From Night Sweats to Brain Fog: How to Navigate Perimenopause

Dr. Simmons: There are emotional ups and downs that can come with a transition in hormones. We can certainly experience symptoms like muscle aches, body aches. There are weight changes. I can name any part of the body and tell you what estrogen and progesterone could potentially do if they're decreased.

Courtney Allison: [upbeat music] Welcome to Health Matters, your dose of the latest in health and wellness from NewYork-Presbyterian. I'm Courtney Allison.

This season on Health Matters, we're covering your health from A to Z, asking our experts to break down the health topics and wellness trends we're all curious about. Today, we're at N for night sweats, one of the many symptoms of perimenopause.

Perimenopause is having a moment right now. For many women, it's a confusing and often overwhelming time, from night sweats to fatigue and brain fog, and just not feeling like yourself. To help, we spoke with Dr. Cassandra Simmons, chief of obstetrics and gynecology at NewYork-Presbyterian in Columbia. You can also find her at NewYork-Presbyterian The One in Westchester. Dr. Simmons demystifies perimenopause, breaking down the science, the symptoms, and the treatments that can help women better navigate this transition.

Hi, Dr. Simmons. Thank you so much for joining us on Health Matters today.

Dr. Simmons: Thank you for having me. I'm excited to have a great conversation with you today.

Courtney Allison: So I'm excited to talk with you about perimenopause. It is really in the conversation right now. So to start, could you please define perimenopause?

Dr. Simmons: Perimenopause is a transition in hormones that occurs in women. I like to think of transitions in the reproductive life of a woman in terms of times when hormones shift. So we think about the time around which your menstrual cycle is gonna stop for 12 months, and the duration of that time varies for everyone.

Courtney Allison: Could you kind of break us down, like a quick health class definition of what's happening to our hormones when we enter perimenopause?

Dr. Simmons: So when I talk to my patients, I talk in terms of the actual hormones that are being shifted and what their impact is on their feelings of wellbeing. But what we're experiencing is a change in our estrogen, progesterone, and testosterone. Not only are the quality of our eggs that we've had since puberty diminishing, and as a result they have a diminished amount of estrogen and progesterone and testosterone that they may produce on a monthly basis, but also as a result of the lower hormones, we're not ovulating as frequently, and so we may have some menstrual side effects and changes in our menses until they actually stop for 12 months.

Courtney Allison: And when can we expect this process to typically begin? How do we know we're in perimenopause?

Dr. Simmons: So it varies for everyone, right? Most women are gonna transition fully into menopause at 51. In the fourth decade of life is when they may start to experience some of the symptoms of perimenopause. In the past, we used to really just talk about perimenopause in terms of the one year leading up to not having menstrual cycles. I want the message to be that perimenopause is when you're beginning to feel symptoms, and not so much with regards to an actual age.

Courtney Allison: So am I correct that it sounds like that could be a years-long process potentially?

Dr. Simmons: It could be several years, and the symptoms can wax and wane because perimenopause is a time of fluctuation of hormones. It is not a time when you are no longer fertile, but there's subfertility. The reason that we're having menses during our reproductive lives is because our body is preparing for something every month, right? And so as your body decreases its ability to do that, it's commensurate with a decrease in hormones sometimes. Then that can start even in the 30s, so I never dismiss symptoms. If someone is having symptoms of menopause and they're 30, we need to investigate so that we can ensure that we're not missing the diagnosis of an early menopause, for example, or perimenopause.

Courtney Allison: I think with symptoms, many people think of hot flashes or night sweats, but it seems like the impact can be much broader. Can you talk about how perimenopause can affect someone's daily life?

Dr. Simmons: There are emotional ups and downs that can come with a transition in hormones. Like if we think about some of the other transitions like puberty, pregnancy, perimenopause, postpartum, right? We can experience symptoms like muscle aches, body aches. Some women will experience frozen shoulder. There are sexual side effects, a decreased interest in intimacy, dryness in the vaginal area that can affect a woman because of the lower hormones. There are weight changes that one can experience, and the last one that I always mention is brain fog. Women in the workplace can be affected by menopause, and the brain fog can really affect feeling cognitively sound. That's the one that I always forget because of my own brain fog.

Courtney Allison: And I appreciate you mentioning the workplace because I think it's difficult when these things could happen at work, giving a presentation and suddenly you have a hot flash. What's your advice to women who are experiencing symptoms at work and struggling?

Dr. Simmons: It's important to understand what's going on with your body. I'm big on owning it, right? Sometimes I'm in my office and I'm mid-sentence with a patient, and I say, "Give me a moment, I'm having some brain fog," and I own it. I think it's important for women to understand that we are going through changes and to support one another, particularly in the workplace. The more we are owning our feelings and owning the way in which our bodies feel, the easier it is for us to garner a little bit of empathy among our colleagues.

Courtney Allison: I think it's wonderful to have that support. I also appreciate what you shared about talking with patients. I would love it if a f- doctor shared something that I'm feeling too, you know? It's also humanizing.

Dr. Simmons: Yeah. If I can humanize that a bit and explain that I'm also going through my symptoms, I think that that makes it easier.

Courtney Allison: Absolutely. So speaking of all these wonderful symptoms that are impacting us, could you please talk about what's causing them, particularly night sweats?

Dr. Simmons: If we think of what we call vasomotor symptoms, and those are going to be your feelings of heat intolerance, those can occur during the day for the most part, and those are called hot flashes. And then they can also happen at night, night sweats. And the main hormones that are implicated are going to be estrogen and progesterone. Those are the two hormones that are driving the changes for hot flashes and night sweats.

Courtney Allison: And why can they disrupt sleep so significantly?

Dr. Simmons: Couple of things. One is that if you're having night sweats, obviously you're awakened. If your temperature feels uncomfortable, it disturbs your sleep, it wakes you up. That can really affect the way in which we function on a daily basis. Progesterone also can affect our energy levels, and so if we're really fatigued, we're having night sweats, we have low progesterone, we have low testosterone, that level of energy the next day to rebound from a night that had a few disturbances can be really challenging.

Courtney Allison: You mentioned testosterone. Could you say more about testosterone and how it's playing a role in perimenopause?

Dr. Simmons: Testosterone is important in our metabolism, our energy levels, and our muscle mass. And the way in which we deposit fat in the lower abdomen can cause some women to have some body image concerns or issues with feeling like they're exercising and they're not experiencing the changes in the weight that they experienced in the past. Muscle mass does decrease over time because we have less testosterone.

Courtney Allison: What surprises people as a symptom of perimenopause? Anything they might not realize is connected?

Dr. Simmons: Bloating. A lot of the GI symptoms because of the fluctuation in hormones, just not feeling great, not feeling energetic. I get questions about shoulder pain, joint pain, cardiac health, hair shedding, particularly in the front or on the top of the head. There are implications with regards to our sight.

Courtney Allison: It does seem like one symptom we hear a lot about is, "I just don't feel like myself." Is that something you hear from patients?

Dr. Simmons: Absolutely, and I think a lot of that has to do with the brain fog where people feel like they're word-finding, where they felt like in the past they felt sharp. We can't understate the importance of hormones in our functioning overall. I can name any part of the body and tell you what estrogen and progesterone could potentially do if they're decreased.

Courtney Allison: And so how do you guide patients through treatment options for perimenopause?

Dr. Simmons: I put the treatments in three buckets, and those are going to be holistic options, prescribed but non-hormonal options, and then prescribed hormones. So let's take the first one, holistic options. There are great supplements that one can experiment with. Maca root, wild yam, ashwagandha, those are all hormone balancers. You've got dandelion, which has been emerging as anti-inflammatory, just amazing supplement that we may find in some of the menopausal supplements now just to help with the GI symptoms. And then we also have omega-7s. Those are found in macadamia nuts and are healthy fats to help us with our cardiac health and also help with hormone balancing. Shatavari root. And a menopausal supplement that puts a little bit of each one in one supplement I think works pretty well reducing inflammation, helping with hot flashes, balancing hormones, helping with sleep. In menopause, it's important to keep your vitamin levels, especially vitamin D and calcium, your B complex vitamins, to the appropriate levels. My patients that are experiencing anxiety, I always talk to them about the what ifs. "Well, what if I never get to go back to what I looked like before?" And then, "What if my hot flashes never get better?" So that might be someone that may benefit from a cognitive behavioral therapy to kind of help to formulate the thoughts in a way that's healthier for them. It's a great way to really address the emotional symptoms that might occur from someone going through this really challenging time. And then the second bucket is going to be our prescribed options. For someone who feels like they may have experimented with some of the supplements but aren't quite ready for hormone replacement, or they have medical conditions that prevent them from being able to explore hormone replacement. With those particular prescribed options, we can help with the emotional symptoms, the anxiety and depression that might occur during perimenopause. We have options also for hot flashes and night sweats. And then estrogen and progesterone, testosterone hormone replacement essentially brings your hormone levels back to levels that are comfortable for you. And oftentimes we try to find the lowest effective dose of hormone replacement that's actually going to make one feel better, and we tailor the decision based on which hormones we think are actually causing the symptoms that they're experiencing.

Courtney Allison: I imagine hormone therapy still makes some people nervous. How has the science and conversation changed in recent years? How do you counsel people?

Dr. Simmons: Yeah, this is an important question. Back in 2002, there was a study that was published in The New England Journal of Medicine, and that was a study of thousands of women that were taking dosages of estrogen and progesterone. And the study was terminated early because of a slight increase in breast cancer that they found in the women that were taking estrogen and progesterone, testosterone, compared to those who were not. And that's a landmark study in women's health. It changed everything with regards to how women approached menopause, and many women, now scared because of potential breast cancer, stopped their hormones that they were taking previously and experienced significant symptoms as a result. Since then, the study has been reviewed, and in fact, there was not the same impact on breast cancer that was initially thought in the study. The types of hormones were extremely potent compared to what we use now, which are more what we call bioidentical, or more identical to the actual estrogens and progesterones that our bodies actually make. And since then, we have multiple formulations of estrogen and progesterone, either extremely low dose or moderate dose, or higher dose for those who need it. And It has really revolutionized the way in which we approach hormone replacement. Many studies are showing that from the standpoint of longevity, cardiac health, that hormone replacement has significant benefits, especially if one is on it for 10 years.

Courtney Allison: And we're hearing a lot about GLP-1 medications. How do they factor into this conversation around perimenopause?

Dr. Simmons: It's important to understand that while GLP-1s are beneficial with regards to weight management, it's important to understand that we want to feel good in our bodies, and there are options like GLP-1s that can help us do so. But they should be moderated. They should be managed. We don't want to lose too much muscle mass because our estrogen and progesterone are already doing that, and the testosterone is also competing for our energy, and all of these lower hormones that we're experiencing are affecting our bodies and our bones.

Courtney Allison: Can lifestyle factors help? Can I exercise my way through this, or eat right, connect with friends?

Dr. Simmons: I love that you just mentioned connect with friends because I think that there is a huge emotional component to being healthy. That sounds cliche, but actually if you do spend some time and go out and speak with people about how you're feeling or just about anything in general that makes you happy. And of course, there are lifestyle factors, right? So it's important for a woman to have about 150 minutes of exercise a week, and there should be some weight bearing incorporated in that. The more muscle mass that you have, the faster your metabolism, the more energetic.

Courtney Allison: How important is it to understand the whole woman when treating for perimenopause?

Dr. Simmons: It is so important. I love this question because when a patient comes into my office and they say, "Hi, I'm here for my annual," I pull up my computer and I say, "You thought you were here for just an annual, but we're gonna talk about everything from head to toe." And then I ask the cadre of questions that I have. It's so important to ask the questions that we ask, and it's important for our patients to share with us because we need to be a part of that journey. Women's health is not just limited to hormones. It's important for us to understand how those hormones really affect the entire body.

Courtney Allison: Dr. Simmons, thank you so much for this message and all the amazing insight you shared. I cannot wait to share this with my friends.

Dr. Simmons: Great. I can't wait for them to come see me. [laughs]

Courtney Allison: [laughs]

Dr. Simmons: Send them on over.

Courtney Allison: Our many thanks to Dr. Cassandra Simmons. I'm Courtney Allison. Health Matters is a production of NewYork-Presbyterian. The views shared on this podcast solely reflect the expertise and experience of our guests.

To learn more about Dr. Simmons's work with patients, check out the show notes. NewYork-Presbyterian is here to help you stay amazing at every stage of your life. Join us next time when we talk about what's behind the rise of cancer in young people and advances in oncology treatment. That's in two weeks right here on Health Matters. So you don't miss it, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get podcasts.