All About Perimenopause: Signs, Symptoms, and What’s Not on TikTok

Perimenopause is trending on social media, but how do you separate the viral “hot takes” from clinical reality? This week on The Savvy Patient, co-hosts Dr. Gillian Goddard and Erin Stein deliver a fun, fluff-free masterclass on what is actually happening to your body. From the difference between perimenopause and menopause, to the metabolic shifts people rarely talk about. Plus, we dare to discuss the mood swings, brain fog, sex function and vaginal atrophy. This episode offers a no-nonsense guide to decoding your body and getting the right treatment. Hit play to skip the algorithm myths and get the medical truth.

We take a moment to remind you that while this is a medical discussion, it is not providing a diagnosis or treatment or any medical advice. The only way to get a diagnosis, treatment or medical advice for your particular condition is through a discussion with your doctor.

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This episode was produced and edited by Erin Stein. Music: “All We Live For (instrumental)” by Wolfclub licensed through Audiio.com. Intro and outro edited, and video created, by Ian Mayer. The Savvy Patient logo by Amanda Spielman.

TRANSCRIPT

00:00 Intro

00:33 Defining Perimenopause (and Menopause)

05:57 Metabolic Signs Versus Symptoms

10:07 Bone Health

14:39 Vasomotor Symptoms

22:50 Sleep Disruption and Its Causes

26:59 Cognitive and Mood Changes 

35:54 Vaginal Atrophy (The Sag) and Dryness

48:06 Sexual Function

52:20 What's Not a Symptom?

56:20 Getting Treatment

01:00:03 OUTRO 

Gillian Goddard: Hi, and welcome to the Savvy Patient.

Erin Stein: Hello. This is going to be your favorite episode. Or not. 

Gillian Goddard: Do you say that every time? 

Erin Stein: I know. No, I don't think so. But we're getting to the ‘hot goss’ this time. Perimenopause, everyone's favorite. It's on everyone's lips these days.

Gillian Goddard: It's certainly on everyone's lips these days. That is 100% true.

Erin Stein: Or at least on their phone. On their Instagram and their TikTok. Let's start with perimenopause versus menopause because I think in the past these things were all talked about as menopause things. And now in our enlightened age…These are really perimenopause symptoms that we're going to talk about today. Is that right?

Gillian Goddard: Well, they can kind of be both, but we'll talk because there are some symptoms that you're more likely to experience in perimenopause and some symptoms that you're more likely to experience in menopause, but there's definitely crossover. So, I think it makes sense to start with a quick refresher on what is perimenopause, what is menopause and how we think about the stages of perimenopause and menopause.

Erin Stein: Yes, we'll do a short recap. For all the info, listen to the Lady Cycles episode for more detail than you ever wanted.

Gillian Goddard: Exactly. So, let's remember the bridge between the reproductive years and perimenopause is the late reproductive stage. You might have symptoms during this time, but your periods are still regular, and most women enter the late reproductive stage between the ages of 35 and 45. Early perimenopause is when your periods start to become irregular, which means that your cycle length from the first day of one period to the first day of the next period varies by more than seven days. So, a 22-day cycle followed by a 35-day cycle followed by a 28-day cycle. That's early perimenopause. Late perimenopause is when your periods space out by more than 60 days. So, all of a sudden, you're going two or three months without a period. You might go a lot longer. You might go 10 or 11 months without a period. But this is the point at which periods become much more widely spaced. And we know that once you've gone about 60 days without having a period because of perimenopause, your last menstrual period is likely to be in the next one, two, three years. Then we have early menopause. Early menopause, you actually don't know you're in until you've already been in it for a year. So, you have your last menstrual period. You don't know it's your last menstrual period until you haven't had another period for 12 months. So that's how we define menopause. You go a full calendar year without having a menstrual period when we say you're in early menopause.

Erin Stein: I have a question. Do you ever have one more period randomly after 12 months?

Gillian Goddard: Yeah. It's a really good question. Typically, we would say that if you have menstrual bleeding even once after that, when you've gone more than 12 months without a menstrual period, even if it's like 12 months in a day, you should talk to your gynecologist about it because irregular bleeding in what is technically perimenopause can be a sign of bad things like endometrial cancer. Doesn't mean it always is, but it's something that you should bring to your doctor's attention and have checked out. So early menopause is sort of also broken into a couple of different stages. There's early menopause part one and early menopause part two. Early menopause part one is the first two to three years. It's a time when women tend to be very symptomatic. So, the first two to three years after your last menstrual period. Remember, for a big chunk of this time, you actually think that you're potentially still perimenopausal. And then part two of early menopause is sort of the next three to five years. So, these are really the years up to about age 60 or 65, depending on when you have your last menstrual period. And then there's late menopause, which is the rest of your life. And that's really when women start to come out of the classic symptoms that we're going to talk about today.

Erin Stein: Mm-hmm, mm-hmm.

Gillian Goddard: The Renaissance, the Act Two.

Erin Stein: The renaissance you keep promising. So, we're going to talk through a lot of symptoms today and they can happen during all of these stages.

Gillian Goddard: To some degree, but some symptoms are more likely to happen in some stages than others.

Erin Stein: This is fun. Okay, first of all, a lot will be happening during this time. Lucky, lucky us. There's a variety of things. Some are the obvious symptoms that we all talk about, like hot flashes and night sweats, which I guess are the same thing, but we'll get to that.

Gillian Goddard: Ha! Yes. Yep.

Erin Stein: And then there's other things happening, like your period changing, which we just went through, but there's also just bigger, systemic fun things going on that are not necessarily symptoms, I guess.

Gillian Goddard: Yeah, we would call those signs. So, a symptom is something that you experience like an irregular period or a hot flush or mood changes. A sign is something that your doctor can see on a physical exam or on a blood test. A lot of what we're going to be talking about in this first set of signs would be signs that your doctor would see on a blood test. These are metabolic changes that happen when estrogen levels begin to drop. These changes we often see occurring gradually throughout the perimenopausal transition. And what we tend to see is we tend to see cholesterol levels rise. Good cholesterol falls, bad cholesterol rises typically. We see blood sugar levels start to rise in many cases in people who are predisposed toward pre-diabetes and diabetes. And that is largely based on your family history. And we see blood pressure levels rise. A huge portion of the US population has high blood pressure. And in women, it often occurs in the late perimenopause or early menopause stages. And that is also related to dropping estrogen levels. And so, these are some of the signs that your doctor should be looking for. But it's always a good idea to ask about them, particularly if you have a family history of diabetes or heart disease, or if you yourself have a history of preeclampsia or gestational diabetes in pregnancy, because those are indications that you're at increased risk for these metabolic changes.

Erin Stein: These are important things to think about in general and we don't talk about them as if they are perimenopause symptoms, but they are all related to this shift and that's why it's super important to keep going to the doctor and getting your physical and getting your bloodwork and checking your blood pressure and your cholesterol. I suspect that this falls off for some women because you're focusing on the symptoms we're about to get into and not on just a plain old boring physical. You feel like you're going to the doctor enough, you're fine. But these shifts are also happening and need to be tracked and potentially dealt with as well.

Gillian Goddard: Yeah. Yeah. They do, because as we mentioned in a previous episode about cardiovascular health, cardiovascular disease is the number one cause of death in women more than everything else combined. 

Erin Stein: And they're not making documentaries about that.

Gillian Goddard: They are not making documentaries about that. It's not quite as sexy. It's not as sexy as perimenopause.

Erin Stein: Yeah, no, they're making documentaries about murderers, not cardiovascular disease. Because it's, yeah, less entertaining to talk about cardiovascular disease. But here we are trying to entertain you while we talk about cardiovascular disease.

Gillian Goddard: Correct.

Erin Stein: What else would be a sign?

Gillian Goddard: So, the other thing that can happen metabolically, and we don't always think about this as being metabolic, although we do talk about it a little bit more than we do about cardiovascular disease, is bone loss. Our bones are very dynamic. They change all the time. And this is something that we don't talk a lot about. Estrogen helps us maintain our bone density. And so, when our estrogen levels fall, particularly in menopause, so after our last menstrual period, we start to lose bone density. And as we start to lose bone density, that can put us at risk for low bone mass, which is what we used to call osteopenia. And it can put us at risk for osteoporosis. Falls and fractures are an enormous cause of death and disability in women as they age. And the time to sort of head this off is in the perimenopause and early menopause years.

Erin Stein: The time is now.

Gillian Goddard: The time is now. This is where weight bearing exercise comes into play. making sure that you're getting adequate calcium becomes important. 

Erin Stein: This is where my calcium gummy vitamins come into play.

Gillian Goddard: Yeah. Yep.

Erin Stein: The time is now for me specifically. I know that I have this starting to happen. I need to work on it. And I will say, I know that because I asked the doctor for a bone scan. They often will not suggest it until you turn 50, but I am thin, which puts you at higher risk. And my mother has it, there's a family history, which puts me at higher risk. So.

Gillian Goddard: Mm-hmm. Mm-hmm.

Erin Stein: I used the breast cancer as an excuse. I said, I'm going to be going on these medications. I would like to check my bone density now to get a baseline before I go on any medication that may affect it or not. And so, I got a bone scan. So, I already know that I need to start working on it, but they wouldn't have done it if I hadn't asked. So, if you think you might have concerns, talk to your doctor about it before you turn 50.

Gillian Goddard: The guidelines actually say if you have risk factors, you should have a bone density test at menopause. So right at that time, around your last menstrual period. If you don't have any risk factors, and there's probably not so many of us who have zero risk factors, but if you don't have any risk factors, you can actually wait until you're 60 or even 65. But many, many people have risk factors and need a bone density test right around their last period.

Erin Stein: Yeah, and I will say the test is easy. 

Gillian Goddard: It's the easiest test. It takes two seconds and requires nothing of you but laying there. It's not painful.

Erin Stein: Yes, I want to advertise this because I didn't know what it involved before I went in and got it. I just knew I should be asking for it. There's no needles, there's no injections, there's no nothing. You just lie on a table, and they scan you and you're done. It was fantastic.

Gillian Goddard: Yep, it's actually a very, very low radiation X-ray. And so, yeah, it doesn't involve anything except for lying still.

Erin Stein: Yes, you do. They would like you to do that. But that was it. So don't be afraid of the bone scan is my message and perhaps seek it out.

Gillian Goddard: Yeah. So now let's get into symptoms.

Erin Stein: Good, let's do that!

Gillian Goddard: So, symptoms are the things that we feel, the things that we experience physically as we are making our way through the perimenopausal transition. And the symptoms can really be divided into four separate categories. Vasomotor symptoms. Mood and cognitive symptoms. Genitourinary symptoms. That one's a mouthful.

Erin Stein: Ugh. The worst.

Gillian Goddard: And a category that's like musculoskeletal symptoms plus everything else. Sorry, I didn't make the categories.

Erin Stein: Okay. That sounds like the trash bin category, like just whatever you want to throw in there.

Gillian Goddard: I work with the framework I've been given. And the reason that's important is because that's how studies are done. 

Erin Stein: I don't know about “important,” but relevant perhaps. All right, which one, which of these categories you want to start with Gillian?

Gillian Goddard: Okay, there we go. Well, let's start with vasomotor symptoms because these are sort of the classics. Vasomotor symptoms are symptoms that you feel that are often related to your temperature sensitivity. Mostly hot flushes and night sweats. Hot flushes and night sweats are actually the same thing. It's just that hot flushes happen while you're awake during the day, and night sweats happen when you're in bed asleep at night. Both can be hugely disruptive. There are studies that suggest a huge amount of the sleep disruption that women experience during the perimenopausal transition is actually related to night sweats and that it's the discomfort of either being hot and or being cold and wrapped in like wet sheets and pajamas that actually disrupts women's sleep. And that when we treat night sweats, that women start sleeping much, much better.

Erin Stein: When you have a hot flash or a night sweat, what is happening? Like, what is your body doing?

Gillian Goddard: Yeah, so we have a temperature sensor in our brain, in our hypothalamus, and the goal of this temperature sensor is to keep our core body temperature stable within a range of, say, a degree or so. Estrogen acting in our brain actually puts a little more give in that system. It makes that temperature sensor a tiny bit less sensitive. So, when estrogen levels are dropping precipitously, which can happen throughout perimenopause and the very earliest parts of menopause, the temperature sensor gets especially sensitive. And so, our core temperature goes up a tiny, tiny bit. And the hypothalamus senses that and it tells all of our blood vessels to dilate, and it tells our sweat glands to sweat to cool us down, to return us to that goal core body temperature. And we experience that as a hot flush. We get flushing because of the dilation of our blood vessels, and we obviously get sweating. And then core body temperature drops and a lot of times the hypothalamus has overshot the mark because again, we're now dealing with this very sensitive temperature sensor and then we can actually become kind of cold and clammy because now we're sweaty. And this can happen throughout the day. You can imagine like when you're covered in sheets and blankets and pajamas that sweating leaves you clammy and cold, wrapped in wet fabric.

Erin Stein: So, what about the opposite? We don't describe the opposite, which I think I might be experiencing these days, which is basically a cold chill, a cold flash instead of a hot flash. I feel like I cannot get warm ever.

Gillian Goddard: Yeah, I mean, this is something that does happen because that temperature sensor that's in our brain, it's gotten more particular about its goal temperature in both directions. It's not just specifically sensing heat. It's sensing a deviation in the core body temperature in both directions. So, yes, you can. I absolutely have both. What I think is really interesting about hot flushes and night sweats is that they're really easy to measure because you can literally have someone like make ticks on a page every time, they have one. There are actually now sensors that you can wear, although they seem quite large and intrusive, that you wear on your skin just below your boob, that will measure the number of hot flushes and night sweats that you have over a given period of time. I think that's a piece of technology that's probably superfluous. A piece of paper and a pencil would probably do just as well. But they're really easy to measure. And so, when something's really easy to measure, it becomes a great metric by which we can define something. And so that's why hot flushes and night sweats has become the thing that we are often measuring when we're determining how severe or not somebody's experience of the perimenopausal transition is. And it's also the first thing that was measured as a response to treatment with hormone therapy Plus, we know that about 80% of women will experience hot flushes and night sweats during the perimenopausal transition. And more than 40% of those women will report that their hot flushes or night sweats are severe and disruptive. And so, this is a nearly universal experience.

Erin Stein: Yes, but I just want to give a shout out to my fellow women who are cold all the time. There was a period where I thought maybe I was having night sweats, but it might not have actually been a night sweat. It could have been because I went to bed with socks and cashmere pajamas and five blankets and then two cats came and sat on top of me and then I was sweating to death, but lately, it's been very hard for me to just get warm. Like I have to layer on all the things and my husband's like, what is the matter with you? It's nice outside. I'm like, I'm cold.

Gillian Goddard: Yeah.

Erin Stein: It should get equal play is all I'm saying. The hot flashes get all the glory.

Gillian Goddard: Fair enough. They do. They do.

Erin Stein: So that's a fun one. So, hormone therapy helps regulate your temperature essentially.

Gillian Goddard: It does because you're giving that estrogen back to the brain to widen out that window the temperature sensor is trying to keep your core body temperature within. The good news for women like yourself who should not take hormone therapy is that the new non-hormonal treatments for perimenopause and menopause are actually also targeted really specifically at hot flushes and night sweats. I'm talking about two drugs. One is called Veozah, the other is called Lynkuet. They're relatively new. And basically, what they do is they act like estrogen, but only at those temperature sensors in the hypothalamus to broaden out the range of acceptable body temperatures and they've been shown to be quite effective for many women. They work very quickly. And so, if you are someone for whom hormone therapy is not an option, when we're specifically talking about hot flushes and night sweats, the non-hormonal options can be particularly helpful. And we find that when we treat vasomotor symptoms, whether that is with hormone therapy or non-hormonal treatments, we oftentimes fix sleep or at least dramatically improve sleep for the reasons that I said, which is that when we're uncomfortable, it wakes us up.

Erin Stein: Waking up sweaty is gross. Whether it's because of my cats or not. Well, I'm glad you answered that question because I was about to ask it and will continue to ask it for all of these things. It seems logical that wild fluctuations in temperature would cause a lot of sleep disruption.

Gillian Goddard: It's quite gross.

Erin Stein: Is there a separate version of sleep disruption that also might be happening or is it really just you're sweaty or not?

Gillian Goddard: It’s really unclear. There's a study called the study of women's health across the nation or SWAN, if you will, and that study has a bunch of little studies within it and one of those little studies is about sleep specifically. So, all the participants in SWAN answer questions about their sleep and then this subset of a few hundred women actually underwent formal sleep studies where they could compare what was going on with their sleep next to what they were recording or reporting about their sleep, right? So, we've got objective data and their subjective experience. What they found was that their subjective experience was not necessarily born out in the objective data. Meaning… shall I translate that into English? 

Erin Stein: Yes, please.

Gillian Goddard: Meaning, the women reported a lot more sleep disruption than was actually seen on their sleep studies. This is how we know that most sleep disruption is related to night sweats because they could measure night sweats in these sleep studies as well. So, there is this phenomenon that when people go in for sleep studies, they actually sleep better than they do at home. And one of my attending physicians when I was a resident explained it as being like the vacation phenomenon. People go on vacation, and they come home, and they want to buy the mattress that they were sleeping on at the hotel because it was so comfortable, and they slept so well. But really, the reason they slept so well is because they were relaxed in a way that they are not relaxed when they're at home sleeping on a normal night. And so, he had observed that people sleep quite well during sleep studies because they're in a clinical setting being monitored, and they know that their only job while they're there is to sleep which is very different.

Erin Stein: No pets or children or phones or lawnmowers.

Gillian Goddard: And they're not going to let you oversleep. I don't know about you, I got up twice last night, once around midnight when I knew that my teenage children may have still been awake and went around and turned off lights and locked doors that others had neglected. And once, you know, three, four o'clock to pee. Getting up once in the middle of the night to go to the bathroom is actually technically considered to be normal. But I always put a little asterisk on that and think about what happens when you get back in bed to try to go back to sleep.

Erin Stein: Yeah, getting all the way out of bed does make it harder to go back to sleep for most of us, I would argue. I wake up a lot during the night, so I think that sleep disruption is a difficult one to tease out because like you said, a night sweat is an obvious one but there are so many normal life disruptions happening—

Gillian Goddard: A noisy sleep partner.

Erin Stein: You might have things happening outside that are noisy. You might have a cat that suddenly jumps on top of your bladder and that's why you need to get up and go to the bathroom. You might have a dog; you might have a child. 

Gillian Goddard: You might have an early meeting or an early flight and you're worried about it, yep. 

Erin Stein: You might be worrying about that. Yep. I know when I have to get up early, I'm worried about getting up early and then I just don't sleep. I do not trust the alarm.

Gillian Goddard: Yep. That's an incredibly common phenomenon. You're not alone in that.

Erin Stein: Again, I think it's because of that Seinfeld episode where he misses the marathon.

Gillian Goddard: Is that the one where Elaine talks about driving to JFK and she's then “I hit the Van Wyck” is I think about that every single time I drive to JFK, which is not all that infrequent.

Erin Stein: Any other vasomotor symptoms?

Gillian Goddard: No, and I would say one thing to know about vasomotor symptoms is that they tend to percolate along sometimes even in the late reproductive stage into perimenopause. They tend to crescendo in the year before and the year after your last menstrual period, and then they tend to taper off. Although, that's a generalization and individuals may have very different experiences.

Erin Stein: Crescendo is really a fancy word for these. Trying to make it sound better in that case. The other thing that might be disrupting your sleep are the mental, cognitive, mood things happening. Your brain can be very annoying when you're trying to sleep.

Gillian Goddard: Yeah, the cognitive and mood changes. Indeed, indeed. We actually don't understand a lot about why women experience cognitive and mood changes. We know that there are estrogen receptors throughout the brain. So, we know that it is very likely that the drop in estrogen is having effects on our brain and how our executive function is working and our moods, but we really don't have an explanation like we do of hot flashes and night sweats. We can't say, well, then estrogen drops and then this happens and then this happens, and this happens and that's why you want to kill your family in a rage when you're in perimenopause. We don't have those step-by-step explanations. But what we do know is that it's quite common, both mood changes and cognitive changes. And what we also know, and I think that this is reassuring to a lot of people, is that the cognitive changes are temporary. So, I'm going to say that again because it's super important. The cognitive changes are temporary. This is not a sign of early dementia. It is not. We've done cognitive testing on women throughout perimenopause and menopause, and we have seen changes in learning and changes in cognitive function. Once the upheaval of the menopausal transition settles out women find that again that their cognitive function improves. So, this is one of those areas where it's really important to remember that this is temporary, if annoying.

Erin Stein: Well, yeah. It is terrifying. And for many women who are productive and used to handling a great number of things no problem, having a working memory that like can remember everything…To suddenly walk into a room and be like, I was about to say something, I was about to do something, I don't know what either of those things are.

Gillian Goddard: Yeah, it is. It's very disconcerting.

Erin Stein: I don't like it.

Gillian Goddard: I know.

Erin Stein: I don't like it at all. I don't like it because sometimes it means my husband is right, now.

Gillian Goddard: And that just makes our irritability and rage toward them increase.

Erin Stein: Yes. Exactly. And I immediately thought of that show Snapped and whether they actually did a study to see what age these women were when they snapped and murdered their husbands. But I want to be clear, we're not actually suggesting that everyone is literally murderous. 

Gillian Goddard: Right. Right.

Erin Stein: You are highly irritated.

Gillian Goddard: Yes. Irritated, irritable, anxious; new anxiety can be a sign of perimenopause.

Erin Stein: I've seen it described a lot this way and this feels accurate to me: You just stop giving a shit about making other people happy. You have to focus on yourself. Quite literally, you have more going on to deal with of your own physical self. You can't ignore it anymore. And we've all reached a stage in life where we're a little more comfortable with ourselves, hopefully. 

Gillian Goddard: Mm-hmm. Mm-hmm.

Erin Stein: You just don't give a f-ck. So, we're not going to make nice and do all these things to make everyone else more comfortable and that gets perceived as rage or being a bitch or whatever and it really isn't. Like, you're not actively being mean to people. You're just not coddling them anymore.

Gillian Goddard: That's totally a fair assessment and on some level, not on some level, I think it's probably a good thing that women are less concerned about social normality.

Erin Stein: Indeed, it's unlearning some social conditioning that was probably not serving us in the first place.

Gillian Goddard: Yeah, yeah, yeah. Exactly.

Erin Stein: But back to cognitive function. Is there anything to be done about it during this period or are we just suffering through until your promised renaissance?

Gillian Goddard: There is not a lot of evidence around what is effective or not in treating the cognitive changes of perimenopause and menopause. There was a study done recently that showed that hormone therapy does not improve cognitive symptoms. But there are studies that suggest that it does. There's a lot looking at sleep and helping women get adequate sleep as a way of improving cognitive function and mood. And of course, when it comes to mood, when it comes to anxiety, irritability and depression, SSRIs, selective serotonin reuptake inhibitors, and these are classics like Prozac, Zoloft, Lexapro, can be helpful. So that is worth considering and cognitive behavioral therapy can also be helpful and that's a very specific type of talk therapy. This tends to be one where we know a little bit less. It hasn't been as well studied. There haven’t been great studies designed to look at whether hormone therapy improves mood and cognition. And so, the reason we don't have a good answer is because we just don't have the data.

Erin Stein: This is just a complicated web because again, all of these things could affect your sleep and not getting enough sleep affects your brain function. Especially as we get older, we know those all-nighters are affecting us a lot more than they used to. 

Gillian Goddard: 100%.

Erin Stein: But also speaking specifically about anxiety and depression, everything women are dealing with during this time, aside from your physical situation, whatever it may be, we're stressed out. There's a lot to be anxious about. There's a lot to be depressed about. We'll have a whole ’nother episode. 

Gillian Goddard: Yeah. Yeah, we live in this world.

Erin Stein: Yes, definitely. But also, we do want to talk about just being the sandwich generation, which I don't love that name, but they don't come to me when they name these things. Most of us are dealing with aging parents and other relatives. And that is sad and depressing and stressful depending on how cooperative they are or not. And then many people like you have children who are growing up, figuring out what to do with their lives, maybe about to leave home.

Gillian Goddard: They should.

Erin Stein: Or they've left home.

Gillian Goddard: Or they've left home. My children are lovely, but even the little cherubs that they are, as they're getting older and more independent, they are not always making the decision that I think is best. And unlike when they were three and I could make a decision for them; when they're 18 and 16, you got to let them make some decisions for themselves and figure these things out on their own. But that doesn't make it any easier to watch.

Erin Stein: Right, right. And then many of us are also working so there's a lot; we're all dealing with a lot. And so, it's hard to say how much of it is the increased emotional load we are all dealing with versus perimenopause. The timing is basically the same.

Gillian Goddard: Well, and we'll talk about this in a minute when we get to the musculoskeletal and grab bag. This is a phenomenon that is not unique to the mood symptoms. This idea that some of this is just bad timing potentially.

Erin Stein: Can't wait for the grab bag. Good times.

Gillian Goddard: So, moving from one cheery topic to the next, let's talk about vaginal atrophy.

Erin Stein: Good, yes, let's please talk about that.

Gillian Goddard: So vaginal atrophy and all of the symptoms and wonderfulness that can surround it are collectively called in the medical literature, the genitourinary symptoms of menopause. Essentially, this is one where we do know exactly what happens.

Erin Stein: Okay. That's something.

Gillian Goddard: Estrogen levels fall. As estrogen levels fall, delicate tissues that make up the walls of the vagina and the mucosa of the vulva become drier and thinner, less moist, and plump.

Erin Stein: Hahaha!

Gillian Goddard: And the pelvic floor can develop some laxity. The muscles and ligaments that suspend the uterus and vagina in the pelvis become looser in many cases and less efficient at holding everything in place. And between the dryness and the lack of plumpness of the vulva and vagina and the laxity of the pelvic floor, everything can kind of slump down. That... 

Erin Stein: Sag.

Gillian Goddard: Yeah, sag. That sagging, as it were, actually brings the opening of the urethra from which we urinate and the anus closer to together and changes the pH and the sort of good bacteria that live in the vagina. And this is a setup for vulval vaginal infections like yeast infections and BV [bacterial vaginosis]. It is a setup for urinary tract infections. It can cause urinary symptoms like incontinence and frequency, feeling like you need to run to the bathroom, feeling like there's pressure on your bladder all the time. It is all really unpleasant. This is one of those symptoms that tends to actually happen later during the perimenopausal transition when estrogen levels are quite low. But again, everyone's experience is a little bit different.

Erin Stein: What I'm hearing is, just when you think it can't get worse, it can.

Gillian Goddard: It's probably not inaccurate.

Erin Stein: The full description that you just gave us is a horror movie a little bit. It is not a fun thing, but obviously makes sense. It's only logical that these things would result. Your boobs aren't the only things that are sagging and that's gravity is acting. 

Gillian Goddard: Gravity acts on all of us.

Erin Stein: I did not have children, but I imagine if you've had children, some of this might be already happening or accelerated because you have stretched things out. 

Gillian Goddard: Yeah, so having delivered vaginally does increase your risk for some of these symptoms. And the more vaginal deliveries you have had and if you've had birth trauma related to those vaginal deliveries and physical trauma like tearing and that kind of thing. It may augment this process. So that can be a factor. There's good news though.

Erin Stein: Is it Kegels? Is that the good news? Is it the... what's the Gwyneth thing? the egg? Yeah.

Gillian Goddard: No! The jade egg? No, please, don't put a jade egg in your vagina. Please don't. There is no evidence to suggest that putting a jade egg in your vagina will do anything.

Erin Stein: But it makes sense if you're holding it in there that you're exercising those muscles, doesn't it?

Gillian Goddard: I have no response.

Erin Stein: You might need to have a response for that. Clearly it makes sense to people. They bought these eggs.

Gillian Goddard: Well, my response would be that doing a Kegel or participating in pelvic floor therapy with a trained professional is not the same as walking around with something inserted into your vagina for many hours a day. And you can actually get pelvic floor dysfunction from doing that. And if we're already dysfunctional, we don't want to make it any worse.

Erin Stein: Let's repeat that. The egg can make it worse. So, you don't want to do the egg, jade or otherwise.

Gillian Goddard: Not better. You don't wanna do the egg. I shudder. However, there are some evidence-based things that you can do. The number one evidence-based thing that you can do is to use vaginal estrogen. Vaginal estrogen is not the same as the estrogen you get through a hormone patch or the estrogen that you take by mouth. Vaginal estrogen is a cream, a tablet, or a ring, that releases estrogen just locally into the vaginal wall and into the tissues of the vulva. Vaginal estrogen has not been shown to increase your risk for breast cancer or heart disease. And now many experts are suggesting that even women with estrogen positive breast cancer can safely use vaginal estrogen, although obviously you want to have a conversation with your oncologist about your specific case. But that is the party line that vaginal estrogen is the number one treatment for vulval vaginal dysfunction in perimenopause and menopause. It's the treatment number one for nearly everyone.

Erin Stein: Because it's moistening and plumping. Okay, but it's not going to re-elevate. Like, things that have sagged are not going to suddenly rise back up?

Gillian Goddard: No, it can. They will actually moisten, plump, wake up and head back north to some degree. Yeah, yeah. And you want to, just because you're taking systemic estrogen, so say you're taking hormone therapy or a birth control pill, that does not mean that you don't also need vaginal estrogen and you can take them together.

Erin Stein: That's kind of exciting, actually. Two follow-up questions. Can you take this proactively? Like, should you start before you get to that point? And, or, how do you know when you're at that point?

Gillian Goddard: So what I would say is we don't usually recommend it proactively, but even just having vaginal dryness, which is sort of the first step on this path toward vaginal atrophy and genitourinary symptoms like UTIs, you don't have to get to the point where you're having UTIs all the time before you can do this, just having vaginal dryness is a good enough reason to start vaginal estrogen.

Erin Stein: I'm going to ask the difficult question, because that's why I'm here. How do you know you have vaginal dryness?

Gillian Goddard: It's uncomfortable. One of my patients described it as the walls of her vagina being like two pieces of Velcro and when she moved, they were being ripped apart. Yeah.

Erin Stein: Eww! That seems like something you would know.

Gillian Goddard: Some people will also have like itching, vulvar itching. That is a mouthful. 

Erin Stein: I don't say that usually. Is that more internal itching?

Gillian Goddard: Well, the vulva is the external part of the genitalia. And so, people will have increased itching of the outside skin of the vulva.

Erin Stein: Makes sense. I think people will probably mostly think about this during sex and lack of...

Gillian Goddard: This is true. Some women will have a lack of lubrication and that's…

Erin Stein: …lubrication. That's the word I was looking for.

Gillian Goddard: …that's the word. Yeah. So many women will experience a lack of lubrication. They will experience sometimes discomfort, obviously, like if things are not responding the way they are supposed to respond to. Foreplay and what have you. Obviously, sex can be uncomfortable. This is a great place to add some lubricants to your repertoire. This is an area that women tend not to deal with and there's a lot of room for improvement. Just getting women started with treatment earlier. We used to tell women that they should try vaginal moisturizers first before trying vaginal estrogen. But last year, the guidelines actually changed and vaginal estrogen is first line for everybody.

Erin Stein: What, just smearing cream down there? I mean, the moisturizers you mentioned.

Gillian Goddard: Yes. So, there are moisturizers that are specifically formulated to be safe for vulvovaginal use. Replens is one of the more common brands. These are in the drugstore next to like the Monistat and the condoms and the sanitary pads. All the good stuff.

Erin Stein: Mmm, all the good stuff. I think maybe it's not 100 % clear. It's an external and internal shift. Like there's tissues on the outside and the inside that are drying out and being unmoistened and unplumped.

Gillian Goddard: Yes, that's exactly right. We're talking about the lining of the vagina, which is internal and the tissues of the vulva, which are external.

Erin Stein: And the urinary issues you're having are a result of the impact of that, right?

Gillian Goddard: Yes, because the opening of the urethra is in the vulva.

Erin Stein: They're all right next to each other.

Gillian Goddard: And then also some of the urinary symptoms are related to the pressure the uterus can put on the bladder as the uterus…

Erin Stein: As the sagging occurs.

Gillian Goddard: Yes, as the sagging occurs. That's a good way of putting it.

Erin Stein: Okay, good, I feel like we've made that as clear as possible. Cause who talks about that? Right?

Gillian Goddard: I would say until recently, no one was talking about it.

Erin Stein: I'm not enjoying talking about it, but it does seem pretty important to my daily life, potentially.

Gillian Goddard: Yeah. Yeah. Women suffer hugely for no reason.

Erin Stein: And nobody wants to be sitting there itching their crotch.

Gillian Goddard: No! It's frowned upon socially.

Erin Stein: We want to help you avoid that. Ahem. We touched on it, but changes in sexual function is obviously a related perimenopause delight.

Gillian Goddard: Yes. So, I think that changes in sexual function come both from vaginal changes, vaginal dryness, vaginal atrophy, and discomfort with sex. A lot of women complain that they have no desire for sex. And the cause of this, you'll be shocked to hear, is not well understood.

Erin Stein: Shocking.

Gillian Goddard: Shocking. Women have some testosterone, just like men have some estrogen. And so, we think that sexual desire in women is at least in part related to testosterone. And there are studies both in women who are premenopausal and in women who are menopausal that testosterone can improve sexual function and sexual desire. But this is an area that is probably more complicated than giving some vaginal estrogen and some testosterone, although those things may be helpful and are worth considering.

Erin Stein: Again, there are a lot of factors potentially at play. If you're super stressed out and dealing with all these things and anxious, depressed, busy, exhausted, not sleeping well… It might be challenging to be in the mood.

Gillian Goddard: Right, exactly. Not only that, like teenagers are tough to deal with in this way. In a way that younger children are not. For one thing, they stay up later. For another thing, they can be very cognizant of what is happening. In a way that can make parents and teenagers feel a little uncomfortable.

Erin Stein: Sharing a space. it was not obvious at first where you were going with that. But yes, you do not want to subject your children to your own intimacy, right? Like those things should be kept separate and private and it does become more challenging when they're up late.

Gillian Goddard: No. And teenagers really like to talk in the post-10 p.m. time period. So.

Erin Stein: So not a sexy situation, but also not something you want to be experienced by anyone else in the house. So, it's a challenge. It's a challenge. That's why parents go on vacation, I think, right? That's the idea.

Gillian Goddard: Yeah, it gets tricky. It is. It gets tricky. I think so. It's interesting. We did a very unscientific survey of newsletter readers back in the day about their sex lives and the people having the most sex were the retirees, the people in their 60s who were retired or worked from home and the kids were out of the house.

Erin Stein: Mm-hmm. I don't have children and I'm gonna say this is a low point in this period of life. There's just so much else going on.

Gillian Goddard: Yeah, there's so much else going on.

Erin Stein: And, you know, your body's imperative to reproduce is no longer quite so imperative.

Gillian Goddard: It is true.

Erin Stein: That's essentially what's happening, what all of this is.

Gillian Goddard: Right, the goal of our reproductive hormones is in fact to get us to reproduce. And so when we're running low on eggs, those hormones are like, what's the point?

Erin Stein: Also, you're running low on eggs, everybody. It should be obvious, but maybe not. We've covered all the major things, but a lot gets dumped under perimenopause. We did mention murderous rage. Again, I don't think we're all murderers. I do think we have less patience for other people's crap.

Gillian Goddard: Yes. No. A little on edge from time to time.

Erin Stein: But what else gets thrown in here? Which, to be fair, this is quite a grab bag of crap that we have walked through, so I think it's fair to just chalk everything up to perimenopause in some respects.

Gillian Goddard: I understand the impulse. I really do. What you're referring to are like the aches, the pains, frozen shoulder. That's one that gets brought up all the time. It is unclear how much of the aches and pains, the joint pain, that kind of thing is really related to the drop in estrogen and how much is related just to the fact that we're getting older.

Erin Stein: Yeah. Mm-hmm.

Gillian Goddard: There is some interesting phenomenon that are just starting to be studied around estrogen’s effects specifically on ligaments. And actually, one of the reasons that this is getting studied is because somebody realized that young female athletes were injuring their ACLs a lot. But this research is in its infancy and is really not ready for prime time. There is some data from the Women's Health Initiative study where the women who were given hormone therapy did report fewer aches and pains than the women who were not given hormone therapy. But the study was not powered to look at joint pain and, back pain and all these things that people start to experience in midlife. The frozen shoulder question is actually a really fun one people talk about. 

Erin Stein: I don't think it's fun if you have frozen shoulders.

Gillian Goddard: Having it is not fun. No. So but what we know is that frozen shoulder occurs most often between the ages of 40 and 60, which happens to coincide with the perimenopausal transition. However, they have done studies that looked at whether men or women get frozen shoulder more often. So, we would think if this was a phenomenon of perimenopause that men would get frozen shoulder less often than women. And that is not true. Men and women get frozen shoulder at similar rates, and they've looked at when a woman gets frozen shoulder between the ages of 40 and 60, where is she in the perimenopausal transition? Is she premenopausal, which you might be in your early forties? Is she fully postmenopausal? And it's completely random. There's no correlation between where you are in the perimenopausal transition or not and getting frozen shoulder. And so, it's pretty clear that frozen shoulder is not a phenomenon of perimenopause. In fact, the biggest factor about whether you'll get frozen shoulder or not is one of genetics. Got to look at your parents again. Yes, some people are just more genetically predisposed to develop frozen shoulder.

Erin Stein: Really? That's wild.

Gillian Goddard: Tis true. Injury also plays a role.

Erin Stein: Frozen Shoulder just seems like you played pickleball too much, you know, like it doesn't sound like something you inherit.

Gillian Goddard: It's adhesive capsulitis, so the shoulder capsule becomes covered in adhesions and the likelihood of forming those adhesions is genetically based. So, you're genetically predisposed to form the kinds of adhesions that cause frozen shoulder.

Erin Stein: So, we debunked a myth and learned something new. Well, I did. And probably everyone listening did. So, see if your parents ever got frozen shoulder. That's interesting.

Gillian Goddard: The reason I think it's important to try and pick apart at these things is because when we blame them all on perimenopause, A, we don't give people the treatment that they need, and B, a lot of women ignore their perimenopause symptoms and don't talk to their doctors about them. And so, I worry when we tell people something is just part of perimenopause, that it's just another symptom that is going to get ignored.

Erin Stein: The problem really is that these symptoms all get dismissed and thus ignored. Or perhaps ignored is the wrong word, “suffered through” because I think if you're having them, it might be difficult to ignore them.

Gillian Goddard: Fair, fair, if you are having joint pain, it can be quite debilitating. But also, if you think it's just perimenopause, you might not seek medical help.

Erin Stein: You might not because you might already be suffering through all your perimenopause symptoms. And so, you might just continue to suffer through all symptoms that you're having, and you shouldn't do either of those things. Listen, it does mean going to the doctor a lot more than you used to go to the doctor. And that is very annoying, but you got to do it.

Gillian Goddard: Yeah. Yeah. Agreed. I hear that.

Erin Stein: I have lower back pain, neck pain, I've now had MRIs, it is not perimenopause, it's just my spine. So, it's worth looking into these things, don't write it off, but also don't write anything off, even if you think it's quote unquote just perimenopause.

Gillian Goddard: Agreed. 

Erin Stein: If it's bothering you enough to affect your daily life, then you should go to the doctor. That’s our message. 

Gillian Goddard: I wholeheartedly agree with that.

Erin Stein: Now, part of the challenge of that is that this was, again, a wide range of symptoms that we discussed and related health outcomes and changes that I don't think will all be covered by one doctor.

Gillian Goddard: Yeah, that is a challenge.

Erin Stein: So, it's not like you can go to the perimenopause doctor and talk about your perimenopause because it's touching so many different things. So, you need to talk to multiple doctors about your perimenopause.

Gillian Goddard: Yeah, it's true.

Erin Stein: That's hard because we talk about it like it's one thing and it's not.

Gillian Goddard: That's true. it's both logistically challenging. It takes time to make appointments, go to appointments. But also, I think that how this idea of perimenopause gets taught very widely from one discipline of medicine to another or doesn't get taught, by the way.

Erin Stein: Yeah, so perimenopause and menopause, a really fun time that lasts forever, it seems like. But it doesn't, Gillian keeps telling us it doesn't. But the point is, you may only have a couple of these things, but all of them are potential outcomes because your body is changing. Welcome to second puberty. That's what's happening.

Gillian Goddard: Yes, welcome.

Erin Stein: Welcome. So, you need to know about these things. You got to recognize them, and you got to go get treatment for them.

Gillian Goddard: Hear, hear.

Erin Stein: Right? That's our message. So, good luck. We're going through it with you.

Gillian Goddard: We're right there with you.