You know, it's interesting that what you mentioned, even that may not be happening. I mean, how many people, women were sent for calcium score, you know because they had a mom who died, at the age of 58, right?

So even those things at basic, like how people are consistently screened for diabetes, because as you transition through menopause, one of the things that happen is because of all those abdominal metabolic changes, your more prone to diabetes, or if you're diabetes that you already have, it gets worse.

So how many people are trained to realize that in that transition, all those things metabolically changes, that honestly, like, why do you even care about this stuff?

Because it all affects how long you live and how you. Have you made it past menopause or are you going through it now? I'm Dr. Pat McShane, and on the Women's Health Span Voices podcast, I'll guide you through the menoppausal transition and beyond.

helping you to thrive in this powerful time of your womanhood. And has had roles as physician executive in a number of different organizations and some quite specific training in performance and other kinds of issues that are relevant to our discussion today.

So, so good to have you with us, Dr. Hannah. Welcome. In your current clinical practice, you have fashioned a practice with women physicians, executives, and professionals going through and having gone through their menopausal transition.

And I suspect that you kind of came across that role in sort of how I came, across this podcast, which is finding that there was a gap in the treatment of women and the information that was available for women going through menopause for one thing and then into the full menoppause condition.

So maybe you could comment a little bit about what drew you into that realm of practice. Yeah, I think a lot of times what draws us into what we end up doing is probably what's happening to us and around us.

And I did not expect myself as I was going through the perimenopause and menopausal transition, how much is going to affect you and your performance as an executive and as a doctor and a mom.

as a wife, and I realized that the same things that patients complain about, the brain fog, I'm not as sharp, or I am not this. And when it starts happening to you, you start asking questions, why?

And obviously you started digging deep to fix it. I think that fascination with that, that's end up sort of completely changing my career path, because I made the decision that I probably can give back more.

by helping women optimize their performance. And that started with me and my friends who were in the higher level roles. I think giving this back to the world, this ability to not struggle through perimenopause and menopausal, but actually strive.

use it as an opportunity to pivot and know that you can achieve so much more. It's not a decline, it's actually the time for you to grow and excel and just be different to you.

So you, in our prior communications, you mentioned that professional women actually are more likely to kind of suffer, I use that word broadly, from the issues that happen to most of us as we transition through menopause.

And tell us a little bit more about why that might be or the kinds of issues that come up for professional women in this transition time. I think if you're working always on the highest level, you have to be at the meetings.

You need to appear to sharp. you need look great. All these extra requirements that women are required to perform and then suddenly you may not be sleeping as well, or you're noticing, and we know it's been studied, that there are some problems that are temporary, but they are problems with memory and concentration and sort of how fast you are thinking on the spot.

you're so in tune at performance on the highest level that you start noticing that, even if other people may not notice, but you do. And I think it has to do with probably also the women who get into those roles, so the woman who gets into medicine, or the succeed because you're running the family on the side.

You're writing two jobs the whole time. So you high performer and therefore your requirements for you are much higher. And as soon as you start minor decline or your perceived minor declining, you'll become very hard on yourself.

I think that exacerbates the stress, and exacerbate some other things like, Obviously in perimenopause, we start redistributing weight, right? It becomes more abdominal and the sleep starts becoming a problem.

And so it's kind of a collusion of multiple factors. But for somebody who is performing the highest level and they don't have a break, right? They, they just work in seven to seven.

I mean, if you work into those executive roles, or if your doctor currently in our healthcare system, you know, You may be working eight to five, but all this extra in basket and extra work or extra other things.

So throw into that the fact that you have some cognitive, even though it's minor decline, right? Or something perceived or inability to, you wake up at three o'clock in the morning for no reason and suddenly your sleep is disrupted and then the hormones start colliding.

I think it is because you're working on such a high level and you don't have a break, You don' have time to rest. I think this is why you got becoming more affected and because you have those high expectations for yourself.

It's almost you become your own enemy because You have such a high expectation your work your worst critic. Yeah Yeah, and and many women at that stage in life at our stage and life are dealing with aging parents, as well as children who are going through multiple transitions and so on.

And your experience when women go to their healthcare practitioners, their physicians or PAs or NP's with issues, they may be dismissed or told that it's not really going on, tell us a little bit more about that in your experiences.

I think it's a common sort of thing in medicine that when the labs are normal, a lot of time we jump to conclusion everything else is normal. And it is not just menopause.

I mean, I can give you a hundred different conditions, you know, how many women with thyroid dysfunction, their labs on normal but we know now that 20-30% of them are actually not functioning and they do have brain fog.

We're not supplementing them the way we probably need to supplement them. So this normal is not normal. And I think that's probably one of the hardest thing is for the doctors to step back, who again, I don't blame the doctor's when you have 15 minutes and you pressure to address, especially in primary care, multiple things all at the same time.

When you want to get preventative stuff done and do this and this, and stepping back and saying, wait, what is actually troubling them. What is actually driving this?

And kind of look outside of normal and say, what is normal anyway? Because, you know, just because your labs are normal, that doesn't mean that you're performing, right?

I think most of the complex things in medicine are not identifiable on labs. And I that's where the other problem is that the women come to you and they say but why can't you just test all the hormones?

But that you and I know that unfortunately, as you go through the perimenopause, the problem is not that your hormones are low, hormones high, they're fluctuating like crazy.

And you're doing whatever hormone test at that moment outside of making sure that other hormones interact like thyroid and other things. It's not helpful.

So then if we can't even define the normal. of normal, then how do we actually help the women? And I think sometimes, and again, I've done that. I'm sure you've down that, where like, you know, when things are normal and so when you start going through this yourself, it's like when your a pediatrician and you don't have kids, or you tell your patients, please don's sleep with your kid, like you kept the infant in your bed and then you become a mom and your like oh my gosh, am so exhausted, i'm going to let them, so I mean, think that actually going though that transition yourself And realizing that, hey, patients are not wrong.

They're just not always able to articulate what's not normal. And then you cannot rely on the labs to tell them. But at the end of the day, I always tell patients, you know, not just for an impairment of course, but all this complex conditions, like say you're in a chronic pain or we cannot explain your symptoms or there's a lot of conditions like that.

We are limited in medicine, how much we know. and I'll always ask them, do you want a label? Or do you want to be better? And I can help you to better because there's a lot of ways to make you feel better.

I cannot always label you or give you say, hey, this hormone is dysfunctional or this lab is out of line. But I work with you and look at you as a whole.

human with your life and all the interactions in life, and how the life influences how hormones interplay, how your diet interplays with that. I mean, we're so complex.

How your gut microbiome may be influencing this and so many other things and kind of build a path for you with you. to make you feel better and optimize you versus label you.

But so that to me is, yes, that's the problem. I say the, the fault of normal. And we, a lot of times we'll fall into this kind of trap of. That's normal is not normal Yes, and we may or may not be measuring the right things.

We think that we're doing a comprehensive look at an individual's physiology or what's wrong with them. But in fact, as time marches on, we keep learning that there's more complexity to heart disease or arthritis, joint pains, et cetera, than we thought five years ago or 25 years, certainly, when many of us trained and there's been so little research on the menopause transition per se and then into the Menopausal years, how women's physiology differs.

We have different diseases that we experience and we experienced the same diseases differently than men. So a lot of things that need to be made up here that hopefully we're starting to do some of that work.

So in your experience, what are the main things that you would advise a woman to either do or stop doing to kind of mitigate as much as possible with her normal lab work, the symptoms that she's having?

I mean, honestly, first, you start by understanding what driving the symptoms, and also understanding that it's not one thing. It's probably three, four different things.

And therefore, the treatment that you're going to come up with is going be very much individualized. You're also trying to understand genetics. what happens to your parents, you know, grandparents, not just when it comes to sort of menopause transition, but it's actually that and all of the other metabolic parameters.

Because perimenopausal menopsis is really huge, Not just hormonal change, But the metabolic change. And I think a lot of this place into each other. And then you add to that the stressors, as you mentioned, like as we speak, you know, I, You know I have one kid who's getting married.

Another one is getting having a baby and my mom developed dementia and she's like a fourth parent with dementia. and it's learning to first of all, understand how all of those things, not just, metabolic stuff.

Like I personally have diabetes, and horrendous cholesterol genetically. It's all. Place into this and I think one of the biggest things I've realized in the transition was We're so used to saying, you know You eat less you exercise more and you're going to be great and then a lot of women would real would would see very soon at that age is actually a Lot of times when you cut the calories and You just exercise where you actually may not do well.

So that was to me a big eye-opener to see that, hey, it's actually what you're eating. It's maximizing the protein. And it how you exercising, you know, introducing more resistance training, not just aerobic exercise.

One of the biggest things I personally realized that I didn't realize my triggers and how it's going to influence my body reaction. Also, you may need to think through basic things, recreational smoking.

What you could tolerate before you're not going tolerate. You're going get the brain fog next day. Alcohol. Alcohol one glass at night. Oh, maybe so like all of those things that work before the 30s You know suddenly they don't work anymore and they any minor change both in what you eat Like high sugar intake like simple sugars, right some facade people triggers could be high dairy intake so it all depends because what other things are happening and then you make those changes based on a one real patient at a time and not just what the books are saying, especially as you just mentioned, the book actually studied men, not women.

So if you actually look even into cardiovascular conditions or any conditions, you know, there are very few studies that had women in them or proportional women were smaller.

How we react to all those different things is very different than men. We're not little men. We are completely different with a whole set of hormones and other things.

And our medical care system is designed basically to say, oh, you have high cholesterol and some coronary calcium, go see a cardiologist. you know, your blood sugar is rising a little bit, you're hemoglobin A1c is elevated, go see a diabetologist, an endocrinologist.

You know so the compartmentalization and then pretty soon somebody's on five medications, side effects, none of them is working quite right and maybe no one has really looked at some of the more fundamental underlying causes such as you've been mentioning.

So even those things at basic, like how people are consistently screened for diabetes, because as you transition through menopause, one of the things that happen is because of all those abdominal metabolic changes, your more prone to diabetes or if you're diabetes that you already have, it gets worse.

So how many people are trained to realize that in that transition, all those things metabolically changes that honestly, they like, why do you even care about this stuff?

Because it's all affects how long you live and how you. And bone density is another one that we should be probably checking 10 years earlier when we can really do something rather than finding it when someone's 60 years old and they're already severely osteopenic and at risk for fractures.

Yeah. Yeah, and, you know, in vitamin D and vitamin B12 in patients who are taking midformin for PCOS, there's so many aspects of just basic medicine that we could do to optimize people.

And I think even that is not happening because, again, we're looking at people in the box and not as these complex humans that interact with a super complicated environment as well.

and in a 15-minute appointment and your primary care has changed or your insurance has change. And so you can't use that primary-care physician any longer.

So it's tricky. One thing I say on a frequent basis on these podcasts is if you're not happy with the answers that you are getting from your care providers, Get another opinion.

Basically, reach out and don't allow yourself to be dismissed. And, you know, it's tough because, again, our insurance system, but once you hit 65, at least you have Medicare.

But even as Medicare, we know Medicare subsidizes procedures. Medicare does not subsidize. By I mean subsidized, who do we pay for? Which doctors do it pay fork?

It's not the doctors who keep you healthy, right? By the time you need a knee replacement and by the we need the stent, the system failed because all of this is Most of it, I would say, is preventable.

And most people don't even realize that most of the cancers we see in patients are also preventible through a lot of basic things. But the basic thing are not so easy to achieve.

One thing you mentioned, meals, what you eat and when you Eat is important. Sleep consistency is Important. And that can be so difficult, especially if you're dealing with a partner or a spouse with medical issues or child with needs or grandchildren support, you know, et cetera.

So it can, it, can. Yeah. And I was just going to mention, I think the huge aspect is sort of the psychological as well as sort stressors that exist. I mean, the reason why I work with women who have to perform on the highest level is they are surrounded with a tremendous amounts of stressor.

and I, think that most of us don't even realize that we may not be perceiving stress. Like some people feel anxiety or some, people will feel depressed, but some sort of those symptoms, but they actually the body is reacting.

And this is why they're having a brain fog possibly, or this probably why there may be waking up at three o'clock. I'm not saying it's all psychological.

It's actually not. But we do know that as you transition through menopause, if you're predisposed to depression or anxiety, it gets exacerbated. So, and the hot flashes go into this whole thing and how it's relate to stressors around you and to sleep and two food and so you can just tackle one thing.

You really have to untangle and create the support system. Psychological support, system, medical medication, support systems, exercise, supports system diet support.

System, you know, mindfulness based stress reduction and all those things that could possibly come in. And again, the exercise what type of exercise. In addition to everything I mentioned, how are you going to make sure that you don't fall when you're 60? And that contributes to fractures.

So I think we have tons of amazing opportunities to use this time to pivot. and make these women stronger, smarter, you know, more capable and it could be the prime of your life and not the decline.

You talk from a systems performance perspective about coming up with a plan and what you just outlined sounded to me a lot like a a And tell us a little bit more about how you would go about doing that with a woman, because obviously you can't sit in a 15-minute appointment and go through, you know, exercise, diet, social support, etc., etc.

How do you do that bit by bit with with the woman? I think some of this is also using the right questionnaires beforehand. I mean, it's getting the data.

So the framework that I use that, uh, I actually published in my book that was more on physician leadership. It's called guides and it based on the scientific method.

And it. You gather the information, you understand what's happening. Your identify the root causes and you build the plan to execute, and then you iterate the plant.

So apply the same thing to the patient. This is why if you send all the right things to first identify, what is the background? What is it genetics? what are we looking at?

You know, What happened before what prior conditions happened? Before you know what medications that they take and you now what supplements are they taking?

So you kind of gather all this info a lot of times if You have it beforehand. and you can quickly sort of start seeing patterns before you even see the patient, then you could actually dive in with the patients in whatever time you have with a patient and hopefully have more time than last time to start kind of double checking what they mentioned, understanding again.

understanding what is truly happening, and also sort of working together to identify the causes. Because I always said to the residents that I used to train, when everything failed as the patient, they will give you the diagnosis.

Don't make assumptions that you know. And I think one of the differences that i've learned over time is you co-design care. So you don't tell them what to do because they're never going to come in and do it.

But that's where the motivational interviewing comes in. This is when people come up with the answers and it's not you, the doctor comes up for the answer.

They're going be likely to implement those answers. And also understand how the habits are forming. Like you can't ask people to 20 things. You know that if they are committing to something, especially if their committing in writing to you to one thing and you give them two weeks or three weeks, or a month, They are likely to follow that then when you're trying to say, oh my gosh, you are so wrong.

You should quit smoking and quit drinking. And you do this and you this, and forget about this. That's never going to happen. We don't function like this." And even the most sophisticated women who are super great and they used to exercise and do things, if anything, the more you push on them, they're likely they are going be more stressed and it's going backfire.

Co-designing this plan to fit into the reality, right? So if somebody, again, being culturally sensitive, if they are certain cultures and they eat certain foods, how do you influence them and the family to understand that maybe that is not helpful in the menopause transition.

I mean, I'm from Belarus and I can tell you if you eat the typical Russian foods, you're going to have more hot flashes. Yeah, so you really have to rethink.

bread and sweet stuff and other stuff, you know, high in saturated fat. So you have to step back and say, we know that the closer you eat to the sort of Mediterranean diet, plant-based diet.

You know green Mediterranean that there's all those things where you again, your food comes from clean sources of fruits and vegetables and then good sources.

Protein with some carbs in, like high Fiber carbs like you know brown rice versus white rice like those things will actually help you with hot flashes You know, and if your hot flushes are better, you're probably going to have less brain fog and this is just one aspect of the diet, right so Designing what's possible within the framework of that patient?

Not my framework, not your framework Pat, what is their framework? What is the environment? You know, What can they possibly do? And another big sort of thing that I've noticed over the years in my experience, don't make assumptions.

I had patients who you look at and you're like, they will never follow this. And they're the ones who follow it. Then you have patients, who look super educated and super sophisticated and they understand everything and give you all the right answers, cannot follow one thing.

So really, like, don't make assumptions and not what you think it really diving in. And this is why that framework, it's like a scientific method, right?

You build the hypothesis with them, you co-design the plan, but until you test it, You do not know what's going to happen. And so you test it and it backfires, you go back and re-evaluate.

Obviously we get the right labs, right? Also, meanwhile, and then again, we test that against the changes you made and did you make an improvement? So again as much as people think that AI can practice medicine, I would say that I use a lot of AI for other different things in life, like smoking meat and baking and other things and I love AI, but is the interaction with the patient and it's co-designing things with a patient, and doing all of these multiple aspects of psychosocial stuff in that each patient needs a different solution that fits within their frameworks of life.

How about telehealth? I mean, that's such a blessing for certain conditions and certain situations, but I think if you don't start out by actually seeing the person, it must be keep like playing with one hand tied behind your back as a physician because you're just not seeing full reaction of the woman to your questions and suggestions.

Hard to say, you know, because it's very interesting that, and again, that's what comes from my executive years. You know we lived through COVID and it was fascinating to see that when we, we obviously went on almost full telehealth and then we went back.

So in, in the field of psychiatry and psychology, tele-health patients prefer much more than in-person and in a field like primary care, they flew back to in person.

And so I actually, Trying to understand that puzzle. So I do say that I think that telehealth brings us an ability to reach to patients that we usually would not reach.

And again, going back to those high functional women, they're so busy that they are probably likelier to connect with you on tele-health at the time of their convenience.

than walking into the office and there may be. So anyway, it's a great question. Personally, find it harder to do telehealth, but that's what I'm doing.

And that more for personal reasons because I have kids in five different places and I had to. adjust and realize that I have to be able to practice medicine from anywhere.

Yes. And some of us who are traveling or taking care of children or elderly parents or whatever, the convenience factor of telehealth is enormous for the patient as well.

So it'll be interesting to see how this plays out. I think there's more and more studies about what conditions are best treated with tele-health and what maybe should not be.

I see a lot of people who have primarily telehealth-based practices, and I'm just wondering, how does that work for you? You know, because sometimes you'll pick up something in an office setting that you never would on a telephone or a computer screen.

So that'll be interesting. It's also generational, I think. I have to deal with the reality that our kids and even us would rather be on telehealth at a convenient time for us.

And I guess that's where the trick is then what can you do in addition to seeing the patient, what information you're gathering. to compensate for some of that stuff as well.

So we've talked a lot about changes, changing various things in our lifestyle that may mitigate once we kind of sorted out the probable or potential causes of symptoms.

that a woman may be experiencing and habit formation. And you said you can't just tell somebody, do this, don't do that, stop doing this. Do less of this and I'll see you in a month.

You know, it's not going to work that way. So what have you found, practically speaking, does work with trying to instill a new habit with a women, assuming that she has agreed to it, as you've said, not just us making a pronouncement, but the person buying on to that.

Honestly, it depends on the habit we're trying to form. getting them to commit to what are they capable of doing within their current sort of lifestyle and structure that they have.

So, and again, it's such a hard thing to say because it is so individualized. And again that's why I say AI cannot do that because you're sitting there and you are getting a feel of what's possible.

Again, you may be right or you might be wrong. But again, committing to one thing at a time if possible. And again listen, if you come in and when your diabetes is completely out of control, right, and we're talking about basic stuff, then you may need to commit to two or three things.

But then, you need have a faster follow up to see what was possible, it also depends again when they know their life depends on it. they're more likely to make a change.

So I was talking about the soft change versus like we're going from A1C of 12 to get them somewhere under eight fast because they'll be in a hospital and they feel feeling horrendous, right?

So if they just had a fracture, I guarantee it probably will be easier to take vitamin D and go to physical therapy because, they know that for them to recover and get back to normal.

You know, there will be changes that will made. So, I mean, it's hard to answer, but I would say get them to articulate the change they need, get then to commit to that change and ask them what and how often and get it in writing.

In writing? Yeah, like get in the writing, you know. And also have that ability to say, hey, would like to just email me. Like, email me with your sugars, I want to see this.

I can tell you that. Your blood pressure, yeah. Right. What I mean to be… How much exercise you did this week. Yeah. Yes. The best example I have is like I had gestational diabetes like four times, probably five, but whatever, the time when it was picked up.

And it wasn't, had the doctor that would make me send my blood test. My blood sugar readings every week, and listen, that was an endocrinology fellowship.

And I was already a doctor for 10 years, right? And it made me do stuff and commit to stuff. And then I, the doctor ended up going, working for a pharmaceutical company.

She went back to practice later, Cornell. But, and I with somebody else and they were like, but you know everything, you're an endocrinology fellow. At that time, I think I already was an immunologist.

This was my next pregnancy. You know, everything. Just take care of it. And the difference was drastic. I mean, I still did okay, but I said to myself, That piece of paper at that time was an email to be sent.

I think I was faxing it actually. That was, I guess, we're going looking back at 15 years, right? And I needed that. And everything about this, that I can give lectures on gestational diabetes, you know?

I already had that thing that was my kid number five when it happened. Why am I not asked to send it? Because it took so much more effort for me to control my sugar.

because I wasn't accountable to anybody. And this is why we know in studies that if people live in social circles, that's where people exercise, everybody exercises.

You know, there was a famous study, I think, from Journal of Medicine where, like, they studied obesity and sort of all those different things. So again, tied in whatever change you're making to, how are they making it?

Is there a husband or significant other is going to make it with them? Are they going change their diet for the kids as well? Because you know what, if you do eating all the bad stuff, what are you teaching your kids?

You know, believe me, I've done that. My kids are healthier than me and they're the ones who are teaching me. But kind of flipping that whole framework and say, hey, they don't need simple sugars.

They don' need to drink juice. Do you think you can commit to actually make their health better? Because this is what's going to happen. I have a little anecdote about that accountability and reporting on things.

For on and off during my professional life, I would have And again, that would hold my feet to the fire. You know, if our appointment was on Monday, I'd be like, oh my God, i didn't do any sit-ups and push- ups on Saturday.

I better do them because she's going to know on monday that I didn' do anything. And then on Tuesday or Wednesday, it was so good on Monday, and I'm ready to do more today.

So, I've always suggested to my couples when I would see them for fertility, if they really were starting from zero exercise, get a trainer, you know, a few can afford it for sure.

It'll hold you accountable and you will see more changes that way. So yeah, accountability is big. I think that's a great point and a lot of times honestly I end up seeing people as couples.

And sometimes, because they're both my patients, sometimes it's because I wanted to see what's happening and understand the dynamic. Because most people want to help their significant others.

They really do, but they themselves may not understand what it means. And ultimately, whatever change we are making is good for everybody because honestly, I always say nobody would need doctors if people would eat right and exercise, manage their emotions with the right thing.

And sometimes it's by feedback, sometimes is the breathing exercises. I mean, there's so many things, you know, that people jump to pills, but we know that hypnosis helps with heart flashes.

Does anybody know that? Or things like that. And if you can get that partner either to be accountable together or a friend. So I do think what you mentioned about the exercise and the trainer is huge.

I have subscription to Peloton, to the gym, and until I got myself a trainer, I could not build my muscles. for the same reason. And again, I can give lectures and all of that.

We all know the right thing to do, by the way, when you lecture people, please don't lecture, people because most people know what to. Is that flip between knowing what you do and actually building into the habit is the hardest thing, which is why I think that book atomic habits is a really good book.

Right. The one, yeah. Yeah, but yeah, so it's. Like I'm trying to figure out how to merge some of his concepts and a few other things into what I am practicing.

That'll be the next podcast when I figure that out. And we'll come back and talk about thyroid sometime too. So there's so much to talk. Oh my God. The thyroid is a whole other ball game that's, that probably comes as close to menopause to this sort of how we mismanaged it over time as I guess the healthcare.

To be continued, we'll definitely get you back to give us your experience with that and obviously your expertise, not just your experiences, but anyway.

So Dr. Hannah, this has been just a wonderful time of chatting about a little bit broader concepts than what some of our other podcasts have been. but very, very important things for people to understand about managing their symptoms and managing interactions with their healthcare providers.

So thank you so, so much. It's been great to chat with you. Thank you. And I just, the only thing I want to say is the final words for all the women who'll be watching, or maybe men are watching with their women as well, is this is not the time of decline.

This is a time a flourishing, this the first time in your life, you know, that kids are probably out of the house or getting closer to be out the of house, and you can do things that you've never thought was possible.

So look at this time and realize that they can build your strength. You can feel your condition. It can be so many things around you and thrive and you can be 80 and 90 and be skiing and doing the best things that you've never imagined you could do.

Thank you for that message. That's something we need to keep hearing over and over again. So, my listeners and watchers, if you appreciate this kind of information, please like and subscribe and tell your friends.

It'll help to get this wonderful information out to more people. Thanks and we'll see you again soon. If this episode spoke to you, please share it with a friend ready to take charge of her health.

And please leave a review. It helps more people to find us.

Hanah Polotsky, MD, MBOE

Why Menopause Feels Harder for High-Performing Women