Cardiovascular disease is the No. 1 killer of women nationwide, yet during midlife—the crucial time for prevention—many women fall out of regular medical care.

Host Dr. Rachel Pope is joined by Dr. Lisa Larkin, an internal medicine and women's health expert and founder of Ms. Medicine. They discuss why women's cardiovascular risk spikes around menopause and what you can do about it now.

Dr. Larkin highlights a failure in the healthcare system: women aged 40 to 60 often receive the least medical care, right when prevention is most critical.

The perimenopausal transition causes rapid and significant metabolic changes:

• Cholesterol rises and HDL protection declines.
• Development of insulin resistance.
• Increase in visceral fat (the "risky fat" around organs), which is a marker for cardiovascular disease.

Standard risk tools often underestimate risk in women because they don't account for sex-specific factors like adverse pregnancy outcomes (preeclampsia, gestational diabetes). Women are also often allowed to run higher blood pressures, missing opportunities for early intervention.

Dr. Larkin stresses that Body Composition is more important than BMI, as most women gain risky visceral fat during this time. She recommends tracking body composition annually.

For women in their mid-60s who ask if they've missed the boat on prevention or Hormone Therapy (HT):

• Assessment is Key: Dr. Larkin performs a highly individualized assessment, often utilizing a Coronary Calcium Score to check for established plaque.
• If Risk is Low: A patient with perfect health metrics and a Calcium Score of zero may still be a candidate for HT to treat symptoms and support bone health.
• If Risk is High: The priority is to aggressively fix every single risk factor (hypertension, elevated lipids) before considering hormones, as established plaque may carry more risk with estrogen.

Dr. Larkin emphasizes that women must be their best advocates because the healthcare system is currently failing to provide the comprehensive care needed during this pivotal stage of life.

This episode addresses a terrifying but common experience for midlife women: the cognitive changes, or "brain fog," that pop up during perimenopause and menopause. Many women fear they are experiencing early-onset dementia.

Host Dr. Rachel Pope speaks with Dr. Rita Shkullaku, a board-certified internist with a special interest in nutrition, obesity, and hormones as they relate to cognitive wellness and healthy aging.

Dr. Shkullaku confirms that brain fog—forgetfulness, concentration issues, and a blank mind—is very real. She notes that having "mild cognitive issues for eight to ten years has no small impact" on high-functioning women.

The problem stems from both:

• Direct Effects: Estrogen drops affect the brain’s ability to use the prefrontal cortex and manage stress.
• Indirect Effects: Severe sleep deprivation from night sweats and hot flashes dramatically worsens cognition.

To distinguish serious issues from hormonal brain fog, Dr. Shkullaku uses the Self-Report vs. Intervention rule: women with typical brain fog are aware of their struggle, while those with true early dementia are often unaware and brought in by family.

Management requires a holistic approach, starting with the foundation:

1. Prioritize Sleep: Address the underlying hormonal issues or anxiety that keep you awake.
2. Redistribute Responsibility: Normalize the struggle and ask partners/family for help to create time for self-care.
3. Complex Cognitive Training: Pick up a new complex activity (like a new instrument or language) to engage the brain differently.
4. Nutrition: Follow the MIND Diet (a hybrid of the Mediterranean and DASH diets).

Treatment: If medically eligible, Hormone Replacement Therapy (HRT) is a great option, primarily by eliminating sleep-disrupting symptoms. If not, Cognitive Behavioral Therapy (CBT), mindfulness, and addressing reversible causes (like iron or B12 deficiencies) are crucial.

In this episode of Perimenopause: Head to Toe, Dr. Rachel Pope sits down with Dr. Karen Connor, a seasoned physical therapist with over 20 years of experience, to discuss how perimenopause and menopause affect the pelvic floor. Dr. Connor shares her extensive expertise in pelvic health, shedding light on the changes women experience during this stage of life and how pelvic floor physical therapy can help manage and prevent complications.

Key Highlights:

• What is the Pelvic Floor? Dr. Connor explains the role of the pelvic floor muscles, their importance in overall health, and how they provide support for vital organs.
• How Perimenopause Affects the Pelvic Floor: Learn how hormonal changes during perimenopause and menopause lead to tissue thinning, reduced elasticity, and muscle weakening, all of which can affect pelvic floor health.
• Pelvic Floor Exercise: Dr. Connor emphasizes the importance of pelvic floor exercises like Kegels, and why combining these with other physical therapy techniques is crucial for comprehensive pelvic health.
• Heavy Lifting and Pelvic Floor Health: Dr. Connor shares her insights on lifting heavy weights and how it can impact the pelvic floor, offering practical advice on how to protect it.
• Managing Pelvic Pain and Prolapse: From pain with penetration to prolapse, Dr. Connor discusses how pelvic floor therapy can help women manage these conditions, even if they're already experiencing symptoms.
• The Importance of Working with a Pelvic Floor Physical Therapist: Dr. Connor highlights the benefits of seeing a pelvic floor physical therapist for tailored care and exercises that address the unique needs of each individual.

For Women in Perimenopause and Beyond:
Dr. Connor stresses that no matter where you are in your health journey, pelvic floor physical therapy can help manage symptoms and prevent future complications. Whether dealing with prolapse, incontinence, or pelvic pain, proper treatment can significantly improve quality of life.

About Dr. Karen Connor:
Dr. Connor is a highly experienced physical therapist, educator, and pelvic health advocate. She co-authored the book Sex in Your 60s and has served in various leadership roles within the American Physical Therapy Association. Dr. Connor currently runs a private practice, Cleveland Pelvic Wellness, alongside Dr. Jessica Jenkins, where they provide specialized pelvic floor therapy to women in Northeast Ohio.

Resources Mentioned in the Episode:

• Cleveland Pelvic Wellness Website: clevelandpelvicwellness.com
• Sex in Your 60s (Book co-authored by Dr. Karen Connor)
• The Menopause Retreat - November 14th

This episode features Dr. Diana Ponsky, a renowned facial plastic surgeon in Cleveland, Ohio, who leads Ponsky Facial Plastic Surgery. Double board-certified in Facial Plastic Surgery and ENT, Dr. Ponsky specializes in natural facial rejuvenation. She discusses how hormonal shifts impact the face and what women can do about it.

Dr. Ponsky notes that a sharp drop in hormones around menopause can feel like an "acute switch" in aging.

• Collagen Loss: Women can lose up to 30% of their collagen within five years around menopause, followed by a 2% loss each year.
• Structural Changes: Low estrogen affects receptors throughout the skin and bone. This causes skin to become coarser, fat to descend, and even facial bones (like the jaw and areas around the nose) to atrophy, which can flatten the brow arch.

Aging gracefully is about slowing down the process, which Dr. Ponsky compares to constant maintenance on a car.

• Proactive Care: Genetic predispositions mean some women benefit from early surgical prevention (like brow lifts or fat transfer).
• Lifestyle: Rigorous skincare, sun protection, and avoiding repetitive motions (like drinking through straws) are crucial for maintenance.
• The Role of HRT: Dr. Ponsky is a firm believer in Hormone Replacement Therapy (HRT), even starting in perimenopause, to slow the loss of muscle mass and bone density (including in the face).

• Fillers: These are volumizing agents (like hyaluronic acid) that replace lost volume; they do not lift. Dr. Ponsky cautions against overuse, as too much filler can distort muscle movement.
• Never Too Late: For those who missed the prevention window, aggressive treatments like deeper lasers and fat transfer can still yield great results, combined with a commitment to nutrition and a long-term care program.

Dr. Ponsky reminds women that given we are living longer, tending to our bodies is necessary. It's not vanity; it's ensuring a high quality of life long after menopause.

In this episode of Our Womanity features a conversation with Sundae Bean, a transformation facilitator who supports individuals and organizations as they traverse through life quakes and other major shifts. A trusted voice for navigating life between worlds, Sundae is currently dedicated to organizational transformation in Switzerland and is widely known for her podcast, IN TRANSIT.

Perimenopause: A Biological Transition

Sundae explains perimenopause as an externally led transition—something that happens to you, not something you choose. This can overlap with other life transitions:

• Internally Led: Changes that come from within.
• Performance Led: Pursuing a big goal, like a promotion.
• Externally Led: Changes that come from our environments.

She emphasizes the importance of distinguishing between a genuine emotional response and a biochemical one, noting that while feelings are real, their source may be hormonal rather than a true reflection of your reality.

Strategies for Navigating Hormonal Shifts

Sundae offers practical advice to help manage symptoms like "monkey mind":

• Reality Check and Blood Check: Use this dual approach to test what's truly going on. Talk to a trusted friend to get an outside perspective, and work with your doctor to get yourself evaluated .
• Trust Your Body: Sundae shares her own experience of listening to her body's "yummy yes" for yoga over a "hard no" for running. This highlights the importance of trusting your body's needs over external advice.
• Find Your Body Compass: To counter feeling out of control, she suggests a simple exercise: take three deep breaths and hold the fourth until you can feel your own heartbeat. This grounds you and gets you out of your head.

Perimenopause as a Growth Opportunity

While difficult, perimenopause can be a time for growth.

• Self-Advocacy: It may force you to become your own best advocate, taking charge of your health when the system feels unsupportive.
• Adapting Strategies: Acknowledge that old strategies might not work now. A coach can help you develop new approaches.
• Bending Reality: Sundae encourages listeners to honestly assess where they might be "bending reality"—acting as if there are more than 24 hours in a day. This awareness is the first step toward delegating and prioritizing.

Advice for Healthcare Providers

Sundae offers advice for healthcare providers to better support their patients.

• Listen to the Patient: Ask, "How have you been?" to understand the full context of their life.
• Validate Their Experience: Don't dismiss symptoms. A simple, "That sounds hard," can be incredibly validating.

Refer When Needed: If you cannot provide the necessary care, refer patients to a coach or other specialist.

This episode of Perimenopause: Head to Toe features Dr. Sameena Rahman, an OB-GYN and specialist in sexual medicine and menopause. She is also the founder of the GYN and Sexual Medicine Collective

Dr. Rahman highlights that women in their mid-40s often experience confusing bodily changes. Symptoms include:

• Menstrual Changes: Unpredictable periods, with some becoming heavier or stopping for months.
• Physical & Emotional Symptoms: Intimate dryness, reduced libido, sleep issues, hot flashes, brain fog, and irritability.

The conversation addresses challenges within the medical system.

• A Patriarchal System: The doctors agree that the healthcare system is historically patriarchal, resulting in a lack of research and understanding of women's health.
• Medical Training Gap: The doctors note that medical school training often overlooks the significant emotional and cognitive effects of perimenopause, focusing instead on hot flashes and irregular periods.
• The "Double Whammy": They point out that because the OB-GYN field is largely female, there's an unspoken expectation to manage all aspects of women's health with limited resources, leading to provider burnout and inadequate patient care.

Dr. Rahman, who is South Asian, discusses unique challenges for women of color.

• Earlier Onset: Women of color, including Black and South Asian women, often experience perimenopause and menopause earlier. This is linked to allostatic load, the cumulative "wear and tear" from chronic stress.
• Stigma: Cultural factors like stoicism and taboos around sex lead to a reluctance to seek medical help.
• Health Disparities: The episode notes higher rates of heart disease and diabetes in the South Asian population.

Dr. Sameena Rahman is a board-certified OB/GYN, sex-med gynecologist, menopause specialist and a clinical assistant professor of OB/GYN at the Northwestern Feinberg School of Medicine.  She is the founder of the Gyn & Sexual Medicine Collective, a successful concierge practice that emphasizes evidence-based medicine and an affiliate of Ms. Medicine.  Dr. Rahman is dedicated to evaluating and treating each patient with compassion, trauma-informed care, and an awareness of personal bias. Additionally, she hosts the podcast Gyno Girl Presents: Sex, Drugs & Hormones.

Her upcoming book, "Brown Girls Disease? A Guide to Sexual Health and Empowerment Through a South Asian Lens," explores sexual health issues from a unique cultural and religious perspective.

In this episode of Perimenopause: Head to Toe, Dr. Rachel Pope welcomes Dr. Danette Conklin, PhD, a Clinical and Health Psychologist and Assistant Professor at Case Western Reserve University School of Medicine. Dr. Conklin shares her expertise on the intersection of behavioral health, weight management, and midlife transitions, including perimenopause and menopause.

As Director of Behavioral Health Services for both surgical and non-surgical weight management programs at University Hospitals Cleveland Medical Center, Dr. Conklin has a unique perspective on how psychological and biological factors influence health during midlife. She has also contributed to establishing menopause clinics in Cleveland, helping women navigate the physical and emotional changes of this life stage.

We discuss:

• How behavioral health intersects with perimenopause and menopause
• Managing weight, mood, and lifestyle changes during midlife
• The role of psychology in supporting cardiovascular and metabolic health
• Strategies for navigating stress, sleep, and emotional shifts
• How to advocate for yourself and your care during midlife transitions
• Practical ways to support wellness, including the use of non-prescription supplements like MiM, which are designed to help with peri- and post-menopause symptoms

With her extensive experience on national committees and advisory boards, including The Menopause Society and the American Society for Metabolic and Bariatric Surgery, Dr. Conklin provides practical guidance for women seeking to thrive during this transformative stage of life.

In this episode of Perimenopause: Head to Toe, Dr. Rachel Pope is joined by expert dermatologist Dr. Melissa Mauskar, who dives into how perimenopause and menopause affect our skin. From changes in the face to thinning skin, Dr. Mauskar explains why skin and hair transformations during this time are not only inevitable but also manageable.

Dr. Mauskar is an Associate Professor in the Departments of Dermatology and OB-GYN at UT Southwestern Medical Center. She specializes in dermatology, with a focus on vulvar health and dermatologic changes that come with different stages of a woman’s life.

In this episode, you’ll learn:

• How estrogen, progesterone, and testosterone affect your skin.
• Why you might notice acne, dryness, or thinning hair in your 40s and beyond.
• The importance of topical estrogen for maintaining skin thickness.
• How perimenopause might trigger or worsen conditions like eczema, psoriasis, and even melasma.
• Tips for preventing skin aging, including the importance of sunscreen and good skincare routines.

If you've noticed changes in your skin, this episode offers expert advice on how to address them and what you can do to prevent further damage.

About Dr. Mauskar:
Dr. Melissa Mauskar is an expert in dermatology and vulvar health, with extensive experience in addressing the skin changes that women experience during perimenopause and menopause. She is the founder of the Vulvar Health Program at UT Southwestern and frequently presents at symposia on women’s health dermatology.

Welcome back to Our Womanity! In this episode, Dr. Rachel Pope sits down with Lindsay Means, CNP, a nurse practitioner at the Ear, Nose, and Throat Institute at University Hospitals Cleveland Medical Center. They explore how perimenopause and menopause affect ENT health and the common issues women face during this time.

Lindsay Means earned her Master's in Nursing at Malone College and became a Family Nurse Practitioner in 2009. She began her career at University Hospitals in Cleveland in the department of Gyn/Oncology. She remained in that specialty until 2015, when she transferred to the ENT department, working for the division of Neurotology. She currently manages patients with a variety of ear-related issues, including dizziness.

• Dizziness & Balance Issues: Lindsay discusses how dizziness is one of the most common complaints she sees in women during perimenopause and menopause, with a focus on vestibular migraines and balance problems.
• Understanding Vertigo: Learn the difference between vertigo (spinning sensation) and other balance issues, and why many women mistakenly associate dizziness with vertigo when they’re actually experiencing lightheadedness or unsteadiness.
• Hormonal Changes & Migraine: How perimenopausal women may experience vestibular migraines without traditional headaches, with hormonal fluctuations potentially making these symptoms worse.
• Meniere’s Disease vs. Migraine: Lindsay explains the overlap between Meniere’s disease and migraine-related ear symptoms, and the importance of proper diagnosis to avoid confusion between the two.
• Ear Health and Dryness: Perimenopausal women may experience itchy ears due to dry skin and changes in earwax production. Lindsay shares practical advice, including oil drops to alleviate symptoms.

This episode highlights how perimenopause and menopause impact different systems of the body that are often overlooked, such as ENT health. Lindsay’s insights into balance disorders, migraines, and ear-related issues provide valuable information for women navigating this stage of life.

Remember, you don’t have to suffer through it! Seek help if you’re experiencing these symptoms, and don’t hesitate to reach out to healthcare professionals like Lindsay who specialize in ENT and balance disorders.

In this episode, join Dr. Rachel Pope and her colleagues, Dr. Anne Sammarco and Dr. Maria Shaker, as they reflect on their recent trip to Tanzania. Dr. Pope shares the personal connection she has with the country, dating back to her early career when she worked on a research project about obstetric fistulas. Fast forward nearly two decades, and she returns with her colleagues to assist with fistula surgeries, childbirth injuries, obstetrics, and women's health care.

• The Early Days in Tanzania: Dr. Pope recounts her initial time in Tanzania working with Utu Mwanamke (Women’s Dignity Project) and conducting a study on the social reintegration of women who underwent obstetric fistula surgeries.
• CCBRT Hospital: Now a much larger charity hospital, Dr. Pope reflects on how much the Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) hospital has grown, offering services for vulnerable populations and providing high-quality care in a resource-limited setting.
• A Team of Experts: Dr. Pope, alongside Dr. Sammarco and Dr. Shaker, shares their unique collaboration during the trip, combining their skills in obstetrics, gynecology, and urogynecology to provide critical care and training at CCBRT.
• Cultural Exchange: The episode highlights the importance of exchanging knowledge with local medical professionals, offering education to Tanzanian medical students and residents while learning valuable insights from their practices.
• Global Health Impact: The trio discusses the complexities of global health, including how resources and cultural factors shape patient care. They stress the importance of capacity building and sustainable healthcare practices that extend beyond short-term missions.

The episode also covers the broader themes of women’s healthcare advocacy, access to surgery, and the need for global solidarity in providing equitable health services to underserved populations.

Resources Mentioned:

• CCBRT – Comprehensive Community Based Rehabilitation in Tanzania
• Roe Green Foundation – Support for global health initiatives
• What is Obstetric Fistula?

If you’re passionate about global health, women’s empowerment, or the importance of providing sustainable medical care, this episode will inspire you to consider the ways we can all make a positive impact.

A huge thank you to the Roe Green Foundation for sponsoring this impactful journey, CCBRT for hosting the team, and all the medical professionals involved for their dedication to women's health globally.