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Dear Doctor - Part One

Dr. Nancy Lipsitz



In the last 5-6 months, I have gained 20 pounds and I have gained more in my mid-section. It’s not budging, what can I do?


This is one of the most common and challenging questions that my patients ask! As your hormones change, your lean muscle mass decreases and body fat increases. Since muscle has a higher metabolism rate, as your muscle mass decreases, your metabolism in general decreases. Even if you are doing the exact same things that you have always done and you have not changed nutrition or exercise, unfortunately you will likely see weight gain and you will likely see a redistribution of fat around your middle. The average amount of weight gain is 1.5 pounds per year but for some women it can be more. These changes do even out over time and most women stop seeing weight changes about two years after their last period. Also, it is very common to have interrupted sleep in perimenopause and menopause and this interrupted sleep can lead to more snacking and more calorie intake. The increased weight, especially around your abdomen, can increase health risks such as heart disease and diabetes, so it is important to address, both for your long term health and for your well-being in general.


So, what can you do?! Hormone therapy is not likely to help much at all - it may help slow some of the weight gain, but its impact is really quite small. However, hormone therapy may help with sleep, so it may help to decrease nighttime snacking.


Since your muscle mass decreases over time, the most important first step is to build and maintain muscle – both to optimize your health as you get older but also to boost your metabolism. I recommend doing strength training at least two times per week. This does not mean that you have to go to the gym as you can find great strength training videos online. You should also aim to do other aerobic exercise for at least 150 minutes per week. Find something that you enjoy doing on a regular basis.


Unfortunately, your body needs fewer calories in your 50s than it did when you were younger and that is no fun! Even with the weight change that you are seeing, it is possible to prevent and control it. I recommend focusing on healthy foods that you enjoy. Increase vegetables and fruits and focus on whole grains and foods that are less processed. Avoid a lot of added sugar and limit alcohol intake.



Can I use HT if I have a family history of breast cancer?


The overall increased risk of breast cancer with hormone therapy is quite low – less than one diagnosis of breast cancer in 1,000 women taking hormone therapy per year. Even if you have a family history of breast cancer, studies show that taking hormone therapy does not add to this risk – so yes, you can take hormone therapy even if you have a family history. You should, however, meet with your doctor to review your medical history and risk factors for breast cancer and you can decide together if hormone therapy is right for you. If you have a family history of ovarian cancer or a strong family history of breast cancer, such relatives with breast cancer before age 50 male breast cancer, or several relatives with breast cancer, then you should discuss with your doctor whether you might benefit from genetic testing. Are there other medicines that I can take to help with hot flashes if I don’t want to take hormones? Yes, there are definitely other options, but they are not nearly as effective as hormone therapy! The non-hormonal prescription medications include antidepressants (SSRIs and SNRIs,) gabapentin, clonidine and oxybutynin.


There are 2 FDA approved nonhormonal treatments. One is a low dose of paroxetine, an antidepressant. Another is fezolinetant and it was just approved in 2023 which is very exciting! Fezolinetant works in a new way in that it directly targets the hypothalamus in the brain where hot flashes and night sweats are triggered. We will likely see more medications similar to fezolinetant in the coming years as these are more effective options than other non-hormonal methods.



My scalp and skin are suddenly so itchy – help!


Itchy skin is very common in menopause, although it is one of the symptoms that many people do not talk about. When estrogen decreases, less collagen is made and more collagen is broken down. With less collagen, the skin is not as effective at retaining moisture, which is why your skin may be more dry. And dry skin can be very itchy! Any moisturizer that helps your skin retain moisture can help. I recommend starting with a product that contains shea butter, glycerin or ceramides. Hyaluronic acid can also help your skin retain more moisture. A dermatologist can also offer other treatments.



How do you reconcile the joint pain with the need to move more so that I don’t gain more weight? It’s hard to work out when everything hurts all the time! Also, how come noone warns you about joint pain?!


Even though about 50% of women have joint pain in menopause, the discussion about joint pain too often gets forgotten or dismissed amidst the louder talk about hot flashes and night sweats! Joint pain is very common and it tends to peak in women between the ages of 45 to 55. If you are having new and/or persistent joint pain, I recommend that you see your primary care doctor to make sure that you do not have specific reasons for the joint pain, such as arthritis or hypothyroidism or reaction to medications, that would merit evaluation and specific treatment.


However, if no other reason is found for the arthralgia or joint pain, you should know that typically it improves over time. There is certainly a catch-22 here because we recommend maintaining physical movement but it may be too painful! And staying at a reasonable weight will place less stress on your joints. I recommend starting your exercise very gradually so that you do not overload the painful joints. One study showed that a diet low in carbs, meats and fats decreased joint pain. Joint pain is not a classic indication or reason to start hormone therapy, but if nothing else is helping, you can discuss a trial of hormone therapy with your doctor.



How can I find an OB/GYN who actually knows their menopause stuff?


Good question! We receive minimal to no education about menopause in medical school and our menopause training in OB/GYN residency is also incomplete. So that means that each individual gynecologist needs to take it upon his or herself to self-educate. Your general gynecologist may be very up to date about menopause care but that is always a fair question to ask him or her.


Alternatively, you can go to the website for the Menopause Society and search for a practitioner who has received specialized training and is certified by the Menopause Society. There are also new online sites that offer virtual menopause care – some of these include Midi Health, Alloy, HerMD and Evernow.


If you already have a relationship with a physician who knows you well, I recommend asking about his or her menopause knowledge. If you feel that your symptoms are not being addressed, then you need to find someone who is hearing and addressing your questions and concerns.



 

Dr. Nancy Lipsitz is a Harvard-trained obstetrician/gynecologist who practices in Nashville, Tennessee. She is also a Menopause Society Certified Practitioner who loves helping women optimize their health and well-being during perimenopause and menopause. Dr. Lipsitz is chair of the ob/gyn Innovation Committee at her hospital and she enjoys enacting positive changes at the community and hospital level.


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