5 Surprising Things I Learned Studying for The Menopause Society Exam

2 days ago

5 min read

After 8 years in practice (and 25 years as an ACSM-certified exercise physiologist), I figured I knew menopause pretty well. Then I sat down to study for The Menopause Society certification exam, and let me just say here: I was humbled more than once!

And I PASSED. I'm now a Menopause Society Certified Practitioner (MSCP), and I'm so grateful to bring that training to the women I care for at Avra Health in Longmont, Colorado.

Some of what I learned surprised even me. So let's break down five things every woman in peri/menopause (and every woman who loves one) should know.

1. "Bioidentical" hormones are available FDA-approved

I hear this all the time: "I want bioidentical hormones, so I have to go to a compounding pharmacy." Not true!

"Bioidentical" just means the hormone is chemically identical to what your ovaries make. Several FDA-approved products fit that description (The Menopause Society, 2022):

Estradiol: patches, gels, sprays, vaginal forms and pills
Micronized progesterone: capsules
Estradiol + progesterone combined: one capsule

FDA-approved products are tested for consistent dosing, and many are covered by insurance or cost less with discount programs. Compounded hormones still have a place for some women (for example, an allergy to an ingredient or a dose that isn't made commercially), but now you know you have choices.

2. On thyroid medication? Starting oral estrogen can change your dose

If you take thyroid hormone (like levothyroxine) and start estrogen as a pill, your TSH needs to be rechecked.

Here's why. Estrogen taken by mouth passes through the liver first, and the liver responds by making more thyroxine-binding globulin, or TBG (a protein that carries thyroid hormone in the blood). More TBG means more of your thyroid hormone gets "bound up" and less is free to do its job. In one classic study, women on thyroid replacement who started oral estrogen needed a higher dose to stay in range (Arafah, 2001).

The same first-pass effect raises SHBG (sex hormone-binding globulin), which binds testosterone and estrogen. So oral estrogen shifts several of your "carrier proteins" at once.

Recheck TSH about 6-12 weeks after starting oral estrogen
Transdermal estrogen (patch, gel, spray) skips the liver's first pass and has much less effect on TBG
Never adjust your thyroid dose on your own; work with your prescriber

3. Bone loss starts BEFORE menopause

Most women think bone loss is a "later" problem. It isn't. Bone loss speeds up in late perimenopause, roughly 1-3 years before your final period, and keeps going fast for a few years after (Greendale, 2012).

That means the window to protect your bones opens while you're still having periods, often in your mid-to-late 40s. By the time a DEXA scan finds osteopenia, a lot of that early loss has already happened.

What I talk with my patients about:

Progressive resistance training, the most bone-friendly exercise we have (Watson, 2018)
Enough protein, calcium and vitamin D for YOUR body
An individual risk/benefit conversation about bone health, including whether MHT makes sense for you

I am a strength-training doctor after all. This one fired me up!

4. Gabapentin can help hot flashes AND sleep

MHT (menopausal hormone therapy) is the most effective treatment for hot flashes. But not every woman can take it (for example, some women with a history of breast cancer or blood clots), and not every woman wants to. That is HER choice.

I was surprised by how well a medication most people know for nerve pain fits here. The Menopause Society's 2023 Nonhormone Therapy Position Statement recommends gabapentin for hot flashes and night sweats (The Menopause Society, 2023).

It's often taken at bedtime, so the drowsiness that can be a side effect becomes a bonus for sleep
It's a great fit for women whose hot flashes are worst at night
Common side effects include dizziness and drowsiness, so it's started low and adjusted

It's one tool, not the whole toolbox, but it's a good one to know about.

5. SAM-e has held its own against tricyclic antidepressants

I'm a crunchy naturopathic doctor, so this one made me smile. SAM-e (S-adenosyl-L-methionine, a compound your body makes to run methylation) has been compared head-to-head with tricyclic antidepressants for depression. A large government evidence review found SAM-e worked about as well as those conventional antidepressants (Hardy et al., 2002).

Why that matters in midlife: mood changes are common in perimenopause, and many women want options.

A few honest caveats:

Many of the older trials were small and short, and some used injected SAM-e rather than capsules
It isn't right for everyone, including people with bipolar disorder
It can interact with antidepressants and other serotonin-affecting medications
Supplement quality varies a LOT

So, talk with your doctor before starting it. If you're struggling with your mood, please reach out for help; you don't have to ride out those waves alone.

The Bottom Line

Menopause doesn't mean you are broken. It's a natural transition, and you have more say in how it goes than you've been told. The more you know, the better your choices.

My approach hasn't changed with four new letters after my name: root cause first, then MHT when it's appropriate and when YOU want it after a conversation of risks vs benefits (in Colorado, you will be referred to our Women's Health Nurse Practitioner, Kyrie Anderson for a hormone discussion, but in AZ and WA I'll handle any prescriptions). What has changed is my understanding of all the options and nuances of peri/menopause - including how hormones affect risks of cancer and stroke in different populations.

Menopause care in Longmont, Colorado

At Avra Health, we see women in peri/menopause in person in Longmont, serving Boulder County and Northern Colorado (including Boulder, Niwot, Lyons, Erie, Berthoud and Loveland), and virtually across Colorado, Arizona and Washington.

60-minute initial visit, in person in Longmont or virtual
Body composition (BIA) and heart rate variability (HRV) testing at in-person visits
Hormone therapy, nonhormone options, functional labs and optional genetic testing

Ready to get some clarity? Book your first visit at avra-health.com.

I'll be honest, studying for this exam gave me a few night sweats of my own :-)

Dr. April Graham, N.D., MSCP, is a naturopathic doctor with 8 years in practice and has been an ACSM-certified exercise physiologist for 25 years. She is registered in Colorado and licensed in Arizona and Washington. This post is for education only and isn't medical advice; talk with your own doctor before changing any treatment.

References

Arafah, B. M. (2001). Increased need for thyroxine in women with hypothyroidism during estrogen therapy. New England Journal of Medicine, 344(23), 1743-1749.
Greendale, G. A., et al. (2012). Bone mineral density loss in relation to the final menstrual period in a multiethnic cohort: Results from the Study of Women's Health Across the Nation (SWAN). Journal of Bone and Mineral Research, 27(1), 111-118.
Hardy, M. L., et al. (2002). S-Adenosyl-L-Methionine for Treatment of Depression, Osteoarthritis, and Liver Disease (Evidence Report/Technology Assessment No. 64). Agency for Healthcare Research and Quality.
The Menopause Society. (2022). The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 29(7), 767-794.
The Menopause Society. (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 30(6), 573-590.
Watson, S. L., et al. (2018). High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: The LIFTMOR randomized controlled trial. Journal of Bone and Mineral Research, 33(2), 211-220.