Expert Insights on Perimenopause and Menopause: Understanding Changes and Challenges

Perimenopause and menopause are key transitions in a woman's life that are often misunderstood. In this two-part expert discussion, Catherine Staffieri, MS, RDN, and Dr. Kathleen Jordan, MD, dive into the complexities, discuss where traditional healthcare falls short, debunk common misconceptions, and illuminate the often-overlooked aspects. 

Catherine is a nutrition manager at Nutrisense and a self-professed data nerd who counsels members through various life transitions and health concerns based on their body's real-time data. Dr. Jordan is an internist with a background in telehealth and private practice and the Chief Medical Officer at Midi Health, a virtual care clinic focusing on perimenopause and menopause.

Catherine: I'm so excited to chat with you today, Kathleen! A couple of years ago, I did a deep-dive research presentation on menopause for our team of health experts at Nutrisense, and I'm thrilled there's been so much attention and light being shed on this part of a woman's life since then. 

On a personal level, I am getting there myself. It's heartening what companies like ours are doing to help women navigate this stage in a healthy, balanced, and optimistic way.

Kathleen: Thank you! Yes, that's our goal at Midi Health. It's so important—I've been working in women's health for several years, focusing on all the midlife changes. I'm also midlife myself!

Catherine: I like midlife. I think that's a better way to describe it. Menopause makes people think about just the hormones.

Kathleen: I like to say midlife because it makes people think broadly about everything happening in midlife.

Catherine: Yeah, it's not even necessarily what you're eating or how much you're exercising; it's also the stress you're under. 

It's such a stressful time in your life otherwise, too: your kids are potentially grown and flown, you've got to take care of your parents, maybe continue your career, but also enjoy your life a little bit. And there are a lot of different stressors than in earlier decades.

Kathleen: Oh yes, and I think those are some of the significant stressors that ultimately affect metabolism, nutrition, lifestyle, sleep, and self-reported happiness. And on top of that, you’re dealing with  a decrease in serotonin and active dopamine. 

During perimenopause and menopause, you also don't have as many feel-good brain hormones at your disposal. So you're stressed, not sleeping, your metabolism changes… then your cholesterol levels go up, and your insulin sensitivity worsens. And when you’re tired, it can be easy to reach for the wrong foods for energy.

Understanding Perimenopause and Menopause

Catherine: Right! So you need support at this stage in your life. That's the perfect way to introduce what you do at Midi. I love that you offer so many different ways to approach the changes of menopause. As we know, there are lots of other things happening.

At Nutrisense, we examine all that with blood glucose as the marker. You also examine the whole spectrum of transition symptoms that can make you feel like you have a disease; let's call them the physical manifestations of the changes in your hormone levels.

With that in mind, how do you approach the difference between perimenopause and menopause? A lot of people don't even know that menopause is after your last menstrual period. I think people don't understand the demarcation. 

Kathleen: To put it simply, menopause is the point in time when you're 12 months post your last period. Postmenopause is for the rest of your life after that point.

Throughout the perimenopausal stage, your ovaries start to make less estrogen and progesterone. As those hormone levels drop over a five to 10-year period, you can accumulate symptoms.

Catherine: It doesn't happen overnight. 

Kathleen: Right! There are a lot of symptoms people associate with menopause, but they don't understand that they've likely been accumulating symptoms for several years leading up to it.

And time and time again, women will come to Midi around menopause, and we're delighted they do, but when we start them on hormone replacement therapy, they say, "This is the first time I’ve felt good in five years. Why did I not come five years ago?" 

So, I want women in perimenopause, which typically begins in your 40s but can vary depending on each unique body, to understand that they don't need to wait to get treatment.

Catherine: All those changes we discussed come in, and everything from your daily routine to diet management gets more complicated. 

Kathleen: Of course. And then your metabolism changes too. So, it's not surprising that women in midlife struggle with weight gain. Almost 90 percent of our patients ask us for weight management advice.

This doesn't mean they all want to lose lots of weight, but they're all noticing that they have to put in a lot more effort to maintain their usual weight baseline. 

We talk to many people, within the context of glucose management, about muscle mass, too, at this stage. Women, in particular, also experience sarcopenia [age-related muscle mass and strength loss].

We discuss exercise as something helpful in various ways. It's not just about the calorie burn. Believe it or not, you burn a lot of calories just sitting. You definitely burn more calories if you're exercising, but it's more about how it helps you sleep, which triggers hormone responses and improves insulin sensitivity.

And there's lots of clinical evidence that shows that exercise, which helps with managing blood sugar levels, does help decrease the risk of breast cancer.

Catherine: The high glucose levels gunk up the mitochondria, the repair system, everything... 

Kathleen: They gunk it up, they really do. I'm going to borrow that phrase.

Catherine: Please do. I haven't trademarked it yet! 

And then, in addition to all those changes in your body, there are also so many misconceptions around treatment and so many options for women to wade through. You can now pee on a stick, and it'll tell you if you're in menopause or not! 

On the one hand, it's great that there's awareness so that women can take control, but it's not necessarily all giving you the correct information. I would say peeing on a stick may not be that helpful in terms of assessing where you are in perimenopause.

Kathleen: I'm glad there are more product offerings and interest in the space. I agree, though, that part of that means many things are coming to market with little evidence or understanding of how to use them meaningfully.

That's why we purposefully designed Midi to be a care company. Our product is the care and advice we give. Our commitment is to wade through the science and deliver evidence-based care. We may refer and recommend products, but we partner with you to decide what is best for you.

Catherine: That's exactly what we need; that's part of our mission at Nutrisense, too! As women, we need experts who provide up-to-date, evidence-based recommendations on cutting-edge science. 

The advancements there are significant, too: there's a North American Menopause Society now where you can be board-certified in menopause therapy.

Kathleen: It's excellent, and there's been renewed interest lately. Approximately two years ago, the number of NAM-certified professionals was a few hundred; it just broke a thousand. So the numbers have tripled, but there are still just a handful of practitioners providing this care. That's why we use telehealth and some of the efficiencies of tech-enabled tools to make it accessible to all women through insurance.

Catherine: It's necessary, mainly because some of the more significant challenges women encounter when seeking healthcare around this stage are that no one is listening to them.

Plus, you could see an endocrinologist or your OBGYN separately, but you want someone who can give you more 360-degree support!

Kathleen: That is part of the problem. Many symptoms that come up in midlife benefit from a multidisciplinary infusion of knowledge. I'm an internist; we have many OBGYNs, a naturopath, a sleep expert, and a skin and hair expert. 

We work collectively to help women in midlife. We've trained our clinicians on a multidisciplinary influence, and we support them in the backend with all these specialties behind them. 

I can meet with a woman and share the naturopathic options with her. I can also share the evidence around hormone interventions and non-hormone prescriptions. It all helps her wade through the pharmacy aisles with the mountains of supplements.

The Role of Supplements and Data in Menopause Management

Catherine: And talking about the supplement angle itself—as a registered dietitian personally and on our entire team of nutrition experts at Nutrisense, too—we see people already on a whole host of supplements. And is there an evidence-based reason for it? 

We like to see it in the data regarding glucose management. For example, a glucose supplement like berberine works well for some people. But the most important thing to remember, at any stage of life, is that it all works for some people and doesn't for others! 

This gets harder to navigate and figure out on your own as a woman who, if they've never really been mindful of these symptoms, all of a sudden they're aware but maybe don't understand the severity. Do you see examples like that, too? 

Kathleen: Oh yes. I'll use your example of berberine, which is heavily marketed for weight loss. You're so right about how important it is to dig into the data before taking it. 

There's a lot of evidence that it can help with cholesterol (which is connected to weight management). Then there's emerging, promising, small-scale research that it can help with weight. So yes, we would recommend it, but we would also look at all the evidence and data first.  

One of the things I hear in visits all the time after we figure out what's best for the individual is, "Oh my God, I feel so much better now [that they're on whatever the plan is]; I wish I did this five years ago." But, before we get there, I often hear, "I don't know what's happening. I'm doing nothing different, and I've gained 20 pounds," or "I can't believe my cholesterol is high. I've never had high cholesterol. This isn't me, right?"

So sometimes, the numbers and the data demonstrate what's going on and show that things are changing, highlighting the importance of midlife being a time to lean into healthcare. For the most part, many of us are healthy throughout our early lives. But as we get into midlife, things start to change.

We know our cancer incidence increases, so we have to do cancer screenings regularly. Our metabolism changes, so we have to start mitigating cardiovascular risks. What we do now will help prevent frailty and fractures in the next few decades. 

The Preventative Power of Glucose Monitoring in Midlife

Catherine: I totally agree. We have to help them see the power of prevention. You're healthy now, but you might edge into that prediabetic phase in a couple of years, or suddenly go through perimenopause and start seeing higher triglycerides or cholesterol levels, or have an autoimmune flare.

We have to plan ahead with the bigger picture, including looking at trends over time. I'm curious about your approach to that with women going through the perimenopause or the menopause transition. It's not a straight-line decline, right?

Kathleen: Oh yes, I wish we had hormone monitors like we do continuous glucose monitors! Information is powerful. We've long known that when you measure anything, you can improve or manage it. Because it means you're paying attention to it.

So, having the tools to measure your serum glucose is great. I have personally tried tracking my glucose, too, a couple of times now. 

I was always blessed with a relatively high metabolism, so I did not have weight issues when I was younger. But now, in midlife, I do! I used to eat whatever I wanted and didn't pay much attention to it. And when I put the monitor on, wow, it made such a difference. I realized certain foods make my sugar shoot up that didn't before. So, be prepared for that!  

It's so helpful even if you do it intermittently.

Empowering Women Through Education and Awareness

Catherine: Oh, for sure. Seeing the aha moments of food and stress is always really interesting for all the women I work with. Even if you haven't eaten anything, and suddenly you see a change in your data, and you wonder what it is—maybe it's a stressful call from work, or you have something going on at home… you don't even realize how much you're carrying and how much you're dealing with until you see the data. 

What role do you see education and awareness like this playing in empowering women to take control, especially in midlife?

Kathleen: We've talked about how data can invoke change and improvement, but what can be really important is that data can be affirming and comforting. It's when you know that you're not crazy!

A big part of what we do at Midi is affirm women, reassuring them that what they're going through is common. All women who have periods experience menopause. It's triggered by very organic changes, and knowing that makes people feel better. It's a shared experience with so many nuances, and we don't discuss it enough. 

Now, because of what I do, I'm always involved in these conversations. But 15 years ago, in my general practice, where people didn't identify me as a menopause expert, it was not a common conversation. 

I love that it's being discussed and that we’re talking about it here, too, because that will help and empower so many women.

Breaking the Silence Around Menopause

Catherine: Totally. Menopause used to be something that just happened; it was not to be spoken of. Even with things like hysterectomies—women would be conditioned to think, "This is not anything; I'm just going to rest for like six weeks or so." 

Kathleen: Yes, which is why we need midlife and menopause conversations. It can be a great time of life. I personally don't miss getting my period! It can be a wonderful time—if you do it right, of course. Because your body is changing, and you need to adjust to feel better, you need to make some adjustments.

Check out part two here, as Catherine and Kathleen continue the conversation. In the second installment of this expert chat, they'll dive deeper into chronic conditions like prediabetes in midlife, detailing how they intertwine with menopausal changes and what women can do to manage their health proactively.