Menopause overview with Dr. Heather Hirsch

Dr. Heather Hirsch, who leads the Menopause and Midlife Clinic at Brigham and Women’s Hospital, breaks down what women should expect as they go through menopause. We discuss hormone therapy, hot flashes, changes in metabolism during menopause, and the Women’s Health Initiative. Hirsch also explains how cognitive behavioral therapy can be beneficial when dealing with the symptoms that arise during the menopausal transition.

One of the most helpful things someone can do is cognitive behavioral therapy. Your listeners are probably pretty savvy and they probably know what CBT is, but it’s basically biofeedback with either a psychologist or maybe a psychiatrist to sort of help to cool, calm yourself down etc. The main problem is that it costs money and that takes a lot of time and there’s just a lack of trained psychiatrists and psychologists in this area around midlife.

Dr. Heather Hirsch

Emily Kumler: I’m Emily Kumler and this is Empowered Health. This week on Empowered Health we’re going to be talking to Dr. Hirsch who’s an expert on menopause and I feel like menopause is sort of one of those transitions in life that we could talk about every week because it’s just not that well known and it’s sort of hard to believe because I feel like it’s all that a lot of midlife women want to talk about from the weight gain to the hot flashes, to the sort of idea that you’re about, maybe you’ve got a third of your life left to lead and what are you going to do with that time. And we spent four episodes earlier this year looking at it from a very clinical perspective, looking at it from the perspective of studies that have been done and how sort of terrible some of those studies were and what a waste of money they were in large part, which we’ll talk a little bit about this week because they studied sort of the wrong population of people when it came to hormone replacement therapy. So those are really good. Well sort of thought out thorough episodes. If you’re interested in menopause, I’d really suggest you go back and listen to those. They’re fun and they’re informative and I feel like they do a pretty good job getting into the current research. Our guest this week, Dr. Hirsch is going to be sort of talking about some of the stuff that we talked about earlier that she’s also going to get into the idea of how cognitive behavioral therapy can be really beneficial for women who are in menopause or going to start being in menopause as well as looking at sort of the different pills on the market, birth control pills and how they have changed over the last even say 20 years. And so we’re going to get into all of that and give sort of an overview of menopause.

Dr. Heather Hirsch: Well, hi, I’m Heather Hirsch. I recently moved to Boston to lead the Menopause and Midlife Clinic at the Brigham and Women’s hospital and I have such a passion for midlife women’s health, specifically around perimenopause and the menopause transition. A lot of my education is in all areas of women’s health, so everything from breast health, sexual health, bone health, contraception, family planning, PCOS, you name it. I’m pretty well versed in, but as I had been going on my career and sort of niching down, I’m really finding this focus now on the menopause transition and hormone replacement therapy and really debunking all the myths around that aspect of life.

Emily Kumler: Great. Oh my God, we have so much to cover.

Dr. Heather Hirsch: Yeah.

Emily Kumler: I feel like you know, what would be helpful is maybe just start by like why are you honing in on this sort of transitional midlife period? Because for me personally being at the, you know, I’m 42 so I’m not really in the thick of it yet, but I already feel like I am and I feel like we had Nina Coslov on whose done a lot of really interesting work about like the late reproductive phase. And one of the things that I’m struck by, which I would love to have you sort put in context for me in terms of all the work you’ve done is like why isn’t this better known? Right? Like it’s not like this is some new phenomenon. Like we talk about like diabetes and it’s like type two diabetes is taking over the world and it’s like that’s kind of a new phenomenon, right? Like this is not new. Any woman who ages goes through this. And so why, you know, can you sort of put that in context for us? Why is the change becoming such a like for the first time kind of an interesting medical time to look at?

Dr. Heather Hirsch: I think that’s an excellent question. I think that perhaps the women who are entering menopause right now in the last 10 or 20 years, they’ve become really internet and online savvy. And so as they are now entering menopause, they’re really not accepting some of the answers their doctors are giving them, which, while I’m making big assumptions, some doctors are excellent. But what I always hear and the reason that this is become really my career, my mission is that they feel dismissed, they feel confused, they feel frustrated not only by society at large and the media, but also by their physicians. And so, you know, my kind of running hypothesis is the women of today who may be the baby–actually maybe a little bit after the baby boomers, I’m not sure what generation that would be, but I think they’re like, Oh no, I’m not standing for these, you know, dismissive answers. I really want to know what else is out there. And so you have on one aspect there really, there’s a group of women who are being a lot more proactive and raising awareness. And then there are things fueled by the media, whether it’s fear based or not fear based that women are sort of saying like, huh, I’m, I’m finding this in my inbox and finding this on Facebook. I’m finding this on whatever social media platform I might use. And I want to know is this true or not? And so there’s sort of this demand from both perspectives I think of, I want to, I want better than when I’m kind of getting and what the heck is really going on?

Emily Kumler: Yeah. I mean I think that really is, it’s such a good summation of it too, because I mean, I think even from the research side of it, right? Like so forget the sort of consumer everyday woman, but like looking at the confusion over hormone replacement therapy. I mean I feel like for me, like some of these studies are, the biggest travesty is like that we’re even calling these scientific, right? I mean I think some of the stuff is like, you know, you’re testing the wrong aged women, you’re skewing the results. Like you’re, it’s so strange to me that, you know, these are very, and you probably have to be a little bit political and careful. I don’t, right. So I can say all these things, but like the Women’s Health Initiative, I mean like there’s so, so much money went into some of these things and you’re like, oh my God. Like really? Like we’re going to rely on this to make our medical decisions moving forward.

Dr. Heather Hirsch: Exactly. So to give some context, I myself, I’m in my late thirties and so when the Women’s Health Initiative came out in the early two thousands I was like in college. So none of this really kind of was in my sphere until you know, many, many years later. And now that I sort of deconstruct and break down the Women’s Health Initiative to physicians, you know, that’s what I love to do in some of my, when I’m educating other physicians, I’m really breaking the women’s health study down. And exactly like you said, I’m looking at who are we really studying, what were we really using? And obviously that we were extrapolating data that didn’t apply to a large majority people. We’ve really harmed a lot of women because of that. And I will have physicians come up to me, you know, ten, 20 maybe even 30 years older than me and they’ll say, you know, my wife is still on estrogen. I never took, I don’t dare take her off of it. Or, you know, they’ll say, Heather, you know, you weren’t a practicing physician at the time, but nothing really shook like the physician’s mindset, like more than this. Like it was almost as socially fueled sort of fear based landmark study that like we all remember going into work that next day and all the questions sort of coming in and pulling women off our hormone therapy and at that time they just didn’t have enough information to deduce whether it was bad or not. And also at the same time women were totally scared and confused and physicians at the same time we’re confused.

Emily Kumler: And so I feel like we should just pause for a second and give a little bit of background. We did a bunch of episodes on menopause earlier where we get into all of this in great detail so people can go back and listen to those. But the Women’s Health Initiative was a epidemiological study that looked at a large cohort of women, but most of them were post-menopause. Is that, that’s fair to say?

Dr. Heather Hirsch: Right, so–

Emily Kumler: I should let you do the debunking rather than me trying to pull all the facts out of my ass.

Dr. Heather Hirsch: You know, yeah. Really briefly. It was a, it was actually one of the biggest randomized controlled trials the country has ever seen. And so you’re right, tons of money went into this. So that means there was a lot at stake and there’s probably a lot of egos at stake too. Right. And the average age of the women in this study was 63 and a half. Whereas what they really were hoping to get was younger women who were entering menopause or around the time of women enter menopause so 50, 51, 52. But you know, socially at the age of 50 women are really busy. They might have little kids, they might be taking care of their adults. There’s at the peak of their careers. And so what they really got in the WHI was a skewed population exactly like you said of women who are in their mid sixties and older. So the age range was from 51 to 79 so.

Emily Kumler: Which is crazy, right? Cause like those are not people who are perimenopausal. I mean I guess peri in the Latin sense of the word around, right. But like on the other side of it, most likely.

Dr. Heather Hirsch: Absolutely Emily. So that fits the physiology of someone who recently had a ton of estrogen in their body and then there’s one year post-menopausal is completely different than maybe someone who’s been without estrogen for two decades. And so when the results came out in the early 2000s they lumped all these women together and sort of just said, ah, these are the results that we’ve found when really that was just not helpful. It wasn’t really the whole story. And then the way the media spun it, because they love to instill fear and guilt in women around any reproductive choice, even if it’s at the end of your reproductive lifespan, you know, really scared the heck out of people.

Emily Kumler: So, and those results indicated basically that like if you were on hormone replacement therapy were more likely to develop cancer.

Dr. Heather Hirsch: So, right. So they said there was a 24% increased risk in invasive breast cancer, which is a really scary way to say it was really actually two to four women in a thousand over five years who took an oral medication and called PremPro.

Emily Kumler: And this is like also another example of using like relative risk versus absolute risk as a way of like telling a better story.

Dr. Heather Hirsch: Absolutely. Absolutely.

Emily Kumler: Okay, so let’s just get into some of these myths, right? A little bit more. So like estrogen is something that most women naturally produce. And then as you go through menopause, it dips and it comes back and then it dips again and it comes back. There seems to be some sort of wonder protective part of estrogen. And so the idea is you take estrogen to help you through menopause or perimenopause and that alleviates some of the discomforts that come along with menopause. Is that accurate to say something like that?

Dr. Heather Hirsch: Yes. So you’re absolutely right. So in my probably more biased and scientific opinion, I think that estrogen is really good for the female body. In fact, if you think about like in the cave days, we probably died at childbirth or like long before menopause, so we were probably meant to have estrogen around most of our lives and now we’ve nearly outlived our lifespan to the point where we go post menopausal and can spend a third of our lives without estrogen. Now, not all women are symptomatic and they fly through menopause, they don’t have any symptoms and the majority of women, about 75% of women, do have symptoms and we put this fear based culture that estrogen replacement is dangerous and that a lot of that stems from what we just mentioned in the WHI, but we have tons of data. In fact, most menopause specialty positions stand behind the fact that when therapy is taken within 10 years of menopause, it’s relatively extraordinarily, it’s relatively safe. It controls symptoms and there’s actually a lot data to show that it is preventive for heart disease. Although the way currently stands, estrogen’s not at the approved for primary prevention of heart disease, but there’s plenty of data to show that it does so and estrogen is a vasodilator and opens up those vessels so that you get better blood flow and better blood flow around your heart means a better heart overall. So it’s fascinating.

Emily Kumler: Well, so talk to me a little bit about how like people who are on the pill often experience weight gain and weight gain is also sort of something that women complain a lot about in terms of going through menopause. And so that sort of like feels to me like a counter indication or something. Right? Like if you’re taking estrogen or like even let’s say you go through menopause and you’re taking estrogen to help, that doesn’t seem to have any impact on weight, does it?

Dr. Heather Hirsch: Exactly. No. So most of the time when women go through menopause, their metabolism slows and research shows this can be up to about 25% which is pretty daunting. That means you have to exercise more, eat less just to maintain your weight. And that weight also shifts sort of into the mid belly and like, you know, breast tissue area, which is very frustrating for women. And actually a recent study just came out about a month ago showing that women who take estrogen replacement have improved lean muscle mass, i.e. basically they have better muscle mass, which probably translates into better metabolism. And so what I think is when you go through menopause, your metabolism dips and you gain weight and not that estrogen necessarily is going to help, is not necessarily a weight loss pill or weight loss option. But in a lot of my patients who use it in conjunction with the good diet exercise, they actually see that it does help keep their metabolism sort of where it was. And so they find that they don’t have to work so, so, so hard because that weight gain is insanely frustrating for so many of my patients. And they’ll come in and say, you know, my hot flashes are horrible, but the thing I can’t stand the most is my weight loss or my hair loss and things like that.

Emily Kumler: You mean weight gain?

Dr. Heather Hirsch: Yeah, weight gain is so, so, so frustrating for a lot of women. Now going back to the birth control pill, there’s a little controversy in terms of the birth control pill and weight gain. So when we actually study this, we actually don’t see that the birth control pill causes weight gain. Meaning what we randomized women, we would give them placebo or the pill. We don’t see any difference in weight gain on the birth control pill. Now that’s not to say that if someone listening has experienced weight gain on the pill and they say, Oh no, as soon as I stopped it I was better, et cetera, et cetera. There is definitely, you know, some people who do notice that it can cause some weight gain, but for the majority of people, weight is gained while on the pill. It’s probably more of a lifestyle or diet thing. For example, a lot of women will start the pill when they go off to college and you’ve got a lot of confounding factors. So college your, you know, all of a sudden eating new foods, you’re staying up late, maybe you’re drinking alcohol, you’re, you know, your life’s kind of totally off. So women, a lot of the young women will think like, oh, you know, this birth control pill, you know, I gained all this this freshman 15 it’s the birth control, the brain. It’s probably more diet and lifestyle.

Emily Kumler: That’s interesting. I mean it’s hard to tease that apart, right?

Dr. Heather Hirsch: It’s really hard. Yes, it is really hard.

Emily Kumler: And can you talk a little bit about how the pill has evolved? I mean, I feel like when I was, you know, whatever, in my early twenties late teens, there was like two kinds of pills and they were super strong. And actually I remember anecdotally being on the pill when my husband and I were dating and he was like, this is the best birth control in the world because you just sit in the corner and cry all the time. Like this is not, no one wants to have sex with you. Right? Like this is not, we don’t have to worry about anybody getting pregnant. And you know, so for me I always was like, oh, I must just be really sensitive to this. But my understanding is that they have now been able to come up with like micro pills and all of these different versions of it that still, you know, prevent pregnancy from happening, but maybe with fewer side effects. Can you talk a little bit about how that medication itself has sort of evolved over time?

Dr. Heather Hirsch: Yeah, absolutely. You know, they have taken the doses of estrogen and lowered it tremendously, almost by 50% or more. There’s some pills like Lo Loestrin that are really a fraction of the estrogen that we eat that they used to use in say the 70s and maybe into the 80s. I’m not entirely sure. So the scientists who developed birth control pills pick a really high dose of estrogen to ensure that your brain would say, oh my gosh, there’s enough estrogen we can just shut down ovulation. So that it worked so that you didn’t ovulate that’s why you didn’t get pregnant. But over the years, we’ve found that by lowering that estrogen, we can get away with lowering it still very much so that you don’t have this massive, you know, systemic effect of a synthetic estrogen that by lowering the dose that’s helped significantly with side effects like mood symptoms, weight gain, breast tenderness and et cetera. And then on top of that, we’ve also changed the types of progesterone or the progestin that’s in that combined oral contraceptive pill. And actually, you know, back to the point about the weight gain, I actually, I think that when the doses that we use today is probably more the progesterone component that causes some bloating or water retention that is probably the weight gainer. And so by sometimes switching up the type of birth control and using a different progestin, I can find that women who say I otherwise don’t mind the, like that I don’t have to put anything in my body. I want to use this option. But you know, we can sort of, there’s so many different options. So there’s four different generational types of progestins that we can choose from. So one of my biggest pet peeves is when I prescribed someone, I’m very thoughtfully prescribed them a certain type of birth control, you know, and then the pharmacy just gives them this generic version of whatever I’ve thoughtfully come up with and women get really frustrated. So there’s a lot of different changes that have come about the pill that have made it a little bit better for women who otherwise do well with it. And then of course there’s so many other options now that if they don’t like the systemic symptoms like mood or weight or whatever, low libido, that’s another one that can happen. They could use a non-hormonal option, they can use a long acting contraception. So it’s really, really just fascinating now how we essentially how I and other physicians sort of manipulate our hormones actually in a way to give women, I think their best quality of life for the season that they’re in.

Emily Kumler: So do you have like a preferential one or is it really you listen to the patient and sort of get a sense of their hormonal fluctuations in some way?

Dr. Heather Hirsch: Absolutely, yes absolutely. I definitely am an “there is no one size that fits all” kind of doc. And my residents, this will frustrate the heck out of them or my, cause they’ll say, you know, what’s your go to for birth control? What’s your go to for hormone replacement? And I really don’t have one because it depends so much on the person’s situation, their priorities, their past experience with either we’re talking about the you know either kind of hormones, birth control, hormone replacement and their lifestyles. So it really comes down to all of those things. So then my little computer brain kind of will help come up with a couple of options and then I’ll have my patients sort of pick and choose from there.

Emily Kumler: That’s so nice. So I mean how much time do you spend with people would you say like, I mean that’s, this is like a big topic on the podcast, right? Is that like women have to advocate for themselves more and be more educated when they go into the doctor’s office. Not because there’s any kind of malice involved in the interaction, but just because of the limited amount of time.

Dr. Heather Hirsch: I know. Absolutely. I actually just did a podcast on seven ways to get the most out of your doctor’s visit because I have absolutely agree so.

Emily Kumler: Oh we’ll totally link out to that. That’s a great resource for people.

Dr. Heather Hirsch: Yes, yes, yes. And you know it is a little bit from my perspective also being a patient myself, but if I can offer like a tip is that one of the things that I mentioned a lot for to advocate for your listeners is to journal your symptoms for as long as you can before you go into your office visit. Because if I have, if I am spending less time sort of, you know, doing recall bias and figuring out how long you’ve had these symptoms for or how far apart your periods are or what was that name of that pill that you really didn’t like. If you can journal and bring all that information in with you, that’s great cause I can see it and then we can spend the majority of that visit really talking back and forth about the couple of different options that I think are going to fit that patient the best. So yes, I typically, I typically have 40 minutes with a new patient and 20 minutes with a return patient and we use every second of that time. And sometimes I go over and that’s very frustrating. But my patients always know if they’re sitting in the waiting room is because I’m taking my time with each and every patient.

Emily Kumler: I mean, 40 minutes is like absurd. I feel like in today’s environment, I think like the average visit is like five minutes or seven minutes (Editor’s Note: Recent studies have estimated the average visit to be 13-16 minutes) or something. It’s like…

Dr. Heather Hirsch: Yeah, yeah. Luckily, you know, I think there’s a couple things at play at an academic institution that’s affiliated with a hospital, a teaching hospital. Sometimes you can get away with a little bit more time versus like a private practice.

Emily Kumler: Also I feel like a lot of what you’re doing is nuanced, right? So you’re kind of like playing detective. So you know, based on someone’s age or you know, other health conditions, but then you’re deducing down a ton of information to try to figure out what might help them.

Dr. Heather Hirsch: Yes, absolutely. You’re, I am, I’m a little like detective. That’s my job. I’m a medical detective. Absolutely. And so the more information someone can come in with that, they’ve kind of already structured and I can get this glimpse or this bird’s eye view of like the last three months or six months or whatever it is, the more time we already kind of had to spend on what options I think would be, would be really good. And I think also too, I definitely want to acknowledge my, my really solid training. So after I did residency, I also did a women’s health fellowship. And so, you know, her personally, my knowledge of this specifically has gotten really, really good. And I also practice now consultative. So that means that’s really what I’m just focusing on. So it is my strength. It is, you know, something that I think about and read about all the time and I just, I love doing. I love the fact that no one size fits all. It makes my job actually fun and it makes, I think for my patients a much more satisfying outcome.

Emily Kumler: And so what, at what age do you recommend people start thinking about hormone replacement therapy? Like is there a sort of an average that you’ve come across just in your own practice?

Dr. Heather Hirsch: You know, that’s a really good question. I love, occasionally I will get a patient who says, comes to my office and says, you know, I feel fine. I’m noticing my periods are skipping a little bit and I just want to know what could come. And I think that is great because they just want to visit with me. They probably don’t need anything at this point. They just basically really want to have some education and some foundation and some things to look for. And so I think if you start thinking about this at perimenopause, that’s a really good time. There’s no wrong time. One of the things I advocate lot for or I kind of think is interesting is how our generation, you know, may talk to our kids about menopause because I dunno about you. My mom didn’t talk to me very much about menopause. It was really only when I became a menopause specialist that I started caring a little bit more about her story, you know, and she’s convinced, she’s like, I had my tubes tied and that was it. You know, I think that is interesting to see if this generation or the generation is going menopause now that the women who are in their 50s and forties and 60s if how they’re talking to their daughters and et cetera. Because I think just like opening the dialogues that people know, like your period starts and your period sucks and you have to get tampons and pads. Like one day though, it’s going to end, and here are the things that happen then, you know, and if someone’s been suffering, another thing, you know, on the other end of the spectrum, [?] women come to me and they’ll say, you know, I’m now 67 and I’ve been having hot flashes for two decades and everyone’s been telling me they can’t help me but I really need help. And so there’s never a time where you’re, you’re too late. Now at that point if you’re a little bit older, the risk-benefit conversation just a little bit different and a lot of things are individualized and depending on, you know, your medical history and your background and your priorities, but there’s no right or wrong time. But you know, ideally if you start journaling some of your symptoms in, you know, that mid- to late forties, I think that there’s, you know, no harm in it certainly can’t hurt you and just gets you more in tune with your body and also just your, your own health priorities. Cause they might not be the same as your friends or you know your mom.

Emily Kumler: Yeah, no, definitely. And I wonder whether there are any things that you recommend to people. I mean, I think one of the symptoms of perimenopause or this late reproductive phase is having more severe PMS.

Dr. Heather Hirsch: Mhm.

Emily Kumler: And I think sometimes that seems to be the thing that people really are like out of the blue, they’ll realize that they’re really agitated, you know, or that they’re really anxious and that that’s become like sort of a new symptom to them. And I wondered whether, I mean I’ve definitely heard that anecdotally from friends and I think we covered that a little bit and when we did the menopause series earlier this year. But I wondered like in regards to that, there also seems to be like some research, although I don’t know how rigorous it was about the benefits of exercise and that that can help with, you know, sleep disorders around menopause and obviously with weight gain and with hot flashes too. Is there any, do you have any like recommendations for things like exercise or other like sort of non-pharma things that people can start with?

Dr. Heather Hirsch: Yes, absolutely. And that’s a great point. In fact, there has been a lot of interest in research on the onset of worsening or new mood disorders in this perimenopausal phase, you know, I definitely want to also speak on the lifestyle changes, but to that point we have found that estrogen replacement in that perimenopausal phase that you’re having new onset or worsening depression or anxiety way out of baseline, estrogen replacement actually really does help. And we don’t yet know all the nuances of why and maybe having to do with the way the receptors are on the brain. But you compare that to using either an SSRI or an antidepressant or

Emily Kumler: Which I think is what is routinely prescribed.

Dr. Heather Hirsch: Prescribed, yeah, exactly. And I actually think, you know, the risk benefit ratio for using estrogen replacement is much more favorable. Now to get to the lifestyle recommendations. There’s also definitely been a lot of interest in research in this too and there needs to be much, much more, there needs to be plenty more. One of the most helpful things someone can do is cognitive behavioral therapy. So you know, your listeners are probably pretty savvy and they probably know CBT is, but it’s basically biofeedback with either a psychologist or maybe a psychiatrist to sort of help to cool your calm yourself down or an etc. The main problem is that there’s just that costs money that takes a lot of time and there’s just a lack of really, you know, trained psychiatrists and psychologists in this area around midlife.

Emily Kumler: Yeah, so that’s so interesting. I’ve never heard that before. I mean I think of cognitive behavioral therapy as like good for the kind of like PTSD and like I’m scared of bridges. Though people have told me to go, you know, like this sort of like face your fear.

Dr. Heather Hirsch: Are you really scared of bridges?

Emily Kumler: I have like in the last few years have developed this weird thing where I just start sweating when I have to drive over a bridge. To the point where like my kids are like, oh my God, mom, are you going to be okay? And I’m like, no talking in the car.

Dr. Heather Hirsch: Isn’t that fascinating? That is fascinating.

Emily Kumler: Fascinating. I mean, I was like a fearless child. Like, I, nothing bothered me ever. And so it’s like very strange to have something that’s so ridiculous, you know?

Dr. Heather Hirsch: Yes. Yes.

Emily Kumler: And people are like, Oh, maybe you’re scared of heights. And I’m like, no, I like have no problem in planes. I’ve no problem like skiing down a very steep slope. Like it just seems to be connected to the bridges.

Dr. Heather Hirsch: That’s very fascinating.

Emily Kumler: And it’s like a self fulfilling prophecy cause I’m like, my hands are so sweaty that I’m gonna like slip off the wheel and then we’re all going over.

Dr. Heather Hirsch: Oh my gosh. You know, it’s, that in of itself is a great example of something like in your early forties, you’re noticing that maybe, I’m not sure exactly when it started, but you’re noticing sort of this new thing that otherwise were totally fine with and it’s kind of unexplained.

Emily Kumler: Yeah.

Dr. Heather Hirsch: And so it’s fascinating. In terms of exercise, there has been a lot of different research on this and you can find either a null results, a positive result. And so it’s a little mixed. And, you know, my personal opinion is there’s no way exercise can hurt. And you know, it’s probably just being smart about what type of exercise works for some people. So, you know, your sympathetic nervous system, your fight or flight, sort of that runaway from the bear kind of come in to get to you is going to be wrapped up if you do, you know, high intensity interval training or cardio. And so if you’re already feeling a little anxious or maybe you’re already having a lot of hot flashes, you might want to do more like gentle yoga, meditation, pilates, barre classes. So I think it’s, there’s no way that I could probably hurt a person. We, you know, again, research goes kind of back and forth on this, but overall I think if you find that exercise helps absolutely is a great, you know, it’s something we use for mood disorders, anxiety and depression, you know, outside of midlife related anxiety and depression. So I’m a big proponent, I’m a big avid exerciser myself and so, you know, as long as it’s not causing anyone more distress, there’s no way it can be harmful. And there’s a lot of other lifestyle things that are really cool. I’m actually doing research with a company called Ember Wave. Ember Wave is a product that came out of three MIT graduates. It’s now actually a Cambridge Massachusetts based company and they have this personalized heating and cooling device that you wear on your wrist. So it is now commercially available and you can go to emberwave.com and a retail store about two, $300. And essentially if you’re getting a hot flash, you can tap it and it sends a cooling sensation down your arm. And I’m actually, working with this company to do research studies. It’s been, you know, obviously used commercially and they’ve found anecdotally that menopausal women suffering from hot flashes do, do really, really love it. So that’s fascinating. And of course there’s all types of cooling blankets, cooling scars, cooling clothing of course, dress in layers, handheld fan, you know, prop your fan up at work if you need to. Keep the house, you know, it’s 65 degrees if your spouse will let you. All of those are great lifestyle things that people can do as well.

Emily Kumler: So just to go back to the cognitive behavioral therapy as a treatment for severe PMs, what is that about?

Dr. Heather Hirsch: We are kind of looking at this in terms of hot flashes also for mood and anxiety that either start in perimenopause or into menopause. So it would, you know, not having gone through it myself and actually quite frankly not prescribing it very much because of the lack of psychotherapists or therapists who are well trained in midlife CBT. I would imagine it’s really just, you know, using your own, your own regulatory system to notice when you are starting to either get anxious, depressed or sweat and to keep yourself sort of out of those situations. Figure out what your triggers are, try to avoid them or try to combat them with things that will help keep you either calm and cool or literally calm and cool, so.

Emily Kumler: Correct me if I’m making this assumption and it’s not right, but it sounds like there is an assumption underlying that that hot flashes are brought on by some emotional slash neurological anxiety being one kind of response. Is that I didn’t know that.

Dr. Heather Hirsch: Yeah. So the pathophysiology of hot flashes is something that we’re still really trying to figure out. And what we do know is that the menopause, when we lose estrogen, that hormone has something to do with the way our thermal regulatory zone in our brain works and it, and it narrows a lot at when we lose the hormone estrogen. So here’s an example. When I get out of the shower and I’m not menopausal, so when I get out of the shower and I go somewhere that’s really hot, really cold, my body can make that adjustment without me really noticing it too. And that’s an extreme example is like a shower. Let’s say I was walking down the hallway, went sitting in my office, which is nice and cool and I walked out into the hallway and it was nice and it was really toasty. My body could. It has a wide range where it can fluctuate and work within that zone and I won’t sweat or anything like that, but when you are menopausal and you lose that hormone, something happens where that thermoregulatory zone really narrows so that the adjustment to even a very ambient change in temperature that you or I might not notice, it can really trigger a hot flash or same idea could also be triggered by some type of emotional response, some type of neuro response and we’re trying to really kind of figure out how this is all happening, but we do think that it involves this narrowing of the thermoregulatory zone in our brain.

Emily Kumler: I mean I feel like this is so fascinating and again like just leads me to believe like why hasn’t anybody been curious about this in the last hundred years?

Dr. Heather Hirsch: Right.

Emily Kumler: I’m Emily Kumler and that was Empowered Health. Thanks for joining us. Don’t forget to check out our website at empoweredhealthshow.com for all the show notes, links to everything that was mentioned in the episode, as well as a chance to sign up for our newsletter and get some extra fun tidbits. See you next week.

Guests