Dr. Pauline Maki, Professor of Psychiatry, Psychology and Obstetrics & Gynecology, joins this season’s final bonus episode to talk about managing the emotional symptoms related to menopause and how to reduce stress and help have a “calm” menopause.
Bonus Episode: A Calm Menopause with Dr. Pauline Maki
Dr. Pauline Maki, Professor of Psychiatry, Psychology and Obstetrics & Gynecology, joins this season’s final bonus episode with host Dr. Mary Jane Minkin to talk about managing the emotional symptoms related to menopause, how to reduce stress and help have a “calm” menopause. The experts unpack how estrogen can affect brain function and mood. The conversation covers how common menopausal symptoms and experiences, including brain fog, stress, hot flashes and disturbed sleep, are related to overall mental health. Dr. Maki and Dr. Minkin also discuss disparities in women’s health and how socioeconomic status and race can affect women’s brain health in midlife. Methods to help reduce stress are detailed to give listeners actionable ways to improve their mental health.
About Dr. Pauline Maki:
Dr. Pauline Maki is Professor of Psychiatry, Psychology and Obstetrics & Gynecology and Associate Dean for Faculty Affairs at the University of Illinois at Chicago (UIC). Dr. Maki received her Ph.D. from the University of Minnesota and postdoctoral training at the Johns Hopkins University School of Medicine and the National Institute on Aging. For the past 25 years, she has led a program of NIH-funded research on women, cognition, mood and dementia, with a particular focus on the menopause. Dr. Maki is Past President of the North American Menopause Society (NAMS), Current Trustee of the International Menopause Society, Chair of the Society for Women's Health Research Interdisciplinary Network on Alzheimer's Disease, and Immediate Past Head of the Neurocognitive Working Group of the Women's Interagency HIV Study. She won the 2018 Woman in Science Award from the American Medical Women's Association and the Thomas B. Clarkson Outstanding Clinical and Basic Science Research Award from the NAMS (Healthywomen.org).
menopause: unmuted is designed to raise awareness, encourage communication, and share information. It is not designed to provide medical advice or promote or recommend any treatment option.
Mary Jane Minkin
It's time to unmute menopause. Hello, and welcome back to menopause: unmuted, a podcast series sponsored by Pfizer. Menopause is a major transition in life with a lot of changes, many of which can be positive. I'm your host, Mary Jane Minkin. I'm an obstetrician gynecologist and clinical professor at Yale University School of Medicine. And in this collection of bonus episodes, I'm talking with experts to dive into some common health concerns women experience in midlife. I spend a lot of time talking with my patients about the physical symptoms of menopause. But so many women also experience emotional symptoms and changes to their mental health. That could be anything from irritability to anxiety. And many women dealing with these changes feel the impact on their relationships with family, friends, and work colleagues. But as with almost everything related to menopause, the more you know, the better you can cope. Mental health is a key part of your general health. And it's a topic that patients and healthcare professionals are learning about more all the time. So, to go into more detail on creating a calm and emotionally regulated, menopause. I'm delighted to be joined by today's guest, Professor Pauline Maki. Thanks so much for joining us, Pauline.
Pauline Maki
Oh, thanks for having me. It's a pleasure to be here.
Mary Jane Minkin
Pauline, could you please tell our listeners a little bit about yourself and your work?
Pauline Maki
Sure. So, I'm a professor of psychiatry, psychology and obstetrics and gynecology at the University of Illinois at Chicago. And for the past 25 years now, I've been pursuing a program of research to understand how hormones like estrogen and progesterone affect women's brains, how women's cognitive function and mood changes as they transition through the menopause and what we can do about this.
Mary Jane Minkin
Thanks, Pauline. And, of course, Pauline's too modest, but I would like to add that she's a former president of the North American Menopause Society and currently serves as treasurer of the International Menopause Society. So, we've got you a real expert today here. To get us started, could you explain how does a woman's brain change at menopause?
Pauline Maki
Yes, thanks for the question. So, we have a new understanding of this issue. In the past, we focused primarily on the post menopause. And we didn't see a lot of differences between women who were pre-menopausal and postmenopausal of the same age. But it turns out that if you look at the perimenopause, that's the time when these cognitive changes appear.[1] We used to think that estrogen affected mostly reproduction. And now we understand that areas of the brain are full of these receptors for estrogen. And some of those areas of the brain are areas that are involved in the way that we remember, that the way that we concentrate, in general ways that we think.[2] And so what happens as cycles start to change, estrogen becomes more variable, and the brain’s attempt to cope with that, that seems to be responsible for women's cognitive complaints.[1] So, they complain about their inability to retrieve words, names of people, they complain of a kind of brain fog. And we think that this has to do with, in part, the brain's attempt to try to adapt to these changing levels of estrogen.
Mary Jane Minkin
Thanks so much, Pauline. And of course, one of the lines I always use with my patients is you know, people sometimes accused them of dreaming these symptoms up and I say, “Yeah, when they tell you it's all in your head,” I say, “yeah, it is in your head, but it's right here in your brain.” So, anyway. So, thanks so much for explaining what's actually happening in the brain, Pauline. But can you go into some detail on how women typically feel these changes? Because it can present some new and unfortunately uncomfortable feelings?
Pauline Maki
Yes, certainly. From a cognitive perspective, what research studies show, when they perform these cognitive tests, as they transition through the menopause, there's a dip. And that cognitive ability that women show a dip in is something we call verbal memory.[3] So, Mary Jane, this is what you and I are doing right now. So, you and I are having a conversation, we're using words, and then your audience will want to try to perhaps remember what we're saying right now. So that's verbal memory. So, it's the ability to take in information, like stories, word lists, grocery lists and the like, and then recall it at a later time. And it's that ability, that seems to reliably change. Now, part of this as well reflects menopausal symptoms. So, it's not just the estrogen that's contributing to these cognitive changes. It's women's vasomotor symptoms, so their hot flashes and their night sweats, our studies show links between those symptoms and cognitive changes,[4] as well as sleep changes,[5] especially sleep changes that occur with hot flashes,[4] and then mood issues.[2] And so, while the menopause transition itself is associated with a decline in memory, all of those other menopausal symptoms can affect other types of cognitive ability. So, when you and I are sleep deprived, maybe our attention isn't as good, maybe we feel a little foggy in how we're thinking. And so, there are many factors that influence cognitive functioning at this time. And it has to do with changing levels of estradiol affecting memory systems, and other symptoms affecting not only memory, but other cognitive abilities.
Mary Jane Minkin
And question, many women, of course, have heard about things like serotonin, can you bring in some of the interplay between serotonin and estrogen?
Pauline Maki
Sure, yeah. So, there are chemicals in our brain, which we call neurotransmitters that are key chemicals in our mood, that are key chemicals in how we remember. So, when we think of serotonin, for example, we think of antidepressants. And it turns out that estrogen and serotonin are close friends in the brain. The receptors for estrogen are located in the same brain areas as the receptors for serotonin. And when those estrogen levels become erratic at the perimenopause, that tight coupling between estrogen and serotonin seems to go awry.[2] And that seems to contribute to some of the mood issues at menopause.[2]
Mary Jane Minkin
Again, thanks so much for that information, which is very helpful. And can you go a little bit more into the issues about hot flashes, because of course, this is the other thing I hear about every single day are women who are troubled by hot flashes, which makes their work life so much more difficult, they wake us up at night. And one thing that I encourage my patients to do is to talk to your healthcare professional, because we can help work on the hot flashes, help work on the sleep and get people feeling better.
Pauline Maki
Yeah, so this is such an important topic. So, we know that hot flashes and night sweats are really the hallmark symptom of the menopause. And we now know that women, on average, continue to experience those hot flashes and night sweats for 7.4 years and even longer in in women of color.[6] And so, these are symptoms that persist beyond the perimenopause. And so, these hot flashes in our work have been shown to be very closely associated with memory performance in women, and also with brain function and brain structure.[4] So, what we find specifically is that the more hot flashes a woman has, particularly at night, the worse her memory function.
And you asked, Mary Jane, about sleep. So, when you measure sleep objectively, and when you measure hot flashes objectively as women sleep, you find that when women have a hot flash on the monitors, 75% of the time, they're waking up. 75% of those hot flashes are accompanied by awakenings.[7] And so, what that means is that hot flashes contribute to our sleep disturbance. And of course, you don't need a PhD in neuroscience to know that the more sleep deprived you are, the worse your cognitive function.
Mary Jane Minkin
Well, I certainly always encourage my patients to try to let me help them with their hot flashes. Many of our patients, of course, are quite worried that some of these symptoms actually mean they have Alzheimer's disease. And indeed, of course, we know that some menopausal women are misdiagnosed with Alzheimer's.[8] Can you talk about the confusion there? Because I'd like to really address some of those worries for our listeners.
Pauline Maki
Thank you so very much for that question. There's a lot of misinformation about this topic circulating now so I really appreciate the opportunity to clarify. What is the link between a woman's experience of memory lapses at midlife and the risk for Alzheimer's disease. And the bottom line is that they're separate things. So, the memory issues that women have during the menopause are related to these changes in estrogen. And longitudinal studies show that most women bounce back.[1] Okay, so it's a time limited issue.
Well, we know that these changes in memory are very normal. What happens to the brain in the post menopause is it becomes what we call plastic it becomes flexible, and it adapts to this change in estrogen. So suddenly, the new normal is low levels of estrogen and the memory circuits adapt to this change. Now what about Alzheimer's disease?
So, it turns out that about 35% of the risk of Alzheimer's disease can be controlled by what we call modifiable risk factors.[9] So, these are factors that we can change in order to optimize our brain health as we age. And they include such things as maintaining our heart health, which means maintaining a healthy blood pressure, and good cholesterol levels.[10],[11] It includes engaging in cognitive activities and these are challenging cognitive activities, like learning a new language, not something we're good at.[11] It's a challenge cognitively that's good for the brain. It includes exercise.[9],[11] It also includes avoiding things like avoiding smoking, avoiding traumatic head injury.[11] And it includes things like eating more of the Mediterranean diet, so less red meat, more legumes, more fruits, and vegetables, and the like.[12] So that's about 35% of the risk for Alzheimer's disease can be controlled by those kinds of factors.
Mary Jane Minkin
So, what's good for your heart, is good for your brain.
Pauline Maki
Yes. And at midlife, it's a really good time to consider your heart health. And, in particular, we know that women who have early hot flashes and who experienced those hot flashes at a sustained level are among the women who have the heightened risk for heart disease later in life.[13] So, we think about the hot flash almost, particularly the early hot flash, as a sign to make sure that you're getting your heart checked out. So, make sure to talk to your health care provider if you have early hot flashes and make sure that you get your blood pressure checked and your cholesterol levels checked. Just make sure that that you're optimizing your heart health.
Mary Jane Minkin
And that's terrific empowering news, Pauline. So, to our listeners, please embrace everything that Dr. Maki is saying because that's very important.
Pauline Maki
Yeah, it can be a very empowering time. A very empowering time for women.
Mary Jane Minkin
Thank you, Pauline. You're listening to a calm menopause, a bonus episode to accompany season three of menopause: unmuted. I'm your host, Mary Jane Minkin. And today I'm joined by Professor of Psychiatry, Psychology, and Obstetrics and Gynecology, Dr. Pauline Maki. You can listen to all our previous episodes and find more information at menopauseunmuted.com. Pauline, a lot of my patients complain of significant stress at this time in their lives. They've got a lot of things going on with work, with kids, with parenting things, like that and dealing with their elderly parents. Can you talk about some of the roles of stress and all these problems?
Pauline Maki
Thank you. Yes, women at this point in life have tremendous responsibilities. We call it the sandwich generation, they're taking care of older parents, they may be taking care of children, if they have them, they are at the peak of their earnings, right, because they're at midlife. And they have all of these stressors. And what I like to say to women is that it's really important that you be kind to yourself. And kind and understanding that your way of reacting to these stressors might not be the way that you would have reacted if you weren't transitioning through menopause if you weren't experiencing this hormonal variability. So, you might ask, okay, Pauline, you know, what's the science behind this? Or are you just trying to give an excuse for women, so if you’ll let- indulge me, I'm going to give you a little science to back up the desire that we need to be kind to ourselves at this time. And so, this is how we study stress in the laboratory. So, the way that we study stress in the laboratory, is we tell women that in five minutes, you're going to give a speech in front of three people and the speech is about why you are the perfect candidate for your dream job.[14] That's a stressor. It's called the Trier social stress test. So, this is what we do in the lab. So, this is how we measure stress. So, what does menopause have to do with the way that women respond to this kind of stress? Well, it turns out that when women are in this situation, they report stress, as you might expect, but their bodies also secrete more of this stress hormone called cortisol. And cortisol is a stress hormone that can really impair our ability to think clearly. Okay, a little bit of stress is actually very good for [for] our cognitive function, little bit of stress is a good thing, chronic stress is not a good thing. So, in this study, they measured how variable estrogen levels were, for eight weeks before women went into this stressor.[14] And what they found is the more variable these peri-menopausal women's level of estrogen was before they went into the stressful situation, the more stress they reported, and the more cortisol that they secreted. Now, did all women show the same amount of variability? No. So this is one of those factors that can differ from one woman to another.[14] And that can explain in part why some women respond differently to these stressors. So [so], how do we respond when we're stressed? We become a little punchy, we become a little irritable, right? So, I really want to give women permission to be kind to themselves to normalize this experience, to understand a little bit about the science that backs up their experience that they're not able to control their stress reaction, like they used to be able to, and also to give them hope, because that estradiol variability is time limited. Once they transition through the menopause, those estrogen levels will stabilize. So that's a natural process by which the brain will adapt better in terms of its stress response.
Mary Jane Minkin
Excellent science and excellent explanation. Thank you so much.
Pauline Maki
You're welcome.
Mary Jane Minkin
Pauline. In this last section of the podcast, I'd like to talk with you about a very important issue that I don't think is spoken about often enough, how factors like socioeconomic status, and by that, I mean, how financially comfortable you are,[15] race and education level affect women in midlife,[6],[16] particularly as they pertain to menopause.
Pauline Maki
Thank you, this is a very important topic, because there are huge disparities in women's health, particularly at menopause.[10] And some of this is tied to race.[16] So, we know for example, when we think about the idea that you want to bring your healthiest brain into late life, we [we] know that Black and Latina women have more hot flashes than white and Asian women.[6],[16] So, with that risk factor that menopause related risk factor, we really need to be thinking about race and socio-economic status. Earlier, we talked about stressors. We know that women who have some financial challenges that they experience more stressors, more chronic stressors, and we've also talked about how the variability in estrogen levels makes our ability to handle stress more- it’s challenged, right? So, women who face those challenges have a greater challenge optimizing their brain health.[11] And it turns out that Black women in particular, have an elevated risk for Alzheimer's disease.[17] And part of this is because of health disparities, disparities in the way that heart health is maintained in women of color compared to white women.[18] And so, when you don't have access to good health care, you bring those risk factors into late life. And that's not good for your brain.
And it turns out that there's this idea that has some- quite a bit of scientific backing that one of my mentees actually studied in her research, which is this strong Black woman idea: and this is the idea that Black women are key to holding communities and families together.[19],[20] And part of that role means that they minimize their own needs in service to their family needs.[19] And so, they don't often seek the health care that they need to because their motivation is to take care of other people and to be strong.[20] And so, we need to find ways of making sure that as we pursue this mission of optimizing brain health in women at midlife, especially through the lens of menopause, that we take into consideration the health disparities, the barriers to care that women of color face, so that we can also aim to optimize their brain health so that they're bringing the healthiest brain that they can into late life. So, [so] that's all to say we have a lot of work to do, and that the experience of one woman can be very different from the experience of another particularly when you're talking about race and ethnicity.
Mary Jane Minkin
Thank you, Pauline. Now, for this final section of our discussion today, could you point listeners towards some reliable ways to help minimize stress at midlife?
Pauline Maki
Yes, this is the empowering part. So, let's talk about the emotional response that some women can have to the menopause. So, we talked about the role of estrogen variability, so women can talk to their health care provider about what they can do to minimize variability and estrogen at this time, and to promote their emotional well-being. So, talk to your health care provider if you're having that experience. And then let's talk about stress reduction techniques that that we can do.
Exercise is a way of enhancing our brain health, both in terms of our cognitive health,[21] and in terms of our depressive symptoms.[22] And yoga is very good for stress; it helps us to regulate our stress response.[23] Social engagement is key to our brain health,[11],[24] to our heart health,[25] and actually to our overall mortality.[26] In addition, when we're around people who we like we have this reward response, our brain has a positive response to social stimuli, like engaging in conversations, and that's very good for our overall well-being.[27]
There are things we need to avoid when our mood is low. And one of those things is drinking too much alcohol. So, what is that, drinking more than two drinks in a day or seven drinks per week? Turns out that's not good for our mood.[28] So, while it might make us feel better in the moment, the long-term effects are not positive. In addition, excessive alcohol is not good for brain health.[29] We don't bring our best brain into late life if we're drinking too much. So that's something to be avoided.
A Mediterranean diet is something to be embraced.[30] So, we want to have more beans, more legumes more vegetables. So, does that mean we have to change our diet entirely? No, it just means that we might grab the hummus instead of grabbing the chips. So, we want to eat more of this healthy kind of diet, we want to just start making better choices. And then finally, there’s something called Mindfulness Based Stress Reduction.[31] And this is a form of meditation that allows us to pay attention to a stressor in our life. But what it trains us to do is to not respond emotionally to that stressor. So, this is this is all very positive news for women. There’s a lot we can do to optimize our mood, and to optimize our cognitive function.
Mary Jane Minkin
That’s terrific, Pauline. I absolutely agree, as you said that being kind to yourself is such a great place to start, because so many good habits can evolve out of that. And we've got some great tips on diet and exercise in our other bonus episodes, too. So do check them out. Well, Professor Pauline Maki, thank you so much for joining us today and sharing such fantastic insight.
Pauline Maki
It's been my pleasure, such a pleasure talking to you. Thank you for the opportunity.
Mary Jane Minkin
Thanks to you for listening to a calm menopause. The last of our bonus episodes to accompany season three of menopause: unmuted. If you haven't already listened, do check out our previous bonus episodes, where I've been talking with experts about good nutrition, the benefits of strength training, and how to foster a healthy sex life during menopause. And if you'd like to share your story, do take a look at the show notes where you can find details of how to get in touch and more information on the topics we've discussed today. You'll find it all at menopauseunmuted.com. And if you have any questions about your own menopause, talk to your health care provider that might be your OB/GYN, primary care provider, nurse practitioner or midwife. There are even designated menopause practitioners that a woman can visit if she needs more information. Special thanks to the women's health team at Pfizer and to Studio Health for producing this series. Take care and keep talking.
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