Jenn Salib Huber is a Registered Dietitian and Naturopathic Doctor and has a wealth of experience in perimenopause and menopause. She also runs an online program called The Thinking Woman's Guide to Perimenopause and Menopause, and it's a self study program that's open to women in any stage of perimenopause and menopause. And I'm, I've been hearing such great reviews about this program. So definitely check it out.
Jenn Salib Huber 01:55
Something that became really apparent to me is that the hormonal soup that we're swimming in between 35 and 55 is very unique, so the first half of our reproductive life is pretty stable. You go through puberty, you have 20 years where you're churning out an egg every month or two. As a result of that, you had a pretty predictable hormonal soup. You can certainly still have some shifts over the course of the month. Women can experience PMS, they might have bits and pieces that might feel a little ugly, but in general, it's predictable.
Once you hit perimenopause, which is somewhere between 35 and 45, for most women, it becomes a totally different soup. All of a sudden, what was known and what was familiar and what you could live with and work with and manage becomes very different. And so women started coming in at 35, 36, and 37 with anxiety that they'd never had before or all of a sudden were having really heavy, painful long periods, or were noticing body changes that they couldn't explain. The research tells us that most women are misdiagnosed or not diagnosed as being perimenopausal. They're misdiagnosed with depression, with anxiety with insomnia with all of the labels that we try and treat without actually looking at the root cause.
Once I started to notice that in my practice, I became really driven to wanting to help women understand what's happening, because it is normal. It does happen to all of us - different experiences - but I really wanted to work to support women through this natural normal process and help them to feel empowered on the other side.
Georgie Kovacs 03:33
So let's talk about what is perimenopause.
Jenn Salib Huber 03:37
So let's start with menopause because it's easier to actually start from there and work around that. Menopause is actually one day. You are considered in menopause when you have not had a period for 12 months. Everything before that is perimenopause. And everything after that is post menopause. It's not a linear path.
What I tend to see happen, and what the research tells us, is that there are three stages to perimenopause.
There's very early perimenopause, which is most likely to be women, often late 30s, early 40s, they might start to experience a missed period or a shorter period, or they might start to have a night or two of night sweats or hot flashes the day before their period. Maybe they're experiencing mid cycle, sleep waking that's new to them. And maybe it's not enough that they can piece all the pieces together. So they might go years without ever connecting the dots or having the dots connected for them that this is related to their hormones. They're looking at all of the other reasons. So very early, perimenopause is difficult sometimes to stage unless you're working with somebody who knows what to help you look for.
Early perimenopause is probably what's been more recognized over the last few years. This is when we're regularly starting to have some period changes. You're not missing them from month to month, but they're also not the same from month to month. You might have a short one, a long one, a heavy one, a light one. It's defined by that unpredictability.
Late, perimenopause is when you're not having regular periods on a regular basis. So you're regularly going 2, 3, 4 months without having a period.
Typically, it's the cycle patterns and the period symptoms that help us to stage people, which helps us to figure out what hormones are in play at that various stages.
Georgie Kovacs 05:20
What role does someone like you play in when someone comes in to work with you? Tell us what happens. And then I'd like to get to what happens when you're going to an allopathic or more traditional type of doctor. I'd love to do that comparison.
Jenn Salib Huber 05:36
In general, when people go to see an integrative practitioner, someone like a naturopathic doctor, who looks at the whole person, from a holistic perspective, the first thing that we do is to try and figure out what's going on. Sometimes, that means looking for things other than hormones, right? So oftentimes, women will come in and say, “I know it's my hormones. Can you help me feel better?” Over the course of talking to them and getting their history and learning about them, it's like, well, it actually might not be your hormone.
The first thing is to really work with somebody who can look at your symptoms through the lens of perimenopause, but also has the experience and the knowledge to look for other things. That could be important too. Sometimes, people will get great advice from a friend or a neighbor or sister, but it's not the right advice for them, because maybe it wasn't the hormones.
We start with a really good history of what's happening now, but also what your reproductive history was.
So did you have PCOS?
Did you have endometriosis?
Did you have difficulty getting pregnant?
Was there any that did you have irregular cycles?
Was there anything in your history that can help us to maybe figure out what's going on or to figure out if this is actually perimenopause, or maybe it's part of the other condition that you had?
We might look at testing; we might look at hormone levels. For the most part, perimenopause is diagnosed by symptoms. There isn't a single test that can tell us whether you’re perimenopausal.
There is for menopause, We can measure a hormone called follicle stimulating hormone (FSH). If it's above a certain level, we can be pretty sure that your ovaries aren't working anymore. But we don't have a test like that in perimenopause because most women still have enough hormones that they're having a period. If you're still having a period, there's no blood test that's going to be able to tell us more than a history and good conversation will be able to tell us.
A lot of what I would do with someone is to have a conversation asking:
How are you sleeping?
Do you have difficulty falling asleep or staying asleep?
Have you started waking up in the middle of the night? And is that new for you?
Have you started to notice that you're feeling hotter or warmer a few days before your period? And is that new for you?
Do you feel anxious for no reason? And is that new for you?
So it's a lot of trying to figure out what's new, what's different, and when it's happening in the cycle.
Once we can stage someone and say, ‘Okay, I think you're in very early perimenopause,” we can be more certain that we need to work on supporting progesterone, for example. And so we would use a combination of diet, lifestyle, herbal medicine, maybe acupuncture - those types of treatment options to help support this normal process.
This is not a disease. This isn't something that needs to be hit over the head in order to be stamped out. We really just need to support the body through this process. And there's so much that we can do with food and with herbal medicine, and with integrative treatment options.
Georgie Kovacs 08:28
So the way I'm hearing this is as we enter this life stage, there are things that happen that can feel disruptive to your day to day, and there are things you can do to ease that.
Jenn Salib Huber 08:41
Yeah, so here's a perfect example. So because perimenopause, like I always say, is defined by inconsistency, understanding that a lot of that inconsistency has to do with fluctuating levels of estrogen. Because the number of eggs that we have and the number of follicles that we have shifts a little bit from month to month, our estrogen levels can actually vary pretty wildly.
With perimenopause, we often think about estrogen decline as being the most important piece, but it's actually not. It's the variability. And with that variability, we can have changes in sleep and serotonin production. Estrogen levels can help to support serotonin production, so as estrogen levels go higher, serotonin can be higher as estrogen levels can be. Lower serotonin can be lower. We can also have effects of cortisol. Cortisol being a stress hormone, that can have an impact on other hormones.
A lot of these things may not have even been noticeable in our 20s and 30s, because we have this nice steady level of hormones, are now very noticeable. They're now front and center. So if we can support that fluctuating level of estrogen, if we can support neurotransmitter production, if we can support managing that stress level, then the hormone symptoms will be less noticeable and more manageable. So if sometimes we're not treating the hot flashes, we're treating the things that are interfering with how your body copes with that change.
Georgie Kovacs 10:14
If you look at the optimal way a woman's body evolves, meaning, let's assume we have a woman that you're working with. She's not sleeping great, and it's been regulated. And then menopause happens and you have that whole shift in estrogen. We hear vaginal dryness. We hear you go on hormone replacement therapy. But then I also hear women say, “Oh, my God, your 50s are the best.”
Excluding Instagram posts of “everything is great,” what should we expect? And how do we live that amazing life in our 50s?
Jenn Salib Huber 10:49
That's a great question. One of my big “why's” is helping women to understand that perimenopause and menopause is not a death sentence. It is not the end of the world. Life does not go downhill after that. But it could be a rocky few years. I use the analogy of “you're going to get there either way, but you can choose to either take the bumpy road or the paved road.”
The paved road is where you pull in your supports.
Pelvic floor therapist
Family doctor or gynecologist
It's about building that team of people who can help to cushion you through those bumpy rides. When women don't get that support, when they're left to just drown and flail and try to make it to the other side of the lake without support.
I think that's when women get to the end, and they feel exhausted. By the time they hit their 50s, they're like, “Oh my god, I have nothing left in me to give. I'm exhausted, I'm tired. I haven't slept for 10 years, I've been dealing with all this stuff.” It can take them a really long time to recover.
But when women are supported, when they're taught what's happening, and when they're taught how to, sometimes I hesitate to use word manage, but when they're taught to cope with these changes as normal and natural, they feel empowered. When you come through this experience that you share with half the planet, because we all go through it in some way or another, it can energize you. It can really motivate you to want to do your best in other parts of your life.
I think that what I really want women to understand and what I am starting to see on social media, and I love to see women saying it doesn't have to suck. It's not that everything goes downhill. It's that everything changes. And let's work on that change together. And let's support you through that change so that you can actually feel better on the other side than you did before.
Georgie Kovacs 12:46
If I have this team, so you mentioned a few different ones, the pelvic floor physical therapy, what do they help with?
Jenn Salib Huber 12:54
Pelvic floor physiotherapists, I think, are the unsung heroes of women's health. So many of the ones that I've worked with have been amazing in that they help women to understand a part of their body that they may never have thought about or talked about. So unless you had severe incontinence or unless you have severe pain with intercourse, you may not even know that a pelvic floor physiotherapist exists. They can help women who are having any pain:
Pain with intercourse
These are quality of life issues for women. Once you get to be in your 40s, and if you've had kids, or if you have anything else happening, these might be issues that you don't bring up with your doctor or you feel like nobody has a solution. So you're just going to live with it. I often refer to pelvic floor physiotherapists, and they can make an amazing difference in women's quality of life.
Georgie Kovacs 13:53
The pelvic floor physical therapists can help but then also, what about the hormone replacement therapy? Can you talk about that, because I've heard so many different things about it. And it's unclear whether it helps, when you should use it, how long you should use it, and some of the side effects.
Jenn Salib Huber 14:09
Hormone replacement therapy (HRT) has probably been one of the most debated topics in women's health, I think really ever. For the most part, it has had a mixed history. For the longest time, back when hormone replacements first started, women were put on it, and they were never taken off. My dad was a gynecologist, and there were women in his practice, who were in their 80s, who were still on hormone replacement therapy, because that's just how it was done. You're in menopause, you need hormones. Here. You're on hormones.
I was still seeing that in my practice in Nova Scotia. People coming to me at 75 saying, “I'm still taking this HRT. Do I still need to take this?” I think that it was not properly used for a long time, but I don't think there's any question about whether it works. It does work for women who have severe symptoms that are disrupting their quality of life, and I think that it has an important part to play in helping women through this time.
But there are a lot of other options that women can try before that. So in my practice, I used to say that probably about 5% of the women who came to me for help, weren't able to respond or didn't respond to integrative treatment options. I would refer them to another practitioner to look at hormone replacement therapy. And I think the goal now, based on the evidence we have, is that using hormone replacement therapy for up to two years likely does not come with increased risks, especially for people who don't have a history of breast cancer, uterine cancer, a strong family history, history of clots, or anything that would put them at risk. Otherwise, using it for up to two years can be helpful, and it's safe for most people.
I think that most of the women who choose to go that route, because they haven't responded to other things are happy with that choice. I think that's fantastic. But I think that, again, working with a practitioner who's knowledgeable and asks:
How do we manage the risks?
How do we use it for the shortest amount of time possible?
What is the safest preparation?
There's certainly still some debate between conventional hormone replacement therapy bioidentical hormones. The advantage of bioidentical hormones is that they can be customized to each person, so it's not a one size fits all prescription. It's very much a, this is the stage you're in. And so a woman who's in very early perimenopause, who's not responding to integrative treatment options might opt for a bioidentical prescription that has more progesterone, because that's the hormone that she needs more in that particular phase, whereas a woman who hasn't had a period for six months may opt for a prescription that has a higher amount of estrogen. So it can be customized to the stage. And I think that that comes with some advantages.
Georgie Kovacs 16:42
What is the role of hormone replacement therapy? Because if you hit that pause, and your estrogen levels, are they first of all, are they gone? Or are they just so low?
Jenn Salib Huber 16:59
For the most part, in our reproductive life, 95% of our estrogen comes from the follicles. So the follicles that grow the eggs are actually what produce the estrogen. When we run out of follicles, we run out of that source of estrogen. Because our body needs a little bit of it, part of our adrenal glands can actually help to produce a bit of estrogen. And we can also produce a bit of estrogen in our fatty tissue, adipose tissue or fat produces a bit of estrogen, and we get a little bit of estrogen from our adrenal tissue. So we do have some because we need some
Getting on the role of estrogen. Estrogen replacement therapy is primarily directed at symptom management. So prior to the big debacle 10 to 15 years ago about whether or not it was safe or not, there used to be a lot of talk about its potential benefits in that it could reduce the risk of heart disease and osteoporosis.
Those benefits are no longer really the main reason that women are choosing it, because the studies really aren't showing that there is significant benefit, or if there is, it's likely not balanced out by the risks when we're looking at the role of estrogen. Yes, it plays a role in heart health. Yes, it plays a role in bone health. Yes, it plays a whole role in cognitive health. But whether or not hormone replacement therapy, benefits, those outcomes hasn't really been shown yet.
Georgie Kovacs 18:20
If it's ideal to be on them for only two years, and it's because of the limited not lack of limited estrogen in our bodies, what happens after that two year mark? If someone is in that position, where they really need to be on it, and now it's been two years, and they have to go off of it, are they starting all over again with those symptoms? Or is it that once someone reaches a certain stage, in their post menopause phase that it doesn't impact them as much or they can do other things?
Jenn Salib Huber 18:54
So it's a great question. A lot of it comes down to genetics. Some people are genetically wired to have symptoms for a longer period of time. One of the ways that we can predict our own experiences is to look at our mother's experience and to talk to other women in our life who've gone through it. In general, if your mother had a terrible symptomatic long menopause, chances are you might as well but genetics aren't everything.
What we do before, during and after influences are experience and so that's the crux of where I think I come in. When I'm working with women, my goal is to introduce good sources of phytoestrogens and fiber into their diet to support their estrogen levels through the next 10 or 15 years. If we can establish that and do the items below, one's experience of menopause is going to be very different than someone who's not doing those things.
Healthy ways of dealing with stress
Support healthy sleep
Incorporate joyful movement on a regular basis
If you suffered for five years, went on HRT for two years and didn't really do all of those other things, then chances are, when you come off of that, you may have some return of symptoms. Depending on your genetics and your circumstances, it still may be crappy. But eventually it does die down. Women usually aren't having hot flashes in their 70s. The symptoms will naturally die down on their own. You're going to get to Rome one way or the other, but how you get there is up to you. And so that's where working with a practitioner, like myself, or someone else who's well versed in not just the hormone piece, not just estrogen, not just progesterone, is looking at the big picture, and how we can support the whole experience makes the difference on the other end.