Understanding Hormones During Menopause with Dr. Mary Jane Minkin

We know ‘em, we love ‘em, and sometimes we hate ‘em: HORMONES! We were recently lucky enough to welcome Dr. Mary Jane Minkin to our webinar series for a conversation on the top things you need to know about menopause and hormones.

Dr. Minkin is a clinical professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the Yale University School of Medicine, and has been in private practice in New Haven (CT) for more than 40 years. She is board-certified in obstetrics and gynecology, and she practices at Yale-New Haven Hospital. She earned her medical degree from Yale Medical School and her undergraduate degree from Brown University. She did both her internship and residency at Yale-New Haven Hospital, the former in internal medicine, the latter in obstetrics and gynecology. She is a fellow of the American Congress of Obstetricians and Gynecologists (FACOG), and has been a Menopause Society Certified Menopause Practitioner since 2002. Dr. Minkin has been Director of the Sexuality, Intimacy and Menopause clinic in the Division of Gynecological Oncology, in the Smilow cancer center at Yale New Haven Hospital since 2008. She has also been Director of the Yale Obstetrical and Gynecological Society (YOGS) since its inception in 2006.

Dr. Minkin has won numerous teaching awards, including the Irving Friedman Award, given by the Yale School of Medicine’s department of obstetrics and gynecology for excellence in clinical abilities and patient care, and the Francis Gilman Blake award, awarded by the graduating class to the clinical attending who taught them best. She has twice received the Association of Professors of Gynecology and Obstetrics ‘Excellence in Teaching’ Award, annually awarded to one faculty member from each member teaching institution, has three times been awarded the Resident’s Teaching Award for best community attending physician, and has been a member of the Society of Distinguished Teachers in the Yale University School of Medicine since 2002.

She provides menopause education on her website madameovary.com including articles, videos, and podcast episodes.

She was joined by our co-founder Anne Fulenwider for this webinar, which we highly recommend you watch on our YouTube! Portions of the interview, which has been edited for clarity and brevity, can be found below. Please note that this blog post is for educational purposes only, and should not be used as personal medical advice.

Dr. Mary Jane Minkin: It’s always a pleasure being with you. You suggested we get started with a brief overview of the hormones involved in [the menopausal] process and how we get there. And, before we start, I want to apologize because I use bad words sometimes. 

I define menopause as the “pooping out” of the ovaries. The problem is that when your ovaries poop out, it’s not an on-off switch, unless you go into surgical menopause via a hysterectomy or having your ovaries removed. For most people, it’s a gradual pooping out. Some days the ovaries are working a lot and some days they don’t work at all. And there’s no exact prediction of how long this course is going to take. It can be overnight, which happens to about 7% of women, it can be a year, or it can be many years.

And, how do we define menopause? If you have gone a year without a menstrual period, you can say you are fully menopausal. Some people would also say postmenopausal–the terms are sort of interchangeable at that point. Your ovaries are still making very low levels of estrogen, but it’s nowhere near the magnitude we make before we go through menopause. The average age this happens is about 51. The most common time is between the ages of 45-55. But my definition of normal is actually 35-60. And it’s hard to predict what category you’ll be in, although family history is relevant.

Now, let’s talk about the ovaries pooping out. They poop out on the three major hormones we make, which are estrogen, progesterone, and testosterone. These levels decline in a jaggedy fashion. What does that mean? Sometimes it means funky periods, because the ovulation process is disrupted. We stop ovulating on target, we ovulate not as well, and we don’t make as much progesterone when we do. I like to think of it this way. I stole this concept from my friend Dr. Nanette Santoro: Think of the uterus as a lawn. Estrogen is fertilizer, and progesterone is the lawn mower. When progesterone levels are out of whack, periods can be heavy and crampy, or straggly. And sometimes if that’s the case, progesterone can be your best friend. It will help control those symptoms. But for many people, they’re also feeling the consequences of less estrogen. That means hot flashes, night sweats, sleep disorders, achiness, bladder issues, all sorts of fabulous things. And if somebody's got estrogen coming down and progesterone coming down, we need to address both. Okay? Next: testosterone. It does go down, but it’s a lot more smooth. It’s a gradual decline. And it also happens later. 

Anne Fulenwider: We have lots of questions that have been submitted both in advance of this webinar and that are coming through now. Let’s get to some of those. First, let’s talk about birth control and perimenopause. Are you seeing a lot of people talk about how much they don’t like the birth control pill in general? Dr. Mary Jane Minkin: Some people are anti-medication. I try to teach my medical students that you have to know your patient’s beliefs and what she’s interested in. Some people hate medicine, some people love medicine. But you have to meet people where they are. I love birth control pills, and I also love a progestin-coated IUD. Both will help control the bleeding. And, both will provide birth control. You are fertile until you’ve gone that magical year without a period. I personally have delivered three 47-year-old women who were not infertility patients! Fertility declines with age, but it’s not zero. Anne Fulenwider: And, obviously everyone comes to this with their own history and their own thoughts, but for people who are "against medication," I like to remind them that these are hormones your body made for many, many years. It’s not a foreign object in your body. Dr. Mary Jane Minkin: And also, the average age of menopause is 51. And life expectancy has gone up. The average age of menopause in the United States in the year 1900 was 48. And at that time, the average female life expectancy was also 48 years. Yes, there were a lot of childhood diseases, women died in childbirth, and of course there were postmenopausal women in the United States in 1900. But the average age of menopause and the average life expectancy were both 48. You were supposed to go through menopause and die. Now, we live a lot longer. And we want to make sure that time is healthy and active. Anne Fulenwider: We could have a whole conversation just on that. I want to get to a question from an audience member: “What are the primary benefits of MHT for women in menopause? What about several years after menopause? Should I stop taking it after age 65? I’m 58 now.” Dr. Mary Jane Minkin: Excellent questions. Well, 58 year olds are youngsters and so are 65 year olds. So, you're a youngster. It's fine. So the key thing is the way I look at hormone therapy is I look at it from two viewpoints. One is symptomatic relief, which is what most women are driven by. But there are also health issues involved. If you are symptomatic, estrogen is the best therapy. There are other options we have, but estrogen is the best thing and it will help with all of your symptoms. It can help with hot flashes, night sweats, vaginal dryness–of course you don’t have to use the systemic stuff for that–and all of those other fabulous things. And then there are the health issues.

We know that estrogen helps prevent bone loss, helps prevent osteoporosis. You need to stay active, eat healthily, get a lot of exercise, get your calcium, your Vitamin D. And estrogen is also amazing for the prevention of osteoporosis.

Then there’s the question of, can it prevent heart disease? Here’s the simple way to think about it: How many guys do you know who had a heart attack when they were 40 or 45? I’m sure everybody listening knows somebody. How many women do you know? Not many. Now, what lets us get away with not having heart attacks as young as men do? In our 60s, we get plenty of heart attacks. So, you start to wonder, is it something about estrogen? And then studies started to come out that looked at women who took estrogen. And they seemed to have a lot fewer heart attacks. Now, when they did the WHI study, which was initially looking at heart disease, they did not find that estrogen therapy was protective. But you have to remember that they were studying women who were way past menopause. What we now believe is that if you start estrogen early, there is some protection. It’s not official, so please don’t quote me. But it does seem to provide some heart protection. And, if you go into menopause early, like 35 or 40, you need estrogen, period. Your risk of heart disease goes up. So please talk to your doctor about estrogen. 

Next, the brain. First, in menopause, many women report brain fog. And this is a temporary phenomenon for most women. But there are some women who unfortunately have really significant changes that way. A lot of the problems may come from disrupted sleep. But we also want to look at whether estrogen may help dementia. The WHI says no. But again, the women enrolled in the study were aged 65, minimum, and were as old as 79. However, in the long-term analysis, particularly in the estrogen-only group, it was shown to be protective. But again, we’re not supposed to talk about that. And again, the data is all over the place. I can’t officially say that estrogen protects against Alzheimer’s and dementia. But it might. And there is so much more research that needs to be done. 

Anne Fulenwider: Thank you so much. So, this next question from our audience is sort of HRT 101: “Can you discuss the different types of hormone replacement therapy available and how they work? I'm confused about specifically the spray and the patch. Are they used together?”

Dr. Mary Jane Minkin: Basically, there are many ways to administer estrogen. And when I was a little girl, estrogen was easy. There were two pills available, no patches. And it was like, okay, you get the big dose or you get the little dose, what do you want? That was easy. Now it's more confusing, because there are a lot of good choices.

The major differentiator is whether you take oral or transdermal estrogen. If you choose oral, you take a pill every day. The transdermal estrogen options bypass the GI tract. And then it’s a matter of preference. The patch you change twice a week. There are also some gels, which are daily gels. There’s a spray, and those you use daily. You have to do what works for you. The main reason to choose transdermal over oral is that there is a very slight increase in clotting issues with oral, so for some people transdermal may be a better option.

Anne Fulenwider: I think this is a really good time to talk about systemic versus local.

Dr. Mary Jane Minkin: Absolutely. Vaginal estrogens are really nice for dry vaginas and dry bladders. The official term is called genitourinary syndrome of menopause. Many women develop incontinence, many women get frequent UTIs. There’s vaginal dryness, painful sex. And if you have any of those problems, I strongly encourage you to use vaginal estrogen because it can really help. UTIs can be fatal.

Anne Fulenwider: Another question we get all the time: “How long can I take hormones, which ones are safe, and for how long are they safe? I’m 59, 8 years post menopause.”

Dr. Mary Jane Minkin: Thank you for bringing that up. The answer is that there’s no expiration date. People used to bandy about this five year number. But there’s no magic in five years. I tell people they can stay on estrogen as long as they want to stay on estrogen. As long as it's safe for them, they're not having complications, and they're fine. And we follow them regularly. Anne Fulenwider: Okay, one more. I think this is a super important question. It’s about mental health and menopause: “Can you talk about depression associated with hormonal transition periods?” Dr. Mary Jane Minkin: This is actually a very, very important question. The answer is, I don't know. What I can say is that if somebody has a history of depression, they unfortunately have an increased risk of recurrent episodes. That includes postpartum depression. Menopause can also trigger it. So, if you do have a history of depression and you’re starting menopause, it may not be the world’s worst idea to check in with your mental health provider. There is also some data that shows that estrogen can help with depression. The other thing you can’t separate out is sleep. People who don’t sleep aren’t in a good mood. So if you’re up every night hot flashing, you aren’t going to be chipper and cheerful. Estrogen can help, and so can other things. Sleep is so important. And a typical woman who is 50 years old is going to have a lot of stuff going on in her life. And she needs sleep!

Anne Fulenwider: Dr. Minkin, we're so grateful for your time. Thank you.

Dr. Jane Minkin: Thank you so much! Come visit me on madamovary.com. As I tell people, what could be more exciting than a dry vagina podcast? 

To watch the whole webinar, head to our YouTube! And, follow us everywhere @myalloy to stay up to date on all of our events.