Pauline (00:00)

how do you know if it's perimenopause or if it's just Tuesday?

Stephanie T. McNally, MD (00:05)

That's where a very delicate dance needs to happen with a clinical team. And you know, the pendulum was we don't talk about this stuff, this doesn't exist, and now it's all based on it, this is what it is. there are physiologic changes that occur in bodies that are not necessarily specific to estrogen and progesterone.

Pauline (00:46)

Hello and welcome back. I'm Pauline Walfisch here with my faithful co-host Megan who's gonna introduce our guest and I am so grateful to have her here today because gonna talk about something near and dear to my heart these days. Megan, would you do the honor?

Megan (01:06)

Yeah, well, so today I have a bit of an ulterior motive in asking our guests to join us today. So maybe it's something to do with reaching my mid forties and feeling like I've entered somebody else's body, but

I figured maybe there's a few others out there that also are experiencing some of these fun changes. A little night sweats, maybe unexpected weight gain, some thinning hair. I don't know. But if it does sound familiar to you, keep listening because today we have Dr. Stephanie McNally as our guest. And Dr. McNally is the medical director at the Katz

Institute for Women's Health, located on Long Island in the New York metropolitan area. And she's also the system director for the Center of Menopause and Midlife Health, where she works to create standards of care for the treatment and research of perimenopause and menopause. So today we've asked her here on the podcast to talk about perimenopause and menopause. What are these symptoms? What are some new understandings around it and how women can seek

support that they

Need instead of suffering through the symptoms alone.

So, thank you so much for joining

Stephanie T. McNally, MD (02:26)

Thank you guys for having me.

Pauline (02:28)

this is gonna be so much fun. I should just sit back.

Megan (02:31)

Ha ha ha.

Stephanie T. McNally, MD (02:33)

It and you already alluded to some of the symptoms. So every part of your body has an estrogen receptor. So anything that estrogen can touch, as those estrogen levels decline, you're gonna notice a change. And this perimenopausal transition is so different for so many women.

Think of it like you buy an elastic for your hair and it's perfect and you take it a off that little board and you put it in and it holds your ponytail. And then after a few years of use it kind of stretches and you're gonna try to do it over and over to make sure and sometimes you even tie it back together when it pops. That is how we need to start looking at this perimenopausal transition. That things are good, they hold things in place, and then all of a sudden, ooh, that

Elastic is not holding so much and from head to toe, head to sweats, to joints, to ear ringing, to skin changes, all very real. And Megan, the thing that you really alluded to and the same thing Pauline that we've talked about before

Because the estrogen cycles are so varied, each woman is gonna experience it it very differently. And that's that personalized medicine approach. So yeah, buckle up. This is gonna be a hot,

Megan (03:45)

Ha ha ha.

Stephanie T. McNally, MD (03:46)

sweaty ride.

Pauline (03:47)

And is it like different

Megan (03:48)

Yeah.

Pauline (03:49)

month to month in the same person?

can that happen?

Stephanie T. McNally, MD (03:52)

Yeah,

when we talk about

kind of fertility windows. and you guys do a lot in this space for women during that antipartum, postpartum, preconception. But the perimenopausal and menopausal transition really do have a lot of changes. So for some women, their cycles are really affecting their mood or affecting their heat sensations. And this idea of everyone having the immediate red and sweating is not accurate. So

Megan (04:19)

Mm-hmm. Yeah.

Stephanie T. McNally, MD (04:21)

yes, it's different for every woman.

And that's why awareness about this and discussion is really the place to start.

Pauline (04:29)

So it's not just hot flashes.

Stephanie T. McNally, MD (04:30)

Nope,

not at all.

Megan (04:32)

So what are some of the greatest hits that you I know you mentioned a few of them, but

Stephanie T. McNally, MD (04:37)

Alright,

I love this. So if we're doing kind of the top ten, let's talk

about the perimenopausal percentage first. So

for women that are not on hormonal intervention, headaches, mood changes, breast tenderness, these are some of the things that are first going to show up as symptoms, even before cycles start to change.

The cycles tend to be an accordion. They get closer together and then they space out. So I have women who are like, Oh my God, you're never gonna believe this. My period is regular, every 28 days. yes, but when you were in your 20s, you didn't get a period more frequently than every three months. So it's that accordion change, and then those hot flashes.

The nighttime sweats, the mood changes, the irritability, the I don't feel like myself in my body, which is the most common thing. Skin, hair, boobs, arms, GI, meno belly, vaginal changes, libido changes, really so many things impacted. So kind of the top things is what is the perimenopausal things, and then

Megan (05:52)

Mm.

Stephanie T. McNally, MD (05:52)

in the menopausal transition, those things escalate.

Megan (05:55)

Can you tell define the difference between perimenopause and menopause?

Stephanie T. McNally, MD (05:59)

Absolutely, and this is why it's a little bit trickier when we're dealing with perimenopause. So menopause is defined one full year without a period, and that's for women that have cycles and have a uterus present. That's it, done. But when we're talking hormone replacement therapy, HRT formally, but hormone therapy, and we're gonna- I know we're gonna get into this.

You're giving back to a woman whose ovaries have really stopped functioning at a high level. So you're giving back to a zero base, basically.

The perimenopausal transition, where there is an early and a late stage, is when you're skipping weeks or a month, and then when you start skipping more than three months, it's that transition that gets you closer to menopause. And when these hormones are really changing and erratic, that's why the treatment is so much more challenging because sometimes the hormones are really high and you feel great, then you start to space out those cycles, and then you don't.

feel as good. So it's that real roller coaster in perimenopause until the stoppage after one full year.

Pauline (07:07)

These hormones the- they

just keep they just keep us on our toes, right? So for people who went through infertility and then pregnancy and postpartum and maybe had mood changes from hormones, now we're doing it again in perimenopause.

Stephanie T. McNally, MD (07:24)

Those are all those great memes on the internet where who's gonna win the battle of the hormones, the pubertal girl in your house or the perimenopausal one? The perimenopausal woman is gonna win every time. Because that adolescent transition no doubt.

That adolescent transition is a few years in the making, and then for the perimenopausal into menopause, it's really the lifetime. So your perimenopausal transition with irregular cycles and symptoms could be three years, it could be seven years, it could be a decade, and then guess what? When the period stops, you've gotta then deal with menopause. So we win every time.

Megan (08:05)

Yeah. Well

Pauline (08:06)

Yay.

Megan (08:11)

One of the differences too, like, we know that teenagers are going through hormone changes. everybody knows that, right? Puberty is kind of obvious. But for women who are in this, I don't know, late thirties through I guess menopause can go through what, seventies? Like early seventies or

Stephanie T. McNally, MD (08:33)

So we think the average age of menopause in the United States is 51, 52 years old. But once you've hit that full year, you are menopausal for the rest of your life. So whether you use the term postmenopause or menopausal, I like that. I prefer that term because that's that's our life moving forward. No cycles.

Megan (08:53)

And I remember my, you know, hearing my mom talk about it, the only thing she ever mentioned was hot flashes. that's I think was historically the only language that we really put to or we my mom's generation really put to it is that, oh I'm going through menopause, I have hot flashes.

But now there's seems to be a lot more understanding.

Pauline (09:14)

Flashes and insomnia, right?

Stephanie T. McNally, MD (09:16)

Yeah, and a lot of the insomnia is related to that vasomotor symptom, that night sweat, that hot flash during your sleep cycle that wakes you up. But Megan, you're absolutely right that the vocabulary and the terminology was very specific, that it was just the hot flash. And over 80% of women do have some type of vasomotor symptom. And we use that more broadly because this

Video of people with the red and the sweating and smoke coming out of their their heads because they are so hot, that's really one example of that temperature change where there are gradients to it. And when you're talking about culture and vocabulary, people may not even be be describing it like that.

A feeling of heat inside, a temperature dysregulation. I used to be cold, now I feel warm. It's about understanding how women are communicating that temperature change, that thermal regulation. And for some women, it's mild. I feel a little hot, I go about I get go about my day. There's a moderate amount that kind of you know gives you pause for a second, but you don't need to stop, and then that severe level really interrupts your day-to-day. So, like I said, there's a gradient

and even how we're eliciting that information from women is really important. Yes, a hallmark, but that's just one piece of it that really is that worst in that year leading up when those cycles are spacing out and that year that you've gone through that full time without a period.

Pauline (10:52)

Here's the question that I I wanted I've been dying to ask you.

it used to be that perimenopause was hot flashes and insomnia and then they realized it was also mood changes and then they realized it was also dry skin and then they also realized it was wrinkles and it feels like it's suddenly become everything is perimenopause. I don't like the way my husband smells it's h perimenopause. My eyes are dry perimenopause. I have an itch in my ear, perimenopause.

Megan (11:22)

Anxiety, we

get yeah.

Pauline (11:24)

how do you know if it's perimenopause or if it's just Tuesday?

Stephanie T. McNally, MD (11:30)

That's where a very delicate dance needs to happen with a clinical team. And you know, the pendulum was we don't talk about this stuff, this doesn't exist, and now it's all based on it, this is what it is. there are physiologic changes that occur in bodies that are not necessarily specific to estrogen and progesterone.

There are neurochemical changes, dopamine, serotonin, epinephrine.

the chemicals where you guys spend most of your time, but then insulin, glucose, thyroid. So really looking at your body in a holistic way from a metabolic approach, knowing that hormones are not just sex steroid hormones, and really

making sure you're going through these symptoms in a very strategic way. So that way it's not just perimetopause. Because

that's my fear.

And I think yours as well. Oh it's just this, get over it. Oh you're aging,

Megan (12:32)

Mm-hmm.

Stephanie T. McNally, MD (12:33)

you're not gonna sleep, get over it. And that's a real problem.

Pauline (12:38)

Yeah. And it can go, you know, just sort of like postpartum anxiety and depression, Like we can either over pathologize it and blame everything on this, or we can really be dismissive and be like, you're just getting older, it's just normal. Yeah, you lost your sex drive. well, too bad. Like that's what happens. there's this balance of of you know what is actually happening.

Stephanie T. McNally, MD (13:00)

And that's where that personalized medicine is really key because it's gonna be different for all three of us on the call of what our treatments are, what our symptoms are, what our tolerance level is. And if we can just kind of sidebar into the libido piece, because you teased it out, the biggest sex organ is your brain. So all of the factors that are happening in our lives are going to be

put in this constant order of what's a priority and oftentimes that sexual health, which is part of our overall health, is what takes the way back.

Megan (13:38)

Especially after many for many women that are going through this experience, it's like having children, then raising young children, and then the stresses that come with teenage children. Yeah. And so that can kind of correlate with the same period of time. And yeah.

Pauline (13:57)

Yeah. And not to mention, so many perimenopausal women don't feel like their brain is actually working well to begin with.

Brain fog, I think, is one of the like number one things we hear.

Stephanie T. McNally, MD (14:09)

Yeah. And you know, in the in the medical space there was an article that came out in JAMA in the last week talking about

cognitive changes, Alzheimer's, and the brain fog component, which then also kind of falls into that categorization. So taking a step back, if you are not sleeping and you are not eating well and exercising, all the things that we try to do, right? That priority list, but if you break it down into the vital sign of sleep, if you're not sleeping, your brain function is going to be affected.

So is it that you're getting woken up at night by these hot flashes and that's why you're not sleeping? Well, then that's something we have to treat and help you with. Word recall and the quickness to it is something that does decline in the perimenopausal transition and tends to bounce back. So we I know exact I know.

Pauline (15:08)

You're giving me hope, Doctor McNally.

Stephanie T. McNally, MD (15:12)

But this is also a really important thing. This is for women going through a natural menopausal transition.

So word decline comes back. And then what we need to start to parse out in medicine is who are these women that are at higher risk that shouldn't just wait for that menopausal transition, but do need to be referred for workups, for other cognitive changes. And a big thing, menopause does not equal Alzheimer's.

Menopause does not equals Alzheimer's. There are other risk factors in genes and family history that contribute, and women are more likely to have it. And the association with an early menopause and Alzheimer's means that.

You may show symptoms earlier. So, this complexity of estrogen and Alzheimer's is not a one-for-one. Meaning, treatment for prevention of Alzheimer's disease is not estrogen in the current state. And that's where people get a little confused. And that's why I said that natural menopausal transition for women going through surgically or chemically induced menopause, they will have this immediate jump off the cliff drop in their estrogen. They need

To be replaced because there's brain functionality, there is cognitive change that does respond quickly to that decline.

Different than that natural progression. So really being able to parse

Pauline (16:38)

Yeah.

Stephanie T. McNally, MD (16:38)

out where estrogen has been shown to be helpful. So again, this study, we know early surgical menopause, they need interventions. We know that women are more likely to have Alzheimer's, but a direct correlation of menopause to Alzheimer's disease, that that is not where we want people to focus on. And right now we don't have estrogen treatment for Alzheimer's. That's another big piece of the puzzle that we don't want

But

to be misleading for women. But bounce back.

Pauline (17:08)

Is there some truth

in that, you know, HRT can either delay Alzheimer's or prevent it? I'm hearing kind of rumor about that.

Stephanie T. McNally, MD (17:22)

and that's the thing. If

if we're talking about long-term data as we're collecting it, that's gonna be evolving. The early surgical menopause patient, the early chemically induced patient, giving them estrogen does help their cognitive function and prevent certain plaques of developing in the brain. great researchers like Lisa Mosconi have shown this in MRI studies, so that we know.

It's a matter of do we then offer this estrogen treatment and we what dose, what modality to then do a prevention? That is not part of our current state at all. Will it evolve to that place? Maybe. But that's where the research has to come out. These surgically early menopause, different.

the natural age of menopause is a place where we are not giving estrogen therapy for prevention.

Pauline (18:17)

So we know that there's some connection. We just don't know yet how much, what it means, what to do about it. And I I will never forget your very popular video about how they never research the female body. Are they researching this?

Stephanie T. McNally, MD (18:38)

Yes, yes, yes. So it wasn't up until nineteen ninety-three the number one movie just to kind of level set in that year was Jurassic Park, the original one.

And that's the year that they mandated that women need to be included in research for sex and biology

differences. So we know that certain things are more common for biologic female. We know that there is role for estrogen in all parts of our body, and so research in many aspects of cognition, we've got to figure out the stratification: who's at high risk, who may be beneficial for it, who needs to be referred for neurology. All that is evolving, and that's just one aspect: cardiovascular protection.

Bone health, doses, intervention, treatment. I can pick all of the things that we didn't know about because we weren't studying it for the last, you know, hundred years, but now as that research is evolving and still yet, there's a very small percentage of research dollars that's being put into women's health.

Pauline (19:36)

Yeah, which you know, who runs the world? It's girls. Like we

Megan (19:42)

Yeah.

Pauline (19:43)

need the research.

Megan (19:45)

I think I saw last week, I mean, can't be quite sure because I'm sure it was on Instagram. them doing a study for perimenopause and GLP1s. And I'm curious if that's something that it's like, well, there's so many people who are on them, so we might as well just take a look at it, or if they are noticing things that

might actually be supportive for people.

Stephanie T. McNally, MD (20:12)

The peptide GLP1 space is very unique, and I use the word peptide because there are things that are regulated versus not, and the GLP1s really were medications for diabetics. Then they started looking longitudinally for other benefits, cardiovascular,

metabolic health related to the diabetes, but then also weight. So in perimenopause specifically, treating perimenopause with a GLP1 is not the current state, right? That wouldn't be

Megan (20:41)

Mm.

Stephanie T. McNally, MD (20:41)

my diagnostic code. But the other factors that may be playing into this transitional period from that metabolic piece, that cardiac risk, that endo

Is something that we really have to explore, knowing though that it is not the fix for everything, but there's going to be benefits for people in various stages of their perimenopausal transition. For example, is it gonna help with cognitive function? Maybe. Is it going to help with autoimmune, anti-inflammatory processes? We've seen that in some of the data. So why we're prescribing it needs to be the real focus because there are side effects.

From GI changes, And when you're losing fat, because people are looking at it too from the outside, you're also losing lean muscle mass. You're also affecting your bones. So lean muscle mass, which we lose the biggest percentage, dun dun, dun, dun, in perimenopausal transition.

You're losing that cardiovascular protection because lean muscle mass is a marker for that part health. So again, you may be looking great on the outside, but what's happening on those other facets? Are you weightlifting? Are you weight training? Are you eating enough of a balanced diet that you're getting vitamin nutrition, enough protein? Because protein is what helps build the muscles. That's the building block. And when you do lift or work out, you're actually tearing fibers and rebuilding them

Stronger. So it's it's really interconnected and not a

Megan (22:17)

mmm

Stephanie T. McNally, MD (22:18)

you're in perimenopause, you're gonna get this medication. You're in perimenopause, you have these risk factors or things going on. This needs to be regulated and monitored in a holistic way. So I think that's where some of the online digital companies are great for access, but do they have that long term trackability and standards? Again, not calling anybody out. It's just

this is what needs to be done in medicine.

Pauline (22:45)

Yeah. And it's complicated. It's not it's not one size fits all. I think the the GLP ones have at least from my non-research experience, proven how complicated the brain gut connection

Stephanie T. McNally, MD (22:58)

Yeah.

Pauline (22:58)

are. the medicine started for diabetes, then they use them for weight loss, then they're finding it helps with substance use and now maybe it helps

Stephanie T. McNally, MD (23:05)

Yep. Right.

Pauline (23:06)

with like we're just

figuring out how all these things work, but it's really complicated.

Megan (23:13)

Well and you think about it too. I mean you're talking about lean muscle mass, but what's also a risk factor for women in menopause is or that age at least is osteoporosis. So it's like we lose that muscle mass, then we're at risk for, you know, all kinds of challenges with that. So there's always like this cost benefit that we don't necessarily look at when we're looking at an ad on TV. Yeah.

Stephanie T. McNally, MD (23:38)

Right. And and that's where too I love how what you're talking about, Megan,

we talk about getting cardio, we talk about weightlifting, we talk though about balance, not only our life balance, but also if you are doing things where you physically have good core strength and are more balanced, you're not gonna have as much of a risk to fall because if you have weak bones, that's how you get fractures. So it's really looking at it holistically and there are people watching being like, I don't have the time. Totally get it

But carving out little things during your day, if you're at a desk, is your desk moving up and down? Can you do some bands or something right there where you're literally, we're women. Multitasking is in the dictionary for us.

Pauline (24:20)

I mean if you've been in my office I have little dumbbells on my desk.

They they made it to one of the social media videos this week.

Megan (24:28)

I was just looking

at where's my weight vest? Where's my

it makes me laugh, but it's like my friend's husband is always like, You can always tell these paramenopausal women out there on the street because they've got their weight vest on.

Stephanie T. McNally, MD (24:41)

And what's

what's funny about the weighted vest is that it it's great to like help with our posture when we're walking, but you also you're not targeting joints as well. Right? You're just kind of like, I'm carrying this around. It's

Megan (24:52)

Mm, mm hmm. Carrying it.

Stephanie T. McNally, MD (24:56)

targeted

lifting of your joints and and that's how you want to get the stimulation, just walking is not kind of causing those reps that really is where you're pushing your body. So that's a big thing. If you're weight training, you are pushing your muscles, a weighted vest is not doing that consistently.

Megan (25:15)

Good to know. Got my dumbbells out too then.

Stephanie T. McNally, MD (25:19)

So you gotta get a bigger size. Let's go up.

Megan (25:22)

Bigger size, okay.

Pauline (25:23)

So are you

saying that weight training replaces estrogen?

Stephanie T. McNally, MD (25:30)

No, absolutely not. Weight training is an auxiliary to our health maintenance in the perimenopausal transition to maintain our lean muscle mass. Also then helps with balance because if you're weightlifting, you've got to make sure you don't topple over. And really then helps stimulate bone growth. So not an a hormonal supplement at all, a health maintenance addition.

Pauline (25:56)

And I heard you explain once meno belly in a way that like I had never really thought about it. you

said something like your body's gonna figure out how to do it and that's how meno belly shows up. So w you say it better.

Stephanie T. McNally, MD (26:11)

All right. So your body makes different hormones and there's different types of estrogens. Estradiol E2 in the medical world is what your ovaries primarily make when you are in that reproductive phase of your life.

So your body is smart, and we know that estrogen receptors are everywhere in a biologic female. So your body starts to find places where alternative estrogens can potentially be made. It's made in peripheral fat. So as that strong, potent estrogen, the estradiol 2, declines, your body's metabolism slows down. Our hormones that make us feel full go down.

and that's where the GLP1s help, where our desire to eat, that satiation hormone goes down. Like we said, we don't feel full.

And we want to eat more. So that balance is off, related to changes in estrogen, that strong estrogen. And so peripheral fat makes a different type of estrogen, one that's not as strong. So kind of that's where a lot of us find the redistribution, because our bodies are finding ways to make alternative estrogens.

Pauline (27:24)

So the you said peripheral fat?

Stephanie T. McNally, MD (27:27)

Peripheral

fat. Viscer s it's for visceral it's really visceral

Pauline (27:31)

Biceral.

Stephanie T. McNally, MD (27:32)

fat. and that's where it's found mostly on our belly and in our butts.

Pauline (27:39)

And not in a good way.

Stephanie T. McNally, MD (27:40)

Well you know what? Listen, we should own our bodies and feel good in it.

Megan (27:44)

Like showing my kids a book of like it was like a b biology book or whatever for kids. And it was like this is your body in your teens, twenties, thirties, forties, fifties, so on and so forth. And like I kind of appreciate it. It was a

drawing, a a cartoon. But it was like the belly and the you know, butt and the thighs and the legs and it was like this is what a woman's body and what what a man's body looks like in the 40 to 50 year old range, and I was like, Oh like it was for me. I was like, oh there's

Pauline (28:16)

Yeah.

Megan (28:16)

not something wrong with me. It's just like, you know, that's somewhat of what our bodies do.

Pauline (28:24)

But it's not like the

fat distributes to make it look like you had a BBL, right? Like

Megan (28:29)

No

Stephanie T. McNally, MD (28:29)

No

Pauline (28:31)

that's what I meant, like in the good way, right?

Stephanie T. McNally, MD (28:33)

No, I

I had a hunch that you're not getting the the benefits of that

intervention. But yeah, it's the the metabolic changes, the hormonal changes and the redistribution and that's kinda where it goes because our bodies do make some estrogen and and fat cells.

Pauline (28:50)

The body's really fascinating, all of the things that it does.

Stephanie T. McNally, MD (28:54)

Yes. And it's about owning it too. What are realistic health expectations versus the vanity? And y you need to feel good in your skin. There's no doubt about that. But where's the line that you may look amazing, but can you walk up a flight of stairs?

Megan (29:10)

Right. And you may look amazing, but is it impacting your mental health? Like that's our side of the things too. It's like

Stephanie T. McNally, MD (29:15)

Correct.

Megan (29:15)

what it what did it cost? Yeah.

Stephanie T. McNally, MD (29:18)

Right, and then I have patients that do look at it from that they notice the changes in their body and then that mental health really impacts their stress and their sleep and their cortisol. So there's no way of separating it.

Megan (29:30)

When it comes to like treatment, how should people talk to their providers? especially like the in the different stages. So let's say somebody's at an earlier stage versus really struggling and might have more severe symptoms.

Stephanie T. McNally, MD (29:44)

Say it just like it is. Come in with your little checklist of stuff, hand in you know, notebook or on your phone, and go through it. I'm experiencing these things. So if if a clinical team member and you guys, this is the area that you live in, you've got to open the door, right? Tell me, tell me.

If we open that conversation for open-ended, that should hopefully bring a patient to us. But then also you kind of trigger some questions like the head-to-toe that we talked about. But have patients come empowered. These are my symptoms, this is what's happening. And start to collectively get on to the same page and create a plan. And a plan may not be in one session. And I think that's a big piece to this too. You may not walk away with every hormone that you've read about on the internet.

And that's okay. You also want that health component, you want the mental health component, put all the pieces together and then regroup about what's the right treatment plan for you.

Pauline (30:45)

So I I'm just thinking about like some of the stuff we hear from clients, some of our own experiences. logistically, am I having this conversation with you at the same time that I am on the exam room table in my gown open

Megan (31:02)

He

Pauline (31:03)

to the front? Like is that how I schedule this

Stephanie T. McNally, MD (31:04)

Yep. Always open to the front.

Pauline (31:06)

appointment?

Megan (31:07)

Yeah, always

open to the front. Is that for breast check? Okay, good.

Stephanie T. McNally, MD (31:10)

Breast check, yeah. Yep.

Pauline (31:12)

But like, do I really wanna be talking about all my menopause symptoms while I'm sitting there on the exam table? Is that my option?

Megan (31:20)

they've only

got fifteen minutes, Pauline, I mean.

Pauline (31:22)

I know.

Stephanie T. McNally, MD (31:22)

Okay. So

it depends on the workflow of the practice and the practitioner. an annual GYN exam is just that. We're coming in for these routine health maintenance, PAP guidelines have evolved, so it's not even a PAP every year. that is very different than the perimenopausal menopausal consult because it really runs through things systemically.

I've tried to incorporate it into a session with a telehealth follow-up. Some people do telehealth intakes and then an in-person follow-up. So there really is a few ways to approach it, but the menopausal, perimenopausal intake with all of these symptoms is a separate visit, and whether you piggyback that on in your annual exam, that's okay.

So there's different ways of that health systems are doing this, of which it really has to meet the woman where she's at. Perfect example. New menopause consult can be done via telehealth. We're running through your symptoms, we're running through your history, we're running through your labs. What else am I missing that I need to help you to the next step? Then there's a pause. We put all the pieces together. oh you're due for your annual. Okay, you're gonna come in, we're gonna put this piece together, we're gonna talk about it. That visit may be a

Little bit longer, but rather than have you have multiple visits, if we can combine it, I'll tell you that we're gonna have that visit plus this, and that's how we're gonna approach it. So it really again has to be individualized. And I got a little bit more granular, but basically a very broad answer is that an annual GYN visit is not a perimenopausal menopausal consult. It requires a much more collaborative midlife approach and menopause consultations

Medications

can and should be done by intake of a GYN and/or internal medicine and/or family medicine. And there are also some very savvy endocrinologists, metabolic health specialists that kind of cross over but do that full evaluation. What is an exceptional menopause consult? This is something your patients can take. It is open-ended, it is symptom-focused.

It is me as the clinician running through all of those symptoms from head to toe, from hair to meno belly getting cardiovascular risk assessments, breast health risks, family history, metabolic changes, and bone if it's appropriate, depending on where you are in your transition. All of these things make it an exceptional visit, and then we're able to put the pieces together. Part of that evaluation is always mental health.

Pauline (34:03)

I love that you are doing that and I know that not everybody is, right? And people I'm guilty as charged, tag it on to their annual visit, like, well I'm gonna be there anyway, I might as well ask. But it really takes more. It deserves more time.

Stephanie T. McNally, MD (34:19)

And that's why if some clinical office hours run late or it needs to be cut off or something like that, i it is a separate and again, for people that I've known for a long time that I've taken care of, I kind of know the basics, but also if you've messaged me or messaged somebody else, I can start to put it together and then I'll follow up with you and set up a telehealth. Alright, this is the beginning of it, this is your annual plus, then we're gonna have to do some more.

Megan (34:45)

I wanna be cautious about bringing this up, but because I do know that not everyone has access to quality healthcare and so some of these online bigger menopause, perimenopause focused companies may be really helpful to some people. But I do I do wanna know your opinion on

What to look out for if you are feeling like you need to go that direction.

Stephanie T. McNally, MD (35:13)

It really depends on where you are at in that transition period with your health and the online digital companies really get patients in quickly. So

Megan (35:24)

Mm-hmm.

Stephanie T. McNally, MD (35:25)

it depends on them being able to meet you where you are. So a a kind of a a roundabout answer is it really has to be personalized to what a woman needs. I don't think

A hundred percent digital is the way that we should be approaching it because complications, problems arise where a combination, a true hybrid will be the key to success for midlife health. You guys live in that space too.

Pauline (35:52)

Yep, hundred percent. So One question I want to get out there. What the heck is happening with these estrogen patches? They are hiding, they are hard to get. I I mean, I have never seen something like this.

What is going on?

Megan (36:09)

It's like the Christmas present

that everybody wants on the shelf nobody can get.

Stephanie T. McNally, MD (36:14)

The most wonderful time of the year is if your package arrives.

Megan (36:16)

Yeah.

Stephanie T. McNally, MD (36:19)

Kidding, not kidding. So yes, this phenomenon that has occurred in the midlife space when they reanalyze the WHI has really put women's health at the forefront, but pharmaceutical hasn't caught up. What do we mean by that?

Women's Health Initiative done in the 90s with the average age patient 64, 63 years old. That's more than 10 years past menopause. Looking at heart risk, breast cancer risk, and the study was stopped, and it was on an oral combined equine estrogen. This is basically

pregnant

horses, they took their pee and made estrogen. They gave it to women orally,

and then a synthetic progestin.

And they stopped it because women were having bad outcomes, especially when it came to heart disease. But when this data was reanalyzed in the last few years, women that were in that first ten years of the menopausal transition, not even considering perimenopause, they actually had better health outcomes, less all-cause mortality, when it was estrogen alone. Again, this is oral combined, different than the bioidentical topicals.

women did better. especially when it came to heart disease and breast cancer reduction in the estrogen alone. So again, reanalyze the data.

People started talking about it, and it's again, Megan, you said it was the hot flash was the only thing that was talked about. Really invigorating this conversation. So as people started talking about it, less cardiovascular risk, less blood clot risk with transdermal estrogen when it's bioidentical than other combinations oral. This is why there's a back shortage of these patches because lower risk, health benefits, decreasing symptoms.

Reanalyzation of the data and the pharmaceuticals just haven't caught up. Yep.

Megan (38:13)

Yeah, they're like, I'm

Pauline (38:12)

So supply and demand.

Megan (38:14)

not taking this and I'm not dealing with this anymore. Yeah.

Stephanie T. McNally, MD (38:17)

It's

i it the supply has not met the demand, which again I'd be curious if it was for other medications for other people, but we're not gonna go there.

Pauline (38:27)

You mean like if it was Viagra?

Megan (38:29)

Yeah.

Pauline (38:31)

We wouldn't

have a shortage. Yeah, I kind

Stephanie T. McNally, MD (38:33)

I don't think so. But that's

Pauline (38:35)

of would agree with you.

Stephanie T. McNally, MD (38:36)

that's speculative. But we don't want to speculate,

Pauline (38:39)

I mean

this is our podcast. We like to speculate.

Stephanie T. McNally, MD (38:42)

We like just

Megan (38:42)

Ha ha

Stephanie T. McNally, MD (38:45)

So yeah, the it and people will call and be like, You didn't call it in. I'm like, I called it in, it doesn't exist

Megan (38:51)

Yeah.

Stephanie T. McNally, MD (38:52)

So there are twice-a-week patches, there are gel sprays, there are topical gels that you could put on it. So spray, gel, those you have to let your skin dry, but there are alternatives. There also, which I've been leveraging more, vaginal estrogen rings at a higher dose that treats systemic symptoms. So we talk about vaginal estrogens for dryness, UTIs

pain with sex, but there's one specific one that is a higher dose for systemic flashes that could help treat multiple things. So there's multiple modalities. You've gotta go, you've gotta advocate, we gotta keep fighting to get these medications produced.

Pauline (39:37)

So if you can't find your patch at your pharmacy or the thirty seven local pharmacies, call your doctor and see if there's some other estrogen.

Megan (39:47)

Spray, gel, ring,

something. Yeah.

Stephanie T. McNally, MD (39:49)

Yeah. The the gels are kinda they look like little like ketchup packets and you peel it off every day and you rub it on your arm, you keep it dry for two hours and then you go to bed.

Lovely.

Megan (40:01)

You have another question, Pauline?

Pauline (40:01)

Yeah.

one is

postpartum and perimenopausal at the same time.

Stephanie T. McNally, MD (40:08)

So when we're talking about age-related changes, as women are delaying their fertility or choosing to be parents later in life, they're closer to the menopausal, perimenopausal transition. So when you are going through fertility.

And especially if your cycles have already spaced out or their stimulation hormonally, you may be postpartum in your 40s, getting closer to perimenopausal transition, where cycles may be erratic. So that really amplifies what's happening. And that's why we can't just say, Oh it's postpartum. Oh it's perimenopause. You don't know, especially for women that are having later in life families.

And that's why you've gotta get a full evaluation in terms of their cycles if they've come back, their family history, their medications, their symptoms. So knowing that perimenopause can start as early for some women as their thirties, and as women are delaying fertility, that crossover is gonna happen in some women and needs to be addressed.

Pauline (41:25)

Double whammy.

Megan (41:26)

If there's one thing

that no mom told you that either you or your clients or excuse me, patients, have to learn the hard way around perimenopause menopause, what would you say that is?

Stephanie T. McNally, MD (41:38)

That this poop is real.

Megan (41:41)

Ha ha ha.

Stephanie T. McNally, MD (41:43)

It wasn't even discussed.

Megan (41:45)

Yeah.

Stephanie T. McNally, MD (41:46)

and that's what we're kind of working our way through, right? We talked about what are all the symptoms. The biggest chief complaint I get is I don't feel good in my skin. I don't feel like I'm in my body.

So, how do you talk about that when you have no idea what's really going on? Because we didn't learn it. In medical school, I may have had one hour of lecture in four years. I did a four-year residency in OBGYN and I'm double board certified in surgery. Maybe another two hours in training. Wild.

So what's the biggest thing missing is that we didn't even talk about it. That goes back to the research and the information, the misinformation. You wanna get real, the WHI study owes women three decades of apologies because it didn't parse out different ages, different risk factors in that regard.

Pauline (42:36)

Yeah. So we're we are coming at this with not enough historical information, trying to catch up with what people are figuring out in real time, and then

Stephanie T. McNally, MD (42:47)

Yep. Flying you're building the plane as we go.

Pauline (42:50)

our systems are struggling to keep up. But women should ask.

Stephanie T. McNally, MD (42:56)

They should ask and I love how you broke it down from the system level to the individual because there are gaps in all of it, but you've gotta advocate and find those people that understand where the gaps in knowledge are, where it's a doctor that's an influencer, not influencers that are doctoring.

And I would look in this space for midlife, those of us that are certified through the menopause society. So MSCP, Menopause Society Certified Practitioner. This means that you've done additional education and testing with maintenance of certification, your CMEs, specifically in this space. We attend national conferences, we meet to review cases, we collaborate in research across the country. These are

the people that really should be the ones providing you with that up-to-date information.

Pauline (43:51)

Great. So we're gonna put all this information in the comments. it has been it is always so nice getting to spend time with you and to pick your brain and hear all of the latest we go we go way back when our age related interests were pregnancy and postpartum and now as as we have

matured.

We have new interests.

Stephanie T. McNally, MD (44:19)

We're vintage like Gucci.

Megan (44:23)

Well I'm really glad that are people like you that are leading this charge because it's time

Stephanie T. McNally, MD (44:30)

It it's time but

Pauline (44:30)

We need it.

Stephanie T. McNally, MD (44:31)

it also is the collaborative effort, which I again I'm so glad to spend time with you guys because

It is about that mental health, the metabolic health, the hormone health. I mean, you can't separate it. And I think that's where medicine has been so siloed. And doing things like this where we're, you know, the crossover events, if you will, really shed light onto an audience that's following you for your expertise, but then also realizing, wow, these menopausal changes are impacting my mood. Oh my gosh, and all of these things are connected.

I do wanna give a shout out too that the first FDA approved non hormonal medication for vasomotor symptoms for hot flashes is paroxetine So the trade name is Brisdelle

what they did is they took a specific 7.5 milligram dose, got clearance by the FDA to market this and sell this to women for vasomotor symptoms. Peroxetine.

So this is kind of the area that you live in, all those neurochemicals connecting. So the treatment is not only just hormones, it's SSRIs, SNRIs, neurokinin one in three receptor interactions with newer medications. Again, brain's health connects to everything. Your hot flashes start there. Your

Megan (45:54)

Mm.

Stephanie T. McNally, MD (45:55)

neurochemicals are not just your sex hormones. So this is why this collab is spot on.

Pauline (46:02)

Fascinating.

Megan (46:03)

Yeah.

Stephanie T. McNally, MD (46:03)

We slay.

We slay

Pauline (46:10)

That's right. We rule the world.

Thank you so much.

Megan (46:14)

Thank you for taking this time. It was amazing.

Pauline (46:16)

We'll see you soon.