Ep 166: Fertility and Perimenopause Dr. Adrienne Mandelberger
Fertility Forward Episode 166 :
Perimenopause is a topic that is not discussed often enough and having the conversation helps empower women to know that they don’t need to suffer through it! Today, on Fertility Forward, we are discussing all things perimenopause with the CEO of Balanced Medical, Dr. Adrienne Mandelberger. She is a minimally invasive gynecologist and menopause specialist with a passion for preparing women for perimenopause. Tuning in, you’ll hear our guest debunk some perimenopause and fertility myths, symptoms of perimenopause, why diagnosis is difficult through testing, and the importance of tracking symptoms. We delve into perimenopause symptom types and treatment options before talking about the incredible benefits of hormone therapy to mitigate perimenopause symptoms. We even discuss why perimenopause does not mean infertility! Finally, we share what we are grateful for today. To hear all this and more, be sure to listen now.
Rena: Hi everyone. We are Rena and Dara, and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
We are so excited to welcome to Fertility Forward today, Adrian Mandelberger, who is a board certified gynecologic surgeon and menopause specialist. She is the founder of Balanced Medical, a gynecology and preventative women's health practice on Long Island and the founder and CEO of the virtual education company, All Things Menopause. Dr. Mandelberger is passionate about educating and empowering women to make informed choices during the menopause transition. Her special interests include the intersection of ADHD and perimenopause. Yay, Adrienne! So excited to have you on today. Adrienne and I went to college together. We graduated in 2008 and worlds collide here we are in the same field, and so, so honored, proud of you, impressed. Thank you so much for coming on and we're so excited to hear your take on hormones and fertility and perimenopause.
Dr. Mandelberger: I am thrilled to be here. And, and I don't know if you know this, but I also feel connected a little bit to RMA because I rotated through as a resident, so I was yeah, and I was, I was a fellow co-resident with some of your famed Dr. Lucky Sekhon and Leigh Rosen and so they're all pals of mine.
Rena: Oh, I did not know that. Well, you are in good company. Amazing! So tell us about you, your practice, and let's dive right in. I think this is such a hot topic and we haven't really covered this before in the podcast.
Dr. Mandelberger: So that's great. So I'm excited to talk about it. Well, I am by training after residency, my generalized OBGYN residency, I did specialized training actually in minimally invasive surgery. So that was sort of my first, my first full all in venture. It was operating, which I still do and love. I also did general gynecology in my, my earlier years as an attending. And it was so quickly and so obvious to me the glaring gap in my own training in perimenopause and menopause care. So that, that pretty early in my attending career, I realized I had to educate myself more on it just because I feel like I didn't learn it and I didn't know fully how to help my patients. And once I did that and started treating patients, I realized even more how much there was that need, how grateful patients were, how, it's not easy, I joke, but how I used to call it like, this is so easy. Do they're, it's fixable, you know what I mean? It's, you can treat patients’ symptoms and they feel so much better. And so I kind of, and, and the other part of things was I realized there was, because of the unmet need, there was this sort of, I call it the counterculture of these clinics that were providing non-evidenced based care, potentially even dangerous care. And these poor women, that was the only way they could find any care. And so I was like, I have to go do this and I have to do it the right way with science backed, you know, evidence-based practice, but at the same time have that time to be able to devote to my patients carefully 'cause that was the other thing they were only finding in these clinics was outside of the insurance based model where you're hitting it every 15 minutes, they were, they were seeing providers that were listening to them and they felt validated. And unfortunately many of them ended up with alternative treatments that aren't ideal, but they still were seeking out that because that's a huge part of it, if not most of it. So anyway, that led me to open my own practice, which I am about eight to nine months in of my brand new practice, Balanced Medical where I still do gynecologic surgery, but there's also a heavy emphasis on menopause care, perimenopause care, as well as just preventative women's healthcare. I'm just kind of trying to fill in all these gaps that I see that just aren't happening and I feel so strongly that need to happen for women.
Rena: So I'll disclose because this is a safe space that, so I'm 39 and I had my annual GYN appointment the other week, and I asked her, I said, I can't believe I'm asking you this, but when do I think about going off the pill? Like how long do I stay on this for? Because, and Adreinne, you can obviously confirm or deny this, I would say at 39, like, am I in perimenopause? Am I right there? How do I know? And I think that that really touches our patient population with people, with women trying to conceive, you know, everyone sort of hears the age of 35, right? But what does that mean? What is perimenopause? Are you still fertile after you're in it? How do you know? Tell us everything.
Dr. Mandelberger: So it's a great question and I, I'm glad you're bringing that up as a 39-year-old, because from my realm, I don't treat fertility, you know, it's, it's, it's, I'm a little bit away from that at this stage in my career. So I see the other end of things. And to me, 35 is like, wow, you are fertile, ready to go like, like peak reproductive age, which of course is, is not often the case. But that age is marked as sort of a risk of declining fertility, right? And, and unfortunately there, there are so many women out there that do see that experience that, and even at younger ages. However, for many women who don't have issues with infertility, they can remain fertile for a long time. Okay? Even those with infertility can become fertile or, or have a spontaneous good ovulation and, and have fertility. So this is one of the big misconceptions that I try to dispel in my office on an almost daily basis. I mean, I have so many women come to me in their forties, maybe even early fifties, maybe even late thirties, who are not using contraception and do not want to get pregnant because they think that they're too old, they're not fertile. That is often absolutely not true. And again, even in cases where there's a history of infertility, there still is that chance. So, so that's a, a big one. And, and I want, I don't want women to think that they can't get pregnant, assuming that if you're a couple or or a person, that pregnancy would be devastating. There are some, obviously, circumstances like that, we have to be sure we have some sort of effective contraception in place because the fertility can decline and the biggest thing that that's related to is most of the time is the quality of eggs. And so that can happen anywhere from 35 to to 40 to 45, wherever that happens. But let's, let's use as an example, let's use premature ovarian failure, premature ovarian insufficiency, you know, where this is happening on the earlier stage. Okay? So these women are technically approaching or in menopause early - early thirties, late twenties even at times. However, until they hit that menopause where you're a full year without ovulation, the age of your eggs at 30 is a 30-year-old egg that, that's probably genetically appropriate and a fertile, good quality egg. So just because you're approaching menopause doesn't mean the quality of your egg is poor and doesn't mean you can't get pregnant.
Dara: I didn't realize that.
Dr. Mandelberger: Right? It's, it's a really common misconception. So the way I approach this is if you're getting, assuming you're somebody who gets a period, obviously there are some who don't for other reasons, but if you are getting a period, you are probably ovulating and there is a chance of pregnancy. So even in my older patients, so now let's say I'm talking to somebody who's 55 and not yet menopausal, they're probably perimenopausal, but they have not gone a full year without a period. They do get periods sometimes now they say, there's no way I'm gonna, you know, get pregnant and have a baby, right? And unfortunately that is also not true. And again, so now 55, the likelihood of, of egg quality being high is, is, is minimal, right? I mean, the, the likelihood of a full term healthy pregnancy, spontaneous pregnancy, is extremely low, but you can get pregnant. So whether it's, you know, an egg that probably will not make it all the way to a healthy delivery, you can still get pregnant. And, and most women at that age would not want to be dealing with any situation like that. So it's just very important for all of us to understand that up until full blown menopause, you can get pregnant. And in the case of premature ovarian insufficiency, actually there even is a recommendation to continue contraception because just in case an occasional ovulation slips out, you can still become pregnant. So, so it is, you wanna keep that contraception on board. Now, to your question, Rena, how do I approach my patients who say, you know, when do I stop birth control? It's a very individualized choice. Obviously there are always options that you can transition to if you're not ready to, or if, if you are sexually active and you don't with a male and you don't wanna get pregnant, there's alternative options. The pill is not the only option. And sometimes I do counsel my patients, you know, as we age, the risk factors change in our own bodies, right? So there's always small risks to the pill, whether we're 20 or 50. But as we age, you know, for example, the risk of blood clots goes up slightly. Now I still use the pill all the way up until 55 at times, but if somebody gets more concerned with some of the risk or some of the side effects change, perhaps a change to something like an IUD or permanent contraception or even just condoms might be warranted. If there is, for whatever reason, a very good likelihood that somebody or, or somebody's 50 and still on the pill and they're like, well, how am I gonna know when I'm in menopause? Because if you're on the pill, hormone testings are gonna look like you're on the pill, you're really not able to know and, and you're still getting a period because you're on the pill. And so with that, I often tell my patients, well, we can just, it's a little bit of a trial and error. Sometimes, you know, we can say, well, let's, let's take a pause. We, you can continue to 55 if you want, or if you wanna see if you're there now, we can stop the pill, use other, another form of contraception, wait six months a year to see if you do regain a period. If so, if you were happy with the pill, you can go back on the pill or another form of contraception. But if no, if no period in that one year timeframe, then, then that's menopause. At 39, you know, the likelihood of full-blown menopause is low, that would be considered premature menopause. Perimenopause is certainly possible, but again, that does not mean we're infertile
Rena: Let's talk more about that because I feel that's our patient, you know, our patient population are women that want to get pregnant, right? And so I think they hear perimenopause and that feels really frightening because that feels like the end of the fertile window. So can you tell us sort of like how you would define that, when that might start? What are symptoms?
Dr. Mandelberger: Right. So, well, to start, just to reiterate that perimenopause does not mean infertility. So just to dispel that for, for, you know, your listeners, if they are trying to conceive and they might be experiencing some of the symptoms that I'm about to mention, it does not mean you're infertile. Okay?
Rena: Okay. I want everyone to hear that for sure. That's super important. That word perimenopause just instills fear in anyone trying to conceive.
Dr. Mandelberger: Exactly. So the other part of your question is, is what are some of the symptoms? How do you know? So there is a, a technical definition. There's like one agreed upon by some criteria. You know, there are criteria for these definitions. I personally don't love this definition. I think that symptoms occur actually much often for much sooner than the defined perimenopausal timeframe. But I'll explain for, for the sake of being accurate and for your listeners. So there's, there is a criteria called a Straw 10 Criteria. It’s the stages of reproductive aging workshop where it was essentially a consensus gathering, I believe, at the menopause one of the menopause society meetings where experts got together and decided on these stages. And so essentially there's early reproductive, you know, there's pre-puberty, early reproductive, peak reproductive years, late reproductive years, and then there's some overlap between what they call the menopause transition as well as perimenopause. And they start at the same time. And according to this criteria that start date is when someone has experienced irregular cycles. So it's defined actually by the periods of greater than seven days duration, meaning, like, maybe you had a 21 day cycle and then a 32 day cycle. So that's a, you know, the full, the full cycle duration. So two of those differences in a row. So essentially like 1, 2, 3 periods that each of those intervals varied by seven days or more.
Rena: Okay, wait, sorry to interject, but would this apply – because this is so applicable to our patients - if someone had been on birth control for X number of years, if they're going off the pill and they're, would this apply to them? Should they be worried? Should they not? Is that not related?
Dr. Mandelberger: So, that's my, that's one of my big issues with this criteria is that's really the only way they defined it and it doesn't apply to so many women. So for example, women with PCOS, I mean that probably applies every cycle of their life, you know! Or women that have IUDs, women that have had hysterectomy, which may be, those don't apply to your patients, but certainly women coming off the pill, it can take a few months to regain a correct cycle. And some patients just don't have perfect cycles. Even without PCOS. Some patients are a bit irregular, so it's not necessarily so accurate.
Dara: I was gonna ask also, in terms of, you said irregular more than seven, can it be less, like less people who have maybe shorter cycles, would that apply as well?
Dr. Mandelberger: By shorter cycles? Are you referring…
Dara: You know, on the average, the 28 days if someone gets their period less than those 28 days with that?
Dr. Mandelberger: Yeah, so it's just the, the, the full length of the cycle has to vary from months to month by more than seven days.
Dara: Month to month. Plus or minus. Okay
Dr. Mendelberger: But again, so that being said, so that is according to the Straw 10 criteria. I personally really don't agree with this criteria. Like if I was on that committee, I would've, I would've dissented because the truth is, number one, there are so many women that that does not apply to. And number two is we actually start to see sometimes debilitating symptoms way before that. And there's such a variety in how patients present. I have patients that will get a perfectly regular period all the way up until 53, and then suddenly they drop off for six months. And so were they not in perimenopause if they're getting half flashes, you know? So it, it's really not a great perfect science. I mean, for, for the sake of research, I mean, we do need definitions, but I think our current definition is problematic. The other thing is, I all the time hear patients that feel dismissed by their doctors, because again, they're feeling these debilitating symptoms and they're told they're not in perimenopause, which technically, you know, might be accurate, but then, then what? Okay, now what, you know? I, I just feel dismissed because I'm miserable and they told me it's not perimenopause. So now what? So for those reasons, it's, it's problematic. So what I will say in my practice, how I, how I use sort of the definition is really if the, the life stage makes sense, the hormonal status, like for example, not on the birth control pill or whatever, hormonal status makes sense. Other factors are not part of it, like their thyroid is normal or, or whatever. And the symptoms are known symptoms of menopause and perimenopause. That's it. Okay. That that is typically it, it's, it's a very wide range. Now that being said, that leaves open a lot for interpretation. So I feel fatigued and nothing else, and I'm 36. I don't know, it could be, might not be, you really can't tell with, with testing. So it can be really tricky. What I often find, and some of the ways that I can tease these things out is what I often find in what would technically be considered late reproductive stage is symptoms of things like PMS, like symptoms before the period can accentuate, especially mood symptoms. What we see in perimenopause is these wide range in hormone levels throughout cycles. So one cycle you might actually ovulate twice and get these surges in hormones, or you might have a really profound corpus luteum cyst that's surging your progesterone levels that then suddenly drops. And so these can precipitate sometimes really significant mood symptoms. Some people get PMDD in the perimenopausal timeframe, whereas before they were kind of fine. It might change the blood flow of the cycles as opposed to the length of the cycle. So again, if you get these estrogen surges, that's gonna build up your lining and if that then drops, you're gonna get a heavier period. And the other thing that sometimes we see in the premenstrual timeframe are your typical symptoms. So some, some patients actually get things like hot flashes just right before or during their periods even though they're getting a perfectly regular period because that's the lowest point of estrogen levels in your cycle as well as progesterone. So those are often, I would say one, some of the more common ways I see perimenopause present.
Dara: For me, I, I feel like the hormones I would think would play a big role in terms of whether you're in perimenopause or not. Is testing accurate? And that's what I wanted to hear is like, is there a specific protocol to test?
Dr. Mandelberger: Nope. So the, so the, again, back to the Straw 10, it's a clinical diagnosis based on the period. Now you can get labs, right? You can, you can check day three labs, for example, if, if you are, and you would need to do that, a few cycles really. Everybody's different in their hormonal pattern and how they start to enter menopause. And everybody is different from cycle to cycle. Some women present as just basically like a gradual decline in their estrogen levels and that is the, the easiest to detect, right? So we can look at your day three estradiol. Your FSH is going to rise slowly on day three. And, and that would be, you know, relatively persistent. Your periods actually might get lighter if you have general lower estrogen levels. But for most of us, especially in the earlier perimenopause or late reproductive age time frame, it doesn't necessarily look like that as I, as I mentioned. I mean the highs can be higher, lows can be lower or not, but really essentially the hormones can be all over the place from cycle to cycle. And so if you're getting labs, they might look perfectly normal, they might even look perfectly normal three, three periods in a row…
Dara: That's frustrating
Dr. Mandelberger:...but you could still be in it. Yeah, so, so there's really not a good reliable method of testing for perimenopause. What I often do in lieu of let's say just, you know, a diagnostic blood test is, is track symptoms. So that can be really helpful if somebody does get a period and a regular period at that, it can be not very difficult to track, you know, what are their symptoms and when are they occurring in your cycle and is there a pattern? And if there is, you can kind of target what is the quads of these symptoms? Is it when your estrogen and progesterone levels are dropping? Is it because of high progesterone? You're getting really bad breast tenderness. So these things I find more clinically useful in treating symptomatic women. So because it's not a one size fits all when it comes to perimenopause.
Rena: Well, lemme ask you a question. Okay. Like, a patient of mine is coming to mind, so she's trying to conceive for a second child. First one, no problem. She's had, I've been seeing her for, for awhile, so, so over a year and I've seen her have these symptoms, which very much sound text with PMDD, like right before a period she had very bad mood swings. She started Lexapro, but it's still the same mood things before a period. She is having trouble conceiving the second one, she's, she's fairly young, I wanna say it's the window of like 36 to 39. She's done IUI and is told everything looks fine. But if you're in perimenopause, would you present though, as you have follicles, you are ovulating or no, you wouldn't,
Dr. Mandelberger: Yeah, you would. I mean, like I mentioned, it's the change in sort of variation of hormones. I mean, if you're talking about things like ovarian reserve now, why does perimenopause occur, right? Like why do these changes start happening? It is related to ovarian reserve, which in all of us declines over time. Some people, you know, if there's receptors for whatever reason are more sensitive versus less sensitive, you know, that can start. And whenever their ultimate menopause is gonna be, these symptoms can start earlier or later in that how much reserve is left. But sure, I mean in the earlier perimenopause, again, you can be fertile. So, you can see follicles, you can ovulate, you can get pregnant and especially with, with assistance. And does that answer your question?
Rena: Yeah, absolutely. I was just trying to think. Right. Okay. And then, but it sounds like okay, you, you can be in perimenopause and you can know that, but yes, you still can conceive, you're still fertile because you're not in menopause, it's just a precursor.
Dr. Mandelberger: Absolutely. Like these things just need to be separated, right? I mean the only thing as it relates in my mind to fertility as far as perimenopause goes is, is it like I would be thinking of a few questions like, are you getting a period? And if so, how regularly? You know, that's number one. How old are you? You know, how long have these eggs been hanging around in your body? And have, what's the likelihood of genetic mutations having occurred related to egg quality? That's kind of it. And, and then there are other, as I'm sure you all know in the fertility world, the which is you're in it more than I am. There are ways to measure ovarian reserve, like central follicle count and, and AMH. But again, those are not great tests of natural fertility. They're, they're tests that are looking at, you know, are you likely to respond to an IVF stimulation? They are correlated to menopausal-ness or perimenopausal, but it still does not predict the age. So we still won't really, can't reliably say, based on this AMH or this central follicle count, you know, you're gonna be in menopause in five years or, or whatever it is. So it's like a, it's a relative, yes, but overall we just, there's just so much we don't know about this.
Rena: So it's more just, okay, here's some information about yourself and you take with it what you take with it.
Dr. Mandelberger: Pretty much. I mean that's, that's another reason that it's important to see somebody that's very well informed in menopause so that they don't misguide you or, you know, tell you that you're infertile. I've had patients tell me that their doctors told 'em to come off of birth control because there's no way they could get pregnant. And they come to me and they're still getting regular cycles and they're like in their forties and and they're not, they don't have sterilization or anything like that. So, so yes, these things are very much different paths. So for example, I have a, not even a patient, it's a, a personal relationship that somebody who's, who's young, early thirties, just got married, wants to have a baby, was her AMH, was tested for whatever reason before even trying, and it was found to be well under one. And she's like, well what does this mean? Is it, am I infertile? Am I, you know, am I gonna be able to get pregnant? I'm like, probably I, if you were my patient, I wouldn't have tested that, you know, until you at least gone and tried. Go try to get pregnant and see what happens. However, let's keep in the back of their mind that this might mean you might go a little early. And so that is a consideration, right? So I'm like, maybe if it doesn't happen in a few months, maybe you consider freezing some embryos. You know, or so it's like a more of a long-term. It helps to plan, it helps to consider if it's a younger woman with symptoms who hasn't had any children yet, maybe doesn't have a partner or hasn't been planning on it in the next five years. But now maybe it should be on the radar more closely because while you could very well be perfectly fertile right now, if you went and tried the time to infertility, true menopause might be shorter than we anticipated. So that is how I view it more in long-term planning than I'm telling you if you're infertile or not right now.
Rena: I think that's powerful and I mean, as we always say in the podcast, you know, knowledge is power. So just knowing that, having that information, not panicking, having a great care team and just filing it away.
Dr. Mandelberger: Got a plan, we have the information, now we can have a plan. Like when my, the person I was just mentioning told me that, I'm like, okay, well how many kids are you, are you thinking about, you know, because yeah, you could probably easily go get pregnant now, but if you wanted three, four kids, you know, that's gonna be over this time span of however many years. That's what we need to be thinking about.
Rena: Absolutely.
Dara: I feel like this should be a, a discussion. I, we talk about this oftentimes with other guests, just the fact it's so great that you offer this to people and, and it, it sounds as though that you have this discussion with people at a much earlier age, a point in time. I think a lot of times people wait until there's something that they potentially think isn't great, but I think there should be a discussion when someone meets with their, their absolutely gynecologist it should be a conversation.
Dr. Mandelberger: Absolutely. And, and you know, given the nature of my current practice, my patient population has skewed towards post-reproductive. You know, they're finished, most of my patients, not all of them. In my former practice I saw, you know, the entire, the entire age range and, you know, younger patients, I would always bring up things like egg freezing and future fertility plans. I mean, it is, it's important to, to discuss. I mean it can be a difficult subject approach, right? It's very, obviously, as you both know, it's a very sensitive subject to many. It's really can be triggering to some. But, so I sort of tread lightly, but it's, it is important to broach so that you make sure, 'cause I never want my patient to, to talk about it when it's too late. So you always now I agree completely. Knowledge is power.
Rena: Well, okay. And then lemme ask you a question for our patients who, or listeners who, who may be tuning in who are right on that cusp, they're done having children and they are, they're really experiencing the symptoms, maybe they're trending more into menopause. What might you do? And I have actually a fair amount in my practice. What might you do? How would you treat someone who is experiencing the uncomfortable symptoms of menopause? How might that be managed? How are we comforting women who are going through that transition?
Dr. Mandelberger: So perimenopause can be really tricky, especially if you're getting periods over. Like if we're thinking that we still have years to go, which is the case for, for many, it can be tricky. And that's where one of the things I really like to do is track the symptoms with the cycle so that I know what are we treating here? Are we treating like high levels? Are we treating the drops? Are we treating the climbs? Where are we treating is crucial and likely, like what hormone are we even treating? Because some symptoms can come from progesterone drops, from estrogen drops from highs, you know, of each or both. So that's my sort of first question. And then as a far as, and then also are we treating bleeding problems or are we, what, what's symptoms are we treating? Are we treating hot flashes? Are we treating mood changes? Because the approach to each of these is quite different. So I try to think of it somewhat systematically. I have like a sort of four, I think of symptoms as sort of these five buckets of symptom types. And I think of treatments as like, depending on what we're treating again, but sort of like four treatment methods or options. So I'll start with the symptom types if that 'cause that might be helpful. So when I think of symptoms, I think of big overarching categories of hormone roles, right? And specifically I'm referring to mostly estrogen, but also progesterone. So one of the biggest roles is neurologic, right? Not always what we think of first, but it really probably is almost first in my, in my mind it's almost first. So everything from mood, cognition, attention, so estrogen and dopa, that's why it's a special interest of mind. Estrogen and dopamine are intimately connected. So focus, attention, planning, executive function, memory, short-term memory, all of these things. Mood of course, sleep, huge role in sleep. Architecture, ability to fall asleep, ability to stay asleep, ability to get REM and deep and I mean it can cause headaches, you know, highs and lows, mood, sleep, vasomotor symptoms. So that's the other big category that is actually technically neurologic. So vasomotor symptoms meaning hot flashes and night sweats and even palpitations sometimes are regulated by the brain. And estrogen specifically regulates this on the brain. So that's another big category of neurologic. There's also some peripheral neurologic like zingers you can get, but that's sort of a, a less common category. So those neurologic symptoms. And cognitive, by the way, again, with the, with the dopamine. So brain fog and, and memory loss is a huge one. So neurologic. Inflammatory is one I think that's sort of underappreciated. So estrogen is a quite potent anti-inflammatory in our bodies. And when we lose our estrogen, this can be sometimes more of a later finding or again, a cyclic finding at those low dips. Any kind of funky inflammatory changes can happen. So for example, if somebody has an autoimmune disorder, these can, they can either increase or decrease, but, but estrogen is an anti-inflammatory so rheumatologic conditions, joint pains is related to inflammation. So body aches and pains and itching, things like dermatologic conditions can kind of come out from low estrogen. So neurologic, inflammatory. Metabolic. Okay, huge one. Weight gain especially around the middle. Increase in our visceral fat and then findings on our labs, right? We get insulin resistance, we get LDL rising for our cardiovascular risk, go up with dropping. That's one of the first findings I actually see that's - secret side note, this is not scientific, but this, I sometimes use LDL trajectory as a perimenopause type, part of my diagnostic criteria personally, because it's just like invariable, everybody, even if you don't get elevated, everyone bumps during perimenopause. So LDL rising, weight gain and insulin resistance are really big ones. And then the fourth big category is, I call it like tissue integrity. And this mainly relates to, I mean it's every tissue in our body, but especially vulva-vaginal tissues, right? The activity of estrogen there. Not to mention our skin, our collagen, our bones. Okay, so basically maintaining this good quality integrity of tissue. And then with elasticity, exactly you know, ability to stretch, ability to snap back thickness of the vaginal walls, neurologic innervation, vascular innervation of the vaginal walls and everywhere in our, in our external tissues. So that's a really big one. And also that can sometimes be a later finding. So, so when people always say like, oh, I'm through with menopause and now we're talking older patients, I'm through with all that. Yes to many, but don't forget about your tissues because those only can get worse potentially with time. And then, and then the uterus is our sort of last little category of bleeding or new pathologies. If we're getting surges in estrogen, we can have fibroids come about, you know, we can get worsening endometriosis, we can get polyps, we can get just like heavy or painful periods without, without physical pathology. So, so those are the five. So metabolic, inflammatory, tissue integrity, neurologic, and then uterine symptoms. And then as far as treatment options, so, so the uterus is like its own animal as far as treatment. So you know, it depends on what we have to treat with the uterus and bleeding, whether it could be surgical, it could be hormonal management of bleeding or pain. But one of my favorite choices is a progestin IUD of course not, you know, we're talking now past reproductive, we're not actively trying to get pregnant. A hormonal IUD can be very potent at controlling symptoms of bleeding and pain and less symptomatic universally for patients that are very sensitive to external hormones. And then the other main methods of treatment, so the one that sort of is, I don't wanna say always, but most commonly offered to women that more women would know about would be the birth control pill. So this is your sort of standard, tried and true method that most OBGYNs, if, if the subject is broached or if they decide to, to offer a treatment, would offer as potentially sometimes the only possible treatment would be the birth control pill. Now it is a great treatment and hands down it's a very good treatment because it suppresses the menstrual cycle. So most symptoms, as we mentioned a few times now, are from the highs and lows throughout the cycle. And so if I call it like break the cycle, just make it even keel, you're not gonna ovulate. This will suppress a lot of symptoms. That being said, many women experience symptoms, pretty significant side effects on the pill. Maybe don't wanna be on the pill for whatever reason, don't wanna be on synthetic hormones for whatever reason, personal choice. So, so not everybody is amenable to that treatment option. So the third big category, and this is something that should be done in concert with all of the other categories anyway, is I call it like turn down the volume. So any symptoms we can, we can work towards quieting or reducing the, the signal, right? Reducing the badness of these symptoms with major lifestyle changes. I mean just they cannot be underemphasized. Exercise is like our most potent drug that we have for every single condition under the sun related to aging, not related to aging, just it's like our amazing panacea that is too often ignored. So exercise is huge. Of course, quality nutrition, lowering inflammatory foods, lowering our stress levels. So, so all of these things, sleeping well, all of these things that are contributing to an overall healthy body are going to sort of turn down the volume on the badness of the symptoms largely related to inflammation, but also just neurologic loudness. And then the last method is hormone therapy. So traditional menopausal hormone therapy. And I always caveat my patients because most of my patients come in asking for menopausal hormone therapy, which is a very appropriate and and reasonable option. Now, guidelines, this is off guidelines, I will say because guidelines, the menopausal hormone therapy are indicated for menopausal patients. So after the one-year hypothetically, and then again, a lot of my patients are only offered that, so you can't have hormone therapy, I'm told so many times for my patients, they were told they can't have hormone therapy until one year after their last menstrual period. A lot of times by then, that's like the worst is over sometimes at that point.
Dara: Yeah, they're suffering so much. You would think that there should be hopefully treatments beforehand if people are having these night, you know, hot flashes and pain per perhaps there, I would hope that there'd be options before then?
Dr. Mandelberger: You would hope. I mean, usually in that scenario patients are told birth control or bust, otherwise you gotta wait until a year passed. And I believe that that's very wrong. But that is technically like the by the book, right? I mean that's, that's what the indications are for, that's what the guidelines say, but there's also lots of off-label use that can be life-changing to patients. And so hormone therapy, we can use this to sort of, I call this raise the base, we turn down the volume in lifestyle and we raise the base with our hormone therapy. So it softens the blow of the highs and the lows. Now the hormone therapy when given appropriately is not a ton of hormones. It's actually less than your sort of average level throughout the cycles. It's not a huge dose of hormones. So it kind of just softens some of these, these highs and lows, which can really help mitigate a lot of the symptoms. That being said, your natural cycles are still gonna be wild and random. And so I always counsel my patients that this is not a panacea, this is going to help improve your symptoms, but you still are gonna have variations between cycles and you still may have symptoms. So that is certainly an option. And then what I didn't also mention is, of course there are non-hormonal options as well of medical therapy. This is very symptom-dependent. So we have to look at the exact symptoms that patients are experiencing and tailor that, tailor treatment to those. There's really no other, aside from hormones, there's no other treatment and hormones and lifestyle, positive lifestyle changes, there's no other treatment that kind of hits all of the symptoms. But we do have several targeted treatments such as SSRIs or non-hormonal hot flash treatments. Veosah, for example, is, is a, a great new drug. So we have other ways to target each individual symptom.
Dara: I love the way that you said that it's, it's, it's not fully getting back to the before, but like turning the dial, the volume down, so you don't experience any of the extremes. That's a, a beautiful way for me at least to, to visualize that. And it's sounds a little bit more reassuring that and, and at least being honest and saying you still may have these variability, right? But it won't be as heightened
Dr. Mandelberger: Right. Either way.
Rena: Yeah. Soften the blow. Well, this was, I mean, I'm sitting here like, I haven't been sleeping, I've been very itchy. I've been checking my dog for fleas, like maybe I need to, I'm gonna, we're gonna talk offline because I'm, I'm maybe that's explaining a lot of what's going on for me. So I think this will really resonate with our listeners. I mean, I think as women, right? I'm so happy because I feel, I don't know if in recent years I've just been more attuned to it because as I age I'm now phasing in going into different phase of life so I notice perimenopause menopausal stuff more or is the dialogue really just getting louder? And our women, I think speaking up more to say, we don't wanna take this anymore. You know, we want to feel better. And so I'm so grateful to have you out there working for women providing such amazing care because I don't think anyone should suffer and we should feel the best that we can. So you're a wealth of information and knowledge and such a great practitioner and it's such a gift to have you on.
Dr. Mandelberger: And on that note, I just wanna say for anyone out there, you don't have suffer through this, okay? There are options and there are safe options and, and hormones historically have gotten a really bad rap. We have new ways of giving them, we have good data that show that, that dispels some of the scariness. So you really don't have to suffer. Please come see a menopause specialist.
Dara: On that note, how can our listeners find you? What's the best way to contact you?
Dr. Mandelberger: So I have two main routes. I have my, my practice and then I have an educational company that I am trying to just teach us to as many women as humanly possible. So if you're in the state of New York, I'm currently only licensed in New York, you can see me either in person on Long Island Great Neck currently will be in Port Washington ultimately. It's called Balanced Medical. My website is www.balancedmedicalny.com. But that's my practice. And then in the greater state, we can do, I do do telemedicine as well. If you're outside of the state of New York, you can check out All Things Menopause, which is all-things-menopause.com, where I have a virtual course and other offerings for education, including a lot of free materials by the way that I keep creating and then just giving 'em out there because I want everyone. So check that
Dara: That's, I love that you have that option for people outta state that they can still,
Dr. Mandelberger: I can't treat you medically, but you can learn a lot.
Dara: Get resources from you and, and still yeah, learn, learn from you in a, in a different way. That's really smart.
Rena: Thank you so much for coming on and sharing your time and knowledge. We are so grateful to have you. I think this was fabulous. And obviously we'll link everything in the show notes for people to find you. And the way we like to wrap our episodes is by sharing something that we are grateful for. So a gratitude that you have today.
Dr. Mandelberger: I am grateful, and this is such a cliche, but I really am grateful for this opportunity to talk to you guys because I'm trying to reach as many listeners as possible so that they know. And I think probably a lot of your listeners either don't feel ready to hear it or are not talking about it. So I'm, I'm so glad to be able to reach a, a different, different demographic of patients so that they can feel prepared and empowered.
Dara: I'm gonna piggyback on that. I mean, I, I'm thrilled we had this conversation today. I, I'm a little older than you ladies and I'm definitely experiencing some perimenopausal symptoms and it's, it's great to know that there are people out there, there's resources like yourself. I got a lot of information out of it today in terms of the actions that I can take and really so much more knowledge, which is, is power. So I, I'm really happy that I had this, it's, it's a lot more reassuring and, and less scary as it really shouldn't be. And the fact that we're having this dialogue and conversation again makes, makes me feel really happy to know that I'm not also doing it alone and that there's support. So thank you. Rena?
Rena: I mean, I, I feel like I always say the same thing, but sort of similar and I was reflecting when you were talking, just so grateful to have people like you in this space. And I was thinking about Adrian and I went to Cornell and I have actually a couple of other calls this week with Cornell grads that I knew from college who went into the space of women's health. And I mean, I'm certainly someone that has imposter syndrome at times, but just how proud I am of these women that I went to school with. We graduated the same year, and how cool it is to reconnect and see what people are doing. And Dara, obviously, you're so successful. And just to work with other women who are driven and motivated and successful and to see where we've come, I think it's really cool. So I'm not like a rah rah college person, but I think this is, is awesome. You know?
Dr. Mandelberger: I had the same thought coming into this conversation because I feel like I have connected with like a lot of our, our years like starting to come into their own, I feel like. And it is just so wonderful to see everyone. Yeah. And the amazing, thank you.. Thank you both so much for having me.
Dara: Thank you so much for listening today and always remember: practice gratitude, give a little love to someone else and yourself, and remember, you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.