It’s 3 am. Do you know where your hot flash is?

If only you had one in within reach of your bed...

Perimenopause looks and feels different for everyone.   We do hear recurring themes, many of them expected.  I’m not going to reinvent the wheel when this piece by the NYT is so well written.  Please, please, please read it if (when) you have questions.  It’s a great, well researched, easy to read reference.  

10 Menopause Myths the Experts Can’t Stand - The New York Times 

But I will do my best to answer some things, right here, right now.

Why do my hips (joints in general) hurt?   

• nobody really knows.  Many of us have SI (sacroiliac) joint pain, which is technically in the lateral low back.  It’s a bitch.  Redundant PT treats it, until you don’t do the exercises, and the pain comes back.  Perhaps yoga is the answer.  Less sitting, more walking.  Less stress.  probably Greek yogurt.   

• but there’s also the pain right over the hip sockets, the one that flares when you try to sleep on your side so that you don’t snore.  Like when you were pregnant and petrified that you were going to sleep on your back and somehow damage your baby.  So you slept on your side, only to wake up with a throbbing pain in the hip holding all your weight.  Pillows only help so much. 

• The weight gain and distribution shift to our bellies in perimenopause doesn't help either. Studies confirm, yes, this is a real thing. But not why it happens or how to prevent it. Useless.

Brain fog is real.  What can I do about it? 

• tricky.  A lot of it traces back to disrupted sleep, which has so many causes for those of us in middle age.   The easy answer is to get better sleep.  How to do that is more complex.   

• Some studies with HRT (hormone replacement therapy) showed improved brain function and focus.  Many of these were before the landmark WHI (Women’s Health Initiative, the largest randomized controlled trial on hormone replacement) that turned everyone’s perception of HRT upside down.   

Okay, yeah.  Let’s talk about why we’re not talking about hormones. 

• give your doctor a little compassion.  If she’s your age, or older, she lived through the pendulum swing of HRT.  In the late 90’s, it was fabulous; everyone should be on it.  So many studies showed that it could be a cure-all for middle aged woes—you name it, HRT made it better.   Not just vasomotor symptoms (the catch-all term for hot flashes and night sweats) but vaginal dryness, UTI’s, dementia prevention, bone density, mood disorders. We almost had to find a reason NOT to use it.  It was the Oprah giveaway of prescriptions: “YOU get hormones and YOU get hormones and YOU get hormones...” 

• Then, at the turn of the century, just after we realized that Y2K wasn’t really going to be a disaster, the WHI came out.  Suddenly, nobody wanted HRT.  It was going to give us all cancer and blood clots.  The benefits that were seen in prior, smaller, observational studies didn’t pan out in larger studies.  Or the risks outweighed the benefits for most women. And the largest study, the WHI, was cut short and will never be replicated.  It didn’t answer all the questions that it set out to.  Which leaves us where? 

• No easy answers.  HRT can be a godsend.  It can be scary.  Yes, there are risks.  Nothing is risk free.    What was an easy yes for most women became a long discussion of pros and cons.  And 20 + years later, the black box warning has been removed.  Which does nothing to simplify that discussion. 

  
  

F.D.A. Will Remove Black Box Warnings From Hormone Treatments for Menopause - The New York Times 

Why can’t I remember anything? 

• see sleep and brain fog above.  Also, give yourself some grace.  You are likely in a sandwich of launching and caregiving for the young people and the elderly in your life.  You’ve reached a career point where you can see or have seen the top, and maybe it’s not what you expected.  Everywhere you look there is something that you were supposed to have been doing or eating or not drinking that was going to keep your brain perpetually youthful.  

Why am I a sweaty mess when I’m trying to get dressed after my shower? 

• you’re in a hurry.  Probably.  Your nice warm shower felt so good on your hips and low back, and now you have to get dressed and go somewhere.   

• My quick and easy tricks for this, which may or may not work for you:   

  • If you have time, put on just your underwear and lay on your back on your cool (and hopefully clean) tile or hard surface bathroom (ideally) floor.  Try to touch as much of your skin to the cold floor for a few minutes.  No bra, since under the boob is where some of the most annoying sweat collects.  Weird but effective.     Plus, getting up and down from the floor is good for mobility.         

  • Your hairdryer likely has a cold setting or button.  Use this as you get dressed and ready.  It can be your best friend.  

  • Keep your feet bare as long as possible, and try to push as much of them into the floor as you can without it being weird.  This also helps when you’re getting ready for bed, or when you wake up with the 3 am hot flash. 

    

    An ice bar would be ideal...until it melts.

    
    

Speaking of 3 am: 

• maybe your bladder woke you up, or the cat, or a sound.  It doesn’t matter.  But now you’re hot and miserable, and you have to pee.  And now that you’ve done that, you’re wide awake.   

  • Mine is always within minutes of 3 am.  It’s generally once a night, and tolerable.  If you’re still hot, take off some clothes and/or covers.  It’s your bed.   Move the pet that has you pinned.  Flip the pillow to the cool side.  Deep breath, it’s going to be okay.   

  • If this is happening more than you want to deal with, then have the hormone conversation.  Once a night is manageable for me.  The goal with HRT in most studies is to get patients down to 4 to 6 vasomotor episodes per 24 hours.  If you have 2 a day, you may not notice much improvement. 

Is HRT for me? A totally made-up calculation: 

• Take your age in years 

  • Subtract the number of months since you had a period 

  • Add the number of times you wake up overheated and can’t get back to sleep per week 

  • Multiply by the number of pets that pin you in a position in bed. 

  • Take this to the power of the number of times a week someone calls you irritable. 

  • Divide by the minutes you stare at your clock in the middle of the night. 

  • Add each alcoholic beverage you consumed today.  

The result is the likelihood that you might benefit from HRT.  It has a 50% accuracy.  If you have any absolute contraindications for HRT, this formula is null and void. 

• But seriously, most studies with HRT have at least a 40% placebo effect, and some of the benefits alone don’t justify the risks.  It’s a conversation. 

  
  

Why don’t we check my hormone levels? 

• First of all, what does that even mean?  Estrogen and progesterone, which fluctuate throughout the month?  If they are “normal” and you are miserable, are you going to say, oh, well, I guess HRT isn’t for me and I’ll just suck it up?  No.  We treat the symptoms you have, starting with the lowest effective dose.  We can always go up if needed.   If you’re still having periods, then the starting dose is higher, like that found in low-dose birth control pills or the vaginal contraceptive ring, to control the symptoms.   

• The utility of a lab test depends on the clinical situation.  Some other hormones can change treatments, but you have to look at the whole picture.    Yes, our thyroid function can change as we age, so that’s worth checking out.  When our thyroid activity is low, our metabolism drops and we feel sluggish, with weight gain and changed periods.  Wouldn’t we all like to take some thyroid hormone and boost your metabolism and energy levels?  (Don’t do it, there are nasty side effects to over-replacing thyroid hormones.)  Most of the time, we are going to have totally normal thyroid function.   

• There’s a lot of hype about bio-identical hormones and male hormones, like testosterone.  There’s not a lot of data on the utility or safety of checking or taking these.  Hormone replacement prescriptions are regulated and checked for the amount and quality of the substances they contain.   If it says 1 mg of estradiol, then 1 mg of estradiol must be present, or it fails quality control.   

  • Compounding pharmacies are not regulated in the same way.  Over the counter herbal and “natural” remedies don’t fall under these guidelines.  The amount of active hormone (if any) in any of these can vary from non-effective to excessive, and can vary from batch to batch.  Beware anyone who tests for profit, and then sells you a replacement based on those results.  Follow the money. 

Why can't we just do this at my well exam? Does it really need extra time?

• If you’ve been on HRT or low dose birth control pills and haven’t had big life or health changes, great.  She’ll refill it for you.  If you haven’t been on HRT, you deserve a full discussion of what works best for you; risks, benefits, and alternatives; why your aunt Pam has her estrogen and testosterone checked every month and yam cream—whatever things you want to ask.  Reread the first sentence: Perimenopause looks and feels different for everyone. 

• Expecting your doctor to wedge this discussion in with your cholesterol check and your mammograms and blood pressure isn’t fair to either of you.  How many minutes have you been reading this?  More if you clicked on the useful information from the Times instead of just my rant. You don’t want to come back to the clinic for another appointment—I totally get it.  This is a great topic for a video visit, where you can get information in real time, and a prescription.  Even better: when you do your well exam, with primary care or your OB/GYN, let us know that you want to discuss hormones/perimenopause further.   We can’t do your well exam remotely, but we certainly can and do manage HRT without you physically being in clinic.   

Despite what you’ve seen online, we don’t want you to “tough it out”.  There are options.  Notice the use of "we". Your doctor doesn't want you to suffer either.