Side Project Podcast 1: Perimenopause with Allison Lewin

Julie Liegl (00:35.501)

What we’re talking about today is something I heard about for the first time when I was 43 years old, when someone said that maybe a certain thing that was happening to me is perimenopause. And I was like, what are you talking about? What is perimenopause? And I discovered there’s this whole world out there that apparently explains all the reasons that things are changing and we’re going crazy and it lasts 100 years and no one ever talks about it. 

Allison Lewin (03:05.55)

Yes, so perimenopause is a transitional period leading up to menopause during which a woman’s body is going through hormonal changes that can affect her menstrual cycle, her mood, and her overall health. Perimenopause often starts in one’s early 40s and it can last from 4-10 years typically, and symptoms will creep in. I would say the telltale one for a lot of women is their periods start to fluctuate and change. Their flow might be heavier or lighter, they may skip months, or what have you. 

And then menopause, by definition, is when you’ve gone 12 months without a period. For Menopause, actually, the average age is 51. And then Postmenopause is basically after you’ve hit that menopause time period – that one day where you’ve gone 12 months without a period. And then you’re postmenopausal for the rest of your life. 

Julie Liegl (04:39.645)

That’s interesting. So menopause itself isn’t actually a phase. It’s really just a mark of transition from perimenopause that lasts a long time and postmenopause, which God willing, also lasts a long time.

Allison Lewin (04:49.442)

Yes. Exactly. Though I will say I and others will use menopause as kind of a collective term to talk about all these phases. Like you’re going through menopause, you’re in the menopause transition. That’s typically how people talk about it.

Julie Liegl (05:04.317)

Okay, so dumb question. How come no one ever told us about this? Like, we got puberty education, and we went through pregnancies, but no one told us about perimenopause. Why is no one talking about this?

Allison Lewin (05:20.398)

Yeah, all this terminology is just coming out of the closet. So it has been taboo for many years and there’s been a stigma around talking about menopause. I’d say there’s a stigma around aging. In this country, women typically, more so than men, are made to feel less attractive as they’re aging, and menopause is something that kind of signals that you’re in those post-reproductive years.

I think because of the stigma, women haven’t been educated. They haven’t had the open conversations. Another factor is that a lot of doctors are not aware of all the factors of menopause. There’s different studies that indicate between 20% and 30% of OB-GYNs do not have any education in menopause. And even if they had it in medical school or residency, it was like one elective. Crazy, right? Women’s health concerns have often been marginalized or overlooked in a lot of different categories, and this is just one big example.

Leyla Seka (07:23.289)

So Allison, you said something I wanna touch on. You sort of said people often aren’t educated and so they’re making decisions without information. It’s a little odd to me that half the population moves into this stage for over half of their life, hopefully, and very few people are studying it. When I was a kid, I remember people were like, “Don’t take the hormones or you’ll get breast cancer.” But the thinking is different now. Can you break down what happened with hormones and what the landscape looks like now?

Allison Lewin (08:26.414)

Absolutely. This is one of the biggest sources of misinformation I like to address because a lot of women are scared of taking hormones, so they don’t seek a potentially great solution to mitigate their symptoms and help them live longer, healthier lives. The WHO study was started in 1993. It was 160,000 women, and it was supposed to run for 15 years, but in 2002, it was abruptly halted and all this press went out. There were all these news conferences about the fact that estrogen and progestin, the combination therapies for menopause hormone therapy, increased the risk of breast cancer, heart attack, and stroke. Basically they said the risks outweighed the benefits. Again, this is disseminated to the media, but apparently a lot of the people who were executing this study weren’t even consulted before this announcement was made. 

And so let me break down some of the reasons why this study was problematic. It was poorly designed and it was poorly executed. First, I’d say the HRT or MHT that was used then is a different form than what’s used today. They looked at one dose of estrogen and one kind of combined therapy, estrogen and progesterone. It’s actually the progesterone that had the impact on breast cancer, not the estrogen. The estrogen-only arm actually reduced the chance of breast cancer. So that’s kind of an interesting fact a lot of people don’t know. The doses used were higher than what is typically used today. 

Another thing I kind of tell people, have you ever taken birth control? Wow, well guess what? The hormone levels of birth control are way higher than what’s in MHT. 

Another big factor was older women were the focus in the study. The average age was almost 63. So when you think about that, we talked about how people typically enter perimenopause in their early 40s and the average age of menopause is 51. So these women were not given this therapy during the time in which it would be most effective. 

So the WHO study just wasn’t designed right. The participants weren’t representative of the people that would most benefit. And there are really great benefits. There’s now a pooled statistical analysis of 30 clinical trials that found that women who begin hormone therapy before age 60 have a 39% lower risk of death than women who don’t take hormones. And the specific things that it helps with are cardiovascular disease, it reduces the risk of diabetes, osteoporosis, and there’s more and more indicators that it may help with brain health and reduce the chance of dementia. 

Now that said, there are people who it is contraindicated for them to take MHT. If you have blood clots or history of cardiac issues, liver disease, or if you have had breast cancer or ovarian cancer, then often the doctor will say you shouldn’t take MHT. But the majority of women are able to take it very safely.

Julie Liegl (13:53.715)

Full disclosure, I am on hormones and it’s interesting because I actually saw a doctor yesterday and it’s time to schedule my mammogram. And they were like, “Well, you really need one now that you’re on hormones.” And this is not the doctor that prescribed my hormones – it’s more of a generalist – but the misinformation is still out there. It’s like a rumor that can’t die.

Allison Lewin (14:19.15)

Well, in the stats I told you that OB-GYNs aren’t always knowledgeable. Think about how much worse the stats are for primary care physicians or other specialists. They just have no idea. But I don’t blame the doctors. I blame the education.

Julie Liegl (14:32.047)

Exactly. Allison, you mentioned symptoms, and I do feel like we went straight to the HRT and the MHT, but I’m glad you addressed symptoms because I wast told about perimenopause, but I’m on an IUD, so I have no idea what’s going on. I don’t have a cycle. And I’m now under the impression that everything that goes wrong from the age of 40 and beyond, if you are female, is probably a perimenopause symptom, but I’m guessing that’s not completely the case. So what are the symptoms? Can we blame everything on perimenopause once we turn 41?

Allison Lewin (15:07.758)

It’s funny you say that because I literally say to a lot of women like anything that’s going wrong, it may be perimenopause, which actually I think is reassuring. Like, it’s not you – it’s the raging hormones in your body. So I kind of categorize the symptoms as physical, cognitive, and psychological. 

Julie Liegl (15:13.701)

It’s like the Mercury in retrograde of middle-aged women.

Allison Lewin (15:36.294)

Physical, I think everybody’s familiar with hot flashes or night sweats. Hot flashes can last several minutes and be super intense and like make you sweat or go red in the face. So I don’t treat them lightly. And I think also the research that I’ve read is that the hot flashes specifically are the most important thing to try to mitigate, because those can have some long-term implications. There’s also dry mouth, dry hair, dry skin, acne, heart palpitations… 

But let’s talk next about the cognitive. I think we’ve all heard about brain fog and short-term memory loss. I go into the room and I forget what I was going to find. Or even, you know, I try to remember three things, but I can only remember one. So this fuzzy feeling of just not being able to remember things or not being able to process information as quickly. And just maybe you feel like you’re not as sharp as you used to be. It’s distressing if you feel like you can’t function. And I think it’s one of the primary reasons why about 10% of women leave the workforce during menopause – because they feel like they just can’t perform. 

And then there’s the psychological aspects, which are also incredibly distressing. Anxiety and depression are way more common in women during perimenopause and menopause than other times. It’s very common for women to have panic attacks in menopause and just not realize why they’re happening. 

Oh one other on the physical side is a big group of symptoms called the genitourinary syndrome of menopause, GSM, or all the stuff that goes on “down there.” So it’s vaginal dryness, irritation, pain during sex. It can be frequent UTIs, urinary frequency, stress incontinence. Basically the decreasing estrogen in our bodies is making all these tissues weaker and the pelvic floor muscles aren’t as strong. So you’re more prone to different issues. Some women get really embarrassed to talk about it. They don’t want to go to the doctor and mention their sex lives, but the more you kind of reveal and are very upfront and direct about what’s affecting you, the more they can address it. 

Leyla Seka (19:07.983)

Yeah, I think that we made kind of a joke in the beginning about like, why do I pee every time I exercise really hard? And I’d have plenty of friends that have had surgeries and done different stuff to try to address it, but yeah, no one talks about it, right?

Allison Lewin (19:27.756)

No one talks about it. The one thing I’ll say, I’m like a poster child for vaginal estrogen. Vaginal estrogen is the best invention and like so many women should use it, but a lot of women are also confused. Like if I’m taking a patch and I have a pill, can I use vaginal estrogen as well? Absolutely. You can use many different forms of estrogen. 

And just to talk about forms for a little bit, if they’re perimenopausal or menopausal and they’re having symptoms and they want to address it, they are typically going to take a form of estrogen and a form of progesterone if they have a uterus. If they don’t have a uterus, then you don’t need the progesterone. The progesterone is to protect the endometrial lining so you don’t have a higher risk of endometrial cancer basically. But there’s so many forms of estrogen – pills, patches, rings, sprays, gels.

Julie Liegl (22:12.051)

I’m starting to see a lot about putting estrogen on the face. Is this the next frontier? Are we going to start putting it on like Nivea body lotion now? 

Allison Lewin (22:18.882)

Yes. we’re lathering it everywhere! No, actually you don’t want to put too much all over your body because your body is absorbing it. And so you don’t want to have too high levels if you’re putting it everywhere. But there is a lot more talk of potential benefits of putting estrogen on your face to help decrease fine lines and reduce the signs of aging. I will say I have not come across studies that specifically research how safe that is. But I’ve heard some dermatologists on podcasts talk about it and say this is the next thing. Like you should be using sunscreen, you should be using tretinoin (which is retin-A), and you should be using, you know, estrogen in your face. So TBD.

Julie Liegl (23:40.051)

All right, we’re talking a lot about estrogen and stuff. I wanna talk about my favorite substance, which is wine. Why can’t I drink it anymore without waking up in the middle of the night? My favorite drink has kind of started breaking up with me as I’ve been in my perimenopause journey. I would like to toast to it, but I would be up all night.

Allison Lewin (24:11.404)

I hear from so many women that wine affects them very differently, or any kind of alcohol. It’s like I’ve had one glass of wine, and then have a hangover the next day, or I wake up in the middle of the night. And there’s really two things happening here. With the decreased hormones in your body, your body’s not metabolizing alcohol the same way it did in the past. So it’s going to affect you more or differently than it had. And so that may cause you to wake up in the middle of the night and not get the REM cycles that you would have gotten before and not have as restful sleep. 

But the other problem is sleep disturbances, which are a really big symptom of menopause. And typically it is women telling me, I wake up at three or four a.m. and I just cannot get back to sleep. But I think also the sleep problem in combination with the alcohol, you might have night sweats, and you’re gonna wake up sweating and irritated. And then maybe because of that wine, you’re not able to fall asleep as quickly. It also makes you pee more. So for a combination of factors, that glass of wine may not be doing your body any favors. I’ll also just say, I am not recommending that people totally eliminate wine from their diet. It’s always about moderation.

Leyla Seka (28:11.567)

Okay, I have one more question back to the hormones. So if we are in menopause for the rest of our life, do we do the patch and like all these creams for the rest of our lives?

Allison Lewin (28:25.262)

Potentially. Again, I think the philosophy used to be like five years or the least amount of time needed. Often your symptoms will change as you go further into menopause. You know, there was a philosophy that you don’t want to use it for a long time. That is slowly changing, and it’s done on a case-by-case basis with patients and their doctors to determine what’s right. But I’m going to go to my grave using MHT because of things like the long-term health implications. I’ll use osteoporosis as an example. So your bone density, your muscle mass is decreasing with the decline in hormones and MHT can help you kind of maintain that. So if you go off MHT, you’re gonna lose some of those benefits. So yes, maybe you didn’t have the osteoporotic damage occur while you were on hormones, but when you go off, that process is gonna start up again. So I don’t want that to happen. So long story short, I’m going to use it as long as I can. Now I will say, maybe in a few years, I’ll try to decrease my dosage and see how I feel and adjust if necessary. So MHT is not a static exercise usually. 

Julie Liegl (30:29.329)

I have to say, I’m sleeping better than I have in 20 years now that I’m taking progesterone. Like, it’s changed my life. And to your point of taking it to the grave, somebody would have to give me a really compelling reason to stop using it. Cause I sleep through the night, and I have not done that in so long. It’s really incredible.

Allison Lewin (30:33.966)

That’s awesome. And how important is sleep? We’re reading more and more how diminished sleep really can affect your mental health, your brain productivity. So sleep is one of the most important things we can do in terms of self-care and lifestyle. So getting good sleep kind of overrules a lot of other things.

Julie Liegl (31:10.003)

What about all these other things like supplements that people are talking about? I have friends who are doing magnesium and there’s turmeric. There’s all these other things. Are those placebos? I went to a whole lecture about like red thistle, or something. I can’t even remember half of them. 

Allison Lewin (31:27.618)

Yeah, I think you really want to talk to a nutritionist for in-depth information about what’s right for you and your body and given your health history. But I’ve not seen evidence that a lot of these supplements are going to have the same impact as MHT in terms of symptom mitigation or long-term health impacts. Now, that said, just from a health and aging standpoint, there are probably some nutrients you want in your diet that if you’re not getting them from the food you eat, you may want to supplement them. The best example again is calcium. For strong bones, you wanna have calcium. So calcium is a must do in my mind. Vitamin D is another one that affects a lot of your body systems, but it helps you also absorb the calcium. 

Magnesium, there are many different forms. And some people take it to help them fall asleep at night. So if you’re taking supplements, that’s a good one to take. Omega-3 is another one that comes up quite a bit. But I was totally over supplementing for a while. I had my tray with like my million different capsules, morning and night, and now I’ve actually pared back, because I realized that a lot of supplements don’t necessarily do what they’ve promised. All I’ll say about supplements is be careful about the manufacturers you use and make sure they do third-party testing.

Hopefully this all helps. I know I felt I was going crazy during perimenopause and maybe other people around me thought I was too. So the more they know about the realities of what we’re facing, the less it’s stigmatized.

Julie Liegl (38:47.901)

That’s great. The good news is Leyla and I were already crazy. So I don’t think anyone noticed when we entered perimenopause.