Perimenopause & Menopause: Hormones, Gut Health & Whole-Body Wellness (with guests Drs. Chrisandra Shufelt and Jami Kinnucan)

Part 2 of the Women's Health Series

Your digestion suddenly feels different, your sleep is falling apart, your mood and patience are all over the place — and you start wondering whether it’s stress, aging, or something bigger. Joined by two extraordinary Mayo Clinic experts, Drs. Chrisandra Shufelt and Jami Kinnucan, we pull back the curtain on perimenopause and menopause, explaining how shifting estrogen and progesterone can ripple through the entire body — from constipation and bloating to metabolic health, cardiovascular risk, and even the gut microbiome. Most importantly, this episode reminds women that these changes are real, common, and worthy of attention.  

• Defining perimenopause versus menopause as a life stage and why symptoms vary so much 
• Linking estrogen and progesterone changes to motility, constipation, bloating, and visceral sensitivity 
• Discussing microbiome shifts, dysbiosis, and how gut health may influence estrogen recycling 
• Outlining cardiometabolic changes including central weight gain, lipid changes, blood pressure, and insulin resistance 
• Clarifying brain fog, sleep disruption, and increased anxiety and depression risk during perimenopause 
• Reviewing SSRIs and SNRIs as options that may also reduce hot flashes 
• Covering bone loss timing, hormone therapy limits, and when DEXA scanning makes sense 
• Summarizing what is known about IBS symptom severity and what is less clear in IBD 
• Debunking hormone panels in perimenopause and pointing to menopause-trained clinicians 
• Breaking down soy, supplements, placebo effects, and lifestyle factors like weight loss and exercise snacks 
• Detailing vaginal estrogen for dryness, painful sex, and recurrent UTIs, including how to use it correctly 

This episode has been sponsored by Ardelyx.

References for this episode:

The 2022 hormone therapy position statement of The North American Menopause Society

The association between metabolic dysfunction-associated steatotic liver disease diagnosis and vasomotor symptoms in midlife women

Impact of Menopause and Clinical Considerations in Patients With Inflammatory Bowel Disease

Understanding the sexual concerns of older women presenting for care to women's health clinics: a cross-sectional study

Find a Menopause Practitioner: Menopause.org

Learn more about Kate and Dr. Riehl:

Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast

Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.  

The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment.  Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

Transcript

Welcome And Women’s Health Focus

Kate Scarlata, MPH, RDN 0:00

This podcast has been sponsored by Ardelyx.

Kate Scarlata, MPH, RDN 0:06

Maintaining a healthy gut is key for overall physical and mental well-being. Whether you're a health conscious advocate, an individual navigating the complexities of living with GI issues, or a healthcare provider, you are in the right place. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food, and the gut. Come join us. We welcome you.

Kate Scarlata, MPH, RDN 0:37

Hello, friends, and welcome to The Gut Health Podcast. We are your hosts. I'm Kate Scarlata, GI dietician.

Dr. Megan Riehl 0:43

And I'm Dr. Megan Riehl, a GI Health Psychologist. This is part two of our women's health series. And today we're talking about how shifting hormones during perimenopause and menopause impact the gut, as well as why that matters for your entire body. But also, why don't we talk more openly about the stage of life that affects half the population? I ask myself this all the time. Yes. And, you know, it's because this time overlaps with everything else: career, family, stress, different life stage happenings. It can be hard to tell what's actually driving symptoms. Is it your lifestyle or hello, am I now in paramenopause? So today we're opening that conversation and we're getting into the stats, the symptoms to watch for, and how and when to start talking to your provider and which provider to talk to, because no one should feel like they have to just push through this or figure it out all alone.

Kate Scarlata, MPH, RDN 1:43

That's right, Dr. Riehl. So here's the reality: up to 70% of women report new or worsening GI symptoms during this time. And falling estrogen doesn't just drive hot flashes, it's tied to changes in metabolism, cardiovascular risk, and even gut microbiome changes. And let's talk about mood and cognition. That's happening. It's happening. So when the microbiome is balanced, it supports steadier estrogen levels. But when it's disrupted, say in dysbiosis, when it's just this unbalanced microbiome, less estrogen is recycled, which can really amplify the natural decline during this transition.

Dr. Megan Riehl 2:25

So the gut microbiome isn't just along for the ride, you're saying. It's helping to shape symptoms across digestion, bone, heart health, and mood, our mood and cognition. So, in other words, this transition is not isolated. It's very much whole body. And to help us unpack all of this, we are joined by two incredible experts. Dr. Chrisandra Shufelt is a leader in women's health, menopause, and cardiovascular research at the Mayo Clinic. And Dr. Jami Kinnucan, a gastroenterologist at the Mayo Clinic, and a friend to the show who brings deep expertise on how hormonal changes impact the gut. Together, they are going to help us connect some of the dots.

Kate Scarlata, MPH, RDN 3:10

Yeah, and these are confusing dots to connect. So it was really nice to have two experts join us for this episode. So whether you're a woman in your 30s or 40s and you're just starting to notice some subtle changes in your body or well into menopause, this episode will give you a clear, science-backed understanding of what's happening in your body and what you can do about it. So thank you so much, Dr. Shufelt and Dr. Kinnucan, for joining us today. I'm going to get right into the question. So

Why Hormones Affect The Whole Body

Kate Scarlata, MPH, RDN 3:43

this one is for you, Dr. Shufelt. How do changes in hormones, estrogen and progesterone, during perimenopause affect metabolic health and body composition?

Dr. Chrisandra Shufelt 3:54

That's a great question. I think first of all, it's important to define kind of perimenopause versus menopause. So really menopause is the natural normal stage that guess what, half of your adult woman's life will be spent in. So it's not like a period in time anymore. We call it a life stage. And it's defined really as the last menstrual cycle, as well as you can also obviously go through surgical menopause if you have both ovaries removed. And then perimenopause is really that the stages leading up to that final menstrual cycle. And I always call this the roller coaster of hormones because when you have a menstrual cycle during your reproductive years, presumably they come every month, as they should. That's a normal signal. And you get this nice upswing in estrogen, and that back half you get an upswing in the progesterone. But during perimenopause, it can become somewhat erratic. There's early and late stages of perimenopause. Late stage is you're getting closer to the final cycle, but it's obviously lengthening out. That's when we really start to see some of the metabolic changes occur, is more towards the latter stage of perimenopause, and then of course swinging into menopause as the final portion of that stage. But metabolic health is important, and we certainly speak a lot to the fact that in body composition, body composition is interesting because weight gain is just a natural normal phenomenon of aging, whether you are male or female. However, due to all these fluctuations and hormones, where you're laying down your weight changes and shifts. So you're getting more central weight, you lose a little bit more lean mass. And so where you were used to kind of that hair shape, you kind of turn more to an apple if you must compare it to fruit. But there's also the carrot, those people that just stay thin. But I will say that's one of the big changes is body composition. We certainly know that metabolic health is important as well. I always say it's an opportunity for prevention in the perimenopause and menopause stage. We see changes to things like cholesterol, lipid panel, LDLs can go up, triglycerides can go up. We also see that blood pressure in not all women, but in some can go up as well. And then finally, metabolic syndrome. We see this along with the weight gain that you see, we start to see insulin resistance and then results in a higher uptick of metabolic syndrome during this period of time. It's not all bad news, I will say, because a lot of it is an opportunity, like I said, for prevention and a discussion with providers and getting on these risk factors before they kind of get away with us.

Kate Scarlata, MPH, RDN 6:30

Exactly. And I think of women, you know, that don't know this and their body starts shifting and changing or getting the muffin top. And, you know, it's like, what is happening right now? So I think education in advance. So maybe they can change their diet a little or get exercising a little differently and or lean into the fact that there's going to be changes, and that's okay too, right?

Dr. Megan Riehl 6:55

Well, I think that's the key, right? That we want the opportunity to normalize these things and to know that I think body image is certainly one of the things that a lot of women are thinking about because it's a tangible, observable thing that either you or someone else in your life is observing. But the why, the why these changes are so important, and then the what. What can we do? Who do we turn to? How do we have these conversations? And when is it in our early 30s, our mid-30s, our 40s, and probably along that roller coaster that you just alluded

Estrogen, Exhaustion, And Heart Risk

Dr. Megan Riehl 7:31

to? So I think when maybe you're using Dr. Google or you're talking to your girlfriends, estrogen is going to come up in the conversation. And so, what is the relationship between this declining estrogen level of menopause and then also tying back to another risk factor, which is our cardiovascular risk factors? Can you start to educate us on the wonders of estrogen?

Dr. Chrisandra Shufelt 7:55

Well, I think it's important to really define that this is a natural normal stage of, like you just said, of a woman's life. And but declining our own levels of endogenous estrogen is much different than replacing it. And we do not use hormones to treat some of these changes with the cardiometabolic or cardiovascular risks specifically. But what we can certainly say is that even in the perimenopausal phase, we start to see women have hot flashes and night sweats. We just published a big study using the Flow app where we did a worldwide global survey of perimenopause, and we actually identified top key complaints were, of all things, exhaustion. That was the top complaint. And I think if you can talk to any woman in the midlife and they're going through perimenopause, that's pretty common. It might not be hot flashes and night sweats. So all of these fluctuations can disrupt our sleep. It can then disrupt our lifestyle, disrupt our cognitive. We've also shown that there's a lot of menopause in the workplace is an important, you know, topic as well as treatment. So the declining estrogen levels, yes, play a role, or what I call, quote, ovarian aging plays a role in some of these cardiovascular risk vectors, but we certainly are not using estrogen to treat them. We're certainly treating using estrogen to treat symptoms of hot flashes and night sweats, as well as some of the other complaints that we hear. But the decline in our own levels of estrogen is really what sets some of these changes up. But replacing that estrogen isn't going to reverse all those changes. Meaning we see 90% of women in perimenopause and menopause have at least one risk factor for heart health. Well, obviously, we don't want to treat the hot flashes, but we don't treat it with the estrogen. But that tells you something right there. A lot of it is also based on aging.

Kate Scarlata, MPH, RDN 9:47

It's interesting. And I think the exhaustion piece, it's probably like multifactorial, right? So if you're having hot flashes, you're waking up at night, night sweats. I mean, that's going to contribute to the exhaustion too. So it's just this whole process. Your body is just changing, and so many things are interacting at the same time. And again, more information, more understanding, like it makes sense you're exhausted. You have all these, you know, other things going on in your body at one time. Heavy cognitive load.

Dr. Chrisandra Shufelt 10:19

Heavy cognitive load. And then we're also the sandwich generation where, right, we're taking care of our elders, we're taking care of our youngers, and then we're taking care of our communities and our careers and our society. And that that also plays a big role, as as you well know.

Kate Scarlata, MPH, RDN 10:34

Oh, yeah. As I'm watching my granddaughter today and have a 90-year-old father-in-law, yes.

Dr. Megan Riehl 10:40

Well, and I was driving in my car with my three kids in the back, and I was talking to a girlfriend who happened to be a physician, and you know, she's trying to ask me questions and I lost track of where she was at. And I said, gosh, you know, I think this is perimenopause. I better start talking to my doctor. And she said, Megan, your name, mom, has been yelled no short of 15 times in the last three minutes. I don't know if it's perimenopause, but there's lots of different factors that could be contributing to why you don't remember the question that I asked you. So, you know, lots of challenges.

Dr. Chrisandra Shufelt 11:14

It is all additive. And at the end of the day, as if, you know, there's a threshold that you meet, and then it's it's all additive.

Kate Scarlata, MPH, RDN 11:21

We

Constipation, Bloating, And Gut Motility

Kate Scarlata, MPH, RDN 11:22

got to cut ourselves a little slack. So let's transition into the gut a little bit with Dr. Kinnucan and talk a little bit about how changes in estrogen and progesterone may lead to bloating and constipation and maybe a decline in GI motility potentially. What's going on there?

Dr. Jami Kinnucan 11:39

Absolutely. Estrogen and progesterone both influence gastrointestinal motility, and thus could potentially also have impacts on visceral sensitivity and what we perceive in terms of symptoms that are happening. Progesterone slows smooth muscle contraction. It can lead to slower transit overall, which then in an aging population can be seen as constipation and bloating. How oftentimes I have these women who are saying, I was always so regular, and then something happened. And what happened was age and changing in hormones. Estrogen modulates motility as well, but also can contribute to visceral sensitivity and serotonin signaling. And so the declining or the fluctuating levels over time, especially as women are aging, can often worsen some of the symptoms that we see in our practice of bloating, change in bowel habits, and increase in gut sensitivity. And these can then also be amplified in patients who may already carry a diagnosis on the DGBI or disorder of the brain gut interaction or irritable bowel syndrome if they've been given that diagnosis. And so you can imagine a patient who already maybe has baseline constipation, this is not helping. And then as an aging population, we also see we're starting more patients on GLP1s, either because they have changes in their insulin levels, they've been given a diagnosis of diabetes, and they're maybe dealing with now obesity and weight management. So there's a lot of things that I think are at play, but independently we know that hormones can directly impact the gut and gut motility.

Kate Scarlata, MPH, RDN 13:09

I often think too about just pelvic floor. You know, we're losing muscle mass, you know, there's also that piece of things changing hormonally and, you know, pelvic floor disorders. And, you know, is that a contributor to are we seeing an uptick in people in menopause with just pelvic floor dysfunction around muscle loss? I don't know. I'm just this is a sidebar, but I'm thinking about that as another risk factor.

Dr. Jami Kinnucan 13:36

Well, I think I have never sent a patient for an anal rectal manometry test that was normal. So I think that there is a lot of the population, whether it's men or women or both, that are walking around with undiagnosed pelvic floor dysfunction. And it starts when, you know, we're when we're little and we we're learning to use the restroom maybe the wrong way, or we use our own techniques to be able to produce the bowel movement, but maybe aren't doing it in the most healthy way, you know, or we're not keeping our knees up, so we're not using a squatting potty. And so it just continues to exacerbate what we've taught our pelvic floor to do. And then, yes, if you're having an overall loss of muscle mass in aging, and that happens for both men and women, we're, you know, that certainly could exacerbate that uh as well. And so when you slow it on the gut and your pelvic floor, your door out isn't functioning as well as it should, or optimally, it just contributes to the whole cycle. Yeah. And it's really hard to overcome that. So everyone probably suffers from a little bit of pelvic floor dysfunction. But I again, I've never seen a normal anal rectal manometry test. So maybe the pretest probability is fairly high in the GI clinic.

Dr. Chrisandra Shufelt 14:42

But well, and don't forget about the role of estrogen on vaginal health as well, because that's is also an area of great interest. And also it's a very estrogen-dominant tissue. People don't realize that this is not a tissue that's going to get better on its own. So adding to kind of the pelvic floor area, you have loss or thinning of the lining of the vaginal lining again. Therefore, that can lead to dyspareunia, that can lead to a lot of discomfort and increased susceptibility to infections. It's easy to be treated also with topical vaginal estrogen creams or a tablet.

Dr. Megan Riehl 15:15

Okay. So I'm hearing you say if you're having, you know, pain with sex and that's something new with you, again, those are drivers of conversations with your doctors. And there are going to be some easy fixes and some that are not. And,

Brain Fog, Mood Shifts, And Sleep

Dr. Megan Riehl 15:27

you know, this next question around the brain and cognition, maybe not such an easy fix, but help us kind of understand, Dr. Shufelt, a little bit about how these hormonal changes can influence the brain and menopause. And this is wheel, you talked about this starting the brain fog, cognition, mood regulation. And then are there increased risks for anxiety and depression at this stage of life?

Dr. Chrisandra Shufelt 15:54

Well, absolutely, there is an increased risk for anxiety and depression in perimenopause. Believe it or not, it actually is a much higher rate in perimenopause than it is in menopause. And I always tell my patients, look, at the end of the day, we got to treat you for this period of time. And it might not that you need to be treated for going long term, but recognize that it's probably this really these jagged shifts in hormones that can contribute to these mood changes. And I just don't feel like myself kind of mood or having that really short fuse to snap when you know this probably wouldn't have bothered you as much 10 years prior. So there is also that vulnerability during perimenopause, and it there's actually a position statement, believe it or not, by the menopause society on this specific topic and ways to treat it. So I think recognizing that that's common is important. We also know that frank depression is can happen during perimenopause. And even if you've had one episode of depression in the past, it's more likely to come back during perimenopause. And it may not carry over to menopause, but it could. So that's an opportunity to have that discussion as well. Cognition is another interesting. So cognition is I can't remember where I put my keys. And I've had a patient tell me that. How many patients have told me that? And here's what I say: well, here's the good news. You've remembered that you don't know where you put your keys. It's the people that don't really remember they had keys that obviously is concerning. Cognitive complaints at perimenopause and menopause are not associated with any long-term impact. Oh, I'm gonna say that again. Yes, it is not associated with dementia, it is not associated with cognitive decline at a later stage in life, it is a common occurrence and likely due to just our brain adjusting to these lower estrogen within our brain itself. Also, coupled with that, the loss of sleep leads to what I call the chronic jet lag phase. So if you've ever had a flight across the Grand Seas and woken up in another country and it's eight hours later and your body's still back eight hours before, you know you feel brain fog. So if you're not sleeping through the night, you're just gonna feel that effect. And it compounds itself night over night, overnight, if you're not getting adequate sleep. And now we have so many trackers and abilities to look at how our quality of sleep is. And I think they're the best utilization of these trackers is to actually identify key triggers that give you a poor night's sleep, or recognize that, hey, if I have a glass of wine, I might have a poor night's sleep, or other things that can trigger it. I think those are habits that we start to develop, and it's a great opportunity as well.

Dr. Megan Riehl 18:45

That's fantastic advice. And should we expect that our reproductive health physicians may be prescribing an anti-anxiety or an antidepressant, or is that something you would typically refer out for?

Dr. Chrisandra Shufelt 19:00

I'm comfortable prescribing an anti-anxiety or an antidepressant. And the way that I explain it is if I could do a blood measure and show that your serotonin was a little bit lower and you need to hold on to it, then you might be more comfortable taking it. But the other good thing is that a lot of the SSRIs and SNRIs can treat hot flashes without even using estrogen. So there's a lot of crossover into the area of the brain that controls hot and cold perception. And then therefore, that also crosses over into serotonin. So it's something that I'm comfortable with doing as well.

Dr. Megan Riehl 19:33

And that's something we can revisit too. I've had a lot of patients where they were prescribed something, I think probably in the perimenopause stages. And then, you know, even 20 years later, they're still taking that SSRI and kind of going, do I still need to be on this? So if that's you, you know, it's worth a conversation to potentially get off of a medication that maybe served a purpose and might not, you know, be needed any longer.

Kate Scarlata, MPH, RDN 19:57

Yeah, very important. Very important.

Bone Loss And Estrogen Timing

Kate Scarlata, MPH, RDN 20:00

Let's switch gears a little bit and talk about hormonal changes during menopause that affect our bone strength. And why does a lower estrogen level increase the risk of bone loss?

Dr. Chrisandra Shufelt 20:14

First and foremost, the most bone loss we see is that first year after the final menstrual cycle. So that's it's not gonna keep degrading, degrading, degrading. Estrogen is important for maintaining bone loss. It's not a treatment for osteoporosis. It's gonna maintain any further bone loss. So, and actually, the transdermal applications of estrogen have shown more benefit on bone than let's say an oral tablet of estrogen. So going through the skin for multiple reasons, including how it is metabolized in the liver, is actually one of the benefits for bone health. And actually, there's one indication for using estrogen therapy, and that's for bone prevention of osteoporosis. The most common question I get at the time, or if you put this into chat GPT, "what about my bone health?", is to do a screening for bone DEXA at the time of menopause. And that's actually not recommended unless you have significant risk factors. I know a lot of people have been on long-term steroids in this population, or perhaps you need to ask about rheumatoid diseases or autoimmune diseases, and if a mother or a father have had a hip fracture, that puts you at a little higher risk for bone health and more vulnerable at the time of menopause might be worth and it puts you in that category where we do want to do a bone DEXA scan. But in general, if we start to do bone DEXA scans at the age of 52, which is the average age of menopause, the fact of the matter is those bone scans are going to not help us predict who gets a fracture risk in the future, which is why we're not using it as a screening tool unless you fall into a higher risk. But I think it's important to note that the estrogen, if women's are having hot flashes and night sweats, one of the benefits of being on hormone therapy, especially the transdermal. Is the prevention of any further bone loss.

Kate Scarlata, MPH, RDN 22:02

But once they have a diagnosis of osteoporosis that you wouldn't recommend it, I just want to make sure I have clarification.

Dr. Chrisandra Shufelt 22:10

We are not using estrogen to treat osteoporosis. It would prevent any further bone loss. But again, we don't want to be starting a woman like let's say she's 65 and it's been 15 years since menopause and she goes in and has a bone scan and it shows osteopenia or osteoporosis. We do not want to start those women on estrogen for the purposes of further bone loss. Number one is because there's been a gap here of more than 10 years since she likely went into menopause. And we know there's higher risks for cardiovascular health as well as stroke and blood clots. But also, number two, it's not the first line of treatment and it's not a treatment for osteoporosis per se.

Dr. Megan Riehl 22:51

Perfect. That's helpful. Thank you. Okay, Dr. Kinnucan.

IBS, IBD, And The Microbiome

Dr. Megan Riehl 22:55

So tell us a little bit in your world of IBS and IBD. Is there some evidence linking menopause to worsening? You you talked about this a little bit earlier, especially in in terms of severity of IBS or DGBI with menopause. But how about IBD as well and what mechanisms are driving this?

Dr. Jami Kinnucan 23:15

Yeah, you know, I think these are only more recent conversations because of experts like Dr. Shufeld and people really investing time into this space. You know, we we didn't really talk much about the impact that estrogen and progesterone have on the gut microbiome. We talked more about, you know, the impacts in motility. But certainly we know that the gut itself is very sensitive to changes in estrogen and progesterone from a gut microbiome standpoint. And we know that the diversity and the health of the gut microbiome are ultimately a lot of the mechanism around what we're thinking about, why patients may have worsening IBS symptoms and why there might be an increased risk for inflammation around inflammatory bowel disease because of a change of a more pro-inflammatory microbiome diversity as opposed to a really diverse, balanced microbiome, where getting potentially dysbiosis. So there's stronger evidence out there for irritable bowel syndrome because we do see the worsening of symptoms around abdominal pain, bloating. Obviously, we talked about constipation and motility. So I guess if you're on the IBS diarrhea side, maybe that's a good thing if your gut motility slows down a little bit. But again, it's the hormone effects on not only the motility, the visceral hypersensitivity, as well as the gut microbiome and where that may play a role. There's a little bit less out there for inflammatory bowel disease. And Dr. Shufeld and I recently wrote a review really addressing the impacts of hormone changes, perimenopause, menopause, on inflammatory bowel disease, and trying to sum up what is out there. Menopause has not necessarily been consistently associated with an increased risk for relapse of inflammatory bowel disease, but we do know that patients may experience their symptoms differently. And maybe that's because of the motility shifts, the microbiome shifts, and many of our IBD patients do have that overlap with irritable bowel syndrome. Estrogen can have immunomodularity effects, and the declining levels, though, you would assume may be associated with an increased risk for disease activity. Maybe this is the theory around because there was a study that was published that looked at post-menopausal women with IBD who were started on hormone therapy and found that when they compared that to the same women that were menopausal with IBD that were not on hormone therapy, that they were less likely to have a clinical relapse of symptoms. And so is that because of inflammation or is that because hormones are helping regulate some of the things that we had just talked about? So I think really those mechanisms around motility, the visceral hypersensitivity, and then the microbiome shifts that then potentially have an impact on immune modulation, but no convincing evidence that menopause is triggering patients who are otherwise doing well to come out of an inflammatory remission. But they may be experiencing some of the what would be expected from a change in the estrogen progesterone levels.

Dr. Megan Riehl 26:11

Well, I'm so glad you guys put this research together and have been diving into this area of focus because there's just not enough. There's not enough conversation. And because of the way the brain and the gut are connected and our hormonal shifts and the microbiome having an effect on pretty much all aspects of our body, it's very hard. At least as a GI psychologist, I may be biased, but it's very hard for me to untangle the two. And so I hope that you'll continue to do this searching and we'll link your paper in our show notes for our listeners.

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When To Seek Care And Testing

Kate Scarlata, MPH, RDN 28:04

I have a question for you, Dr. Shufelt. At what point should a patient undergoing or in the midst of perimenopause or in menopause, when should they seek guidance or help for symptom control? Is it any time, I guess, but are there certain things that would sort of red flag you they may need some hormonal therapy or adjunctive care?

Dr. Chrisandra Shufelt 28:29

So perimenopause is a little bit trickier because there's a lot of symptoms that can occur, and no two women experience perimenopause the same. Some women have hot flashes and night sweats as their primary complaint. Some women have mood, as we we talked about some of the challenges with anxiety and depression. And some women just quite frankly have sleep disruption, which we can account to a lot of different things, but it might be just the hormonal changes. The one thing I'll say is that if the symptoms, and but not all, not everything is perimenopause, just as Megan mentioned, with kind of the cog some of the cognition, you know, if you've got a busy life and everything going on at once. But it's important that if you are experiencing symptoms just to talk to your provider about it and talk to your doctor. And if you want a provider that is specifically specialized in menopause, the menopause society, which is menopause.org, has a list of specialized providers that actually have to take a continuation of medical education specifically in menopause and get accredited every two years. So because this is a field, as we all have heard, that's completely changing almost every two years. We're getting more and more information, which is a good thing, but you need to have a provider that's also up to date. And so you can literally put in your zip code and it'll come up with a list of providers in that in your area that is accredited. Of course, it's not, it's just a certification. It doesn't necessarily mean accreditation for their medical knowledge, but again, it's something that's there. The challenge with perimenopause, and I'll say this, we don't want to check hormones in perimenopause because it's just like opening the stock market today. Is it up or is it down? I don't know, and nor will it help me treat you. So getting a hormone panel or trying to go into your provider and say, I need my hormones checked. If you haven't gone through menopause, it's going to be variable through every day of that month, and it's not going to help me treat you. Times that I do check hormones, number one, is if they're much younger, because the average age I mentioned for the range from perimenopause and menopause, I think 45 to 55. 52 is the average age of menopause. But if they're much younger, like under 40 or even under 35, and they're getting these symptoms, that might be a reason, or they've stopped having their periods for three months. That might be a reason to get hormones. But during perimenopause, it's not as helpful. But, you know, I think taking an internal gut check and not just saying is that's a funny thing, a gut check. But saying, is this really bothering me to the point where my quality of life is disrupted, I'm not able to make it throughout the day, or it's constantly on my mind that why am I anxious? That's the time to go in and talk to a provider. And it might not necessarily be that hormones are the answer in perimenopause. It might be another treatment because truly, sometimes giving hormones in perimenopause can make you know bleeding patterns worse. A lot of things need to be taken into consideration. And then after menopause, after you've gone 12 months without a period, if you're getting severe symptoms like hot flashes and night sweats, that's also the time to go in. Because with the majority of women, hormone therapy is safe. There are women who have contraindications to not being able to take hormones, meaning like they've had a blood clot themselves or, you know, a heart attack or an estrogen-sensitive cancer, not necessarily just breast cancer, but other estrogen-sensitive cancers. The important thing to note, though, is that we have good non-hormonal treatments that can treat symptoms of hot flashes and night sweats. So women don't need to, I don't want to say suffer, but they don't need to go and deal with hot flashes throughout their day and the exhaustion that might come along with it with having night sweats at night. There are good options available.

Kate Scarlata, MPH, RDN 32:19

I'm just so glad you said that about the hormone panel because I feel like everyone's out there balancing hormones is on TikTok and whether it's, you know, get them checked, and people are doing all these crazy hormone tests and probably not a really good idea, at least in perimenopause.

Soy, Supplements, And Lifestyle Evidence

Kate Scarlata, MPH, RDN 32:39

Dr. Kinnucan, did you raise your hand?

Dr. Jami Kinnucan 32:41

I sure did. I have a question for our resident expert. So I hear a lot in our clinic, you know, patients who are trying to be healthier in terms of diet and they're trying to eat more protein, they don't want to lose muscle, or maybe they are taking in GLP1 and patients getting concerned, especially patients around the risk of exposure to the estrogens from different plant-based proteins, so soy-based proteins. Is there any truth to that, Dr. Shufelt? I'm putting you on the spot.

Dr. Chrisandra Shufelt 33:11

Well, we actually looked at soy as a treatment for hot flashes in the non-hormonal position statement by The Menopause Society, which I was the lead author on. We looked at a lot of different options, not just soy, but we looked at a lot of dietary changes. That is there anything that can really impact hot flashes and night sweats. And soy at the end of the day is a weak form of estrogen. And a majority of people, and this goes back to the gut, when you metabolize soy, you're not metabolizing it into S equal, which is what is the active metabolite that can entreat hot flashes. Not having soy through your diet throughout your whole life. The people that do probably are the ones that have less hot flashes because their body adjusts to it, as opposed to just at the time of menopause, all of a sudden onboarding with this huge amount of soy, that's probably not going to be helpful for you at the end of the day. There you go. Your soy latte. If you like soy, have your soy latte.

Dr. Jami Kinnucan 34:04

I do like soy latte, 10 grams of protein.

Dr. Chrisandra Shufelt 34:06

I don't think it's gonna, it's important for protein, but if you don't like the taste of soy, I wouldn't be adding it on to treat any other symptoms. And then the final thing to say is that, you know, interestingly enough, there are differences in ethnicities across for hot flashes. And in Asian cultures, have lower hot flashes compared to westernized Caucasians and black women. So there is a difference, and probably it is a cultural norm that has something to do with diet, but it hasn't been extensively studied enough for us to be recommending one shift to another, especially for soy.

Dr. Megan Riehl 34:39

So interesting. Okay, so start our daughters on soy now and help them out later. Any other foods that you've studied that are coming up that we could buffer our diets with or supplements? That's something that people are always Googling and wondering about.

Dr. Chrisandra Shufelt 34:58

The supplement industry, again, nothing had really panned out above and beyond what we see comparative to placebo. Estrogen studies in general have very high placebo rates. So if you get the placebo, there's generally a 30 to 40 percent improvement in symptoms. And that's about what has been seen in placebo in supplements, is about a 30 to 40 percent. And a lot of supplements, again, at the end of the day, if it's helping someone and it's safe in terms of what their other medications, but you just have to be cautious about some of the regulation and some of the studies that are presented, what was the motivation behind it, who sponsored it, and how is the data being presented for an N of 14? So, you know, really nothing has come out of the supplement industry to say, yes, this is absolutely something that's gonna help. So that's why the non-hormonal position statement didn't support the use of supplements. And I don't think we're there for diet. There hasn't been anything that's been overwhelmingly positive for diet. What did work, believe it or not, for hot flashes, weight loss. So weight loss actually helps decrease hot flashes. So that's a great lifestyle modification. And in fact, at Mayo Clinic, Florida, we're studying right now the use of GLPs versus placebo to reduce weight to see if that improves hot flashes. So I think the bottom line is stay tuned because there is a lot more to be said about lifestyle, especially at the time of perimenopause and menopause, that can probably improve overall quality of life because at the end of the day, this impacts global women. And not all women have access to hormone therapy in other countries. So what we do for lifestyle is also important in midlife for prevention as well as what we do for hot flashes and night sweats.

Dr. Megan Riehl 36:49

So optimizing sleep to the best of our ability, managing stress, you know, social connection. I think there's something to be said about speaking with other women about this topic too. Oh yeah. To hey, what's going on with you? When did you start to experience these changes? And also our familial relationships, asking our moms, our grandmas, what was their experience? Is that true to inform kind of what may be in the pipeline for yourself, having that conversation if you're able with a living relative?

Dr. Chrisandra Shufelt 37:20

So a maternal age of menopause can impact and give us a better understanding of when a woman, it's not an exact science. It's but it is, you know, if your mother went into menopause at 35 or 40, it's likely that you might be going into menopause at an early or premature age, but it's not an exact science, like I said. Asking an older sister, that's also helpful as well. And then the girlfriend effect is exactly what you're describing. And I think now more than ever, we're getting a lot more information fed to us through social media, through influencers, through advertisements. And then that actually allows us to then have conversations within our own group of friends. But then that that opens the door to then go talk to your provider or find out who they're talking to.

Dr. Megan Riehl 38:04

And that's the key, right? Because we'll get fed the women's health supplement. And I get these in my inbox all of the time. And you're right, we're half the population. So we're a nice little target of people that can be suffering and, you know, be willing to fork out $50, $60 for a pill that might probably not do much. So, you know, I think there's probably more benefit from an emotional standpoint to connect with your girlfriends and commiserate and celebrate and get through this roller coaster. Feel less alone.

Dr. Jami Kinnucan 38:37

It highlights just the importance of diet in terms of managing some of these symptoms too, right? So eating the rainbow, truly increasing the amount of fiber exposure that you have, fresh fruits and vegetables. I haven't seen the necessary strong research on this, but could this reinstate the microbiome? So it gets back to sort of that pre-menopausal stage before everything changed. And so can you potentially supplement that with diet? And maybe patients who've been doing that and are proactive in terms of how they incorporate dietary changes and diversifying the types of fruits and vegetables that they're eating might, you know, eventually do better when they do get to that point where they have changes in their hormones.

Kate Scarlata, MPH, RDN 39:22

I think about it just with the changes in the vagina, really, and you know, changes in pH and different types of microbes that are producing more acidic compounds and metabolites, and that can really change risk for infection. We see that even when people go really low fiber and their pH in their stool goes up, and more pathogenic microbes like that environment. So you would think theoretically, like Dr. Kinnucan said, you know, eating those rainbow fruits and vegetables and getting the fiber into the diet may have some downstream effects. Microbes are playing a role here in even estrogen metabolism, but also this effect on pH changes, which can increase people for infections like UTIs. And

Vaginal Estrogen And UTI Prevention

Kate Scarlata, MPH, RDN 40:13

I just I know you touched upon this, but I'd love to just wrap up with the UTI or urinary tract infection risk and use of vaginal estrogen, because the first time I heard about vaginal estrogen, and I had surgical menopause, so I had a young menopause. I heard it on Twitter or X these days, a couple, you know, gynecologists talking about vaginal estrogen and uh kind of piqued my interest. So can you just talk a little bit about that, Dr. Shufelt, and why UTIs are more prominent in this population? And is vaginal estrogen concerning for blood clots and other things? Are there risks or less risks that we are concerned with with using that kind of preparation?

Dr. Chrisandra Shufelt 40:58

Absolutely. I think this is such an important topic. I had a patient just yesterday break down in tears because no one had told her about topical vaginal estrogen cream, and she was having such painful relations with her spouse and having recurrent UTIs that she thought at 52 this was it. And we had a long conversation about intimacy and this is part of your relationship. And she's like, but the lubrication isn't working. So what happens? And I mentioned that the vaginal tissue is very estrogen sensitive. Believe it or not, it is very thick in our younger years, meaning the cell lines, the epithelial cells are anywhere from 30 to 40 layers deep. So think of it like the inside of your cheek. After we lose estrogen, and not all women, but about 50% of women earlier on, they can get thinning and frail vaginal tissue. And what that results in is those cells flatten, become very thin, and then that results in you lose what I call the hills and the valleys. When you have so many plump layers of epithelial cells, they kind of start smushing together and you get the hills and the valleys after that. They thin out and become flat-lined. Not only does that happen, but you mentioned the pH. The pH changes and you become more susceptible to things like infections, vaginal infections, as well as bladder infections. Women are especially at increased risk for bladder infection, obviously, because of the location of our urethra and the shortened length of the urethra itself. So I prescribe a lot. I likely say I hand this out like Halloween candy. Lots of vaginal estrogen. I know a lot of a lot of terms I use, but this is topical and it's important to also describe how to use it. So the cream comes in an applicator. It is FDA approved, bioidentical, or there's a synthetic form on your insurance plan. This is nothing that you need to pay out of pocket for. We already pay enough in the pink tax, so we don't need to be paying more taxes towards other things. So make sure it's an FDA-approved product that's a cream-based form. And you pull it up into an applicator, about one, sometimes two grams, it depends. And you insert it halfway into the vagina, plunger it in. With your finger, though, you've got to sweep it into the tissue. Because just like getting out of the shower in the morning, if I told you to put lotion on your legs and you just put a big glob of lotion on your legs and walked out the door, it'd be on the floor. And so for the majority of women, they say, well, it's messy. I don't want to use it. It's because you need to rub it into the tissue in order for it to do its job. And so that then allows those cell layers to thicken back up. The other thing is that this is topical. Minor amounts go systemic and meet your bloodstream, but it even doesn't. Require a progesterone if you have a uterus. If you have to take a patch or a pill of hormone therapy, estrogen, and have a uterus, we always have to have a progestational agent on board. But if you just use topical vaginal estrogen, it doesn't stimulate the lining of the uterus that we're concerned. So that tells you how minimal it's absorbed. In fact, the FDA has removed the black box warning now off of all forms of estrogen and hormone therapy. But in particular, I think it's important because the vaginal estrogen, a lot of women I was prescribing it to, I would have to describe the black box warning and say it's going to come with these risks of dementia and heart disease. It's not. This doesn't apply to that. It's topical. So important area of women's health, important area of midlife sexual health, and important area of UTI health. So if you are having these symptoms, talk to your doctor about it. Even if you're perimenopause outside of that week that you might have a menstrual or some bleeding, you can still use this. The important also consideration is it's just to use it twice a week. But when you initiate it, we do a two-week loading dose. So you got to kind of fill up your tissue first. And then after you fill up the tank, it's just twice a week from there on out. There's also a vaginal tablet. I call it the Tic Tac. It's a vaginal estrogen Tic Tac looking tablet. It dissolves, also generic and also FDA approved, but it doesn't cover as much territory if you're having those initial really dry symptoms to kind of get the tissue more robust. And then finally, with the cream, I also have women put a little bit on their finger, like an M&M size, and use it on the outer labia. The only area you want to kind of avoid is the urethra because it'll get a little irritated. But those are my go-to when I talk about women's sexual health. That's kind of my first line. And then also during relations lubricants.

Dr. Megan Riehl 45:54

So amazing. Tips and tricks. This is so helpful. Hills and valleys. I'll never think of vaginas the same. I know. And I'm like touching my cheek and thinking about that. And yeah, that's a good comparator. I love it.

Kate Scarlata, MPH, RDN 46:09

Yeah. Well, I just think of women suffering with UTIs chronically. I mean, I've had a couple and they're miserable. And so, you know, having that and want to have a relationship with your husband or partner and constantly getting a UTI, that's no way to live. So I'm glad we have some solutions, but I just think a lot of people don't know about them. So that was really helpful.

Dr. Megan Riehl 46:33

We greatly

Speed Round And Final Takeaways

Dr. Megan Riehl 46:34

appreciate this conversation today. And we're going to wrap up with one of our favorite things to do, which is a speed round just to get to know you both a little bit better. So we're going to ask you the same questions and you just give us a quick answer, but we'll listen to Dr. Shufelt first. What is one wellness trend that you think is underrated?

Dr. Chrisandra Shufelt 46:56

Sleep.

Dr. Megan Riehl 46:58

Okay.

Dr. Chrisandra Shufelt 46:59

I think sleep is probably the basics, getting back to the basics, and sleep is a wellness trend that we need to have a better sleep habit, especially in midlife. And moving your body through space and sleep is probably an is something that I think is underrated.

Dr. Megan Riehl 47:12

What is your guilty pleasure TV show or podcast?

Dr. Chrisandra Shufelt 47:17

Oh, I love a mystery podcast or a TV that's a documentary on a mystery that is unsolved or has twists and turns and surprises and shocks at the end. That's my guilty pleasure.

Dr. Megan Riehl 47:31

I love that. And what's one thing you do just for joy? It doesn't have to be health or productivity, just for joy.

Dr. Chrisandra Shufelt 47:39

Probably getting coffee. Especially in the morning.

Dr. Megan Riehl 47:43

I'm with you. Uh-huh. And what's something that is always in your fridge?

Dr. Chrisandra Shufelt 47:49

Oh, something that's always in my fridge, which my kids know as berries. I have any kind of berries in my fridge right now. I've got raspberries, blueberries, and blackberries, but that's always in my fridge. It's my go-to.

Dr. Megan Riehl 48:00

It's a good one. And if you weren't in medicine, what would you be doing?

Dr. Chrisandra Shufelt 48:05

This is actually very funny because I really enjoy throwing kids parties. And when my kids were really little, I always said if I wasn't a doctor, I'd be a party planner.

Dr. Megan Riehl 48:16

Well, this is so exciting to know. So now, you know, eventually you might end up heading in that direction. I love that.

Kate Scarlata, MPH, RDN 48:23

It's a great skill to have. All right, Dr. Kinnucan, let's get started with you. So, what's one wellness trend you think is underrated?

Dr. Jami Kinnucan 48:33

I figured out why Dr. Shufelt and I are such we're friends because you basically took all my answers. But I would say around wellness trend that's underrated, I think the focus that people have on wanting to move their bodies, but feeling like, oh, I couldn't get to the gym for that 30 minutes or 60 minutes. And so they just kind of scrap the day. It's kind of like you didn't eat the healthy breakfast, so you're just the rest of the day is a wash. I really think those exercise snacks, the ability to move your body even in short periods of time, has shown to have so many health benefits. So exercise snacks are underrated. Getting out there, even if it's we have uh treadmills down down here at Mayo Clinic, even if it's just moving on a treadmill during a meeting for 30 minutes, that for me feels like it's a good investment in my wellness.

Dr. Chrisandra Shufelt 49:21

I can attest that I have seen Dr. Kinnucan on meetings on the walking treadmill desk many times.

Dr. Megan Riehl 49:28

I have also seen her Peloton for a meeting. She's, you know, a living example. I like that.

Dr. Jami Kinnucan 49:33

I have I do have a Peloton desk. Yeah, right. That's right.

Kate Scarlata, MPH, RDN 49:37

Exercise snacks. It doesn't have to be a marathon. I like that. What's your guilty pleasure TV show or podcast?

Dr. Jami Kinnucan 49:45

Oh gosh. Well, recently we just watched, I'm gonna put in a plug, so I do things I just watched, like a docuseries type thing. So I just watched Love Story about JFK Jr. and Caroline. And that I really enjoyed watching that. And I know it was dramatized, but I really enjoyed watching it. Obviously, the ending is very sad. And then following that on Netflix or on Hulu, they also have uh hidden footage from their wedding. So if you see the love story and you kind of get the, you know, the whole history, and then you watch the hidden footage, it was really cool. So I really liked that, but such a good show.

Kate Scarlata, MPH, RDN 50:18

Okay, so what's one thing you do just for joy, not for health, not for productivity?

Dr. Jami Kinnucan 50:25

It happens to help with my health and my productivity. I really love moving my body every morning at 5:45 with bar. I love the community that's there. I love the strength training that's a part of it, I love the flexibility. So I think it checks a lot of those boxes. I find joy in waking up at five o'clock in the morning.

Kate Scarlata, MPH, RDN 50:46

What's something that is always in your fridge, Dr. Kinnucan?

Dr. Jami Kinnucan 50:51

Cottage cheese. The good, the blue tub of cottage cheese is I have at least six tubs in there right now.

Kate Scarlata, MPH, RDN 50:59

That was like my college favorite protein, you know, little mini fridge. I always had like crackers and cottage cheese. It was so filling and delicious.

Dr. Jami Kinnucan 51:08

I love the they have these egg life noodles that are high protein noodles. And then you take cottage cheese and you put them over the egg life noodles, noodles and cottage cheese.

Kate Scarlata, MPH, RDN 51:18

I like that. Just make sure you get your vegetables mixed in there, girl. All right. So if you weren't in medicine, what would you be doing?

Dr. Jami Kinnucan 51:25

I forgot how I answered the last time I was on your podcast. I think I answered the same thing because just like Dr. Shufelt, I would have been a wedding planner, but I didn't want to work nights and weekends. Little did I know that becoming a doctor also was working nights and weekends, but I would have been a wedding planner. I really enjoy planning events and parties, so much so that I am the uh social chair for the Department of Medicine here at Mayo Clinic in Florida and the GI division. We just had our social event this Saturday, kickball tournament.

Dr. Megan Riehl 51:55

Oh, I love it. Well, did you know you had an additional Mayo Jacksonville uh co-chair potentially to join you?

Dr. Jami Kinnucan 52:02

I didn't, but you you are now you are now getting roped in. That's right.

Dr. Chrisandra Shufelt 52:06

But my party planning is children's party planning. I mean, there's I literally I know how to throw a good, mean six-year-old party with puppies and all and bounce houses and yeah.

Dr. Megan Riehl 52:19

I like that. Well, this is a fun part of the show, but you both shared a lot of expertise that our listeners are going to be so grateful for. And quite honestly, I hope is just the beginning of some ongoing conversations because we're just really skimming the surface here. So thank you incredibly from the bottom of our heart. This is such an important topic, and we really appreciate both of your expertise. Yeah, thanks for coming on.

Dr. Chrisandra Shufelt 52:44

Thanks for having us discuss this for having us. Very important topic.

Subscribe, Share, And Community

Kate Scarlata, MPH, RDN 52:48

All right, friends, listen, subscribe, and share the gut health podcast.

Dr. Megan Riehl 52:53

Thank you for joining us as we grow this gut health community. We hope you enjoyed this episode, and don't forget to subscribe, rate, and leave us a comment. You can also follow us on social media at The Gut Health Podcast, where we'd love for you to share your thoughts, questions, and experiences. Thanks for tuning in, friends.