You might not fully understand the menopause experience unless you go through it — but author Catherine Newman’s latest novel “Sandwich,” might get you pretty close. Catherine and Mayo Clinic menopause expert Dr. Taryn Smith join us to discuss the book, which wonderfully captures the complicated feelings and sometimes surprising symptoms of menopause.
You might not fully understand the menopause experience unless you go through it — but author Catherine Newman’s latest novel “Sandwich,” might get you pretty close. Catherine and Mayo Clinic menopause expert Dr. Taryn Smith join us to discuss the book, which wonderfully captures the complicated feelings and sometimes surprising symptoms of menopause.
This episode was made possible by the generous support of Ken Stevens.
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Dr. Denise Millstine:Welcome to the “Read. Talk. Grow” podcast, where we explore women's health topics through books. In the same way that books can transport us to a different time, place, or culture, “Read. Talk. Grow.” demonstrates how they can give us a new appreciation for health experiences. Books can provide understanding of health topics and provide a platform from which women's health can be discussed.
At “Read. Talk. Grow.,” we use books to learn about health conditions in the hopes that we can all lead happier, healthier lives. I'm your host, Dr. Denise Millstine. I'm an assistant professor of medicine at Mayo Clinic, where I practice women's health, internal medicine, and integrative medicine. I am always reading and I love discussing books with my patients, my friends, my professional colleagues, and now with you.
Our book today is “Sandwich” by Catherine Newman. Our topic once again is going to be menopause, though we'll be looking at some aspects of the topic that we haven't previously discussed, so stay tuned. My guests today are Catherine Newman, who has written a gazillion pieces, columns, articles including canned bean recipes for magazines and newspapers, and has also written two memoirs, two kids’ life skill books, and a middle grade novel.
“We All Want Impossible Things” was her first adult novel and was featured on
“Read. Talk. Grow.” for an episode about being a friend to a friend who is dying. Catherine is our first repeat author, which is so exciting, to discuss her second novel, “Sandwich,” which was released in 2024 to great acclaim. Catherine, welcome back to the show.
Catherine Newman: Thank you. I'm so glad to be back.
Dr. Denise Millstine: Our second guest is Dr. Taryn Smith, who's a board-certified internal medicine physician, women's health specialist, and certified menopause practitioner at Mayo Clinic. Dr. Smith completed internal medicine residency training at Mayo Clinic in Jacksonville and a women's health fellowship at the Cleveland Clinic. Her clinical areas of interest include menopause, sexual health, complex contraception, and gender-based differences in medicine. She's the author of several scientific publications. Taryn, welcome to the show.
Dr. Taryn Smith: Thank you. I'm happy to be here.
Dr. Denise Millstine: The novel “Sandwich” is a family story. It's structured around a beach cottage familiar to this family over a typical Saturday to Saturday rental in the Cape Cod town of Sandwich, where our protagonist, Rocky, is a middle-aged mom of young adults and daughter of aging parents whose menopausal transition has been full of some unwelcome surprises and also a lot of nostalgia.
Catherine, I am hoping you understand how much I enjoy your writing. You have moved to my list of. I will read anything that you write. When I was reading “Sandwich,” I texted two of my affectionately termed book nerd friends to say just that, and they agreed wholeheartedly. You tackle real issues, but layer in humor and keep it real. Thank you for approaching it this way.
Catherine Newman: Thank you so much. That's really nice to hear.
Dr. Denise Millstine: I'm somewhat curious who you were picturing as your reader of this novel. I thought you were picturing me, a middle-aged woman going through her own menopausal transition, but I was recently at an independent bookstore and saw a 20 somethingish woman pick it up and show it to her friend and say, “I just read this book and I loved it. I read it in a day.” Are you seeing readers across the age spectrum for “Sandwich?”
Catherine Newman: That's a great question. And weirdly, I am. And I also pictured people like us who, you know, we're kind of hitting menopause. I thought it was going to have a very narrow band of readers, and like a lot of young women are talking to me and being like, “Oh, I read it. And it made me think about my mom.” And I think that's like, I don't know, this kind of connection among reproductive generations. Like, it, that's the only thing I can really think. And you know, there's a character woman character in her 20s in the book and maybe her voice is it's of interest to young people. But I don't totally know.
Dr. Denise Millstine: Well, you have mentioned with your previous novel that much of your writing, your fiction, is informed by your real-life experience, and even writing fiction allows you to, I think you've said, tell more of the truth. So not only is Rocky inspired by some of your experiences, but some of the other characters are inspired by people you know.
Catherine Newman: Yes, that is true. Yeah, everybody in the book is inspired by somebody I know, usually the person who has their exact analog in my life. So yeah, and I think, you know, the young adult woman in the book, Willa, is very much my daughter, and my daughter is if I have one person I'm writing for, it's her. Like, you know, people say, who are you writing for? Don't you worry that you're going to offend people with some of the topics you talk about? I always think you can't write for the people who are going to be offended, like, they're going to hate you anyway. So I always just write for my daughter because I know she'll love it. So maybe weirdly, because I wrote the book for her, it's speaking to other people her age.
Dr. Denise Millstine: And probably a component of what I wish I knew as I was going through my hormonal lifespan, that’s going to happen when I was middle aged.
Catherine Newman: I mean, “hormonal lifespan.” Exactly. I'm just writing that down because that is so what I'm trying to write about.
Dr. Denise Millstine: So Taryn, in one of the first scenes of “Sandwich,” where we recognize that Rocky is going through her menopausal transition, she's in a line at a bakery with her husband, and she is profoundly angry at him, that he could possibly not know what pastry she was about to order. She somewhat recognizes that this is out of proportion, but when you're seeing women who are coming in for menopause consults or to talk about perimenopause, are you seeing similar irritability and mood change complaints?
Dr. Taryn Smith: Absolutely, definitely. So even women who have never had mood issues, ever in their life can start to experience the irritability, the moodiness, anxiety, even depression once they start to transition into menopause. Women who have previously had mood issues or premenstrual symptoms, PMS symptoms before periods. Sometimes they can experience an exacerbation of that. But the short answer to your question is absolutely. This is something that I see pretty commonly.
Dr. Denise Millstine: And one thing I find with patients in this age range, is that it's really helpful to connect those dots to say, “You know, it's possible that what you're experiencing now is definitely related to these fluctuating hormones.” And I've seen many have that moment where to some degree they feel better because maybe I'm not the monster I'm telling myself I am. Or maybe my partner is not this terrible person who I'm treating him or her as he is. Would you agree?
Dr. Taryn Smith: Definitely. I would definitely agree. And I would also say one thing that I've noticed now that we're talking about menopause more now, that is more mainstream. A lot of my patients are coming to me asking, is this related to menopause? Because they, you know, read “Sandwich” or they've seen some sort of article. And so, you know, thank you, Catherine, for writing this book because I think it's just going to empower women. And I'm seeing that more and more in my practice.
Catherine Newman: I feel like then you're not on top of every other thing feeling either like you're crazy. Or like it's like morality issue, you know what I mean? It's like it's amoral. It's not moral or immoral. It's menopause like it's, it's neurochemical. And that for me is just, was a huge relief. Like I had a really great OB who really was like, “This is what's happening to you. And it helped me feel so much less crazy.”
Dr. Denise Millstine: Well, I know often in the world of menopause among professional colleagues, we emphasize that menopause is not a disease. If you are lucky enough to live long enough as a woman or a person born as a woman, you will go through menopause. It is just a stage of life which you know, we can do things to manage the symptoms and the outcomes, etc.
So another episode in the book is when Willa, who we've already mentioned, says to her mom, “Old women, what are they even good for? It's not like you're making babies anymore.” This is an important thread in “Sandwich” regarding menopause that I want to spend some time on. Catherine, talk about menopause, the end of fertility. No longer being a woman who could bear a child. This clearly was important to many of the aspects of this book.
Catherine Newman: Yes, it's so interesting because even if I — see, like, pregnancy and parenthood rewired my brain such that I had this persistent orientation to having more children, even though rationally I didn't want any more children. So I felt as that part of my life sort of biologically wrapped up. Even though I'm 55, I'm not going to get pregnant again. I'm not going to have another baby. But there's this weird undercurrent. I might, you know, that even though I'm not planning to. Until very recently, I felt like I could have. And kind of wanted to, even though I really, really didn't want to. So the giving up of that, has been really profound. And I don't want to overshare, but it's also really interesting.
Like if you're in a body with a uterus and having sex with a man and you've been doing that your whole, like reproductive life, as I have like to drop the possibility of conception out of that equation. It's a really big deal. I am now not going to get pregnant from having sex, that's new to me. That's never been the case for me before. So anyway, it's just a really it's kind of a big deal. I mean, Taryn, I don't know what you see in your patients around this or if they have occasion to talk to you about it, but it's such a kind of profound reorientation towards a body, towards sexuality.
Dr. Taryn Smith: It certainly is. And it's understandable because at this point in life, you know, most of your years have been reproductive years. You've spent 30 to 40 years having periods and being able to get pregnant. And so when that starts to change, it's reasonable for to understand how you can mourn that loss of the ovulation and in reproduction and being able to get pregnant. So it's certainly understandable. But I will say every woman is different. I have some patients who look at it another way and say, “Oh, thank God, I can't get pregnant anymore or thank God I'm not having periods anymore.” Who wants to deal with that? So, you know, every woman is just so different in terms of how she processes this transition from a reproductive standpoint. But some women are just glad to give it up.
Catherine Newman: Yeah. And some women — I know for a fact because it's me — feel both things. Like I actually feel truly both ways about it, that I'm really happy to have it behind me. And I feel more and more like I'm living in this body, not as like an object in the world, but as a self with agency. And I'm not like a decorative thing in the world. I'm like a person, that's pretty new. And then I'm sad to give it up like I it's just a lot of different things. It really is. And I am nostalgic, you know, I loved being pregnant and I'm never going to be pregnant again. It's just that weird that it only moves one direction and it's so weird. It's not like you then return to fertility, like that's it.
Dr. Taryn Smith: It's so final. Like the final chapter.
Catherine Newman: Yeah, yes.
Dr. Denise Millstine: Just I like the phrase that Taryn used that “mourned the loss.” And then to layer that with, with Catherine saying it's the loss of the possibility, even though you were intentionally choosing not to become pregnant. Now it's not even an option anymore. And I would say it probably is mixed for many, if not most women, that there's that recognition of the closure and then also the liberation of the no longer having to worry about whether you'll have an unintended pregnancy.
Of course, this is once your menopausal, meaning you've stopped having cycles. Taryn, do you want to mention the Russian roulette that happens a little bit in the perimenopausal years when we start to have irregular periods, and now our fertility is not stopped, but it's actually unpredictable.
Dr. Taryn Smith: Oh yeah. So perimenopause, like you said, is Russian roulette, sometimes it seems like anything can go during perimenopause. But how I often explain it to my patients, I don't start with perimenopause. We kind of start from the beginning, from the reproductive years. So during those years we're having fluctuating hormone levels. But there's this really nice rhythm, very, very tight rhythm. So the hormone levels fluctuate to prepare for ovulation. They fluctuate to prepare for pregnancy. And then if we don't get pregnant, we rinse and repeat essentially. So we have a menstrual cycle and everything starts over.
And then when perimenopause comes around, then we start skipping beats. And so we know longer have that really nice rhythm. Sometimes the hormone levels are elevated. Sometimes or not we might ovulate, we might not ovulate. And so one of the first things that we can see periods start to become irregular. They get spaced further and further apart as your ovaries are trying to keep up with ovulation and estrogen production. They can't. And so over time the levels of estrogen just get lower and lower and lower. And then when the beat just stops, that's menopause. And so once things stop, we're not going to go back to those reproductive years. We're not going to ovulate again or get pregnant.
So that's kind of how I like to explain it. But you're right. Things can be all over the place during perimenopause, in terms of the hormonal fluctuations. And a lot of that is responsible for the symptoms that women experience. Those rapid fluctuations can be really irritating to the brain and can cause the irritability and the mood changes and hot flashes, and a lot of the other symptoms that we see.
Dr. Denise Millstine: They can cause changes in bleeding, too, which Catherine, you describe in “Sandwich” as your period doing this kind of horror movie swan song, which I think you're referring to often these cycles with very heavy bleeding that many women have to navigate in, they're typically in their 40s and into their early 50s. So thanks for that phrase.
Catherine Newman: You’re welcome, I know. And the clots, it really. Yeah. It was really something.
Can I say something that maybe is TMI and you can just edit it out. But Taryn, I had this really weird experience where I would feel somewhat erroneously confident, but my fertility was behind me. I would have unprotected sex. And then I swear to you, the having of unprotected sex would trigger ovulation and I felt like my body was tragically just grasping at opportunities to, like, squeeze out one more tiny little baby and I just felt like, okay, I need to be more careful than this. That's how I felt, like I could have gotten pregnant during perimenopause. I feel like I, I mean, I know you're saying that's just true, but I really feel like it's such an odd time because you're almost done, but you still have these kind of hormonal motivators, you know, that are kind of like, that weird voice in your head that's like, go ahead. It's totally safe. But it's actually not. It's so, so strange.
Dr. Taryn Smith: I've actually never heard anybody describe that sensation before, of feeling like ovulation is being triggered by intercourse. I don't know that it necessarily happens that way.
Catherine Newman: Yeah it may well not.
Dr. Taryn Smith: But I will say, you know, it is smart to have that healthy ounce of caution because there's not a good way to track whether or not you ovulated during perimenopause. And so there is always that looming possibility, that if you're having unprotected sex that you can get pregnant. And I've certainly seen it in my practice in women of, you know, various ages, even up to 56, I've, I've seen it happen. Yeah. So if you're if you're still having those irregular periods, you haven't gone a full year without having a period at all, then, then that possibility does remain that you can get pregnant.
Catherine Newman: Thank you.
Dr. Denise Millstine: And to be clear, there are women who are in their 40s and 50s who would welcome a pregnancy. So that's fine. But if you're somebody who is not wanting to become pregnant, this is where it needs your attention.
And one thing that Rocky experiences during this week at the beach is really thinking about some of her past pregnanciesy, is not necessarily with her two children, but with pregnancies that she's lost and really being nostalgic for her desire to have had more children at one point. And then the grief and the loss that comes with that. Those scenes were so powerful, Catherine, and I think need to happen more, where we recognize what women navigate when they have pregnancy loss.
Catherine Newman: Thank you. Yeah. I mean, it's one of those weird things. I feel like it's shifting a little. Taryn, I don't know if you feel this way, like the culture is shifting more towards talking about it, but miscarriage has been an oddly secretive part of women's lives. And it's so weird. It's like there's so much shame attached to it. And it's I can't tell if it's because it's like a cross between a really heavy period and doing something wrong as a mother. It's like a confluence of weird things that we're not really supposed to talk about. I don't know, but I really know for everybody who's experienced a miscarriage, who I've spoken with, including myself, like that feeling that it's an odd thing to process aloud. It's so strange. There's no other grief that we would expect someone to just carry privately like that. It's so I was hoping to write about that a little bit.
Dr. Denise Millstine: I really appreciate how you approached it gently, how these moments come to Rocky and different scenes. It's not a big, in-your-face, but she talks about the summer that Jamie was a certain age and Willa was this age, and she remembers a component of it which really weaves it through the book that I think is so well done, because that's the truth of it, that it will come back to you in moments that somehow bring it back to the forefront. And I wholeheartedly agree. In fact, miscarriage is one of the topics that caused us to create “Read. Talk. Grow.” One of our first episodes that we recorded was “Brood” with Jackie Polzin, about the grief from miscarriage because to your point, pregnancy loss is incredibly common and yet talked about so infrequently. And I think one of the reasons for that is that in order to tell somebody that you've lost a pregnancy, very often, it's also the time that you tell them you were pregnant, because culturally, we've opted to not tell people that were pregnant until a certain point in time. And so many women will navigate that essentially alone, maybe with their partner, maybe with a very close circle. And I hope we can change that and support women better in the future.
Catherine Newman: Yeah, me too. And the reason we don't tell people who were pregnant that early is in case we miscarry.
Dr. Denise Millstine: Exactly.
Catherine Newman: Because nobody wants to be stuck saying that. But it's so odd that we wouldn't call upon our people to support us through that. I mean, the other thing, and maybe this is a bridge too far for a lot of people, but you can be pregnant unintentionally and miscarry and still grieve it. I mean, you cannot have wanted to be pregnant and grieve the loss. It is so complicated and I feel always like pregnancy just, there's something about pregnancy that is like being inhabited by some other life form that takes over your way of thinking about things. Like even if you were like, oh, I'm not going to have another baby and then you're pregnant, it's like you've gotten on this train that you are now just riding towards the station, even though it wasn't your plan. And it's so strange. And so to say to somebody, and “I got pregnant, I didn't want to, but then I miscarried. And now I'm sad.” It sounds so crazy, but a lot of women will understand you, is how I feel.
Dr. Denise Millstine: It's like mourning the loss of not being able to become pregnant, even though you know full well you didn't want to become pregnant. Yeah, it's still a loss.
Catherine Newman: Yeah. And it's not all kind of rational. Like it doesn't actually adhere to sort of rational thought all the time.
Dr. Denise Millstine: Taryn, in one of the scenes, Rocky goes to the gynecologist and she's asked for her number of pregnancies and her number of live births, which is really common nomenclature for us when we're taking our gynecologic history. But Rocky, the character comments that those questions should come with a trigger warning. What do you think?
Dr. Taryn Smith: You know, honestly, I've never thought about it that way. But there's some truth to that. You know, Catherine, like you mentioned, some women mourn the loss of that pregnancy, even though they didn't necessarily intend to get pregnant. And so we can bring up all these different emotions in women. So to relive the thought of, you know, having that loss or even having an abortion because of whatever their circumstances are, they may have been facing and some women just, you know, aren't necessarily emotionally ready to relive that or talk about it, or they put it behind them and they feel like they've kind of moved on. And here it is again. It's popped up, but now I have to think about it. And so yeah, I can definitely understand how Rocky would want a trigger warning before going to the gynecologist.
Catherine Newman: Yeah, it is. It is like a history that you drag around and it it's kind of just always with you in that way. It’s weird. It's so private, but you're also forced to divulge it sort of semi-regularly, which is, it's just an odd thing. I understand it from a medical perspective, but it can feel so kind of traumatic, so you can imagine that you're being judged even though you're really likely not being judged by your practitioner.
Dr. Denise Millstine: I mean, I think it makes sense to obtain that history when somebody is looking at becoming pregnant. But, you know, maybe when you're 55 and wondering if you're menopausal, your total number of pregnancies, to your total number of live births is maybe not that pertinent. You know, in so many ways and so this is the power of books, right, to open our eyes to things that we do and never pause to think about how cold that could come off and how somebody might need a trigger warning for it. So there we go.
All right. I want to talk about menopause symptoms. I'm going to mention some of the ones that come up in the book, and some of your really eloquent ways of describing them, Catherine. I want to hear from both of your thoughts. So, of course, the big daddy of menopause is hot flashes, or what we often call clinically vasomotor symptoms. Rocky mentions them several times in the book, and we know that the experience of hot flashes is different for many women, and even an individual woman will have a different experience as she goes through the menopause transition. The hot flashes aren't always going to look the same, but here's one description: a hot flash is being that your vagina is shoveling coal into a terrible furnace.Catherine, where did that come from?
Catherine Newman: Well that passage, Rocky is accusing her family of kind of looking away politely when she has a hot flash, as if the hot flash itself is sort of a gynecological episode, just because of its association with menopause, and that's annoying to her. And I do think that any of the menopause things, because they attach to this process that is sort of inherently gynecological, it always feels like it carries all this weird awkwardness for everybody. Like you're not supposed to have a hot flash that people can see because it makes them somehow think of your vagina. It's the weirdest extra thing that you just have to, like, carry around with you with menopause. So that's where that came from.
Dr. Denise Millstine: Taryn, I'm going to guess you have never described hot flash as being related to the vagina shoveling coal, but we know to Catherine's point that actually the impetus for the hot flashes not in the vagina, but actually the brain. Can you talk about that a little bit?
Dr. Taryn Smith: So what we know now, hot flashes start in the brain and what that can feel like essentially for a woman, a lot of what I hear commonly from my patients, they describe it as feeling like they're suddenly on fire, feeling like they're burning from the inside out. So that's kind of a really common description. Is just feeling on fire, feeling burny, feeling flushed, and having that sweating and kind of feeling flustered. Especially these hot flashes can happen at any time, right. You could be in the middle of a presentation at work. You can be in the middle of a podcast talking about hot flashes or in front of your kids like Rocky was, and then suddenly start turning beet red and start sweating. And so some women can feel a little embarrassed because they're looking around and they're the only one that's hot. And you're like, is it hot in here? And everybody's like, no, it's you. And so some women can feel a little embarrassed by that and be a little irritated, you know, as people are looking at them or trying to look away to pretend like they don't notice what's happening. And so I kind of chuckled. I thought that was really funny when Rocky got irritated by that, because that is something that I see my patients expressing that they do get a little bit irritated as people are trying to ignore the elephant in the room with than hot flashes.
Dr. Denise Millstine: Well and it's an exciting time in menopause science because we are making some strides in elucidating what the mechanism in the brain is that causes or is at least related to hot flashes, which is a potential target for some new therapies that we're seeing come to the market. So hopefully, at least scientifically, we will stop treating this as a necessarily gynecologic issue and treat it like the endocrine issue that it is.
So relatedly, you talk about pelvic sweating. You even comment that the vagina sweats in the night, referencing that it has so much trouble producing moisture during sexual activity, for example. So, Taryn, maybe start with this one. The sweating that now starts to happen in middle age, perimenopause and menopause, that's more in the genital area.
Dr. Taryn Smith: So typically when we're talking about menopausal hot flash, the most common presentation is kind of a (chest flushing and sweating.) So in the chest, the neck, behind the neck, the scalp. And you know, that's kind of the typical distribution of the sweating. But some women can have sweating in other areas like in the groin, not necessarily the most common presentation, but it is certainly is something, something that we can see.
Dr. Denise Millstine: And that lack of fluid at other times is the vaginal atrophy that Rocky just is so upset to hear about. She says “It's like her vagina is withering away,” after she leaves the gynecologist office with a prescription for a medication that she's told probably won't be covered, and it's going to cost several hundred dollars. Catherine, that is a social comment, in addition to an experience comment, do you want to talk about vaginal atrophy and its treatments as they pertained to what happened to Rocky?
Catherine Newman: Yeah, so that part of the book is based on my experience, which is that, I really didn't know that much about menopause, which is very strange. And just I know that you both understand this, this kind of absence of information. But like I read all the time and I'm really not afraid to get information, and I crave it and I'm not squeamish about anything. And I headed into menopause with an oddly unrobust sense of what was in store for me. And I think I had heard like, oh, you know, you might have some vaginal dryness. But like, I thought that's what lube was for. And then it's like on a different scale entirely. It's not even, it's like apples to oranges, like lube doesn't really quite touch this thing, whatever it is. And I knew nothing about it, I truly did. I was like, I went to the doctor and was like, I don't really understand this. Like I'm not afraid to use lube. And she was like, “We're in a different realm now. You're going to need like a prescription medication.” And, my doctor prescribed like a, you know, a vaginal insert, which is estrogen, right? Is that what I'm getting?
Dr. Denise Millstine: It can be. It probably is.
Catherine Newman: Yeah. It's it's something called like estradiol or something like that. And then it's great and like it solves the problem. But I did not, I just knew nothing about it truly going into it. So I'm sure you guys are a step ahead of your patients in that way of anticipating that they're going to have experiences that they won't be anticipating, because it's just the weirdest thing.
Dr. Denise Millstine: So we need to write an article, “When lube is not enough.” Taryn, will you talk a bit about vaginal atrophy and the difference between lubricants, moisturizers, and then the vaginal estrogen that Catherine’s mentioning?
Dr. Taryn Smith: Yeah. So like many things in menopause, atrophy is a spectrum. Generally speaking the definition of menopause is those ovaries are no longer producing estrogen, especially at the level of where they were doing reproductive years in perimenopause. So estrogen levels decline to very, very low minimal levels. The thing is estrogen is like food for the vagina, right. So when she doesn't have it anymore, it's almost like those tissues in the vagina and the lower bladder are being cut off from nutrition. And so if you think of any living organism that's being cut off from nutrition, things are going to change. The tissues are going to be much thinner than they were before. They're not going to be as healthy as they were before. And what that looks like is things hurt if you try to, you know, have intercourse and there's friction or any kind of trigger or rubbing of the tissue that can be very uncomfortable when those tissues aren't as healthy as they were before.
And so that's essentially what atrophy is. The tissue starts to thin out. But like I mentioned, it's a spectrum. So even though this process can happen to the vast majority of women, what you experience may be different with it. I have some women who have vaginal atrophy and they don't really notice anything. Intercourse isn't, you know, much different. If it is, you know, they can use a lubricant and that might be sufficient to relieve any kind of discomfort. And I have other patients where the atrophy has gotten so extensive to where, you know, it hurts to wear leggings. They feel like they're chafing. And so, you know, it's a very broad spectrum of experiences.
And so to speak, to the differences in the treatment options generally speaking we've got hormonal, we've got non hormonal treatment options. The biggest difference between those the hormonal options are going to supply those tissues with that nutrition. So we're giving estrogen back to the tissues. And so as we are nourishing the tissue we can start to heal the tissue and regenerate tissue and to some extent take those tissues back to where they were before menopause, if not fully, pretty close to where they were in health before menopause occurred.
Whereas those nonhormonal therapies, we're not giving that nutrition back but we are coating the tissue. We are moisturizing the tissue. So we're making things feel much more comfortable, or at least that's the goal. But we're not necessarily fixing the underlying problem.
Catherine Newman: And would this be a good time for you guys to talk about hormone replacement therapy? I mean, just because I feel like that is the other thing on the table for all of this, and I know that that's changing so fast. What the recommendations are.
Dr. Taryn Smith: Yes. You want me to take that, Denise?
Dr. Denise Millstine: Yeah.
Dr. Taryn Smith: So hormone therapy. Oh, there's so much to be said for hormone therapy. I feel like we could probably talk for hours just about hormone therapy alone. But generally speaking, hormone therapy is probably the most effective treatment option for managing menopausal symptoms. It's not for everybody, but for the average healthy woman who's really close to menopause, less than ten years out of menopause, or less than the age of 60, it tends to be a good option, a relatively safe option. So long as she doesn't have a lot of medical issues, it does tend to be a really good option.
You know, the sad part is that there was this big study many years ago that scared several women and physicians away from using hormone therapy. It kind of was responsible for driving menopause and hormone therapy out of our medical curriculum, curricula. And so a lot of physicians aren't just as educated as they would have otherwise been if that study hadn't been published and marketed the way that it was. While it scared people off of hormone therapy, there was a lot of value. There were a lot of valuable points from that study that have kind of shaped what we know now. And so not to get into the nitty gritty details, but to kind of give you a synopsis, what we know now is that you got to give it to the right person. If you're not giving the hormone therapy to the right person, then bad things are going to happen. Again, you know, a healthy woman who's newly menopausal or close to, you know, close to the menopause transition, that's going to be the best candidate for hormone therapy.
Catherine Newman: Thank you.
Dr. Denise Millstine: Thank you for that question, Catherine. I think that in the discussion about the vaginal products, one point to hammer home is that the vaginal estrogen products, the majority of the vaginal estrogen products, treat the vagina. They'll also treat often the urethra, which is the opening of the bladder. But they're not going to help you with your hot flashes, which is the predominant driver for when we're going to use what we call systemic hormone therapy or hormone therapy that's going throughout the whole body.
That being said, if you're somebody who's on systemic hormone therapy and having these vaginal symptoms, so whether it's pain or discomfort or recurrent, excuse me, recurrent urinary tract infections, you may need vaginal estrogen at the same time that you take systemic therapy. So this is a very, very complicated.
We created an episode of “Read. Talk. Grow.” with the current president of the Menopause Society, Dr. Lisa Larkin, discussing the book “Amazing Grace Adams” by Fran Littlewood.
Catherine Newman: Okay.
Dr. Denise Millstine: Wonderful book, I'm guessing you're laughing because you've seen the cover, which is pretty in your face.
Catherine Newman: It's like a middle-aged woman flipping someone off.
Dr. Denise Millstine: Yes, it totally is. But in that one, Grace is struggling and she's literally got prescription for hormone therapy in her purse and she just isn't taking it or just isn't using it. So super complicated topic, but vaginal estrogen is typically something that most women are able to use. So that is the set of symptoms that our listeners are navigating. Please, please talk to a doctor or a healthcare professional about it.
Catherine Newman: I would drive around one of those advertising cars that just said, like, “Talk to your doctor about vaginal estrogen!” I really would I would do it for free. I feel like I was maybe put on earth to talk to people about vaginal estrogen. It's like a total game changer, a total game changer. I had so many UTIs before I started using it, and it has just changed my entire relationship to intercourse, honestly. Like I'm not afraid. I was so afraid. I started to be like, I don't know, we could do this. And then I would like end up at the clinic again. Like, you have to factor in the time, you know, the treating a UTI every time you think about being sexually active. So best to avoid that is my feeling.
Dr. Denise Millstine: Yeah. Lots of strategies. So women who are navigating that, should definitely talk to somebody. Although you driving around in a vaginal estrogen car is probably not what your young adult daughter is hoping for your future, just guessing.
Catherine Newman: She would love it. She's such a bad ass. She would like love it.
Dr. Denise Millstine: So there are so many components to “Sandwich,” which is just a beautiful book, and I'm hoping that we've given enough information to listeners to pick it up and to read it and to explore some of the other areas of menopause, as well as being a mom and a daughter, having aging parents, having children who are becoming independent from you, having a relationship that you've been in for decades. You do it all, Catherine, and you do it with grace and with humor. And I want to thank you again for writing “Sandwich,” and I want to thank you, Taryn, for coming on the show to talk about menopause with us.
Dr. Taryn Smith: Thanks for having me.
Catherine Newman: Thank you both so much. I learned a lot and it was so nice to get to talk to you.
Dr. Denise Millstine: “Read. Talk. Grow.” is a product of the Women's Health Center at Mayo Clinic. This episode was made possible by the generous support of Ken Stevens. Our producer is Lisa Speckhard Pasque and our recording engineer is Rick Andresen.
Visit our show notes to see the books discussed today and for links to other health education materials. Follow us on social media like Instagram and Facebook, or reach out directly to our email readtalkgrow@mayo.edu with suggestions for books or topic ideas. We'd love to hear from you.
The podcast is for informational purposes only and is not designed to replace a physician's medical assessment and judgment. Information presented should not be relied on as medical advice. Please contact a health care professional for medical assistance if needed for questions pertaining to your own health. Keep reading everyone!