Women Uninterrupted is an inter-generational podcast bringing you difficult, different and uninterrupted conversations about being a woman.
Listen while two women ask a gynaecologist about the menopausal transition to the end of their reproductive lifespan; that point at which the ovaries stop producing reproductive hormones.
Host: Anna Thomas Guests: Dr Teena Thomas, Kavita Saini & Nisha Narayanan
Title music - The Carpet Beat:Maya Dwarka
It was around 8 pm one day that my husband walked in and found me sobbing softly on my bed. He asked what had happened, but I had nothing definite to say. He was confused and concerned. His patience slowly gave way to irritation. My thoughts were in turmoil and my open helpless face reflecting the chaos in my mind did little to explain the situation.
He insisted that we go out for dinner, perhaps reasoning to himself that it would brighten me up. I felt rather childlike as I obediently followed him to the car. As our car moved out of the basement, my soft sobs gave way to rather loud wailing. The colony guards peered into our car. My husband begged me, “Please stop crying; everyone will think I am a wife beater!” I covered my face with my dupatta as we drove, and gradually I regained my composure.
It had been a few months, yet I couldn’t bring myself to discuss my recent forgetfulness, my fragmented sleep and an isolated incident of mind fog. Perhaps the fear of a possible mental illness stopped me from doing a simple google search.
It was my 23-year-old son who sat me down, looking squarely in my eyes, and insisted on knowing how I was really feeling. He then googled and explained to me that I might be peri menopausal. There was no hint of embarrassment or hesitation in his voice as he addressed the subject. I, on the other hand, struggled to maintain a calm mind.
Somehow no one had ever bought up these concerns - not my conservative mother, my vociferous girl friends or my highly educated husband.
My mother sleeps like clockwork. No matter when she goes to bed, she’s always up at about 7 AM. It’s been like this all my life so, as you can imagine, when she started sleeping in till 10, complaining of brief and irregular sleep, I was more than a little concerned. On top of this, as someone who has had several depressive episodes, I could recognise buds of the symptoms in her. My usual upbeat, high-functioning mom was spending more time alone, despondent at times. Although I initially attributed this to some ‘event’ that must have happened, I sat down with her to look through what these symptoms could mean. People are often wary of online diagnosis, but I have found it an excellent tool to find your footing, to just start. When the possibility of menopause came up, I, realising my mother’s age, felt it was highly likely. Women, or rather, those born as women, go through an entirely distinct set of experiences. I have friends with PCOD, who have to suffer through immense pain during their periods. These should not be experiences we go through alone. I hope we can bring about more medical attention and societal awareness towards these conditions.
Anna: Hello, I’m your host, Anna Thomas, on Women Uninterrupted and my guests tonight are Kavita Saini and Nisha Narayanan, both content and communication professionals. Welcome, Nisha and Kavita. In this episode of Women Uninterrupted, we are talking about the final phase in a woman’s reproductive lifespan, the menopause. And so, I brought in a trained menopause clinic practitioner, Dr Teena Thomas, who is an obstetrician and gynecologist. Welcome, Doctor. Before I pass the mic to Nisha and Kavita, here are two questions. Let me start with one actually; a question from a listener, Divya Nair from the Netherlands: Why can’t menopause happen once and for all overnight without making a pomp and show for months together? Is there any way to reduce the pomp?
Dr Teena: It can happen overnight for some people. It also depends on our lifestyle and our attitude. If we correct that, most of it gets corrected.
Anna: Is there a solution, like a one-pill solution?
Dr Teena: There is no one-pill solution. No magic.
Anna: Taking the mic to Nisha here, who says she took an AMH, an Anti-Müllerian Hormone test. Never heard of that till you told me. How did you begin that journey? What symptoms made you take one?
Nisha: Yeah, so I’ve always had very regular periods. Got pregnant when I wanted to, have never had any issues with reproductive health, but close to the age of 40, my period started to get less heavy and still on time; but after the age of 40, it started to also get more and more spaced out. And I started to worry that there might be some health issue. I went to the doctor, and she did a checkup and she thought everything was fine. At the age of 43, though, she asked me to take an AMH test. And it turned out that my AMH levels were negligible; way below the range. She told me that I had pretty much run out of eggs and that I had hit menopause. I continued to have my periods occasionally - maybe like, once or twice a year. Since, I think, 2020, I’ve not had my periods at all, and I’m 47 right now. At around the age of 45, I think I pretty much got it done with.
Anna: Is that early menopause? What is early menopause?
Dr Teena: Early menopause is when it is earlier than what you expect, but menopause can be - not early - it can be a premature menopause or it can be a regular menopause. Premature menopause happens any time before the age of 40 years. The ideal age is 51 plus or minus. If it happens before that, you call it early, but not very significantly, in medical terms. Either it is premature, which is less than 40, or it is a menopause which can be early or late - average age, as I said, is 51. Anything before 46-47 would be early; anything beyond 52-53 may be late.
Anna: Are those both concerns: early and late menopause? Do we take ourselves to the doctor?
Dr Teena: Usually not a concern. But till we reach the menopause age, our estrogen levels are very good in the body. And estrogen is what protects our bones and heart. So, the better option is not to have an early menopause. But then, it is not in our control, so it has to happen when it happens. If it is very early, we can take precautions to protect ourselves. Otherwise leave it, if it’s not troubling.
Anna: What kind of precautions? I think Kavita here, is expecting early menopause.
Kavita: I was 39 when I started getting hot flashes, and a little bit of brain fog and fatigue - and I’m 45 now. It still continues - my periods as well as hot flashes. What should I be doing?
Dr Teena: You’re 45 and you’re having your regular periods still.
Dr Teena: So, what you started - hot flashes at 39 - may not be a perimenopausal symptom. Perimenopausal symptoms start two to three years before menopause. What you are having may be PMS - premenstrual syndrome - which may be a little broader variety. These are not menopause symptoms. PMS may be something like perimenopausal, so maybe, your symptoms are part of premenstrual and not perimenopausal. Perimenopausal is actually two to three years, or three to four years, and may run four-five years before you stop the period.
Kavita: I saw a gynecologist and she said she will give me some hormone, or whatever. But she asked me to wait…
Dr Teena: Now since the periods are coming monthly regularly…
Kavita: …but the cycle is getting shorter and shorter.
Dr Teena: The flow is getting shorter or the number of days?
Kavita: The duration between…
Dr Teena: It should get longer and longer when you are reaching menopause. This process starts from 40 plus: mostly in the latter half of your 40s, you start getting into a phase of perimenopause and if there are no hormonal imbalances or any associated organic problems in the uterus, then the duration between periods will become longer. You may start getting them once in two months, once in three months, once in four months, once in six months and then once in a year. And finally, one year of no period is called menopause.
Anna: If this is a PMS symptom, is there a way she can treat it, any particular…
Dr Teena: PMS is a quality-of-life issue. Perimenopausal symptoms and PMS are quality-of-life issues: you treat when it affects the quality of life. The first line of treatment for that are certain vitamin tablets, which you take and it brings down the problems by 50 to 60%, the symptoms. For some persons, when you bring down the symptoms by 50-60%, they are very happy and they are done with it. So that may be enough treatment for them. Some people may not be happy with that; they’ll still be having hot flashes, they will still have difficulty in travelling, going outside and everything; then you can go into second line of treatment. Second line of treatment can be hormonal pills. There are further treatments depending upon your requirements or symptoms. If it’s just hot flashes, it may just be controlled with hormonal pills.
Kavita: All right, that makes sense. Thank you.
Nisha: Doctor, considering that I had a relatively early menopause, are there any risks associated with that? I had read recently that there’s an increased risk of dementia maybe, or more cardiovascular problems going forward.
Dr Teena: In a normal reproductive-age-group woman, the estrogen release may be around some 100 units - 50,10, 20 to 100 units - per day, whereas in menopause, the ovaries have stopped working. So, there is no egg release; there is no hormone release from the ovaries. There is no estrogen coming from the ovaries. Your daily release of estrogen is only two micrograms/three micrograms...it’s very less. From 100 to this 2 or 3 is the range when you are in menopause. Now, where is this estrogen coming, because estrogen ovaries have stopped completely. So, this estrogen is coming from the fat. A very minimum amount of fat gets converted to estrogen; then your adrenal glands may release a little. Such a difference in estrogen level gives you lots of symptoms, because that is what has been running you through your reproductive lifespan.
If I tell you the symptoms that happen during menopause, you will be able to understand how it is protecting you. So once your estrogen starts falling, or you reach menopause, then you have many symptoms like hot flashes - any time of the day and early mornings and late nights - you might just sweat. It doesn’t become a problem when you’re working in an AC (air-conditioned) sector. But it matters when you’re going for a wedding. It will be AC, you know: others will be fine, but you will be just dripping. So how do hot flashes affect your quality of life? You start stopping to go to public functions, you start avoiding a lot of rush; you must be window shopping and enjoying and stress levels decreasing all this while, but now you would prefer not to go.
Dr Teena: These are the problems that women have at menopausal age. Hot flashes, one. Number two: skin becomes brittle, softer, weaker, thinner, easy bruising...Then vaginal dryness comes in. So, sexual problems come in, dyspareunia comes in - difficulty in having sex - there may be painful sex and all that. That becomes a problem for some people: then the genital areas are all dried up so there may be itching. Last thing: because of this urogenital dryness, there may be recurrent urine infections coming in. So, that has to be dealt with. A lot of mood changes. The bone absorption comes down and even the deposits in bone comes down. So, there is a lot of bone de-mineralization. And the heart is protected by estrogen: you would have heard many “25-year-old boy had a heart attack”; “35-year-old boy had…” but have you heard a 25-year-old girl having? No, because we are protected. So, god has given us so much estrogen to protect, and then suddenly one day he just takes up all the estrogen and then you are at higher risk of bone damage and heart problems than men of the same age. So, when you shift, for some people, the shift may be very abrupt. So, the first question Anna asked me: isn’t there a pill that can make a sudden difference? Believe me, that sudden difference is so painful. That is why it happens over one or two years, where you slowly and subtly take the changes which are happening in your body and reach gracefully into your condition called menopause.
Nisha: How do we counter the effects of menopause? How do we counter the bone loss?
Dr Teena: The first thing is, we should understand where we stand. Half of the people are suffering, and they don’t know why they are suffering. They are ready to suffer. So that doesn’t work out. Find out what is happening, the changes in your body, what is it that is affecting you, and meet your gynecologist to help you with what can be done. There are many problems which may come at the same time, which may not be menopause-related, but they may all be put into that category. So hot flashes, if it is very bad, we have treatment: hormone replacement therapy. So, as I told you, first line of treatment: we can give some vitamins and see if it works. If there is sufficient decrease, then that is enough. Otherwise, we go for hormone replacement therapy. Your genito-urinary problems and recurrent urine infections: know that this is coming. I am a person who drinks half a litre of water; all my life I have been drinking half a litre. Now at 50 years, if I still drink half a litre, it doesn’t work out. I should understand that and drink two litres daily. Then my urinary symptoms will come down. Sexual problems: you have already lot of lubricant gels which can help you. Go ahead and get those and use it.
Mood changes actually is the biggest problem, I feel; rest all you can manage yourself. Mood changes, you are actually troubling the people in front of you. Your trouble is less. Today, when my husband says anything, I get angry very fast. So past six months that happened - that’s happening. So, he says I can’t talk to you anything, you get angry. Neither he realises, neither I realise, because I have no time to go through that menopause cycle. So, train yourself, do meditation, do yoga, do things which will help you. You should make your children and your family members and your husband aware that you are going through that period of stress. They have to understand, so support is also very much required.
The last line, as I told you, is a hormone replacement therapy which can be used to treat. In cases when there are early menopause, you can put them on hormone replacement therapy, because, a person who’s gone into menopause at 42- 43, they have lost 10 years of their good part. So you can put them on hormone replacement therapy, provided they understand how it is to be taken, what is to be done, and continue.
Anna: What are the risks of HRT? I mean, risks, because they say that it could lead to breast cancer if you take it for more than a year.
Dr Teena: No, it doesn’t lead to any breast cancer. Benign tumors are increased risk with HRT, but doesn’t increase, as such, breast cancer. For that matter, any tablet you take comes with that benefit and risk. You always see whether the benefit is more than the risk. So, when it is just hot flashes, maybe in six months to one year, HRT will help. Taking HRT doesn’t increase all these risks, provided – see, after 40 years, every woman should do ultrasound breast every year. That is, whether you are on HRT or whether you’re not; that’s a screening, evidence-based medicine rule of the world. So, if you’ve been doing yearly ultrasound breast, you pick it up. You don’t do that, but once in a while pick up a tumor and then say that’s because you have taken HRT - it doesn’t work like that. You have to be monitored. So, if you have been on chemotherapy and breast cancers and all, then probably we don’t put them on HRT; but otherwise, the benefit is much more than the risk.
Anna: The UK recently announced that you can buy – I told you about that - they can buy HRT OTC (over the counter). What do you think about that? That gives the woman the agency…
Dr Teena: I don’t know how it works like that because HRT is of different types. It is a combination of estrogen-progesterone, or it can be just estrogen, okay? So, if a person is in perimenopause and has not reached menopause yet, you know, obviously a combination is required. You can’t manage with one. If the uterus is there, you need the combination: estrogen alone doesn’t work. So, over the counter HRT doesn’t work. HRT are hormones. They cannot be given over the counter, unless your population is so much educated that they know…It’s not possible. There can be a sequential monthly HRT where you bleed every month; there can be three-monthly bleeding HRT; there can be an HRT with which you don’t bleed at all. So, a person on the road cannot do an OTC and decide what I want to do, right?
Anna: I have a question from Priyanka Devgan, Bangalore: How important and how safe is it to start taking calcium/lifting weights, because I have been told I have menopausal symptoms. Is there anything I should look out for. Any risks in suddenly doing it?
Dr Teena: As I told you, calcium absorption also comes down. So definitely after 50 years, taking calcium helps, along with vitamin D3. Absorption has to happen. Plain calcium doesn’t work, so have vitamin D3. You can check your bone mineral density to see how often you need: There may be people who need regularly; there may be people who require alternate months or something. Lifting weights and exercising: it helps to bring up the bone mineral density. So, it is better you do that.
Anna: I think she’s thinking about risks like, you can’t suddenly start lifting weights one day.
Dr Teena: No, it is not that overnight your bones have become brittle. They become brittle over 20 years. So, at 70, if you have not been doing anything and suddenly at 60-70, you start lifting weights, it doesn’t work. But at 50, you are still good to go.
Nisha: Yeah, going back to early menopause, because, obviously, I’m a little worried about that. Anecdotally or whatever, do you find that more women are menopausing earlier than before?
Dr Teena: Yeah, definitely. I have myself, in the last one year, seen five cases of premature menopause. In the first 15-16 years of my practice, I have seen only four or five. In the last one or two years, I have also seen four or five. So, definitely the number is increasing; maybe lifestyle, maybe late pregnancies. Because of late pregnancies, infertility. A lot of IVF treatments, hormonal pumping of IVF: these are all the causes. They don’t get conceived: you put tablets to make them ovulate. When you give tablets to ovulate, you are increasing the number of eggs that are taken up monthly. Even if people are exercising, half of the population is not doing what we used to. If you compare to their mothers, who were doing work at home, rushing to office – that’s a lot of exercise, and that is not happening now. With COVID coming in, 70% are working from home. Yeah, so lifestyle is a big change.
Anna: Here’s a question from Sandhya Govind in New Zealand. I’m just starting menopause and my BP has been very high for the past 10 days. I’ve had a full checkup and there is no apparent reason for it. Could this be a hormone fluctuation?
Dr Teena: 10 days of BP may not be menopause related. Can’t tell (from the question) if the mood changes are very high. Blood pressure can be stress-induced, can be obesity issue, exercise issue, can be renal, can be our own body structural thing. 10 days of BP doesn’t mean that she’s going to continue. Probably lifestyle change will help it. Do take tablets for that.
Kavita: A friend of mine had premature menopause. She was 28 when she had it. If we take that example, and then consider the kinds of things that happen in our body because estrogen is not being released, should she be on HRT?
Dr Teena: Because she’s 25 years prior, definitely. Not only for protecting her for long life; it is for her own development: she needs periods monthly. Once there is menopause, there’s no period. So, HRT is definitely required. At 28, mood changes may be very bad. So, menopause has also effects on your confidence levels. Definitely, HRT is an answer for it.
Anna: Dr Teena, I need to ask you about post-menopausal symptoms. How long can these symptoms last, once you hit menopause?
Dr Teena: Usually the most severe ones last for six months; then it usually subsides. Some may stop in one or two years. Mildly, it may continue for five years also. But the major chunk is for the six months.
Anna: How long have you been having hot flashes, Nisha?
Nisha: I’ve had since, I think it was, 44, maybe two years before menopause. And two years after menopause. Not too bad. but still, I do have hot flashes. Mood - I don’t know if it’s related to life events or if it is related to…it’s not too bad.
Anna: We really can’t define, whether mood is due to…
Dr Teena: Somebody else has to decide that (laughs)
Anna: What does HRT involve? Is it expensive or is it a pill or…
Dr Teena: HRT can be in many forms. One is pills. S0, tablet form, not very expensive. It may be somewhere around the contraceptive pills you take. It can be patches: estrogen patches are now available. Then there are inserts available. And estrogen gels are available for the genital dryness.
Anna: Thank you, Dr. Teena. I think we need to have more conversations about menopause. We’re already talking about having more conversations about periods and how to talk about menstruation. It’s time we start talking about menopause…and there are a large number of menopause clinics coming up, so that’s a good sign. If you have more questions on this episode, write to us at this email: email@example.com with the subject line Women Uninterrupted. Thank you, Kavita, Nisha; thank you so much, Dr. Teena. Signing off on this episode of the Women Uninterrupted podcast brought to you by The Hindu.