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It is that time of life, midlife, menopause, and you aren't sleeping so well. Is melatonin the answer?

Menopause and midlife aging happen at about the same time for most women, but they aren't exactly the same. Menopause is when periods stop because there are not any more eggs to ovulate in the ovary. It's the last period, and it happens at about 50 years of age in most women. Midlife is a little harder to define, but it is that middle of your life from about 40 to 70, after you are young, but before you get old. Maybe it's really from 30 to 60. It depends on where you are as to what range you will embrace. I embrace the 40 to 70, but 30 to 60 is probably better.

We are about as strong and as smart, and I'm not saying wise, as we're ever going to be in normal biologic function at about 30. After that, we begin to age with decreasing muscle mass, bone density, and cognitive speed.

We are usually really great sleepers until midlife. Of course, there are some kids who are naturally short sleepers, and there are those people whose sleep rhythms don't let them really fit into their daily lives. They're night people, but they have to get to work at 7:30 in the morning, so their sleep is disrupted. There are the years of infants and young children that wake us up at night. There are years of jobs that shift hours. But left to our own devices, we are often pretty good sleepers until the middle of our lives.

It's a combination of anxiety, all things for which you're responsible, adolescents in their 20s, finances, juggling stuff keeps us awake. Aches and pains with aging and stiffness keep us awake. And then menopause with hot flushes keeps us awake.

Now, what is melatonin? Melatonin is a small molecule that was originally thought to be made just in the pineal gland in the brain. Its function originally was thought to help us set our circadian rhythm, our internal clock. Pineal melatonin is suppressed by bright light. And when lights get dim, melatonin rises because of its own natural daily rhythm and the lack of suppression by light and helps us signal sleep time. As we age, we make less and less melatonin and that's the midlife aging part.

Now, we know that melatonin isn't only made in the brain, and its function isn't only to help our clock give us daily rhythms. It's found in our gut and may help our gut bacteria have a rhythm, and it's found in the placenta and the ovary and it's an important antioxidant in the body. There is much more that can be said about it, but let's get back to menopause and melatonin.

So you're a midlife menopausal woman and you're having difficulty sleeping. You're having a hard time getting to sleep and your hot flushes wake you up. You're not so interested in taking estrogen hormones for your hot flushes, but you should be and you've read about melatonin. Does it work? Is it safe to take? Can you get addicted to it? Can you take it for a long time?

Does it work? An international group of researchers published a summary of what we know about this in the journal "Sleep Science." Several studies done around the world suggested that a three-milligram dose of melatonin before bed helped with sleep. Women were given melatonin or a placebo and asked about sleep, physical symptoms, hot flushes, and psychological symptoms, and these all got slightly better when people took melatonin over placebo.

Of course, getting better sleep can help with joint aches, psychological symptoms, and hot flushes, but melatonin does a lot of amazing stuff and maybe melatonin was helping.

It was safe with few side effects. Some women in both the placebo group and the melatonin group had side effects of sleepiness and nausea and vomiting and headache, but the incidence was not different in the two groups. People who took placebo and people who took melatonin had the same rate of side effects.

Is it safe to take for a long time? The answer is probably yes. It is not addictive in the traditional sense. There's no evidence that a low dose leads to higher dose usage. There's no evidence that higher doses over three milligrams is more effective. There's no evidence of withdrawal.

The main problem is that there's no control over what's actually in the bottle when you buy it at the grocery store or the health food store. You might be getting melatonin or you might not.

The NIH has a Center for Complementary and Alternative Medicine with a short page about melatonin. They note that a 2017 study tested 31 different melatonin supplements bought from the grocery store and pharmacies. For most of the pills in the melatonin bottle, the amount of melatonin didn't match what was on the label and there were other compounds in the bottle. The biggest concern was 25% of the bottles had serotonin in them, and serotonin is a regulated drug with side effects that can be harmful at low levels.

Melatonin is widely used in Europe as a sleep aid, and supplements are regulated in Germany. So they have to have what they say on the label in the bottle, and no other funny stuff. In the U.S., they could sweep up what's on the lab floor, stick it in a little capsule, and you'd be none the wiser, and no one's watching.

So what do you do if you want to take melatonin? It would be good to talk with your clinician and make sure you don't have any contraindications. They should know that you're planning to take it and it should be on your medication list.

Although the USP verified label on supplements is not a guarantee that you're getting what you think you're getting, it's a start. The USP label indicates that the product has been subject to voluntary testing and meets U.S. pharmacopeia convention standards, that's the USP part, meaning the product is accurately labeled and free of harmful substances. This does not mean that it's been tested by the FDA, but it's better than nothing.

Now, of course, melatonin is found throughout the plant kingdom, and a wonderful paper in the journal "Nutrients" from 2017 listed the melatonin contents of common foods. Some mushrooms have a lot of melatonin. Portobello mushrooms are the basic white and brown ones that you can get at the grocery store have a lot. Seeds and nuts have a lot of melatonin. And pistachios win the top melatonin prize in the nut family.

Sprouted seeds also have a lot of melatonin and sprouted lentils are at the top. I can see a dinner salad with sprouted lentils, mushrooms, and pistachios being perfect to help you sleep. Your gut will love it and you won't feel guilty. Both of those factors are important for a good night's sleep.

It turns out that roasted coffee beans have a lot of melatonin, and coffee has some, but coffee is defeating the purpose.

So there are a lot of reasons you may not be sleeping well in midlife. The American Academy of Sleep Medicine would suggest behavioral approaches, such as bright morning light and daily exercise, a bath before bedtime, and no coffee after noon, limit alcohol at night, and no screen time just before bed to suppress your melatonin.

Having said all that, international studies suggest that melatonin in low doses can be helpful for midlife women struggling to get to sleep. So sleep tight, and thanks for joining us on The Scope.

Interviewer: I think many of us have already heard or know that mindfulness can help with stress and depression and anxiety, but did you know mindfulness can also help with a lot of physical conditions as well, such as pain management, high blood pressure, diabetes, heart disease, AIDS, cancer? It can help improve your sleep, stomach issues, and even eating disorders.

Trinh Mai is a mindfulness educator at The Resiliency Center at University of Utah Health. And mindfulness can help all these physical ailments as well, huh?

Trinh: Yeah. Isn't that wild?

Interviewer: It is wild. Tell me more about that. I mean, how does that work exactly?

Trinh: What all of those conditions share in common is that chronic stress can contribute to all of those conditions — hypertension, diabetes, heart disease, digestive conditions. Often stress is at the root of it, and stress is also the outcome of a lot of health conditions. So if there's a practice like mindfulness that can help you to better manage stress, then it's going to help you to better manage those symptoms.

Interviewer: This isn't something right now that I think a lot of physicians necessarily do. I bet you I could go to my doctor and say, "Hey, tell me about mindfulness and how that could manage my diabetes." You might get a blank stare. So are more and more physicians kind of adopting it, or how is this manifesting itself in traditional healthcare?

Trinh: Actually, how I came to mindfulness was my neurologist. I don't just teach this, I practice it and I'm a believer because I went to my neurologist about 10 years ago and said, you know, "I'm having all these neurological issues, pain, numbness." And we did a workup, and luckily I didn't meet any particular diagnoses, but she said, you know, stress often contributes to pain.

So she actually recommended that I take mindfulness-based stress reduction, and that's a course that I currently teach now so I feel really lucky. But that course changed a lot for me. It helped me to become more aware of what triggered my pain, and then it helped me to be aware of, you know, how I react to my pain can actually reduce it or exacerbate it. Sometimes the reactions actually make things a lot worse than the initial problem.

And then I, through the practice, actually became more aware and then I hopefully have been able to reduce my pain in other aspects. Hopefully, I'm less of a pain as a parent and as a partner. But yeah, it's awareness. That's what mindfulness is. And when you're aware, then you have more choices of what course to take.

Interviewer: I know a lot of people personally, and probably even me a few years back, if a physician in medicine would have told me what your neurologist told you, I'd be like, "Oh, they just can't figure out what it is. This is ridiculous." I can almost hear somebody going home and go, "Yeah, they told me I need to be more mindful. How's that going to help? Give me a pill, give me a diagnosis, tell me what's wrong."

And I think a lot of us have a hard time believing that stress can cause some of these other health conditions. So that story was great because I think it just really illustrated, you know, it did, it made a difference in your life and it can make a difference for a lot of people.

So let's get to the question now. So somebody is listening to this podcast, maybe they're suffering from one of the things we mentioned, maybe it's something else. How do they do it? Let's give somebody a first primer and then we'll give some resources.

Trinh: Yeah. So let me start with, first of all, I think that a lot of people that I've taught they'll tell me, "Oh, yeah, it's not for me because my mind races and I just can't make it stop," or "I can't sit still, that makes me too nervous." Well, you know what? I totally get that. I come from generations of people, particularly women, that cannot sit still. Like my mom, she's 70 something, she's retired, but she does not sit still. So I totally get that.

And it's like anything, the more we do, the stronger our muscles are to be able to do it, and the better we get. The other thing I think it's important to know is that you don't have to make your mind stop. So I'm going to just repeat that. You do not have to make your mind stop. We can't necessarily control that, but what we do have control over is if we pay attention to it or not, and we can bring attention to our bodies.

So for example, if I were to ask you now, can you bring attention to your feet on the ground and feel the surfaces of the ground? And if you can do that, you're practicing mindfulness.

Interviewer: That's it?

Trinh: Yes. And, you know, your mind's going to wander off to, "Oh, well, I got better things to think about." And that's cool. But when you notice that, you can bring it back.

So now I'd like to invite you to bring your attention to your breath and maybe see if you can pay attention to three breaths, the inhale, the exhale, feeling the air enter the nostrils, and opening up your body. Exhaling completely, feeling the body contract.

The mind wanders off. You notice. That means you're aware and you bring it back to your breath. And then at the end of the next exhale, maybe just check in and notice how you feel. See if there's any shifts.

Interviewer: I feel more relaxed already, and we did that for like, what, 18 seconds. That was amazing.

Trinh: Thanks for practicing along, Scot.

Interviewer: That was fantastic. So it doesn't seem like it's hard. You just kind of have to be paying attention. I'd imagine there's a lot of resources that you can get to it. There's apps I hear advertised or probably YouTube videos. Is there any place, in particular, you'd like to go for somebody who just wants to start?

Trinh: So, you know, I'm biased. I work for Wellness and Integrative Health here at the University of Utah, so I am going to invite you there first. You might want to check out the University of Utah Wellness and Integrative Health YouTube channel, and it's under Be Well Utah. So that's the series that you can check out.

And then, you know, taking courses, trying a class is a lovely way to get support and structure and a community to start a habit. So we have two courses. We actually have three. We have Everyday Mindfulness, which is an introductory course, and it's four weeks. And then we have the gold standard, which is Mindfulness-Based Stress Reduction. And that's the one that John Kabat-Zinn started and has decades of research behind it. And that one is nine weeks.

And then I just started a self-compassion course during lunch, and that's only an hour long for four weeks. So a few options for you to just, you know, try it out and see what it's like for you.

Your arthritic joints ache, and there's a soft chair and a great book that's calling you. Tomorrow, you'll get a little exercise. Really?

After 50, it's use it or lose it. That refers to your brain, your bones, your joints, your muscles, and your heart. And after 50, the best perspective is move it or lose it.

Although many of the studies on aging and exercise use men as research subjects, more and more are including older women, and some specifically focus on women. Women are more likely to develop fragile bones from osteoporosis and creaky joints from osteoarthritis, and both are significantly improved with exercise. Women are more likely to be diagnosed with depression and anxiety, which may be like asking for directions. They are more likely to ask for help with these conditions than men, so are given the diagnosis more often.

The most common, crippling diseases of aging that lead to loss of life and quality of life include diabetes, hypertension, heart failure, and dementia. All can be modified for the better with exercise. Now, not all exercise does the same thing, and the same kind of exercise can be boring. Some exercises are off the table because of joint pain. Running is less likely to be comfortable with knee arthritis even though there's evidence that moving those joints makes them better. Some exercises are easy on your knees, but you have to get into a swimsuit, you know, hat black piece of Lycra that's hiding somewhere that you haven't put on for some years. The good news is that Lycra in old swimsuits seems to be infinitely stretchable, and at the pool, in the water aerobics class, it's just a giggle. You're under the water. Nobody can be looking at you, and you can look at everybody walking by. What fun.

For women in midlife, the following types of exercise are important. They don't need to be done every day and they don't take a long time, but some mix needs to be getting into your exercise salad.

Cardio. Ugg, I hate it when my heart beats fast. I spent a professional life as an OB-GYN working to stay calm and keep my heart rate down. But I know that getting my heart rate up is good for my brain and my heart.

Let's start with the brain. Randomized trials have found that short bouts of high-intensity exercise, 5 to 10 minutes, increases your capacity to do cognitively challenging tasks that require what's called executive function, to hold one thing in your brain that helps you solve the next step. That's really important in living. Being cardiovascularly fit, being able to do and doing cardio decreases your risk of developing dementia. It also improves insulin function, which decreases your risk of diabetes. There are lots of videos about short, high-intensity workouts, HIIT, high-intensity interval training. You don't want to run in public? How about stairs? Six minutes of going upstairs as fast as you can. Can only do it for a minute? Can only do it for 30 seconds? Work up to it. You don't have any stairs? Get a little step, 6 to 10 inches. Up one foot, then down. Up on the other foot, then down as fast as you can for a few minutes. It's okay to hold on to a chair if you're worried about your balance. Swimming, biking, rowing, running, hiking uphill, or any exercise that get your heart rate up is the right thing. Make your heart work a little is good for your heart.

Strength training. Now, post-menopausal women can put on muscle, and muscle improves insulin function. Being strong means that you can get out of a chair. Being strong means that you can rebalance yourself if you get tippy. Weight-bearing exercise in mice builds new memory neurons. Now, remember, mice like to run. They don't like to lift weights. So maybe it was the stressful new thing that was making them build new memory neurons. This probably works for women too. Or it works to improve cognitive function because new exercises, novel physical activities build more brain connections. You can do this at home. There are videos of six-minute workouts. Developed by The New York Times is a good one, that works all your muscle groups and there are bunch of them available.

Stretching and flexibility. Of course, yoga is the poster child for stretching and flexibility, but yoga was developed in a country where people have been squatting since birth, and they're more flexible. Still there are a lot of videos about stretching and keeping a range of motion in your neck, your shoulders, your hips, your knees, and your feet.

Balance. Tai Chi is the poster child for senior citizens doing balance, but there are balance exercises that you can do at home while you're brushing your teeth or waiting for the water to boil while you're making coffee. And you can Goggle "balance exercise for seniors" on your YouTube. You aren't senior? Okay, you can check out balance for deniers. There's any age. I'm a fan of Bob and Brad, the most famous physiotherapists on the internet, in their opinion, and they have lots of balance exercises.

How much? The American Heart Association recommends 150 minutes a week of moderate exercise, a brisk walk, or 75 minutes a week of vigorous exercise. And that's only about 10 and a half minutes a day if you're doing it vigorously or a combination of both. Recommendations for midlife women for resistance training, read weights, are 20 minutes 2 to 3 times a week. The 20 minutes could be several sessions of the 6-minute workout. Put the phone down. Put the book down. Walk away from the computer. Ten minutes, three times a day, upstairs, some weights, some balance. Mix it up. Pushing and pulling and lifting in the garden counts as resistance training.

Ten minutes, only 10 minutes, your heart, your brain, your joints, your mood, your sleep will all get better. Then do it again. And thanks for joining us on The Scope.

Hot flashes, they are hard to describe and women experience them differently, and it's been a really long, hot summer. But what if that summer lasted 15 years?

All women who live long enough and it really isn't all that long, just to about 51, will have their ovaries stop working. When that happens, estrogen levels fall. And about 85 percent of women who make that transition from ovaries on to ovaries off will experience hot flashes.

The baby boomers, formerly the largest generation in the U.S., now replaced by the millennials, are aging and 6,000 women in the U.S. enter menopause each day. By the year 2020, coming right up, about 50 million women in the U.S. will be post-menopausal, one-third of all women in the U.S.

The two signature symptoms of estrogen withdrawl are hot flashes and vaginal dryness, and both are treated pretty well by estrogen. Many women are not distressed by these symptoms and good for them.

But AARP, formerly the American Association of Retired Persons—but as not all members are retired, they are just AARP—anyway, AARP did a menopause survey of their female members between 60 and 69, and 72 percent said that menopausal symptoms interfered with their lives and eight percent said it interfered a great deal.

Now, these women were actually about 10 years from their menopause. And when their ovaries stopped working 10 years ago and they're still having symptoms, 20 percent said that they had vaginal dryness, 24 percent had hot flashes, and 23 percent night sweats. Of course, some had all three symptoms and some had none.

Women with severe hot flashes typically experience them for seven to 15 years, and 15 percent of women with severe hot flashes experience them for more than 15 years. Now, what in the brain makes this hot flash happen? Do only women get them?

Recently, some very cool research on hot flashes was done in mice, and they found that the KISS1 neurons, kiss isn't that cool, KISS1 neurons that are part of the brain that make up the ovaries and testes work, so these KISS1 neurons make the ovaries and testes work, actually have their feet on the ground in the part of the brain that controls temperature.

These KISS1 neurons in mice work the same way that those neurons work in humans. Activating KISS1 neurons initiated a fast rise in the mouse's skin temperature followed by a drop in core body temperature. The same symptoms occurred in male and female mice. Removing the female mouse's ovaries made this temperature swing worse. We know that men that had their testes removed or who take medication for prostate cancer that makes the testes stop working can have hot flashes.

Now, we don't know if the mice who experienced these changes in their body temperature experienced distress, but some other studies suggest that they seek out cooler places in their cages. We don't know if they have spikes in anxiety or irritability, or if they're having hot flashes and they're getting angry, but that would be an interesting experiment to do.

Hot flashes at menopause may have more complex neuron functions than just KISS1, and about 15 percent of normal women never have hot flashes with menopause. So it's complicated. But understanding some of the brain's mechanisms might help us to think about new therapies.

Now, back to that survey from AARP, 46% of the women surveyed said that they had never discussed menopause with a health care provider, and only 1 in 12 had been referred to a menopause specialist. So what's the takeaway from all these numbers?

One, most women who experience menopause will have hot flashes.

Two, most women who experience hot flashes will tolerate them.

Three, most women with hot flashes will find that their flashes decrease in a couple of years. That sounds like a long time to me in a long, hot summer with hot nights.

Four, about one in eight women will have significant distress from their hot flashes and they'll go on for a long time. For 50 million women who will be post-menopausal in 2020, one in eight of 50 million is a lot of women.

Five, women who bring to their experience of menopause all the physical, social, cultural, environmental, emotional, financial, and spiritual experiences. In other words, hot flashes can be wrapped up in all of the seven domains of women's health.

Six, there are quite a few options other than estrogen, which works best, for managing hot flashes, and most clinicians don't know about all of the options.

Seven, if you are suffering from hot flashes that seem to go on and on and on, the longest summer ever, talk to your clinician. Ask them what is their training in menopause and ask what they know about different options. If you try some of the options they offer and you're not getting better, or if you don't like the side effects of the options, you should seek out a menopause specialist.

Eight and last, many specialists called reproductive endocrinologists have training in menopause. And some physicians, primary care providers and OB/GYN's have a special interest in understanding menopause and caring for women who are having difficulties. Some clinicians have made it their special interest in their practice. It could be a search, but your doctor probably knows where you can get help.

At University of Utah Health, you can use our app for finding a doctor who has an interest in treating menopause symptoms. That will get you started. The most important thing is that we're learning more and developing and understanding new options. So no big sweat, and thanks for joining us on The Scope.

updated: November 12, 2020
originally published: September 6, 2018

Interviewer: You're getting older and you're noticing that you're peeing more during the day, during the night. Is this normal? That's coming up next on The Scope.

Today, we're talking with Dr. Kirtly Parker Jones. She's the expert on all things woman. Dr. Jones, the scenario is you're 40, 50, you're getting up there in the numbers and for whatever reason, you're just starting to pee more. You're starting to wake up more in the night, you're starting to take a little more breaks during the day. What's going on? Are you normal?

Dr. Jones: Yeah, this is, well, remember we talked about normal . . .

Interviewer: Is she normal?

Dr. Jones: Is she normal? Welcome to the overactive bladder club. Welcome to the potty club. It turns out that urgency, meaning a bladder that contracts before it's really, really full is quite common. And the range in studies go from five percent to 30 percent of women by midlife have what they consider an overactive bladder and sometimes even leak a little.

Dr. Jones: So let's talk about medical or structural problems that might lead to this. We're not talking about stress incontinence, meaning you got to go when you cough or sneeze. This means you're just kind of walking around and then you got to go and then you just went and then it's an hour or two later and you've got to go and it's just going. First of all, the most common that causes urgency, meaning I've got to go is a urinary tract infection. But if this has happened over a long period of time, that's not going to be it. A UTI, a urinary tract infection, is actually an acute event.

Interviewer: And usually hurts, doesn't it?

Dr. Jones: It usually hurts. Now, there are women who have fibroids or something in their pelvis that's growing that's leaning on their bladder. So just as when a woman's pregnant and the baby's head is leaning on the bladder and they have to go all the time, if you have a big fibroid on your bladder or another pelvic mass, that can be a benign mass and it could have been growing slowly over years and you just know that you can't hold as much. So those are some reasons.

There are people with neurologic problems, multiple sclerosis, and other conditions that can make kind of an overactive bladder and that's what you see on the TV, it's called overactive bladder.

The most common reason is we don't know. So I call it idiot-pathic, instead of idiopathic, meaning it's unknown, I call it idiot-pathic. And it has to do with an aging brain. And that is the kind of ability to calm your bladder that you had to learn at two so that you could be continent and not pee in your pants all the time.

As you get older, you lose some of that so your brain can say, "Oh, I think I want to pee and I want to pee now." You can retrain your brain to say, "No, I really don't. I just went two hours ago and I haven't had anything to drink." So mindfulness training actually works very well.

So we have classes here at the University of Utah in mindfulness training specifically to help women with overactive bladder. As I said, it's common. Five to 30 percent of women complain of this. So they have to get up once or twice at night.

Now, another important reason before I get back to the overactive bladder is I see women walking around in their yoga pants with their water bottle. And they have water bottle with them everywhere because it's part of their drinking, drinking, drinking so that certainly can be part of it in women who are trying to watch their weight know that drinking water is good, and then they're drinking buckets of water and they have to go.

And those women, when you ask them are when they keep a diary, actually will let you know if you have them pee in a little thing we called the hat that sits in the potty so you can measure it. They are peeing a lot because they're drinking a lot.

There are other conditions like diabetes where you have a lot of sugar in your blood. Those people actually become dehydrated because when you have to get rid of the sugar, you have to get water out with it so those people pee a lot.

So there are a couple of things that are medical that caused frequent urination but those people are peeing in buckets and when you have to get up in the night and you get out of bed and you just pee a little bit, so that's urge incontinence or urgency we call it. There are ways to treat it.

Now, there's medicine to treat it but the medicines make a little difference. So they did some randomized studies where they looked at medicines that are actually, you see them advertised on the TV. They may decrease the number of urge episodes a day by one or two so you're still left with a moderate amount.

Interviewer: You're still pretty much going regularly.

Dr. Jones: You're still going. You are. And they have side effects of dry eyes and dry mouth, and what do you do when you have a dry mouth?

Interviewer: You drink more.

Dr. Jones: You drink more. So I think what we usually try to do is help people retrain their brain.

Interviewer: So mindfulness is the best solution.

Dr. Jones: Mindfulness is one of the best solutions and making sure that you don't have a lump in there, that you don't have diabetes, that you don't have other conditions that will make you go that are medical concerns. The most common is the brain just isn't as good at suppressing that bladder spasm as it was when you were 20, and now you need to retrain your brain.

Interviewer: So if you don't have a medical condition like diabetes, or urinary tract infection, and you're getting up there in the numbers . . .

Dr. Jones: Yeah, in the numbers.

Interviewer: In the numbers, right? We're just going to call them the numbers, and you're peeing a lot more than you used to, this is normal.

Dr. Jones: This is normal and I'm sorry.

updated: August 13, 2020
originally published: May 11, 2017

You've been so good about your family planning. You've always used birth control, but when can you stop? This is Dr. Kirtly Jones from Obstetrics and Gynecology here at University of Utah Health Care and this is The Scope.

So you've spent all your life planning your children. You had your babies when you wanted them. You didn't have any extra babies. You've really been good at it, but when can you stop? The answer is when you or your partner are using some form of really good birth control so you can stop. If your partner has a vasectomy, well, that's great.

Now, a really good form of birth control was menopause. So let's talk a little bit about your contraceptive method and menopause. First, fertility, we know, declines starting at about 30. We know that women who are trying to get pregnant sometimes struggle in their late 30s and certainly do in their 40s. The difficulty is that a pregnancy in your 40s that's unplanned is a definite problem because women in their 40s who get pregnant, even though they're not very fertile, do have higher risks of complications in pregnancy, like high blood pressure and diabetes.

They're actually more likely, believe it or not, to have twins. And they have more complications in terms of blood loss and a whole lot of other problems just with the pregnancy. And of course, we all worry about the difficulties in chromosomal abnormalities in our babies that increases in women after their 30s. So women are more likely to have complications in pregnancy. They are more likely to have a baby with a chromosomal anomaly like Down syndrome and importantly, they are more likely to miscarry. And by the end of your 40s, you are really likely to miscarry.

However, you don't want to get pregnant even though your chances are low. So when, even if you're being very careful, when is it time to stop? Okay. So let's now talk about menopause. Menopause is defined as when you haven't had a period for a year. Then that last period a year ago is your menopause. Now, you have to be of the right age.

So the average 20-year-old who hasn't had a period for a year is probably not in menopause. She hasn't run out of eggs. She may have another reason for not having her periods. But women in their late 40s and early 50s who haven't had a period for a year are very, very likely to be in menopause. So if you haven't had a period for a year, then you're likely in menopause and you can stop using your contraceptive method.

However, it's difficult to know if you're in menopause based on your periods if you're using a contraceptive method that changes your periods. So let's take, for example, birth control pills. Birth control pills block ovulation but give you hormones that make you have a period every month. So you can be in menopause, have no more eggs, be completely infertile, but because you're taking the pill, you'll have a period every month.

So how do you know, if you're on birth control pills, that you're in menopause? Well, the difficult answer is you have to stop your pills and see what happens. If you stop your pills, and you're about 52, and you don't have a period for six months, then you're in menopause. But what happens if you are 52, and you're still fertile, and you stop your pills, and you get pregnant? Well, the option is, of course, to stop your pills, see what happens, and use a different method, a barrier method, use condoms, use foam. Remember, you're not very likely to get pregnant because you're not very fertile and you're not very likely to stay pregnant because you're likely to miscarry. So that's one option.

The other option is to say, "Well, why don't I just stay on my pills because going through the perimenopause," those years when your periods are totally unpredictable and not very pleasant, "why don't I stay on these nice little periods that I like on the pill until I'm about 54?" We know that at 54, about 90% of women have gotten through menopause. At 50, the average age of menopause, only 50% of women are menopausal. But by 54, about 85 to 95% of women are menopausal. So you just stay on your pills and stop at 50 and you're very likely to be done.

Let's talk about an IUD that has hormones in it. For women who have an IUD with hormones in it, many of those women have very light periods or no periods at all so you may not know that you're in menopause. You may have some hot flushes because your estrogens have gone away. You may use a blood test, which doesn't work very well for women on the pill, but it can work for people with a hormone-containing IUD. You could do a blood test called FSH and if that is really high, then it's likely, not guaranteed, but likely, that you've run out of eggs and you're in menopause.

Or you can just stay on that IUD that has some hormones in it until you're about 54. And many women in their early 50s who have hot flushes may want to take a little estrogen and they have the progestin protection. They protect their uterus lining against abnormalities with that little hormonal IUD. So wait until you're a little older and then take your hormonal IUD out.

If you're taking a shot like Depo-Provera, about 80% of women on Depo-Provera don't have periods so you won't know when you're in menopause. Well, the same kind of strategy goes with Depo-Provera as it does with the hormone-containing IUD. You can just wait till you're a little older or you can stop, use a backup method. You can stop your shots, use a backup method, and wait and see if you start your periods again.

So this is kind of a complicated question. The good news is that for women who stop their method, whatever it might be, at 50, then, in fact, the chances of getting pregnant are very low. How low is low for you, though? If the chances of getting pregnant and having a baby is 50 to 1 in 100, is that a number that you're willing to take a risk for? Not me. For me, that's no, I wouldn't take a 1 in 100 risk of a baby, that with all the complications of a pregnancy at 50 is. So I was much more willing to push my contraception out to 54 and then say, "Now I'm ready to be done."

So it's a personal choice. It's one that you discuss with your partner, with your family, if that's what you want to do, in terms of what their thinking about future childbearing, what kinds of risks are they willing to take if you do get pregnant? But definitely talk with your clinician because there are some options that are really good ones to make this transition with low fertility, but still some fertility, and some good therapy for menopausal symptoms.

So many women actually use a low-dose birth control pill to help them with their menopause symptoms. So that's the difficult answer for a difficult question, but I want to say good for you for having been such a good contraceptor all these years. And thanks for joining us on The Scope.

updated: January 28, 2021
originally published: September 29, 2016

Dr. Jones: What do Utah women who've had lots of babies have in common with female paratroopers? This is Dr. Kirtly Jones from Obstetrics and Gynecology from University of Utah Health Care. And if you want to know the answer, stay tuned to The Scope.

Dr. Jones: So what do women who have lots of babies through the vagina, through vaginal birth, or maybe only one baby, have in common with female paratroopers who haven't had any children? Both groups are at increased risk for pelvic prolapse. This means their inside female parts are falling out. Having a vaginal birth and repeated trauma to the pelvic floor, as a female paratrooper can have, can cause the support to the uterus and the cervix to stretch and then drop a little lower in the vagina.

Commonly the cervix may be as low as at the entrance to the vagina and occasionally the cervix and uterus may actually be positioned outside the vagina. This is called pelvic organ prolapse. Not only can the uterus come down, but the bladder can come down leading to urinary leaking or difficulty urinating. Both situations can be uncomfortable. Today in The Scope radio studio, we're talking with Jan Baker, a nurse practitioner in the Pelvic Floor Clinic at the University of Utah. She specializes in the evaluation of pelvic organ prolapse and in the non-surgical management of this common problem. Jan, welcome to The Scope.

Jan: Thank you, Kirtly.

Dr. Jones: So how common is this? Not very many female paratroopers, but a lot of people have had babies.

Jan: Well, it's likely more common than our statistics tell us because this is, again, one of those unspeakable problems that women don't want to talk about. But it is thought that about one and a half to 1.8, almost 2 women per 1000 women have prolapse, some form of prolapse. But when we do studies of women with no symptoms of prolapse and they're examined, up to 50% of those women can have prolapse. Although it may not be where they're noticing it, but they have started to develop prolapse. So prolapse symptoms usually peak right around age 60, but about half of the women that seek care for prolapse symptoms are usually between the ages of 30 and 60. So it is quite common.

Dr. Jones: So what conditions can cause this? We mentioned having births and we mentioned being a paratrooper.

Jan: The biggest risk factor is childbirth, then just getting older.

Dr. Jones: Oh, great.

Jan: Because, unfortunately, the longer you're alive, the more and more gravity has its effect.

Dr. Jones: Gravity wins. Gravity always wins.

Jan: Gravity always wins, but obesity, menopause, family history, race . . . Latinas and white women are more likely to get prolapse, and a previous hysterectomy also seem to play a role in the development of prolapse.

Dr. Jones: So what are the symptoms a woman might have that would suggest that they might have this problem?

Jan: Well, the most common early symptom is kind of this mild pelvic pressure or maybe a mild kind of a backache at the end of the day. Maybe some mild urinary frequency, maybe feeling like they need to go to the bathroom a little bit more frequently.

Dr. Jones: And later on?

Jan: And then, later on, they may start to notice a bulge coming from their vagina, or they may start struggling with a bowel movement and that is usually what brings women to seek care.

Dr. Jones: Yeah. So what can be done about it?

Jan: Well, if the prolapse is not very bothersome, watchful waiting is a very good option. Education, though, at this time, can really be important. Because, although we don't know for sure, many experts in the field believe that weight loss, managing constipation, managing a chronic cough, reducing high-impact aerobic exercises such as jumping or running or jumping out of an airplane, or a trampoline, jumping on a trampoline. Using vaginal estrogen, smoking cessation and doing a pelvic floor muscle exercise might slow down the progression.

So actually talking to women about these things, maybe that might make a difference. You know, these interventions make sense because you're not continually putting pressure on the pelvic floor, but we don't have any good research to support their use. But they do make sense and they don't have any side effects.

Dr. Jones: Well, that's good. Actually, just knowing that what you have is there and it's common and it's not cancer, it's not a tumor. This is just life on the planet Earth and we can't move to a smaller planet with less gravity. So if a woman doesn't want surgery or isn't a good candidate for surgery because of her age or medical conditions, what are some of the non-surgical options?

Jan: So if the vaginal bulge has started to bother them, a vaginal pessary is a good option for her. And it's really good for those women who don't want to have surgery, who maybe cannot have surgery because they have medical problems that make it not a safe option.

Dr. Jones: Or they're going on a walking trip to Europe right now, no time for surgery. What can we do until I get back?

Jan: And maybe they can postpone, they want to postpone surgeries, but they want to be comfortable, exactly.

Dr. Jones: So can you help me with what's a pessary?

Jan: Well, a pessary is a device that fits inside the vagina and it's made from rubber, plastic or a silicone-based material. Lots of sizes and shapes. And what I do in the clinic is I fit a woman. We basically put a pessary in and see how it fits. The only reason a woman would know that she has the pessary in place is that she doesn't have the vaginal bulge anymore. She should not even know that pessary is in place. And what's interesting is pessaries have been used before Christ. And what they used were pomegranates, and more recently, potatoes have been used. Although, we don't recommend those use now because we have pessaries that have been developed by scientists.

Dr. Jones: A little cheaper, though, but having said that I would rather have something that was made out of silicone than something that might sprout. Well, okay, so how well do they work?

Jan: Sixty-three to 83% of women can be fit with a pessary and of those women that can be fit, 76 to 80% of those are satisfied with their pessary.

Dr. Jones: And how long can you use them?

Jan: Well, you can use a pessary as long as you want to.

updated: October 22, 2020
originally published: September 17, 2015

Interviewer: Did you know that when women have heart attacks the symptoms are different from men? True. You're going to find out more about that next on The Scope.

I was surprised to find out that heart attack symptoms are actually different in men and woman. We're going to learn more about that right now with Dr. John Ryan, he's the director of the Dyspnea Clinic at the University of Utah. Men and woman, heart attack symptoms are different, is that true?

Dr. Ryan: It's true to a certain extent, so the traditional concept we have of heart attacks being the crushing chest pain, hand on your chest, sweating, vomiting and presenting to the emergency department and be found to have a heart attack, is seen more commonly in men, however, part of the issue is is that women also experience these, but tend to ignore them more. So yes, they have the symptoms, but they just tolerate them better or dismiss them as being a heart attack, because many women don't feel that they're predisposed to a heart attack.

Interviewer: So for example if you were to ask somebody what kind of pain you're feeling, one person might say it's a level ten, same amount of pain...

Dr John Ryan: Yes, exactly.

Interviewer: ...number five, women are doing the same thing with these symptoms.

Dr. Ryan: Exactly, yeah, so there's a tendency to dismiss the symptoms, so therefore the symptoms often times need to be more severe or more advanced before woman present with them and then by the time they're more severe and more advanced, they're then different, so instead of having left sided chest pain or pain radiating down the left arm, they now have central chest pain and it's radiating down both arms. So that's what ultimately can make the syndromes different. Also, women often don't feel that they should have heart attacks.

Interviewer: They don't have time.

Dr. Ryan: Not only do they not have time, but it's a problem that men have. And this is a serious misconception because cardiac heart disease is the biggest cause of death of women in the United States.

Interviewer: Which is a surprise to a lot of people.

Dr. Ryan: Surprise to a lot of people and it's an important public awareness issue so therefore when women again, when they get their chest pains, or their symptoms from the heart attack, not only do they tolerate it more than men, but also they dismiss it as being a heart attack, sure, sure, why would I be having a heart attack, I'm a woman.

Interviewer: Sure.

Dr. Ryan: I don't have heart disease.

Interviewer: Why do women dismiss, I mean, what is it about a woman's body that they tolerate it more? Any idea?

Dr. Ryan: Probably a pain threshold issue.

Interviewer: We've heard that before.

Dr. Ryan: Exactly, yeah, women often claim to have a higher pain threshold than men, and that's probably true and in this, and that's a very, that's an advantage, but ultimately that ends up hindering people in terms of presenting when they are having their heart attack. So that's probably the issue.

Interviewer: The symptoms are the same but different, they experience them differently, but at the end of the day, are heart attacks different?

Dr. Ryan: So the heart attacks are still associated with significant morbidity, significant mortality and so in that regard they are just as ominous and just as sinister. And the pains, again, the classical pains that people get or that people are taught, is that the central chest pain or the left sided chest pain, radiating down into the left arm, woman often times don't describe this as pain but will describe it as a pressure or a tightness in the chest, all of which are various adjectives that really impact how you perceive pain and again that reflects how you perceive pain. But ultimately the prognosis is still serious, still ominous, and still needs to be treated, taken very seriously and women need to be aware of the fact that they are as likely to experience cardiovascular events as men.

Interviewer: Is there a take away that you would have?

Dr. Ryan: Although we want to see patients when they're having heart attacks, we want to prevent patients from having heart attacks all together, so the more important aspect would be for women to be proactive in order to preventing events, so doing exercise, eating healthy, having heart smart diets and trying to, staying on top of their blood pressure, cholesterol and so on so that we don't end up seeing them when they've had a heart attack.

updated: February 23, 2022
originally published: February 7, 2014