Where Are We On The Science Of Menopause?

Menopause research began in earnest about 30 years ago. Two experts want you to know that we’ve actually learned a lot—and it’s not all bad.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Ira Flatow?

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• 0:16Speaker 01

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• 0:31Flora Lichtman?

  Hey, this is Flora Lichtman, and you're listening to Science Friday.

• 0:37Flora Lichtman?

  Today in the show, what do we know about the science of menopause?

• 0:41Speaker 03

  It always makes the hair stand up on the back of my neck when I hear, "We don't know anything about menopause. There's no research." That's absolutely not true.

• 0:53Flora Lichtman?

  Menopause is kind of having a moment.

• 0:56Speaker 04

  Everybody, we are here with the one and only Halle Berry, and we have one big thing in common. We are both in perimenopause.

• 1:07Speaker 05

  Actress Naomi Watts was among the first to speak openly about menopause. I had never heard that heart palpitations was a symptom of menopause. I wanted to do this because when I was going through it, there was nothing. There was nobody. I felt literally like I was going to die.

• 1:29Flora Lichtman?

  Besides the celebrity testimonials and Oprah special, there have been a bunch of books that make menopause or perimenopause a plotline. All this to say, menopause, at last, has gone mainstream. But it wasn't until about three decades ago that menopause research really kicked into gear. And since then, we've made big progress in understanding this basic biological process that affects half of the population. But there are still many more questions to be answered. Here to help sort through the science of menopause are my guests, Dr. Monica Christmas, Associate Professor of Obstetrics and Gynecology at the University of Chicago, and Director of the Menopause Program at UChicago Medicine, and Dr. Keri Carvenen Gutierrez,

• 2:11Flora Lichtman?

  Associate Professor of Epidemiology, and the Director of the Center for Midlife Science at the University of Michigan, based in Ann Arbor. Welcome to you both to Science Friday. I'm excited to be here. Thanks for having us. Carrie, let's start with some basics. What is physiologically causing menopause?

• 2:33Speaker 06

  Yeah, that's a really good question. So menopause itself happens because the hormones that control our menstrual cycle in our body, which are mainly estrogen and progesterone, are produced in much smaller amounts in the ovaries as women age. What happens is that these hormones don't stop all at once, which is why we see the menopause as a transition rather than as an immediate event. And what we see with menopause and many of the symptoms is due to estrogen dropping because it affects many parts of the body, not just the reproductive system. And so when its levels go down, it can lead to a variety of different symptoms that are hallmark,

• 3:16Speaker 06

  like hot flashes, night sweats, and so forth. And we define menopause clinically and for research purposes as the point 12 months after a woman has her final menstrual period. And that marks the end of her reproductive years.

• 3:31Flora Lichtman?

  So is the menopausal transition the same as perimenopause?

• 3:36Speaker 03

  The perimenopause transition is when you start having those menstrual cycle changes up to the last menstrual period. And perimenopause also includes the menopause transition plus that one year before, you know, the menopause actually is defined.

• 3:57Flora Lichtman?

  So you don't know that you've completed menopause until like 12 months after you've completed it? Does that sound right?

• 4:03Speaker 03

  It's true. It is retrospective. But it's important to say that there's not one menopause syndrome that every single person gets. There are people that get very few symptoms, if any at all, that are short-lived. And then there's people at the other end of the spectrum, too. And I think that's where things get confusing.

• 4:22Flora Lichtman?

  Well, how do you figure out whether what you're experiencing is normal or not?

• 4:27Speaker 03

  From a clinical's perspective, you know, I don't get to choose what's really bothersome to people. The hard part about this discussion is that, and what's most confusing to clinicians as well as is the people experiencing the menopause transition, is that this timeframe also coincides at a point where we are aging. And it's often difficult to truly disentangle what's truly due to menopause versus what is due to the chronological aging process. However, that menopause transition where our hormone levels are fluctuating, and it's not often the absence of estrogen, but it's that fluctuations because sometimes before those ovaries kind of conk out,

• 5:10Speaker 03

  they start malfunctioning a little bit. Sometimes they're creating more estrogen than is really needed. And then sometimes they're concluding less. And it's often that fluctuation, especially for things like mood swings or anxiety that are triggering those type of symptoms. And the good news is it doesn't last forever.

• 5:30Flora Lichtman?

  Carrie?

• 5:31Speaker 06

  So, one of the studies that has done a tremendous amount of work in understanding and disentangling these two ideas of reproductive aging versus chronological aging is the study of women's health across the nation, or affectionately called SWAN. That study has been going on for nearly 30 years now and has followed a cohort of over 3,000 women from their pre-menopausal life stage into their mid 70s now. And so, we can analyze our data in a way that will help us disentangle which changes or which types of symptoms a woman might be experiencing that are in fact due to that menopausal transition versus those that are due to aging as processed overall.

• 6:14Speaker 03

  And it's also a diverse group of individuals, which is really exciting, too. It's racially and ethnically diverse. So that data is such a meaningful contribution to midlife women's health and understanding it.

• 6:29Flora Lichtman?

  Well, do people of different demographics experience menopause differently? Are there correlations or trends there?

• 6:38Speaker 06

  We do have data from SWAN, and we do see that there are notable differences in menopause experiences, particularly between black and white women. In particular, we find that black women, on average, tend to reach menopause at a slightly younger age compared to white women, and they have a more symptomatic experience. They report experiencing hot flashes and night sweats with greater prevalence. They have longer durations of those symptoms, and often with greater severity.

• 7:09Flora Lichtman?

  Why?

• 7:10Speaker 03

  That's a good question. And yeah, I don't I don't know that we can answer that one, but they're definitely not just for Black women, but things are multifactorial. And there are lots of things that play into it. You know, SWAN looked at just cohort from the United States. But if we look at at data that's international, too, depending on where you live, what your socio-cultural influences are, what your underlying mental and physical health is, all play a role in how you experience the menopause transition. You know, one of the things that came with SWAN, too, I actually used their data for some of this to publish a paper, was that the uptake of treatment was different, too, meaning in our SWAN cohort,

• 7:54Speaker 03

  that more white women were open or receptive to taking hormone therapy, whereas the other racial, ethnic groups preferred more complementary or integrative modalities for managing their symptoms as well.

• 8:08Flora Lichtman?

  What is the treatment for menopause?

• 8:11Speaker 03

  It depends on what we're treating. And more recently, in the media, almost hormone therapy has become synonymous with menopause. Now, I feel like there's this demand for hormone therapy, like it's the antidote to aging or the cure-all for everything, which it is not. Spoiler alert. What does it help? Well, we know that hormone therapy helps minimize hot flashes and night sweats. It's one of the most effective treatment options for managing those symptoms. But, you know, again, how we manage things really depends on what the person's symptomatology is. And that perimenopause timeframe, often, the first symptom is changes to the menstrual cycle.

• 8:53Speaker 03

  And, you know, and they can be varied. Some people, they're they get shorter, they get lighter, they space out, and then they just politely go away. Other people may notice that their menstrual cycles are getting heavier. Often, the mood swings are the most common during that perimenopause transition, too. And so if we think the mood swings are truly just due to these hormonal fluctuations, hormonal birth control can actually help to stabilize hormone levels so that mood is better, too. But that's not a first-line treatment for mood disorder, so they might need a mood stabilizer like an antidepressant.

• 9:28Flora Lichtman?

  Carrie, are there long-term risks of hormone therapy?

• 9:32Speaker 06

  The early 2000s were hallmark by the finding from the Women's Health Initiative, or the WHO, that I think scared a lot of individuals, a lot of women, a lot of clinicians, given that the finding was that the usage of hormone therapy was associated with an increased risk of breast cancer and an increased risk of cardiovascular disease in some women, including blood clots, stroke, and heart attack. Understandably, those findings led to a lot of concern. We saw in our data from SWAN that there were dramatic changes in usage patterns. And there's been an ongoing debate continuing in the field about when, for who, and how long hormone therapy should be used.

• 10:14Speaker 03

  So it gets really complicated, but there is a finite, there's a window of opportunity, I'll say, or this timing hypothesis that we call it in medicine, when the benefit of hormone therapy seems to outweigh the risk. Now, we can never say that there's zero risk, but in younger individuals, meaning under the age of 60, or within 10 years of the onset of menopause, however, in individuals over the age of 60, or more than 10 years from the onset of menopause, that risk-benefit profile starts to shift a little bit, where we start to see more risk associated with long-term hormone therapy use. And those risks are actually increased in cognitive decline, increased in cardiovascular

• 10:58Speaker 03

  risk, stroke, blood clots like pulmonary embolism or deep vein thrombosis, increased in gallbladder disease, and then an increased risk in breast cancer, especially with estrogen and progesterone together. So it's not just an easy answer.

• 11:13Flora Lichtman?

  Do different experiences of menopause correlate with or cause different long-term health outcomes?

• 11:21Speaker 06

  Yes, we do see that. From the data in Smon, this is, I think, one of the most pressing research questions that we have now about the menopausal transition and understanding what the experience of menopause is and how it relates to one's long-term health. We certainly know that individuals who go through a very early menopause, before age of 40, 42, have earlier incidence of some major healthcare outcomes, including cardiovascular disease and osteoporosis. But we do need to understand better how those changes in physiologic health outcomes across the board, including brain health, cardiovascular health,

• 12:04Speaker 06

  metabolic health, that do occur during the menopausal transition, whether or not those are persistent and associated with long-term health outcomes for major age-related diseases. And those changes that we might be looking at during the menopause include things like the timing of the menopausal transition, how quickly one goes through the menopausal transition, and how symptomatic their transition is.

• 12:36Flora Lichtman?

  After the break, why the way we talk about menopause matters.

• 12:41Speaker 03

  It's not always a negative experience, but if we portray it that way, then, you know, our minds are very powerful. If we tell people that this is horrible, they believe it.

• 12:50Flora Lichtman?

  Don't go away.

• 12:55Speaker 01

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• 15:18Flora Lichtman?

  You know, I know that we're we're learning a ton more every day, thanks to you two. And at the same time, I also know that medical research has historically sidelined women, ignored women. And I wonder how you think that has affected our knowledge of this process that affects half the population.

• 15:38Speaker 03

  You know, absolutely, and it does impact things. One of the benefits to menopause having its moment right now, as you said, is that it is shedding more light. And hopefully with shedding more light, it sheds more money because that's how we promote and have more research findings.

• 16:00Speaker 06

  Yeah, I want to go back to something that Monica said that I think is really important. It's not that we have a lack of understanding of menopause. But I think the work to do now is to really turn this time, this menopause is a movement, into action, and this also leads into policy. There's now more than a dozen states in the country that have legislation being considered related to menopause, whether it's increasing training for healthcare providers in menopause science, whether it's workplace accommodations, or something of the sort.

• 16:36Speaker 03

  I love allowing for workplace accommodations that support women that are going through this timeframe that are not penalizing, because just because, and I'm in this age group myself, just because we're menopausal does not mean that we're not productive contributors to the fields that we are in. And so I definitely don't want to get to a point where we have created for a natural condition that happens to 50% of the population that we are over-medicalizing it to and then penalizing women. I think that when we think about, you know, menopause support, it's both ways. How do we create a medical system, not just the physician part of it, that we accommodate

• 17:20Speaker 03

  coverage for the visit itself as the support, mental health service support, as well as drug support? So that's my two cents.

• 17:29Flora Lichtman?

  Before we go, what is the biggest piece of misinformation you deal with around menopause or perimenopause?

• 17:35Speaker 03

  What always makes the hairs stand up on the back of my neck when I hear, "We don't know anything about menopause. There's no research." That's absolutely not true. Now, with all things in medicine, we are constantly looking for new innovative treatments or understanding novel ways to manage things. And that's just the beauty of science, which both Kari and I are in this field probably, because it's ever-changing. But we build on the heels of all of the research and information that we've had that's come before.

• 18:08Flora Lichtman?

  Kari, do you have a hilt?

• 18:10Speaker 06

  I do have a hilt. I think one of the most common myths related to menopause is that it's always a negative experience.

• 18:20Speaker 03

  Oh, yes.

• 18:21Speaker 06

  I think we talk a lot about the symptoms, and it does. It brings challenges. Many people find it to be bothersome in many ways. But I think the reality is that many people often find freedom and new possibilities and improvements in some health conditions as they transition through the menopause. It's freedom from periods and menstrual symptoms. It is bringing relief, perhaps, from certain health conditions like fibroids, or PMS, or endometriosis. It's often an opportunity for a health reset. The menopausal transition will often be a time period when women take restock of their health and make positive changes. And we

• 19:03Speaker 06

  often do see that with the greater focus on relationships, children might be leaving the home, it's an opportunity for a new chapter. And with that, it's sometimes seen as a time of renewal. We actually do see that some mental health metrics tend to improve as one goes beyond the menopausal transition. And so it's an opportunity for women to really take care of themselves and foster their health in a way that will improve their life and their well-being for the decades to come.

• 19:34Speaker 03

  Kari, that's so important. In many cultures, this is a timeframe where women are held to a different even level of esteem. You've reached this age and this wisdom period, it's really respected. Unfortunately, I think in our country, though, that aging women are often stigmatized in a negative way, and that fuels this more negative conception or connotation of menopause. So I'm so glad you said that because it's very true. It's not always a negative experience. But if we portray it that way, then our minds are very powerful. If we tell people that this is horrible, they believe it. I get lots of patients now in their 30s asking me what they can do to prevent menopause. And I often look and say, "Die." And I don't think we want...

• 20:19Flora Lichtman?

  Okay, well, I think that's the perfect place to leave it. Thank you both so much for being with me today and for this thoughtful conversation.

• 20:30Speaker 06

  Thanks for focusing on menopause. I think it's an important topic and glad to have been here.

• 20:36Speaker 03

  This has been wonderful. I'm honored to have been asked, and thank you.

• 20:40Flora Lichtman?

  Dr. Monica Christmas, Associate Professor of Obstetrics and Gynecology at the University of Chicago and Director of the Menopause Program at UChicago Medicine. And Dr. Carrie Carvenen-Gutierrez, Associate Professor of Epidemiology and the Director of the Center for Midlife Science at the University of Michigan, based in Ann Arbor. If you like the show, rate and review us wherever you listen, or just go straight to guerrilla marketing. Take a friend's phone and subscribe them to this podcast. Today's episode was produced by Shoshana Buxbaum. I'm Flora Lichtman. Thanks for listening.