Menopause, Perimenopause, and Active Women Ep 122

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Well, I'm happy to be here. Thanks for the invitation. My name's Abby DeVries. I'm a family physician and have been in practice for a little over 20 years. And about 4 months ago, I started my own direct primary care practice, really focused on women in midlife. So in that kind of late 30s to early 60s range. And over the last couple of years, I've really kind of dived deep into menopause and perimenopause care. Still learning as the rest of the medical community is as well, but have really tried to learn as as much as I can about how to help women really thrive in this phase of life and then age strong. So I'm doing a lot of menopause hormone therapy along with all the preventive management and chronic disease management. So. That's awesome.

And just a little plug, you are, for those of you who are listening in the Triangle area, you're in Chapel Hill.

Yes, I'm Chapel Hill. My office is in Durham. I do a lot of care virtually. I can see anybody in North Carolina, but, and also if people live really close to me, I'll actually do a home visit. But a lot of care is done in my office in Durham, so.

Very cool. All right, so you mentioned the direct primary care model. Tell me how that's different than what we're typically used to and from something like concierge medicine.

Yeah, so direct primary care is a model that has been growing really steadily since just before COVID and it's a membership-based primary care model where you pay a monthly fee and kind of have pretty guaranteed access same day or next day, longer visits, ability to access your physician via text or email, um, or a quick phone call because you're not kind of tied to that visit that, that provider isn't kind of dependent on that visit for the revenue. Smaller panels and just a, a much more approachable aspect. You can, if you have a high deductible health plan, submit your membership fees to the HSA and get reimbursed pre-tax on that. But we typically don't bill insurance, so we're not double dipping like a concierge model where we, where typically people will bill insurance and then pay a kind of retainer fee. So it's a one, one fee kind of for, for most services within the kind of primary care scope.

Okay, cool. That was a great explanation. So what led you into getting deeper into understanding these women at this wonderful time of life?

Yeah, well, as it often happens, I kind of reached that phase of life myself, but also was, was doing a week-long continuing education. Harvard does a really great primary care training every March, and one hour of this, you know, 40-plus hours of training was on menopause, and it really piqued my interest, and I realized that what I had been taught in medical school— I was in medical school when the, the WHI trial came out in 2001— um, I really kind of had not learned what the, the facts were. And, and then also there's been new data that's come out to really show the safety and, and real, um, benefit potentially for hormone replacement therapy. And so I've just tried to learn everything I can, um, and it's, it's kind of through podcasts and books. And, um, there's some really great female physicians kind of leading the charge on this, and, and I'm happy to be on board.

That's so awesome. Um, we'll have to get into like some of your heroes at the end here.

Yeah, I have some props.

Yeah. Oh, so good. Okay, great. So when women are, and of course we're speaking to a lot of endurance athletes and high performers, people who really wanna do amazing things, what are some things that we need to maybe even think about before we reach this stage of life? And then as we ease into, what are some of the things that we're looking for from a symptom perspective? Is it somebody like you who can help us understand our unique hormone profile? Like, do my hormones look the same as your hormones? Like, is it, is it all exactly the same? Should we all be having these exact curves in various hormones? And what are the— some of the things that we need to look for?

Yeah, so if you're, you know, premenopausal and, you know, anywhere kind of generally younger than your late 30s, if, if it's the typical pattern, you should be having regular cycles unless you're doing some sort of hormone therapy that, you know, birth control or an IUD that would make you not have a cycle. So you should be having regular cycles and the bleeding should be manageable. And that would indicate that you're sort of having the typical rise and decline of FSH that triggers the estrogen and progesterone to cycle. And so that would be considered, you know, normal menstrual functioning. And then, you know, one thing that happens often with endurance athletes, as you know, is periods of amenorrhea. And that is actually really a low estrogen state. and has a pretty profound effect on bone mass for one thing. So people who've had a history of that or celiac disease, which is a pretty common thing that as well is underrecognized as a cause of low bone mass in the future. So those would be potential things that people have a history of that to think about, you know, getting evaluated sooner for bone mass. And then, you know, I'm trying to think if there's, I don't think there's anything else really typical for athletes other than that that I would caution about. But sometimes people will think, you know, they're getting lazy or something. And, and really they're entering this premenopause phase and their hormones are shifting. And that really does change kind of the profile of, of, of, of endurance. And, and, and there is things you can do about that so that the feeling like people shouldn't just give up when they reach a certain age.

Yeah. Yeah. So are there certain symptoms that maybe we should potentially be expecting? I mean, I'm not, I'm, I would assume that it varies widely. Woman to woman, but maybe forgetting our car keys all the time is not just in our imagination.

Exactly. Yeah. So the common things in perimenopause are this brain fog or forgetfulness, like feeling like, do I have early dementia? That's a big one. The other huge one is sleep disruption, especially that kind of 2:00 AM wake up where you're up for 2 hours and kind of get into this anxiety spiral. That is classic for perimenopause, and it typically comes from a drop in progesterone. People will also know kind of mood changes, maybe being more anxious. And one thing to note is if people have a history of challenges with mental health postpartum, some of those same hormonal changes are happening in perimenopause, and they're definitely higher risk for anxiety and depression, ADHD-type symptoms in the perimenopause phase as well.

So is it when there may be some level of experience of anxiety or brain fog, Not to say that psychology and psychiatry is not a wonderful field, but would you say maybe assessing hormones might be a good first approach?

Yeah. And we don't necessarily check levels. It's more based on, you know, what is your age? What is the kind of, you know, complex of symptoms that you have that we can sort of say, this sounds like perimenopause. It seems reasonable to try some low-dose hormones before we jump to say an antidepressant or an ADHD medication or a big workup. Making sure that we're kind of ruling out some other things too. Thyroid is another thing that often goes haywire in this age. Um, anemia. The other big thing is, is bleeding pattern changes. So either really heavy menses or irregular kind of longer cycles. Um, so if you're starting to have that, uh, then that can definitely be a sign too of perimenopause. Okay.

Um, so is there— in that case, is it like, okay, let's start on some level of progesterone, or Are there any tests to understand, like, you know, certain time? And I've also heard, oh, do your best to try to get tested the first few days after your menses, or, you know, what's, what's up with all that?

Yeah, I mean, so your hormones do cycle throughout the month. And so a level is just that one hour of time that you're getting it tested. So it can be a little bit informative, especially if someone has a reason why they're not having a menstrual cycle, like they have an IUD or they've had a hysterectomy. An estradiol level can be you know, a little bit directional at least. We typically don't just test progesterone. And then testosterone is something maybe we could talk about later, but we do check those levels. So typically, if I see a woman who comes in saying, you know, they're waking up, they're feeling more anxious and like a little bit more fatigued, I'll just say, well, let's just try a little progesterone. And then, you know, if they get closer, if they're having hot flashes or more kind of menopause-type symptoms, joint pain, frozen shoulder, then we'll throw on the estrogen patch. But we don't have to wait until, you know, the periods are gone to try any of the hormones.

Okay, good to know. And then does that continue through menopause, like, are— or do strategies change?

Yeah, so they can. So every— so everyone experiences things differently. So some people will have terrible symptoms during perimenopause, and then once hormones kind of level out, they feel great again. Some people kind of sail through perimenopause and then develop really severe symptoms like hot flashes, joint pain, things like that, a year or so after menopause. So everyone is the unique individual. And what dose of hormones is working for you today may not be what's gonna work for you in a year or two. Typically, once you get through menopause, again, we can kind of get to a dose that's pretty steady, and I wouldn't anticipate having to tinker a lot. But during perimenopause, definitely. You know, some people feel like they only need hormones during part of their cycle, for example. So it's really a kind of just, let's try this, and then let's be in touch in a week or two, and let's see what's working and what's not. And that's one of the beauties of this model model is that, you know, you don't have to wait until you see the doctor again in 3 months to kind of figure out what's, what's working, what's not working.

So definitely, I'm also thinking of the woman who might be like, okay, well, now that I'm menopausal, which I'll have to have you touch on what officially is the definition of menopause, um, and then maybe even, uh, officially with the definition of perimenopause and those types of things, that way people have some context there. But let's say they're like, okay, well, my kids are out of the house now, um, and, you know, whether it's related to hormonal changes or Oh my God, now I'm going to do an Ironman or I'm going to run a marathon. Or would that— would you anticipate that changing any potential tweaks in hormones? And you may not know the answer. And, you know, like, I find that this is an amazing emerging field that we've just been ignoring for a long time. So yeah, I ask you a lot of questions. Yeah. How about habit? So you're welcome.

Well, let me just start with the last one since I remember that.

I don't—

I have not seen or had experience with like what big lifestyle changes do for the hormone needs. I think it would be let's just wait and see. And if we need to adjust it, we absolutely can. And then as far as kind of definition, so menopause is actually one day when you have not had a period for 12 months. Now, we— well, and then you're post-menopause, but we typically talk about post-menopause as menopause. And then perimenopause is the years leading up to the actual menopause day. And that can be, you know, 7 to 10 years. And so if the average age of, of menopause is around 51, that means some people experience it much earlier. So late 30s is often when perimenopause will start for women. But then, you know, again, people can sail through into their late 40s and then suddenly, you know, start experiencing it. So it's a, it's a big range.

What's the typical age range for menopause?

So it's like 51 is the average. And so it's kind of that late 40s, early 50s. And, but again, then some people can still have regular cycles up into their, their mid-50s. And you can absolutely get pregnant in perimenopause. And so sometimes people think, well, I'm not having regular periods. There's lots of opportunity for pregnancy. So you wanna make sure that you've got that covered as well.

Okay, cool. So I would anticipate that especially you mentioned bone density, that exercise is still important.

Absolutely.

Perimenopause, menopause timeframe.

Yeah, yep. So it's like hormones plus exercise and obviously healthy diet as well. But yeah, so the bone mass starts to decline pretty rapidly in the year or two leading up to menopause. Menopause, which again, you don't know when that is until in retrospect. And so that's another reason we don't say you need to wait until you get through menopause to start hormones because you're, you're adding that protection in right when you probably most need it if you start when you develop symptoms. And then the strength training is, is huge for maintaining bone mass. And so you wanna do progressive overload. And this goes for your, you know, runners and stuff like that too. They really need to incorporate the strength training. It's critical.

Yes, absolutely. So what I've seen is people who may have been used to like heavy volume or heavy loads then have to tweak to reduce their overall load of running or whatever endurance exercise they're doing and make sure they're prioritizing that strength training.

Yeah.

So, okay.

Yeah. And not the pink 3-pound ones, but you need the, you need to be progressively adding. Yeah.

Yes. You just touched on a massive nerve of mine. Ladies, pick up the big things.

Yes, please.

Yeah, obviously do so wisely.

Yeah. And get a trainer if you've never done it. But, and you, you need to be doing more and more in order to, to stress the, so that you get these micro tears on the, the bone that then stimulate bone growth. So critical. And then obviously calcium and vitamin D are important as well.

Absolutely. Cool. Okay. So getting back to some hormones, we very bri— like it snuck outta your mouth, but I know that you have more to say out of it about testosterone. So I know that women actually make it, right? But what's the amount? What should we lean towards? How do we know whether we need it? So yeah, are there certain types that you prefer to use and why?

Yeah. So maybe let me back up and talk about estrogen and progesterone first. So, you know, your ovaries are really your main source of estrogen and progesterone. You get a little bit of estrogen from fat cells, but it's a different type. So essentially when the ovaries shut down, estrogen and progesterone are gone. And we know there's this massive benefit from estrogen for bone health. Also probably cardiac and brain health. So, you know, you get the estrogen on board whenever, again, whenever those symptoms of low estrogen start. Progesterone has to be on board if you have a uterus, because if you don't, you're kind of just stimulating growth of the uterine lining. The progesterone kind of balances that out. So if you have an IUD or don't have a uterus, you don't have to take oral progesterone. But if you otherwise, you should be taking probably oral progesterone, which has its own benefits, like I mentioned, especially with the sleep in perimenopause. So sometimes women who don't need it will take it anyway. So that's estrogen. And then there's also vaginal estradiol, which because we have so many receptors in that area, often the systemic estrogen is not enough. And so I almost universally prescribe vaginal estradiol. It's like, why not? So those are kind of the three that you want to definitely get on board. And then testosterone is a little bit different. Testosterone in men and women, it's starting in their kind of early to mid-30s, starts to gradually decline. It's not like the cliff with estrogen and progesterone. And there's a lot of debate debate right now about the kind of whether we need testosterone or not. I mean, we still do make it, so it's not like it disappears. And there is definitely, um, the ability to harm with testosterone. So pellets where you end up with a very high dose, more like a male dose, can cause lasting changes— male pattern baldness, voice deepening, facial hair that does not go away. So you want to be very judicious with testosterone. It is indicated in women for low libido. But there is some thought that it also helps with bone mass, muscle mass, brain fog. And so sometimes I'll use that in perimenopause, like with just progesterone, and then we add in the estradiol later, or with postmenopausal women if they've got all the things on board and they're still struggling with the libido. And then the formulation, there's various ways to do it. So there's not an FDA-approved formulation for women. So I typically will use the men's gel that is a daily dose, and women would use a 10th of that dose a day. That way you know what you're getting. It just makes it a little messy and hard to measure out. But you can also compound it if people prefer something they just dial up and rub on like a cream. That's perfectly reasonable as well. So that's testosterone. So I think, you know, probably in your community, people are used to thinking of testosterone as like the bodybuilder drug, and we're not using doses like that. And so, you know, if there is an impact on muscle mass, it's probably small. And it probably really just has more to do with kind of overall energy level, kind of emotional health that can lead you to perform better physically versus just actual direct effect on the muscle.

So is the gel something that you would apply to like, is it transdermal or is it intramuscular? Yeah. Okay.

Yeah. All right. Yeah. It's, and you can pull it up into a syringe so you can measure it more accurately or you can just kind of eyeball it and you put it on areas where you're unlikely to develop hair growth. 'Cause you can get hair growth with, you have androgen receptors there. So it's pretty safe if monitored. And so that's the one case where we definitely check a level because there are women who do have kind of higher than average levels already and you wouldn't want to add more because you could risk the side effects. And then you want to make sure you're not overshooting with the treatment. So typically checking within about 4 to 6 weeks after starting the hormone treatment.

What could be some potential symptoms that they would notice if the dose is too high?

Yeah, so the, you know, hair thinning, acne. The acne would probably be the first one because it would just, you know, come up more quickly.

Chin hairs.

Yeah. Yeah, yeah. And again, that's irreversible. You know, you probably don't have any singers in your group, many, but like, they will know, they will know, you know, professional singers would be really cautioned about testosterone because you can have a voice change that's not reversible. So it's definitely the highest risk, I think, of the things that I prescribe. I think estrogen and progesterone seem pretty low risk in comparison, but. Okay.

And then are you mostly doing oral progesterone or is there also a, Transdermal?

Yeah. So they're the, the bioidentical. And I should also say that, and we have to talk about bioidentical for a minute, 'cause I think people get kind of seduced into the compounded formulations 'cause they're personalized and bioidentical. The estradiol that is transdermal is exactly what your body makes and it's comes from plant sterols. And so it is, but it is the identical molecule and then FDA approved and regulated. So you know exactly what you're getting. Progesterone, also the oral one, is, is exactly what your body makes. The molecule itself is too big to be absorbed through the skin. And so you, you really can't, and you can buy it compounded that way, but you really can't be assured that you're getting enough progesterone to protect your uterus if you're using the transdermal. But if people don't tolerate the oral for a variety of reasons, it's in peanut oil. So if they have a peanut allergy, you can compound it. Without the peanut oil, or you can use a synthetic topical progesterone. And then there's also, you know, apparently you can also use the oral pill vaginally. There's just not a lot of great data on it, so you have to kind of monitor as well. Okay.

And when you're saying monitor, is that like testing levels every few months?

Yeah. So progesterone levels, we don't really— it's more just, you know, potentially doing a pelvic ultrasound periodically. I mean, what you'd worry about is do you have unopposed estrogen for your uterus? And so So whatever form of progesterone you're taking, you want to make sure you're getting essentially the equivalent of that 100mg oral tablet a day to your uterus, or that you have an IUD.

Okay. So we've obviously been discussing hormones. What are some other factors that women need to consider from, like, a longevity perspective? I know you mentioned vitamin D and calcium and doing your strength training.

Yeah.

Anything else that we're looking at or need to keep our eye on?

I mean, I think those, those are the big, the big things that the diet, lifestyle, prioritizing sleep. You know, there's all kinds of data about, you know, poor sleep and people who sleep less than a certain number of hours a night, probably 5, that they have higher risk of cardiovascular disease. If you snore, making sure you get evaluated for sleep apnea. Sleep apnea is much more common in postmenopausal women than in premenopausal women because 'cause something happens with the estrogen, kind of you get increased laxity in the neck area. So, and it's not necessarily, so, you know, it could even be a serious athlete. It's not the typical, you know, male overweight short neck that you see in women. And the symptoms can be different. So if you really are not feeling like you're getting good sleep, getting evaluated for sleep apnea would be pretty critical. And then prediabetes, diabetes is also much more common in the perimenopause, menopause space, you know, even for athletes, I would say. And so making sure that you're getting routines Screening for that and taking measures to decrease insulin resistance if that's something that, you know, we all have different genetic tendencies. And if you happen to be, you know, a little bit more insulin resistant at baseline, even if you're an elite athlete, it can creep up on you. So kind of monitoring that. Same with cholesterol. Certainly not smoking, thinking about alcohol use. I mean, I think we used to say, well, if you're having just a glass a day, it's fine. But more and more data is coming out showing that there really is no, there's no physical benefit for alcohol. So there's probably a kind of community social benefit, but telling yourself that the red wine's helping your heart is probably not true anymore.

Not so much.

Yes.

I read a fascinating story or a study about the polyphenol content in non-alcoholic beer and how it reduced the incidence of colds after a marathon. And they were drinking like a liter to a liter and a half of non-alcoholic beer. So maybe the industry has been pushing these polyphenols like, oh, you know, this red wine phenols is so good for you. It's like, but the alcohol's not.

No, no. And I don't know whether the carbs in the low alcohol beer would be either.

So yeah, you still have some, you still have some. Um, so yeah, speaking of insulin resistance and, you know, genetic tendencies and perimenopause, menopause, one of the things that I'm always encouraging, and now it's over-the-counter, folks to get is if they can, um, bring— and this is a CGM— if they can come at it with a lens of curiosity instead of like like, oh, I feel shame that my blood sugar is spiking. Like, oh my gosh, what am I— like, not panicking, just like stepping back, gathering some data, and then making little tweaks. But it seems like from y'all's end is that is a hard thing to, uh, even if they're creeping up, that is a hard thing to actually get a prescription for. It's like you have to be— so tell me a little bit about that.

I mean, well, for, for insurance to cover a CGM, you generally have to be on insulin, like a diabetic on insulin. But you're right, I think that they're like $50 now to do a 2-week— you put on for 2 weeks.

Yeah, like a month is $99.

Yeah. And I, I think that is totally reasonable. And, and you don't wanna get obsessed about it. I mean, I wouldn't say put one on and never, never stop, but just, you know, do it periodically and understand what, how your body's reacting. Because some people can tolerate oatmeal cuz of the fiber content and other people oatmeal sends their blood sugar sky high. So it's just understanding what your unique pattern is and understanding how if I go for a 10-minute walk after a meal, how much does my sugar drop? And so is that worth kind of investing is just the positive reinforcement and, and kind of like you said, understanding your own body. And so I'm a huge fan of that as a just a kind of periodic check-in.

Yeah, love that. Very cool. All right. So if we take everything that we just talked about, which was a lot in a very short amount of time. So thank you. What are the top 3 takeaways that you would leave people after this episode? Okay.

So first thing I would say is, you know, as far as hormone replacement therapy, I've now coming at it from a place of, well, why wouldn't you use hormones? So what are the reasons that you shouldn't versus why should you? Because of the ability to help you kind of live your best life now and prevent bone loss, you know, likely improve your cardiac risk profile, decrease your risk of dementia. So, you know, start with that. But then also, So, you know, how do you optimize nutrition and then how do you stay active? And being active is both, you know, cardiac, probably getting in some, some thing where you're really getting your heart rate up high to improve your VO2 max. Obviously the strength training, which we talked about, and then flexibility and balance. And, and the, so I think that it's sort of a trifecta of, you know, give, giving yourself what we, you know, evolutionarily would have had probably if we didn't used to die when we were 50. Um, and then, and then taking care of yourself, um, with the, the lifestyle issues is what I would say.

That's so awesome. All right, so Dr. Abby DeVries, how can people get a hold of you?

Yeah, so I am on Facebook and Instagram and TikTok at Sabia Health NC. That's S-A-B-I-A, and that's how you spell Sabia. And then on my website is sabiahealthnc.com, and people can sign up for introductory sessions or schedule an appointment or join the membership through there as well.

That's awesome. And you had also mentioned, do we have any homework, any good books or people you like to follow?

Yes, absolutely. Yeah. So there's the Menopause— is it? And like I said, yes, exactly. But my current fan favorite is Kelly Casperson's book, The Menopause Moment. She's a urologist. This is a fantastic book and she's also hilarious. And then the other one, especially for your group, I would recommend would be Unbreakable by Vonda Wright. And she's an orthopedic surgeon and she's got a whole exercise program in here as well as nutrition. And then one more would be Heather Hirsch is another very vocal. She's been doing menopause care for about 15 years now and it's a perimenopause book. Menopause has had a moment. Now we're moving into the perimenopause moment, which is pretty much uncharted territory. It's been great to read about.

Oh, that's so great. I, I love the work that you're doing. Thank you so much for serving the community and for serving us on this podcast. And I mean, that was so much in such a small amount of time. So Dr. Abby DeVries, thank you so much for coming on the podcast.

Thanks for having me.

Thanks for listening to the Find Your Edge podcast. If you like what you heard, don't forget to subscribe on your favorite podcast platform so you never miss an episode. And if you're interested in learning more about our endurance coaching, sports and wellness nutrition, metabolic and sweat testing, triathlon training team, or our triathlon training library, be sure to check us out at theenduranceedge.com. And don't forget to follow us on social media at The Endurance Edge. Thanks again. And we'll catch you next time.