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Welcome to “Should I Call a Doctor?” The podcast where we dive into trending health topics to separate fact from fiction. We bring in experts to talk about all things health, to empower you with knowledge and answer your questions hosted by Inova Health.
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Come to?
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Should I call a doctor?
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The podcast where we dive into
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the questions you have about
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your health and today's trending
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health topics to separate fact
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from fiction.
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I'm one of your hosts, Doctor
Samuel Zhao.li, an internal
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medicine physician at Inova.
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I'm Tracy Schroeder, I lead
communications for Anova.
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Doctor Sam will give you the
clinical perspective while I ask
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the questions that keep patients
up at night.
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We are here today to talk to
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Doctor Aaron Pierucci, an ob gyn
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with Inova.
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She's a Menopause Society
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certified practitioner and the
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chair of obstetrics and
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gynecology at Inova Fairfax
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Hospital.
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Thank you so much for being with
us today.
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Thanks for having me.
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So give us a little bit about
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your background as a physician
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and how you got interested in
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menopause.
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Yeah, so I've been practicing in
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the Northern Virginia area since
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twenty twelve, when I graduated
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residency and came back home
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because I'm a lifelong northern
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Virginian.
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Um, and, you know, I found that
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my patients were growing up with
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me and asking me questions that
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I didn't have the knowledge to
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answer.
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Um, and so that's really how I
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started my own educational
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journey on learning about
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menopause, learning about the
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new data.
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Uh, since the Women's Health
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Initiative study twenty five odd
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years ago, um, and, you know, it
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really opened my eyes to a
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whole, you know, part of Ob-Gyn
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that we hadn't really been
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trained on, but was something
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that women that were aging and
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coming into midlife and
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menopause, you know, really
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needed and were denied for a
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long time.
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It does feel like there is a
certain wave of support and
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interest in a hunger from women
to have this information.
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What has long been sort of
dismissed as just part of aging
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or just deal with that, or your
symptoms may not even be real.
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Now people are paying attention,
and there's a greater
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appreciation for all the changes
a woman's body goes through.
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You know, when they're getting
into those, you know, late
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forties, early 50s.
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Um, tell us about what that
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looks like and what you're
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seeing in your patients from a
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symptomatic perspective.
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Yeah.
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So it really can be widely
varied.
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And of course, you're getting
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your, you know, the most classic
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symptom, the vasomotor symptoms,
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hot flashes, night sweating, you
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know, up to eighty percent of
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women are going to experience
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that.
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But I get a lot of complaints
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about brain fog and cognition
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issues.
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Um, sleep disturbances are huge.
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Joint aches and pains are
feeling stiff.
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You know, a patient told me
recently she felt like the tin
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man and she needed to be oiled.
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Um, that's a great description.
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And I, you know, I think, you
know, women are still out in the
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workforce wanting to be active.
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They're moms.
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They need to be present.
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And they're finding that all
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these little symptoms are really
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impacting their day to day
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functioning.
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That makes sense.
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And so it's great that they're
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finally, there's more attention
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on it.
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Now there's, you know, you were
talking, you know, part of your
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intro was, you know,
certification in menopause from
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the menopause Society.
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Tell us about that.
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Is that is the menopause society
a new thing?
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Is that something that a
certification is just recently
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available, or is it just more
people are taking an interest in
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doing it now?
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Yeah, I know the Menopause
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Society has been around for a
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while and it's kind of our, um,
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you know, preeminent governing
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body when it comes to putting
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out recommendations for
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menopause care.
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Um, and they've, you know, I
think it's a new, a renewed
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interest in becoming a certified
practitioner so that patients
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know if they're coming to you,
they're getting, you know,
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knowledge that is based in
science and, and, you know,
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based in fact, whereas there's a
lot of ability, ability to
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obtain treatments, um, you know,
out in the community that may
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not be based in that.
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Yeah.
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That, I mean, I think there's a
lot just from sort of my own
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social circles, I see and hear a
lot about people pursuing, you
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know, different supplements that
they see online, like, oh,
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creatine, I have to have
creatine now or all these
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different magnesium choices.
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And, and it's hard to know like
what the right mix is and not
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find yourself in a position of
having to take like ten
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different supplements over the
course of a day when you're
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seeing a patient for the first
time, what do you, how do you
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sort of approach their care?
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Do you start with labs?
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Do you start obviously, you
start by understanding what
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symptoms they're having.
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But, you know, talk to me about
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how you kind of think about
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that.
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Yeah.
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So always first I'm looking at
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what's their age, what are their
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medical, you know, what's their
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medical history?
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Looking for any big red flags
that would tell, you know,
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direct me in a certain way in
terms of, um, what treatments
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would be medically appropriate.
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That's knowledge I want to get
before I even go into the room.
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And then I first sit down and
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say to the patient, tell me why
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you're here.
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Tell me what's bothering you so
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that they could really just lay
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it out.
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Um, and then that lets me know
to, okay, what, what is going to
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be a goal of, of treatment?
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What kind of things are
bothering them?
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Because really, again, it's not
one size fits all.
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And, um, there may be different
things that patients feel is the
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most important thing to them.
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Mhm.
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Um, and then yeah, like maybe
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some of those symptoms go away
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if you're sleeping through the
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night.
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Exactly.
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Yeah.
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And, and so we really look at
that and then, you know, we look
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at what would fit into someone's
lifestyle the best because
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there's lots of different
options out there.
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Um, I think, you know, that was
a downfall of some clinicians
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that were in the past trying to
treat menopause, but they didn't
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know about everything that was
out there to treat it.
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So they kind of approached it
like, here, take this pill.
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That's the only option there is,
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um, you know, and so we look at
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that and try to find the best
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regimen.
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Um, I'm also really honest with
patients that there's no magic
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bullet for everything.
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Yeah.
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Um, and nothing's without side
effects and, and risk and we
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talk about all of that.
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That's great.
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And so, you know, talk a little
bit more about like, what's the
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difference between perimenopause
and actual menopause?
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And how does a woman sort of
assess which stage they're in?
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Um, so menopause is the absence
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of periods for twelve
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consecutive months.
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Okay.
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And there's really not any one
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lab test necessarily that can
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determine menopause and
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perimenopause.
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These are what we call clinical
diagnoses.
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Um, and so absence of periods
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for twelve months, that makes
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you menopausal if you don't have
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a uterus.
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So you don't have periods, then
sometimes we use lab work, um,
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to look at certain levels to see
are they elevated?
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And that can give us an idea.
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Um, but again, not always
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necessary in a certain age of a
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patient, you know, we are going
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to treat that patient's symptoms
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really no matter what the lab
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says.
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Um, and then perimenopause,
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that's actually a diagnosis that
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or a term that we use a lot and
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we hear on social media and
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people use, it really refers to
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the time before the last
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menstrual period and even
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incorporating the twelve months
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after.
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So peri means around around
menopause.
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So perimenopause and the
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transition into menopause really
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starts with cycles becoming
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irregular.
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So menstrual irregularities
where you see plus or minus
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seven to ten days or so in
variation of cycle length.
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And that's happening in more
than just one cycle.
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Um, and then that starts to tell
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us, okay, you're probably
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entering into the transition
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into menopause.
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And then once you're going sixty
days or more with no period,
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that signals the late
transition, where probably your
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last period is going to be in
the next two to three years.
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Okay.
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So that's kind of where we look
at it.
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Now, if someone is having
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regular periods and they have
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not seen any of these, um,
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irregularities yet, can they
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still be starting to come into
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that transition?
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Yes.
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They would, they would be
termed, uh, they wouldn't be
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perimenopausal yet or in the
menopause transition, they would
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still be what we call late
reproductive stage, but they can
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still have symptoms.
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There's not like a, you know,
demarcation line, right?
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And so sometimes we are using
menopausal hormone therapy in
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those younger women or patients
that still have regular cycles
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to tackle symptoms.
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So you talked a little bit about
some of the symptoms.
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What symptoms do you feel like
tend to get overlooked either by
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the patient or by physicians,
and maybe attributed to aging or
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stress or other things?
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There's so, you know, there's so
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much overlap between, you know,
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what might just be, you know,
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normal stuff that's happening
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because of whatever's going in
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your life, you know, that kind
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of thing.
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Sleep disturbances, mood
changes.
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Um, you know, sometimes like
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heart palpitations and things
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like that.
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You know, patients, again,
attribute a lot to stress.
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Um, that kind of stuff.
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Sometimes, you know, until a
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patient gets to a breaking
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point, a lot of times kind of
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gets Pooh poohed, especially too
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if they're not having those
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menstrual irregularities.
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So they're not necessarily
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putting two and two together,
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right?
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Okay.
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It's not getting connected then.
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And what are, you know, talk.
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You mentioned hormone therapy a
minute ago.
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I want to talk about that, but
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maybe talk about first sort of
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the range of treatments that you
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that you do for different
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people.
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Yeah.
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There is so much out there from
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lifestyle modifications, you
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know, optimizing your weight,
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your exercise, your sleep, um,
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non-hormonal treatments.
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We can use, um, some of our
medicines that we commonly use
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to treat mood disorders, to
treat vasomotor symptoms.
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Um, you know, sometimes things
like gabapentin that, that treat
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pain and things like that, um,
can treat symptoms of menopause.
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Um, we also have some newer
medications on the market, um,
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notably the Neurokinin three
receptor antagonists, which
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actually target the receptor in
the brain that has to do with
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regulating your temperature.
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Um, there's also a newer
medicine in that family that has
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just come on.
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The market also helps to improve
sleep.
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So we've got a lot of options,
even outside hormone therapy.
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So, you know, patients who a lot
of times previously thought
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there was no options for them.
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There are lots of options.
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And I often to, you know, some
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of those non-hormonal things
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we're going to even use in
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patients who are using hormone
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therapy to help really optimize
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things.
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How much are you going sort of
the medication route versus also
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looking at supplements like the
magnesium, the creatine, B12,
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etc.. Are you usually doing a
mix or are you kind of going
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down one path?
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I feel like there's a lot of
social media content that's
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like, here's the optimal, here's
all the supplements I take.
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And a lot of times it's
sponsored.
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There's an ulterior motive,
obviously, by whoever's pushing
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out how wonderful it is.
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But I do think that leads to a
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lot of patients not having a
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clear view of how they should be
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seeking treatment.
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You know, I am not a huge, huge
supplement person because the
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supplement industry isn't
regulated by the FDA.
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So, you know, you can take a
magnesium supplement, but are
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you really getting what it says
on the bottle?
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Well, nobody really knows
because, you know, this is not
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this is not regulated.
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Um, and so they can sometimes be
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a nice adjunct, but the mainstay
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of treatment for most healthy
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women for menopausal symptoms is
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going to be, you know, therapy
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with the hormones, um, or these
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other treatments that have data
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behind them.
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Um, you know, but that being
said, yes, you know, I mean, I
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will say I want patients to get
their nutrition from the food
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they eat, right?
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So we talk a lot about
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optimizing nutrition, utilizing
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our awesome support services at
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Anova through, you know,
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dietitians.
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We have available, we have
someone who really is interested
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in menopause and midlife.
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Um, you know, she probably, I
don't know if she hates me yet
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that I send so many people to.
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I have to get that name, uh, and
you know it.
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I want people to be eating
right, practicing good sleep
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hygiene, exercising and really,
you know, supplements can be a
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nice little added benefit.
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That's helpful.
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That's really helpful.
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And so let's talk a little bit
more about hormone therapy
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because I know for reasons I
don't necessarily know.
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Maybe you can shed some light.
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Hormone therapy seems like it's
had controversy over the years,
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or people think it's linked to,
you know, an increased risk of
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cancer or, you know, different
things like that.
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Tell me what's true about
hormone therapy.
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So hormone therapy was actually
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was more widely used than it is
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today in, you know, the
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seventies.
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80s 90s.
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Um, a study came out in the
early two thousand called the
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Women's Health Initiative study,
um, that had several different
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arms, but one arm of the study
that looked at women taking
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estrogen and progesterone
together, um, was stopped early
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because of perceived risks.
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And that was risk of.
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Blood clotting and, and, you
know, cardiovascular disease and
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then risk of breast cancer.
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The risk was not framed
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appropriately to the public in
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terms of how great that risk
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was.
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Okay.
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And even potentially overstated.
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Right.
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Overstated.
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That's.
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Yeah.
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And, you know, even the study
investigators have come out and
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said, yes, we did not present
that to the public correctly.
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And we caused alarm that really
probably wasn't warranted.
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Um, you know, many people don't
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know that the arm of the study
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that looked at estrogen only in
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women without a uterus continued
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for several years and did not
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find any increased risk of
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breast cancer.
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Interesting.
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Okay.
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Yeah.
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That wasn't very well that
wasn't publicized.
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Right.
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Um, and so it really made the
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pendulum swing totally in one
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direction that everybody got
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scared.
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Even physicians got scared.
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Um, even though the study had
some design flaws.
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Average age of the the woman in
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the study was in her early
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sixties.
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It really wasn't the population
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we give hormone therapy to
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because timing of when we start
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that matters.
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Um, it it used hormones that are
generally not the, um, regimen
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that we start with, and that is
our preferred regimen.
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So there was a lot of flaws in
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that study and, and data has
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come out since, but for some
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reason, medical education,
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residency, education for OB
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GYNs, you know, just general
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physician knowledge never kept
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up.
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Okay.
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And women were just told, no,
this is dangerous.
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This is not safe.
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This is going to give you a
blood clot in breast cancer,
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which is not, you know.
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Yes.
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Are there still risks
associated?
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Absolutely.
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But for most healthy women in
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the right age, the right time
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frame, those risks are small and
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acceptable.
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And I feel like some of those
risks have even been associated
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with being on birth control in
your you know, they are.
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And and many people take that
because the risks are so minimal
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compared to the benefits.
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Exactly.
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And so maybe a similar sort of
view on this as well.
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Yes.
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That the risks for most, you
know, there are some women who
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because of certain health
conditions, we say you can't use
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birth control because it's going
to increase risk of a blood clot
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or something like that.
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Too high.
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Um, it is the same for hormone
therapy.
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Um, that there are definitely
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populations that it's not
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appropriate for.
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And I think that's why it's
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important to see a clinician who
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understands how to look at
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someone's medical history and
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know which populations those
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are.
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So when you do have a woman that
you're like, this is this is
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suitable for you, this is an
appropriate treatment for you.
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Tell me, what kind of is it?
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Is it a pill, a daily pill?
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How do they take it and how
like, what are the benefits they
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start seeing from it?
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Yeah.
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So we have lots of different
formulations.
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Um, we have formulations that
are absorbed through the skin.
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Formulations that are taken
orally and formulations that are
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absorbed through the vagina.
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Mhm.
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Um, which also are like absorbed
directly into the bloodstream.
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Um, for most women, we try to
start with those regimens that
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are absorbed directly through,
uh, through the skin or the
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vagina into the bloodstream.
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They don't appear to increase
your risk of a blood clot, heart
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attack, or stroke.
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Um. Oral preparations, like a
birth control pill to, um, have
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to be metabolized by the liver.
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They're thought to increase
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liver clotting factors and thus
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give us that small increased
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risk there.
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Okay.
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So if we can start with
transdermal, we like to, but you
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know, doesn't mean the other
stuff is, you know, it's not
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it's not ever, you know,
appropriate for somebody.
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Um, so lots of different things.
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And that's why I talk to
patients about what's going to
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fit into your life the best.
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You know, if you've got, you
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can't put on a bandaid without
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getting real bad irritation,
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then a patch isn't for you,
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right?
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You know, we're going to we're
going to talk about that.
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Um, there's also again, we go
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over all the other options too
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outside of using hormone
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therapy.
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Um, that might be appropriate.
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Um, and different hormone
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therapy that we use to treat
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different conditions in
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menopause.
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So we, you know, there's
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systemic symptoms and there's
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vaginal symptoms and they're
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treated differently.
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Um, some benefits that patients
are going to see is symptom
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relief usually very quickly.
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Um, and still we're using this,
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you know, we can talk a little
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bit about the, you know, health
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benefits of HRT, but still the
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recommendation is for symptom
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relief.
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Um, and they're going to see,
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you know, ideally about a sixty
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to eighty percent reduction in
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their symptoms in that first six
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week period.
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That's considerable.
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Yeah.
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They, they start to notice it
right away, right away.
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Um, and then one thing we do
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know that hormone therapy can do
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is protect your bones and is
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going to, you know, help prevent
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some of that bone loss that
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happens rapidly after the last
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period.
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Oh, wow.
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And that's so important as you
get older.
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Keeping those, keeping that
strength in the muscle and all
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of that too.
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Um, that's really good to know.
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What would you say, you know, at
what point should someone seek
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care when you know, because
there's a lot of times I think
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women, to your point, busy.
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They might be working, they
might be moms, they might be
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taking care of parents.
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You know, it's hard to kind of
find time to get your, you know,
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see your doctor.
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But at what point should you
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stop powering through the
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symptoms and really say like,
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okay, it's time to talk to a
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doctor about this and get some
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medical intervention.
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Yeah.
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Of course, if you're I mean,
really severe symptoms.
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Palpitate heart palpitations,
chest pain.
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Um, very bad, irregular, heavy
bleeding.
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Sometimes that happens in that,
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you know, transition into
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menopause.
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We don't want people to be doing
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that, you know, unchecked, um,
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mood symptoms that are just out
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of proportion with what's
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normal.
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Suicidality, things like that.
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You should always see your
clinician right away.
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Um, and those should be
investigated.
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Um, but I mean, I feel like, you
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know, because I definitely get
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patients that come in and
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they're like, well, do I need
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this?
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And I say, well, you tell me,
are you functioning?
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You know, and everyone's, you
know, how it impacts someone
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will be different.
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I've definitely had patients who
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say, I have a couple, you know,
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I have hot flashes, but they
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don't really impact my day to
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day.
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So I'm okay with them.
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All right, fine.
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But if someone's like, I cannot
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be in this meeting and start to
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tear up or all of a sudden be
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covered in sweat, it's impacting
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my work.
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It's impacting my ability to
function.
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You know, I haven't had a good
night's sleep in months.
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It's time to to talk about that.
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Yeah.
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Get an intervention.
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The life can be better.
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Absolutely.
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Yeah.
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And I think women are just used
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to taking care of everybody
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else.
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And so I definitely have
patients that say, I should have
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been in here six months ago.
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I should have been in here last
year.
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This has been going on for a
long time.
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I'm sure they do, because once
they get the relief through
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whatever regimen you give them,
they feel so much better.
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They're like, oh, why did I
wait?
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I mean, I feel like that's true
for so many healthcare things.
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It's like, why did I wait?
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This could have been better,
faster.
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What haven't I asked you that
you would want our listeners to
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know and understand about
menopause, that it shouldn't be
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expensive to be treated.
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So if you're going to see a
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clinician and you're having to
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pay a lot of money to see them,
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to have lab work done to buy
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what they're selling, then you
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know, there that is not, in my
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mind, ethical.
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And you should be seeking out a
clinician that is using FDA
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approved medications that will
be covered by your insurance.
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And ideally, that has the
certification and the knowledge
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to not only prescribe all these
things, but troubleshoot them,
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tweak them as needed, change
them if needed.
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Um, you know, so seeking out,
uh, someone who is menopause
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society certified is ideal.
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Um, additionally, like, you
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know, nothing, nothing works
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alone.
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There's no, like I said, there's
no magic bullet.
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So we always have to do the work
with optimizing our lifestyle
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and, you know, making sure that
our sleep hygiene is good.
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So our sleep can be good and
making sure that we're reducing
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stress levels and making
exercise part of our daily
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regimen, because all of those
things are going to enhance
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treating these symptoms.
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That makes a lot of sense.
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Doctor, thank you so much for
being with us today.
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This is great information.
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Thank you for having me.
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Thanks for tuning in.
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We hope you enjoyed this
episode.
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