Transcript:

Jamie Forward:  Hello, and welcome. I’m Jamie Forward. I’m your host today, and I’m one of the founders of Feminess. This webinar is part of our Evolution series aimed at helping women learn more about perimenopause and menopause. Today we’ll talk about treatment options, how you can make changes to manage your symptoms, and share advice to help you advocate for yourself. We’ve also set aside time for your questions. If you haven’t already submitted your question, feel free to send them now via the Q&A box on your screen. I also want to remind you that this discussion is intended for educational purposes only and should not be considered medical advice

For guidance that’s right for you, please talk with your own healthcare team.

Now let’s meet our guest. We’re joined today by Dr. Peggy Margetson from Trust Women’s Healthcare. Dr. Peggy, welcome. Can you tell us about yourself?

Dr. Peggy Margetson:  Hi, thank you so much for having me. I’m so excited to have this talk. And I can talk about women’s health all day. So, as mentioned, I’m Dr. Peggy Margetsom. I am a board-certified women’s health nurse practitioner and the founder and CEO of Trust Women’s Healthcare with locations in Brooklyn and Deer Park, NY. For those of my New Yorkers that are here, you kind of know we were representing Brooklyn, and we’re also representing Long Island. I opened Trust Women’s Healthcare five years ago because of this reason, because women’s health is definitely under attack, it’s understudied, it’s not represented enough. And I’m just tired of women suffering through conditions that we can help.

So, I am looking forward to having this conversation with you all today. I hope that you tell a friend, bring a friend, and you get some great information.

Jamie Forward:  Well, thank you so much for that, Dr. Peggy, and thank you for what you do at Trust Women’s Healthcare. So, we’ve titled this program Three Ways to Get the Relief and Care You Deserve. I might argue the most important step is to find support and speak up so that you can advocate for yourself. So, let’s start there. For many women, a symptom, or a gut feeling, can tell you that something’s wrong in your body, but they may have never even considered perimenopause or menopause. So, Dr. Peggy, what symptoms might they notice? What’s common?

Dr. Peggy Margetson:  So, that’s a great question. And common is not really such a common thing, right. Because it varies from person to person, woman to woman. I always say that women know exactly what is going on with them. You just don’t feel right. There are 30 plus symptoms that can happen during perimenopause and menopause. However, it can mimic so many other symptoms and other conditions.

So, women are left trying to figure out and go down this rabbit hole as to what is going on with them. They try to talk to friends, family. They even go to their providers. There was research that came out that said that women will go to maybe three to five different providers before they are diagnosed with a condition. And perimenopause is no different. I always say if you are feeling off and that’s what women tend to feel first, something is just not right. It’s in their gut. They’re losing interest. They’re depressed, they’re hot, they’re cold, they’re irritable. They’re feeling different things going on in their bodies, and they just don’t know what’s going on.

So, I always say rule of thumb is what’s common for you may not be common for someone else, but if something is off, it definitely needs to be investigated.

Jamie Forward:  Yeah. Well, thank you for that. And yeah, there’s a multitude of symptoms, and I think you’re exactly right. Feeling off is certainly worth the trip to visit the physician to get the conversation started.

So, just to level set with our audience though, before we move on, can you briefly just define perimenopause and menopause?

Dr. Peggy Margetson:  Sure. So, perimenopause is the transition that happens before menopause. So, I’m going to start with menopause first because then perimenopause will make sense. So, menopause is when you’ve got 12 full months, and again it’s full months, with no period. So, if you’ve gone 11 months and 20 days with no period, and that 21^st day you get a period, it starts all over again. And that is perimenopause. Perimenopause is that transition before your last menstrual period. It can happen seven to 10 years. And in Black women and women of color, it’s more severe, and it lasts a little bit longer. And it’s just a multitude of symptoms because your ovaries are, it’s like a hill. It keeps going up and down.

And there is just a multitude of symptoms.

And some may get all, some may get some, some may get one. But it’s that transition that just feels not normal for you.

Jamie Forward:  Well, thank you for that explanation, Dr. Peggy. That’s really helpful. So, I’d like the audience to respond to the poll we just put on screen. We’re curious if our viewers are getting care from a menopause specialist. So, Dr. Peggy, what does it mean to be a menopause specialist?

Dr. Peggy Margetson:  Wow. Okay. So, menopause is not new. It’s a natural transition that women have been going through since the beginning of time. When you say specialist, training is — specifically in my training, we did not discuss all that menopause and perimenopause endures and happens. We maybe got maybe an hour lecture. No one really focused on it. So, being a menopause specialist, it’s really the continuing education that I have seeked out, and many others, to really hone in on what is going on during midlife.

So, a menopause specialist is 1.) I think is passionate about this space, right. I think that the passion will be seen throughout the visit. Also, has done countless, countless hours of continuing education conferences, reading papers, and also within the patients, listening is very important. And also with a menopause specialist, it’s invested into your care and your health beyond the reproductive years. So, I think that that’s important to know as well. And just someone that is fully versed in perimenopause and menopause. And not all your providers are, even though they’re OBs, they’re GYNs, they’re primary care.

And I always say give providers some grace because this education was lacking in a lot of our training.

Jamie Forward:  Yeah. Well, thank you for that.

And as you can see from our poll results here, more than 60 percent of our audience is not receiving care from a menopause specialist. So, getting the right care for women is so challenging, right. So, what circumstances can mitigate access to care, and how can we overcome them?

Dr. Peggy Margetson:  So, that is the very reason why I opened Trust Women’s Healthcare because of the lack of access. Women’s health, as I said before, is under attack. Women are dismissed and ignored. And specifically, are Black women. And so, that’s why a lot of our symptoms are ignored and dismissed. Barriers to access can be long wait times. It can be in lack of insurance, especially within certain demographics, certain areas. Between Medicaid, a lot of providers and places don’t accept Medicaid. We happen to do that because I believe that women should receive good care regardless of their socioeconomic status, regardless of their financial status, and regardless of their insurance.

So, I think that that’s really, really important. But there’s just a lot. Transportation. Remember, women, we’re the centers of the family. So, we are caring — we’re in the sandwich generation. Many of us, we’re caring for our parents, we’re caring for our kids. So, that all comes with access. You may not have the time. And we tend to neglect ourselves. So, it’s multifactorial. I wish it was one thing, but there are just so many barriers to care around this midlife and finding the right provider that be able to fit into that box may not happen.

Jamie Forward:  Sure. And I think that really starts with putting yourself first, right. I think that’s the first sort of barrier and for a lot of women. So, yeah.

Dr. Peggy Margetson:  Absolutely. We have to be selfish. And I said, if you’re not good, you cannot be good for anyone else. You have to take care of yourself first. They always use the analogy when the plane is losing cabin pressure, they always say put your mask on first, and then you help others. It’s kind of the same thought.

Jamie Forward:  Sure. And you mentioned this, but what about for women that don’t have insurance or easy access to good care? So, are there resources available? Can you just think of any resources off the top of your head that might be useful to anyone watching, or something they can share with a friend?

Dr. Peggy Margetson:  Absolutely. So, the Menopause Society, they have a great tool where you can find a provider that is menopause-trained, that is a specialist. You just literally go on their website, put in your ZIP code, and it’ll show a plethora of providers. There are telehealth as well that is afforded to you. And then also, social media is a blessing and a curse. Social media is a good search engine. And so is YouTube. So, I think finding those will be very helpful, and it’s a great start. Also, your friends are going through this. Women are suffering in silence. I can’t tell you how many patients come to me and say, “Wow. I didn’t even know my friend was going through this until I started talking about it.”

So, within your circles, within your organizations, someone will be able to refer you. We’re good at referring and telling where we’ve gotten our hair done, or getting nails, or getting an outfit. But no one wants to share where they receive care. That is all part of it. And if you’re receiving good care, you have to share that information.

Jamie Forward:  Yeah. And I would argue that women do want to share that, right. I just moved recently to a new city, and I reached out to a friend I have here and said, “Give me all your doctors.” And so, it’s worth an ask for sure. But speaking of social media, what are some of the myths you hear from women that are coming from social media? Do you hear anything more often than not?

Dr. Peggy Margetson:  Oh, absolutely. How much time do we have?

Jamie Forward:  Right. Yeah.

Dr. Peggy Margetson:  So, I hear that menopause is just a short phase, it will pass.

Jamie Forward:  Sure.

Dr. Peggy Margetson:  I hear that hormone therapy causes cancer. I hear that after age 60 you can’t use any hormone therapy.

I hear that menopause is only hot flashes. I hear that you just have to bear with it. There are no treatment options. What else do I… I hear everything. The amount of things that also women are using because also during this time, there are a lot of vendors, products that are trying to monetize off of this time and off of the insecurities of a lot of women, of what they’re going through. So, they will try so many different over-the-counter products before they see a provider. And I say you don’t have to do that. We’re here. We want you to come in and talk to us.

Jamie Forward:  Yeah. Well, thank you. That really points to the fact of you being here. Thank you for taking time out of your day so people hear directly from a menopause specialist. I feel like that’s something that some women may not have ever even talked to or heard from one. So, that’s why something like this is so important.

But beyond getting support from a clinician, women also need the support of their loved ones. And you really talk about this so beautifully. So, their partners, family members, even their workplace. They need to communicate what they’re going through and ask for support. So, how can they best do that?

Dr. Peggy Margetson:  So, that’s the reason why I also created the Menopause Connection because this transition is not just about the individual. It’s about the families. It’s about the community. So, everyone needs to be real educated as to what is going on with midlife. So, let’s start with home.

Jamie Forward:  Sure.

Dr. Peggy Margetson:  Having that real conversation with your partner as to what is going on because again, your partner, they want to help. They want you to feel better. But if they don’t know what’s going on and having that open and honest conversation, they can’t help you. Also, bringing your partner to the visits with you. Maybe hearing firsthand what is going on. And I encourage that at my practice that I see a lot of couples coming together.

And I also educate because sometimes not to say your partners don’t believe you, but sometimes they don’t believe you. It’s just fact. But I think hearing it from a clinician, and then also they may have questions that you may not be able to answer. Also, talk to your children about it. Sometimes mommy may not be in the mood.  Or mommy may have an off day. Be honest with them because your families are blaming themselves for what is going on. And again, a lot of women are suffering in silence, and having that real conversation also, it scares them. Also, with sex and intimacy, having that real conversation. Midlife looks very, very different.

You have to redefine what that looks like for yourself first and your relationship. Also, when it comes to the workplace, there are a lot of companies now that are implementing menopause policies.

So, definitely speak to human resources to see what policies that their company has for you. It can be something as FMLA, maybe keeping the temperature down so that it’s not hot. And then also just a common…I know there are some companies that have respite rooms where if an individual is having a moment, they can go to that quiet room and collect their thoughts and just be by themselves while they collect themselves. There are a lot of resources. I think that 1.) Identifying what you need in order to feel supported and what that looks like. And also knowing that your family, they want to be there to help you. And we have to include them into the conversation.

You do not need to do this alone.

Jamie Forward:  Yeah. Well, if a partner wants specific advice for how to be supportive, what’s the most important thing that you would tell them?

Dr. Peggy Margetson:  One, come to the appointments.

If your partner is going to their first appointment, definitely come with them. Also, educating yourself. There are some great resources out there. The Menopause Society, I can’t mention them enough. They have some great resources. I know I have some blogs on my website as well as my social media in terms of how partners can help. And then asking the question, what can I do to help? It can be something as simple as if she has been asking you to clean out that garage for months. It can be something as simple as that. And then jotting your questions down, so when you go to the appointments, you’re able to address it as well. And then you can speak to your provider. Speak to your provider.

Maybe speak if available, if you have sisters, a mom, maybe you can speak with them and how you can best support your partner as well.

Jamie Forward:  Yeah. That’s really great advice. So, once women have access to the support they need, or they’re doing better about speaking up, the next way to get relief is to understand their treatment options.

So, Dr. Peggy, what options can provide reliefs? Let’s start with hormone replacement therapy.

Dr. Peggy Margetson:  Okay. So, hormone therapy, which it’s been called menopause hormone therapy, it is the most effective treatment for perimenopause and menopause symptoms. Perimenopause is a diagnosis of exclusion. You can get hormone therapy during perimenopause, but again, we want to make sure that there is nothing else going on in the body that are causing these symptoms. Hormone therapy looks like many different things. There is estrogen, which is estradiol. There is progesterones, or progestogens that actually help. There is also testosterone. No one thinks that women make testosterone, but we actually do. It’s not as much as men, but we do make testosterone.

Specifically, estrogen is responsible for thermal regulation.

We have estrogen receptors all over the body. So, when you’re going through perimenopause, the hormones are declining. So, one day you may feel well, one day you won’t. But the symptoms are as a result of it. So, estradiol or estrogen is very, very important. It comes in many different forms, whether it’s an oral tablet, a gel, a patch, a mist, a vaginal cream. And if you still have your uterus, you must be on a progesterone as well. Progesterone, I say is your sedative hormone. It’s the one that helps you sleep. And it’s the one that helps you relax, and you’re not as irritable. But I also do prescribe it for women without a uterus because of the benefits. And they also come in injections.

That is an option as well. And testosterone is usually responsible for our libido, our energy, our muscle mass. It can come in a topical cream. It could come in an injection. There are some providers that do pellets. So, it’s really educating on what hormone replacement is effective based on your symptoms because you may have symptoms where you may not need estrogen at this time.

Maybe you may need to start up with testosterone. So, it’s important to talk with your provider regarding it. Hormone therapy is safe. There are some contraindications with it and that’s when you speak to your healthcare provider, but for relatively it is pretty safe. Side effects, every medication has side effects. But most importantly, hormone therapy does help with prevention against your bones, your heart, your mind. So, it’s not just the symptom management, it is also the prevention piece that we forget during this midlife. Estrogen is our superpower, it’s our protector. It protects our heart, it protects our bones, it protects our mind. So, when we lose it, what’s protecting it?

And that’s why heart disease sets in. That’s why bone disease sets in. So, it’s something to really consider. But for those who are just scared or can’t take hormones, there are non-hormonal options.

And they actually help with just symptom management only. It doesn’t help with the prevention. It can vary from medications to antidepressants. There are pain relievers like gabapentin that does help with hot flashes. And then like I mentioned there are supplements that help with symptom management only. And that will reduce some symptoms by 30 percent. So, as you can see, you don’t need to suffer through this because again, remember, seven to 10 years is a long time, but it’s important to speak to your healthcare provider, specifically one who’s really versed in this space to give you the different options that are afforded to you.

And together, you need to decide what your menopause journey, what do you want it to look like? And I asked that question every time women come in. What do you want it to look like? Yes, you want to feel better, but that’s important in the treatment options that we recommend.

Jamie Forward:  Okay.

And we’ll get into sort of what you can do a bit later in the program. But obviously there are options, right. There’s hormonal. I know that I have friends that just had bad experiences with birth control many years ago and are just opposed, so the fact that there are non-hormonal options is so promising. But before we talk about what happens once you start getting treatment, we have another poll for the audience. So, we’re asking if viewers are confident if they’re receiving good menopause care. So, Dr. Peggy, how do you know if you’re getting proper care?

Dr. Peggy Margetson:  So, receiving proper care is when your questions are answered. You leave that appointment feeling good. You feel that you have a wealth of knowledge. You are feeling confident that you can get through it, unless you have the brain fog. And sometimes when you leave the office, you’re like, okay. What did they talk about? But for the most part, you leave that appointment feeling confident.

You feel reassured. And then if treatment options are prescribed to you or recommended to you, as you start with in the treatment options, you start to feel a little bit better. If you’re having any type of adverse effects or side effects, you’re able to contact your provider, you’re able to get an answer. So, it’s the communication. And also, the follow-ups. When are you getting a follow-up appointment? Usually in my practice, we do our first follow-up two months because specifically with estrogen, it can take sometimes four to eight weeks to work. So, getting a follow-up but also knowing that you can follow up at any time, you don’t have to wait till that two-month appointment.

So, getting good menopause care is based on the individual needs. And it’s really you feeling like you were heard, and you weren’t dismissed, and that you left with a clear plan that you are okay with, and that’s attainable.

Jamie Forward:  Yep. Okay. Well, it seems about more than half of our audience either are not receiving good care, or they don’t know if they’re receiving good care.

Dr. Peggy Margetson:  Oh, no.

Jamie Forward:  But I think that’s why they’re here today, right.

Dr. Peggy Margetson:  Yes.

Jamie Forward:  So, I think part of getting good care is advocating for yourself, just like you talked about. So, communication comes on both sides. So, Dr. Peggy, what questions should women be asking about their treatment options?

Dr. Peggy Margetson:  So, first and foremost, when you are going to your appointment, we may not be able to cover everything in one appointment. Sometimes it is the time constraints, it can be that we need some follow-up, some preventative screening tests need to be done, some blood work. So, just know that the expectation is you may not leave with a prescription in hand. Also, jotting your questions down before you get there. It is important to know…everyone has a smartphone. If you like the paper and pen, jot down the symptoms that you’re having as you’re having them, when you’re having them.

Knowing what your numbers are, your baseline numbers, your blood pressure, your heart rate, maybe getting your labs done. So, again, remember, I say a lot of these symptoms mimic other conditions. So, going to whether it’s your primary care or another specialist, having your blood work that you just had drawn, having access to it, or bringing them with you. Knowing your family history. So, I think if you have all of those jotted down, it will be a succinct and really good appointment because you’re getting all your questions answered. Because I can’t tell you how many times patients come into the room, and sometimes there’s the anxiety.

You’ve been suffering for such a long time, and you just don’t know what to ask. And you draw a blank. I come in the room and they’re like, “I had questions. I don’t know what they are.” Thankfully, we ask questions, but sometimes we don’t know what’s in your head or what’s going on when you’re at home.

So, we may not ask the question related to the symptom that you’re having or concern that you may be having. So, jotting that down before your appointment is key. Bringing a support person. Because they may be able to fill in the gaps that you were probably not seeing. I had a patient one time she came in with her partner, and I asked her, I said, “Are you irritable?” And she said, “No. Not at all.” And her husband turned around and was like, “Yes, she is. She is more irritable than usual.” And she was like, “Wow. I didn’t even realize that.” You may not realize things are going on.

And then once you’re able to bring all of your questions, your records is great as well — we love records — having that conversation, making sure your preventative screening is up to date and what your expectations are.

Jamie Forward:  Yeah.

Dr. Peggy Margetson:  And then I think that’s a good starting point.

Jamie Forward:  Yeah. Really, that will help you to maximize the time because we’re all sort of working on limited time.

So, yeah, just sitting down and taking a few minutes or even just jotting down in your notes app before you get there.

Dr. Peggy Margetson:  Absolutely.

Jamie Forward:  Yeah. So, once you’ve started therapy, how long does it take to get relief?

Dr. Peggy Margetson:  Well, it depends on the therapy that you’re on. So, if women are on hormone therapy, specifically estrogen can take four to eight weeks to really feel the full effects.

Jamie Forward:  Right.

Dr. Peggy Margetson:  Depending upon the dosage, depending upon the route. Progesterone, you may feel it a little sooner than the four weeks. Testosterone takes a longer time to work. Sometimes it can take three to six months. But again, that’s questions that you should ask, and that’s the answers that the providers should give you once a medication is prescribed. Supplements may take a little bit longer. Also, consistency. How consistent are you with the medication regimen? Many times, women come in, it’s like, “Oh, I forgot to put this on. I forgot to take this medication.” So, being consistent is important.

And also, again, it depends. Some symptoms, some relief happens sooner than others. Again, you can’t compare yourself to your loved ones or your friends because everyone is different. They may be able to give you an idea, but don’t feel like something is wrong with you because you’re not in the same path or the same relief timeline as someone you know.

Jamie Forward:  Sure. Well, I think that’s such a great point. And I guess it’s the thing of how do you know if it’s working? It feels like if you’ve got the hot flashes and night sweats under control, but then you’re still having some brain fog, what’s really the barometer for symptom management? What’s the threshold? I guess it’s really about setting a goal with your doctor too, so I’m going to…

Dr. Peggy Margetson:  Absolutely. So, what I do is when I have that initial appointment with a patient, we kind of go through all the symptoms. And let’s say I prescribe a treatment option. Let’s use hormone therapy, for example. They come back two months later.

I first ask them, “How are you doing?” And they’re like, “Okay. Well, I’m doing better.” So, then I go back to the first visit, and I said, “On the first visit, the initial visit, you reported XYZ symptoms.” And then kind of going through, “Is this better? Is this worse? Do you get symptom management?” So, really going back. So, I go back with the initial visit because that gives us 1.) It refreshes your mind. Again, it tells me whether you’re getting symptom relief. And then also, it gives me the opportunity to present to you if we should increase the dose, maybe we should try a different management, or if it’s not working at all.

So, it’s really important to again, jot down your symptoms because you’ll know if you are feeling better. And most often, women do feel better when they’re on these management plans. But again, it’s that conversation, that follow-up. And I also know when women are feeling bad when I don’t see them.

Jamie Forward:  Right. Yeah. Yeah.

Dr. Peggy Margetson:  I don’t see them.

Jamie Forward:  Right. And that’s kind of what I was going to ask you, what you’ve really sort of touched on is what does follow-up care look like once you’ve chosen a treatment? And it sounds like checking in after two months. And then after that, is it six months and then maybe a yearly check-in?

Dr. Peggy Margetson:  Sure. So, my office provides preventative GYN care as well. So, I will do the initial visit, two-month follow-up. So, the two-month follow-up is to really see how you’re doing. If you’re doing well, we don’t need to make any changes. Then I see my perimenopause and menopause patients twice a year. If we are not quite got to the treatment plan that is right for you, we will meet and have a follow-up monthly, every two months, every three months until you are feeling well. And at some point, if you’re not, we need to explore other options.

Jamie Forward:  Okay. That’s great advice. This is a bit of a moving target, so it’s going to take time, it’s going to require some patience.

Dr. Peggy Margetson:  Absolutely.

Jamie Forward:  Let’s move on to the third way to get relief. So, focusing on what you can control.                                 

Sometimes, of course, we hear often about exercise, in all aspects of life as being very beneficial. So, how can that help you during the menopause transition?

Dr. Peggy Margetson:  So, I always say I wish I had one magic pill that would do it all. But, unfortunately, we don’t. The medications, supplements, non-hormonal therapy, all of that will do will get you but so far. But it’s important for lifestyle modifications. How are you eating? Exercise, strengthening those bones, strength training. There are other things. Maybe you might need therapy. You might need again, wellness care, having that self-care day. There’s acupuncture, there’s hypnosis, there is vacation. There is not just one thing that will help you during this time, so incorporating what you can. And I want to be realistic because no one is saying you have to do all of these things.

You have to figure out what is best. But at the very minimum, there should be some exercise at least three to four times a week because again, you’re getting older. We need to work out that heart. We need to strengthen those bones. And you could work out in your house.

Jamie Forward:  Right.

Dr. Peggy Margetson:  You don’t need to join a gym. You don’t need to go to Pilates studio. What could you do? You can put a YouTube video on. Diet. There are nutritionists that can help you. You don’t need to do this alone. There are nutritionists that can help you pair food because remember, during this midlife, there is a redistribution of fat. So, you’re gaining weight that you probably have never gained before. So, really knowing what foods to pair together will definitely help you.  Those are the minimum amount things that you should do. And then everything else, you can add on as needed.

Jamie Forward:  Yeah. And I don’t think anybody here watching or otherwise has ever not heard that exercise will help.

So, I think that that’s just the thing that exercise and diet really impact everything. So, we’ve been talking about things you can do, but I think symptom management is important for long-term health. So, why is it…you don’t have to white knuckle it and you shouldn’t. So, why is it so important to get symptoms under control?

Dr. Peggy Margetson:  Because it’s specifically hot flashes can exacerbate certain conditions. So, for example, if you have high blood pressure, not controlling your hot flashes can make your blood pressure worse. Making your blood pressure worse can lead to heart disease sooner rather than later. Also, feeling better. There was a study that came out also that said that hormone therapy reduces the risk of dementia. So again, getting that estrogen back into the brain. Also, osteopenia and osteoporosis.

If you don’t address these symptoms sooner, then that puts you at risk for bone loss. We all know our seasoned women that have had a slip and fall and broke a hip. Whereas our 20-year-olds can fall down a flight of stairs, and they get up feeling fine. And it’s because of the bone loss. So, again, it goes back to the preventative state. We don’t have our protection of estrogen. So, we need to manage those symptoms, whether it’s hormone therapy or other management options so that we can prevent a lot of the cardiovascular, the diabetes, the osteoporosis. So, there are so many other conditions and complications that can come from lack of symptom management.

Jamie Forward:  Yeah. I think that’s such a great point to really just try to get ahead of anything that you might see in the future. So, well, now it’s time for Q&A. So, if you haven’t already submitted a question, you can submit it anytime in the Q&A box on your screen.

And we’re going to try to get to as many as we can. This is what I got before the program. Kim said, “I hear a lot about bone density being affected during menopause. When should I have a bone density scan?”

Dr. Peggy Margetson:  As soon as you start having these perimenopausal symptoms.

Jamie Forward:  Okay.

Dr. Peggy Margetson:  It’s just because the literature and the guidelines say 65. By age 65, you could potentially have some bone loss.

Jamie Forward:  Sure.

Dr. Peggy Margetson:  So, really when you start to feel those symptoms, just getting a baseline would be very, very helpful. And then also, there are things that can decrease our bone density. So, being on certain birth control like Depo Provera when you were younger, that could have done that. If you have an eating disorder, that can decrease it. So, we don’t know what your bone density looks like without this baseline. So, speak to your provider regarding getting a referral. And it’s not painful. You just lay down, and there’s a scan of your bones.

And it takes literally five minutes.

Jamie Forward:  Okay. And you can ask your primary care or your GYN.

Dr. Peggy Margetson:  Yes. You can ask any of your providers to give you a referral for it.

Jamie Forward:  Okay. Great. That’s good to know. I’ll put that on the list. So, Sharon sent in a question as well. She wants to know what age is too old to start hormone replacement therapy.

Dr. Peggy Margetson:  So, after age 60, and this is based on the literature, we start to look at risk and benefits. I’ve had 60-year-olds, I’ve had 70-year-olds come in and feel cheated out because now this craze about hormone therapy, and they felt like they missed out. So, it’s really having the conversation about based on what does their current health look like, what are their symptoms, and then also the prevention piece. So, that is a conversation you have, but there is no absolute after a certain age you missed out. That is the old school thinking that once you reach 60, that you can’t be prescribed hormone therapy.

I think it is a conversation to have with your provider and then together to make that decision. I have my 79-year-olds that you couldn’t pry it out their hands even if you tried.

Jamie Forward:  Well, that’s good to know.

Dr. Peggy Margetson:  Yes.

Jamie Forward:  So, we received this question from Jill. Does placement of the estrogen patch matter? Is there one area that’s better than another for absorption?

Dr. Peggy Margetson:  That’s a very good question. I get that very often. I have patients, again, you put the estradiol patch lower abdomen or buttocks. Sometimes on your side, by your thigh, by your hip. I’m sorry. It depends. Absorption looks different for everyone. I always say rotate it to see which one gives you best absorption. I have patients that say if I put it on the right butt cheek, I don’t get as well of absorption as a left butt cheek.

I don’t know. Again, this is what I’m reporting. So, it all depends on what it looks like. Remember, it’s put on where there’s subcutaneous fat. So, if you don’t have as much, it won’t be absorbed. So, again, it’s trying all the areas out. And then sometimes the patch may not work for absorption for some women. It just doesn’t. So, that’s something that you talk to your healthcare providers regarding different methods and different routes.

Jamie Forward:  Yep. Okay. And yeah, on the last part program, we talked a little bit about the estrogen patch shortage. And so, women have been kind of forced to switch to a gel or otherwise. So, that’s good to know as well.

Dr. Peggy Margetson:  Yeah.

Jamie Forward:  So, Dr. Peggy, this one comes from Michelle. She says, “What role does the birth control play when also using the HRT patch?” I’m assuming she’s referring to estrogen there.

Dr. Peggy Margetson:  Correct.

Jamie Forward:  “I’m perimenopausal, and I only bleed when I forget the pill.” Can you talk about that?

Dr. Peggy Margetson:  Of course. Of course. So, first I will say that during perimenopause you can still get pregnant.

Jamie Forward:  Okay.

Dr. Peggy Margetson:  That is a thing. So, I’m assuming that if you’re on the estradiol patch, you’re on a progesterone-only birth control. You should not be on an estrogen and progesterone birth control pill with the estradiol patch. So, if you are, you need to clarify that with your provider.

Jamie Forward:  Okay.

Dr. Peggy Margetson:  So, that’s the role that it plays. Remember I said progesterone. If you still have a uterus, it protects the uterine lining. And it’s an oral. Micronized progesterone has some benefits, but if you’re perimenopausal and you’re still sexually active, you can get pregnant. So, we will prescribe estradiol in the different forms, and it’s a progesterone-only birth control to not only protect the lining but also prevent pregnancy. Yes. Progesterone-only birth control, you have to take it the same time every single day. If not, your body’s looking for it, and it will start to shed and have your period.

Jamie Forward:  Okay. Okay. That’s great. Really good information. Important to note there. So, we received this question from Abby. She said, “I’ve recently read that perimenopause can aggravate and/or cause tinnitus, which is ringing in the ears. What can you do about this symptom?”

Dr. Peggy Margetson:  That’s a biggie, the ringing of the ears.

Jamie Forward:  Sure.

Dr. Peggy Margetson:  So, again, remember perimenopause diagnosis of exclusion. I can’t stress that enough because we’re having this conversation everybody. I don’t want you to just think that, oh, it’s perimenopause. So, if you’re having tinnitus, ringing in the ears, it’s important that you see your primary care, you see an ENT to make sure that there’s nothing going on. Hormone therapy can help with it as well, believe it or not, because it is a symptom. But sometimes, it takes a while that ringing in the ears just definitely just happened. So, if I have a patient that is controlled on hormone replacement therapy, is still getting the ringing in the ears, I do send them to ENT for some relief.

Jamie Forward:  Okay. Great. That’s good to know. So, Stacy sent in this question. She said, “It’s so hard to perform at work sometimes when I’m not sleeping well or can’t remember things. Any advice on what we can do to help with this?”

Dr. Peggy Margetson:  Sure. So, again, I’m going to start with the non-hormonal now, and then I’ll go to the hormonal. So, if you are not getting any sleep, what do your sleep patterns look like? So, we have to look at that first. Are you drinking any caffeine close to bedtime? Do you have the TV on? Do you have your phone and you’re hearing the text message come in? What do your sleeping habits look like? So, I think that’s important for you to really evaluate that.

Jamie Forward:  Okay.

Dr. Peggy Margetson:  Now, there are supplements like magnesium glycinate that can help with sleep. Is the room warm? Maybe looking at the blankets you’re using, the temperature. So, looking at those as well.

If you don’t get enough sleep, you’re not going to function the next day. You’re going to be fatigued. But then also during this transition, although you’re getting sleep, you’re not getting that deep REM sleep where it allows you to really, really get into that zone and really get rested. That’s where hormonal therapy, progesterone, specifically micronized progesterone comes into play. Women get the best sleep sometimes and it’s a deep REM sleep. The dreams may be a little crazy, but micronized progesterone does help with sleep. And what was the other? It was sleep and something else.

Jamie Forward:  And remembering things.

Dr. Peggy Margetson:  And the brain fog. The brain fog is a biggie. Again, making sure there’s nothing going on. I do send women to neurology even though I probably think that it’s perimenopause and menopause. But I do send them to neurology. And estradiol specifically helps with brain fog. Women tend to feel a little bit clearer.

Again, sometimes you might need to jot things down on your phone. Some things are just age-related. It just, it is what it is. We’re going to forget things as we get older. But if it is really impacting your work and your life, then definitely we need to get some management in so that you can function and be able to really feel like you’re clear and you’re able to function during the day.

Jamie Forward:  Yep. And I always like to remind people, and we’ll have a program posting about this next weekend or next week with a reproductive psychiatrist. But the brain fog does go away.

Dr. Peggy Margetson:  It does.

Jamie Forward:  And the cognitive thinking comes back. So, we’re just remodeling right now.

Dr. Peggy Margetson:  Absolutely. And when it goes away, you feel great. And you couldn’t believe how much that impacted your life.

Jamie Forward:  Well, that’s good to know. Something to look forward to.

Dr. Peggy Margetson:  Yes.

Jamie Forward:  We got this question online. So, what do you think about chronic fatigue in someone on full HRT?

Estrogen patch, testosterone cream, and progesterone oral. So, it sounds like experiencing chronic fatigue.

Dr. Peggy Margetson:  So, chronic fatigue. So, remember, progesterone also is a sedative hormone. So, depending upon the dose of progesterone you’re on could cause fatigue the next day. So, progesterone comes in 100 milligrams, 200, 300, 400. So, depending upon what your dose is, you may need to look at that. Also, if it’s chronic fatigue, what are your other labs looking like? Again, hormone therapy will do, but so much.

Jamie Forward:  Sure.

Dr. Peggy Margetson:  So, we need to investigate as to why do you have this chronic fatigue? Did you always have it? What do your numbers look like? Are you anemic? What is your diabetes risk? Again, there’s sometimes that, again, we need to investigate a little bit further because if you’re on all hormone therapy, estrogen, progesterone, and testosterone and you are not feeling better, then it may not be hormonally related.

Jamie Forward:  Yeah. And I would like you to sort of reiterate, this is something you and I spoke yesterday, but we were talking about making sure that you’re ruling out everything else.

So, before you prescribe, what do you require?

Dr. Peggy Margetson:  So, I require an up-to-date preventative screening. That looks like your cervical screening, your Pap smears, your mammograms. That’s very important. I do not start anyone on hormone therapy until they’ve had an up-to-date mammogram.

Jamie Forward:  Yep.

Dr. Peggy Margetson:  And again, hormone replacement therapy doesn’t initiate cancer, but if you haven’t had a mammogram in years, there can be an active malignancy going on. Me giving you hormone therapy can exacerbate that. So, I absolutely recommend that before starting hormone replacement therapy. Again, colonoscopy, making sure you’re up to date on that. Your labs, I want to see what your hemoglobin is. Are you anemic? What is your thyroid function? Because again, especially if you’re coming to me in perimenopause, I want to try to rule out as many things that can possibly be causing your symptoms.

Are there some women who have thyroid disorder that is newly diagnosed? That can be causing a lot of their fatigue, their weight gain. So, looking at your vitamin D levels. I’m in the Northeast. We are all deficient in vitamin D. So, vitamin D is very important. So, what does that look like? Look at your diabetes risk. If you’re now prediabetic or you have now developed diabetes, that can cause a lot of the symptoms. I look at your hormones, and I want to just spend just a minute on this.

Jamie Forward:  Yeah.

Dr. Peggy Margetson:  I get a lot of women come in and say, “I just want to check my hormones.” Hormone checking during perimenopause does not confirm the diagnosis. It’s just information.

Jamie Forward:  That’s right.

Dr. Peggy Margetson:  So, if your provider, again, your provider should explain why checking hormones may not be indicated. I do it because of information, but it’s not going to confirm your perimenopausal symptoms. It may confirm menopause if you don’t have a uterus and see what your ovaries are doing, but your estrogen levels during perimenopause, they fluctuate.

If I take your blood work today, your estrogen levels can be 900. Next week, it could be 10. So, just to know that they fluctuate, and it’s not a good barometer of where you are in your perimenopausal journey. I also look at your testosterone levels. I looked at your prolactin levels. I look at your sex binding globulin hormones. I look at your…there are so many things that I look at because again, I want to make sure that we are ruling out as much as we can before we say it’s perimenopause. And sometimes it can be perimenopause and something else. It doesn’t necessarily mean that you’re not. We just rule that out because you have another condition. But again, it’s the workup that’s really, really important.

Jamie Forward:  Okay. All very important to remember and take into account when seeking care. So, I just also wanted to just touch, we’re kind of going back to social media and stuff.

What is the role of vaginal estrogen in care?

Dr. Peggy Margetson:  Oh, I love vaginal estrogen. It’s a goodie. I think everybody should be on vaginal estrogen.

Jamie Forward:  Okay.

Dr. Peggy Margetson:  Yes, absolutely. So, what happens during perimenopause, menopause, the vaginal tissues start to lose estrogen. Losing estrogen, it loses the elasticity, it loses the lubrication. So, women will find themselves, they have vaginal dryness, painful intercourse. They will also feel increase of the pH, like an odor, a vaginal odor where they are questioning their hygiene. This is all called the genital urinary symptoms of menopause. So, vaginal estrogen, which is very safe and pretty much anyone can be on vaginal estrogen, it can come in a vaginal cream, or a vaginal tablet, or a vaginal ring. And what that does is reintroduces the estrogen to the vagina. It is local.

It does not get systemically absorbed.

Jamie Forward:  Okay.

Dr. Peggy Margetson:  So, just because you’re on vaginal estrogen doesn’t mean it’s going to help with hot flashes.

It won’t.

Jamie Forward:  Okay.

Dr. Peggy Margetson:  Because again, it’s local to the vagina, even though I think that maybe there’s a small amount that does get absorbed. But it’s not going to help with the protection you need systemically. It also reduces, very important, urinary tract infections. That is very, very important, especially for our seasoned women. I think that if you are in menopause, you should absolutely be on vaginal estrogen. Urinary tract infections can cause sepsis, it can cause death, and this is one of the things that can reduce that risk.

Jamie Forward:  Right. And once you start getting UTIs, it kind of doesn’t stop, right.

Dr. Peggy Margetson:  Yeah.

Jamie Forward:  So, getting ahead of it as we’ve been talking about, getting ahead of it.

Dr. Peggy Margetson:  Correct. And then there are some urinary tract infections that are not diagnosed in time. And then it can lead to a kidney infection. And then it’s a cascade of you on antibiotics, you’re going into the hospital. And vaginal estrogen will help with that. And again, it’s covered by insurance.

Please have your providers, if you know anyone in menopause, or your seasoned women in your life, everyone should be on vaginal estrogen. That’s the PSA for today.

Jamie Forward:  Okay. Well, thank you for that. And thank you to our audience for submitting such wonderful questions. And, of course, Dr. Peggy, thank you for your thoughtful responses. So, as we close out our webinar today, what would you like the takeaway to be for our audience besides what we just talked about?

Dr. Peggy Margetson:  The takeaway is you are not crazy. You’re not losing your mind. What you’re going through is natural. It is a natural part of life. Any person born with an ovary will go through this. Listen to your bodies. Find a provider that will help. If you cannot find one, we listed the resources. If you go to a provider and you feel like you’re not being heard, you’re being dismissed, find another one. It can be frustrating. I’m not going to lie. It can be frustrating. But there are providers like myself, and my team that want to help you.

And then also, do your research. I think it’s important to know what’s out there and what you want your journey to look like. It’s shared decision-making. We will recommend, but ultimately it is your decision on how you want your care, what you want it to look like. And just know that you do not have to bear through this alone. You don’t have to bear through it. Most women, a lot of women, spend a third of their life in menopause. That’s a long time. So, you figure if your last menstrual period was at 45 and you live to be 99, that’s a long time, right.

Jamie Forward:  Yeah.

Dr. Peggy Margetson:  And I hope this webinar was helpful. And please share it with your circle. And just know that it is a community, and that you all are not alone.

Jamie Forward:  Yeah. Well, thank you for that wonderful message, Dr. Peggy. And again, thank you for being here and sharing your expertise with us. I’d also like to thank our partners, including Dr. Peggy’s practice, Trust Women’s Healthcare, as well as our friends at Women’s Health Advocates for spreading the word about this webinar.

And, of course, I want to thank our sponsors, Astellas and Bayer, whose support helped make this educational program possible. If you’re looking for more information and women’s health resources, visit our website at Feminess.org, and click on “Learn.” And please make sure you fill out the survey that follows this webinar. We’d love to hear your thoughts. I’m Jamie Forward. Thanks again for being here.