Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Colon. Today we're highlighting menopause and perimenopause management, updated guidelines for hormonal therapies, weight management strategies, and so much more. Joining me is Dr. Mani Shukla. She's an assistant professor in the Department of Family and Community Medicine at UAB Medicine, and she's the medical director of the Highlands Family Medicine Clinic.

Dr. Shukla, thank you so much for being with us. As we get into this topic, which is really just such a good topic, I'd like you to give us a little working definition of perimenopause, menopause, and post menopause for us to begin so we know what we're talking about here.

Dr Minakshi Shukla: Okay, Melanie, thank you so much, first of all, for having me today. and I think this topic is one of the topics which is very close to my heart. so that is. Why, I love talking about it. So let's go to some definitions. so I think the way we like to think about perimenopause is essentially it's a transition phase before the final menstrual period, when you'll see a lot of hormonal fluctuations, your cycle can start getting irregular, and that's the time when you'll start noticing symptoms like heart flashes, sleep issues, and mood changes.

Menopause on the other hand, usually is a retrospective diagnosis, which means that you should not have any periods for 12 conservative months. And only after that we tell that a woman is in the menopausal stage. Usually the average age in United States is about 51 years, when most women will have menopause.

Post menopause is essentially everything after that and you know, the early postmenopausal ears are when symptoms and physiological changes tends to be the most noticeable.

Melanie Cole (Host): Thank you for that. So now we're clear. How have clinical guidelines for menopausal hormone therapy specifically evolved in the last couple of years, particularly regarding timing, dosing, formulation for perimenopause versus post menopause. We're always sort of hearing varying information about hormone therapy. Clear a little bit of that up for us.

Dr Minakshi Shukla: Yeah, I think, in the last few years, we have basically shifted from one size fits all and. To a much more individualized approach, risk-based approach. We now recognize that hormone therapy is the most effective treatment for heart flashes and genital urinary symptoms. And for healthy women younger than 60 years or within 10 years of menopause, the benefit risk profile is very favorable.

So we talk about when to start. That's the timing. We also like to personalize, you know, the dosing, the root formulations. Over the years now, we have various formulations available. We have oral roots, we have transdermal patches, we have topical creams, gels and whatnot. So, based on the patient risk profile, we decide what would be a favorable route to give to the patient.

Again, now we have more lower systemic doses, which are widely accepted for vasomotor symptoms. Vaginal estrogen cream is a great option now for some of the genital urinary symptoms and sometimes. We might prefer even transdermal route. So it really depends on what the patient risk profile is.

Melanie Cole (Host): Well, so Dr. Shukla. There's always conversation about that window of opportunity for starting hormone replacement. Tell us a little bit about the science behind that in practical terms as you're speaking to fellow clinicians and how you even speak to patients about it, because patients have a lot of questions about risk, and as you said, the patient profile comes into play As we're personalizing this now, tell us a little bit about why and when.

Dr Minakshi Shukla: so you know, I always tell my patients, and even for my fellow clinician, that timing matters because remember, estrogen interacts differently with the healthy, recently menopausal cardiovascular system than with the one that has more established atherosclerosis. So do remember as you age, so do your blood vessels. So starting her hormone therapy.

Close to the time your period stops tends to carry a lower cardiovascular risk compared with starting many years later, because probably now you have more established atherosclerosis. It's not a heart disease preventing tool. Again, to remember right. Hormone therapy is not used to prevent heart disease, but for symptom control and starting earlier will usually offer a safer and smoother benefit risk profile.

Melanie Cole (Host): What about non-hormone replacement therapies? Dr. Shukla, how are you incorporating those into your practice these days? As we think about. As you say, symptom management, there's metabolic shifts that are taking place, weight gain, bloating. I mean, there's all kinds of other things going on. Tell us about some of those non-hormone replacement therapies.

Dr Minakshi Shukla: I think non-hormonal options are super important. They are first line for women who can't. Take hormone therapy or who don't want hormone therapy. You know, ultimately it also depends on patient's preference and her choice. And I think they are great adjuncts when symptoms don't fully resolve for heart flashes.

We do have many options. Like we have some of the antidepressants, they are selective serotonin re reuptake inhibitors. We have some of the newer agents like the Neurokinin three agonist. OSA is a great option. the other thing, how do I use them in my practice? Obviously, if there is a contraindication for hormone therapy, I always like to discuss the non-hormonal options with my patients.

Also, you know, sometimes if I can kill two birds with one stone, for example, if I see a patient has mood symptoms, has depression or anxiety, then starting a antidepressant makes complete sense that as it can help with both her menopausal symptoms and even her mood symptoms. So again, looking at that patient risk profile.

Melanie Cole (Host): Well, so that makes a lot of sense. And as an additional adjunct, and we think of those metabolic changes, GLP one agonists are being used more than ever in menopausal women. Do. Or Shukla, when does that kind of pharmacologic support become appropriate and become something you start discussing?

Dr Minakshi Shukla: I do feel, in midlife, again, we all know that there are so many physiological changes, physical changes, which are happening because of aging and menopause. And that predisposes the woman to really lot of weight gain. And we know that declining estrogen levels in the menopause leads to that increased abdominal, and visceral fats.

So I think that near GLP one Agon really offers substantial weight loss and additional benefits, such as improved metabolic health and reduced cardiovascular risk. So I think they should be used as an effective tool, but we do need to also consider the GI side effects. Like GI issues are a main thing with most of the GLP one medications.

The other thing is. Not forgetting the education about maintaining good protein intake, maintaining good strength training exercises, those are all important for a healthy weight loss as well.

Melanie Cole (Host): One of the things that happens to us, Dr. Shukla, is bone density. As we get older, we're losing certain percent per decade. How are the guidelines shifting for preserving that long-term cardiometabolic health, cognitive health, and mobility? As far as bone density, when we think of. The drugs that are out there, the medications and the hormone replacement and what that's doing to help our bone density.

Tell us a little bit about how that all works together now.

Dr Minakshi Shukla: to be honest now, we are really reframing menopause as a key window to protect your long-term heart, brain, and mobility health. So it really boils down to aggressively managing your blood pressure, your cholesterol and metabolic risk and midlife. So most of the time what happens is, you know, you see that women are coming to a doctor's office when they are in the childbearing age and.

Then you see a gap of 10 to 20 years, right? And suddenly around the menopause you will see that once they start having symptoms, they will start visiting the doctor's office again. And that's the key window which we are trying to utilize here, where we are really trying to, you know, aggressively manage all the comorbidities as well.

It also means, as you said, for the bone density. How do we try to like help with that? Right? Prioritizing resistance training for muscle imbalance. We all know that hormone therapy also helps in maintaining that bone density, also supporting their cognitive health with sleep, social connections. Vascular risk reduction.

So menopause care, I think, is becoming much more holistic. It's not just about heart flashes, but it's really about lifelong function and quality of life, which I really try to stress to all my patients and fellow clinicians.

Melanie Cole (Host): I'd like to expand because it is shifting towards this whole body health and things that we run into as we enter perimenopause, menopause, and post menopause. Sleep disruption. You already mentioned depression and anxiety and certainly that's pervasive for many people these days, but if you are menopausal, it certainly can be heightened.

How do you work with your patients specifically on tools for stress reduction, for sleep disruption, because that's a big one as well, and. Evidenced-based ways you know, we talk about exercise. I'm an exercise physiologist, so this is something we've talked about for years and years of exercise and bone density exercises and cardiovascular.

But those other things that come into play, Dr. Shukla with sleep and stress, what do you tell your patients about that?

Dr Minakshi Shukla: to be honest, sleep and vamo symptoms are so closely linked. Night sweats often cause awakening, and that leads to poor sleep, and which often amplifies the symptom burden. That, again, is so closely linked with your. Metabolic Dysregulations so often, to be honest, if we start treating the women's Vasomotor symptoms, you see that they come back and they tell you that, Hey, know it was not a sleeping pill, which you gave me, but I really feel that I'm getting better sleep.

And to be honest, it was actually the vasomotor symptoms which got better and that's why the patient was having a better quality of sleep. Again, talking about anxiety and stress reduction. So going back to our previous question, where we talked about adjunct medications, so not thinking about or not trying to shy away from using our antidepressants if we feel that anxiety is really playing a big part and really affecting the quality of life.

And I often start with, realistic low burden tool, like short breathing exercise, maybe a 10 minute wind down routine brisk walks during the day. Also talking about other things like, cutting down on the ultra processed foods, which really leads to increased calorie density, impairs your satiety, and again, leads to that weight gain so you can see how everything is so closely related and can really have an effect on your health overall.

Melanie Cole (Host): Well, Dr. Shukla, you've given us a lot to think about and really let us know this evidence-based information about things as they're changing because it really is a rapidly evolving field that you're in. So as we wrap up, what advice would you give clinicians? Who feel undertrained in menopause management?

Because I think this is common, and it's certainly not the field for everyone as women come to their physicians asking about risk factors for breast cancer if they start menopause and management and hormonal therapy. And what advice would you give them about learning to treat the woman as a whole person and not just those symptoms?

Dr Minakshi Shukla: I always tell my fellow clinicians, even our resident physicians, students learner, that start with the basics and build from there. Right? Don't shy away. I think the first thing which we need to get ourself comfortable with is asking women if they are having any of the menopausal symptoms, right?

So the first thing you wanna know whether your patient is having any symptoms talking, feeling uncomfortable about talking about vasomotor symptoms. Getting comfortable with some of the non-hormonal options, right. I think most of the physicians probably feel way more comfortable with non-hormonal options compared to hormonal options. So even if you can start there.

And slowly and steadily build your knowledge gaps on starting hormone therapy. That might be helpful as well, using simple shared decision scripts with your patients. Talking about benefit and risk, I know you asked me regarding the breast cancer risk, right? Many women, I think, are afraid that, or there is just, a thought that, hey, hormone therapy causes cancer, which is not true at all.

So learning to talk about those benefit versus risk. Looking at the patient risk profile, again, I would like to emphasize and I think all these tools in your pocket will really help you to take care of your menopausal women. And again, when there is a difficult case, not shying away from seeking guidance For someone who knows a little bit more on this topic, I always say that you don't need to be a menopause specialist to give great evidence-based care with empathy.

I think we can all do it.

Melanie Cole (Host): Wow. That was beautifully said. Dr. Shukla, thank you so much for joining us today and sharing your incredible expertise on this topic. And for more information, please visit our website at uab medicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole