Your Perimenopause & Menopause Questions, Answered by a Doctor

If you’re going through perimenopause or menopause, you probably have a lot of questions. Things are changing, and you deserve answers.

We recently hosted a webinar with Dr. Kudzai Dombo, a prescribing physician with Alloy, and, as of recently, our Director of Advocacy and Outreach. She, along with our community manager, Rachel Hughes, answered questions from our community about symptoms, hormone therapy, and more! We highly recommend you watch the whole thing on our YouTube.

Dr. Kudzai Dombo was born in the US, but grew up splitting her time between Rochester, New York and Harare, Zimbabwe. She graduated from The University of Michigan in Ann Arbor and went on to attend Robert Wood Johnson Medical School, where she graduated in 2001.

As a board-certified OB-GYN who did her residency training in the US in the early 2000s, Dr. Dombo is very familiar with the concerns that arise when it comes to Menopausal Hormone Treatment (MHT). She remembers the headlines after the WHI was published that said MHT causes breast cancer all too well.

We’re sharing some of their conversation below. This interview has been edited for brevity and clarity, and as always, is for educational purposes only and should not be used as personal medical advice.

Rachel Hughes: You are a member of the family, so we’re going to get right into it, but before we do, can you just give us a brief education on hormones? Estrogen, progesterone, and testosterone play critical roles in women’s health. Can you start by giving us a clear breakdown of what each of these does for the body and why they’re so important, especially in midlife?

Dr. Kudzai Dombo: Yes, let’s start with some definitions. So, menopause, by definition, is going 12 months without a period. Peri means around–think of a perimeter. It’s the time around menopause, and it can begin up to ten years prior to menopause. You may not have period changes, but you may have some of the symptoms that are associated with menopause. 

Now, what are the three main hormones that we think of and consider when we think of this midlife transition time? Estrogen, progesterone, and testosterone. There are a lot of different hormones that the ovaries produce, but those are the three main ones. During this time, there are wild fluctuations in the release of these hormones and then an eventual decline. So, we may want to add some of them back. Let’s start with estrogen, specifically estradiol. We know that it reduces not only the frequency, but also the severity of hot flashes and night sweats. We also know it will help improve vaginal and urinary health. It can also act as a mood stabilizer. When you have fluctuations in your estradiol levels during perimenopause, it can lead to mood swings, irritability, depression. So when you are experiencing all of that, sometimes incorporating estrogen in one form or another can improve not only your mood, but also it can improve your cognitive health. And not everyone experiences the same symptoms. Not everybody's going to experience mood changes. For some people, the most bothersome symptom can be joint discomfort where they notice that, “Man, I was able to work out and do certain things and now, I'm just not able to do them as easily as before.” And that may be very distressing. Estrogen helps with bone density. And then there’s our skin. A lot of times we notice that as we age, our skin becomes dry. We also look at heart health. Estrogen can help with cholesterol and circulation. And there are sleep issues. Some women have trouble falling asleep, but other women wake up at 2:00 AM to go to the bathroom and can't fall back asleep. I've noticed that estrogen can be helpful for being able to fall back to sleep. 

There's an optimal window of introducing estrogen to notice a significant difference in your cardiovascular health. The best time to start is before the age of 60, or within 10 years of your last menstrual period.

Rachel Hughes: So, you’ve laid out some of the positives of estrogen. Can we get a little insight into progesterone?

Dr. Kudzai Dombo: Yeah. So, estrogen has many great benefits, but it also can cause the uterine lining to overgrow and lead to a condition called endometrial hyperplasia, which, if left unchecked, can progress to cancer. So, if you have a uterus, we use progesterone to make sure to protect the lining. Additionally, bioidentical progesterone has been found to improve sleep quality. And, in some women in perimenopause, it has been found to have a calming effect.

Rachel Hughes: So just to hover on that for a second. If a woman in perimenopause has no other symptoms, has a uterus, and has anxiety, can they go to their physician and inquire about progesterone alone?  

Dr. Kudzai Dombo: Yes. And, there are articles that have shown the benefits of introducing progesterone alone to help with symptoms during the perimenopausal transition.

Rachel Hughes: Okay, great. Thank you. And then just to round out the trifecta, can you offer some information about testosterone?

Dr. Kudzai Dombo: Testosterone is the third main hormone that is produced by the ovary, and what it has been found to do is enhance your libido. If you have HSDD (hyposexual dysfunction disorder), adding testosterone can improve your desire, it can improve arousal, and it can improve sexual satisfaction. There are also small studies that are not conclusive yet, that show that it can improve your cognition, your mood, your muscle mass, and your bone density and bone strength.

Rachel Hughes: Women often ask us here in this community when we're going to offer it, or if we're going to offer it, or do we offer it? Can you tell us the answer to that?

Dr. Kudzai Dombo: It’s considered a controlled substance by the FDA. So, it’s not something you can prescribe easily. It requires an in-person visit, a visit where you actually are face-to-face with somebody. So, for that reason, we're not able to offer it on the Alloy platform at this time. It’s out of our control at the moment.

Rachel Hughes: Thank you for that. I want to talk about how you like to speak to patients at about three months and check in with them to see how they’re doing symptomatically. I want to talk about that, but before we get to that, can you talk about what women can expect in the first two weeks?

Dr. Kudzai Dombo: Any time you add something new to your body, it is going to take time to adjust. In the first two weeks, you may notice some side effects, which can include bleeding. It can be light spotting or as intense as a full on period bleed. It can be scary, but it’s not uncommon. Another side effect is water retention. You may think you’re gaining weight, but remember, it will level off. I always tell my patients to just be really patient. Your body will adjust and the water retention will go away. And for some women, the side effects can be unbearable, while some women won’t have any side effects at all.

Rachel Hughes: Thank you. Let’s circle back to your three month marker. So, you’ve prescribed your Alloy patient estradiol and progesterone, and it’s been three months. What are you looking for?

Dr. Kudzai Dombo: I always say to aim for 70 to 80% improvement in your symptoms. If we increase the dose to get to 100%, we can also start to experience side effects. So we’re looking at, are you at 70-80%? And are you having persistent side effects? 

Every person is unique and different. So what happened to your best friend may not be how you respond to the medication.

Rachel Hughes: Great. So before we get back to determining what to tweak and how to tweak it, we have a question from a community member which piggybacks off of what you just said. Someone says, “I just started progesterone and estrogen last week. My breasts are so sore. Hopefully this passes?”

Dr. Kudzai Dombo: A hundred percent. Give your body 8-12 weeks, and if you find your breasts are still really sore, then you can talk to your doctor about reducing your dose. I think your body will tell you when something is too high or is not enough.

Rachel Hughes: So, if it’s four months and you have severe breast tenderness or headaches or migraines, when do you consider tweaking?

Dr. Kudzai Dombo: It depends on the symptom. So, for something like migraines, if the patient wasn’t having them before, and we’re four months in, as you said, then we might look at bringing down the estradiol dose. Same with breast tenderness. If it’s something like nausea, that could be your progesterone or your estradiol. So, we’ll try to figure out which it is. And then with water retention, if patients are like, I'm six months in and I'm still bloated, I'm still uncomfortable, that’s another example where it could be progesterone or estrogen. So that's why it's so important that you check in with your doctor, because they can help.

Rachel Hughes: Terrific. Thank you. Next question: How do you approach the treatment of women who want to restart estrogen therapy after the age of 60 or 65? This question is asked often and is really important. 

Dr. Kudzai Dombo: So, as I said, there is an optimal time to start estrogen and progesterone therapy, and usually that's under the age of 60 or within 10 years of your last menstrual period. Let's say you're outside of that window. It does not mean that you can't start. It just means that we take a look at your family history, your personal medical history. What are your risks for heart disease? Should you get a coronary artery calcium score to see where you are? We’ll look at that. And if you do have risk, we can prescribe you a transdermal option. Basically, it’s a nuanced situation. We’ll take a look at your risk factors, and talk about mitigating concerns. And as long as we have a discussion about the risks and the benefits, there's not any absolute reason that we cannot start you on hormone therapy.

Rachel Hughes: That's so helpful. Someone says, “I remain confused as to why and when a doctor prescribes birth control versus hormone therapy.”

Dr. Kudzai Dombo: Got it. That is actually a really great question. So, perimenopause is when you have these wild hormone fluctuations. And usually we’ll offer birth control. The first reason is that there’s still a chance you can get pregnant during this time, and a low-dose birth control offers contraception. The hormone fluctuations you experience also cause menstrual irregularities. The hormone in a low-dose birth control pill is higher in amount than what’s in MHT, and it tells your ovaries to keep quiet, and it helps to regulate periods. Plus, it provides symptom relief. While MHT provides symptom relief, it doesn’t provide cycle control or contraception, so typically during perimenopause we’ll start with low-dose birth control.

Rachel Hughes: Can you talk about vaginal estrogen cream?

Dr. Kudzai Dombo: Definitely. Vaginal estrogen cream is a cream that is applied internally, but also it can also be applied externally. And the purpose of estrogen in the vaginal tissue is it helps it become thicker, so it functions in the way it is meant to function. If you look at the bladder lining, for example, it can get very thin, which can contribute to incontinence and frequent UTIs. So, when we add vaginal estrogen, we’re trying to epithelialize the tissue in the vagina and the bladder so that you're not having those urinary symptoms, or pain with intercourse that comes from vaginal dryness. The cream makes the tissue healthier.

Rachel Hughes: Can I stay on MHT forever? I just started it a week ago. I'm 54.

Dr. Kudzai Dombo: Your body will tell you whether or not you can stay on it forever. It depends on how you do with it and how you change over the years. But, if there are no issues, you can continue.

Rachel Hughes: Somebody asked, what lifestyle adjustments can I make alongside hormone therapy to maximize its benefits? Are there particular exercises, diet changes, or stress management techniques that help?

Dr. Kudzai Dombo: It’s definitely important to look at things that can help reduce stress, because your ability to cope with stress may be diminished during this time. So, whether it's meditation on a regular basis, yoga, or something else, it is important to reduce stress where you can. Stress increases your cortisol, and lower estrogen increases cortisol. That’s number one. Number two is nutrition. Make sure you’re getting enough protein, enough fiber, and drinking lots of water.  It's really important to prioritize some of those things because I think at times, being busy, we're just looking at, “Okay, what do I need to do next? What do I need to do next and get through the day?” Small changes like mindfulness routines and looking at your nutrition, making sure that you have a routine around resistance exercise where you're increasing the strength of your muscle and increasing the strength of your bones on a regular basis–those are so important. Hormones are just one aspect. It's also really, really important that all the other parts of your life, like your social connections, are also in place. I ask patients all the time, “What brings you joy?”

Rachel Hughes: Thank you, Dr. Dombo. You’re just fantastic. We’re so glad you’re here.

Dr. Kudzai Dombo: Thank you.

There’s more where that came from! To watch the whole interview, go to our YouTube. To learn more about upcoming webinars and events, follow us on Instagram @myalloy.