk is about,
"Sleep, sex, and menopausal zest."
Because if you havegood sleep and good sex,
(30:11):
you have a pretty good quality of life.
Sexual dysfunction in women,
it is a little different inyounger versus older women.
Younger women, it doesn'ttypically involve pain
with insertion ofsomething into the vagina.
And again, I'm gonna try notto be too heteronormative here.
So some people have same-sex partners,
(30:33):
some people are having sex by themselves,
so I'm talking aboutfingers, a vibrator, a penis,
anything you insert into the vagina
is not supposed to be painful.
When you go through menopause,
about half of women experience pain,
actual true pain with penetration.
It's not 100% sure that'sgonna happen with you,
(30:53):
but if it does, it is treatable.
And 50 is way too youngto stop having sex.
That's my message topeople who are listening.
If it's painful, we shouldbe able to treat that.
That can be either related
to the effective estrogenat the opening of the vagina
where we need a little estrogen there.
Sometimes it's pelvic floor pain
(31:14):
where there's a spasm on the pelvic floor
and it feels like you goabout halfway up the vagina
and you're hitting a walland you can't get past.
Then there's the wholeelephant in the room,
which is, "Gosh, I don't wantit and I wish I wanted it."
That low libido, it can berelated to all sorts of things.
It can be related tophysical pain, back pain,
(31:38):
chronic illness, chronicmedical conditions.
It can be related to drugs,alcohol, recreational drug use.
It can be related to medications, stress.
If you're running fromthe saber tooth tiger,
Mother Nature does not wantyou to stop and have sex
because you will die.
Libido is complicated
and we spend a lot of time unpacking that,
(31:59):
and those factors canbe involved at any age.
But the thing that makesolder women different
from younger women is that risk of pain.
About 50% of people have it,
even if they've never had pain before.
- It's valuable to hearhow you individualize care
for sexual health and midlife,
especially since many patients are unsure
how to initiate thoseconversations with clinicians.
(32:21):
But clinicians also still feel unsure
about how to even startthose conversations.
Your dual training in OB-GYN
and lifestyle medicinegives you a broader toolkit
for looking at this issue.
How has that dual lens
reshaped the way youapproach menopause care,
particularly from a preventative
and systemic perspective?
(32:42):
- I really wanna do a shoutout to the American College
of Lifestyle Medicine
and the American Boardof Lifestyle Medicine.
You can get board certified, in addition,
in lifestyle medicine.
I found that essential inhaving these conversations
with patients becausemenopause and hormone therapy
isn't just about symptom management,
(33:03):
it's about long-term health.
People are motivated
to start looking at their health habits,
and this is when thechickens come home to roost.
You can get away witha lot when you're 20,
but when you're 60,
your lifestyle choices arereally starting to add up
and people are motivated.
They're realizing that.
So this is a real opportunity.
(33:24):
Many of my patients say,
"I am in the best shapeof my life now at age 65
because I'm paying somuch more attention."
I wanted to get boardcertified in lifestyle medicine
so that I could say, "Here,
let me give you an exercise prescription.
This is what the science tells us
(33:44):
is gonna help you age in a healthy way.
Here's your nutrition prescription,
here's your sleep prescription."
So the pillars of lifestylemedicine are sleep, exercise,
physical activity, healthy eating,
avoidance of toxicsubstances, stress management
and connections to community.
(34:04):
Those are the pillars ofaging in a healthy way.
- That is such a helpful framework.
It really grounds sleepin the bigger picture
of overall health.
And as you mentioned,
many patients are alreadymotivated at this stage in life
to make the change thatwill serve them for decades,
but that opportunity is sometimesnot distributed equally.
(34:26):
We know from research that Black, Hispanic
and LGBTQ+ individuals are less likely
to receive adequate menopause treatment.
From your perspective,
what are the most urgent changes needed
to make menopause care moreinclusive and equitable?
- We have a study called
the Study of Women's HealthAcross the Nation, SWAN,
(34:47):
that was one of the few that looked
at the experience of menopause
broken down by race and ethnicity.
What we found is that Black women
have more severe hot flushesfor longer periods of time
than any of the othergroups in that study.
Almost half experiencedsevere hot flushes,
and they on average last for 10 years.
(35:10):
And Hispanic people are a close second,
Caucasians are in the middle,
and then Asians lessfrequently and less severe
and for a shorter period of time.
We don't know why that is,
but we need so much more data than we have
about the experience of menopause
in different race and ethnic groups.
We really need more research.
(35:31):
And if anybody out there is a researcher
and you wanna contribute towellbeing of women worldwide,
please look into thismore, it's essential.
Having cultural competencearound this discussion
is something we all need to focus on
and do better on becausewe're all on that journey.
Nobody does it perfectly.
We're all trying to increase our awareness
(35:53):
and there's a wonderful article.
Makeba Williams is aresearcher doing a lot
of work in this realm, andshe's written an article
about cultural competencyin menopause care
that I highly recommendto anyone who's listening
and is in a provider role.
And she talks about therebeing three steps of that.
And it starts with cultural curiosity.
(36:15):
You know, we often don't wantto come across as not knowing.
Research shows if you come across humble
and wanting to learn, peopledon't judge you for that.
Your patients are notgonna judge you for that.
In fact, they're gonna be grateful.
And so if you say,
"I really don't know alot about your experience,
but I want to learn
(36:36):
and if you're willing to tellme what it's like for you,
I can provide better care for you."
So having that curiosity and saying,
"Just tell me what it's been like for you
and would it be okay ifwe talked about this?"
So the first part is being curious.
The second step is therespectful query where you say,
(36:56):
"If it's okay with you, I would like
to ask you some questionsabout what your experience is."
And then you dip your toein that water together.
The final portion of it isconnected care where you partner
with that patient in front of you
and you say, recognizing, for example,
you say something like, "Iunderstand you've told me
(37:17):
that you're not interestedin talking about hormones.
All you wanna do is talkabout non-hormonal approaches.
I hear that and I respect that.
To me, it's important
that all my patients have the knowledge.
Would it be okay with you
if we talked about the hormonesjust for your knowledge?"
And then if they say, "No, Idon't wanna hear about it,"
(37:39):
then you say, "Okay, you respect that."
They drive the conversation.
So Dr. Williams, thankyou for that article.
It was really impactful for me,
and I know for many providers,the steps are curiosity,
respectful query, and partnership
in developing the treatment plan.
(37:59):
People feel lonely in theirmenopause transition already,
even if they're highly resourced,
a member of a majority group,
and I can only imagine how lonely it feels
to be navigating it ifyou're not in that group.
- Thank you for walkingus through that article
and highlighting such an important point
that equitable care is truly at the core
(38:20):
of good menopause medicine.
It's such a meaningful wayto close this conversation.
Dr. Adams, I appreciateyou sharing your expertise
and helping us see menopauseas an opportunity for health,
for connection and empowermentrather than just an endpoint.
I know our listeners willwalk away with practical tools
(38:41):
and a broader perspective tobetter support their patients.
Thank you again for sharingyour time and expertise with us.
- Thank you for theopportunity. It was my pleasure.
- Thanks for tuning in.
This episode was broughtto you by Stanford CME.
To claim CME forlistening to this episode,
click on the Claim CME link below
or visit medcast.stanford.edu.
(39:04):
Check back for new episodes by subscribing
to "Stanford Medcast" whereveryou listen to podcasts.
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