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RealTalk MS
Episode 434: Revisiting Managing Menopause While You're Managing MS with Dr. Riley Bove
00:21:38
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- [00:01]
A
I'm john strum, and this is real talk, mississippi. It's December 23rd, and we have a lot to talk about as we count down the final weeks of 2025. It's become sort of a tradition for me to reserve the last two episodes in December to revis revisit the most popular conversations that I've had over the past year. Women represent two thirds of the Ms. Population, yet surprisingly, there isn't nearly enough data related to women's health issues and Ms. With an estimated 300,000 women living with Ms. In the United States who are currently in peri or post menopause, researchers have started to focus on how menopause and Ms. Interact and the best way to treat symptoms of each. And that can sometimes be tricky because so many of the typical symptoms associated with perimenopause look just like Ms. Symptoms. Last March, it was my privilege to speak with Dr. Riley Bovet about managing menopause while you're managing Ms. Dr. Bovet is a neurologist and founding director of the Sex and Gender Enriched Neurology Program at the University of California, San Francisco, and she's considered to be one of the foremost experts on the subject of women's health issues and Ms. You made this episode of Real Talk Ms. One of the most listened to episodes of 2025. In a moment, we'll revisit my conversation with Dr. Riley Bovet. When they enter perimenopause and menopause, many women living with Ms. Face uncertainty, wondering how these phases of life might impact their disease. Dr. Riley Bovet, a neurologist, researcher, and associate professor at UCSF Health in San Francisco, is joining me to discuss the relationship between these phases of a woman's life and Ms. Dr. Bovet has a special interest in women's health from pregnancy through menopause, and she's the author of several articles focused on how hormones impact Ms. And other neurological conditions. Welcome back to the podcast, Dr. Bovet.
- [02:30]
B
Thanks. Happy to be here.
- [02:32]
A
Considering that women make up about 2/3 of the Ms. Population, I think women's health issues are so important. And given the fact that women experiencing perimenopause and menopause represent about a third of the Ms. Population, this is a particularly important conversation. So I'm hoping you'll start us off by explaining what each of these phases or these terms mean, and then explain the difference between these two phases of a woman's life.
- [03:00]
B
Thanks, John. So when we think about the stages of reproductive aging, we really have some buckets. We have the prepubertal years. And then we have basically from the first menses, you know, puberty, menarche, first period, all the way to the final menstrual period. Those are the reproductive years. And then we have, after the final menstrual period, we have the post menopausal years. So one phase that we talk about is those postmenopausal years. The other phase that we talked about when we're thinking about menopause and perimenopause is the, the, the few years before the final menstrual period and the first years after the menstrual period, the final menstrual period, that is the menopausal transition, the perimenopause. So a lot of times patients talk about new symptoms, hot flashes, worsening of symptoms, things like that during the menopausal transition, as their periods are stopping, as their hormone system is sort of fluctuating a lot. And so that is one thing, the perimenopause, and today people refer to it as PERI or midi, and then the other one is the postmenopausal lifespan, where women may live 20, 30, 40 plus years in the postmenopausal lifespan. So I think think about those two as distinct can be really helpful in sort of setting the stage for the conversation.
- [04:31]
A
I know that some symptoms of the PERI can mimic symptoms of Ms. Can you talk about those particular symptoms?
- [04:39]
B
Yeah, and patients come in all the time saying, I don't know if it's my Ms. Or if it's my menopause or what. And there really is an overlap. And so, so some of the PERI symptoms are changes in sleep regulation, changes in cognition. It can be subtle things like word finding, like just not paying as much attention, difficulty keeping things, you know, in your head, not necessarily memory problems. It can also be changes in mood. So more depressed mood, irritability, anxiety, changes in libido, changes in bladder function. And all of these things are going to sound very familiar to our people who have ms, because changes in sleep, cognition, mood, libido, bladder, are all very common in Ms. As well. And so that's really the overlap. In addition, what you want to layer on or actually undo is the contribution of hot flashes. So many women during PERI have hot flashes, and those hot flashes can make all of the symptoms that we described feel worse.
- [05:52]
A
I guess that really begs the question, how can a woman living with Ms. Determine the root cause of what she's experiencing?
- [05:59]
B
Yeah, great question. And I think it's a yes and answer rather than a one Root cause. I think what is important to do is really have women, you know, start seeing their neurologists and their primary care doctors a little more frequently and think proactively about what, what, what is what. So for instance, if someone has difficulty with sleep and they then saying, hey, I just can't tell why I can't sleep. You want to think about, well, could your thyroid levels be changing? Could your bladder be keeping you up at night? And is it, you know, is your once a night going to the bathroom, creeping into two or three times a night? Right. Is it the hot flashes that are keeping you up at night? Sort of thinking, is it anxiety, worry about the empty nest or what's the future of your job or et cetera. So thinking about what, what are the factors that could be contributing? And then when we tackle those, how do things stabilize or improve? I think that approach of really sort of having sort of a detailed checklist in your mind about all of the potential factors and then in combination tackling them may be more sort of effective and result in sort of better symptom management and improvement than trying to say, well, you know, that's not, that's not me as a neurologist, it's really your primary care. Just go to them. No, I think we really have to come together.
- [07:27]
A
We've just been talking about some of the perimenopause symptoms that mimic Ms. How can perimenopause and menopause actually impact Ms. Progression?
- [07:38]
B
Yeah, so I think there's a couple ways and we're just really trying to look at this and we don't see, still have a really clear picture. So one way that I think is, is important and under addressed is the fact that when you are not sleeping well, feeling well during the menopausal transition, you are going to change your behavior. So you may reach for sort of comfort foods, you may not want to go exercise because you're afraid of feeling uncomfortably hot. You know, your joints may ache and that may affect the way that you move around the world. Right. So you're going to have behavioral changes. They can then have downstream effects on risk of diabetes, risk of cholesterol risk, you know, all these other things that affect the brain and brain health. So one way that the perimenopause can affect brain health and postmenopausal, you know, lifespan is just because of the changes in behaviors that happen. The question that I think is still an open question is whether in addition to that, we see that the changes in estrogen and other hormones that, that Arise during the menopausal transition could in themselves cause worsening in brain volume loss, worsening in actual brain health directly through the hormone effects. And that. I think we're still trying to work that one out.
- [09:04]
A
A change in estrogen level drives most perimenopause symptoms. Can you explain the role of estrogen and why the loss of this hormone is so significant for women?
- [09:15]
B
Yeah, so estrogen is what we call, you know, pleiotropic. It has a lot of different effects. So it has effects on bone tissue. Right. So with menopause and loss of estrogen, you can get osteoporosis, osteopenia, it has effects on blood vessel wellness, it has effects on regulation of a lot of other hormones and, and health systems. And, and. And then it also regulates the brain itself. So it has direct effects on neurons and other cells in the brain. And so when we think about what happens when you lose estrogen during the menopausal transition, we have to kind of consider all of those other effects. So, you know, so that is one thing. I think another thing is that there are other hormones that are also changing. So progestogens, testosterone, et cetera, and their brain wellness are a little less studied. It's kind of hard to move sometimes from the animal models to the human models, because human women have longer menopause, really, than mice females. And so sometimes there's something lost in translation there as well.
- [10:28]
A
I know hormone levels can be checked by administering a blood test. So can a blood test determine if a woman is in menopause?
- [10:37]
B
Yeah. So menopause is defined sort of like clinically by the loss of menses. And after one year, the woman no longer. If she has had no periods for a year, you say she's postmenopausal. You look back and say her menopause occurred a year ago at that final menstrual period. That's kind of how we define menopause. That said, some women may have had their uterus removed for fibroids, and then they're not menstruating. So how are we supposed to know what's happening? So there are a couple blood tests that give us clues. First, as the ovarian follicle, sort of like the follicles or eggs in a woman's ovaries decline, there's a decline in anti mullerian hormone, which kind of is an indicator of how many follicles there are. As those follicles decline and there's less estrogen production by the ovaries or variable estrogen production by the ovaries. The brain says, hey, whoops, there's not enough estrogen here. Let's send messaging to the ovaries to produce more. And that is the follicle stimulating hormone. So in general, when we look at a woman's blood levels, we may see that the AMH levels start declining. Estrogen can be variable, but it's really when FSH levels rise, and that's the blood test that typically the doctor orders when FSH levels reach above a certain threshold. That also gives us hormonal evidence that the patient is, you know, postmenopausal.
- [12:03]
A
A woman with Ms. May take steroids to treat her Ms. Symptoms. This can happen frequently over the course of their adult life. What special considerations do women living with Ms. Need to be aware of when it comes to chronic steroid use?
- [12:19]
B
So chronic steroid use has a number of different complications. Risk of infections, risk of diabetes, and risk of bone density loss. And I think one thing that, you know, our patients who have used more steroids over the course of the course of their life should be aware of is that they may need a more targeted bone density screens. So typically, bone density screening starts at age 60, except in high risk groups. And I tend to recommend that my patients get bone density screening starting at age 50 because they may be a higher risk of bone loss and also because there may be a higher risk of falls. And you don't want to find out that your bones are brittle if you've fallen and have a fracture. Right. You'd rather know before that and try to take preventive measures. So I do recommend regular bone density screening in our menopausal women.
- [13:13]
A
Are there other complications that may occur during these phases of a woman's life that are maybe less well known?
- [13:21]
B
Yeah, there's a. There's a number of complications that are very commonly described by patients and on social media and that are not really well measured by doctors and researchers. And that just points to the fact that we haven't really been listening to patients for a long time. So some of those things are joint pain, ligament pain, stiffness. So people commonly have pain, like in their shoulder and other sort of joints. There's the genitourinary syndrome of menopause where patients can have sort of vaginal changes, dryness, atrophy, et cetera, as well as changing bladder frequency. There are very common cognitive concerns that we tend to say, well, you're actually, you know, testing, okay, so you're fine. And patients are saying, no, you know what? I really have changes. So all of that sort of goes in that bucket. And then of course, we have to think about changes in cancer risk, changes in sort of risk of diabetes, sleep apnea, sleep quality. All of these things can change with menopause.
- [14:28]
A
Menopause typically impacts three areas of a woman's health. Reproductive health, immunology and neurological health. What are the most common medical treatments given to women to treat symptoms during this phase of their life?
- [14:42]
B
So in terms of reproductive health, of course we want people to get all of their screens for hpv, cervical cancer, et cetera. We also want people to get treatment for their vasomotor symptoms, their hot flashes. So that may involve hormone replacement therapy be, but it may not. And so I don't want people to not get, you know, bothersome hot flashes treated because, not treated because they're avoiding hormones, because there are other non hormonal options that include vioza, which is a new FDA approved medication for hot flashes, antidepressants, gabapentin, and then also complementary approaches to that. If we think about the immune bucket, we want to think about the fact that the risk of relapses decreases in, in generally with aging and in women after the menopausal transition, the risk of relapses decreases, the risk of infections increases. And so that's a good time to think about am I on the right immune modulatory therapy that's keeping my relapses at bay, but that's also not causing excessive infection risk. And then the third bucket are all of the neurological symptoms that people experience during the menopausal transition and thereafter. So with cognition, you may want to do some cognitive therapy therapy to try to target specific places. You may want to take a medication for sleep, knowing that if you sleep better, your cognition, energy and mood are going to be better. Treatment of depression. All of these things in terms of brain health are really relevant to that neurology bucket.
- [16:20]
A
I'm glad I heard you mention hormone replacement therapy. HRT is a well known treatment for perimenopause symptoms. Is HRT a good option for a woman who's also living with ms?
- [16:33]
B
So in general, I think that we want to follow the guidance for the general population in terms of hrt. So the North American Menopause Society says that HRT is the most effective treatment in women in their 50s or not in their 60s, 70s or other, but who are going through menopause the most effective treatment for hot flashes, Beneficial effects on bone, beneficial effects on mood and quality of life. You know, genitourinary syndrome of Menopause, et cetera. So the groups who really would not get HRT are of course, anybody who does not want to, as well as groups who are higher risk of cancers, notably breast cancer, and groups who are higher risk of blood clots. So women who may be more immobile, less physically active, and higher risk of blood clots or who carry specific genes for that. Otherwise HRT is considered actually beneficial in terms of all cause, mortality and even cancers. For women who are not taking hrt, though, there's many other treatment approaches to hot flashes that that's all about the menopausal symptomatology, perimenopause. When we think about whether HRT is also beneficial against neurologic aging and against, you know, sort of loss of brain volume and function over time, I think the jury are still out because we don't really have the good trials data for that.
- [18:00]
A
Well, I hope we soon will have that data. I think that there are just so many issues related to women's health that and Ms. That have been overlooked that I think now are finally starting to be focused on a little bit.
- [18:15]
B
That's right. And I think patient engagement. Right. So people have to be asking their doctors for guidance. They have to be, you know, sort of raising these questions as well, not to put all the burden on patients. That's not fair at all. But to say, you know, you know, you deserve to get the care, you know, for your life, stage and phase and for your symptoms, and you deserve comprehensive care. And I think holding doctors to that level is important.
- [18:43]
A
Well, as we've been talking about perimenopause, menopause, I want to talk about post menopause life for just a moment. What do women living with Ms. Need to understand about how life post menopause may impact their Ms. Symptoms or Ms. Progression?
- [19:00]
B
So in terms of postmenopause progression and such, I think the first thing to keep in mind is that so much of what we do, so much of our interventions and our symptom management can keep people well. So we want to keep people perimenopausal symptoms well, well handled. We want people to be sleeping, feeling so that they can engage with exercise, rehabilitation, you know, mood management and stay well. I think that's one key message is, you know, there's a lot of doom and gloom when people talk about menopause sometimes. So they think about, oh, well, you know, these things are inexorably going to worsen, and then it's just the end. And that's not true at all. I think we can manage the wellness factors really intensively to optimize well being. And I think then you know, the management of comorbidities as well. And I think those kind of keeping those front and center is going to be the best way to prevent progression and worsening of disability hand in hand with the medications that are available.
- [20:09]
A
Well, Dr. Riley Bovet, I want to thank you for all you do in the lab and in the clinic to improve the lives of people who are living with Ms. And thanks so much for talking with me today.
- [20:20]
B
It's my pleasure. Thanks for featuring this important topic that's.
- [20:24]
A
Going to wrap up this episode of Real Talk Ms. Real Talk Ms. Is powered by the National Ms. Society and you can share this episode of the podcast by letting your friends or family members know that all they have to do is point their web browser@realtalkms.com 434. You'll find that link in today's show Notes so you can easily copy and paste it right into an email or a text. I hope you'll join me next week when we look back at the episode of Real Talk Ms. That you made the most popular episode in 2025. I'm John Strum. Thanks for listening. Stay safe and make healthy choices. Sam.