64: Breaking the Silence: Redefining Menopausal Care for Women with Obesity with Dr. Komal Patil-Sisodia

May 06, 2024

Menopause and the years leading up to it, commonly referred to as perimenopause, are periods of significant change in a woman’s body. Working as a physician, I’ve seen firsthand how these hormonal changes can affect women, especially those struggling with weight.

Unfortunately, if you're in the overweight or obesity category and considering hormone replacement therapy (HRT), it’s easy to feel overwhelmed by the lack of clear guidance and support. The crucial link between weight management, menopause, and HRT often gets overlooked, leaving many women at risk and unsure about their options for treatment.

I recently interviewed Dr. Komal Patil-Sisodia, who is triple board-certified in endocrinology, obesity medicine, and internal medicine and passionate about improving metabolic health in the community. Today, I’m sharing her insights into the significant physiological changes women experience during perimenopause and menopause, the benefits of HRT in improving insulin resistance and blood sugar control, and the intricate relationship between menopause, obesity, and heart health.

Physiological Changes Brought about by the Menopause

The journey into menopause typically begins in a woman's mid-thirties, although it can start as early as just after 30 for some. This time marks the beginning of a decline in reproductive hormones (primarily estrogen) and is a natural part of aging, where our bodies gradually reduce their reproductive functions.

But what’s really fascinating is how our bodies adapt to these changes. As estrogen levels drop, our bodies tend to increase fat mass. When you have increased adipose tissue, you get increased estrogen production from the adipose tissue. So it's almost like a survival mechanism to compensate for the loss.

During this period, women also have a harder time holding onto their muscle mass. And when you’re losing muscle mass and gaining fat mass, your metabolism takes a nosedive. So if you're already struggling with being overweight or struggling with obesity, you're going to be faced with more challenges in weight management when you hit this period in your life.

Challenging Misconceptions: The Truth about Menopause and HRT

Unfortunately, a lot of misunderstanding surrounds menopause and hormone replacement therapy (HRT), much of which stemmed from the Women's Health Initiative hormone therapy trials. These studies, while well-intentioned, tested high-dose hormones on older women and subsequently linked these to increased risks like cardiovascular disease and breast cancer. However, these risks were more about the natural aging process rather than the hormones themselves.

This misinterpretation has led to two decades of reluctance to discuss and properly manage menopause-related metabolic changes. It's crucial to understand that the increase in health risks during menopause is a combination of aging and hormonal adjustments, not just hormone therapy gone wrong. That’s why it's always important to be looking at the latest data and evolving your thought patterns as you move forward.

Hormones, Heart Health, and Cholesterol During Menopause

One of the less discussed but crucial impacts of menopause relates to cardiovascular health, specifically how fluctuating hormone levels can influence blood pressure, cholesterol, and even blood sugar levels.

As women enter menopause, it's not uncommon to see a rise in blood pressure and cholesterol levels, even for those who have previously maintained excellent health metrics. The reason behind this increase often ties back to where and how the body stores fat during menopause. Increased abdominal fat, particularly visceral fat that surrounds internal organs, can contribute significantly to these changes. Visceral fat is particularly notorious for creating insulin resistance, which can then lead to elevated blood sugar levels and exacerbate conditions like diabetes.

For example, Dr. Komal had a patient who managed her type 1 diabetes exceptionally well until she hit menopause. Despite her efforts—exercising, eating right, using her insulin pump and sensor—her blood sugar levels became increasingly difficult to control. This wasn't due to any lapse in her management; it was a direct result of the hormonal upheaval caused by menopause. Compounded by sleep disturbances and hot flashes, her entire metabolic health was thrown off balance.

The Role of Genetics

Another key thing for women to understand as they navigate these changes is how much our genes affect us. We all have different genetic backgrounds that influence how our bodies handle aging and hormonal shifts. It's important to know that sometimes, no matter how hard we try, our genes will play a big role, and we might need extra help. This isn't a sign of failure; it's just how our bodies are built.

When these genetic factors start affecting us, it's perfectly fine—and important—to ask for help. Science and medicine are here to support us and provide options when simply changing our lifestyle isn't enough and recognizing our limits is a strength, not a weakness.

Moving Forward with Knowledge and Understanding

As a medical community, we need to provide women with accurate information and to encourage open discussions about menopause-related health concerns, including those affecting cardiovascular health. For too long, there hasn’t been enough grace shown to women navigating these changes, particularly those struggling with obesity or metabolic health issues.

Addressing menopausal symptoms and understanding the role of hormone replacement therapy (HRT) is essential. Here are the key points Dr. Komal wants us to consider:

Timing of Discussion: Start conversations about potential hormonal changes and HRT as early as your mid-30s. This helps prepare you for what’s ahead instead of waiting until symptoms become unmanageable.There's a common misconception that HRT is only for postmenopausal women who have completely ceased having periods. In reality, the conversation about HRT can begin during perimenopause, when symptoms start to appear.
Benefits of HRT: Research shows that estrogen HRT can increase HDL (good cholesterol), improve insulin resistance, and decrease triglycerides. It's not just about relieving menopausal symptoms but also about improving overall metabolic health. Starting with low-dose estrogen in hormone replacement therapy (HRT) and closely monitoring patient responses can help to optimize benefits and minimize risks.
Risks and Considerations: While beneficial, HRT is not suitable for everyone. It carries risks such as increased blood clot chances, and it may not be advisable for women with certain cancers like breast or endometrial cancer. However, options like vaginal estrogen might be available for these cases.
Individualized Approach: Every woman’s body is different. An early and personalized discussion about HRT can lead to tailored treatments that consider personal medical history and risk factors.
Continuous Medical Support: It’s important to have ongoing conversations with healthcare providers who are knowledgeable and open about HRT. This ensures that treatments are adjusted based on how your body responds and changes over time.
Challenging Old Views: For a long time, the medical community had a limited view on HRT, often advising women to just 'suck it up'. Today, with better understanding and research, there's a push against the under-medicalization of menopause and recognition of the quality of life issues it brings.
Education and Advocacy: Being informed and proactive about your health during menopause is crucial. Education about HRT and its impacts can empower women to make informed decisions and advocate for better healthcare approaches.
Comprehensive Health Assessments: Integrating broader health assessments such as cholesterol monitoring and blood pressure management into menopause care will help to provide more holistic support.
Collaboration and Guidelines: Working collaboratively across medical disciplines will help to to develop clear treatment guidelines that promote holistic and effective care for women navigating menopause.

The transition through menopause presents unique challenges, especially for women dealing with obesity or weight issues, that require greater understanding and support from the medical community. By promoting early and comprehensive discussions about menopause-related health concerns, including the role of HRT, we can empower women with the knowledge and support needed to navigate this phase of life more confidently.

It’s time to move away from outdated views and embrace a nuanced approach to menopausal care that recognizes its diverse impacts on metabolic and cardiovascular health. Through improved education, personalized treatment plans, and ongoing medical support, we can start to support women in the way they deserve during this transformative stage of life.