Episode 18: How To Deal With Menopause with Dr. Michelle Warren
How To Deal With Menopause with Dr. Michelle Warren
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Teri Hausman: I'm Teri Struck. Host of "Beauty Now". I'm on a quest to remain ageless. Today our guest is Dr. Michelle Warren. She's gonna teach us all about the dreaded menopause, how can we fight it!
[Excerpts from Dr. Warren's interview responses before actual interview]
"Most women are suffering from hot flashes and insomnia and it usually makes their life miserable enough so they are hopefully looking for relief."
"Women who are cycling are difficult to treat. You see it's not just the level that causes the hot flashes and the night sweats and the insomnia. It's the fluctuation."
"You have to understand that the majority of these medications that are prescribed for menopause have been studied in women that are post-menopausal, not women who are in the perimenopause. So, we don't have a whole lot of science in terms of treating women in the perimenopause."
"Unfortunately, I see some patients who are very young. I've seen them as early as in their twenties."
Some of it is inherited. It's a genetic issue. Some have autoimmune problems but the great majority, we don't know.
Teri Hausman: Welcome Dr. Warren.
Dr. Michelle Warren: Thank you.
Teri Hausman: Thank you so much for being with us today. So how can a woman that comes to you, I mean, what is the first thing that they do? They come in and get their hormones measured or they have a hot flash? How do women know that they need to come to you?
Dr. Michelle Warren: Well, most women are suffering from hot flashes and insomnia. Those are the two big symptoms and it usually makes their life miserable enough so they are hopefully looking for relief. Some of them have tried medicines that are over the counter but in general the medicines don't work very well if the symptoms are moderate to severe. So basically, symptom relief is what most women are looking for.
Teri Hausman: So can you explain about the difference between bioidentical hormone and pharmaceutical hormone?
Dr. Michelle Warren: Well, bioidentical means that it's a hormone that's the same as the body makes. There are a lot of hormones out there. Some of them are the same ones the body makes. Pharmaceuticals means that it's made by a pharmaceutical company and there are many good bioidentical hormones made by pharmaceutical companies. So you can't really separate the hormones into bio-identical and pharmaceutical. It doesn't really make a lot of sense. It's a question of which hormone is best for you.
Teri Hausman: And how do you know? DO you do blood tests?
Dr. Michelle Warren: No. Blood tests are not helpful and the reason for that is that the blood tests vary so much over the course of several minutes. In another words, one minute a woman particularly in perimenopause can have a very, very high level and the next minute it could be almost unmeasurable. And that's what actually causes the worst symptoms. Or the symptoms of perimenopause as women start into that menopausal time when their hormones are bouncing all over the place. They're getting the worst symptoms. So hormone tests don't really help that much at all actually. It sometimes helps to make a diagnosis when women are very young to measure the pituitary hormones because those hormones go up in an attempt to keep the ovary working at a certain level. And they can be helpful but they're not always helpful either. So blood tests in general are not helpful at all.
Teri Hausman: That's interesting to know because I've always heard, that that was measured you know, on the third day or the 21st day of your cycle.
Dr. Michelle Warren: On the third day of your cycle we will measure hormones to try to determine if the FSH is slightly high. And sometimes the estrogen is high associated with that or sometimes it's low and we use that a lot in women who are trying to have a baby because sometimes you can tell if they're in early menopause in women who are cycling. In women who are not cycling then it's a lot easier. If they're not having periods then it's a lot easier to make a diagnosis of menopause. The 21st day of your cycle is a way of determining if you're making progesterone which will tell you if you're ovulating if your ovaries are producing an egg and that's something we use for women who are trying to have a baby.
Teri Hausman: You're using the estrogen or the progesterone?
Dr. Michelle Warren: The progesterone.
Teri Hausman: If you're trying to have a baby then you try to use progesterone and then what type of ...
Dr. Michelle Warren: No, no. If you're trying to have a baby you're trying to determine if a woman is ovulating and the progesterone will tell you that. Measuring hormones during the cycle is a total waste of money. Because we now have products on the market that are very, very low you know, very small amounts and they give you relief with barely detectable levels of hormones. So measuring hormones is just not a way that's very helpful. We will treat symptoms and we will treat it according to what um, you know we will try to relieve the symptoms and that will sort of determine the dose. But we know now that we can use very small doses. You hardly pick them up in the blood and yet you get good symptom relief.
Teri Hausman: So how does a woman really know when she's entering menopause?
Dr. Michelle Warren: Usually by the symptom cluster. Interestingly, the most often..the first presenting symptoms are irregulatary. The periods start to.. you either skip or they get shorter intervals or longer intervals. And the second thing that women notice are real moodiness um and then the third tend to be hot flashes. That is the eureka moment when people realize what's going on.
Teri Hausman: So if a woman has all these symptoms and they come into you, what do you do?
Dr. Michelle Warren: Well, if the symptoms are severe and moderate to severe, we usually suggest treatment. And um, women who are cycling are difficult to treat but generally we will give them a very small amount of hormone in an attempt to prevent the big ups and downs that occur during the cycle which tend to trigger the hot flashes. You see it's not just the level that causes the hot flashes and the night sweats and the insomnia. It's the fluctuations. Umm, so, early in menopause it's a little more difficult. We will give small amounts of hormones. Many of those women are only having symptoms uh generally around the time of the period when the levels fall very precipitously.
Teri Hausman: But then what do you give? Do you give this new product, Elestrin? or do you give ...
Dr. Michelle Warren: Elestrin is one of the products that can be used, it's a product that's given through the skin and you can get a very even dose of the hormone and you give it daily.
Teri Hausman: Where is it applied? Where on the body is it applied?
Dr. Michelle Warren: Uh, it's applied on the arm, upper arm.
Teri Hausman: On the inside of your arm? or the outside? or does it matter.
Dr. Michelle Warren: Usually it's on the inside of your arm.
Teri Hausman: I was under the impression that the second part of your cycle if you're cycling that the progesterone falls and you should apply topical progesterone. Is that not true? or both.
Dr. Michelle Warren: [sigh] You know, people are trying to push topical progesterone um because we don't have any on the market and you have to go to a special drugstore to have it made up. When in fact, topical progesterone doesn't get through the skin very well. So you have to give very, very large amounts. It's not an effective way of giving progesterone.
Teri Hausman: What is an effective way of giving it?
Dr. Michelle Warren: Well, there are some natural progesterones that you can give orally. Or you can give progesterone directly in the vagina and it gets directly to the uterus which is the reason you want to give it. The only reason for giving progesterone is to prevent the lining of the uterus from overgrowing. When you give estrogen or when you don't ovulate [or] don't make progesterone, the lining can overgrow and you can get really bad bleeding problems the way you do -- you see that in many women at the time of menopause. Women will present with very heavy bleeding and irregular bleeding so the progesterone tends to be very important. But giving it through the skin is not a good way of giving it so that it reaches the uterus and does its job.
Teri Hausman: So you don't really think that's effective at all.
Dr. Michelle Warren: No.
Teri Hausman: And so you're saying progesterone suppositories would be more the way to go.
Dr. Michelle Warren: Umm, well. Progesterone through the vagina is one way of giving it. The standard way of giving it is through medication that's given orally. The problem with progesterone is you want to know whether it's doing its job. So you need the science to tell you that there's enough progesterone in that dosage that's going to prevent overgrowth in the lining because this is a serious problem. If you don't get enough progesterone to the uterus, not only do you get bleeding but you also get problems related to pre-cancerous changes. So using a non-standard form of progesterone is tricky. And the progesterone cream is not a good way of giving it.
Teri Hausman: Will you take us through a cycle? Let's just say a woman is cycling and in the very very beginning you're having your period and then is it the estrogen that drops 'til day twelve? or is it the progesterone or both.
Dr. Michelle Warren: Well, I'm not sure. Is your question what happens at the time of the period? or what happens at the time of the cycle?
Teri Hausman: Well right. Let's just say that a woman comes in and she's having menopausal symptoms but she still has her period and you're going to prescribe either one of your products like the estrogen patch or elestrin or one of these things. What day does the woman start taking the Elestrin or "the patch" or whatever you prescribe.
Dr. Michelle Warren: OK, well you usually prescribe it along with the cycle so you take it with day one of the cycle which is the first day of bleeding and continue it throughout the cycle. In certain women, in order to control bleeding you may had some progesterone in the second half of the cycle. The umm, Elestrin is, I just want to correct what I said. It's applied to the upper arm shoulder area not the inner arm.
Teri Hausman: Oh, OK.
Dr. Michelle Warren: But it is a good way of giving small amounts of estrogen. The women who are still cycling are very difficult to treat. You need to give very low doses. You have to understand that the majority of these medications that are prescribed for menopause have been studied in women who are post-menopausal, not women who are in the perimenopause. So, we don't have a whole lot of science in terms of treating women in the perimenopause. But that's the way I give it, a small amount every day and in some women who have heavy bleeding, I add a progesterone for the second half of the cycle.
Teri Hausman: And so let's move on. Actually, we need to take a break because I want to move on and ask you some more questions about women that have already passed the point of having a cycle. We're going to thank our sponsors and we're going to talk some more with Dr. Michelle Warren.
Teri Hausman: I'm Teri Struck host of "Beauty Now". And we're talking with Dr. Michelle Warren and we were just talking about menopause - what we can do about it. Welcome back Dr. Warren.
Dr. Michelle Warren: Thank you.
Teri Hausman: Now we were just talking about women who were cycling and what can they do with the hormones. And now I want to ask you, let's talk about women that have already passed the point of having their period. How do you treat them?
Dr. Michelle Warren: Well they are somewhat easier to treat because you don't have their own hormones kicking in and they don't have some of the symptoms like breast pain and bleeding. Basically you give the lowest dose that does the job. That's actually what the FDA has suggested we do. So you take a low dose product and we know now that most women respond very well to half the standard doses of hormones that we used to use. So we give a low dose. If they have a uterus, you have to have a preparation that has progesterone with it. Or, if you're going to give the progesterone separately, you give it either every day in very small amounts or you give it cyclically for ten to 14 days out of the month. So, there's several ways of giving it. It depends on the patient and their preferences. And umm, the situation.
Teri Hausman: So, do you believe that taking estrogen or pills orally cause cancer more? Because that's what I read about the studies that have been done with placebo groups and other groups that the people that took oral hormones came up with cancer more often than the ones who were given it transdermally.
Dr. Michelle Warren: No, that's absolutely not true. There's no, no work that suggests that oral preparations lead to higher incidences of cancer. Let me just say that the cancer incidence is very, very small. It's much less than one percent per year which has been attributed to breast cancer. So there is a slight increase incidence in breast cancer and women on hormones but it's tiny. The majority of breast cancer that we're seeing is not related to hormones. If you're on hormones, however, the breast cancer may grow faster so it is very important that women on hormones get yearly mammograms.
Teri Hausman: So you have to be very vigilant and get yearly mammograms.
Dr. Michelle Warren: Yeah, yeah. Absolutely. You have to be more vigilant. But there's no proof that oral is more dangerous than transdermal.
Teri Hausman: So women that are passed the point of their periods can come in to you and you would prescribe... How do you decide which medication is for which women?
Dr. Michelle Warren: Well, some women like a very even dose of a hormone and the transdermals are very good for that. Other women are looking for convenience and sometimes pills are more convenient. If you have a woman with migraines I tend to use the transdermals because I think it gives a more even dose. Women who have certain cholesterol profiles, you know the lipids as we call them, which are dangerous because they can lead to heart disease. Certain lipids like tri-glycerides tend to go up with oral medication, it won't go up with transdermal. On the other hand, the transdermal doesn't increase the HDL which is the good cholesterol which is something that's desirable so some women who need an increase in HDL, I will use an oral medication. So, it's variable and it also depends on the patient's desire. Some women absolutely want the lowest dose and they want the bioidentical hormone and they want to use it for a very short period of time. So you have to listen to the patient and decide what's best for them and what their needs are.
Teri Hausman: How do these women know that their menopause is gone. Do they go off these hormones?
Dr. Michelle Warren: Yeah, that's a good question. You know, how long do you stay on it and how do you decide that you no longer need it. You know and my philosophy is if you don't need it then you shouldn't be on it. It's hard to know why you're on a medication but what you tend to do is tie trait. Umm and you will decrease the medicine and that's why it's very helpful to have a drug, a new drug like Elestrin which is a very low dose because now we can tie trait down even further or even start with these low doses in women. And then basically I tell them to start using it every other day or two to three times a week. And if they don't get symptoms or if their symptoms are only occasional then eventually over a course of a couple months they can stop it all together.
Teri Hausman: What age is the youngest menopausal patient that you have?
Dr. Michelle Warren: Oh unfortunately I see some patients who are very young. I mean I've seen them as early as in their twenties. I have a whole group of patients in my practice.
Teri Hausman: And why is that?
Dr. Michelle Warren: It's a very sad thing. Well, some of it is inherited. It's a genetic issue. Some have autoimmune problems but the great majority, we don't know. We don't know. There's a lot of work going on at the NIH. This is like a death for these women when they find out.
Teri Hausman: Right.
Dr. Michelle Warren: So it's a very sad thing.
Teri Hausman: I've heard that some of these women can freeze their eggs.
Dr. Michelle Warren: Well, we're hoping that you know eventually, if there's a history in the family of early menopause and that's usually if a menopause occurs before age 40 that women who have this history can freeze their eggs effectively. The thing is, the science isn't that refined and the success rate isn't that great yet. But hopefully, in another few years we'll be able to do that. I think the important thing for these women to remember is that when you're young, you really need the estrogen. The estrogen is important for protecting your heart, your bones and certain situations that really will even out the moods. So women who are under 45 really should be on hormone replacement and they shouldn't be scared of taking it. In fact, they're much lower doses than an oral contraceptive and women take oral contraceptives now for many years without any problem.
Teri Hausman: Well how can our "Beauty Now" listeners find a doctor that specializes in menopause?
Dr. Michelle Warren: Well that's a good question because basically we don't teach about menopause in medical school or even after medical school. So you've got to find a doctor that's menopause friendly. I think the best thing is to go to a website like menopause.org and there they have a whole list of certified menopause practitioners. Also, some doctors are very interested in menopause and will advertise that and make an effort to educate themselves on the newest developments. You know the story on the hormone replacement has been so stormy and so confusing for the public. There've been over 33,000 publications since 2002. So it's important to keep up with education if doctors are going to treat menopausal women. And I think doctors who have large practices in menopause and who are menopause certified are a good way to go.
Teri Hausman: Right, because I think, you know, even younger women that have PMS symptoms - a lot of doctors just look at you like you're crazy. They say oh, exercise more, which is true, you should exercise more. Drink water and do all that but when you have PMS, you have PMS! [chuckle]
Dr. Michelle Warren: Right well, there's still prejudices. We know that PMS is a real condition and it's a cluster of symptoms that have been accepted by the medical field and in fact has a diagnosis in the Diagnostic Manual for Psychiatric Diseases. So, it's well recognized but there's a lot of misunderstanding about it just like there is on a lot of women's health issues related to hormones. I do want to mention that there's been some very good news about hormones and that the latest data shows that it prevents calcification of the coronary arteries or hardening of the arteries. And, there was a question about that since 2002 when WHI came out. So, basically, if you're young and you're starting hormones at the time of menopause -- hormones protect the heart and we're no longer worried about heart attacks.
Teri Hausman: Another thing because there's been so much alarming news and cancer and all these different things and women have stopped and then they feel they need the hormones.
Dr. Michelle Warren: Yeah well the cancer issue. It's sort of too bad it was presented the way it was because there is a slight increase incidence of breast cancer. However, it's smaller than we thought before 2002 but you know the press has not emphasized that all. We used to tell patients that there was up to twice the increased risk. It was still less than one percent but the numbers were greater than we're telling patients now but that's not been publicized at all. So, basically, since WHI came out, the only thing that was really different was the issue on the heart attacks and now that the news on the heart attacks is very good. It will protect against coronary calcification and heart disease if you start it when you're young. The question is how long should we keep patients on it. We'll never know. We'll never know. But it's certainly safe for the two to five years that women have the most severe menopausal symptoms.
Teri Hausman: And what's the most important thing that you can do besides hormones? What is some other great advice you can give us.
Dr. Michelle Warren: Well, you know I like to call menopause the adolescence of old age. And basically, it's a chance to change habits. To exercise, to maintain your weight. Maintaining your weight is extremely important because it's a vulnerable time for women.
Teri Hausman: That middle age spread. I see it when my friends turn 40, it's like all of a sudden, their body starts to change.
Dr. Michelle Warren: Yeah, the basal metabolic rate goes down so you're apt to gain weight. Try to maintain your weight. If you need to lose weight it's a good time to try. Increase exercise. Exercise is like a pill. You should take it for the rest of your life. Find something you like to do. If you're smoking, please stop smoking. I mean that's the most important thing you can do for your health. So healthy habits, maintaining or losing weight if you can, and exercise and if you exercise you're gonna be able to maintain your weight.
Teri Hausman: Weight training basically too, right? And then also I heard about...
Dr. Michelle Warren: Be vigilant about your mammograms and ask your doctor about osteoporosis and all those...
Teri Hausman: That's exactly what I was going to bring up. Osteoporosis. When do you start realizing or how do you test if you're in trouble for that.
Dr. Michelle Warren: Osteoporosis, you know, our bones are 80 percent genes. So if it runs in your family you should worry about it as soon as you're getting near menopause in your forties. You could get a bone mineral density study -- a simple study lying on a table like having your picture taken and it'll tell you if you're at risk.
Teri Hausman: What about some of these products like Boniva or what if you just take it.. I've heard there's one that you can take once monthly?
Dr. Michelle Warren: There are all kinds of products now. You can take once monthly. You can even have an IV infusion once a year if you don't wanna, you know, if your stomach is bothered by these products. There's some that will decrease the incidence of breast cancer.
Teri Hausman: Where do you find these people who do the IVs? That sounds really interesting.
Dr. Michelle Warren: Well actually, we're doing a study at Columbia where we're offering it for free but it's available on the market now. It's an IV infusion that's given over 15 minutes. So yeah, I mean, people are welcome to go to the website and find out about it.
Teri Hausman: We're definitely going to link your website with personallifemedia.com and we're gonna have all the information to be able to find you and also on these infusions and the products that you can have. But that's great because I think there's new things every single day and we wanna learn more.
Dr. Michelle Warren: That's right. It's a very fast moving field. I think that's why it's important to go to a doctor who's menopause friendly.
Teri Hausman: And, you can also go to menopause.org, is that right? and find a doctor near you?
Dr. Michelle Warren: Yeah, mmhmm.
Teri Hausman: There's people across the United States that specialize in this and do you recommend that they be board certified and all this?
Dr. Michelle Warren: No, there's no such thing as board certified in menopause.
Teri Hausman: Menopausal doctors or...
Dr. Michelle Warren: Yeah, they come from all fields now. There are lots of women who are gynecologists because gynecologists have traditionally been interested in menopause. But now there are internal medicine family practitioners who are also interested. Umm, and then there are practices where they've hired nurse practitioners who are very expert in handling these problems. Because it's very time consuming to deal with a lot of the issues. So it depends on where you are and who they have available there. But basically a well informed health care provider who's taken some graduate education in this area is what you need.
Teri Hausman: Well, I have a couple more questions. We just talked about the estrogen and Progesterin [poss progesterone]. Are there any more hormones that we should know about?
Dr. Michelle Warren: Well the other hormone that I get asked about is testosterone or male hormone. There is no testosterone on the market for women and as a result it's a very difficult thing to give to women. But, it is possible. In those situations we use hormones that are either made up in the pharmacy or we tie trait down the hormones that are available for men. When do you need it? Well certain women who have early menopause, very early will have very low testosterone levels and will need replacement. What are the symptoms? Usually low libido, loss of hair. Some women who have had a hysterectomy with their ovaries removed. The testosterone may be very low and they may have symptoms like this. It's a very individual thing and there's a lot of science that needs to be done in the area but that's going to be the new hormone that I think is gonna be interesting to menopausal women.
Teri Hausman: And how much do you think that they need and at what time of the month do they need it?
Dr. Michelle Warren: Well, if you give testosterone normally you give it every day or at least three times a week or more than that. You don't need very much. You need a tiny amount that keeps their level probably in the high normal range. You don't want to give it so that it's outside the normal range but the high normal range of free testosterone. There, measuring the hormone is helpful. Because...
Teri Hausman: In the blood. With a blood test.
Dr. Michelle Warren: Yeah, you don't want to give too much. You can judge the response to your dose by measuring levels but this is all...
Teri Hausman: And this is a cream or a pill? Or how do they take it?
Dr. Michelle Warren: Usually it's a gel or a cream that you put on the skin. There are pills available but they're a little more difficult to use and there may be liver problems associated with it. There is one preparation...
Teri Hausman: And you would give this three times a week?
Dr. Michelle Warren: Huh?
Teri Hausman: You would give this three times a week?
Dr. Michelle Warren: Well at least yeah, usually.
Teri Hausman: Very, very little.
Dr. Michelle Warren: Yeah.
Teri Hausman: Very, very little. So basically you just need a consultation and find out what's right for you because every woman's different.
Dr. Michelle Warren: Yeah, absolutely.
Teri Hausman: Well thank you so much Dr. Warren for being with us today. You can get transcripts of our show on personallifemedia.com and you can get links to Dr. Warren's website and find all you need to know about menopause. Thanks so much for talking to us. We want to have you back soon and if you have any more new drugs or any other information you can give us, do another show. Thanks again.
Dr. Michelle Warren: OK. You're welcome Teri. Thank you.
Teri Hausman: Talk to you later.
Dr. Michelle Warren: Bye.
Teri Hausman: Bye bye.
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