In this episode, Dr. Lauren Streicher, a distinguished expert in menopause management, joins to share her insights on this important life stage. Dr. Streicher discusses the complexities of menopause, offering facts and practical advice for women. With a career dedicated to enhancing women's health, she brings a wealth of knowledge from her clinical experience, research, and as the author of several pivotal books on menopause. This conversation explores the main aspects of menopause, from symptom management to the importance of open communication with healthcare providers, and how to embrace this transformative stage of life.
Key Discussion Points on Women's Health and Menopause:
An overview of women’s health and menopause, including high blood pressure, joint pain, insulin resistance, sleep disturbances, and hair loss.
The complex relationship between menopause and painful intercourse, and the importance of accurate diagnosis beyond genitourinary syndrome of menopause (GSM).
Strategies for finding access to a menopause specialist.
The role of estrogen in the management of menopausal symptoms.
Potential benefits and considerations for menopause hormone therapy.
Efficacy, precautions, and recommendations regarding cannabis for menopause relief.
The relationship between menopause and mental health, and how this can impact cognitive function.
How to prepare for doctor's appointments when managing menopause and wanting to address your symptoms and concerns.
Viewing menopause and aging as opportunities to focus on health, well-being, and embracing a new chapter in life.
"The power of education cannot be understated when it comes to menopause. Understanding the changes happening in your body is the first step towards managing symptoms effectively." - Dr. Lauren Streicher
Related to this episode on Managing Menopause:
Resources Perimenopause and Menopause
Related episodes: www.fempower-health.com/perimenopause-menopause
Read Dr. Streicher’s story and follow her on LinkedIn
Midi Health: www.joinmidi.com
Check out Dr Streicher’s Inside Information podcast
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Transcript
We speak so much about menopause on Fempower Health. It's one of our most popular topics outside of endometriosis and, shockingly, the microbiome. And when I did the research, one of the topics that came up was menopause and painful intercourse. And I'd mentioned to you that I had done an interview on genitourinary syndrome of menopause. But to your point, this is all about women being as informed as possible to know how to, advocate for themselves when they're at the doctor's office and understanding some of these conditions before they go and help them explain better what's going on. So tell us more about it could be more than GSM when it comes to painful intercourse.
Well, so this is the thing. If we look at postmenopausal women, we know that the rates of having painful intercourse are quite high, and that is primarily genitourinary syndrome of menopause. The tissue becomes thin. It becomes dry. It loses its elasticity. It loses its lubrication. All of those things that you've already talked about. So if that is the case, in most cases, then the woman is going to do very, very well if she's given a local vaginal estrogen, perhaps DHEA, an oral ospemifene, the right lubricant, not the wrong lubricant, the right lubricant, the right vaginal vaginal moisturizer.
But then there are those women that say, wait a minute. I'm doing all of that and sex still hurts. So what we now appreciate is that while GSM is the primary reason for painful sex in this particular group, it's not the only reason. But let's just talk for a second about the GSM patient who gets her estrogen, and it's not working. My podcast episode is called I'm Using. I'm using vaginal estrogen, but sex still hurts like hell. So when that's the case, when that's happening, what's going on? Well, number 1 is a lot of times women are given vaginal estrogen, but the real problem isn't inside the vagina. It's on the vulva or the vestibule. The vestibule is the area that surrounds the opening of the vagina.
So if you're using estrogen inside and the inside the vagina is moist and lubricated and elastic and everything is great, but the vestibule that's leading to the inside is dry and painful, you're gonna have pain. It doesn't matter how nice the room is if you can't get through the door. So for a lot of women, it really is about treating the vestibule separate from the inside. So that's number 1. Number 2 is when treatment fails, it's very often because there's something going on other than vaginal dryness. Just because someone is postmenopause doesn't mean she can't have one of the other many, many reasons for having pain with intercourse. Let's start at the top of the list with pelvic floor problems. The muscles that line the vagina, the pelvis, the bladder, the rectum can be tight, they can be tender, and they can be the cause of extreme pain even if the tissue is okay.
So that is something that we see in young women, but we certainly see it in menopausal women as well. And then there's the next category where there's a completely different diagnosis that's been missed because too often, women tell their health care clinician that they're having pain with intercourse. If she's 55, 60, 65 years old, they assume it's because of dryness. They don't do an exam. They give a prescription for estrogen. It doesn't work. The woman assumes that the estrogen isn't working when in fact the estrogen may be working just fine, it's because she has something different. Maybe lichen sclerosus, maybe uterine prolapse, maybe one of a very long list of other things that can cause pain with intercourse.
And quite frankly, in most cases, it's more than one thing. You know? You can have dryness, but you can also have something else. So the the approach that I take, and particularly because a lot of women are depending on telehealth now as they should because they don't have access to menopause experts and this is the way to get access to a menopause expert and certainly the approach of Midi is if it sounds like what the issue is is vaginal dryness, Yes. We are going to start with the lubricants, the moisturizers, the local vaginal estrogens, etcetera. However, if you are doing all of those things consistently and correctly and you're still having pain, it's time to get an exam. You have to get an exam. There are certain things that you just can't put your, you know, phone up to your crotch and say, what do you think is going on? You have to actually have someone who knows what they're doing to do a very thorough exam. And that's also part of the problem is a lot of times people will say, also, they should go see their doctor.
Well, you can start there, but quite frankly, the majority of doctors, even really good doctors, are not experts when it comes to sexual medicine and when it comes to menopause. So sometimes you gotta do a little leg work and go see an expert.
Congrats. You know that Midi is now covered in all 50 states. And, you know, there's a lot of telehealth menopause companies, but I think Midi was the first. And by the way, this is not a QVC for Midi. I just wanna say congratulations because it is a great milestone.
No. But thank you, and I appreciate that. And the other thing also, just to be clear while we're on telehealth, is one of the things that I'm new to. I'm new to Midi. I mean, I've been in the menopause space for quite frankly decades, and I've done private practice and academic practice and you name it practice. And when I got interested in this space, I started to look at all of the different companies, because as you said, there are a lot of them out there, And many of them call themselves health, but they're really online pharmacies. They're selling drugs. You know, you basically pay a fee and they will send you their vaginal estrogen or whatever, but they're not providing medical care.
Midi is one of a very, you know, couple of companies that actually have medical experts who have been trained in menopause, who are providing care, the same as if you went to a brick and mortar office. The difference is that you have access. As you said, it's in all 50 states and that's why they take insurance, and that's why they don't sell drugs. You know, you get a prescription. You take it to your pharmacy just like you would for a regular doctor, and they collaborate with doctors in major health care systems, in private practice so that if someone, to my earlier point, does need an exam It's not a problem.
They don't just send you out and say goodbye, good luck. They are going to facilitate that referral. So one thing that I think is important is, obviously, you know, telehealth is an option, but, you know, I had been recommending that folks go to NAMS also to make sure when they do see their OBGYN to make sure they're menopause certified just because of the whole women's health initiative study and how that's affected the training that clinicians are getting for menopause.
What was really interesting, and I haven't done a ton of research on this in detail, but I think it's important for women to know because I think it'll impact our discussion as well for who else to go to, which I know we'll talk about, like, a sexual, medicine expert or a pelvic floor physical therapist is I assume what you're going to say. But I did wanna at least share this, in case you didn't know, but I had friends in New York, which is where I live, who looked up on the NAMS website, and they said they only found one doctor in-network. Every single local NAMS certified doctor was out of network. And I don't know if it's like that in all 50 states.
That's right.
I had no idea. So here I am telling everyone, go to NAMS, go to NAMS, and I'm like, who knew?
Yeah. I mean, Georgie, that's exactly the point is that it's one thing to be able to find a certified menopause expert, but it's another thing to have access to that expert because we see 2 things going on. 1 is they're out of network. They're concierge. It's this cash practice, and they do that quite frankly. And I used to have a concierge practice as well because your typical doctor spends about 10 or 15 minutes per patient for a well woman exam that you're supposed to ram in this entire discussion about menopause. And as a menopause expert, when I see someone for a first time evaluation, it's an hour to an hour and a half, minimally, to really, really do the deep dive. So the true experts have no one's gonna, no insurance company is gonna reimburse for that, so they end up going into concierge medicine or private practice for, you know, fee only.
I can't blame them because it's very frustrating to have a woman come in who says, listen. I'm having hot flashes. I've had a blood clot. By the way, I have breast cancer, and I have diabetes, and you're supposed to, in 10 minutes, tell her how to manage a very difficult problem. So there's that. And then when you do find someone that's in network and that does take insurance, it's about a, you know, a year wait to get in. Truly. I mean, I ran at Northwestern.
I was the founder and ran the menopause center there for 6 years, and the wait list is very, very long because we take insurance, we take all comers, our clinicians are excellent, they do spend time with patients, but you're gonna wait to get in. And, you know, again, that's where telehealth comes in, that, you know, they can be seen quickly and have the appropriate amount of time spent.
I would love to know what are symptoms that we get in menopause that we don't realize, like, either we don't plan for, don't expect, or they're happening and we don't know. Because I think what's interesting is that I've been doing the Fempire Health podcast. This is my 5th season. I've interviewed on all different women's health topics. And what is, you know, clear is we aren't taught about our bodies. A lot of things are normalized. A lot of things are gaslighted. And, you know, there's just a lot we don't understand.
How do you talk about something when you think it's normal? Right.
And you don't even know that it's Right. It's part of menopause. Exactly. Now this happens all the time that I will mention something and someone said, oh, I thought that was just part of aging. And sometimes it is. That's part of the work that I do is to separate what's what's midlife, what's menopause, and what's both, But there are a number of symptoms and long term consequences in our health that are directly related to menopause. And the reason for that is that there are estrogen receptors throughout our body. When people think about estrogen receptors, they think about the genitals.
They think about vulva, vagina, uterus. And people aren't thinking about the fact that we have estrogen receptors in the skin, in our brain, in our muscles, in, you know, many of our organs, in the heart, in our blood vessels. All of these tissues, all of these places in our body are sensitive to estrogen. So, of course, we're gonna have symptoms beyond what we think of as the typical menopause symptoms. I mean, you go up to any woman and say, what would you expect a menopausal woman to experience? And they're all gonna tell you. Yep. Yeah. Hot flashes, sleep, maybe some brain fog, maybe people will talk about vaginal dryness, but most people are not aware that joint pain, for example, some of the skin issues.
These are all repercussions of estrogen. I just did a podcast episode on menopause and the mouth. It was amazing how many mouth issues are related to menopause. I did another one in menopause and the voice. Did you know that voices change at menopause? And this can be career ending for opera singers and voice over. All of these people are taking estrogen so that they can continue to work. This is only the voice. So, you know, you can go down the list of body parts and body tissues that are affected.
And I actually, just a few hours ago, I was doing a webinar for Midi about heart health, and we know that, of course, heart disease is the number one killer of women. And when does heart disease go totally bonkers? It's after menopause because the heart loves its estrogen. Blood vessels love their estrogen. And when estrogen plummets, then we get decreased blood flow. You get an elevation in blood pressure. You have problems with cholesterol. So these are not the typical things that people are thinking about when they think about menopause.
So is it as simple as, you know, I guess, am I hearing you right in that we should all be on estrogen?
You know, if we're if it's someone like me, it's, you know, Georgie. Good for you, but you should still be on it. I'd love to get your perspective.
Yeah. For me, it's very clear. It's very individualized. I would never make a blanket statement that everyone should be on estrogen. Having said that, there are more reasons than hot flashes to consider taking estrogen. As an example, we know that women that have low bone mass, osteopenia, that if they take estrogen, will prevent the progression of osteopenia to osteoporosis. Certainly, women that are having issues in terms of hot flashes, sleep, perimenopausal depression, and anxiety, those are all situations in which someone would benefit from estrogen. The real question is, let's say you walk in the door and you say, I have no symptoms.
I feel terrific. You know? I have absolutely no problems, and I am not really worried about anything. Should I take estrogen? And the answer is, based on what we know now, no. It's, you know, there are some people, it seems, that do absolutely fine without estrogen, and it really is just a case of saying, Okay, what are your concerns? What are your risk factors? And what would be the best approach to that? And the other thing also is sometimes people have this idea that all I've gotta do is take estrogen and I don't need to worry about heart disease. I don't need to worry about my bones. No. That's one factor out of a lot of factors. When we look at all of the risk factors for heart disease in women, loss of estrogen is on the list, and it's high up on the list, but it's not the only thing on the list.
You know, we look at things like having a healthy weight, exercising, and having good cholesterol. There are so many other things that impact that just to say as a blanket, take estrogen and you have nothing to worry about. We know that life is a little more complicated than that.
Exactly. And I'm I'm really glad you said that too because, you know, I was thinking about, you know, let's say someone is coming in and they're to an extreme where they're they're, you know, overweight and drinking tons of wine and they're smoking and, and, and it's not like on the flip side side, like, estrogen is going to, like, fix all that.
Exactly. Then what's also funny is that sometimes we'll say if I say to someone, well, what do you think about taking estrogen? And they'll say, well, you know, I'm worried that it's gonna cause breast cancer. And then I say, well, do you worry every time you have a glass of wine? Because it's the exact same risk. Actually, wine is higher than using estrogen, and people don't think of it like that. So it's really, you know, being aware of what are you gonna gain and what are you not gonna gain.
Yeah. Then that's very true. So you recently spoke at the IshWish conference about menopause and cannabis, and I'd love to get your thoughts on the research. And I guess, first, are a lot of women trying this, and what are they hoping to achieve? And then what are your thoughts on it?
That's what actually prompted me to do this research because I had read a report a couple of years ago that roughly 1 out of 4 menopausal women are turning to cannabis for relief of menopause symptoms, whether it's hot flashes, sleep, libido, sexual issues. And I thought, oh my gosh. Only, like, 5 or 6% of women are using hormone therapy, which is safe and we know to be effective, and yet we've got over 25% of women who are turning to something that's been untested and may or may not be safe and may or may not be effective. But we didn't have any really good research in terms of what women were taking, what symptoms they were hoping to treat, and then what was their perception of how well it was working for them. So what I did was a survey of women who were using cannabis. So the goal of my survey was not to find out how many women are using cannabis. I was recruiting women who already said, yes. I'm either using it now or I've used it in the past.
So the questions I asked were questions like, what symptoms were you trying to treat with the cannabis? And they would check off all of that. And then for each symptom, I would say, number 1, how are you consuming it? Are you smoking it? Are you using an edible? Are you using a lozenge under the tongue? Are you putting CBD on topically? You know, what are you doing? And then I asked, What's in it? You know, I have no clue. THC, sativa, indica. And then the big question, of course, is, do you feel like it's helping you? Is it working for you? And then I also ask questions like, where'd you get it? Who advised you? So I have an insane amount of data, which I have presented at a few medical conferences, and now I'm in the process of writing up a whole big picture to submit to a journal. But it's really fascinating because it's really the first survey that gives us an indication of not just that women are using it, we know they're using it, but how they're using it, why they're using it, and what their perception is of it working. And when I talk to doctors, because as I mentioned earlier, I talk to both worlds. I talk to women, but I also talk in medical conferences. And when I speak at medical conferences, the way that I start off when I talk about cannabis is, look.
I'm not telling you to recommend cannabis. I'm not telling you your patients should be using cannabis. I'm telling you they are using it, and you need to know a little something about it so that you can direct them and, quite frankly, to make sure they don't get into trouble because this idea that it's cannabis, it's natural, you can't have a problem with it, simply isn't true. Just because something is natural does not mean it's safe and does not mean it's effective. Arsenic would be a good example. So I'm always kind of amused when people say, oh, I want natural ways to take care of my menopause symptoms. And my response is always, I want safe and effective ways to take care of your menopause symptoms. You know, the fact whether it's a botanical or whether it's made another way makes no difference to me.
I wanna know, what does it do to your body, and is it safe?
What is your viewpoint on cannabis?
So this is the problem. We have no data. We have absolutely no data. And we know that there are properties of cannabis that make it seem as if it should work, and it depends on the symptom. You know, it's a whole different story whether we're talking about hot flashes or sleep or libido or orgasm or vaginal lubrication, but overall we know that cannabis does have a lot of good properties. It's a vasodilator for 1. It increases blood flow to whatever area it's going to. We know that it has anti-inflammatory properties.
That's gonna be very useful in a number of different circumstances. We know that it can desensitize pain fibers, and we know that it can sometimes make nerve endings more sensitive. That would be really good for women who are having difficulty having an orgasm. But having said that, it's one thing to have these theoretical in the lab pieces of scientific knowledge versus does that translate to what's happening when someone uses it? So the other problem is is that women who are sixties are not the same as women who are twenties, and the reason is not just aging, which is part of it, but because we know that estrogen is actually part of the metabolic pathway for breaking down cannabis, not only in the endocannabinoid system or internal natural system, but the phytocannabinoids, the things that you know, the plant stuff that we're taking. So that means that postmenopause, women are metabolizing cannabis a whole lot slower and tend to have more of a tendency to get into trouble with it. And then we look at interaction with other drugs. And, you know, there's a whole list of things that menopause women need to be aware of. But the question that women really wanna know is, yeah, but does it work? Does it work? And in my survey, the perception is that it works ridiculously well.
I mean, I am getting crazy answers, like, you know, that it relieves hot flashes in more than 90 percent of women. Estrogen's not even that good. You know, that it helps me get to sleep, that it helps my libido, it helps my orgasm. I mean, all of my numbers were really, really high. So is this real? Is this a placebo? I don't know. I don't know because it's an observational study. It's perception. It's not where you take a sham, you know, the real stuff, the placebo stuff, and compare it to the others.
So there's something there. Let's put it that way. I, you know, I I do think that cannabis can be useful if it is given to the right person in the right amount in the right way.
Do you have any precautions? Like, for example, I did, an episode on CBD, and I was going through a lot. It was the middle of COVID, lots of other things going on. But it and, again, it could have been other factors too. I went crazy, and I will not try any of this stuff. So it makes me think, are there obvious contraindications where anyone who's like, I'll try anything. Can you just tell us now, if you are this, don't do it?
Right. Now let me give you some general recommendations. Okay? First of all, it really matters how you consume it. And the majority of women tend to either smoke it or inhale it. This is a big mistake, and the reason it's a big mistake is the advantage of that is you get a quick onset of action, so you know whether it works or it doesn't work, so that's a good thing. But we know we know that if you inhale cannabis, you're gonna damage your lungs. And one of the things that has to be kept under consideration is recreational cannabis. If you do it, you know, once every month or 2 or whatever, fine.
You're not gonna trash your lungs. But we're talking about women that are doing it every day to sleep, hot flashes, mood, all of that. So there is no question, this has been shown, that if you look at an older population and they are inhaling it, there is going to be an increased likelihood of pulmonary problems and also cardiovascular problems. And one of the things that we're also seeing when women inhale is arrhythmias, heart arrhythmias even in people that do not have a history of heart problems. And that data was really found from a population of women who were using it for long term pain control. So, you know, under the blessing of their doctors, they were given cannabis to smoke and they started to have arrhythmias. So number 1, do not inhale or smoke it. Not the way to go.
So then we get to the edibles. The delicious ones, the chocolates, the ice cream, and all the good stuff. So what's the deal with that? Well, this is where I mentioned that metabolism slows down in menopause, and where you're gonna see it is the edibles.
The cookie, they'll have the piece of candy, and an hour later they'll say, it's not doing anything. So they'll have another one. And then before you know it, they've overdosed. Paranoid, anxious, maybe even hallucinating.
They're just feeling like, Oh my God, what did I do? And in fact, if you look in Poison Control Centers, they're seeing large numbers of women in this older population who for just that reason are overdosing. So it's not that you can't use an edible. You know, if somebody wants to use an edible to sleep, for example, that's fine. But when you go to the dispensary and the 12 year old behind the counter is the one who's advising you on what to do, they don't know the difference between a 20 year old and a 60 year old. So whatever they tell you, take a third of it. Just take a teeny little bit and then keep a journal. Keep a journal of how you felt, how long it took you to fall asleep, how long you felt the effects maybe the next day, because you forget that stuff. And when you're trying to find the right dose, that's really, really important.
So start really, really low, lower than anybody tells you, and then if you're gonna bump it up, don't bump it up too fast. You know, give it 3 or 4 days at a present dose before you go up a little bit higher. And it's important to time it. So if you wanna go to bed at 10 o'clock, if you're planning on falling asleep at 10 o'clock, you do not take this at a quarter to 10. You take it, like, at 8:30 or 8. You know, that's part of what you're journaling. That's part of what you're keeping track of. So you can do the edible, but you really have to be careful.
Now the safest, best way for a postmenopausal woman to consume cannabis is using a tincture or a lozenge, meaning it goes in the mouth but you don't swallow it. Either it goes under the tongue where you let it melt or you actually put it inside the cheek. Then you gotta do your best not to swallow it because you don't want it going through the gastrointestinal tract. You want it to get absorbed directly into the bloodstream. And the beauty of using a tincture or a lozenge is that you will get a fast onset of action. So doting wise, you know what you're getting, so you're less likely to overdo it, and you're also not dealing with the pulmonary stuff and the cardiac stuff. What's the downside? Good luck finding tinctures because when you go to your local dispensary, they have them, but they don't have a lot of them. So you really have to look a little bit further sometimes until you find something that works.
And then the next thing is if you find something that's working for you, stick with it. Stick with that brand. Because if you switch brands, even if it looks like it's the same, it's not. No 2 cannabis plants are the same, and therefore, the same formulation in a different brand is not gonna be the same.
So mental health in this perimenopause stage, especially because of all the hormone changes, it's confusing. I know it was. For me. It's like, do I actually have a condition? Is it perimenopause? And, you know, I just think about, like, you know, potentially contraindications. I recently did a whole series on psychedelic medicine, and we were talking about where the clinical trials are. So, like, if someone has, like, schizophrenia or bipolar or something, is there a contraindication for that, or do we not know enough yet?
We know nothing. Nothing. There is no data. And in fact, if somebody was having mental health issues and asked me about cannabis, I would say to them, I can't advise you on that because I have absolutely zero information. Having said that, when we look at mental health issues during perimenopause, that we do know quite a bit about. And, you know, a lot of times people will lump together cognitive and mood, and it's not the same, of course. You know, mood is feeling anxious, feeling sad, feeling depressed as opposed to cognitive function stuff, which is brain fog, memory, word recall, all of that. But what we do know about people that have perimenopausal mood issues, That that is a situation that has been found to be helped by using hormone therapy.
And to your point, when you say, is it just those crazy fluctuating hormones, or is it something else? Obviously, it can be more than one thing. So certainly that's part of what an expert is gonna do is to figure out, is this just because of what's going on perimenopausal with your hormones, or is it because of midlife stuff that's happening at the same time? And that's really important because if it's not perimenopause, if it's midlife, well, then a bucketful of hormones isn't gonna help you. But if it is because of hormonal fluctuations, well, that's not the time you wanna put someone on an antidepressant or an SSRI because that in and of itself can cause problems for women, particularly with sexual dysfunction, some weight gain. So it's not always easy to figure it out, but it's important because the approach and the treatment is different.
So I guess to that point, you know, before we go into some of the other top questions people have, I guess I'd love your perspective on I'm a woman. I've got all this stuff going on, and, you know, we've got social media and podcasts and all these things talking about all this stuff. And we and, you know, we could be airing on the side of, like, overeducation is not the word, but, you know, where it's like, I know what I have. I want you to do this. Right?
Well, that's not over education. Sometimes yeah. I mean, it's Dr. Google, as we say. And so, but I always quote this study because it's so interesting. This was a study that was done some years ago in an emergency room. And every single person that arrived at the emergency room, they said to them, before you came in, did you Google your symptoms? And of course, 100% of them had Googled their symptoms. And then they said, based on your Google search, what do you think is wrong with you? And then they compared that to what was really wrong with them after they left the emergency room.
And not only did they find that over half the people had the wrong diagnosis, but what was most striking is that the diagnosis people thought they had was far more dire than what they actually had. You know, every person with a headache thought they had a, you know, brain tumor. And, you know, so it's a perilous thing to go down the doctor who will move.
And that's why it's so important to find your sources. Know who you can trust. Know who's good. Know who's credible.
And I guess what I'm getting at is, let's say someone listened to my GSM episode, and they're like, go to the doctor. Give me vaginal estrogen. I have GSM. Like, it's more than that. So I guess what I was really trying to get at is, and and I, I completely hear your point, is when we go to the doctor, they're going to ask us questions. And if we don't know what to be monitoring yet You hope. We hope. If we don't know what to be monitoring, it's hard to answer.
If someone says, when was your last period? I don't know. I mean, now we have the apps. Maybe there are people that track. Or when do you get your headaches? I have no idea. You know, what do you eat for lunch? I don't know. If we don't want that kind of an appointment. So if you were to give, like, a a, you know, high level summary of the things people should at least monitor and maybe tell their doctor so, like, when they have something where it could be simply GSM and nothing else, or it could be many other factors and GSM or anxiety, and that's it. What do we tell our doctor?
So this is the way to navigate a doctor's appointment to get the most out of it. There's really 2 categories. There's what I call well woman issues, and then there are problems. So well woman, you know, I'm x years old. What should I know? What should I be doing? What should I be screened for? What should I watch out for? Well woman stuff. And then we get into the problem issues. Sex hurts. I can't I'm up all night hot flashing, you know, that kind of thing.
Anything that is disruptive to you that is impacting on your quality of life, even if you think it is a, quote, normal part of aging, even if you think it's inconsequential, you bring it up. But the way to do it, to, you know, really do it is, first of all, you make a list. And I think a lot of people are unrealistic in terms of what they think they're gonna accomplish at an annual visit, because an annual visit is actually intended to be a well woman visit. It is not meant to be a problem visit. There is no time to do all of this other stuff. So my approach when I was practicing general gynecology is when a woman would come in for her well woman visit and she would say, oh, by the way, sex hurts. And my response would be not to be dismissive, but I would say, Okay, you know, we need to do a thorough evaluation and a thorough discussion. So today, we're gonna do your well-woman stuff.
I'm going to give you some resources and some things I would like you to read, and then before she leaves, I would make another appointment that would be exclusively to discuss that issue. And I think that's a concept that women have a problem with because they feel like, why should I take off work another time? Why should I pay a copay? Why should I go back? Why can't they do it all at once? And it can be done all at once, but not well. And just like if you had a fertility problem, you would not expect that to happen at your well woman exam. You know, that's a separate issue. So I think that part of it is, yes, be prepared with your list of questions and concerns. And to your point, do I think people should read about these things before they go in? You bet. I mean, that's why I wrote my book. You know, my book, Slip Sliding Away, Turning Back the Clock on Your Vagina, is a book about GSM.
If a woman reads my book and then she goes to her doctor and says, I think I have GSM. When you examine me, can you please see if that's the case? And then if in fact the clinician says, yeah. You have GSM, then the woman is smart enough and informed enough to say, well, I know there's a ring, a tablet, a suppository, and a cream. And am I a good candidate for a ring because that's what's the most appealing to me? If a woman doesn't have that information, I can guarantee you that 9 out of 10 times, she is not gonna be given all of her options. So, yes, Georgie, to your point, women should educate themselves. They should be informed, but the mistake women make is sometimes they make their own diagnosis, and then it turns out that's not even what's wrong.
Could also actually negatively impact the appointment because then you're trying to unravel, and maybe the doctor's busy and just, like, don't you know what I mean? There's just so many it can complicate things. But generally speaking, I guess, you know, if if we didn't read up and we're going to our doctor and they're going to ask us questions at the problem visit, wouldn't it be, like, the frequency that whatever's happening, what triggers it, what makes it go away when it's happening, like, that kind of thing is helpful.
Absolutely. Those things are very important. And one of the most important things is timing. So very often, as an example, I will see women in consultation because they're not able to have an orgasm. And when I ask them, okay. When did you first notice that? And they don't know. Well, that's critically important information because it may be that they're not able to have orgasm because that started simultaneous with them starting an SSRI, or maybe it's simultaneous with the change in relationship, or maybe, you know, down the list. But the point is that it is important if you have a particular symptom to think.
When did it start? What makes it better? What makes it worse? Is it there all the time? If not, what brings it on? Those are the kinds of things that are gonna be really useful in terms of figuring out what's going on.
Thank you for that. I appreciate that. So then why don't we run through these top questions and see if we can do and I I don't know how if we can do quick answers. Maybe there's, like, a menopause and high blood pressure.
Rash high blood pressure increases postmenopause and the reason why is because estrogen is a vasodilator, meaning it widens blood vessels. High blood pressure in most cases is because blood flow is restricted. Those blood vessels are smaller. So, yes, high blood pressure and menopause go together, and people don't always know they have high blood pressure without having their blood pressure taken, so they need to get it checked out. Because, of course, high blood pressure over a long period of time will lead not only to heart disease and potentially stroke, but also kidney disease and kidney failure. And you don't want people to find that out when it's too late, when they already have what we call end organ damage, you know, that the kidneys are damaged, the heart is damaged. You wanna know that before it happens. And there's a group of women that are at very high risk that may not know they're at risk, and those are women who had high blood pressure when they were pregnant.
It's so important. Women who either had high blood pressure or who had preeclampsia or even had a pregnancy complication such as a preterm birth are at dramatically higher risk than the general population for developing high blood pressure down the road. And that's I mean, there are a lot of risk factors that people know about, you know, family history and being overweight and smoking and all that. But that's one that not a lot of people are aware of.
I'm starting to be swayed on having a different discussion at my next appointment about hormone therapy.
I mean, honestly, George, but this is the thing. If you had high blood pressure when you were pregnant, it does mean that that is a risk factor, but it doesn't mean that you need to get nervous about it. It just means you need to get your blood pressure checked.
You would be shocked at the number of women that never ever ever ever ever go to a doctor. You know, we kind of think in our world, like, oh, you go to the doctor once a year. And the truth is the majority of the world does not go for a well woman visit. So for anyone listening, if you don't go to a doctor Yeah. Go take your blood pressure at Walgreens, Get a home cuff. Keep an eye on your blood pressure because you don't wanna miss it if it's high, and menopause is a risk factor for high blood pressure.
Okay. Thanks for that. Joint pain.
Joint pain is real in menopause. Why? Because you have estrogen receptors in the joints. And I am old enough to remember when WHI first got released and all those women went off their hormone therapy. And, yes, we had people who came in and were complaining that they, you know, had hot flashes and they couldn't sleep, but I cannot tell you how many women came in and said, my arthritis is out of control. I suddenly can't play tennis anymore. I can't open a jar. Ever since I went off my hormone therapy, there has been a dramatic, dramatic change in my joints. So if someone does have an escalation in joint pain postmenopause, could this be an estrogen related phenomenon? You bet.
But it's also important to keep in mind that other things can cause joint pain. So this, again, is not a do it yourself project. You have to go see someone and make sure that there's not another thing that is causing that to be the problem.
What kind of specialist if someone feels like they're not getting better outside of our typical OBGYN and our primary care, who would they go to?
A rheumatologist.
Let’s talk about Insulin resistance and menopause.
Insulin resistance means that the insulin in your body is not working as well, which means that you are at higher risk for diabetes or metabolic syndrome. And this is also an estrogen related phenomenon. We have this same thing going here. We know yeah. Yeah. We know that estrogen is going to help the insulin in your body work more efficiently, and that's why women who do not take hormone therapy have increased diabetes after menopause, and it's why in every single study, women that take hormone therapy have a decreased risk of diabetes because of that direct impact on insulin resistance.
What about sleep and menopause?
And by the way, can I just say something? Because I know that a lot of this is related to estrogen. So here's where what I'm trying to, I guess, get at is maybe there's someone who wants to try everything else first. Right. Maybe there's someone who is resistant to taking hormone therapy and, you know, to what we started out very early on where it's like, if you're going to, you know, eat cake every single day and not work out and drink wine, like, the and and is going to impact all of these things. And so, you know, I guess just keeping that in mind, I know we can't have, like, an episode on each of these. This is a quick discussion. I guess I would just love to see if you had any nuances there for people to consider, but I love that you're explaining to them how the body works.
Yeah. I mean so this is the thing, Georgia. You know, on one hand, we kinda get on the estrogen train and say, okay. This is all because of a lack of estrogen, which means that estrogen is going to help, but it doesn't mean there aren't other things you can do Right. Or other things that are gonna help. Yeah. It's never just one factor. It's always multiple factors.
So if someone says for whatever reason, they prefer not to take estrogen, certainly, we can offer many, many non hormonal options. So when you look at sleep, sleep is actually complex because there are so many things that impact on sleep. Some are estrogen related. We do know that estrogen in and of itself can disrupt the sleep cycle. Hot flashes, of course, have a big impact. The other thing that we see in midlife is a dramatic increase in sleep apnea, obstructive sleep apnea. And sleep apnea, of course, is when you essentially stop breathing. You get an obstruction in the airway so that someone either snores or gasps or wakes up.
And the reason why this increases postmenopause is number 1, you gain weight for the most part postmenopause, and it is more common in people who gain weight. But even in people who are at a healthy weight, it turns out, and I know this is the same theme again and again, but you have estrogen receptors in the airway. And when those estrogen receptors no longer have any estrogen around, the tissue actually loses its tone. It gets floppier. So that's why women postmenopause have a significant, significant increase in sleep apnea. Now sometimes the symptoms for women are different than men and men, you know, you always think of the big guy who's snoring. Women very often will be normal weight, and one of the things that that women experience, other than fatigue and potentially snoring, is a morning headache. If someone constantly has a morning headache, even if they have no other symptoms, they should be screened for sleep apnea.
The other reason people aren't sleeping is restless leg syndrome, which can happen in all ages, but seems to get worse with age. Of course, then we've also got the general aches and pains. If you have joint pains, muscle pain, back pain, you name it pain, it's gonna be hard to get comfortable and get a good night's sleep. So there's that. And then the final thing, of course, is the snorer in the bed next to you. You know, chances are if you have a partner in the room, that person's gonna be snoring because they're in the same age group you are. So to your point, is estrogen gonna solve all those problems? No. Of course not.
And are there other things to do to get a decent night's sleep? Absolutely. But the first thing is to try and figure out which of those factors Okay. Is what's causing the problem? And sometimes the way to find out is to have a sleep study, to go see a sleep specialist. But the other thing that impacts so much on midlife sleep is alcohol. We know that drinking increases midlife. Why? Well, because people can't get to sleep, so they drink. And then they do get to sleep, but it wakes them up in the middle of the night.
But the other thing is it's the time of life. The kids are gone. You're going out more. You're having more wine with dinner. I mean, alcohol is very much a part of our social lives, which does tend to accelerate midlife. So there's that too. So if someone's not sleeping, the basic questions I ask them, “Are you in pain?” Are you having hot flashes? What's going on with the alcohol? And then we kinda take it from there.
Okay. I love it. So I have 2 more, and they both start with “h.” Hair loss and husbands.
When we look at hair loss, and there's so many different reasons for hair loss. But if we're looking specifically at hair loss that midlife women have, this is called androgenic alopecia. And this is basically a hormonal hair loss in which the hair gets thinner. You get you know, the part seems wider. We're not talking about big patches of hair falling out. We are just talking, overall, the hair is getting thinner. And this happens postmenopause.
We know what happens postmenopause. And sometimes it's genetic, sometimes there's other factors, but sometimes, you know, it just happens. So what can you do about it? Well, we look at a lot of different things. I just did a podcast with a wonderful, wonderful dermatologist, Dr. Helen Gendler, that is actually gonna air in a couple days, and we spent a long time talking about hair. And I said to her, so what about all those vitamins and things that you see advertised on TV? And she was just like, oh my god. Waste of money. Wait. Don't bother.
Waste of money. You know? And she said, biotin, all that stuff that people tell you, it doesn't do a thing. And I believe her because I had significant hair loss, which was made only worse by COVID, and I did it all. You know? I was doing every single biotin and vitamin and all that stuff, and I just didn't see any difference at all. And then I started using some of that topical minoxidil, which theoretically can work, but it's so disgusting. Who can do it for more than 10 minutes? So that wasn't the answer. And then, ultimately, I started using oral minoxidil, and I've doubled my hair.
Let’s talk about menopause and husbands.
So It's so funny that you should bring that up, Georgie, because my husband and I, just yesterday, we actually taped something I was gonna put on Instagram as a reel, but I didn't. I don't know if I will. But we've been talking for the longest time about doing a podcast episode called men on pause, and it's what men need to know about menopause. And I think we do need to get more information out there for the guys. It's actually a book I thought about writing, you know, what do men need to know about menopause and basically take one of my menopause books and gear it for the men.
Yep. I mean, is there outside of just being aware, like, I had a local friend, a gentleman said that he's listening to the podcast to help him with his family, like his wife, his mom, just, like, really understanding women's health. And I don't think every man's gonna always listen to all this information. I mean, I do think it's helpful for them to somewhat understand what menopause is like. But if you had, like, one tip, what would it be?
I would say learn about menopause together.
What happens is men feel like, I don't know what's going on, and she's not telling me. And the reason is, is because she probably doesn't know. And one of the things that I've always encouraged with my podcasts and my books is to listen to it together. It's important to learn about it together as a couple, if you're in a coupled relationship, because it doesn't do any good for a woman to understand why she can't remember why when she walked into a room and why she's sleeping and why her vagina hurts if he doesn't know, and the onus shouldn't be on her to educate him.
What I would like to conclude with is the hope that women should have in this stage of life. You know, I hear things you know, and I feel this way. I'm turning 50 in May. I certainly feel and I I, again, hear it from others at this stage of life where when we get to this point, we're so much more comfortable with who we are. But many of us, all of us, some of us, I don't know, haven't done a study on it, are, you know, afraid of aging. And, you know, yes, it's great that there's all these apps and social media all rallying around menopause and really trying to make it more of an empowered feeling, But I'm sure deep down inside, there's still a lot of fears. And so, you know, we've talked so much about ways to manage it, the symptoms, why some of the symptoms happen. You know, it's been such a helpful conversation that, you know, I I feel like people, you know, are very empowered after listening.
What would be your takeaway for one who may even still be afraid, and nervous about this stage of life?
Well, I could understand why people feel that way because we live in a society that values youth. And not only is it fear of what you might feel or of what medical conditions might be around the corner, but the idea that I'm not relevant anymore. I'm not youthful. I'm not sexy. And we are also dealing in a society where a large number of women are either single or newly single and thinking, okay. Am I gonna be alone in addition to dealing with the unknown of menopause and aging and all that? So I I totally understand where the fear comes from. And what people need to understand is that, first of all, we live almost half of our life postmenopause because average age, menopause is late forties, early fifties, and most women are living, we hope, well into their eighties or even nineties. So this is your life.
This isn't just the end of your life. This is your life. Absolutely. And first of all, I like to think of it in a positive way. No more PMS. No more periods. No more worrying about contraception. No more, you know, worrying about getting pregnant.
All of that is good. You know, once you get into the right mode, you're gonna be on autopilot. You know, you're not gonna have crazy hormonal fluctuations. It's all gonna be good. And it's really a matter of saying, Okay, what am I going to do to make sure that as I age, I continue to be healthy and relevant. And I think that's the other piece of it. We've been talking so much about, as, you know, of course, about health, about what we do for our heart and our joints and all of that. But then it's okay.
Who am I? What is my identity? Because a lot of times when women are going through menopause, for some, it's also around the time when they're retiring, And they lose that identity, and they lose that sense of purpose. You don't have to have a paying job to have purpose. You don't have to have a paying job to have identity. And this is a time of your life when you not only take care of yourself physically, but that you say, Okay, what's my next chapter?
No. Exactly. Well, I really appreciate you making time for this and your commitment, and I love your energy and the way that you're approaching this and discussing it, and I I definitely, will put in the show notes links to the information we discussed today and and how people can get a hold of you because, you definitely want to follow. So thank you so much for this.
Thank you. Thank you for a great discussion.
Guest Bio
Dr. Lauren Streicher, MD, is a renowned expert in women's health, specializing in menopause and sexual medicine as the Medical Director of Community Education and Outreach for Midi Health and the founding director of the Northwestern Medicine Center for Menopause and Sexual Medicine. A Clinical Professor of Obstetrics and Gynecology at Northwestern University’s Feinberg School of Medicine, Dr. Streicher is a Certified Menopause Practitioner, contributing to the journal Menopause and a Senior Research Fellow at the Kinsey Institute. As a best-selling author, she provides insights on menopause through books like "Sex Rx" and "Hot Flash Hell" and hosts the informative podcast “Dr. Streicher’s Inside Information.” Featured on top media outlets like The Today Show, CNN, and NPR, Dr. Streicher’s contributions to women’s health and menopause are widely recognized.
Disclaimer
The information shared by Fempower Health is not medical advice but for informational purposes to enable you to have more effective conversations with your doctor. Always talk to your doctor before making health-related decisions. Additionally, the views expressed by the Fempower Health podcast guests are their own and their appearance on the program does not imply an endorsement of them or any entity they represent.