Part 1 of 3 part series: “The Menopause Series” —
Episode 1: Menopause + Eating Disorders — In this episode, Opal’s Nutrition Director, Julie Church, RDN, speaks with Naomi Busch, MD, about menopause through the lens of an eating disorder physician. Together they explore the biological changes of peri-menopause and menopause, common symptoms, and current treatment approaches. The conversation also highlights parallels between menopause care and eating disorder treatment—particularly around body changes, medical support, and navigating vulnerability during major life transitions. Dr. Busch shares insights especially those with a history of eating disorders, as well as guidance for loved ones who want to offer meaningful support. This reflective conversation invites listeners to better understand menopause and approach it with compassion, curiosity, and informed care. 🎙️
Find Naomi @seattlemenopausedoc and Seattle Menopause Medicine
Other links: SWAN– Study of Women’s Health Across the Nation Study
Connect with Opal:
Thank you to our team…
Editing by David Bazzi
Music by Aaron Davidson: https://soundcloud.com/diet75/
Sound engineering by Ayesha Ubayatilaka at Jack Straw Studios
Transcription provided by Rev.com
Julie Church (00:02):
Welcome to The Appetite, a podcast brought to you by Opal Food and Body Wisdom and Eating Disorder Treatment Clinic in Seattle, Washington. I’m Julie Church, host for today. I am one of Opal’s co-founders and dietician and nutrition director. And today’s guest is Naomi Bush, who is a local physician. She is an eating disorder doctor that’s turned menopause doctor. And Naomi has been kind of in our careers, we’ve kind of been parallel in our work in serving individuals with eating disorders in the local area. And I’ve always admired Naomi’s pursuit of information and kind of being able to give the best care she can to her patients. And I have seen this to be true in how she’s now created this menopause practice at Seattle Menopause Medicine. Yes, I’m excited about our conversation today and one warning I want to give to our listeners, Naomi and I both talk really fast.
(01:01):
So you may want to slow down the speed at which you are listening to this podcast if you are wanting to listen to it at a normal speed. But I’ll power to you if you want to make it faster, but we are fast talkers so buckle up and you are going to learn a lot from Naomi today. Naomi and I’s path began in our careers, obviously finding each other in the eating disorder world. And as you can see, this podcast is about menopause and we’re going to get there. But Naomi, can you share a little bit of your journey to this place and where our paths crossed?
Naomi Busch, MD (01:38):
Yeah. So currently I am working and own a Seattle menopause medicine and I had a very circuitous route to get here. So firstly, I was working in family medicine. I started in community health and then I moved to Seattle and when I came here, I realized it was really difficult to both be a mom and a doctor at the same time. And so I found a practice and I was lucky enough to take over a practice and then design a family medicine practice that worked for me. Also then incorporated multiple other women into my practice. And eventually other people like eating disorder companies started coming to me to ask me for help and that is where I met you.
Julie Church (02:23):
Yes. In the Seattle area, and this is nationally, right? There’s so few patients, doctors, medical practitioners that have specialized in eating disorder care. So we were always very grateful to have you and your work and your expertise in our community for
Naomi Busch, MD (02:35):
Sure. Right. So like owning my own practice allowed me to design the practice that I wanted to do and it turned out that what I was really good at doing was fixing problems rather than actually, I mean, they could be medical problems, but they could also be just administrative problems or whatever. And so when eating disorder companies came to me and said, “Hey, can you see our patients?” And I had no knowledge of eating disorders and then they told me their problem, which is that no one would help them. I thought, “Okay, well that’s not fair. So let me go learn everything there is to know about eating disorders.” And thus became like probably a year long journey to learn everything I could about the medical management of eating disorders. And then I started doing consulting work with them. So for 10 years I ran a private practice and also did eating disorder consult and also just provided I think just like friendship and like community to people around the eating disorder world in Seattle and beyond.
(03:27):
And then eventually I got tired and so that was a lot of work and so I gave my practice to a friend of mine who actually was also interested in eating disorders and so she took over the whole shebang and I kind of took a break and during that time I got old and my friends got older and they started asking me about menopause and specifically my book group started asking me about menopause as I was like the resident doctor in the book group and I realized I knew nothing about menopause and just like eating disorder work, I decided, well, that’s not fair. There should be some place for my friends to go. And so I learned everything I could and probably yeah, the next quicker. I wasn’t working at the time as much. So I learned everything I could in like four to six months, got my menopause certification and then decided to open up my clinic when I realized there was nowhere to send my friends, which meant there was really nowhere for other people to go as well.
(04:22):
And so I also decided when I looked out into the menopause world that it was really interesting because there was this huge intersection between weight inclusivity, health at every size, eating disorder, body image and menopause. And so I felt really compelled to open up my clinic and to do the work I do.
Julie Church (04:43):
Yes, yes. And I do feel as if it’s being talked about a ton. I’m sure it is because of my age, the algorithms on Instagram, who’s getting advertised too. But it is true, right, that in the last 20 years there was a kind of a gap and a silence. Do you want to speak to why maybe we weren’t hearing about menopause much in the last …
Naomi Busch, MD (05:03):
Is it because I
Julie Church (05:04):
Was too young to hear about
Naomi Busch, MD (05:05):
It? No, I think it’s interesting. I think I look back. I mean, I’ve been a doctor for 25 years, which is kind of nuts anyway and I’ve been a doctor for a long time and I don’t remember ever really thinking or hearing about menopause. There wasn’t any reason not to. It was just, I mean, if you want to ask me my personal opinion, which isn’t evidence based. Sure. Yeah. It’s because as women get older, we become invisible and I think anyone over the age of 40 I would say, which I don’t consider very old either. But you start to feel it. You start to feel a little invisible. And so I think in medicine, the same thing happens where there’s a lot of research done on men and I can tell you why that is and not just gender discrimination, it’s also because women can get pregnant, right?
(05:57):
So when they do research, they don’t want women to be pregnant or at risk of being pregnant and so they were excluding them from research for that reason. That is a big reason why. And so we didn’t talk about women over 50 having heart attacks or strokes or what should we do about them. We just sort of lumped them in with men and it was really weird. It was like we kind of just ignored the whole menopause transition entirely. I mean, that’s kind of crazy. Yes. But anyway, and I think that there was also, and there’s a lot of press around this now is that in 2002, the Women’s Health Initiative, which is the really very large randomized clinical trial that was being done was halted and announced by the New York Times rather than the medical community that hormone therapy would increase your risk of breast cancer and chance of having a heart attack.
(06:54):
And so it was halted and then no one spoke of menopause again.
Julie Church (06:58):
Yeah. That’s the thing that I was very aware of. Yeah. All the other deeper thoughts about that are really good to hear as well, but I was very aware of that. I mean, I remember that kind of in my own journey with older women in my life too, of kind of that tension of their conversation around that. And then also I think how often is this talked about intergenerationally and in families and
(07:20):
All of that. And I have very, very little moments in my life of hearing from the older women in my life about it. So yeah, but I’m glad that we’re talking about it now and that it’s getting more common, I guess, and there’s more folks like you that are going out and actually opening practices and making themselves very clearly an expert in it so that I think then it just increases awareness. I think in the same way we’ve seen it with eating disorders, right? It’s just it increases people’s possibilities to get the help or to consider that maybe they’re not alone or that this maybe isn’t normal or that this could be changed, right?
Naomi Busch, MD (07:56):
So
Julie Church (07:56):
I think it’s great.
Naomi Busch, MD (07:57):
Yeah. I mean, I think what we’ve seen, and especially probably in the last three years, especially in the last three years, and I don’t know exactly why it changed, like what happened in the last three years that like people were like, “Menopause,” but I know maybe it’s just the bloom of social media and the bloom of podcasts like this, where people are talking about different subjects. And so I can think about like the few podcasts that were out and then how many there are now and also with like social media bringing awareness both positive and negative to menopause and midlife women. I also tell my patients, I think too, and I think about this sometimes is that I kind of believe it’s a function of where we are as a society and that every year more women become CEOs. There’s a tiny percentage of women who run companies, right?
(08:50):
But every year more people reach that glass ceiling, right? I always just say break through their glass ceiling, right? And like every year that happens and those women are hitting menopause and when that happens and they start getting brain fog, when they stop being able to sleep, when they start having hot flashes while they’re giving important lectures or talking to Congress or at the UN, they’re like, “What is happening to me? There’s got to be a treatment for this. ” And I think it’s those women who actually kind of started seeking help. I believe this to be true, but it’s my opinion and that they actually have paved the way because there were TED Talks about it. If you look back, there’s women in their 70s talking about sort of menopause revolution and freeing themselves of the burden of caring what people think about way before the social media trend.
(09:41):
And so that’s what I think. And that’s what I see in my practice is that people come to me and tell me that like, I don’t know, like let’s make it up like I lead company X, I’m in a room of 300 people and I’m giving a lecture and all of a sudden my mind goes blank and I do not know what the next sentence I’m about to say is, and that might happen on this podcast to me, but I’m just wondering. I know and you can imagine there, and I’ve had people come to me and tell me they’re going to quit their jobs and these are women who are doing amazing things and I’m like, “Whoa, whoa, wait a sec. Don’t do that yet. Let’s see if we can make you feel better.” I mean, I put people on FMLA. I will give them leave up to 12 weeks to get their hormones started to get their anxiety under control, never having to use SSRIs maybe, but like really just being like, “You are in the menopause transition and it is significantly affecting you.
(10:35):
” And I mean, I’ve brought people back to work. It’s kind of amazing. It’s such a simple solution in a way and it’s so hard to believe that these women have sought care from multiple other doctors before getting to me. And anyway, anyway, it’s really, I mean, I know it’s a litle different than what we’re here to talk about, but that’s like where I guess my passion comes from, right? Is like seeing the effect and like thinking no, like me too, right? Me too. I am a 50 year old woman and I am in the top of my game, right? I’m super smart, I have my own practice and I run my family and I go on vacation and I have to be able to function and do all that stuff.
Julie Church (11:15):
Well, okay. So my mind is going in so many different directions, but I do want to highlight that next week I am recording a podcast with a local researcher who has done their dissertation on that exact thing is women, workplace and menopause. So I’m going to be creating or kind of sharing about the research and interviewing that researcher next week. So as a part of this series, they’ll get to talk about that. So that is very relevant and it is not just the biological impact of menopause, but it is psychosocial impact of
Naomi Busch, MD (11:47):
Menopause. 100%.
Julie Church (11:48):
So can you do a quick overview of sort of what is menopause? And I guess I want to caveat this to say that we’ve already talked a lot about women use that phrase and this is going to be a fairly gendered conversation. Can you speak to how this can be as inclusive as possible in our conversation and allow for our listeners of all different genders to be able to take in this information?
Naomi Busch, MD (12:15):
Yeah. I think that we use the word women, but what we really … I wish we had a different word for it, but what we’re trying to say is anyone who’s born with a uterus, people, obviously anyone with a uterus and ovaries will go through, I shouldn’t say uterus, I should really say ovaries, will go through the menopause transition, right? And so anyone and whether you’re non-binary trans, if you have had or have ovaries, like you will go through the menopause transition and it’s really important to include everybody and when we talk about it, it’s easier to say women and that’s unfair.
Julie Church (12:52):
Yeah. Okay. So thank you for mentioning that. So when we talk about menopause, what is happening biologically that we then term as perimenopause and menopause and the transition quote unquote, I’m using air quotes, that you’ve already been using that phrase. So please,
Naomi Busch, MD (13:09):
Yeah. I think that we could all agree that perimenopause is elusive at best and that there is a medical definition of perimenopause and the menopause transition. So there is something called the STRAS guideline, which is, I think it stands for the stages of age of women something like reproductive health, but it was designed many years ago, like over a decade ago. And when you look at the straw guideline and that is how we actually figure out what is perimenopause or menopause, the only thing that really can delineate it is your cycle length and the problem with that is that not everyone has a change in their cycle length prior to just no more periods, right? So what the straw guideline tells us is that, which is again, reproductive health, is that somewhere between somewhere around seven years, let’s pretend, before your last period, you might notice a change in your period, the cycle length, the time between periods of more than seven days.
(14:21):
And that is the definition of early perimenopause, a change in your cycle length by seven or more days and that can last for as long as it wants to last. And then late perimenopause is a change in your cycle length by more than 60 days. So usually a lengthening of. Whereas like early perimenopause, a lot of people will tell me they have like more than two periods, like they’ll have two periods in a month. So their cycles are like 18 days, right? And now you’re talking like cycles are 60 days or in late perimenopause and if that happens to somebody I can tell them research shows that menopause will be in about one to three years.
Julie Church (15:02):
And wait, can you just, what is menopause then?
Naomi Busch, MD (15:04):
Yeah. So then menopause is just when you stop having your period and everything beyond.
Julie Church (15:08):
I think
Naomi Busch, MD (15:09):
It’s
Julie Church (15:09):
Interesting
Naomi Busch, MD (15:09):
When
Julie Church (15:10):
I dove into all the definitions as it mattered to me more, I was like, “Oh, that’s all that menopause is. ” It’s
Naomi Busch, MD (15:15):
Just like no
Julie Church (15:16):
Period.
Naomi Busch, MD (15:17):
No period.
Julie Church (15:17):
Okay.
Naomi Busch, MD (15:18):
And it’s for the rest of your life. People say like, “Well, my menopause was X day,” but you’re like, “Well, actually we’re all men.” Always. Yeah. Every woman who no longer has their period is now in menopause, whether it’s because of surgical reasons, whether it’s because of just general age reasons or chemotherapy or any reason you’ve stopped having your period permanently, we consider that menopause. And then the menopause transition is actually longer than menopause. So like that day of menopause, I should say, the day of your last period, the menopause transition actually goes from early perimenopause. When you enter into the menopause transition, you’re starting to go, you’re going to go through menopause eventually all the way up to like three to five years post menopause, that date. And so that’s like the length of your symptoms. And that’s why that’s important is because you can imagine you can start having symptoms seven to 10 years before your last period and you can have symptoms all the way to the average is three to 10 years.
(16:23):
Some people have symptoms of menopause for the rest of their life. I think studies have shown, and of course these studies only go to 79 or 80, but they still show that up to 79 or 80 year old women, 15% of them still have menopausal symptoms, including hot flashes that are disruptive to their life at that point. So some people will have an easy transition is what I like to say, like they have zero symptoms. So yeah, 15% of people never have any menopausal symptoms. Okay. So that means like the majority of people that 70% that’s left over have symptoms that go for those years and then taper off. So if you never did anything about your symptoms about five to seven years after menopause, you would feel better.
Julie Church (17:08):
Okay. I mean, what’s so interesting is that’s a large part of a person’s life then. It could be 20 years of somebody’s life. If you’re saying seven to 10 before the menopause, the
Naomi Busch, MD (17:20):
Last exam- Seven years after. And then
Julie Church (17:22):
That’s almost 20 years. It’s just a large chunk of somebody’s life. Okay. So what are some of the common concerns? What are some of the symptoms or the things that people then are finding distress in?
Naomi Busch, MD (17:32):
Yeah. So it’s interesting. So again, I mean, coming back to the straw cteria, the reason why I and me and many people, like leaders in the field are like, “We need to revisit this idea,” is because you can’t just use the period or menstruation as a notification of perimenopause because what people are actually coming to see me with are very normal cycles and now they have sleep disruption. They’re waking up at two or three in the morning. I mean, everyone’s first symptom is different. We have no protocol or predictability of what someone’s going to go through. I like to describe menopause as it’s like a box of Legos without instructions, right? That everyone’s going to build a house and they’re going to look a little different, but like you don’t really know. But everyone has that box of Legos and it’s all possible and we know you’re going to build a house and it’s going to be whatever kind of house you’re going to build.
(18:22):
So you could have sleep disruption is a big one where you wake up usually sleep initiation is maintained, meaning like you can fall asleep, but now you’re waking up at two in the morning, three in the morning, which I also like to joke about because if you read Stephen King, which I do, there’s this thing, the witching hour, three in the morning and I’m like, “Oh, maybe you got them from menopausal women.”
Julie Church (18:43):
Totally.
Naomi Busch, MD (18:43):
They always wake up at three in the morning. Anyway, a good one to talk about with that is what could be causing that some people wake up just anxious, like existential anxiety is what I call it. There’s nothing wrong. This is what they tell me. There’s nothing wrong, nothing new. They just feel anxious and it’s like that book where there’s that what bird running around and the sky is falling and they just wake up and they’re like, “The sky is falling.”
(19:11):
But they’re like, “Nothing changed.” And they can recognize the difference. Same thing with depression. They’ll just wake up and feel existential dread and this is not normal. It’s not even normal depression. It just comes on kind of suddenly and then hot flashes of course can start at any time. Some people start having hot flashes in their 30s and it doesn’t mean they’re about to go through menopause, like I just said, it could just be the first symptom and those and hot flashes just so you know, like are defined typically as heat building from the chest up to the face and they can be like really mild, like you just feel warmer than usual. You don’t have to put on a sweater like you used to. They could cause you to feel actual heat and sweating, but you don’t have to take off your clothes and then of course they could be severe where like you literally feel like you’re about to pass out because you’re so hot and they only last maybe 30 seconds sometimes they last for minutes and then they go away and then you have chills.
(20:09):
So that happens. Some people get pretty extreme brain fog, which is of course defined by the user, but when they do research in the brain, what we really see is that there’s verbal processing, very difficult to verbally process, meaning you learn something, you hear something, but then you can’t remember it. And so there’s some like decrease in verbal processing, spatial memory so you no longer remember where you put something and the problem with that I think, I know the problem with that is that your loved ones don’t realize this is happening and so they’re still relying on you to be the ultimate finder of things and that doesn’t happen, right? I can’t tell you how many times my, my husband has said to me, “Hey, do you remember where I put my keys?” We finally had to have a conversation and a calm moment where I was like, “Listen, honey, I no longer remember where you put stuff.
(21:02):
I no longer remember where I put stuff.” So from now on you can’t ask me because every time you ask me, it reminds me I don’t remember. So that’s really frustrating and upsetting to me. So we have a rule. When you take something out of a place, you put it back into the place. That’s helpful. There’s places. But anyway, and then of course multitasking gets affected and then concentration and focus. And so women come to me all the time and think they have adult onset ADHD and I’m like, “No, you might be perimenopausal.” And you can see that those are also really great strengths that women and I’m gendering everybody now too and making huge stereotypes, but those are like strengths of women. And so these were things that we did without ever thinking about them or appreciating them and then all of a sudden they’re gone.
(21:47):
And I feel like the worst part of brain fog is actually this moment where you’re speaking and you don’t know where you’re going or like the word that you cannot remember and it’s on the tip of your tongue and you remember everything else, but it … Anyway, so those are, I would say like the biggest ones. And then of course there’s like some of the physical symptoms, people start getting joint pains. They can get things like frozen shoulder in your 50s. There’s some link with menopause there and estrogen deficiency. People start noticing a change in their blood pressure. These are all the things that estrogen has a beneficial role in. So their blood pressures might go up, their cholesterol might get bad. They might have elevated … This is kind of where we come in, right? Their metabolism changes and so that’s a lead in.
(22:35):
So the metabolism changes and they notice maybe their doctor is now telling them that they have too much sugar around and they have something called a hemoglobin A1C that’s elevated and they might start looking like they’re pre-diabetic and all these things are happening 10 years maybe before you are going to go have your last period. Yeah. Sorry.
Julie Church (22:58):
You didn’t mention any sexual dysfunction, but I feel like
Naomi Busch, MD (23:00):
That’s something
Julie Church (23:00):
That some definitely would be talked about or not.
Naomi Busch, MD (23:03):
I think that, yeah, sexual dysfunction’s interesting and we could have a whole podcast on that because I kind of love talking about sex. But actually, I mean, so vaginal, so with estrogen deficiency people and that can happen very early on is people can get vaginal dryness and vulvar dryness and so sex can become painful. But there’s also, I think what people are noticing is this decrease in libido that can happen and that is what I would say multifactorial, right?
Julie Church (23:32):
If you’re having all of those other symptoms that we just talked about for five minutes, I wonder.
Naomi Busch, MD (23:37):
So I kind of say like, well, and then they’ve done studies on it where they look at people in new partnerships or new relationships and they’re like, it doesn’t seem to be as prevalent, the lack of libido. And you’re like, right, because they don’t have all the years build up to that point, but there truly is a vaginal dryness and things like that that can happen.
Julie Church (23:58):
Thank you. Okay. So that’s a lot. I think the one
Naomi Busch, MD (24:02):
Other thing
Julie Church (24:02):
That you haven’t said specifically, but I just want to clarify for people that might be at the very beginning journey of learning, the lowering of estrogen. That is one of the main tests that actually can be looked at, right? I mean, one of the things that then is being measured, it’s also related to what might be some of the treatments that you would recommend, right? I think that for someone that isn’t even like, “Okay, these are all happening. Why are all these things happening?” Well, because hormones are changing, right? So I don’t know if you want to specify that or say that in a more technical medical way, but estrogen, testesterone.
Naomi Busch, MD (24:35):
Yeah. I think that’s a really good point because one of the reasons I am very passionate about this field is also to kind of a promoter of evidence-based medicine, right? So during perimenopause, it’s very, very difficult to check labs that are accurate and people will sell you this idea that they can check your labs or do fancy tests, which we won’t name because I don’t want to get in trouble, but that costs thousands of dollars and do not tell you anything more than what I just told you, which is that this can happen to you and until you have your last period, right? Or let’s say you have, or people might say right now, they might be thinking, “But I don’t have a uterus so I don’t know. ” Or, “I have an IUD and so I don’t have my periods. How will I know?
(25:28):
Or I’m on continuous birth control pills. How will I know? Is it important to know? ” And I’m like, “It’s not really important to know. What’s important is how you feel.” So if somebody comes to me and they want their labs checked, or I think there’s reasons why I will check their labs and I’ll tell you. So if they’re under 40, it’s not normal to go through menopause. I should have said that. The age of menopause which is deemed natural is if just to naturally go through menopause is between the ages of 45 and 55. There can be later menopause, there’s nothing wrong with that actually, but earlier menopause has prepercusions. And so if anything under 45 is considered early menopause, under 40 is considered premature ovarian insufficiency, which is really important. So I check labs if they’re under 45 and yes, I check estrogen levels and I check a sensitive estradiol, I check follicle stimulating hormone, which is your brain telling your ovaries to make estrogen.
(26:30):
I like to say the higher it is, it’s like someone’s knocking at the door but no one’s answering, right? So your FSH will go up and up if there is no estradiol being made by your ovaries and so the higher it is the more we think, okay, this person is close to menopause or in menopause and one reading of any of these things does not make a rule, right?
Julie Church (26:53):
Sure.
Naomi Busch, MD (26:55):
And then testosterone levels, we check testosterone and I usually check total testosterone and I check a sensitive testosterone and we will check that if someone’s having symptoms of low libido or sexual dysfunction of female arousal disorder or things like that to see if testosterone therapy is viable, meaning that if your testosterone is high, giving more isn’t going to help. So I do check those four, and then those are the basics.
Julie Church (27:23):
And I really appreciate the naming of some of the ways that there’s capitalism
Naomi Busch, MD (27:28):
Integrated into- Yeah, be careful. I want to say that too. I mean, just be careful because women want to feel better and there is a lot of people who will sell you things and checking labs every three months is not necessary. Checking when you’re missing your period is helpful. That is very helpful information, but if you’re regularly menstruating every cycle, we’re going to find pretty normal labs.
Julie Church (27:54):
Great. So as I hear all of this, my brain and because my career has been all in the field of eating disorders, of course I’ve just been feeling and noticing all of the parallels with individuals that have struggled with an eating disorder or are currently struggling with eating disorder and then also layering on perimenopause, menopause and all of these symptoms. Yeah. What do you want the listeners to know about that? I mean the metabolic issues that you mentioned like changes in metabolism and things like that, that can be for many lead to weight changes and body changes, body composition changes as well as actual maybe number on the scale changes, right? So I’m curious what you would say about that and kind of just what your reflections are because you’ve worked with so many people for years in the eating disorder field and been in those hard, difficult moments with them and then now here you are in the hard, difficult moments with individuals in this season of life that is a biological change that will happen to all
Naomi Busch, MD (29:00):
When
Julie Church (29:00):
An eating disorder is something that isn’t going to happen to all. So I guess, yeah, I’m curious what your first things are that you want to talk about or share or …
Naomi Busch, MD (29:12):
Yeah. I mean, again, going back to capitalism, right now we are inundated with weight management and the idea that we need to manage our body siz for health and that has been called out time and time again, you can’t really turn on the news or turn on your Instagram just to look at people’s pictures without seeing something or hearing something. I mean, the football ads during … I mean, I was so upset with those Super Bowl ads with the GLP-1s. I mean, it’s very intense is what I would say. And the menopause world is not immune. If anything, it’s sort of again like the next money grab and Because you can imagine when you put people on weight loss management, they’re going to have to come back and see you over and over again for the rest of their life. And so there is that.
(30:11):
Okay, my cynicism aside. My cynicine aside. But thinking about just the way that women’s bodies change during the menopause transition, which we now know it’s a long time.
(30:23):
I guess we should start with, we know from just studies like SWAN, which is the study of women across the nation, which has been an ongoing study, which is over a decade and it’s pretty cool. I mean, they just watch people age and they do lots of side projects and women are agreeable to this and it’s been really eye-opening. So what we know is that women and I would say all people including men we know gain weight throughout their life. But the difference I think, and a lot of this is my opinion, okay, we’ll caveat with that is that women unlike men are told that they cannot gain weight throughout their life. It is unacceptable for a woman to be a different weight at 20, 30, 40, and 50. She must be the same weight. And I know you’re nodding your head. It’s so frustrating and it’s so true.
(31:12):
And what Swan showed us though is that women gain a few pounds every year, which makes sense to you and me because a 20 year old body is not a 40 year old body and it would be normal for someone to be 10 pounds heavier at 40, right? If they gained a couple pounds, a pound or half a pound. But what women do is that they change what their behaviors are or their eating patterns so they restrict or they exercise more when they get on the scale and they see a change in their weight. And so throughout their life, this is again, Naomi’s theory, is that women have restricted or changed their behaviors up and that has worked for them and I’m again, air quoting worked
(31:51):
For them to control their weight up until age 40. Let’s pretend an average age of 40. And then all of a sudden they get on the scale one day and they’re that three to five pounds change like they’ve always seen every few years, right? But nothing they do will help them anymore. And again, air quoting help with weight management and they try restriction, but they already have restricted their calories to such a low level their body is like, “Nope, this is my metabolism where it is so low, this isn’t going to work.” They try increasing their exercise, but now they’re in a place where the perimenopausal transition is working against them. And so that looks like if you have a fluctuation of your estrogen levels and fluctuations of FSH, what we know is that that changes the way that our muscles respond to energy so they don’t take in carbohydrates as well as they once did.
(32:48):
They really have a hard time using what we would normally think of as a carb lobe before exercise. All of a sudden it’s not working, which means so you go and exercise and then you don’t gain any muscle and that’s because this fluctuation of estrogen and then-
Julie Church (33:05):
I’m thinking about fatigue also.
Naomi Busch, MD (33:07):
Right. You’re also tired. Maybe people have fallen off their paths of like exercise and behaviors and things like this, but even when they go try to get back on that path- That’s what you’re saying. It’s like their body doesn’t respond like it once did and so they get very upset and then again, looking genetically at people, people’s bodies change, right? And so up until now they might have been able to control it and now it’s like it’s doing what it wants regardless. And so therein lies like GLP-1s, right? So now come in the weight loss industry to say to women, “Oh, there’s something wrong with your body, use this to fix it. ” And rather than saying like, “Okay, let’s redefine what is normal and what is again, just bringing up what I said at the very beginning, you feel invisible and so here you are, your body’s changing, you already feel invisible.
(34:02):
So like what is beautiful? What is attractive?” And so it’s just really- And what feels good. What feels good.
Julie Church (34:09):
Yeah.
Naomi Busch, MD (34:09):
And it’s hard.
Julie Church (34:10):
It’s really, really hard. Yeah. And I appreciate it on your website too, how you mentioned kind of how you approach from a weight inclusive lens saying that you take a weight inclusive approach focusing on symptoms, concerns, and diagnosis rather than size. And so I can imagine there are lots of people and I would strongly encourage somebody who has struggled with an eating disorder when they are in this transition to seek out help that is weight inclusive because otherwise yes, you are going to be inundated with the same messages that you were given and you need to have a strong advocate, a strong caregiver, a strong provider that is going to be there for you to say, “Wait, do
Naomi Busch, MD (34:48):
Not let
Julie Church (34:49):
Weight be the focus.” Again, remember where that took you when you developed an eating disorder, how about we don’t focus on that again. We’ve got to keep you away from that focus. So I really appreciate that you’re doing that and you’re bringing evidence-based research care to people and keeping them away from the focus on weight. And I understand many people probably are still seeking you because they’re concerned around that weight change resistance that they’re experiencing and I’m so thankful that you’re somebody that can at least give them a voice and opposition to everything else they’re hearing and perhaps in the same way I think of people when they’re actually nourishing themselves at the beginning and early part of eating disorder treatment, when they start to go, “Oh wow, like my brain is working again and oh, I’m feeling energized and I feel like myself and I want to love others and I have love for myself again.” I could see how you might have some of that same experience when somebody might be coming to you in all of this fog and difficulty and symptoms and everything and then they are treated by you with this compassionate approach and they go, “Okay, I still maybe am having a hard time adjusting to how my body looks or how I feel in my body and wow, I’m actually focused again and I’m sleeping again and I’m feeling more like my body’s a little bit more predictable.” And so I’m hopeful in that, that you’re out there doing this work for sure.
Naomi Busch, MD (36:10):
Yeah, I mean it’s really hard and for me the struggle is real because people come seeking weight loss. I bet. And hormone therapy is not a weight loss therapy. And the weight inclusive approach is really we’re going to get you healthy, meaning we’re going to work on your sleep and we’re going to work on making sure that you’re eating, that you’re eating enough food. Gosh, it’s so hard. I mean people are not eating enough and that you’re moving your body in whichever way is accessible to you and if in treating your symptoms and so if you want hormone therapy, if you want non-hormonal therapy, I don’t have a preference I just want you to feel better. And then once you feel better, then I feel that it’s up to … I mean, I do believe in body autonomy and so if people want to change their body, that’s up to them, but they need to be in a state of mind where they feel like they can make that decision rationally and not based upon what social media is throwing at them or this feeling of, “Oh, it’s this drug, it’s my body and if I just lose weight, I’ll feel better,” which is what the message has been for so long.
(37:27):
With hormone therapy and I guess the way that people probably want to know like, “Well, how does hormone therapy affect your body?”
Julie Church (37:33):
Can I interrupt so that is the main intervention or main treatment that you’re giving people or
Naomi Busch, MD (37:38):
What would you say? I would say that hormone therapy is usually why people seek my care, but then sometimes it’s not accessible to them or meaning they have reasons why they can’t take hormone therapy, which we don’t need to go into, but there are non-hormonal options, medications too, for treatment of like hot flashes or even sleep disruption. And so I think that’s important because you can imagine if people are not sleeping, we know that sleep and if I could just hang my hat on any one thing, like what is really changing people’s bodies, it’s probably sleep, you know what I mean? Like the lack of sleep.
(38:13):
Anyway, so I try to do it all and hormone therapy is a big part of it. I mean probably 80%, 90% of my patients want hormone therapy and when you stabilize people’s hormones, then the things like the body composition changes can stabilize so that the muscles respond and they can build their lean body mass or hold onto it. There is this theory and there is a little bit of evidence that during menopause, the menopause transition, people will notice weight gain in the midsection because it’s well documented that people go from having fat around the hips to fat around the belly. Fat around the hips is considered, and this is so gendered, gynoid. I know about what you’re about to say. And then Android, and it’s so annoying, but like the point is that people will literally tell me this and I’m like, “Yep, that’s normal.” And there’s many theories about why that is, but when you’re on hormone therapy, it just sort of kind of neutralizes it.
(39:15):
It doesn’t reverse it. And so people might notice like they just feel better in their body like, oh, it’s not … They’re going to the gym and they feel stronger. I mean, it’s pretty cool. I mean, that’s cool or like that they have more energy, right? They’re sleeping through the night and so now when they wake up in the morning, they just feel better and it takes the, I want to say it takes the focus off their body a little bit, hopefully.
Julie Church (39:40):
Great. So I’m mindful that we haven’t maybe focused on some of the mental health symptoms and I’m wondering what you can speak to in that regard because I find that in my peer group, my own self, that that is some of the most impactful life interrupting anxiety, depression. So I’m wondering if you can speak to that and if you are treating that through hormone therapy and/or psychotropic medication. Yeah.
Naomi Busch, MD (40:08):
Can you
Julie Church (40:08):
Just speak to that a litle bit? Cause that obviously for those that have struggled with eating disorders, majority of the people who struggle with eating disorders obviously have co-occurring depression, anxiety, other kinds of disorders. So I just would be love for you to speak to that a little bit.
Naomi Busch, MD (40:21):
So I mean 100% so that does happen, but I think so what we know about what we would consider, I like to call like perimenopausal anxiety or depression is that so in this country the guideline used to be that you started with psychotropic medications like name brands like Prozac, Zoloft, Lexapro, like those kind of medications that you would start there and then if you didn’t get better, then you would add hormone therapy, especially if somebody was having hot flashes or other perimenopausal symptoms. In other countries, it’s the reverse. So like in other countries they have recognized, I think the British Menopause Society has recognized that perimenopausal anxiety and depression and I, again, air quoting is a real thing. And so that it can be if somebody has symptoms of perimenopause and also has this anxiety and depression and it just sort of, or just it’s like at the right timing, then starting with hormone therapy, if that’s what they wish to do, can be very effective.
(41:31):
Is it always 100% effective? No. And so what I like to, I talk to my patients, I figure out which way they want to go and that’s what we do. And a lot of times I don’t make guarantees like this is going to completely reverse all of these symptoms, but I will say, we’ll see how it goes. You come back and if we need to, we can add, we know pretty quickly actually, like probably within a month, you know if you need to add something to it. The other thing that I think we didn’t talk about, but I’m going to mention now just to give it some light of day is the collision between premenstrual, what we call premenstrual dysphoric disorders like PMS and PMDD and perimenopause. So that is like a crash. It’s like a terrible accident on I5 in here in Seattle. So basically if people have symptoms of PMS where they get a little, again, a little crabby before their period or PMDD where they have sort of a life changing, disruptive, usually depressive, sometimes anxiety about two weeks prior to their period and then here comes perimenopause where periods become inconsistent, they can start having those symptoms all the time, right?
(42:46):
And so then those people come to me too in a state of despair and I usually will offer a version of some kind of hormone therapy, whether that is contraceptives, like so oral contraceptives or hormone therapy. The difference between those and menopausal hormone therapy is that they control your cycle and menopausal hormone therapy do not. So a lot of people have given oral contraceptives a bad rap in the menopause world because many, many women feel dismissed when offered contraceptives like oral contraceptives instead of menopausal hormone therapy, but there is a place for them and if people are having, if they need cycle control is what I like to say. I see. You need to take control of your cycle. If the moods are cyclical and they get more intense during perimenopause, like let’s take control. Or if you’re having two periods a month, oh, menopausal hormone therapy is not going to fix that.
(43:42):
So let’s take control of that. And so like a lot, I have lots of different tools, not very many, but a few different tools, three to use and I think for mental health it can make a big difference. The other thing with eating disorders or people with preexisting like mental health previous well controlled or maybe they’re off their medications now because they came off of them for their previous depressive episode or I would say that, and again, not evidence based, like this is just my experience over the last few years, people really know the difference. If they say this doesn’t feel like depression, like this is something a different kind of depression, and they will tell me that. They’ll say, “I had a history of depression,” or they’re already on something and they’re like, “This is so different.” The only word I can use is that existentialism.
(44:33):
It’s just different and it can be debilitating.
Julie Church (44:39):
I think when you’re talking about the PMS symptoms too, it’s like some folks I’ve understood too have never really had a lot of that very simple, basic, pretty routine periods and cycles and then the perimenopause season is like, whoa, wait, am I a 14 year old again and having my first periods and trying to figure this whole thing out again?
(45:00):
So much more learning. And I think that the thing that comes to my mind about it is it does draw us into our body. It’s a whole new phase of learning about our bodies, which I think is beautiful and wonderful in what we do in our eating disorder work is embodiment and trying to encourage people to come and trust their bodies again or from it in their eating disorder recovery and still society is not oriented towards that, right? So the drawing away and getting somebody else’s answers about our own bodies is really what our society still tells us to do. And so I just think that this is another phase of life or another condition, another situation that leads people hopefully to get guidance that your body can be trusted, listen, your experience is real and I appreciate that you’re doing that. Okay. So what about a few myth busters to close us out here?
Naomi Busch, MD (45:51):
So the first thing is, do we all need to take creatine?
Julie Church (45:57):
Okay, please let’s talk to that.
Naomi Busch, MD (46:01):
No, creatine has been shown there’s some studies that are like athletes, right? So we’re talking like, I think one of the studies I read was Michigan, University of Michigan football players. So athletes to help build lean body mass. And so I would say yes, like if you are working out and that is your goal and you’re trying to build lean body mass on the days you work out, this is what I tell my patients, five grams of creatine, do you need to load it? No, there can be problems with that, and when do you take it 30 minutes before you exercise up to 90 minutes after and it’s when you exercise that you need it. So it’s not going to build lean body mass. This is the myth. It’s not going to build lean body mass without you lifting weights, okay? The second one is, am I going to get dementia if I don’t take hormone therapy?
(46:57):
Is something bad going to happen to me? And the answer is no. Many people live to be 90, 95, 100 and never have been on hormone therapy before. So we have other ways of surviving without estradiol, our body can make other kinds of estrogens. So we’re not completely estrogen deficient. It’s just that some people have a lot more symptoms than others and those people can benefit. Another myth would be, do I need to stop my hormone therapy when I turn 60 or 65? A lot of people come to me with that question and the answer is no. You can take hormone therapy for the rest of your life as long as it’s serving a purpose. You should never take any medication or supplement if it’s not serving a purpose. And so if you no longer want to take hormone therapy, if you want to take it through your transition, I would say wait five, seven years after your last period, try coming off of it.
(47:50):
And then if you feel fine, great. And if you don’t, go back on it. And also bone health, right? That’s one of the reasons why you should be on, or you could be on hormone therapy for the rest of your life is if you, so you should know what your bone health is. Oh, and the last one, which we didn’t talk, and so we can just open a can of worms and then finish off the podcast because this is my favorite way to open this can of worms is, does hormone therapy cause breast cancer, right? I would be remiss if I didn’t just give its 30 seconds and the answer is we don’t think that estrogen causes breast cancer. The studies on estrogen alone, estradiol, conjugated equine estrogen are either neutral or show that there is a benefit, like a decreased risk in breast cancer.
(48:36):
If you do not have a uterus and you do not need progestogens, then taking estrogen alone can actually be beneficial. Okay. Now take, when you add a progestin in there, like what happens and it’s controversial, there’s like 26 studies and what I tell my patients is this, progesterone we have two observational studies that show no increased risk. They’re observational, which means that the people entered into the study were probably healthier, right? Because those people were already on hormone therapy. We didn’t give them hormone therapy and then follow them. Okay. So you kind of have to sit with that for a second, but from what we know, it doesn’t look like it causes an increased risk of breast cancer. That’s your body’s identical progesterone, which we usually start with. And then progestins, which are synthetic, they look like progesterone. They act like progesterone, but they’re not progesterone, okay?
(49:30):
They’re synthetic, which in this country we have norethindrone and medroxyprogesterone acetate and a couple others. There seems to be a slight increased risk and that risk is not what in medicine what we consider clinically significant, meaning it’s less than one in a thousand and you might think, oh, one in a thousand sounds like a lot. We do a lot of things in medicine that are one in a thousand, don’t really reach clinical significance until it’s higher than that, like on 300 anyway.
(50:02):
I always will check people’s and if you have a high risk of breast cancer in your family, but you yourself have not had breast cancer, hormone therapy is still available to you. I just say know your risk. And so I calculate out people’s risk and then if we add in a progestin, a synthetic progestin, not progesterone, I would say if your risk is 10%, now it might be 11%. So that kind of like qualifies it. You’re like, oh, so my risk really is having been born with ovaries. That is what gives me my risk of breast cancer. Adding this progestin might increase it, my own personal risk by maybe 10 or 20% going from 10% to 11%. And I know there’s a lot of numbers and that’s what I say to people, but the answer is it’s complicated and it’s available, like people should have this conversation with their physicians and if they don’t think that what they’re hearing is what they have been reading, then they need to find a menopause specialist or somebody else to talk to about it.
Julie Church (51:01):
I hope that’s what the listeners have heard and I hope especially those with eating disorders have heard you need not only the menopause expert, you need somebody that understands eating disorders is going to be very sensitive to all of this and continue to align with your recovery goals, keep you in recovery as well as helping you make the best decisions you need to for your own body moving forward in this phase, right? In the transition, menopause transition. So there’s so much more we could talk about. Oh my gosh. Okay. Well, we are going to need to finish it up though. So thank you. Thank you, Naomi, for being with us, for being on the appetite, sharing your wisdom with the listeners. Listeners, if you want to learn more about Naomi and the work that she’s doing, you can find her at Seattle Menopause Medicine and I will make sure to link that in our show notes.
(51:46):
So please check there for being able to quickly find her and I want to also thank Jack Straw Cultural Center for Sound Engineering, Erin Davidson for the Appetite’s original music and David Bazzi for editing. If you want to learn more about Opal’s programming, please visit us at opalfoodandbody.com or follow us on Instagram. Until next time.
