Dr. Lara Briden is also known as The Period Revolutionary. Last year, I interviewed her about her first book, Period Repair Manual, and given the rave reviews, I wanted to make sure I interviewed her again for her latest book, Hormone Repair Manual, Every Woman's Guide to Healthy Hormones after 40. And she has outdone herself. This book has such helpful information to guide you, as you transition through perimenopause and menopause and given the amount of information in the book, we cover the high points so that you get a better understanding of what this transition may be like and how you can support yourself as you may incur some of the symptoms that come with this.
Georgie Kovacs: What are the four stages of perimenopause and menopause?
Dr Lara Briden: Absolutely. Perimenopause is anywhere between two to 10 years before the final period. So it starts in our late thirties or forties. If there are going to be symptoms, and not all women have symptoms, but women who do have the symptoms, are usually at their worst during perimenopause and then most symptoms tend to subside later into our fifties and certainly by our sixties. There are a couple of outlying issues that can continue mainly vaginal dryness, which we can talk about.
So the phases are actually based on broader research, but the way Professor Jerilynn Prior describes it is the following:
Phase 1: Very early perimenopause is when periods are still regular, but we start to develop symptoms mainly from losing progesterone. So I provide her nine list of symptoms. If you have three of those, and you're in your late thirties, forties, this is possibly you. So they include things like periods, getting heavier, increased frequency of migraines, weight gain, insomnia. Although cycles are regular in that very early perimenopause in general, the cycle shortens. By "cycle shortens," I mean, counting from day one to day one of the cycle. If it used to be, say 30 days, it might shorten down to 26 days. That's really common. It's basically just because of higher amounts of FSH from the pituitary, talking to the ovaries, very emphatically to keep ovulating. And that makes ovulation happen more quickly. And sometimes oblation starts to not happen, which is a feature of perimenopause. And when ovulation doesn't happen, we don't make progesterone.
Phase 2: This occurs when you start to get some irregularities. So the cycle counting from day one to day, one could start to vary by up to seven days. That's a little bit, you know, wobbling with a cycle that's normal that can last two or three years.
Phase 3: This begins when you've had a very different cycle, like a 60 day cycle counting from day one to day one. So things start to look quite different, keeping in mind, in the background, you always have to rule out, is it just perimenopause or is it something else? Because I provide a patient story where it was actually PCOS, that was affecting her cycles at that time. So they could still get the other factors, even in our forties.
Phase 4: This is the phase I'm in now, which is when you've had what you think is your final period. And you're in the waiting room to see if you can reach 12 months without a period, which will then mean you graduate to menopause. You've achieved menopause. That's the kind of language that Professor Prior uses, which I love. So I'm waiting to achieve menopause. I have not yet, you know, it's not unusual. I had what I thought was my last period last January or last April. And then I went like nine months and then I got one this January. I'm like, okay. And you have to start counting all over again at that stage. And that's pretty typical. I don't know if I've ever met any woman who had what she thought was her last period.
Then the next phase is menopause, which lasts the rest of our life. So menopause is a life phase that begins one year after our final period.
Georgie Kovacs: Tell us about HRT, or hormone replacement therapy. Is hormone replacement therapy safe and what role does it play?
Dr Lara Briden: First of all, we don't normally say hormone replacement therapy anymore. It's a menopausal hormone therapy MHT and the reason they got rid of the word replacement is you're not replacing. It's not like thyroid replacement or growth hormone. It's not like an endocrine or hormone pathology where you've lost a hormone like low estrogen is normal for menopause. It's a normal life phase. In the book, I do talk about that, how it's really existed for as long as we've been human. I debunk the idea that everyone used to die by 40 and that therefore menopause is just an artifact of modern life. That it's an accident of living too long. That it's not the case.
Yes. Many of our ancestors died young because of childbirth or accidents or infections. You know, obviously that's true, but even going way back into antiquity, we know that several, a significant number of people, including women lived into old age, like into their seventies and eighties. So menopause has been there. Some women benefit from hormone therapy, absolutely both in terms of symptoms and in some cases, in terms of, you know, risk reduction for things like osteopetrosis. So that's real, but also at the same time, some women are fine and you know, don't need it for any of those things.
So I think that's important to understand heading into it. It's an option, but it doesn't have to be for everyone. You don't have to think, “Oh, after I lose my estrogen, that I'm broken.” Our body is recalibrating to lower estrogen, which if you're healthy in all the ways I talk about it in the book, particularly around insulin sensitivity, the real dangers come, if there's insulin resistance, because estrogen normally supports insulin sensitivity and shelters us from some of those long-term negative outcomes from insulin resistance or pre-diabetes. So I do I even state in the book, I think some of the long-term health prevention outcomes that are seen with estrogen therapy is actually mitigating the risks of insulin resistance, but there are other ways to not have insulin resistance.
It's not that taking estrogen isn't the only way. It's not as dangerous as people think like that. I can, I guess I can safely say that. I think modern hormone therapy is generally safe, not in every situation obviously, and certainly not every type. So this is what it comes down to. And I put this right at the beginning of the hormone therapy chapter. We have finally reached the time, thank goodness, when body identical, what used to be called bioidentical, although doctors don't like the term bioidentical, so don't use that term really. Yeah. Well, it depends on your country, I guess, but bioidentical is associated with the old days when, you know, naturopaths and compounding pharmacists were the only way to access body identical hormone therapies.
Not all modern hormone therapy products are body identical, which means they are hormones that are derived still from plant based precursors in a lab, but they're identical. They're made to be identical to estradiol, our main estrogen and progesterone. Now that's a huge departure from what was happening back in the eighties and nineties. I can't even emphasize enough those drugs, hormonal drugs, they were using back then, including Premarin and the horse estrogens and the progestins, which are not progesterone. They had a breast cancer risk much, much higher than moderate, like just to use breast cancer as the example.
Georgie Kovacs: Does modern hormone therapy come with a high risk of breast cancer?
Lara Briden: So modern hormone therapy does not carry a high breast cancer risk. It really does not. If you can get the right prescription from your doctor, which is in the US in terms of the progesterone part of it, the US it's called Prometrium. In some countries it's called Utrogestan. That is body identical progesterone. And that is a huge departure from the progestins. They used to use what we, we look, we know now looking back at the research, like the women's health initiative and put some of those studies, you know, 20 years ago, the breast cancer risk was probably mostly from the progestin they were using back then.
Georgie Kovacs: Didn’t your book mention that progesterone is more helpful in perimenopause and estrogen, and I can't remember if it was all cases or most cases, estrogen plus progesterone once you've hit menopause?
Dr Lara Briden: I guess we'd include that final stage four of perimenopause. This is where my book departs from some other stuff that's out there. And this is from Professor Jerilynn Prior, who is a scientist as well as a clinician. So she's done multiple studies about progesterone, the benefits of progesterone, and those are referenced in the book. And again, as opposed to progestin, I can't emphasize this enough. The difference between progesterone and progestin is so huge.
Georgie Kovacs: Let's clarify something. Progestin is in a lot of birth control, correct?
Dr Lara Briden: There's no progesterone in any type of hormonal birth control. As much as ever, our forties are a time to have natural cycles and not pill bleeds, not drug-induced bleeds.
Progesterone is the hormone we lose first, where during second puberty progesterone, we start to make less progesterone. We make more estrogen, which is important. Estrogen goes up sometimes by three times actually, and then progesterone drops away. So this is the classic estrogen dominance that people talk about. Taking progesterone during, especially the earlier years of perimenopause can bring great relief to mood insomnia, heavy periods, migraines, and the book provides protocols for all of those.
Now there has been this conventional narrative that progesterone is bad for mood. That is not the case. Progestins are bad for mood. Progesterone is normally good for mood. Although some women, it's about 1 in 10, who maybe have tried natural progesterone or Prometrium and did not feel good mood wise on that. So there's a few things going on with that. In general, if you ask your doctor for natural or bioidentical progesterone, you'll get shut down. If you go in there asking for Prometrium (or the brand in your country) and say, “This is a protocol from this Canadian endocrinologist who has studied that Prometrium can be helpful for heavy periods or in different things.” - the success rate will be a lot higher. Very often, taking that can relieve symptoms. It's very sedating, so take it at night.
Georgie Kovacs: Many women seem to be on the hormonal IUD. How does that fit into optimizing perimenopause symptoms?
Dr Lara Briden: Hormonal IUD - Mirena or Jaydess or whatever brand - that's usually a drug called levonorgestrel. The pill totally masks menopause like a combined pill, estrogen pill, totally masks menopause. You could be having pill bleeds into menopause. You're basically on a type of hormone therapy with this synthetic estrogen and the pills.
The pill definitely masks menopause. The pill can even mask symptoms of menopause, because like I said, it's estrogen. It's a type of hormone therapy already.
The hormonal IUD can mask menopause even only in the sense that, if it completely stops bleeding, then you won't know if your period has stopped. Now, it doesn't always stop bleeding for some women. It's just really dramatically lightened bleeding and you still get a real period coming through. So it really depends. If it shuts down your bleeding, then you're not going to know, from the period point of view, if you've achieved menopause or have had your last menstrual cycle. The hormonal IUD, because it's just a progestin - no estrogen, no progesterone - it has no effect on symptoms. It can't give symptom relief for hot flashes or insomnia or migraines or anything like that. Obviously can give symptom relief for heavy periods, because that's the one thing it can definitely do.
What I say in the book is, if you're on the hormonal IUD and you haven't been having bleeds, you're not sure that you've reached that final phase of perimenopause.
At any phase, you'll still go through all the phases of perimenopause. You start getting the increased migraines, the night sweats, all the different symptoms leading through the phases and the hormonal IUD will not do anything for those. You can actually use both the hormonal IUD and Prometrium. And you can actually take progesterone along with that. So with the hormonal IUD, you're still cycling, but you're still going through losing your progesterone, just like anyone else in perimenopause. So there's nothing against combining them.
Georgie Kovacs: What causes ovarian cysts and can they increase during perimenopause?
Dr Lara Briden: First, there are many different types of cysts. Endometrioma is your endometriosis cysts, which is a totally different thing. There's polycystic ovaries, which we won't talk about today, but are not cysts basically. Probably what you're describing are functional cysts, which can grow quite large, which can happen at any age. They happen when there's been a glitch in ovulation. What was supposed to be just the follicle, turning into a Corpus Luteum is now filling with fluid, and it's common.
Part of what's going to be factoring in is being on the pill generally tends to reduce the frequency of those, because you're not ovulating. The hormonal ID increases the frequency of them because it sort of impairs ovulation just enough to increase the frequency. In fact, I think it's something like, of women on the hormonal IUD, 5% develop ovarian cysts.
Is it more common in perimenopause? I'm not a hundred percent sure, but it wouldn't surprise me. As a quick takeaway, for what it's worth, for reduced risk reduction for ovarian cysts, I would just say to know the risk of the hormonal IUD potentially.
My two quick things for risk reduction is really take a look at cows dairy, where I think the inflammation from dairy seems to be quite unfriendly to the situation. And the other one is iodine, which you'll notice I talk about at great length for breasts, breast health, the ovaries love iodine as well.
Clinically, I feel like iodine helps to reduce the risk of ovarian cysts. All of this said, please also read the safety section in my book about iodine because it can harm the thyroid, especially if you have Hashimoto's or autoimmune thyroid disease. And there are unfortunately all different doses out there. You could get a dose, you could, he just bought iodine online. Like no joke you could get anywhere you could be taking anywhere from a hundred, 100 micrograms per dose to 50,000 micrograms per dose, depending on what you end up buying. So you really do need to think about the dose and the safety. But all that said, I prescribe iodine all the time for my perimenopausal patients.
And for what it's worth, iodine is becoming one of my favorite treatments for endometriosis.
Georgie Kovacs: How does perimenopause impact libido? I interviewed a hormone specialist, and she had mentioned that there are patients that come to her and there isn't an equation for level of testosterone and libido. We know libido's complex cause there's mental health factors that could contribute and all these underlying causes. But I'd love for you to talk about libido and perimenopause / menopause, the role of testosterone, because I know that you also mentioned in the book that you're a little bit nervous about testosterone.
Dr Lara Briden: Testosterone in excess causes weight gain and contributes to insulin resistance when it's in excess compared to estrogen and progesterone. When you use testosterone appropriately and at the right dose, it can increase desire. You also need estrogen and progesterone in place, especially estrogen for vaginal tissue thickness of the tissue and everything.
I thought about libido a lot like in writing the book. It's because we have this stereotype that libido always goes down with menopause. I actually don't think that's true from my reading of the literature, from my own personal experience, to some extent, I think so many things factor in and I'll just talk about them sort of briefly. There's certainly, there's a big section in chapter 10 of Hormone Repair Manual about what's called the genitourinary syndrome of menopause. Vaginal dryness is just part of that, but some women could have prolapse. Like if you like, obviously if you have symptoms, if your vagina is not comfortable for all different reasons, that's going to affect desire big time because if it hurts or you're embarrassed or that it requires treatment.
That's when actually vaginal estrogen really comes into it plus other things. Feeling comfortable down there, not dry, all of that needs to be addressed. This is if women want to keep having sex, and I don't think we have to necessarily assume that every woman has to keep having sex, but most women probably do or many women probably do not just sex or masturbation. One of the biggest factors with desire is fatigue and thyroid and other things affecting general energy because you have to have that general mental energy to want to have sex.
It makes sense to me actually, some of the drop in desire that has been attributed to menopause generally is actually from the natural boredom that occurs after 20 years of marriage. I don't think it's bad to say that that's happening for both partners. That's a reality. So I think once you kind of factor that in.
One of the questions I ask about desire when I'm trying to figure out what's going on is, “Do you still, when you're watching a sex scene or romantic scene that's well done, do you still get that little pang of interest? To me that's quite a good marker of what's actually happening with desire rather than, how often you feel like having sex with your partner.
Georgie Kovacs: You've talked about vaginal dryness and some of the hormones that you need for that. Are there other considerations not yet mentioned?
Dr Lara Briden: Vaginal estrogen is number one. And just to circle back to our conversation about safety, vaginal estrogen is safe. From every angle, even potentially for when you have a personal history of breast cancer. I provide a quote from ACOG in there about the safety of vaginal estrogen. So that's just something to know about and not be scared of. And that that's some of the longer term treatments too, because most symptoms are only during the phases of perimenopause, including just after the final period, but that vaginal dryness and the bladder symptoms that go along with it and all of that will just continue to progress without some treatments.
So I will talk about vaginal estrogen. I talk about the importance of a microbiome, potentially the role of vaginal probiotics. I talk about zinc for vaginal health, which I just want to mention. I've seen good results with patients. I think zinc can help to maintain the integrity of the epithelial cells in the vagina, which is important for then they make glycogen that feeds the good bacteria in the microbiome. So there's a close relationship between the health of the tissue and the microbiome.
Georgie Kovacs: What I'm hearing is the importance of taking care of yourself earlier rather than later. I myself am struggling with random anxiety in the middle of the night and it is debilitating. I’m nervous to visit my doctor because I don’t have the energy of debating what should be given because not all doctors are aligned.
Dr Lara Briden: You're right. It's true that premenstrual mood symptoms can worsen or amplify during these years for sure. And it can reach the point of not being able to go through many more cycles like that. It can be quite debilitating. Depending on the doctor, there may be limited options. There is the option of course, to access Prometrium, which is the progesterone. For what it's worth, for progesterone, it's also available as progesterone cream and you don't need a prescription for that. It can be a first step to help with mood. Certainly I've had patients and many friends who say progesterone cream. I talk in the book about magnesium, taurine, B6 plus