Menopause, Minus the Mystery: What Every Clinician Should Know

Transcript

Lauren Brown-Berchtold: Hello and welcome to CME on the Go, the podcast specifically crafted for family physicians by family physicians. Whether you're seeking clinical insights, professional development, or simply a sense of camaraderie, you'll find it all here. Plus, you can earn CME credit with every listen. So, grab a coffee—maybe your ninth espresso, like me today—hit play and let's embark on this journey together.

I'm Lauren Brown-Berchtold, and I'm the program director for the Valley Consortium of Medical Education in Modesto, California. And even though this is premiering in early September, I gotta say, from our recording date, happy Taylor Swift 12 for all those who celebrate.

Let me throw it over to my co-host to introduce themselves.

Jason Marker: I don't drink much caffeine, but I'm just gonna channel my inner Lauren Brown-Berchtold, who's had nine espressos today, and say, Hi, I'm Dr. Martin, and I'm an associate program director at the residency program at Memorial Hospital in South Bend, Indiana. I'm so excited to be here with you today.

Tamaan Osbourne-Roberts: Well, I, gotta say I’m feeling all outta sorts here with my mango-acai-lime smoothie. I'm gonna go a a little more relaxed here. Yeah. So I’m Tamaan Osbourne-Roberts, a federally qualified health center family physician from Denver, Colorado, who works primarily with underserved Spanish-speaking patients and is also boarded in lifestyle and obesity medicine.

I'm also an occasional medical executive and policymaker, an early career scholar of happiness studies and a professional science communicator and professional comedian.

LBB: I hope the comedian skills get pulled out today, but really I need you to channel more T-Swizzle love so I can get more of those jokes into these podcasts.

TOR: I shall make that change swiftly.

Starting with an in-training exam question

LBB: So, it's not totally impossible that my caffeine intake of the day was triggered by anxiety because I knew I was gonna open us with an ITE question. So I probably should have had, like a, a warning before I said that. But this is your warning: ITE question incoming.

JM: All right, give it to us.

LBB: You see a 50-year-old female for a health maintenance exam. She's the primary caregiver for her father, who has dementia, and she heard that Alzheimer's disease is genetic and asks if there's anything she can do to reduce her risk. She is in perimenopause and experiences hot flashes. She recently started a kickboxing class and drinks one to two beers per week. On exam, her vital signs include a blood pressure of 138/80, a pulse of 63 and a BMI of 30. Which of the following should you recommend to decrease this patient's risk for dementia?

A.    A memory training app on her smartphone.

B.    Abstaining from alcohol.

C.    Testing for biomarkers associated with Alzheimer's disease.

D.    A target systolic blood pressure of less than one 30.

E.    Hormone therapy with estrogen and progesterone.

I could talk about how I feel, but I think it's obvious. Tamaan, what do you think about when you hear this question?

TOR: Well, first of all, since you're asking me to comment, my first thought is I thought we were friends, Lauren. I thought we liked each other. I'm the uncaffeinated one here.

LBB: I know. It’s tough love.

TOR: I'll say that, uh, it was probably the appropriate kind of a thought, and it it wasn't that way until you kind of read through E. I mean, so, if you look at the evidence for all of these, what you end up seeing is that memory training apps and studies are not showing a benefit for decreasing risk for dementia. And interestingly enough, complete abstinence from alcohol does not necessarily show a decrease in risk for dementia. It actually shows an increased risk, by the studies we have, as does overconsumption. It appears a sweet spot right now might be somewhere in the center.

Now, that's not to talk about the overall harms of alcohol. That's an entirely different question, and one perhaps we'll discuss in another episode. There's mounting evidence for overall harms. But, in regards to dementia only, so our listeners don't write in any yell at me, somewhere in the center appears to be where that is for dementia specifically.

And testing for biomarkers associated with Alzheimer's disease, I think most of our listeners know, is generally not indicated, in terms of assessing risk.

And then we come to the other two, uh, targets: systolic blood pressure less than 130 millimeters of mercury. That is the correct answer, if you will. That is the thing that has been shown to decrease risk for dementia.

Destigmatizing hormone therapy

But then we get to this sticky kind of thing about hormone therapy with combined estrogen and progesterone. And what we know is that for women in their forties and fifties, hormone therapy with estrogen only has demonstrated a significant decrease in dementia, while the combined estrogen plus progesterone therapy has demonstrated a nonsignificant decrease. So that answer's not correct because the answer would be unopposed estrogen therapy, but that has its own concerns and risks that we're going to talk about later.

This is sticky to some degree because of all the controversy occurring since the year 2002, before I entered med school, around the Women's Health Initiative, the seminal study, very large, approximately a hundred thousand participants on Women's Health run by NIH, and more importantly, some of the conclusions at that time indicating harm from combined and unopposed hormone therapy. That finding was statistically nuanced. It was reported widely in the medical and non-medical media in ways that were not statistically nuanced and had a real effect on generations of physicians, including myself, in terms of our utter reluctance to consider hormone therapy in any possible circumstance.

Over time, as that finding has been analyzed and picked apart and has gone through this process that we call science, where there is a repeated scrutiny in, in discussion and interpretation of what we're seeing in pure numbers, we've reached a point where it really looks like there are appropriate indications for hormone therapy, inappropriate indications for hormone therapy, and nuances in terms of the type of hormone therapy and the potential benefits. Unfortunately, as oftentimes happens with signs, when something gets stuck in the media, it's a little hard to undo, and I kind of feel like that's why we're here today.

LBB: I completely agree. The idea of menopause minus the mystery, for me, does really center around the hormone replacement therapy idea and the holdout of what came out of the Women's Health Initiative. I got nervous even throwing this question into the run of show today because I knew that someone somewhere was going to get upset about it, but it's such an important topic, I had to take those personal feelings aside. Like I tell my residents: “You can be mad at me. I can take it. I'm strong enough for it.” And so for our listeners, same thing. I can take the professional disagreement, but this is a really important topic. And if we think about it from the numbers, just looking at all women—and, as we've said on previous podcasts, we're talking about women who were assigned female at birth—when we look at all women as a cohort, more than 25% based on just age alone are likely to be postmenopausal. So this is a huge percentage of our patients who might be coming in with concerns that they may or may not be voicing about postmenopausal state. And if they don't have questions, should we have questions and recommendations for them?

Defining menopause

LBB: So, first thing, what is menopause? This is the ovaries running out of reserve and we are changing how our hormones are running in our body. Natural menopause, quote unquote, is this process that happens to all women between the ages of about 45 to 55, with a median age of around 52, and it lasts for years. It can last for five to eight years, several years after you have gone through actual menopause, which is a clinical definition. And so, we'll talk a little bit about the role of testing later, but the actual definition of menopause being you haven't had a period for 12 months, and so those basic terms can be maybe confused, can maybe be confused by our patients. It's really important for us to be knowing that this is a natural physiologic occurrence and it can be uncomfortable, right?

And so with those basic terms kind of down and those basic timelines, I, want to go back to that it question above. It has a line that says the patient is in perimenopause and experiences hot flashes.

Jason, I was writing out this run of show and I was like, man, if I had a nickel for every time I heard that, and then I thought more about the end of that statement and I was like, well, I'd probably have like 50 to a hundred nickels. It's not as exciting as I thought. But can you walk us through what women might experience as some of the symptoms when they are peri or postmenopausal?

Symptoms of menopause

JM: Yes, I can happily do that and, and I would have more nickels than you, but it's a lot. This is a very frequent topic of conversation for family doctors who are taking care of women in midlife, so let's dig into what those symptoms are. Let's talk about sort of the typical things for that woman who's between 51 and 54, like, in that median age.

Whereas more common to have more of the symptoms. So hot flashes, yes, absolutely hot flashes and night sweats. We don't have to dig into what that really means; people understand what that means. Those can cause sleep-disorder problems in their own right, but also sleep problems are just a part of menopause, even absent of whether they're caused by hot flashes and night sweats.

Vaginal dryness is not too uncommon. Irregular periods, of course, are happening during that moment until there's been a year of no periods, which is really the definition of menopause. And other physical symptoms like breast tenderness, headaches, sometimes joint pains, changes in the skin and hair.

There's a whole cluster of emotional and mental health problems that need to be considered as well. Mood changes including irritability, anxiety, feelings of depression, a brain fog. Someone will describe fatigue, feeling unusually tired or lacking energy. And then some urinary symptoms, often some increases in frequency or urgency, decreases in libido often and chain fluctuations in the weight of a person.

All of these can be either very common to nonexistent. It really is a bell-shaped curve. I think there are some women who, even in their late thirties and early forties, will begin to occasionally miss a period, have an occasional night sweat, and start to have a few of these things, and the intensity of those seems to accelerate as they get into their early fifties.

So that's really what we're talking about as far as these symptoms of menopause.

TOR: Yeah. You know, when I'm talking with patients, one of the things that comes up oftentimes is that they're oftentimes saying, “Well, Doc, can you go ahead and test me for menopause?” I will say that I'm actually probably on the less common approach to this, inasmuch as, you know, given the patients I'm working with, I do actually have a tendency to order a quick FSH to look to see whether or not it appears menopause is happening, has happened, is in full swing—really, where they are in the process.

That having been said, I think it’s actually very important when working with patients, whether you're ordering testing or not, to let patients know and help them understand that this is a normal physiological part of aging. And the same way we at this point have learned not to pathologize aging as a whole, it's important not to pathologize menopause. Now, that's not to say it's comfortable. There are plenty of things you don't like about aging in many different contexts and things you would rather change, but to help people understand this is not a disease per se. This is a change that your body is going to go through, many other bodies have gone through, and you know that it's important to think about maybe managing some symptoms, but not treating this like it's something that needs to be cured. Really helping them to manage it.

Understanding menopause: The distress is real

LBB: Yeah, totally. It's this interesting tightrope to walk of, this is normal and how do I not minimize the distress or discomfort that the patient in front of me might experience?

It was really interesting, and you guys might have seen this as well, there was discussion around a recent AFP editorial that came out in July of 2025. And the reason that I saw it was not because I'm great at reading my AFP journal. It’s because I was on Facebook. I had a resident who came to me and said, “Did you see this pop up on Reddit?” And the AFP article that we'll put in the show notes ended with the statement “Menopause is a positive life experience for many women.” And all I gotta say is, I saw people go nuclear on social media. My resident was really confused. I was really confused. I mean, I, guess I could believe it, but I have never heard of that.

Jason, I know you and I were talking a lot about distressing symptoms with this.

JM: Yeah, I mean, I think that everyone's experience will be her own. Every person with a uterus's experience will be their own when it comes to what their relationship with their menopause is going to be. I've obviously never personally experienced any symptoms of menopause, but the distress is real for many women, and they would like to partner with us to talk about how they could ameliorate the most troublesome of the symptoms that they are having. And they often also don't want to overmedicate it for any longer than they have to, which is part of the messaging from the Women's Health Initiative.

So we're in a perfect spot as family doctors to partner with these patients to find what is the sweet spot we are trying to strive for in this doctor-patient relationship for how we choose to manage this normal physiologic thing, which may have positive but certainly has also negative elements for many of the people who are going through it

Like you, Tamaan, I pause before I order lab testing for these patients because what is the purpose for me ordering those? Is it because they have a family history or a personal history of some breast cancer? And I really need to know whether they're in menopause or not. Like, why am I doing this? And we do need to be aware of how to do that. But I make the supposition here that it's not something I'm going to be doing on most of the people in my practice who need me to do that, who are talking to me about doing that, rather.

So, yes, the lab testing: An elevated FSH usually over 30 or 35, depending on your lab, along with a low estrogen level, is usually indicative of a person who is in menopause and who's bleeding heretofore could be considered up for evaluation for postmenopausal bleeding, an important workup that we need to sort out from premenopausal or perimenopausal bleeding.

Different workups there for sure. And then you can get into, you know, whether you need to do other testing with LH levels or anti-mullerian hormone levels or testosterone levels, which sometimes can be on menopause panels that may be available in your community. Also, checking things like a thyroid-stimulating hormone, because many of the symptoms of menopause can overlap with the symptoms we might expect with thyroid conditions as well.

So anyway, I think you're right. We don't wanna over-medicalize this. We also want to take it very, very seriously and partner with them to decide who is the smartest candidate who needs some labs, and how do we want to move on into the treatment phase for them for the symptoms they'd like us to treat.

TOR: Yeah, no, it's, it's a really great point, Jason, that we really have to be very, very careful with all of the testing around this. Not simply the testing around menopause, but, you know, around related conditions related to dysfunctional uterine bleeding and other sorts of potential associated symptoms.

One of the conditions that comes up for me, and something that oftentimes looks like menopause but is in and of itself, if you will, the only pathologized version of it is premature ovarian insufficiency. And that really can be described simply as menopause occurring before age 40, which is typically considered an early timeframe for that. It's distinct from menopause, obviously, because unlike menopause, which is a normal change of aging that's expected to be seen, this is not expected to be seen. It has all of the short-term difficulties that we see with menopause, from hot flashes to hair loss to depression to a range of the other sorts of associated and comorbid sorts of symptoms and conditions we see. But then it actually increases the risk for normal risk we would associate with aging and menopause as well: increased risk of osteoporosis, increased risk of cardiovascular conditions, increased risk for cognitive decline and dementia, these sorts of things. So it's actually very important to treat premature ovarian insufficiency, typically by hormone use, to really avoid increased risk for all of the short-term and, especially, long-term conditions.

Hormone-replacement therapy (HRT)

LBB: That is a great segue into talking about hormone replacement therapy, or HRT, and what we're going be talking about right now is HRT for patients who are going through this quote unquote idea of natural menopause or the planned menopausal transition between the age of 45 to 55, as normally expected, rather than primary ovarian insufficiency.

And so kind of going back to level-set a little bit about what we talked about at the very top of the episode with you, Tamaan, the elephant in the room is interpreting the Women's Health Initiative from the 2000s. And so there have been so many really great reviews of this controversy. We're not going to replicate. We'll just drop those reviews into the show notes. But, like you said, that early data that did not have the nuances really parsed out about where we see harms and benefits and in what groups and with which medications. That’s where the media picked up and ran pretty sensationally saying, in essence, hormone replacement therapy is going to kill everyone.

And so for generations of physicians—you said that you were included in that, Tamaan; I was included in that as well— I remember the classes in medical school saying, Don't prescribe hormones based on this data. And the biggest concerns were really about the prevalence of coronary heart disease and breast cancer prevalence and death. And that was where the backlash really came from.

With that said, let's talk about how we should have a modern interpretation of the Women's Health Initiative. What we know is that it takes an average of five to 10 years for new data and thoughts within the medical community to get into everyday practice. So let's contribute to that and contribute to a modern understanding of the safety that we have with hormones. Jason, can you talk us through that?

JM: Well, you know, I'm just an old country doctor, and let me just tell you the way I kind of approach this with the majority of my patients, and then I'll maybe dig into a little bit more nuanced approach to that.

What I'll often say to a woman who's having bothersome vasomotor symptoms of menopause is, “Let me make sure I understand your personal risk factors for cardiovascular disease, your family history around breast cancer, and some things that we've already talked about in this episode.” And then if I do not find some very clear contraindication, I say to her, “There are many things, hormones and non-hormonal strategies, for trying to ameliorate these symptoms for you, but a season of your life spent on some hormone replacement chosen wisely at the right dose for a period of time should be very safe for you, will be the best way to get rid of these symptoms, certainly the clearest way to really tackle what's at the root of the symptoms that you’re having. And if we do that for a few years and then have a few trials off of it, to see how you do, that is a very safe approach to managing the vasomotor symptoms.”

Now, that usually is enough to generate a little back-and-forth conversation, depending on what she may or may not have read about the Women's Health Initiative. And then we can get into some more nuanced conversation if we need to, so we can talk about combined hormone replacement therapy versus estrogen alone—the potential benefits of estrogen alone therapy and the potential risks of combined. The fact that starting it at a time of menopause is probably a little safer than waiting years down the road, that we need an individualized approach, but that bioidentical hormone replacement is not necessarily better than regular standard synthetic replacement therapy. That we should limit the duration to a period of time and be willing to assess how she does without that after periods of time to see whether longer term duration is needed or not, and that throughout the period of time that this person is on hormone replacement therapy, we should have regular visits so that we could have some shared decision making about the ongoing and longer-term use of those medicines.

TOR: Yeah, and in thinking about HRT, another thing that we have to think about, obviously, are contraindications. The upside to this is that contraindications tend to be pretty straightforward and similar to contraindications for when we prescribe these sorts of hormones for a variety of other conditions, whether that be gender-affirming care, typical use of oral contraceptives or other sorts of things.

They include cardiovascular disease or a history thereof, a history of DVT or other types of venous thromboembolic disorders or events including inherited coagulopathies, active liver disease, estrogen-sensitive cancers, obviously unexplained vaginal bleeding.

And an important one to consider that we don't always consider is actually pregnancy. A lot of the time we kind of consider, well, menopause, OK, they can't get pregnant. Actually, there's substantial risk for people becoming pregnant during the menopause process because of dysregulated ovarian release. This actually happened to one of my faculty members when I was a resident.

LBB: Oh, my God.

TOR: You know, she had a menopause oops baby, if you will, and was happy to welcome that person into their life. But it was definitely an adjustment because she was not planning on becoming pregnant at that time in her life.

Beyond that, having a patient-centered conversation around risk and benefits, in my opinion, is the biggest determining factor for starting. Patients should really understand: Here are the benefits you can expect, both short and long term. Here are the risks you can expect, both short and long term. Is this mixture good for you? And if it is, then this is something you can consider. Formulations for prescribing. There are a lot. Much as we've discussed. As with oral contraceptives, there are more than we can even begin to think about listing here.

However, there's a great AFP article from 2023. We'll drop it into the show notes. It has charts, it has flow sheets, it has dosing recommendations. It makes hundreds of wonderful fries. Okay, maybe not the last thing. But the long and short is that it's a wonderful resource to be able to use for this.

That all having been said if you've decided to use systemic hormone replacement therapy because of vasomotor symptoms specifically, and just kind of need to have like that one thing in your back pocket, it's reasonable to consider oral estrus or Premarin. Those are very commonly used formulations and are very well known and well tolerated.

And of course, you'll need to make sure to add Prometrium if the patient still has a uterus to prevent end risk for endometrial cancer.

LBB: Yeah, I think everything that you guys just said, I really hope our listeners pause, think through the things that we just said. Relisten if you want, because the end takeaway of the nuanced look at the Women's Health Initiative is: No, there does not appear to be any increased risk of all-cause mortality or cardiovascular disease. And the one thing that was found is in women with a uterus, yes, there is a slight increased risk of breast cancer, but there's not an increased risk of death from breast cancer. And the benefits are that this is really going to be the most effective way to treat our vasomotor symptoms and potentially some of the other less common things that are being experienced by women going through menopause.

And like you said, estrus and Premarin, along with Prometrium, if you do have a uterus, it's easy to reach into your back pocket for those things. There are so many other formulations and if you want to use other formulations, certainly do it, but I would definitely recommend pulling up that article and having those doses and those names listed, because it's going to be so much easier.

But that's the baseline of hormone replacement therapy: estrogen plus progesterone in some format. Now, with that said, if you have a patient who's coming to you and saying, “Hey, I actually don't have a lot of vasomotor symptoms. I don't have hot flashes, I don't have night sweats, I'm having genital urinary symptoms, and that's my main concern,” that's where you're going to say, “I probably don't need to be offering systemic hormone-replacement therapy.” And that goes into that conversation with the patient about shared decision making and what are the goals of treatment. Instead, what you can reach for is just over-the-counter lubricants or, if you do need some amount of hormone, you can consider topical Premarin, which is going to be really well tolerated in the vast majority of patients.

Non-hormonal options

LBB: If we could transition though from hormone replacement therapy because we might still have either some doubters who are listening to us, or some patients who, when you do your risk assessment, are unable to take systemic hormones, we have a lot of non-hormonal options for vasomotor symptoms as well.

Those are classically going to be gabapentin, SNRIs and SSRIs and clonidine. And I will be honest: I used to be all about the non-hormonal options and would generally say, sure, I'll do HRT if we fail these. And I think that that approach that I had for several years was really, again, because of some of the indoctrination that I got around the Women's Health Initiative and the story that hormones are bad for patients and dangerous.

And so now I've flipped it. I am in the appropriately chosen patient reaching for hormone replacement therapy at the lowest dose for the shortest period of time. Llike you said, Jason. And then if I can't use that, I'm going to use my non-hormonal treatments. I will sometimes have patients who are really struggling to get off of hormones after they've been on for several years, from a replacement perspective, and that might be where I start bridging with some of these non-hormonal treatments to say, “Hey, I, I can't leave you on systemic replacement for forever, but let's see if we can manage some of these really distressing vasomotor symptoms with other medications.”

When I think through, and I'd love to know your guys' perspectives, when I think through which of those medication classes I'm normally going to be wanting to use, clonidine is an old medication, right? If we're not taking it, we can have issues with rebound hypertension. I can't think of the last 50-year-old female that didn't have high blood pressure.

And so I'm generally not going to be reaching for clonidine unless I actually have to. Many people have coexisting issues with depression, anxiety, and so maybe I'm going to initiate an SSRI or SNRI that I could also be treating that psychiatric condition with. And then gabapentin. Man, I have such a ove affair with gabapentin. It can go from such low to such high dosing. It can be dosed at nighttime or multiple times during the day and can be used for all sorts of other, other issues, most prominently neuropathy. And so I use that pretty frequently.

Do you guys have favorites that you're using for non-hormonal menopausal treatment?

JM: I don't think I have anything to say that's not much different than what you did. I usually reach for the SSRIs and SNRIs first, and then back my way into Gabapentin. Just sometimes there's enough baggage with gabapentin and its potential addictive properties that I just want to hold back there a little bit further. And I've gotten a lot of good use out of the SSRIs and SNRIs.

What about you, Tamaan?

TOR: Really, very much the same. I typically start with an SSRI, just well known, well tolerated in patients, understand them from other contexts and can be actually really helpful in treating some of the more mood-related symptoms that we see in menopause as well. I agree with you that if SSRIs aren't working, oftentimes moving to SNRIs, which I lovingly call snories, is kind of my typical second line, and really oftentimes with one or the other of those, patients do receive some relief.

JM: What I think is interesting is we, I think, are smarter now about how we use the hormone-replacement therapy and naturally great. And then we have two other general sort of categories of medicines. One is medicines that have been around for a long time that had other uses that just happen to also be useful for menopausal symptoms. And whether that's these SSRIs or SNRIs or whatever, whether it's herbal products like black cohosh or soy-based extracts, like, those are things that have been around. But what's nice is there's getting to be some research now about medicine classes that are specifically designed to manage menopausal symptoms that have that as their primary indication.

So Veozah, oh gosh, that is hard to say, or fezolinetant is sort of the one that's been emerging over the last couple of years. It disrupts the thermoregulatory response to estrogen deficiency, so it works in the brain to change some things that we know are triggers for vasomotor symptoms. So this is a product that comes to us with a primary indication for menopausal symptoms, not something that we've had around and happen to use for that. I think there'll be more of those as our baby boomer friends get into those older years where they're still managing these menopausal symptoms.

And I would say that there's a few more of these that are outlined in that excellent 2023 article about menopausal symptoms and how we manage those in AFP by our three colleagues Jennifer Chang, Meghan Lewis and Maggie Wertz, it's a great article if you want to go back to July 2023. I mean, figure one, it's worth the price of admission all by itself. It's a very great table and it's a whole wonderful article. I'd encourage our listeners to go look at that. It's linked in the show notes about the approach to the menopausal patient, and even though it's a couple of years old, it's got a lot of information about the very latest stuff in there and I'd encourage you to go check it out.

And the last point that I'll bring up is about other hormonal treatments that aren't hormone replacement therapy in the typical sense. I'm thinking primarily about topical testosterone, which can be very effective for managing some of the sexual dysfunction of the menopausal person.

TOR: Yeah. This is also actually a really fantastic time to help women think about non-pharmacological interventions, which generally are not most people's initial thought around a lot of these. But really there's, there's a number of things that can help. You know, menopause is a condition that causes really a cluster of symptoms. The individual symptoms will respond to lifestyle medicine sorts of treatments. For instance, when thinking about depression, talking about getting out into nature as well as the importance of regular exercise and thinking about brain-healthy foods that are all really important sorts of things to do. Thinking about the increased risk for cardiovascular and other sorts of diseases. Going once again into very typical things we discuss around lowering cardiovascular risk are very, very important.

And also considering whether or not there's some comorbid sorts of things that could be menopause, could not be. Hair loss is a very classic one. This is something a lot of my patients come in with, have a lot of distress, and as much as I think it might be menopause, I think it's oftentimes good, as we've discussed previously, to maybe pull an iron study or check a TSH if there are other symptoms to kind of suggest those sorts of things. And if there are, well, treat them.

Closing: pearls and gratitude

LBB: I don't know about y'all, but I've had a lot of fun in this conversation. I hope our listeners feel like this has been time really well spent. I  don't think we talk about it a lot, but we read all of y'all's comments and see what episodes you're listening to, what episodes maybe are less interesting to y'all, and what we hear from you is that you are wanting details that you can be taking into the exam room and medication recommendations and potentially even dosing in some circumstances that you can then be putting into your EMR. And so we're paying attention to those things, and I think that, in my opinion, this was a conversation that accomplished those requests and goals.

I want to close us with pearls and then go into our gratitude and overall closure.

Top pearl: Menopause is a natural stage of life and it doesn't need to be pathologized or medicalized, but we do also need to believe our patients. If and when they are miserable, we gotta keep coming back to the evidence and educating patients and then, depending on the symptoms that our patients are complaining about, and as long as they are the appropriately selected patient who is not dealing with other contraindications to hormone therapy, don't be afraid of systemic hormone replacement therapy.

Finally, know that there are non-systemic and then non-hormonal options for our patients.

Last thing that I want to say: We've talked a lot about the AFP and we have great articles, but if you are interested in learning more, there is this interesting group called the Menopause Society that has been just exploding over the last couple of years, and it even offers testing and certification in menopausal treatment if that is something that you're looking for or that your patient population might be looking for. So check that out if you're interested.

Let's go into our gratitude for the day. Tamaan, I'm going to ask you to kick it off.

TOR: You know, I'll be a little less flippant this week. My gratitude is there for the many, many different treatments that we have to help patients with this. I know people who have been through menopause, currently in menopause and are going to go through menopause in the future, and the fact that we have ways to help them is really gratifying.

JM: Yeah, I think I'll riff off of that and say I'm really thankful and have a lot of gratitude for the health care scientists among us. I think some of them are feeling a little battered and bruised these days, but we seem to be zeroing in on a way to manage a problem that is really meaningful in what we can do to help our patients.

And we do a lot of work as family doctors. That's delayed gratification. Like, I'm gonna treat you for 30 years and hope you don't have a heart attack. From the work that I do, treating menopause is a way to really bring some immediate gratification to your patient and to our work as family doctors. I'm pleased that we have the science now to show us how to do that well.

LBB: I am grateful for the fact that we are talking about things that have been either taboo or stigmatized in our society, menopause being one of those things. And I think that that is an amazing evolution. I'm obviously also grateful for the anticipatory release of TS 12 and the joy that that brings both me and friends, some of whom are dealing with vasomotor symptoms of menopause and need something to be joyful about.

And so with that, that is all the time we have today. Thank you for joining us for another episode. We appreciate you joining us on the journey to elevate family medicine and to continue this journey. Stay tuned for new content brought to you twice a month with CME on the Go. Visit the show notes for instructions on how to claim CME credit and find additional resources for today's episode.

Until next time, serve from your values, pursue your vision and go listen to something that's Taylor Swift streaming. See you next time at CME on the Go, a production of Inside family Medicine.