(upbeat music) - Welcome back to "Family Health Matters", I'm Shelly Irwin.

With me today, Dr. Diana Bitner, co-founder of True Women's Health, Dr. Robyn Hubbard, obstetrician gynecologist with Grand Rapids Women's Health and Kari Stuart, endurance coach and owner of Stuart Coaching and much, much more.

I only get the best ladies.

Thank you all for being here on a very important topic.

Kari, how do you spend your day?

- Well, I am a mother of three children, so that's of course a big part of my day.

But I also have about 25 athletes that I help them reach their endurance goals and navigate all the different complexities, both men and women, but a lot of women that are in their menopausal years.

- Yes, there is an important angle we'll talk about.

How about you, Dr. Hubbard?

Have you delivered any babies this last month?

- I definitely have, it's a busy baby time.

- Yes, your specialty.

Do you talk to your patients about menopause?

- I do, so I'm a general obstetrician gynecologist and so not only do I deliver babies, but I take care of women at all ages of life, including teenagers, all the way through their reproductive years.

And menopause is a big issue that I take on with my patients.

- Dr. Diana Bitner, thank you for bringing your props.

Looking forward to this.

Talk to us about your specialization.

- So I'm an OBGYN as well by training, and Robyn and I trained together and delivered babies for many years.

But I really wanted to know a lot more about midlife menopause and sexual health.

And so now I spend my day at True Women's Health with several partners and we take care of women focused on whole life health, but also midlife and menopause and sexual health.

- All right, well keep this as layman language as possible.

I'll start with you Dr. Diana Bitner.

How would you define menopause?

- So menopause can be natural menopause where it just sort of starts to happen at 52.

It can be surgical where your ovaries are removed.

It can be chemotherapy induced when chemotherapy or let's say radiation from cancer puts you into menopause.

But menopause means the lack of estrogen caused by the ovaries not making anymore or they're not being anymore to be made.

So it's essentially the lack of estrogen and testosterone that cause symptoms and health consequences.

- Dr. Hubbard 52-ish is the the prime age.

There's also a period and maybe a post.

- Yeah, so menopause officially is no periods for 12 months and the average age in the US is 52.

But there's a huge range of symptoms related to declining levels of estrogen, which is referred to as perimenopause.

And that can start in your 40s and some women even earlier than that and can go on for many years.

- And is it there are genetic link?

In other words, if my mother had a tough time with menopause, of course we'll dispel some miss as well, is there a link here?

- There might be, yeah.

So there's a condition called premature ovarian failure, which can be with other things.

And you go through menopause at a quite young age, like in your 20s or 30s.

And that definitely can run in families, but also age of menopause can run in the families, but it's something that you can't completely rely on.

- And I can still be an athlete after menopause, Kari Stuart.

- Absolutely.

And you can become a better athlete after menopause too.

- I think you've proved that.

(all laughing) - But how do you know I've been through menopause.

(all laughing) It's all good.

- We are athletes and we rise to a challenge, right?

- Yes.

- That's how I need to see it.

- Good, I'm looking forward to picking your brain.

Dr. Bitner, so let's get right to some of the symptoms and we all want to talk about the hot flash, the weight gain, the sweats.

To spell these or it's a fact of life.

- So they're first, they're all real.

20% of women don't have hot flashes.

And of course then the danger is they think that they don't have menopause, and there's a lot going on on the inside related to menopause.

Menopause is a pre-diabetic state, insulin resistance that's why women will gain belly fat specifically, but there's also symptoms such as vaginal dryness, bladder urgency, brain fog, mood changes and changes in sex drive.

- Dr. Hubbard, if one experiences a hot flash all of a sudden, I trust there's no room to panic.

But are there ways to treat these early symptoms?

- Definitely there's a whole wide variety of ways to treat symptoms and hot flashes often will start kind of out of the blue, but gradually they'll increase in frequency and maybe severity so that some people will get a hot flash every once in a while and others will have them multiple times in an hour, so it's quite debilitating.

- You lead your patients through symptoms and symptom relief.

Talk about your symptom circle.

- Sure, and just real quick, it's interesting women of color tend to have symptoms that happen a lot earlier and are more intense and last a lot longer.

And what's sad is that a lot of women of color don't tend to access our healthcare system and get the help that they need.

So shout out for that.

But the symptom circle, I created this a long time ago to really help guide conversation in the office and women would take them home and you know, one woman took it to her workplace and she was like 10 cents a turn for her coworkers.

But these are all the symptoms of menopause so women would know they're not crazy.

And then a cutout is what you can do in the moment even to make them better or worse.

And on the back are the lifestyle changes such as water, sleep, vitamins, fiber, nutrition, for example, high sugar or low blood sugar can trigger a hot flash, like that hot flash in the middle of the night, that can happen maybe because your blood sugar dropped.

Activity including exercise of, you know, strength training, stretching and aerobic and also mind, body and the power of gratitude.

So these symptoms are real and we use this again so women can sort of track what's going on.

- The big picture Dr. Hubbard and then I will go to you Kari.

Will these symptoms ultimately go away?

- For most women they will hopefully, and I think Dr. Bitner and I will advocate for treatment because there is a lot of medical and natural things that you can do to try to help support your symptoms.

But most women will have their symptoms resolved.

But I have women in their 80s that continue to have hot flashes and certainly vaginal dryness, muscle and joint pains, sleep disturbance can continue throughout the menopausal years.

- Right, we'll take this apart.

Alright Kari, so a woman's having a hot flash and she has a race the next day.

What's your suggestion?

- Oh, well, thankfully the hot flash will pass, but women can pre-cool before an event.

If you notice that you kind of tend to run hot once you enter perimenopause, you can bring like a damp towel or something, put it around your neck, make sure you're cooling from the inside out, drinking plenty of water to just cool that core temperature and you know, prepare yourself that those things happen and that you can get through it and you can't let it get into your head.

Like you just experience it and you move on and you keep competing.

- Obviously there's a fact of life that we might not run as fast at 63 versus 23, but what are your general advices?

What is your general advice for women who perhaps want to stay athletically active in their 50s, 60s and beyond?

- Well, I think that it's very important to kind of shake things up because you can't do what you did when you were 20, when you're now in your 40s and 50s, especially when you're starting to experience those symptoms.

- And you may even take, it may be a 40-year-old that may be looking to.

- Absolutely, I'm 46 and I experience symptoms and it's just part of life.

And so just because you haven't passed that menopausal bridge, doesn't mean you can't start practicing these things by increasing your strength training, lifting heavier weights, the stimulus our muscles need in order to get stronger.

We're not getting that through our hormones anymore, so we need to do that through our activity.

So we're used to be able to go and do these long, you know, zone three or medium paced type activities.

Now it's more polarized where you're doing very easy and very hard, and then finding that balance we're getting enough recovery and just, you know, trying just something different.

It's hard, that alone is hard to make that change.

- Working on that rest as part of the the routine.

And why is that?

Why is rest perhaps more important as we age?

- Well, menopause is an inflammatory state, so our body is in an inflammation and so we need to reduce the cortisol so that our body can heal and grow muscle and stay strong.

So that recovery piece, I mean it's good for your mind and your body, and so like you do the work, you do the hard work and then you immediately start with that recovery, cool down, take a couple minutes, deep breathing exercises, let your muscles cool down and really turn off that vagus nerve, right?

That's what it is, so that you're now in that rest state rather than the high cortisol state.

So we need that stress to get stronger, but we also need to be able to turn it off.

- Yes, and then turn it on 48 hours later.

There we are, tell me about the sex deck.

Let's just go there.

(all laughing) - Well one of the big changes that can happen during menopause is lower libido.

And there's two kinds of libido.

There's responsive libido where one responds to a cue such as a partner or certain song comes on, but there's also spontaneous libido that relates more to hormones such as estrogen, testosterone.

And so I created the sex deck because I would go to these lectures and think how am I gonna remember all this stuff to talk to a patient about?

And in medical school and residency, we were not trained in sexual health.

And so I wanted a tool that I could use to communicate, but then also have the patient be able to take home and use for her to understand her sexual health, but then also to communicate with her partner.

So it's the 27 reasons for low sexual desire.

And so they're color coded?

- You want me to choose one.

- No.

(all laughing) It might be a little too, but in terms of like they're color coded for physical reasons such as, let's say distraction or pain or dryness or chronic pain, back pain versus interpersonal relationships.

A lot of partners who've been married for a long time, there might be some distraction, they don't feel like they know each other as well anymore.

The kids have left, how do we reconnect?

And then psychological such as job stress, depression, anxiety, history of abuse.

So it's really, and then on the back of the deck is what are the causes of the problem and then what do we do about it?

So it really helps us all, you know, take a lot of this information and then make it more relatable.

So it's not like play the blame game.

It more makes it objective.

- Yes, and we can laugh about it, but it's a serious matter.

- Serious matter and yeah, sexual health is so much more than.

- Yap, Dr. Hubbard let's talk about some treatment choices.

Say one would like, do I say a hormone replacement?

- Yeah.

- What's out there?

- So because menopause and menopausal symptoms are caused by a decrease in your natural hormones, primarily estrogen and testosterone, we have hormone replacement therapy.

So that's like a general term that relates to any type of added hormone that you would give back.

The primary one being estrogen.

So we replace estrogen, which most of the estrogen in our bodies is produced from our ovaries.

So as those that stops, we can add that back in a variety of forms.

There are oral forms, there are transdermal, like a patch, a gel, a cream, there's vaginal ways to dose estrogen.

So I have my estrogen patch on right now.

- That's all right.

(Robyn laughing) - And they come in a variety of doses and so you can treat menopausal symptoms by replacing estrogen so that you are kind of back to a steady state and it helps control those symptoms and provides for a lot of other added health benefits like a reduction in heart disease and protection of bone loss and improves just almost every cell of your body has estrogen receptors.

So hair, skin teeth, vaginal health.

So there are a variety of benefits.

One of my main symptoms was muscle and joint pain.

When I went through menopause and kind of everything that ever bothered me before started becoming more of an issue and I went on estrogen and kind of back to my baseline again and it was almost like a miracle.

- You know what's so fascinating too is there's really good data about women who take estrogen are capable of building more muscle.

Testosterone, we don't have data in women, we have data in men, but we know that testosterone use in women can be safe and it can help women build that muscle again.

It just needs to be done per guidelines using FDA approved, not compounded and not pellets.

- Yeah, maybe clarify that, sorry.

But that's what that means because I think there's so much confusion between like the terms bioidentical and compounded and natural, and my patients are very confused about what all that means.

- Natural's been this word that was used by marketing, right?

Like to sell compounded.

So the current hormone medication therapy that we prescribe, it's bioidentical.

So meaning it's identical or bioequivalent.

It's equivalent to what your ovary used to make, but it's FDA approved.

So it's actually made in the lab, it's FDA approved, it's consistent.

And we are really concerned about compounded medications.

You know, some people, that's the only thing that works for them, but we can't really rely on it to be the same time to time and hormones, friends are important, you know, very powerful things.

So with the estrogen we can give transdermal or oral, like you said, bioidentical.

Unfortunately progesterone in a patch is not bioidentical, it's synthetic so it can cause side effects.

And vaginal estrogen alone does not get into the blood.

So especially a new product called Envey that doesn't go in the blood.

So there's lots of options.

- Yeah.

- With testosterone, the cool thing is, is that the International Menopause Society is now put out guidelines on how we can use FDA-approved testosterone for men in women at 1/10 the dose.

So we use a cream called Testim, we use generic, we use it off-label, but it's just way safer.

We replace testosterone at the level of a woman, not for a teenage boy.

So those pellets take levels too high and are not safe.

- Yeah.

- So if one chooses to not involve estrogen in their life, could I just sleep right, exercise and then turn to Kari Stuart and say, what do I eat as an athlete and post menopause?

- Well those things can certainly help.

I wouldn't rule out anything.

Every person is different and so you need to keep all of your options open.

But yes, of course like having a balanced diet, eating three whole round, square meals a day.

So a lot of, you mentioned marketing, there's a lot of marketing out there for certain diets and specific things and it's really, it's sad because it's making this transition harder for people.

So the first thing I would recommend is to just start checking in on yourself, journaling your symptoms, how you're feeling as you exercise.

How things are going, do you feel like you have enough energy with the foods you're eating?

And then eat those three square meals a day, two snacks, and then now you have a baseline and now you can start making small changes and see how they affect you positively or negatively.

But if you just start following this trend or that trend, you don't really know what it was that you did that helped.

So yeah, so get that baseline going and then change things.

- Your recommendation and we can go.

Headed into nutrition, meat, how are we doing with meat intake for-- - Well, protein is very important.

I guess meat is a personal preference, but definitely protein.

You know, there's recommendations that range from, I think it's 1.1 grams per kilogram of body weight up to 2.2. athletes might wanna look at that higher end.

And it really depends on your starting point.

If you are eating only a little bit of protein a day, you're not gonna wanna jump up there and eat all of that 2.2 grams per kilogram of body weight, you'll feel pretty sick.

- Do you deal with athletes that perhaps have, women athletes that have gained weight that is that.

Of course muscle weighs more than fat and all that stuff?

- Absolutely.

Weight gain is a part of perimenopause and menopause and it's a hard part and especially for an athlete because we invest so much time in our bodies and there's an aesthetic that comes along with being an athlete and when that changes, you feel like part of your worth has changed because you were tied to that look and feel.

And so I think it's important to just recognize it happens to everybody.

You're not alone.

There are definitely things you can do to fight it, but you know, going back and looking like my 30-year-old self is probably not an option for me and that's okay.

- Yes, I think she looks pretty good, all legit.

(all laughing) Any myth to dispel anything for the 30-year-old to not sweat it as they say is it is gonna happen, Dr. Hubbard?

- Yeah, I mean I think one of the most important things to think about that just kind of crossed my mind was that, you know, when Diana and I trained, very few studies, and this is just in our generation, right?

We're still practicing.

There were like no studies on women.

So here we are like a group of women that are approaching or in menopausal age and the data is so new and fortunately we're having more and more data where studies are looking at women and heart health and overall hormone effects and what estrogen replacement does for you.

And so we have new information and so I think relying on like hearsay and miss from your mom or your grandma or you know, people that are still relying on the WHI study that was released, and a lot of misinformation was propagated 20 plus years ago, but now has been modified.

And I think finding a doctor that really has a lot of expertise in this field.

So seeing a gynecologist or a specialist like Dr. Bitner in menopause health to talk about your personal situation and make a good choice based on who you are and what you are wanting so that you can live healthy.

Back hundreds of years ago, women didn't live past menopause.

- Exactly.

- And so now we are a whole new generation of women.

We're gonna maybe double our life after menopause and we need to be able to embrace it, live healthy, you know, 70 is the new 40s, so we've gotta...

I think that's the biggest thing.

Is like reframe it and don't just think about the way it used to be, but what is the new data and what can you do to live a healthier life?

- I love that.

- The same is true for sports performance.

Like all of the studies are done on men.

So the way a woman trains can definitely look different than the way a man trains and it should.

When you're younger, you should train with your cycle.

There's advantages to that.

And then as we age, make changes as well.

- Sure, well one thing too is, I don't think any woman's care should depend on the level of training of her provider.

So it's to ask questions like of myself, of Robyn, of your provider, like what do you know about menopause?

And if you don't know, that's okay, you don't have to know everything.

Can I see someone who's more comfortable with it?

Right.

So I just brought along to show, this is the textbook by the Menopause Society.

So even just for great knowledge, like, we know that for example, a healthy lifestyle isn't treatment for hot flashes, but it's the most critical foundation, right?

No treatment is gonna be as effective if you're not doing those lifestyle.

But you know, there's a lot of evidence.

So we know that for example, there's a couple SSRI drugs like cousins of Prozac.

So those medicines are not always for depression anxiety, they treat hot flashes.

So Paxil is FDA approved for hot flashes.

Lexapro is the most effective, it's more effective than Effexor for hot flashes.

And there's a whole new class of drugs out by Astellas just came out with VEOZA, Bearers coming out with their drug soon and they work to fix the thermostats.

So they're called candy neuron antagonists.

And what they do is they're non-hormonal and they knock out hot flashes and night sweats within four days.

So I have patients who are breast cancer survivors can't take estrogen.

We know that estrogen doesn't cause breast cancer, but one, if someone's had breast cancer, they can't take it.

So this new class of drugs is just absolutely incredible.

So it allows for women to sleep and recover and rest and feel better - Follow up on that?

- Absolutely, I mean every day I feel like there's something new that can help our armamentarium for patients that have special specific needs or desires in their treatment.

And so this new class of drugs is revolutionizing.

And like the OBGYN world is just like, "Yay, finally we have more options to help women feel better and be more comfortable."

- There are side effects speaking of depression that can be correlated or caused from this Dr. Hubbard.

- Yeah, I think there are many, many women who experience a phase of life around midlife where they just feel like they're going crazy, literally like in quotes.

Like something is terribly wrong and I don't know.

And they develop relationship issues and problems at home and maybe in their workplace because of estrogen deficiency and menopausal symptoms.

And it can really wreak havoc and finding out that there's a reason behind that and being able to seek the appropriate care, whether that be hormones and SSI medication used for the treatment of depression and anxiety, therapy, a complex way to treat somebody as a whole person, it can change everything.

- [Shelley] Yeah, or exercise.

- Well, absolutely.

And eating well and exercise is the important framework there too.

- Yeah, and I love this wheel that you have here because I think there's so many symptoms that people don't even recognize are a symptom.

I just learned that fear can be a symptom.

I was just on a chairlift at Canonsburg and I was terrified.

I've never felt a fear of heights before.

And then I listened to a podcast a couple days later and there someone is saying like, an athlete who used to be able to mountain bike over all these obstacles is now afraid of them.

And I was like, "That is what I was experiencing."

And when you understand why am I experiencing this?

- Gives the power a way.

- Yeah, I would've felt a lot better on that trail.

- Well too, just in terms of the mood changes, if a woman's had PMS during her cycles, if she's had postpartum depression, she's at especially high risk for mood changes in perimenopause or menopause because it's the same physiology.

You know, after you have a baby, your estrogen drops.

When that placenta comes out, estrogen goes to zero and of course your sleep deprived.

So we make our hormones, our brain chemicals when we sleep.

And if there's any extra stressors then it's a lot of new coping with a lot of new things, but with your estrogen down, your brain chemicals actually come down.

So it's really important to understand that they're very closely tied.

- So there's such thing as brain fog in this state.

- Brain fog, word search, memory loss.

Like so many women will come in and say, "I think I'm getting dementia."

I'm like, "No, no, no, no."

Now risk of heart disease also is an increased risk for dementia.

We know that waking in the middle of the night is actually a direct correlation with dementia.

So, and not getting back to sleep.

So it's so important to get treated.

But yeah, it's just amazing how knowing your risk factors can give you power over a situation as it's happening.

- What else?

What else is in this field?

You are a specialist, it's brought up with your-- - Oh, I talk about it every day.

Absolutely, it's such a common thing and something that even women that don't think that they have any issues, they're like, "Oh, my periods just stopped.

I'm not having a lot of issues."

I'm like, "Let's talk about the continued benefits that you might have by considering going on it.

You don't just need it for hot flashes, you can consider using hormone replacement therapy for the other health benefits that it provides you.

And I recommend that."

- For bone loss, right?

- Absolutely.

- So especially exercise helps with bone loss, but without estrogen, bone loss goes down pretty quick in the first five years, 2% per year.

So it's so important to think about just even considering estrogen for that.

- Yes, almost time for final words.

I wanna go back to you though, Kari, say a 60-year-old wants to get involved in an endurance sport.

Where do you start her?

- Well, it depends on where she is starting.

So I'll learn a lot about her and figure out what her strengths are, what her limiters are, and kind of build a plan for her from there.

But it will of course include plenty of strength training, a lot of muscle stimulus.

Probably not a ton of real, real, long, long, long endurance event or training events, but you know enough to get her to the finish line and feel good about it.

- And all this will protect her heart as well.

I trust, yes.

So your closing comments, Kari, coming from your background?

- Well, I think it's just wonderful that we're having this conversation.

You know, five, 10 years ago no one was having this conversation.

And the more support women feel, the more questions they ask, the better they're going to get through the transition and feel like productive people and feel like yourself again.

I think that's the important thing.

So thank you for having me and these, I'm learning so much today, it's wonderful, appreciate it.

- It's all about that.

- You also do some work with a new organization called PT Sports Pro.

- Yes, yes, yes.

So I'm a personal trainer for PT Sports Pro and so I am available to help people strength train there.

- No matter what age?

- No matter what age.

- There we are.

- Nice.

- Dr. Hubbard, give us your solution to this thing we call menopause.

First of all, it's an honor to get there, right?

- It is an honor to get there, absolutely.

We're all lucky.

- But there can...

It doesn't all have to be gloom and doom.

- No, definitely not.

And I think that empower yourself to take control and make time.

It's a hard time in many women's lives, right?

We still have kids that need us and a lot of times we have parents, we're the sandwich generation.

So aging parents that require us, busy work life still and so I think that it's very hard to make self-care a priority, and choosing that so that you take time out to speak with healthcare providers to do the regular exercise, whether you're an endurance athlete or you're just a 15 minute walker every day.

But something to stay fit, to choose good health and diet and explore your options so that you can talk to somebody about menopause and what it might look like.

It's a transition.

You know, there can be 10 years of transitional symptoms until you're completely through menopause that might require some tweaking here and there and it's okay, advocate, ask questions, go see somebody that's an expert.

- And we didn't bring this up but we can possibly end with this.

What about for the caregiver?

The partner that deals with menopause?

- I think knowledge, knowledge is power, right?

So educating your partner about what you might be going through, helping them understand how to support you.

And I think, with sexual health, there's so many emotions that can come at play.

If you have a decreased libido from a hormone change or vaginal dryness or pain with intercourse, your partner may feel like there's something wrong or you're not attracted to them anymore and so I think that it's really important to have communication and education about that, mental health issues, physical struggles that you're having at that time.

- All right, how do we find out more about your services?

- Well, I'm at Grand Rapids Women's Health, so grandrapidswomenshealth.com is the best way to find me.

- Right, bringing the babies in, but talking to those who probably are working on their grandkids or early babies or something.

- I know.

- As such, Dr. Bitner I'd say let's play but a family show.

(all laughing) Couple minutes with your summary and again, did you seek out becoming an expert?

Were you that interested in this?

- I was that interested.

I just couldn't not know.

I couldn't not see and I wanted to be able to spend more time and I love to think about the process of care.

You know, I really think women deserve a checklist for their health.

Just like we use the checklist in the OR.

So at True we use a program called Waypoints where we walk through nine to 10 areas of wellness depending on what a woman wants.

And make sure that we understand her goals in each of those areas and how we can support and break down those barriers.

I think it's important we have pelvic floor physical therapy in our office.

Pelvic health is so important in terms of bladder function, bowel function, sexual health function.

So I really wanted to be able to spend that time.

I miss a little bit surgery and delivering babies, but I'm just so honored that women share these very difficult times like Robyn and I know, and when we're together with a patient or a client, it's really a sacred space.

- [Robyn] It is.

- So I just want women to know and partners to know that there is help.

There's a whole village.

Look at all of us talking about this and to make sure they ask for help and don't settle for there's no answer and you just gotta deal with it.

- Great, all right.

How do we find out more about my symptom circle, my sex deck or my menopause practice?

(all laughing) - So truewomenshealth.com and we do a ton on social because we really wanna reach as many women as possible and really wanna work with everyone here in town to support people of West Michigan.

- Right.

- We have patients from-- - Absolutely.

20 with PCO and hormone issues.

- PCO?

- Yes PCOD, polycystic ovarian disease, so irregular periods, infertility, hair growth in places we don't want, all of those things, all the way to 95 and vaginal dryness and bladder infection, so.

- Great, you do it all and you do it well.

Thank you ladies.

- [Diana] Thank you Shelley.

- Thank you for watching this edition of "Family Health Matters".

Take care.

(upbeat music)