Season 3, Episode 5: Staying healthy through midlife and beyond
Midlife can be exhilarating…and challenging! Key milestones during this time such as menopause bring on physical and emotional changes that affect women’s sense of self and identity. In this episode, we hear from Stacey Shankle, CRNP, who specializes in obstetrics and gynecology at the Midlife Health Center at UPMC Magee-Womens Hospital, about navigating changes in midlife and beyond.
Know the Signs: Both the perimenopausal and the menopausal stages can be extremely hard on the body and mind. Know the signs and symptoms and communicate with your doctor(s) in order to mediate these harsh side effects.
Find Your Support System: Talking to others early can help you understand your body and what’s happening within it. This can include medical professionals, menopause support groups, or family and friends.
The Midlife Health Center at UPMC Magee offers care for women in perimenopause or menopause, with locations in the Pittsburgh area and Erie. Call 412-641-8889 for more information.
Find resources and a provider near you through the North American Menopause Society.
Develop Healthy Habits: As your body changes, your habits may need to adjust to accommodate. Integrating the Mediterranean diet into your life can help to combat many of the menopausal side effects.
Dr. Ellen Beckjord: In this episode, Stacey Shankle, a certified women’s health nurse practitioner who specializes in obstetrics and gynecology at the Midlife Health Center and gyne specialties at UPMC Magee-Womens Hospital, talks about health and health care for women throughout the course of their lives.
Stacey, thanks so much for joining us on Good Health Better World.
Stacey Shankle, CRNP: Thanks for having me, Ellen.
Dr. Ellen Beckjord: Just to start kind of at a foundational level, can you walk us through the main stages or milestones of a woman’s lifetime, especially ones that are relevant to her [reproductive] health?
Stacey Shankle, CRNP: The four main milestones of a woman’s life would be puberty, or menarche, which is the first time a woman gets her period. Then would be childbearing or pregnancy, leading up to perimenopause, and then menopause. So many different stages. But I think we can start at the first one, which is puberty.
Puberty is characterized by when a girl gets her first period.
I feel like puberty and getting your first period … we, as young girls, are almost excited about this because of all of the education that goes on before this actually happens. So [through] your mother or your relatives or sex education in school … you’re kind of prepped to know what to expect. And, so, the average age of menarche is around age 12. And, so, the first period usually starts about two years after the secondary sexual characteristics start developing.
The next thing would probably be you’re having regular periods. Maybe someone would be thinking about contraception at that point. So maybe having that discussion, going to your gyne exams for a regular Pap smear starting at age 21 and then moving into if a woman does want to have children.
Dr. Ellen Beckjord: Yeah, which can also span a long, a long period of time too.
Stacey Shankle, CRNP: Yeah. So, from the time a girl gets her period that does kind of establish fertility. So, as long as a woman is menstruating, there is a chance of pregnancy. So, the average age of menopause is 51 or 52. Just because you’re not getting a regular period, as long as you are getting a period, that chance of pregnancy still exists.
Dr. Ellen Beckjord: Tell me a little bit then, about that period of time, though, when menstruation may become less regular. I mean, what people call perimenopause and, also, you know, curious if you would agree that you started talking about how there’s so much education and awareness and, you know, even cultural significance around that first period, then moving into reproductive health and potentially choosing to have children. After that, does it get a little bit more murky for women? Do you feel like the degree to which women both know what to expect and can access reliable sources of information about what might be happening for them, especially in perimenopause or even into menopause … does it start to kind of get a lot less, I guess, specific, or is there less for women to rely on through those milestones?
Stacey Shankle, CRNP: Yes, definitely. I feel like women are less armed with the knowledge leading into, closer to, menopause than they are during getting or before getting their period. So, in addition to your family …. Judy Blume is telling you about, “You’re going to get your period and it’s going to look like this.”
As an adult, we, or an aging woman, we don’t have sex education at work. We have to rely on our providers. We have to rely on our PCPs, our gynecologist, to give us that information, for us to be educated and knowledgeable about what’s coming up. And there definitely is a lack of that.
It is a very murky period. I love that word that you used. It is very murky. Some women probably feel like they’re swimming through murky water because they just don’t feel like themselves. They feel like they’ve lost a sense of who they are. And I hear that a lot in my practice that, ”I just don’t feel like myself.” And this, so, perimenopause — peri means around — so, it’s the period leading up to menopause. Perimenopause symptoms can happen about four to five years prior to the onset of menopause.
So, like I said earlier, menopause, the average age is 51 or 52. This happens when a woman is one full year without a period. And, so, the years leading up to this one year without a period, or I call these “the rapids.” They’re going to be where a woman notices usually the worst symptoms and where a woman is kind of telling you, ”I don’t feel like myself.”
Dr. Ellen Beckjord: When you say “rapids,” you mean sort of like whitewater rafting type rapids? You know, that the murky water gets pretty choppy at that stage.
Stacey Shankle, CRNP: Yes. Some women feel like they’re going to fall out of the boat. Yes, this actually happened to me whitewater rafting. And it was an awful feeling. I was swimming behind the boat.
So, I mean, I think my number one goal when I practice is, and my number one treatment is, listening. That is all these women want, is they want to walk into an office and they want to feel heard. They want to feel that someone is going to sit and listen to them and not just someone tell them, “Oh, you’re in menopause, it’s normal.” Or, “You’re 42, this is normal. You’re going to have irregular periods.”
We know that it’s normal. We know that this is a normal development of a woman’s reproductive health, just like puberty is a normal development. We expect these changes, but we don’t expect these women to have to suffer through them or feel like they’re alone or fearful because they just don’t know what’s happening to themselves.
Dr. Ellen Beckjord: What an important service that that is then, just to listen and to be a provider in a place where women can come and talk about what’s happening and get some good guidance on how to make that water kind of calm down a little bit and find some smooth sailing.
Stacey Shankle, CRNP: Yes. Yeah.
Dr. Ellen Beckjord: And one last question on the milestones. Do things calm down typically? And at what point would you say, in your observation, like a few years after menopause has officially happened, there’s been a year without menstruation, do things generally level out for women or do some women continue to have struggles that they want attended to during, you know, even the 2, 3, 5, 10 years after menopause?
Stacey Shankle, CRNP: Yes. So, the hot flashes, the night sweats, those tend to get better as time goes on, the farther from menopause you get. The average [period of time] the woman experiences those symptoms is about seven and a half years. But they may never go away for a woman.
So I often have a 75-year-old woman or an 80-year-old woman walk into my office and say, ”I’m still having hot flashes. Is this normal?” And yes, it can be normal. We don’t know why some women, their symptoms last longer than others. Sometimes it can roll down to lifestyle factors. Are you eating a healthy diet? Are you exercising regularly? Obesity. We do know that fat stores estrogen, releases estrogen. So adipose tissue, that can be a part of all this as well.
Dr. Ellen Beckjord: Would it be fair to say that what’s happening for women in perimenopause and menopause is pretty variable? There’s a lot of heterogeneity in the experience, the presentation of symptoms, things like that, which then I can imagine could make some women feel pretty isolated if they’re having experiences that are a little bit farther outside the edge of whatever quote-unquote normal might be. But maybe it’s just that they don’t know enough about other women who are having an experience like theirs. But from the population that you see, you may be able to reassure them. You know, we do see this happen. This is normal for some people and just kind of normalizing that for them.
Stacey Shankle, CRNP: The other part of your question was what was something that may happen to the farther from menopause we get. So yeah, the hot flashes and night sweats tend to get better but there’s something called the genitourinary syndrome of menopause which can cause vaginal dryness. It can cause painful intercourse. It causes a lack of estrogen that causes vaginal tissue to atrophy. This is kind of a big deal for women. But it’s also a very vulnerable subject. So recently, you know, I took care of a woman. She hadn’t had intercourse with her husband for 13 years. The pandemic had brought them together. She said, I’m ready to start having sex again, but I can’t. I physically can’t. Talked her through. So, some treatments for that are topical vaginal estrogen creams, vaginal dilators.
I followed up with her three months later, six months later. She’s now having pleasurable intercourse with her husband and she couldn’t thank me enough. She actually was crying on the phone. So having something, having this resource such as the Midlife Center for Women is so much more than just, I’m helping your menopausal symptoms. We’re helping this woman as a whole. We’re helping her feel better.
In our society, we have so much value on the youth, where our aging population is kind of looked at as not important. This population is just as important as our younger generations. So, it is important for us to put value on these women. It’s the whole second half of our life.
Like, I don’t understand how we can go from birth to age 50 and have so much knowledge about being a woman and then 50 to death … there’s such a lack of a whole half of your life that you just don’t know how to care for yourself properly. That just amazes me.
Dr. Ellen Beckjord: It’s not insignificant. And I appreciate your comment about how not only is it important to value women in the second half of life, but also to value and respect the breadth of experiences that they may be having, whether it’s with respect to their sexual health or their physical health or behavioral health or sense of identity. It’s not like none of those things are in play in the second half of our lives.
Well, let’s talk about the Midlife Center — and you’re an expert in midlife health — tell us what midlife means and some important things to know about this time in our life.
Stacey Shankle, CRNP: The Midlife Center at Magee specializes in gynecological care for women 35 and older that are no longer bearing children. They’ve completed their childbearing, or they just never plan on having a child.
So, essentially, we don’t care for women that are planning on becoming pregnant or are pregnant. And, so, women 35 and older until for their whole life thereafter. Patients can access the Midlife Center through self-scheduling on their own, through Magee’s website. Or you can call central scheduling and also get an appointment with the Midlife Center at Magee.
Dr. Ellen Beckjord: So women don’t need a specific referral to be seen at the Midlife Center. They can opt in and self-schedule calls to get an appointment?
Stacey Shankle, CRNP: Correct.
Dr. Ellen Beckjord: Can you say a little bit about some of the common things that you’re discussing with patients at the Midlife Center, some of the common issues that you’re treating and what’s showing up for women during this midlife phase?
Stacey Shankle, CRNP: The number one thing is hot flashes, night sweats, mood changes. I would say I talk about these three things more than anything else. So, the first thing, like I said, I listen to the patient. How long has this been happening to you? How bothersome is this to you? A lot of women have hot flashes, but they’re able to tolerate it. Is this affecting your work? Is this affecting your home life? And, so, we talk about how bothersome it is. When did it start? And then we talk about treatment. So, after a thorough evaluation, do they have any contraindications?
So, there’s nonhormonal therapy and there’s hormonal therapy. Hormone replacement therapy is the gold standard in treating vasomotor symptoms, such as hot flashes and night sweats. The reason that these symptoms are happening is there is such a fluctuation of estrogen and progesterone during this period of time. During this perimenopausal time, your estrogen levels are decreasing, but it’s not like we can turn on a tap and turn off a tap where it’s all of a sudden off and then we’re done. So they’re hitting their highs.They’re hitting their lows.
And, so, the ovaries are still trying to send this really strong signal to your brain saying, “I want to make a baby still. We’re still going to ovulate. We’re still going to do this. Come on.” And that’s where the hormonal fluctuations just kind of go haywire and produce hot flashes, night sweats, mood changes, joint pain, insomnia. Brain fog — that’s another big one. And, so, I sit down and have a discussion about non-hormonal treatments, such as [whether] we use SSRIs or antidepressants to help vasomotor symptoms.
Another one is called gabapentin, or neurontin, which can help night sweats. So that’s used mostly if women are complaining, you know, “I’m waking up three, four times a night, sometimes more. I feel like I’m swimming in a pool of sweat. My pajamas are drenched.” Some patients sadly have to say they have to keep a change of pajamas next to their beds, bedside table and wake up in the middle of night and change because they’re drenched. Some women are spending thousands of dollars on cooling mattresses and everything just to try to help themselves, which can help. But in the long run, it’s not going to treat their symptoms.
Dr. Ellen Beckjord: Stacy, you’ve done a great job of describing a lot of the physical health symptoms that accompany perimenopause and menopause. But what about mental health and well-being? How are both of those things, both physical and mental health, important to consider?
Stacey Shankle, CRNP: I think the number one thing that we need to remember is that we need to acknowledge mental health wellness the same way that we acknowledge physical wellness in menopause. They go hand in hand, and you can’t have physical wellness without mental health wellness. And, so, just making sure, you know, asking that woman, “How are you?” Listening to her, that’s just as important as treating her hot flashes.
And then we have your lifestyle factors. So a Mediterranean-type diet has really been shown to be helpful for promoting weight loss in menopause. So we know from a general standpoint, if you’re exercising and eating a healthy diet, you’re going to have an overall sense of better well-being. And, so I really talk to my patients about what kind of exercise are you doing, what kind of diet are you doing? And, I mean, we have a lot of these women who are 50-, 60-year-olds that are initially coming to me. You’ve been doing the same thing for 50 years. It may not be the right thing. So let me help you and figure out what you’re doing. But it’s also going to be really difficult to change sometimes.
Dr. Ellen Beckjord: So these are a lot of changes. And there’s, of course, a spectrum of how significant these types of symptoms or changes are for women. But it strikes me that this is significant. Right? And it’s something that’s specific to people who are biologically female go through at a point in their life.
You mentioned this earlier, but I’d love to hear Stacey, more of your thoughts on women’s emotional health as they age, because none of this sounds particularly easy. And then, of course, there’s all of the, I guess, you know, normal age-related changes that can challenge our emotional health as our identity changes, if we’ve had children as their lives change and transition, as we just become older in a society that, as you mentioned, tends to really favor youth.
But what are some important things that women can do or that you think are important for the care delivery system to do to support women’s emotional health as they age?
Stacey Shankle, CRNP: So it goes back to my number-one treatment, in quotes, is listening to the patient. So you hit the nail on the head. These women not only have hormonal fluctuations — which are causing mood changes, causing irritability — they’re at such a different point in their life than they’ve ever been before.
These women are deep in their career or they’re even having career changes. Some of these women are now working from home, which is actually kind of stressful for some women. They’re having aging children.They’re adolescents.They’re teenagers.They’re caring for elderly parents. There’s financial stressors. Or they might have an empty nest, which isn’t always easy either.
So all of these life stressors on top of a biological response to hormonal fluctuations is kind of a double whammy, in the sense that these women feel so anxious.They feel so depressed, and they just don’t feel like themselves.So a lot of women go into talking about their family and talking about their children. And I will literally just look at them and be like, “How are you? How are you?”
How many times do you go to a doctor and they literally just sit down and ask that question, ”How are you doing?” These women want to feel heard.They want to feel supported. And, so I will help them get the resources that they need, such as therapy, cognitive behavioral therapy.The other big piece of mental health is stress relief. So like yoga, meditation, really doing different techniques to help you feel less stressed, which in turn can help decrease the increased cortisol level that comes along with increased stress as well.
Dr. Ellen Beckjord: Do you notice, is it a big shift for some women to make? So, it sounds like first, it’s a big shift for a lot of women that you work with to even be able to focus on themselves and answer that question, How are you doing? Don’t tell me how your kids are doing. Don’t tell me how you’re significant [other]… How are you doing? There’s lots of barriers, I think for most folks to adopt really solid evidence-based self-care regimens. But are there extra barriers, in your view, for women, related to just being willing to take the time and devote their resources to themselves?
Stacey Shankle, CRNP: I think a lot of it comes down to, too, the point of their lives that they’re in. So they’re busy with work.They’re coming home.They’re taking their kids to football or they’re caring for grandchildren. And, so their lives are even busier than they’ve ever been.They are working through their lunch hour because they’re trying to meet deadlines or they’re not drinking enough water because they’re not taking enough breaks because they’re just so busy.
They get home and they’re so fatigued, not just from the hormones, but because they’ve just run themselves dry. Then you just turn on your favorite — you binge your favorite show. You lay down and you order a takeout. So it’s like this vicious cycle of it’s so hard to get out of that busy, busy life.But really just giving these women the tools and the empowerment to arm themselves with and the knowledge that there is light at the end of the tunnel, there [are] people here to support them.There is help. And that’s what I really want my patients to know in the midlife population.
Dr. Ellen Beckjord: It’s so interesting as we talk about this, and I’ll confess that it’s a lightbulb going off for me, which is too, I think in my head, erroneously, I think of menopause as kind of co-occurring with retirement age. But I’m more than a decade off. Right? So you’re pointing out that all of these changes and challenges that accompany perimenopause and menopause are intersecting with a timeline in many women’s lives when they are at their busiest, at the peak of their career, at sort of the, you know, I think of adolescence as the Olympics of parenting. Right? Not that, not that there aren’t challenges before and after that, but it certainly isn’t known for a time in parenting where you can really phone it in or put it on cruise control.
And, so all of these significant things happening in a woman’s life at the age of 51 or 52 are when she crashes into all of these hormonal changes. And so it’s occurring at a really challenging time when women certainly may not need one more thing to manage. But here it is, they’ve got to figure out how to manage this. So it’s wonderful to know about the kinds of help that are available to support women going through this.
Here is a tangential question: Is it true that more women are using IUDs [intrauterine devices] now, like, say, in the past decade than for a few decades before?
Stacey Shankle, CRNP: As far as numbers, I think there’s just more, there’s more awareness about an IUD. We have more research behind it now. IUDs are a great form of birth control. And it’s funny that you bring that up because we actually use IUDs a lot and perimenopause leading into menopause. One of the biggest symptoms that I actually didn’t talk about is irregular menstruation.
And, so, usually women will have irregular periods leading up to when they’re one full year without a period. Their periods usually become heavier or more painful. Or they’re the opposite — some women say they’re lighter and shorter than they’ve ever been. And, so, to help, after we’ve ruled out that there’s no concern of why they’re having abnormal bleeding, we will use an IUD. Most women go on not to have a period at all with a Mirena IUD, or it’s very, very light. And it’s cool because a Mirena is good for eight years. So usually these women are coming to me between the ages of 40 to 45 or even thereafter. I’m like, “Let’s put an IUD on and this is good for eight years. It might get you to menopause.”
Dr. Ellen Beckjord: It’s interesting to think about how IUDs can play a role in addressing irregular menstruation as a symptom of perimenopause. But since so many women with a Mirena, maybe it’s Mirena specifically, go on to not have a period while the IUD is placed, how do women then know when they encounter menopause? Is that becoming an issue that women are grappling with if they’re using an IUD, through that phase for any number of reasons, then how does a woman know when she’s in menopause?
Stacey Shankle, CRNP: That’s a very good point. So, most women go on not to have a period at all. You can check hormones at that point. So, as I said, there are some reasons that it is medically OK and would give us more info than not to check it during that time.
I think the other big thing to look for too, is just the whole clinical presentation of menopause. So, are you having hot flashes? Are you having abdominal weight gain? Are you having fatigue? Are you feeling different than you have in years before? And, I think, that’s another thing that we just need to make sure women, if you don’t feel well and you have questions about it, don’t hesitate to go to your gynecologist and ask questions. Is this normal? And that definitely could be appropriate at that time.
Dr. Ellen Beckjord: Stacey, you’ve done a wonderful job of really illuminating a lot of challenging circumstances and experiences that women can encounter in midlife. But I’d also like to ask what you’re most hopeful about in the context of the future of women’s health in midlife. Specifically, what are you excited about and what are you hopeful about?
Stacey Shankle, CRNP: I think as a health care industry, per se, we are moving more towards wellness. And, so, I’m really hopeful that women will feel confident and be knowledgeable about their life in the midlife. We are always changing. So, from puberty to menopause and thereafter, we’re always changing. We’re all always developing.
And, so, I think we need to get better at incorporating this information into training programs, into even PCP … like preventative care. “Hey, are you having menopausal symptoms?”— and just starting the discussion maybe in a woman’s 40s and a woman’s 30s, so she knows what to look for.
And then just, I think too, just tailoring research more towards menopausal women, and this. So, for instance, one of the big fads now is hormone testing. And I get this question at least once or twice a day. Should we check my hormones? And the answer is no. Are there medical reasons to check your hormones? Certainly. But from a general standpoint, reproductive hormones are not gender specific. They are not age specific. And we don’t have a target range to treat to. So, such as your thyroid hormone, we know exactly through research where this should be for an optimal level. We have medication that can treat you to exactly where you need to be.
From a reproductive hormone standpoint for estrogen, we just don’t have a number that is optimal. And, so, in our office, when we do start hormone replacement therapy, there is no need to do hormone testing. We do not need lab numbers to gauge your hormone therapy. What we do is we gauge, is this working for you? How do you feel? Are you still having hot flashes? If you are, we can increase the dose. If you feel good on that dose, let’s just stay there. And, so, I think, you know, as a society just putting more real information out there that women will have and educate through their primary care, through their general [gynecologist], starting way back to educating providers and doctors better in their training. And I’m hopeful for that.
Dr. Ellen Beckjord: Do you think that’s a message that women need to be reminded of, that it’s OK to ask questions and to speak up if they’re just feeling not like themselves or things are starting to change, that you would encourage them to bring that up and ask their health care providers about whatever it is they’re feeling?
Stacey Shankle, CRNP: 110 percent. I think it goes back to, I think sometimes, we … the questions are so vulnerable and it can be somewhat embarrassing. But I think women, I love when my patients come in. I want my patients to ask me questions, because I know that those questions are what means most to them instead of me just gauging the conversation. And, so, yes, asking questions about even if it’s something so little that you don’t think is a problem, ask it. Not only, you’re getting more information to care for yourself better, and that’s what it’s all about.
Dr. Ellen Beckjord: Well, Stacey, I want to thank you so much for being a guest on the podcast, but I also really want to thank you for everything we talked about today and for the work that you’re doing at the Midlife Health Center at UPMC Magee-Womens Hospital. What an important role that clinic is playing in the services you all provide for women in midlife and beyond.Thank you so much.
Stacey Shankle, CRNP: Thank you for having me. It was a pleasure.
Dr. Ellen Beckjord: UPMC Health Plan offers information and resources to help women enjoy the best health possible. Learn how we support women at every age and at every stage of life by visiting postindustrial.com/goodhealth.
Dr. Ellen Beckjord, MPH, is host of the Good Health, Better World podcast.
Ellen is a behavioral scientist, epidemiologist, and licensed clinical psychologist working at the intersection of population and digital health. A long-time member of the Society of Behavioral Medicine, Ellen currently serves on the board of directors as president-elect.
Her work focuses on promoting health, wellness, and health behavior change. She is vice president of population health and clinical optimization for UPMC Health Plan based in Pittsburgh.
Ellen trained at the University of Vermont, where she worked with cancer survivors and their families, at Vanderbilt University, and at the Johns Hopkins Bloomberg School of Public Health.
She completed post-doctoral research at the National Cancer Institute in the Health Communication and Informatics Research Branch within the Division of Cancer Control and Population Sciences. She spent nearly five years in academic medicine at the University of Pittsburgh and Hillman Cancer Center.
Ellen also is the co-author of “Porchtraits” in which she interviewed people in Pittsburgh during the early months of the COVID-19 pandemic about what they were learning, missing, enjoying, what surprised them, and what they felt hopeful about.
Ellen’s guiding principle: “Lead with love.”
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