SPEAKER_01: 0:09

Hey guys, welcome back to Preview Alliance Podcast. This is Sarah, and today I'm so excited about this episode, guys. We're in October. And if you guys don't know this, it's not just Halloween month. It is about perimenopause, menopause awareness. So I have brought to us an amazing expert, Dr. Lindsay Stan Evan, who's going to be telling us from a reproductive psychiatrist level, from a lady, from a woman, from a mom level, hey, what are we going to be prepared for? Lindsay, welcome. Thank you so much for having me. So tell us who you are, because I got to know you recently and I think you're fabulous and the best advocate for mobs out there, but let our listeners know about you.

SPEAKER_02: 0:48

Yeah, yeah. So I'm a psychiatrist, and then I did additional training to become sort of expert in understanding how mood, anxiety, sleep, thinking are all impacted by hormones and hormonal fluctuations. And so that's called reproductive psychiatry. So reproductive psychiatry specifically focuses on how periods of reproductive transition, pregnancy, postpartum, prior to the menstrual cycle, perimenopause, how those times are periods of increased vulnerability and understanding how actually then the mental health approach might need to be different. So I am trained as a psychiatrist. I did additional work to become, you know, expert in this area. And then I now am working as a visiting associate clinical professor at Colorado University. And then I have and am the co-founder of a group called the Reproductive Psychiatry Collaborative. And I also work on educational initiatives for a great group called the National Curriculum in Reproductive Psychiatry.

SPEAKER_01: 1:50

So those are I love all that.

SPEAKER_02: 1:52

Love all that.

SPEAKER_01: 1:53

And mom and mother. So those are the hats. We love the fact that you're coming to us as an expert and a mom. And what drew you to this? I guess that's always a good question of like, well, what? Because people are like, wait, I didn't even know this existed. But so why did she know this and why does she want to do this?

SPEAKER_02: 2:10

Yeah, yeah. I think a number of things. I think many of us come to this due to our own lived experience. I had my own experience with infertility, with polycystic ovary syndrome, with perinatal mood and anxiety. So it was interesting actually, because all of that actually happened as I was training and I think helped me to really, I think, become really empathetic for my own lived experience about sort of these issues. The other part of this is that as a psychiatrist, I was really struck by the fact that much of what we were taught was based on data or science that had been done in male populations. And I don't want to just use strictly binary terms, but that is actually what the literature was based on. And sort of got passionate about the fact that actually what women experience and the biology of women is different. And so it needs a different psychiatric and psychological approach. And then I met two mentors who really became heroes to me. And so sometimes it's finding those people that you want to be just like Dr. Lauren Osborne and Jennifer Payne that sort of inspired me.

SPEAKER_01: 3:17

I love that. And we're so glad that you're on this path and you're here to help us. So one thing that hit me like a train was when our listeners know that I had to have a hysterectomy unexpectedly in for my second son. And I went into paramenopause, then to menopause straight away. And why do you think that, you know, when we talk about perimenopause or any even menopause, we hear the hot flashes, we hear weight gain, we hear kind of the buzzwords, right? Or the middle life crisis, but we're not hearing, much like we don't hear in pregnancy or postpartum, right? The mental health toll, the mood swings, anxiety, depression, hopelessness. I mean, mine was very severe. Yeah. And more so than my postpartum depression. So why is this noise more about, you know, oh, she's she's, you know, she's got the weight gain, she's hot flash, but it's really it's it's it's darker.

SPEAKER_02: 4:12

Yeah, yeah. I I think there's many different reasons. I think that part of it is that those are not things that we still feel comfortable talking about. And frankly, it's not things that many physicians or doctors talk about enough, right? I mean, I think one of the issues here actually goes back to training. Even in medical school, I remember sitting there thinking, you know, we need to all be very good about asking about mental health and suicide, just as good as we are at asking about what's your blood pressure, right? What's your temperature today? Where's your pain? We don't think of mental health as a form of physical pain, right? The idea that our somehow our brains and our bodies are not connected is uh is very bizarre to me because everything that we produce in our body has an impact on our brain. So when they took out not just your uterus, but also your ovaries, where estrogen was produced, that changed your body and your brain. And I think there's just sort of a stigma against talking about the emotional component of these because we don't see that as biological. But it's it is an illness just like anything else, right? If I'm low in vitamin D or I'm low in iron or I have diabetes and I don't have enough insulin, we give that back, right? And nobody feels ashamed about doing that. But somehow, if we're suddenly deficient in estrogen, we feel ashamed for the fact that we're struggling. And I think society shames us, right? Like somehow that's a weakness. Well, is somebody who's iron deficient weak because they're exhausted? No, they don't have enough oxygenation in their body, period. Right. So it's again, it's going back to this idea that this is biological.

SPEAKER_01: 5:52

Yeah, no. And, you know, the studies show, and you're super up to date with all the research and literature about it, to know, in perimenopause, they're saying four in 10 women are experiencing these symptoms, right? And it's it's things that are very comparable to almost PMS, or sometimes you feel like in postpartum, and it's the irritability, the fear, the fatigue, the tearfulness. But unlike PMS, where we're like, okay, here's a period. Okay, we now like I remember I would get my period be like, oh, I'm normal again. In this perimenopause, menopause journey, which, you know, can start in your 30s or couldn't start earlier if you have like a surgical removal of your ovaries for many different reasons, right? What do you see in this in your practice with your patients? What is the common symptoms if they're going, okay, Lindsay, maybe I am experiencing something different. Maybe this is not talked about enough and I was thinking it was this, but it's actually, I need to dive deeper. Absolutely.

SPEAKER_02: 6:51

So one thing I want to just sort of clarify is perimenopause and menopause, because I think we get confused about it. So basically, perimenopause describes the time leading up to menopause. And you cannot say that you have gone through menopause, that you have completed sort of the transition until you've had one year without a menstrual cycle. Okay. But the issue is that that happens at about the average age in the United States is about 51. However, the symptoms that occur leading up to the last menstrual cycle for a year, right, actually can occur four to eight years beforehand. Okay. So we're talking early 40s for many individuals. And those symptoms are not nothing, right? And that's what you're describing. And because we don't talk about the fact that yes, in fact, these symptoms can really be starting four to eight years beforehand, people don't understand, right? Nor do they talk about the changes that they're noticing. So it's not as though estrogen and progesterone, which I'll tell you about the biology in a second, it's not as though the decline in those hormones, right, as the ovaries sort of shut down, is something that happens overnight. It's a steady decline and it's actually a steady fluctuation as those hormones decline that really cause these symptoms, right? So that's where individuals come in and they will notice that they're having more frequent menstrual cycles, certainly in the beginning, and then they space out. They're having headaches, they're having heart palpitations, they're showing up to the emergency room thinking that they're having a heart attack because their heart's pounding. They're having musculoskeletal pain. I've had patients come in saying, my body hurts. I've seen a rheumatologist, I've seen a guy, you know, I've seen a primary care doctor, I've seen all these people, whole body muscle pain. They're having restless legs, they're having vaginal dryness, they're having more urinary tract infections, they're having pain during sex, they're having changes in their libido, their energy, insomnia, fatigue, anxiety, irritability, concentration coming in and saying, it feels like I am moving through a cloud. I just had this profound brain fog. And the really challenging part of this, right, is that think about where a woman is in their, you know, mid-40s to early 50s, okay? This is peak career, peak motherhood, right? It is the most, you know, sometimes it is becoming a caregiver for one's parents. It is the time probably of some of the greatest psychological changes in one's life, in addition to these very real biological changes that are happening that sort of make it even harder to access one's coping skills or to get through the day, right? It disrupts sleep. We are having trouble focusing and concentrating. The hot flashes wake us up or they are interrupting during the day. The brain fog makes it hard to get work done or to even give a talk in front of people. The musculoskeletal pain, it makes it painful to sort of get through the day. So, in our approach for decades, has been don't talk about it. It's menopause, it's something you have to get through. Okay. It's perimenopause, get through it. There's nothing you can do about it. And we do this a lot when it comes to women's pain and suffering. It's just there's sort of this attitude of this just is something you get through and you don't really have choices or options. And women deserve to be able to go through perimenopause, menopause, also pregnancy, postpartum, and premenstrual concerns with options that are based in evidence. And there are ways that we can treat these symptoms. You don't just have to white knuckle through things, right? And I think that is the attitude is oh, if it's mental, you white knuckle through it.

SPEAKER_01: 10:35

No, a hundred percent. I mean, so I guess it's a good question. So if they're listening, they're going, okay, great. So yeah, I had PMDD all my life, or I had depression during pregnancy, or I had postpartum anxiety. What does that mean? What do I need to be in my head thinking what's coming my way with perimenopause and menopause?

SPEAKER_02: 10:55

Okay. So let's talk about the biology briefly, and then I'll talk about why those individuals are at risk. Okay. So we know that the hormones produced by the ovaries, estrogen, progesterone, that they act in the brain. And they act in the brain in really key places, places that basically affect one's mood, one's concentration, one's sleep, one's attention, even the area in the hypothalamus, which is a part of the brain, that regulates temperature sensation. Okay. So estrogen and progesterone really regulate many parts of the brain that are important in all sorts of neurotransmitters, even things like serotonin, which we all know about from depression and anxiety, is the key neurotransmitter. And so what happens is that when these levels change or fluctuate, okay, that our brains are supposed to adjust to that. Okay. So they basically say, oh, look, estrogen's falling. We're gonna change the level of receptors or we're gonna change the parts of the brain so that we're keeping everything even keeled, right? Our brains are supposed to be dynamic and adjust. But what we know is that that's not as easy for everybody. Okay, so for some individuals, they are differently sensitive to the fluctuations in hormones. So for example, premenstrual dysphoric disorder or PMDD. What happens for those individuals is that with every single menstrual cycle, for example, as estrogen and progesterone decline, and it's particularly progesterone, and that's a different conversation. But as those levels decline right before somebody gets their menstrual cycle, that rapid change causes real psychiatric symptoms and physical symptoms. So that's where the irritability, the anxiety, the change in sleep, a lot of people talk about the profound irritability and then the physical symptoms as well, insomnia or sleeping more. And they talk about brain fog, that there's differences in concentration. And then what happens is as soon as they get their menstrual cycle and those hormones start to come back up again, they feel better. And the same thing happens at delivery, right? There's a rapid drop in those hormones that have been seven to 10 times higher across pregnancy. So it's a huge, you know, roller coaster down. And not every individual is able to sort of adjust as rapidly as others. And we think that is what contributes to postpartum depression. Now, perimenopause is essentially a constant oscillation of estrogen and progesterone as it declines. And so what they're experiencing with that oscillation is very similar to what we're talking about with PMDD and perinatal or postpartum depression, where when they're having these oscillations, this up and down and up and down and up and down in hormones, that it causes this huge change in all of these different areas of the brain. And so if you were somebody who had PMDD, if you were somebody who had postpartum depression, you already know that you're somebody whose brain is maybe differently sensitive to the fluctuations in hormones. And that's not a weakness, that's just a difference in biology, right? Our bodies are different.

SPEAKER_01: 14:11

What would you advise a patient who you saw her, you know, for postpartum depression? You guys, and now she's like, okay, Lindsay, now I'm back, you know, here eight years later. This is what I'm experiencing, or I'm afraid I'm going to experience this. Is there any prep? Is there anything to be aware of, you know, because we always talk about early in pregnancy, like, know your risk factors, get your support set up, find you, you know, if you can't have a you in your state, is it a therapist? Is it OB who feels comfortable to scribe? What can she do like to be actively engaged?

SPEAKER_02: 14:43

So I actually talk to all of my patients about this. And that's why we need to get education out here, is because this shouldn't be a surprise, right? We deserve to know what to expect and when to expect it. And so I will, because I treat so many individuals with depression and anxiety, and we know that even separate from PMDD, many people with depression and anxiety notice that their mood worsens pre-menstrually, even separate again from PMDD, is I'm often having individuals track their mood in their menstrual cycles. And so I'll have them use different apps on their phone. There's one that's called Mac PMSS, there's Flow, there's all sorts of different ones that you can use to really look at where am I in my menstrual cycle and how's my mood as a result. And that's important because then what you know is that I'm, and I say to them, listen, when you're in your early mid 40s and you start to maybe notice that your mood and depression or your anxiety is starting to rev up again, or that the medicines that you're on are not holding you, holding your mood in the same way that they were before, you're not making that up. Okay. That is because the biology is changing and we might need an adjustment. And so I will often talk to them about exactly that, which is that, you know, to be monitoring and looking out for this and to maybe plan to come back for an evaluation or to come back into care or to have an OBGYN who feels comfortable prescribing hormone therapy. And just so that there's an awareness that this can happen and that we do have resources. We do have treatments for this.

SPEAKER_01: 16:20

What is your thoughts about hormone therapy? I'm personally on it, and that has made a huge difference for me. But I know there's a lot of pushback, lack of education, lack of resources, and they don't know really. They're like, okay, should I go to OBGYN? Should I find a Lindsay? Wait, do I have a Lindsay must say? Like all these things if they're like, I'm experiencing this. What's this next step?

SPEAKER_02: 16:42

Yeah, yeah. So a lot of this also comes from the fact that there was research that was done, right? That there was a lag then in being able to redo the research in women and then to be able to get the updates in the research out to people to sort of say, listen, we have updates in the science, right? Science is always updating and sort of saying, oh, we found this new interpretation or we found this new outcome. So essentially what happened is there was an interpretation of some of the earlier studies. You know, this is sort of like the earliest studies looking at hormone therapy. And they basically originally found that hormone therapy was associated with not causing, but that there was an increased risk of clots and strokes, right? And so that's why they took it off the market, right? Or there were all these warnings about it. But what's happened in the last decade is they actually looked at those studies again. And when they separated the population of women to those who are greater than 65 or greater than 10 years past the menopause transition, and those who are less than 10 years or within the first 10 years of the menopause transition, the risk associated with hormone therapy was very different. So for the individuals who were within 10 years of the menopause transition, and that includes perimenopause, they actually found that hormone therapy did not show an increased risk of strokes and clots. In fact, it was cardioprotective, right? We know that actually one of the leading causes of death in females are cardiovascular events, and that the decline in estrogen that occurs is one of the causes of that, right? And so they actually found that it was cardioprotective. It helps with bone strength, right? Falls are also a significant cause of mortality and morbidity in women. There were some cognitive protective factors, and it basically overall decreased all cause mortality and morbidity when you used it within the first 10 years of the menopause transition. And I don't think that information was disseminated. I think we still live in a world of fear because of the old information. And so what we now know is actually that hormone therapy can not only improve quality of life, decrease hot flashes is what it's the gold standard for, right? Adding back that estrogen is the gold standard for that. But also, let's talk about some of the other stuff. Protective of bones, right? So protective against falls, vaginal estrogen that's applied can decrease the risk of urogenital symptoms. And that includes, yes, we're allowed to have quality sexual experiences so that can improve our sexual satisfaction. It also reduces things like urinary tract infections, right? Complications to urinary tract infections cause people to die. And then the other part that's really coming out is that there's real improvement in mood and anxiety and brain fog. And so it's about morbidity, mortality, and quality of life for individuals. And so we're really doing women a disservice by saying, oh, you're in perimenopause, or oh, you're in menopause, you don't need to be on hormone therapy. When in fact, what we know are that all of these symptoms are worse during that time, that the risk of depression and anxiety is two to four times higher during that time. And then once somebody's five years post-menopause, those things tend to get better. And so it's great because the time when these medications are actually safer to use, right, is also the time when the individuals can benefit the most from it and need it the most.

SPEAKER_01: 20:22

No, absolutely. And, you know, even discussions with some of my friends who are physicians about me being on that, and they're like, oh, but the research. And I was like, no, there's new. And then so I always tell people I'm like, it's very difficult as a provider to stay up to date if this is not your thing on the latest and greatest. So it is okay to do your own research and bring that to your provider or find a different provider if you two don't align, but know your own research and that you do not have to live. And I mean, I thought I was going crazy. And I hear that from a lot of other women that are like I survived postpartum, but then man, I thought I was going crazy. And it's the difference I felt was this is an extended period of time. Pregnancy is postpartum. Yep, you know, zero to three, or and then we know outcomes up to six, right? It can live in this, but this is further out. And do you think that contributes? Because there's a high suicide rate for menopause and perimonopause women. Let's, I mean, it's a sobering number, honestly, about being suicidal and taking your own life in this stage.

SPEAKER_02: 21:27

Yeah. Yeah. So this is sort of why reproductive psychiatry exists, is what we know is that during times of hormonal transition, there's an increased risk for mood and anxiety disorders, which includes increased risk for suicide, right? And so, yeah, there's this sort of sobering study showing that there was a seven times higher risk of uh suicide attempts during this population. And I do think that is because we are not talking about these symptoms. We're not educated about the symptoms. We think we have to white knuckle it. And biologically, it is really a time where you are not feeling well and nobody's acknowledging it or telling you you have options. And as we talked about before, psychosocially, you're going through a tremendous amount. Right. You know, you're juggling career, you're juggling children, you're juggling empty nesting for some, you're juggling becoming a care of your parent. It's a lot. I also just want to stress that one of the things that I find also upsetting is that many people will actually present with this sort of not feeling like myself. There was this great article by C O S L O V Koslov that talked about sort of this not feeling like myself syndrome that she sees. And that's worthy of being evaluated for too, right? Like it pains me that you got to the point where you were like, I am going crazy, right? Before anybody would maybe even listen to you, right? But not feeling like yourself is also worthy of getting attention for, right? Like if you're struggling with sleep, hot flashes, concentration, anxiety, and you're just like, I just don't feel like myself. I'm not happy, I'm not present, I'm not motivated, I can't concentrate. We can help, right? And we don't have to white knuckle it.

SPEAKER_01: 23:11

Yeah.

SPEAKER_02: 23:12

Alone. You don't have to do it alone, too. If we're talking about it, then we're not alone. And that has shown evidence. Support groups, therapy for other individuals, just knowing that other people experience this is hugely therapeutic.

SPEAKER_01: 23:25

No, and that's, you know, and I've always said I said it's it's a vulnerability that I think if you've had a lived experience. And if it was infertility, if it was during pregnancy, depression, anxiety, was postpartum with traumatic birth, now perimenopause, menopause, to say, I, you know, I experienced this. And you go, I did too. Like that's an instant, it's not just me, it's not a Sarah character flaw, exactly. Which we like as women like to assume or that we're failing. But we really love bringing evidence and we say name entertainment a lot, that if you know that there is a name to this, what you're experiencing, you're more likely to seek help, you're more likely to get educated and have your family, because a lot of times, like my family, they're like, What's going on? Like, you know, this is not postpartum, is it? Or is it not? Because that's what was blurry in my situation too, was she going through postpartum depression again? Or is this something totally different?

SPEAKER_02: 24:18

Yep. Yes, absolutely.

SPEAKER_01: 24:20

Absolutely. So, what do you say to our listener who is going, okay, great, Lindsay? This is coming my way. Like, I, you know, what's some words of encouragement of success? Because we always like to show and talk about on the other side, you know, the patients that come to you, that they're doing better, that they're living better, that they're managing it, that they didn't suffer through.

SPEAKER_02: 24:44

Yeah, yeah. I love your name, entertainment, right? I think just knowing and educating yourself about it. There's a great book, Estrogen Matters. There is MGH, Mass General Hospital, has a lot of resources. And I also just want them to know that there are options even outside of hormone therapy, although I am a very large proponent of that. So there are things you can do that have been shown to also help symptoms, right? Cognitive behavioral therapy. So learning about watching how your thoughts are related to your feelings, changing the amount of alcohol intake can also change sort of the symptoms that you're experiencing. Just getting help with sleep. So there are apps on your phone, cognitive behavioral therapy for insomnia that can be helpful with sleep. Reaching out to a friend, right? And having these conversations, yoga. I mean, there's really a lot actually that has been shown to be beneficial that feels within our control. And finding a doctor, right? Talking to your primary care doctor, talking to a therapist, talking to a psychiatrist, because there are options to reduce the physical symptoms and also to not feel so alone. And so that's what I would say is that this is not something that has to take over your life. It's something you can live with and flourish over, right? We can flourish through this time. And every woman deserves to have that. They deserve to have this be to be something that is treatable and to have knowledge about it and to have a care plan in place to address it.

SPEAKER_01: 26:13

I love that. And before we let you go, we're gonna ask you what we ask all our guests. So this is your mom hat, not doctor hat, if you lunch with what would you tell now as a veteran mom, yourself, as a new mom, or when you were pregnant that you wish you would have known or someone would have said to you that would have helped you and encouraged you.

SPEAKER_02: 26:31

Oh man. Um I had two babies and I had a baby and a NICU in the NICU. So I think that one of the greatest disservices we do to women is to not tell them about how hard this all can be, right? It's almost like we don't say, listen, breastfeeding can be really hard. And that doesn't mean that you're failing as a mom, right? Or you're not a bad mom if you don't like the newborn stage. I newborn stage was not for me, right? That doesn't make you a bad mom. Or if you have these horrible intrusive thoughts, that doesn't make you a bad mom, right? You know, I think just understanding about how huge these periods of both hormonal transition and life transitions and the fact that they overlap, that that is really the most impactful thing that you're gonna go through. Because I actually think we're scared of talking about the negative as if we're gonna scare people away from doing it, right? Or suddenly create postpartum depression. We can't create postpartum depression, right? It's like, it's like if you talk about, if you tell kids about sex, they're gonna have sex and not use condoms. It's like, no, but we we still have to have a plan in place here. So I really wish that I had known just how hard the sleep deprivation and taking care of myself, that actually taking care of myself was the lifeline to my family, and that that's not selfish. That we don't have to be bleeding and sacrificing all the time. And that's true in perimenopause too, right? We sort of say I'm gonna white knuckle through it, I'm not gonna ask for help. And actually, helping ourselves is how we sustain everything we do, including our kids. It's the most powerful way to demonstrate resilience to our children, is showing them that self-care is important.

SPEAKER_01: 28:18

Well, Lindsay, I am obsessed with your work and everything you're doing for patience, for teaching, for advocating. Well, likewise, we're so grateful that you're on. You're welcome anytime back. We've got a plethora of topics we can pick your brain about. So we love that. But thank you so much, listeners. I'm gonna link some good links to kind of if you guys want to learn more. If you're in certain states, hey, and you're looking for a doctor, Lindsay could be that for you. So we'll we'll play everything there. But we appreciate you guys for tuning in to the conversations to better yourself, to be more educated, to support the loved ones around you, and again, to know you're not alone. So I'll be back next week. Thank you so much.

SPEAKER_00: 29:00

Maternal mental health is as important as physical health. The Preview Alliance podcast was created for and by moms dealing with postpartum depression and all its variables like anxiety, anger, and even apathy. Hosted by CEO, founder Sarah Parkers, and licensed clinical social worker Whitney Gay, each episode focuses on specific issues relevant to pregnancy and postpartum. Join us and hear how other moms have overcome mental health challenges as well as access tips and suggestions on dealing with your own challenges as moms. You can also browse our podcast library and listen to previous episodes at any time. Please know you're not alone on this journey. We're here to help.