Jennifer Stewart: You spoke about sleep, and you also spoke about the importance of exercise when managing perimenopause and menopause symptoms. Dr. Shaw, are there any other lifestyle changes that can significantly improve quality of life during this transition for women?
Dr. Shaw: Exercise, sleep. The other piece I would really say is psychological well-being. It’s protecting our psychological well-being.
Some of the things I say to women are: start saying no. Start saying no to all the requests you get, and I think that’s hard for women. I find it hard to say no. I have to think more to say no than I do when I say yes.
Often, women who are really good at getting things done – they’re executors. They get asked to do stuff a lot, and that can feed our sense of being needed and being productive and having efficacy in the world. But I think saying no is really important.
I think taking some time to think about, to reflect on where you are in your life and what you want – and midlife is the time to do this. So, to have questions like: What are the relationships that really feed me, and what are the relationships that are draining me? Do I need to make some changes in some relationships? Do I need to ask some things of others that are asked of me?
I find that men are really good at delegating and leveraging their supports. So I regularly say to women, “What supports in your life do you need to leverage? You don’t need to do everything on your own.”
Listen to our first episode with Dr. Sarah Shaw
So I really think self-care starts with putting our own oxygen masks on first, and we are not taught that in our culture. That’s where it starts. You know, it’s really hard to prioritize your sleep if you don’t have your own oxygen mask on.
I mean, I had this conversation this morning with a group of women. You know, often, if we have children, we stay up until the children go to bed, managing stuff, puttering around, and planning for the next day.
So we need to put our oxygen masks on first.
Catherine Clark: I want to talk about weight gain. Why do so many women experience weight gain during this time of life, and how can we handle that, even if we’re still as physically active as we have been in the past? I think that for a lot of women, that’s the toughest, most difficult part.
Dr. Shaw: So women, on average, gain about five pounds through menopause. If you ask individual women, they may not agree with what I just said. That’s what the research shows.
Most of that weight gain is due to how we change as we get older. We do become more sedentary. Even if we haven’t changed how much we eat, we don’t need as many calories as we used to before if we’re more sedentary. So much of the weight gain is due to simply aging.
But the fat distribution absolutely happens because of hormones. Absolutely. And this is what really bothers women. Even if you stay at the same weight, that fat gets redistributed from your buttocks and your thighs to your abdomen.
So women, on average, are gaining 4.5 centimetres in their waist circumference. This makes women very unhappy. Our body starts accumulating fat in different places, and it’s so much harder to hang on to muscle. It takes way more work to build muscle.
And the key is truly resistance training plus aerobic exercise, and you absolutely, 100 per cent, need both.
Jennifer Stewart: Okay, so let’s talk about sex and perimenopause and menopause. How does this transition, and then eventually when menopause happens, how does it affect sexual desire, your sexual health, and – you had mentioned – even comfort during sex? What are the impacts, and what are some solutions?
Dr. Shaw: I’m going to start with the solutions because they’re really easy and they work. I’m going to start with the simple solutions.
So, one is lubricant. It is normal to need new lubricant with sexual activity, and that really has to be normalized. The idea that lubricant means you’re not aroused enough, that there’s something wrong with your body, that you’re not into it, is just completely false. It’s not how the body works.
So, lubricant – having lubricant that you like. And I often say to women: your partner is in on this with you. Women bear a large brunt of the health changes in midlife, so share some of this with your partner. Have your partner get a bunch of lubricants; find something that can be his job or her job. Make sure that you have lots of lubricant available.
Vaginal moisturizers can be helpful, but most often women really do need vaginal estrogen.
So, 85 per cent of us will suffer some form of genitourinary syndrome of menopause. Sometimes that’s an increased rate of urinary tract infections, which can be complicated. You can have elderly women; they have bladder infections. They end up in the hospital. They have to get up in the night to pee, and they fall, and they break their hip. It’s actually very serious.
So it can be bladder infections. It can be dryness. The vulva actually changes. The tissue changes. It gets pale, vulnerable, friable. It can easily tear.
In my office, any women who are willing – and we invite all women – we actually put them through a mirror exam. So we ask them to hold a mirror while we’re going through the pelvic exam because women really need to be able to see the changes.
So there are physical anatomical changes that happen. Vaginal estrogen, as I said, is very safe. It’s very accessible. You have a number of different options.
Sometimes it comes in the form of a cream or a little ovule, like a little insert that goes in the vagina at night. Most of the products, you put it in at night for about 10 days before you go to bed, and then you use it about twice a week. So it’s very straightforward.
If sex hurts, there’s no reason why you would want to desire sex, so it’s normal not to desire painful sex. First, we need to make sure women’s bodies are actually comfortable, because if it hurts to have sex, your libido is going to plummet.
So libido and painful sex are separate things, but they’re also interconnected. If a woman doesn’t feel good about her body, if she’s exhausted, if she’s not sleeping, if she’s having hot flashes, if she’s like, “I’m scared I’m going to have a bladder leak when I have sex,” that’s really just such a bummer to your libido.
And libido is one of these complicated things that really involves, in medical terms, biology, psychology, sociocultural ideas we have about sex, and the interpersonal. Like, what was sex like with this person before? Does my partner know what I like? Can I communicate what I like to my partner? Are they interested in knowing what I might like and what brings me pleasure, or what hurts me, or what makes me uncomfortable?
So libido is really addressing all those other key parts. That might mean couples therapy. It might mean just having some good conversations with your partner if you feel comfortable.
We also know that women’s sensation changes over time because one of the basic reasons is we don’t have as much blood flow. The vessels supplying all areas of our body are not quite as good, so sometimes the vibration sense has really gone down.
So we recommend lubricators, lubricants, vaginal estrogen. We recommend vibrators to women, and we recommend women need to know what brings them pleasure.
So if you don’t know what brings you pleasure, it’s going to be really hard to communicate that to your partner. So take some time to figure out what brings you pleasure, and find a supported way to be able to communicate that if you have a partner.
Catherine Clark: Dr. Shaw, we’ve just had a very honest summary from you about sex and menopause. We’re curious to know your advice on how women can have honest conversations about this with their physician, but also, building on what you just said, with their partner, instead of feeling what I think a lot of women sometimes feel, which is shame or embarrassment.
Dr. Shaw: Let’s start with providers. So first of all, I’d say find an experienced provider, somebody who’s comfortable.
I’m amazed. Almost all of the women – like, 95 per cent of women in my office – are happy to do a mirror exam and learn about their anatomy. And I think much of that is because, as a clinic, we’re very clearly comfortable doing this work. And if we’re comfortable, patients can be comfortable.
So when you’re going to talk to somebody, make sure it’s an experienced provider. If they don’t have that expertise, that’s absolutely fine. Ask them who they recommend you speak with, and I think this all starts when you make an appointment with your provider.
Tell the receptionist why you’re making an appointment. You don’t have to go through all the details. It’s like a one-liner. But if you tell them that, then that gets put on the physician’s day sheet. It gives them a chance to think about it clearly.
Like, if they don’t feel comfortable, do they have some referrals? Is there anybody in their network who might have been more comfortable?
Go in with one hope, one hope of what you’re looking for in that appointment. If you go with a laundry list of stuff, it may not get addressed, or it may not get addressed fully.
Make it your one and only agenda item, and have some clear examples. So you want to be able to flesh out a little bit what your concern is and the impact on your life.
So it’s quite different to say, “I don’t really want to have sex anymore,” than going in and saying, “You know what? It’s been painful to have sex for about two years now. I feel I bleed after we have sex. It’s made me really scared to have sex. I’m worried there’s something wrong, and it’s impacting my marriage.”
You can’t dismiss that. That’s like, this is really impacting my quality of life. So that’s where those are the kinds of things that make a huge difference.
Jennifer Stewart: Is pregnancy still possible during perimenopause or menopause, and what should people know about contraception during this stage of life?
Dr. Shaw: Pregnancy is still absolutely possible during perimenopause. So, if pregnancy is not on your to-do list, then you really need to have a method of contraception.
The general rule of thumb is that if you are under 50 years of age and you haven’t had a period for 12 consecutive months, you should actually be using some form of contraception because it’s still possible to conceive for two years.
If you are over 50, then that goes to one year, and that’s really important to know because sometimes we’re giving menopause hormone therapy to a woman to control hot flashes, but menopause hormone therapy is not birth control.
So you may need another form of birth control, whether that is an IUD or condom, you know, whatever you choose.
I would also say birth control is a fantastic form of hormone therapy during perimenopause. It provides contraception. Sometimes – and we have many different choices of hormone therapy, so I’m careful about what birth control I prescribe – but, you know, we talked about how, in perimenopause, you have these hormones that are going all over the place.
What birth control does is it causes ovarian suppression, so it stops all the craziness and it gives you back a steady state of hormones. So you have hormones, but it’s keeping them nice and level. So it provides birth control plus hormone therapy.
Catherine Clark: Okay, so then talk to us about how menopause impacts long-term health risks such as osteoporosis. You mentioned that earlier. Also, heart disease, something that we talked about a little bit earlier in the conversation. What can be done about that?
Dr. Shaw: So our health really changes at midlife. There’s no doubt about it. It all gets very real in midlife.
So your risk of having a heart attack doubles. Your risk of cardiovascular disease doubles. Bone loss – so about two years before menopause and two years after, you lose the most amount of bone density that you will ever lose in this short span of time.
An average woman loses about 12 per cent of her bone density during that period. Some women lose up to 20 per cent, which can be very significant. If you had low bone density to begin with, that may just push you into the osteoporosis category.
Women have an increase in their LDL cholesterol, increased rates of diabetes, increased rates of mental health disorders. Those are some of the big ones.
There’s a huge increase in rates of sleep disorders, not just insomnia, but also sleep disorders like sleep apnea, which we traditionally associate with men who may be overweight or have big necks and drink alcohol. But women, even at a very healthy weight, their risk of sleep apnea increases at menopause.
Jennifer Stewart: So it’s a bit of a scary list, and particularly, it’s a little scary how everything increases so significantly when you hit these decades. So, Dr. Shaw, what proactive steps can and should women take in their 40s and 50s to protect their health as they move forward?
Dr. Shaw: Establish a relationship with a healthcare provider you trust. I think this is really key.
We’ve talked a lot about delicate issues today. Going in for a throat swab for possible strep throat feels very different than going in and talking about your hormones, your sex life, your marriage, the fact that you feel terrible because you know you don’t fit into your jeans anymore, and you’re having hot flashes at the boardroom table. That is a very different conversation than some of the other conversations we may have been having with our healthcare providers.
So, develop a relationship with someone you trust. Book a fulsome midlife health assessment. Everybody needs a preventive care assessment.
That assessment should include a couple of key things. It needs to include a full cardiac panel, and for me, it’s not just your traditional lipid panel. It should include, and this is a simple blood test, doing something called LP(a), which identifies if you have an elevated genetic risk for cardiac disease. Twenty per cent of the population do. So we diagnose this very often in our clinic for a first-time diagnosis.
It should also include something called ApoB, which is the most accurate test to show us about how many atherogenic particles you have in your system.
It should really be someone who understands the reproductive risk factors that are specific to women’s risk of cardiovascular disease. So we have over a dozen risk factors that are very specific to women.
Everybody probably knows the traditional risk factors: overweight, smoker, family history, history of diabetes, those kinds of things. And those things are all still true. But if you are a woman, you have very specific risk factors.
As one example, if you get your period before the age of 12, your risk of cardiovascular disease is 15 to 30 per cent higher. So you need a healthcare provider who knows how to provide sex-specific care.
And because medicine and science have been built on the male body, I argue wholeheartedly: if you are not getting sex-specific care, you are not receiving equitable care. Full stop.
Talk about vaccines. There are some vaccines that make a huge difference, including the shingles vaccine, which we know not only prevents an infection that can be painful, it has benefits in terms of preventing dementia. That research is especially robust for women.
And talk about your bone health early. So there’s something, and you can do a simple FRAX. It’s available online. It’s easier to do it with a healthcare professional, but women can do it themselves. F-R-A-X.
You really want to identify that risk early. We know that there are ways to mitigate bone loss, including hormone therapy. But if nobody tells you, then you don’t know if you’re high risk.
So, standardly, this is done at 65, but that’s too late, you know.
I had my first fracture when I was 40 years old. I was walking to work. I slipped on some ice, put out my arm, and I’m someone who’s exercised a lot all my life. I put out my arm, broke my arm in three places.
I had to advocate to get myself a bone density test, but that’s a real problem. That’s what we call a fragility fracture. If you’re having that, we need to think about that way ahead of time because there are things we can do, not only for you to hold on to the bone density you have, but actually to build it.
And hormone therapy is very effective at that if you’re a good candidate for it.
