Making It Through Menopause

Amanda Newman (00:00):

When does perimenopause begin? What diet is best for menopausal women? How can you address meno belly? All that and more on this episode of The Healthiest You.

(00:12):

Each day, 6,000 women start menopause, a life transition that can leave you feeling every kind of emotion. Hot flashes, sleep disturbances, dry skin, weight and mood changes are just a few of the symptoms. Knowing what to expect and having support in this next chapter can help you gain momentum to get through menopause.

(00:36):

Welcome back to another episode of The Healthiest You podcast, where we focus on women's health and wellness. I'm your host, Amanda Newman. Whether you're on your way to work or enjoying a cup of coffee, take this time to focus on your health. Here to talk about how to navigate each stage of menopause is OB-GYN Dr. Susan Haas with Lehigh Valley Health Network, part of Jefferson Health. Dr. Haas, welcome to the show.

Susan Haas, MD, PhD (01:05):

Thank you. Thank you so much for having me here today.

Amanda Newman (01:08):

So let's start with talking about perimenopause, which is that transitional period leading up to menopause. A lot of things shift for women – physically, mentally and emotionally. When can women expect to start perimenopause and what are the most common symptoms?

Susan Haas, MD, PhD (01:27):

Well, to talk about perimenopause and explain what that is, I think we first need to explain what menopause is. So menopause is when a woman stops getting her periods because her ovaries are no longer producing eggs and no longer producing hormones. The average age for that to happen in the United States is 51 and-a-half, but there's a really wide range. It's considered normal. Most women stop getting their periods and enter menopause between 45 and 55. Anywhere from 40 to 58 is considered normal.

(02:00):

So perimenopause, then, is the time prior to menopause where the ovaries are not working as well as they used to but haven't completely turned off. And this leads to a lot of symptoms, sometimes even more than in menopause, because your hormone levels are fluctuating really widely. During a woman's normal reproductive life, her hormonal system is working in a normal cyclic fashion where estrogen goes up and then progesterone goes up and then they both drop and you get your period and the same thing happens again.

(02:41):

And that would happen once a month during the normal menstrual cycle. As the ovaries are not functioning as well as they should, the process becomes more irregular. Sometimes the hormone levels are really high; sometimes the hormone levels are really low. The ovaries might stop working for a couple of months and then they might start working overtime. And this can lead to a lot of fluctuations that lead to a lot of symptoms. Often the same symptoms that women experience after their periods have stopped completely. Like the classic ones are things like hot flashes, night sweats, vaginal dryness, pain with intercourse. But there are also a lot of other symptoms that happen around this time that aren't. Although they're not as directly clearly related to low estrogen levels, they're definitely related to the changes that are going on in our bodies at this point in time. And those are things like mood swings, concentration problems.

(03:48):

People say brain fog is a really common term that patients use. Weight gain, you mentioned at the beginning of the podcast. Meno belly. Many women find either that they gain weight or that even if they don't gain very much weight, the weight will redistribute to all the wrong places. We know that that central adiposity is the medical term that we use, meaning weight or fatty tissue that's around your middle and around your visceral organs, your internal organs – as opposed to in other parts of your body – has a particularly negative effect on health, on our blood pressure and cholesterol and overall heart health and overall metabolic health. So all of these things are changes that we commonly see.

Amanda Newman (04:35):

That's a lot of symptoms to deal with all at one time.

Susan Haas, MD, PhD (04:38):

It is.

Amanda Newman (04:40):

One of the things you touched on was your period changing, specifically during perimenopause. Would you start to see irregularities with your cycle?

Susan Haas, MD, PhD (04:49):

Absolutely.

Amanda Newman (04:50):

OK.

Susan Haas, MD, PhD (04:51):

Absolutely. So not every woman has regular cycles to begin with. But if we start with a woman whose menstrual cycle is regular, what she'll start to see as she enters perimenopause – the very first thing that might happen is that her cycle length might get a little shorter. Where if she used to have 28- or 30-day cycles, now she's having 26-day cycles or 24-day cycles. And that comes from the ovaries still producing as much estrogen as they used to, but producing a little less of that progesterone in the second half of the menstrual cycle. And then, as the egg cells that are left in the ovary are not as healthy anymore or not functioning properly anymore, sometimes she will have periods come late or skip periods entirely. So at that point, the cycle length would actually start to get longer again – where a period might come a couple of weeks late or she might skip a whole month or two months, and then the periods might come back and be normal for a while.

(05:54):

And this kind of sporadic irregularity is very common and is normal in menopause. What we have to watch for is that there are also abnormal patterns of bleeding that can happen in perimenopause. So, women that are having worrisome periods. Bleeding patterns that I would be concerned about would be periods that are way too close together, like less than 21 days from the beginning of one to the beginning of the next. Women that are getting periods consistently twice in a month. Periods that are lasting more than a week. Periods that where you're having bleeding in between your periods. These are all situations where a woman might want to speak with her clinician to investigate whether those changes are just due to menopause or whether they're due to some other medical condition like a thyroid condition or some kind of gynecologic cancer like cervical cancer or cancer of the uterine lining, endometrial cancer. These things are pretty rare. Most of the time these changes are just due to menopause. However, we need to check for the more serious things before we just treat it as menopause.

Amanda Newman (07:08):

Well, thank you for giving such a thorough response to that because our periods really are such an indicator of what's going on inside of our bodies, and that was extremely helpful.

Susan Haas, MD, PhD (07:19):

Oh, you're welcome. I'm glad to be able to explain it. It's really a pleasure to be able to speak to you and to the community and be able to educate people about menopause and perimenopause and what's happening with our bodies at this stage in our life. I really feel like that's a huge part of my role and something I'm really passionate about. Both educating our community about menopause, and also I really like to take a pretty active role in educating the trainees in our institution. Our residents and actually OB-GYN trainees nationwide don't get great training regarding menopause. It's only one small piece of many, many things that they need to learn. And whatever I can do to help train them so that the next generation of women, who are going to be cared for by the next generation of clinicians, will have better access to good care.

Amanda Newman (08:23):

That's amazing. So many of these changes that we've been talking about, the symptoms that you've mentioned, can really leave women feeling not like themselves. Perimenopausal women may have four to five hot flashes a day. A common question is are there any over-the-counter remedies that can help?

Susan Haas, MD, PhD (08:44):

Hot flashes are such a problem. And so many of my patients come in complaining of hot flashes, not just when they're fully menopausal, but during perimenopause as well. And there are a lot of over-the-counter remedies that are marketed to women. Unfortunately, many of them don't have scientific evidence behind them to demonstrate that they're effective and even really to demonstrate that they're safe. So although we need to be a little bit cautious, we do have many patients that try over-the-counter remedies. One thing that some patients try that has some basis would be the use of soy. And soy ... I would recommend to take soy in your diet, not necessarily a soy supplement that you might find like at the health food store or something, because a lot of times you really don't know what's in those. But whether it's soy milk or whether it's edamame at the Asian restaurant or on your salad.

(10:00):

Soy contains chemicals called phytoestrogens. What this means, these are plant – phyto means plant – so these are plant-based compounds like natural chemicals that work similarly to estrogen within the body. And so sometimes they can help relieve some of the symptoms of those low estrogen levels that women experience. However, we also need to be cautious because for women that have a medical reason why they shouldn't take estrogen, like, for example, a breast cancer survivor. She might also need to be careful with phytoestrogens because we don't really have any scientific data saying that those are safe for her.

Amanda Newman (10:47):

So edamame. I love edamame. I'm so glad that you brought that up. ... That's so interesting though. So soy can potentially help with hot flashes and making sure that you get enough in your diet.

Susan Haas, MD, PhD (11:00):

Potentially. The research that's been done to look at the efficacy of soy has not been particularly positive in terms of showing a huge effect. But I think it's unlikely to cause any danger, and some patients find it helpful.

Amanda Newman (11:20):

Very interesting. What about just coping with these hot flashes? Something I've seen online is people get these little neck fans that they wear. What are you seeing?

Susan Haas, MD, PhD (11:30):

Have you seen there's a beanbag thing that you can put in the freezer?

Amanda Newman (11:36):

Oh, OK.

Susan Haas, MD, PhD (11:36):

And you can put it around your neck.

Amanda Newman (11:37):

Yes.

Susan Haas, MD, PhD (11:38):

And then if you are having neck pain, you can put it in the microwave and heat it up. So it could be like a hot pack or a cold pack. Yeah. Certainly we encourage the use of natural type of behaviors to help women stay comfortable in menopause. And that might be a fan. That might be dressing in layers so that if you get hot, you can take your sweater off. But if you then get chilled after you sweat, you can put something back on. And because you might not know when you move from environment to environment, you might not tolerate that as well as you're going through this hormonal transition.

Amanda Newman (12:27):

Now, something else that is a big topic is menopausal hormone therapy. So could you talk about what that is and when should this treatment be considered during menopause and postmenopause?

Susan Haas, MD, PhD (12:40):

Menopausal hormone therapy refers to giving a woman hormones to replace the hormones that her ovaries are no longer making. So we do this to relieve symptoms and also for certain health benefits, for example, prevention of bone loss. Women are at increased risk for bone loss after menopause, which can lead to osteoporosis. And we know that hormone therapy is not only effective but actually approved by the FDA [Food and Drug Administration] for prevention of osteoporosis, in addition to for relief of symptoms.

Amanda Newman (13:16):

So when should this treatment be considered during menopause and postmenopause?

Susan Haas, MD, PhD (13:21):

Well, not every woman needs to take hormone therapy, but every woman deserves a discussion of whether hormone therapy is right for her. Because in many cases, hormone therapy can be really beneficial, particularly in women who are symptomatic around the time of perimenopause, menopause, postmenopause – throughout the entire transition. Most women are safely able to take hormone therapy. There are some women who, because of their underlying health conditions, can't take hormone therapy – whether that's a history of a cancer like breast cancer or other cancers that might respond to estrogen, or whether that's a history of heart disease or blood-clotting problems or stroke. All of those things make it more dangerous to take hormone therapy because all of those things are risks that are potentially increased when a woman takes hormone therapy. But for the average healthy woman in her 40s and 50s who doesn't have any of those underlying health conditions, the chance of a serious health complication is extremely, extremely remote. So for those women, hormone therapy is generally a good option if they choose to take it.

Amanda Newman (14:51):

Now, what if you can't take hormone therapy? Perhaps maybe you have some of those risks that you mentioned or maybe you just don't want to. What treatment options are there?

Susan Haas, MD, PhD (15:01):

There are other non-hormonal medications that we use to treat particularly hot flashes and night sweats. And the most effective non-hormonal treatment is a brand new medication. And by brand new, I mean approved by the FDA about two years ago, called fezolinetant. This is a novel medication, meaning it works in a new way that nobody has ever identified prior. And it treats hot flashes and night sweats by affecting the area in your brain that triggers the hot flashes and night sweats to occur. So, temperature regulation in your body happens in a temperature regulation center in your brain in an area called the hypothalamus. And we know that when estrogen is taken away, that area becomes overactive. And basically this medication doesn't give the estrogen back. That's what hormone therapy does. What this does is quiet down that temperature regulation center in your brain. So for many women during menopause, I guess the way I like to explain it is, you normally have a certain range of temperature in which you feel comfortable. And if you get too hot, you sweat; and if you get too cold, you shiver.

(16:37):

But there's some kind of in-between range where you feel good, right? It's like the spring and fall that we get for a week each year here in this climate except in between summer and winter. And you feel really good. But when the estrogen is taken away and that hypothalamus becomes overactive, that range of healthy temperatures where you feel good, it gets narrow. And so instead of having a little wiggle room there, you go from too hot, too cold, too hot, too cold, and it's very hard to find that comfortable middle – where this medication will actually, same as estrogen will, help to make that better. So it does have some risks, like any medication. We do have to monitor carefully for liver problems. So someone who had liver disease wouldn't be a candidate to take that medication. But most patients, even patients who can't take hormone therapy for one or another reason or who choose not to take hormone therapy, that would be a good option.

(17:35):

There are other prescription medicines that we use to treat menopausal symptoms other than fezolinetant, and they help with a variety of symptoms. But they don't have the level of efficacy. So they help some blunt the symptoms, but not as much. Most of these are medications that were originally designed or invented to do something else – and that we found as a side effect that they also help with hot flashes, night sweats and other symptoms of menopause. So, for example, gabapentin is a medication that has been used in the past to treat seizures and is mostly now used to treat nerve pain, and is also very effective for menopausal symptoms. Venlafaxine is another one. This is a medication that was initially designed to be used to treat depression and anxiety. And we have found that as a side effect, it also helps with hot flashes and night sweats.

(18:37):

So for women who maybe have a mood component to their menopause symptoms but don't want to take hormones, maybe that's a good choice. The gabapentin, it can sometimes make women a little sleepy. So for women where sleep is a problem and they don't want to take hormone therapy, maybe that's a good choice. And then the other choice for treatment of symptoms, if we're not worried so much about hot flashes and night sweats, but we're more worried about the vaginal symptoms, we call this genital urinary syndrome of menopause. And this includes vaginal dryness, it includes bladder urgency, it includes pain with intercourse. All of these are because the tissues in the vagina and the tissues around the opening of the bladder respond to estrogen. And for some women who can't take hormone therapy that goes through their whole body, what we call systemic hormone therapy, because of the risks we talked about, they can still use topical or local estrogen therapy.

(19:41):

So, an estrogen cream or suppository that's placed on the vaginal opening or the bladder opening or right inside the vagina. And it's given in such low doses that there is almost no systemic absorption. Meaning if I checked a blood test level on these women, their estrogen levels would still be menopausal. And so for these women, almost everyone can take this medication, the vaginal estrogen. In fact, there are many menopause experts who advocate that vaginal estrogen, really if we were doing everything ideally, would be over the counter. And I completely agree with that. It is so safe, and unfortunately the FDA has a lot of warning labels on it. And the warning labels on vaginal estrogen occur because of a policy the FDA has called class labeling. So what this means is that if they put a warning on any estrogen product, every estrogen product has to have those same warnings, even if it hasn't been proven for that particular estrogen product.

(20:48):

And this kind of makes sense when you're looking at a class of medicines that kind of all work the same way and have similar risks. If we looked at four different cholesterol medicines and three of them were shown to have a risk, unless we've proven it differently, we probably have to assume the fourth one does too. But when you look at systemic estrogen and topical or local estrogen, they don't work the same way even though they're both estrogen. And so they really don't have the same risks. But what I see happen is that patients receive a prescription and then they go to the pharmacy to get the prescription filled. And they're given this handout with all of the risks of hormone therapy, and they get really scared and then sometimes they throw the prescription away. And so I try to head this off by explaining that to patients when I give them a prescription. But I can completely understand how it might be really scary. Even though the doctor might've explained that, you might not remember. The pharmacist might tell you something different. Maybe because they're not really this type of clinician, so they don't completely understand.

Amanda Newman (21:58):

I would agree with that, that it is scary. Especially when you see those commercials too, where they talk about a certain medication and then the rest of the advertisement is all of the different side effects and risks. It's scary, and I'm glad that you are explaining it to your patients and taking the time to make sure they understand it. Because they may not get all the information they need when they are with the pharmacist or something.

Susan Haas, MD, PhD (22:23):

This might be a good time to talk about some of the risks of systemic hormone therapy because we talked about how local has almost no risks at all, really. Systemic hormone therapy – meaning a pill that you take or a patch that you wear on your skin or a gel or cream that you apply to your skin that gets absorbed into your bloodstream – means that either, depending upon what regimen you're on, estrogen or estrogen and progesterone, those are the two most common regimens, are absorbed into your body and getting to all of the cells in your body. So just like everything that has benefits, they also have risks. So the most common risks of hormone therapy were actually identified in a study, that now is about 20 years old, called the Women's Health Initiative. This was the biggest research study that was ever done on hormone therapy and probably the biggest research study that ever will be done on hormone therapy. It was many, many, many millions of dollars run by the FDA over many years, looking at women taking hormones and women not taking hormones and comparing them.

(23:41):

And this study ... has been in the press for a long time with a lot of variety of different interpretations, right. So what the study showed is that women taking hormone therapy, compared to those who weren't, had a slightly increased risk of certain serious health conditions. That would be scary things, breast cancer, heart attack, stroke, dangerous internal blood clots. The chance of any one of these things happening in any one year was less than one in a thousand. And it was never been proven to be what's called what we say in medicine, statistically significant. Basically what that means is that the research actually proves that it's true. Was never proven to be true in that way in women under 60 or women less than five to eight years from menopause. So in those women, the risks ought to be even less if at all. And so what this shows us is that those women who don't have a high risk of any of those conditions ought to be able to safely take hormone therapy and at least try it and see what it does for them.

Amanda Newman (25:01):

So the bottom line is just working side by side with your health care clinician or physician to really find out what is going to work best for you based on your preexisting conditions. Is hormone therapy perhaps the way to go or trying one of the medications that you mentioned?

Susan Haas, MD, PhD (25:19):

Yes, there are a lot of options, and the discussion really needs to be. It's a nuanced discussion. There's a lot of factors. And it really needs to be an individual discussion between a patient and her doctor and her clinician to figure out what's right for her.

Amanda Newman (25:36):

So if you've had a total hysterectomy, do you need hormone replacement therapy? As we're talking about this, one of our listeners had this procedure and has developed osteopenia in her ankles. So she was wondering, could this be due to a lack of hormones?

Susan Haas, MD, PhD (25:54):

It's so interesting. There are so many things that this question brings up. It's a really good question, and it's a question I get from patients a lot. And the first thing that I would say is it's hard to understand what the word total hysterectomy means. Because what total hysterectomy means to a patient and what total hysterectomy means to an OB-GYN physician is probably not exactly the same. The word hysterectomy means removing the uterus. So a total hysterectomy is removing the entire uterus, including the cervix. That has nothing to do with the ovaries. But when most patients that use the term total hysterectomy, they mean removing their uterus and removing their ovaries, whereas patients will describe just having the uterus removed as a partial hysterectomy. So this can be kind of confusing. So it's important to understand what surgery the patient had, what organs were removed and what organs are still there.

(26:59):

So for a woman who's had her uterus and her ovaries removed, she is menopausal. So if that was done after she's already menopausal, she shouldn't notice much of a difference if she's already gone through natural menopause before her ovaries were removed. But if her ovaries were removed while she was still cycling, even if she was having sporadic cycles or perimenopausal, she might notice a big change in her symptoms and because she's going to notice, she's going to have a really abrupt drop in her hormone levels. So we often see that women who have what we call surgical menopause, meaning they go through menopause all at once because their ovaries are removed as opposed to natural menopause, meaning the ovaries gradually stop working. Those women with surgical menopause can have more severe symptoms, and the symptoms can come on them more dramatically and more quickly. So those tend to be women that are more symptomatic. And both may have menopausal symptoms like all of the things we talked about, like hot flashes and night sweats and vaginal dryness, but also bone loss.

(28:23):

Bone loss happens fastest in the first five years after menopause. So it's going to happen to us whether it's natural menopause or whether it's surgical menopause. But if you go through surgical menopause early, basically you're going through menopause overall early, a woman would then have a higher risk of bone loss because she has more years of her life, a greater percentage of her life that she's spending without those hormones. And hormone therapy, one of the indications that hormone therapy is proven to help with, is slowing bone loss. So definitely hormone therapy can help with that. It's not right for everyone, and it's not the only medication that's used for bone loss. But it definitely can help in a patient who is otherwise a safe person to take it.

Amanda Newman (29:22):

So how is bone health impacted during menopause and would a calcium supplement be helpful?

Susan Haas, MD, PhD (29:29):

Great question. Women definitely lose bone over their lifetime, and that bone loss increases after menopause and especially in the first five years after menopause. So women who are going through this menopause transition are particularly at risk. And there are some natural things that we can do, like taking calcium and vitamin D. And weight-bearing exercise is also very important, resistance exercise. We want to do that at least 30 minutes at a time, three to five times a week, not that cardio isn't important. Your heart health is always important. But resistance exercise becomes more important as we age, both after menopause and just with the aging process in general. And that is both. Resistance exercise helps keep our muscles strong and also helps keep our bones strong. As far as supplementation specifically, which is what you asked about, there are guidelines for calcium supplementation. Healthy adults should take up to a thousand milligrams of calcium a day, and postmenopausal women need a little bit more, maybe 1,200 or a little bit more than that.

(30:48):

And it is controversial how much calcium supplementation actually helps with bone loss. I do tell my patients that it's best to get calcium through your diet rather than from supplements if possible, and to just add supplements for the difference of what you can't get from your diet. The calcium in your diet is better absorbed and less likely to cause side effects like kidney stones, for example. Vitamin D is also very important, and the recommended range of vitamin D supplementation is anywhere from 800 units to 2,000 units of vitamin D daily. And vitamin D helps keep your bones strong and also helps your body to absorb the calcium more effectively.

Amanda Newman (31:34):

So at any point throughout menopause, both vitamin D and calcium supplements are worthwhile and very important to include.

Susan Haas, MD, PhD (31:42):

At any time during menopause these supplements are important to include, but it's also important to include them throughout your lifetime. Menopausal bone loss is just the end product of what's happening with our bone strength across our entire lifetime. So a woman is building bone, her bones are getting stronger, her bone mass is getting higher through as she's a young adult, up until somewhere around the age of 30. After the age of 30, your bone mass starts to decline and it declines for the rest of your life. But there is a rapid increase in that decline around the time of menopause, and especially in those first five years after. So if you start with a higher bone mass when you're young, and if you start with healthier bones as you transition into menopause, you're less likely to have the severe consequences of osteoporosis later in life. Like vertebral fractures, that's fractures of the bones in the spine, or hip fractures. Hip fractures are the most devastating consequence that can occur as a result of osteoporosis. Up to 25 percent of women will actually pass away within a year after a hip fracture. So it's really important for us to do everything we can to prevent that. And whatever we can do to help with bone mass, including supplementation, exercise and in appropriate patients, possibly hormone therapy, is all a great help with that.

Amanda Newman (33:19):

So we've touched on hormone replacement therapy. Could you explain what the components are of hormone therapy?

Susan Haas, MD, PhD (33:28):

Absolutely, yeah. So for a woman who has not had any kind of gynecologic surgery in the past, we typically give her estrogen and progesterone. It's actually that estrogen that we give. And this can be either orally or transdermals like a patch or cream or gel that goes through the skin. It's actually the estrogen that provides these benefits that I've told you about. However, estrogen does have a serious side effect of increasing the risk of uterine cancer ... endometrial cancer, which is the most common type of uterine cancer, cancer of the uterine lining. So for women who still have their uterus who haven't had a hysterectomy, they also need to take progesterone because the progesterone prevents that from happening. If the uterine lining sees that proper balance between estrogen and progesterone, there's no increased risk. So that is why there's a difference between the hormones that women take who have had their uterus removed, have had a hysterectomy, and the women who still have their uterus.

(34:46):

And this also leads into discussions of the risks of hormone therapy. Because that big study I told you about before, the Women's Health Initiative, that study showed an increased risk of breast cancer – although it was not a huge increase – but an increased risk of breast cancer in women taking estrogen and progesterone. But it showed no increased risk in women taking just estrogen. And so there are really differences in the risk profile depending upon whether or not a woman has had certain types of previous gynecologic surgery. We also give estrogen transdermal, meaning through the skin, as opposed to orally, when possible. And the reason for that is that we can decrease the risk of those serious blood-clotting problems, serious internal blood clots in the legs or in the lungs that can be very dangerous. And those are less likely to happen in women who absorb the estrogen through their skin compared to women that take the estrogen orally.

(36:01):

The reason for that is that when the estrogen is absorbed orally, when it goes through the intestines, then it goes to the liver, and the liver is where the blood-clotting proteins are made. And so it can have a greater effect on blood-clotting problems, the estrogen when it's given orally. So we try to use transdermal when possible, although for some women, for a variety of reasons, oral might be better. The most common side effect to estrogen patches is an allergic reaction to where the patch was placed. So women who have an allergic reaction to a patch or the patch falls off, we do sometimes use oral for those patients.

Amanda Newman (36:47):

So aside from hormone therapy, there's some other symptoms that a lot of women are dealing with during menopause, and one of those is urinary tract infections or UTIs, which are very common at any point throughout menopause. So how can you prevent them? And if you do end up with a UTI, what's the best way to treat it?

Susan Haas, MD, PhD (37:08):

So urinary tract infections can be common and they can be common in this age group for sure. This is one component of a larger problem we call genital urinary syndrome of menopause. And this is a variety of vaginal and bladder symptoms that women get as they have low estrogen and the changes associated with that in their vagina and in their urinary tract. So if a woman has UTI symptoms, it's very important that she contact her doctor for recommendations. If it truly is a urinary tract infection, then oftentimes treatment with antibiotics is required. And urinary testing is typically done to check and see if it's really a urinary tract infection because some women have an infection that needs to be treated and other women have no infection, but all of the symptoms. So some women might get burning when they urinate or urinary frequency and having to go to the bathroom more frequently and really feel like they have a UTI. But then when we test the urine, we find there's no infection, and that can happen for a variety of reasons. That's a whole discussion in itself. But one of the reasons that can happen is because of low estrogen levels, and so that can be treated. One of the components of treatment in that situation might be that local or vaginal estrogen therapy.

Amanda Newman (38:55):

There's so much more to talk about. So we'll be continuing our conversation in part two of our podcast series. Thanks for joining us today and stay tuned for part two, coming soon.