Menopause Decoded for Women with Autoimmune Diseases and Arthritis

Welcome to "Thriving with Arthritis" Podcast. In this episode I have a special  guest, Dr Dr. Cheruba Prabakar,  a specialist in menopause and women's health, to answer questions about menopause and its effects on autoimmune diseases. 

The discussion covers various topics, including:

1. How menopause affects women and its potential link to autoimmune diseases.
2. The use of hormone replacement therapy (HRT) for managing menopausal symptoms and its safety for women with autoimmune diseases.
3. The importance of seeking a qualified healthcare provider for HRT and understanding the risks and benefits.
4. Managing symptoms such as vaginal dryness in women with autoimmune diseases like Sjogren's syndrome.
5. The importance of lifestyle changes, including exercise, diet, stress management, and sleep, during menopause.

Dr. Prabhakar emphasizes the importance of personalized care and regular follow-ups with a healthcare provider to monitor the effects of HRT. She also highlights the safety of HRT when prescribed appropriately and the availability of various options for managing menopausal symptoms.

Check this up: https://www.menopause.org/

More about Dr. Cheruba Prabakar:  is a board certified OBGYN and minimally invasive trained surgeon. She specializes in treating women with fibroids, ovarian cysts, endometriosis, and pelvic pain. She is also a menopause practitioner, certified by the North American Menopause society. She owns a boutique private practice and provides highly personalized, accessible, and unhurried care. Dr. Prabakar also has a "fibroid coaching" program where she spends an hour answering all your questions about fibroids! She is also a speaker on women's health issues. She lives in Oakland with her family.

Website: www.lamorindagyn.com
IG: @thefibroiddoc
FB: @Cheruba Prabakar

Transcript

Welcome to Thriving with Arthritis, the podcast that empowers you to live a better life, despite all the challenges of arthritis and autoimmune diseases. I am Dr. Diana Granita, your host, and a rheumatologist with over 20 years of clinical and research experience.  Whether you're newly diagnosed or have been living with arthritis for many years, this podcast is here to support you every step of the way.

Let's begin. 

 Today we will discuss about a very controversial topic about menopause,  

we're going to answer a lot of questions.

How is menopause affecting us as female? 

Is that increasing our risk to develop autoimmune disease? 

If you have an autoimmune disease, will menopause affect you? 

We will also talk about hormone replacement therapy, if that's a solution or not, if it's indicated for people with autoimmune diseases or not.

Because that's a question that I get all the time from my patients.

 We can also discuss about how we can manage well all these nasty symptoms from menopause. And today 

I'm delighted and honored to have with me a very special guest, 

a specialist in menopause, Dr. Chiruba Prabhakar. Welcome. 

Welcome. 

Thank you so much for having me. I'm really excited to be here and discuss all these things about menopause and arthritis and autoimmune diseases.  Dr. Prabhakar, she is a board certified OBGYN and a minimally invasive trained surgeon. She also specializes in women with fibroids, ovarian cysts, endometriosis, and pelvic pain.

She is also menopause practitioner certified by the North American Menopause Society. And she also owns a boutique practice where she provides highly specialized accessible care and like she likes to say, unhurried care. She's also fibroid coaching. She has a fibroid coaching program where she spends a lot of time to answer all the questions related to this topic.

And not only that, but she's a speaker and an advocate for women's health issues. She lives in Oakland with her family and she's here today to answer our questions.  

I want to say that I am really impressed with your background. It is very important to talk to someone.

about menopause, because a lot of the patients that I have will either transition to menopause and will come to be evaluated for an autoimmune disease or will have an autoimmune disease and now they transition into menopause. 

And it's very hard for me to understand what is related to autoimmune diseases and what is related to menopause.

 My first question ......

can menopause increase the risk to develop autoimmune diseases?  

Yes, that is a great question. As we know, women have estrogen from their ovaries throughout their reproductive years, and this is very protective. It helps our heart, our bone, our brain, and we also know it helps our joints.

It keeps everything lubricated. So as we approach to menopause, the level of estrogen starts to decrease. And so I won't say that, menopause increases the risk of autoimmune diseases, but this is the time when they may be uncovered or discovered. So estrogen may have been compensating for some of those pains and aches, especially with arthritis.

And then when the levels of hormones and estrogen drops in menopause, things start to get a little more sticky or, painful. And so I often see that in the late 40s, Forties to the fifth decade in the fifties, women are presenting with new diagnoses of rheumatological conditions. And there are now being exposed more so because estrogen is dwindling, if that makes sense. 

That's very good to say because a lot of females, once they transition to menopause, they are afraid that they will develop another condition or a chronic condition like an autoimmune disease. Now, I have to tell you that I have patients that will transition to menopause and many times the things become complicated.

My question to you is ...

can autoimmune diseases get worse during the menopause time? 

Yeah, I think it depends on which ones we're talking about. So I think the joint ones such as arthritis, rheumatoid arthritis can definitely worsen a little bit again because of the lack of estrogen and the lubrication of the joints and just in general how our muscles and bones and everything, you know, joints work.

So that can be when we talk about other diseases like lupus, for example. I'm not really sure that is going to worsen in menopause. However, autoimmune diseases can present, can be challenging in terms of treatment of menopause.  That's true, because a lot of our conditions, they do have symptoms like dryness of the eyes, dryness of the mouth.

We have patients with rheumatoid arthritis or Sjogren's disease that will complain about vaginal dryness and during menopause, all of these symptoms will be gone. worsen. 

Do you have any recommendations for patients about how to approach that? 

Yes. So many patients ask me about hormone replacement therapy, right?

Menopause hormone therapy, which is the gold standard for a lot of the things that we talked about. The dry skin, the vaginal dryness hot flashes, sweats, mood swings, brain fog, all of those things. And I want to let the audience know that hormones are very safe, and you should definitely be discussing this with your gynecologist, because as you start to experience these symptoms, there's no need to suffer with it.

So for someone who's experiencing the symptoms you mentioned, definitely seeking some hormone therapy is very important.  

For those with rheumatologic conditions though, this can be a little complicated because we have an increased risk of clot formation with some diseases. It's, I'm thinking specifically of lupus because we have patients with lupus and then we don't want to add estrogen onto that because then you can really worsen your risk of clots.

But there are still other options for hot flashes that are non hormonal. So I really encourage everyone to speak to their gynecologist about all the options out there because I really believe we are at a time in medicine when there is something for everyone and no one should be suffering. You mentioned vaginal dryness and we have vaginal estrogen for that.

So even if you're not a candidate for cystic fibrosis, Stomach estrogen. 

So taking an estrogen pill or a patch or something like that, everyone can use vaginal estrogen. Vaginal estrogen is safe. It's not gonna increase your risk of cancer, it's not gonna increase your risk of clots. So even if you're somebody with lupus, you can still use vaginal estrogen.

It's a very low dose, and so at least that you know everyone should be using.  I'm very happy that you opened a box. for this discussion because for a long time we were taught that hormonal replacement therapy increases the risk for breast cancers and increases the cardiovascular risk.

I remember particularly about the study, I think it was published in the 2000s, and that study was recently revisited.

The initial study said that hormonal replacement therapy will increase the risk of breast cancer, will increase the risk for  heart disease. 

But as I find out, and as patients were asking me more and more, I figured out that whatever I learned 20 years ago does not apply anymore today. 

Please let us know how these things change over the last 20 years. 

Yes, you're absolutely right. This was the WHI study, the Women's Health Initiative in the early 2000s, where everybody was freaking out because they said, Oh, it's really bad for you. Hormones are really bad. Everybody said, stopped their hormones. Doctors stopped prescribing them. And this was a very unfortunate thing because the data was misinterpreted and there was a lot of fear.

But as you mentioned, this has been revisited. 

There have been several follow up studies that have actually been done that show that it is very safe. And in fact, it protects the heart. And the risk of breast cancer is so low. so minor. 

It's, one in 10, 000 women over a period of five years which is nothing compared to the average risk of breast cancer in the US, which is one in eight.

So that is a much higher risk than anything you will face from hormones. And we also have a lot of safer options. So before the standard was an estrogen pill, now we have an estrogen patch, we have an estrogen ring, we have an estrogen gel, so there's many different types of estrogen that we can use that are much more safe to use and so women should really not be afraid of estrogen.

of using hormone therapy. 

There are very few women who cannot use estrogen for example, somebody with an active clot, like a blood clot. And so you should definitely speak to your doctor, but I think there are way more women who are scared of this than really need to be.  

It's very important that you mention that there are so many options, but where would females find the best option?

And you mentioned to go to talk to the doctor, but as there are so many practices that are not quite qualified to prescribe a hormonal therapy, but they do it. 

So what would you recommend from the specialist point of view? 

Where should this female go and get the treatment that they need? 

Yeah, this is a very important topic because there are there are gynecologists out there, who are trained to prescribe this.

But there are also a lot of other practitioners, who are doing a lot of quote unquote hormone therapy and it's, the practices are not necessarily evidence based. 

So I would recommend that everybody look up the NAMS website, the North American Menopause Society. 

There's a directory there where you can find it.

find providers in your area who have taken this exam. In my bio, you mentioned that I'm NAM certified. So we study for this special certification is a special exam you take. And so you're really up to date on the latest and greatest and this information over the last 20 years has changed a lot. So I would recommend going to the NAMS website and, finding a OBGYN who is actually certified in that. 

Thank you so much for sharing that information because that is extremely valuable for people to have. Now, for females that have an autoimmune disease and they want to try a hormonal replacement therapy, 

As you mentioned, the situation might be a little bit complicated depending on the type of disease that you have, and you pointed very well about patients with lupus. 

What the American College of Rheumatology did, finally, a few years back, 

they release guidelines for females that have rheumatological conditions and they need or they want to try hormonal replacement therapy. 

And as you said, lupus patients, if they don't have  antiphospholipid syndrome or the presence of antibodies, they could qualify for that.

But again, I think it's important to have that discussion with your doctor. to weigh the benefits, to weigh the risk, and then make the assessment. 

How about patients with rheumatoid arthritis? Do they have limitations in your opinion?

 No. So patients with rheumatoid arthritis can definitely be on hormone therapy.

And even for patients, without rheumatoid arthritis, many people around menopause start to feel joint pain. They go to a rheumatologist, they get all the blood work. Some people do end up having rheumatoid arthritis. Others don't. They just have another type of arthritis. But once they start the estrogen therapy, they end up feeling a lot better.

And so it is not a contraindication for patients with rheumatoid arthritis. 

And I'm glad you also mentioned about the specific anti the phospholipid antibodies. And it's really A benefit and a risk discussion. Some patients are suffering so much that they'll take the risk and take, an estrogen patch because their life is otherwise miserable.

They can't sleep, they can't, function. They're just have so much brain fog, hot flashes. So for them, that's small risk is worth it. So really being able to. Think about what your priorities are and what you're willing to deal with is important when you go see a physician to have this discussion. 

We had that prior discussion about vaginal dryness. 

A lot of my patients with Sjogren's disease, they do battle  severe dryness. And what is bothersome to them is the fact that their skin is very dry and they have the vaginal dryness. And a lot of the females that I see, they get into more than that because, going through your life and having a sexual life, that becomes a problem.

And you mentioned about the vaginal rings. Are there any other options for these patients that do experience a lot of dryness and they want to, they want to have a normal life or close to a normal life and don't compromise the relationship with their partner?  Yeah, absolutely. So vaginal estrogen also comes in many different forms.

The easiest way is a little pill that you insert in the vagina twice a week. It's not very messy. It's very easy and patients immediately see, a, good improvement with that. There's also creams that you can use. There's a ring that you can use and just leave it in for three months, which is really nice because you don't have to remember to put something in, every single week.

And so there's all these different forms. And so there's options for patients who like one thing over the other and a lot of times if you go on systemic hormone therapy, like a patch that will also improve the vaginal dryness at the same time. So you can get, the double benefit on that.

But yes, I recommend everyone to use vaginal estrogen, really about 50, but especially patients with Sjogren's or other conditions where they have vaginal dryness, because we know that Also, the lack of estrogen can cause dryness around the urethra that can increase UTIs. And so it's just not sex and, vaginal comfort, but it's also other things like UTIs and then you need antibiotics and all of that.

So this vaginal estrogen prevents all of that, which is great.  Do you recommend the combination of estrogen and progesterone, or what do you think about that? Yeah, so this is an important thing I tell all my patients. If you're on estrogen, you must be on progesterone, unless you don't have a uterus. If you had a hysterectomy for fibroids or whatever reason you don't have a hysterectomy, meaning you don't have a uterus, then you can just take estrogen.

But if you have a uterus, we want to balance that estrogen out with some progesterone. So that the lining of the uterus doesn't get too thick or can, lead to endometrial cancer or anything like that. So we always want to balance those two things out. Yes. And progesterone can also help with sleep at the same time.

So which is an added benefit. That's true. And how about the follow up? How many times should the patient follow up with with a specialist like you?  So after we initiate hormone therapy, I write only a three month prescription and I tell patients to come back. Televisit is fine. Just to see how they're doing.

Do we need to go up on the dose? Do we need to take it down? Do we need to change the type of estrogen we're giving them? From a pill to a patch or patch to a gel. So just to see how they're doing. But after that three month mark, then we, then they just see me in a year.

And it's also important to know that estrogen can slightly increase your blood pressure, very slightly. And so it's nice for also to monitor that. A lot of patients now have blood pressure, coughs at home, and so they get a tele visit is fine. But yeah, three months,  one follow up at three months is good. 

During menopause, because we have so many changes, I think that a lot of us, we are also more prone to address our lifestyle. What are the lifestyle changes that you do recommend to your patients during menopause or when they approach menopause?  Yes, that is a great question. I think along with entering your late forties and into the fifties, insulin resistance also goes up.

So we're seeing a lot more metabolic disease, high blood pressure, cholesterol triglycerides, all this other stuff too. So definitely Really making sure that exercise is more like a prescription. You're really doing that every day with a big focus on weights for especially for women for muscle mass and balance and all of that as well as osteoporosis prevention So exercise with a focus on weights a good diet.

I think we all you know, probably eat more poorly than we think we do. So really examining the diet and making sure you're getting enough protein. And then a huge part is actually stress management as well. Stress, we always hear it and we say okay. Really stress does make things worse.

Hot flashes even. And finding, meditation or however it is that you relieve stress, these are the kind of the three pillars that I mention, I encourage patients to work on and sleep also definitely. And we can often help sleep with the hormones that we give. 

 Those are absolutely great advices.

I share the same kind of philosophy as you do. 

Many times patients do not expect to hear those things from a physician. 

The fact that we are more and more that we talk about lifestyle when we manage chronic conditions, it enlightens  me. Makes me so happy. 

Now, tell us a little bit about your practice.

How do you practice? Where do you practice? What do you offer to your patients? 

Because I think   many patients will be very interested to, to find, to work with you because you share so much knowledge and it's clear that you know what you're doing. 

Yes. Thank you. 

, I'm in the Bay area, Northern California.

And my practice is in Lafayette, California. 

I'm licensed in California, so I can see patients throughout California, including Southern California, San Diego, et cetera. 

 I started my own practice in 2022. I have a very boutique practice.

And by that, I mean that I spend, 45 minutes to an hour with every patient.

So in the typical medical system I used to see. 25 patients a day. Now I see eight patients a day and I'm really able to Dive into their health a lot more So coming to the  GYN is a lot more than just a breast exam and a pap smear we do need to talk about the entire the, all of the things that are going on especially around menopause.

And so in my practice, I see my youngest patient is 10, my oldest is 87. So I see patients through all phases of life and I have a special niche in surgical gynecology. So all the things we mentioned, fibroids, cysts, all of that and menopause, I am NAM certified. And so I really have a passion for speaking the truth to patients in menopause and getting them the care that they need.

Because as we discussed earlier, this a lot of misinformation and women are suffering unnecessarily. And yeah, so that's my mission with this practice. And you can read a little bit more on my website. And I also love educating women in social media. So I have a tick talk and Instagram and YouTube channel all with the handle, the fibroid doc. 

Tell us a little bit about your fibroid coaching program.  

 The fibroid coaching program, I started this because I would get requests on social media from people in New York and, other parts of the country where they would say you don't have all these questions about fibroids.

My doctor doesn't really have any time to talk about it. And so I can't technically practice medicine in all these other States, but I created a coaching program where I would just answer questions. for patients on fibroids, or maybe they have an upcoming surgery and they want to ask me questions about that surgery or what they can expect, things like that.

And yes. And I have a whole website for that, the fibroid doc. com. And so you can definitely find all that information there too.  Thank you very much for giving us the time, for giving us your knowledge. Dr. Prabhakar, we are in depth and I hope to see you soon to answer more questions for us.  Yeah, thank you so much for having me.

I really enjoyed this time.    Thank you for joining Thriving with Arthritis podcast. If you find today's episode valuable, please subscribe. Consider to leave us a review as your feedback helps us improve and reach out more people like you. Remember, you are not alone in your journey with arthritis and autoimmune diseases. Together, we can learn, grow, thrive, and not just survive.

Stay tuned for our next episode where we will dive deeper into what's next. More topics that will matter to you. Until then, keep thriving!