ICU – “I SEE YOU” PODCAST
How Does Dizziness Change with Menopause?
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Each person’s experience of the menopause transition is unique. Changes affect sleep, mood, mental acuity, and subsequently, you guessed it, our vestibular system. Reports of the effect women’s hormones play on their vestibular systems are common, but symptoms vary. During different hormonal periods, some women report a new onset of symptoms, while others report a worsening of existing symptoms, and some even report improvement.
In this episode of the ICU – “I See You” podcast, hosts are joined by Dr. Maja Scrakic and vestibular patient Nina Coslov who discuss personal experiences and research on this important topic.
This podcast is a co-production of the Vestibular Disorders Association (VeDA) and Unfixed Media.
ABOUT THE GUESTS
Dr. Maja Svrakic is a board certified neurotologist. She holds a faculty appointment at the Northwell Health Department of Otolaryngology at the Long Island Jewish Medical Center and is an Associate Professor of Otolaryngology at Zucker School of Medicine, where she is also the Program Director for the Residency in Otolaryngology and Head & Neck Surgery. Dr. Svrakic immigrated from Belgrade, Serbia, graduated summa cum laude from Washington University in St. Louis, and received her medical degree from Columbia University. She completed residency in Otolaryngology at the Albert Einstein College of Medicine, a fellowship in Neurotology at New York University, and a Masters in Health Professions Pedagogy and Leadership at the Hofstra University School of Education. She has also authored numerous peer-reviewed scientific articles and book chapters.
Nina Coslov has experienced episodic dizziness on and off for years and like many of us, navigated countless doctors and hypotheses, tried many therapies, and wondered about the relationship of her dizzy symptoms to hormonal changes. Nina Coslov created Women Living Better (womenlivingbetter.org) to provide anticipatory guidance about perimenopause. Intent on better characterizing the path to menopause, Nina focuses on education and research. Nina and her research partners have published seven papers in peer-reviewed journals. Nina was the lead author on “Symptom experience during the late reproductive stage and the menopause transition: observations from the Women Living Better survey” published in the journal Menopause. She also authored the chapter “Women’s Voices: The Lived Experience of the Path to Menopause” in Each Women’s Menopause: An evidenced Based Resource. Nina received the 2021 Media Award from the North American Menopause Society.
Hosts:
Cynthia Ryan, Executive Director of the Vestibular Disorders Association (VeDA) https://vestibular.org/
Kimberly Warner, Founder and Director of Unfixed Media https://unfixedmedia.com/
This podcast is a co-production of the Vestibular Disorders Association (VeDA) and Unfixed Media
TRANSCRIPT
VeDA uses otter.ai to create machine-generated transcripts. This transcript may contain errors.
Cynthia Ryan – VeDA
Welcome to the ICU Podcast where we explore the vestibular experience through conversations between patients and the health professionals who care for them.
Kimberly Warner – Unfixed Media
During this podcast, we invite patients to share their stories and healthcare professionals to ask questions, so they are equipped to better care for and truly see the invisible challenges faced by their patients. I’m Kimberly Warner. And
Cynthia Ryan – VeDA
I’m Cynthia Ryan. And we are your hosts on this journey of discovery.
Kimberly Warner – Unfixed Media
Welcome, everyone to the ICU podcast. This is going to be such an incredible conversation today one that is necessary. And sorry guys, but this one is on menopause and perimenopause. So tune in for your wives and your girlfriends and your mothers and your daughters. But this won’t What won’t be about you today. But it will affect you, I guarantee it. So, every woman’s experience of menopause, the menopause transition is unique. I just turned 40 When my symptoms began, and it’s known that hormonal changes on the path to menopause can begin before menstrual irregularity as early as your late 30s or early 40s. These changes affect sleep, mood, mental acuity, and subsequently, you guessed it, our vestibular systems, or how our brains interpret sensory input. Reports of the effect that women’s hormones play on their vestibular systems are common, but symptoms vary. During different hormonal periods. Some women report a new onset of symptoms while others report a worsening of existing symptoms and some even report improvement. Regardless, lack of information and education can contribute to miss attribution, confusion and definitely fear. But there is hope. New research is identifying the role estrogen may play in modulating vestibular symptoms, and how women can optimize this chapter of their lives through lifestyle changes hormone therapy and finding health care practitioners who are versed in helping women through these powerful changes. Our two guests today are awesome. I’m so excited to have them here. They have a lot to share about this important phase of our lives and how our vestibular systems may be affected. Cynthia, do you want to start the introduction?
Cynthia Ryan – VeDA
Yes, yes. Excellent. Thank you. I’m so excited to have Dr. Maya shrinkage. On our call today she is a board certified dermatologist and one of the very few people that I have found who is an expert in the correlation between the simular problems and hormone changes. She holds a faculty appointment at the Northwell Health Department of Otolaryngology at the Long Island Jewish Medical Center and is an associate professor of Otolaryngology at sucker Zucker School of Medicine where she is also the program director for the residency in otolaryngology and head neck surgery program. Dr. Turkish immigrated from Belgrade, Serbia, graduated summa cum laude from Washington University in St. Louis, one of the big vestibular medical centers in the United States, and received her medical degree from Columbia University. She completed residency in otolaryngology at the Albert Einstein College of Medicine, a fellowship in neurotology at New York University and a master’s in health professions pedagogy and leadership at the Hofstra University School of Education. I tell you becoming a neuropsychologist is a long, long journey. She has also authored numerous peer reviewed scientific articles and book chapters. Welcome, Dr. Rakesh,
Dr. Maja Svrakic
thank you so much. It sounds so great on paper.
Kimberly Warner – Unfixed Media
It’s so extensive, my goodness, you’ve devoted your life to this. So thank you. We also have Nina Kozlov with us today. Nina is actually bridging the patient experience and the expert she’s going to speak on both of those but she did experience episodic dizziness on and off for years and like many of us navigated countless doctors and hypotheses tried many therapies and wondered about the relationship of her disease symptoms to hormonal changes. Nina Kozlov created women living better please check it out. It is an organization that provides anticipatory guidance about perimenopause, intent on better characterizing the path to menopause. Nina focuses on education and research. Nina and her research partners have published seven papers in peer reviewed journals and she was the lead author on symptom experience during the late reproductive stage and the menopause transitions, observations from the women living better survey published in the Journal of menopause. She also authored the chapter women’s voices the lived experience of the path to menopause. In each women’s menopause and evidence based resource, Nina received the 2021 Media Award from the North American menopause society. Welcome, Nina, thank you so much for joining us today.
Nina Coslov
I’m happy to be here. I can’t I can’t wait to share and learn.
Kimberly Warner – Unfixed Media
Meet you. Well, let’s dive in. And we always have every episode began with a little bit of the patient experience. So Nina, can you just get us started by telling us about your experience of dizziness and how it lives? Sure.
Nina Coslov
So the first episodic is a really good word to describe my kind of pathway here. And I went back to my Dizzy folder to kind of chart this too. So I could tell this in a succinct way. But the first kind of episode began for me in 2003. In the spring of 2003, it lasted about two to three weeks. I was 32 at the time, and I’ll come back to that. But it basically didn’t turn up for me for another seven years. And then seven years later, I have sort of December, January 2010 2011. I then was like 3940. That was another kind of three week episode. And then not until May, June 20 2011. And then the summer, and all the way through kind of September of 2012, kind of three, two to three, four week episodes. And then another six years went by nothing. And then again in April, May 2018. And then interestingly, it’s popped up a little bit again last week, which I hadn’t, I hadn’t told you. But you know, until 2018, I wasn’t thinking at all about perimenopause or hormone related anything. But looking back on this, it’s really interesting to me and the linkages. I see. So in May of that first episode, May of 2003 I had just stopped nursing my first child, and I was back at work. And all of these have been kind of exacerbated, there’s something for me that is visual, it’s a visual dizziness. I always say I’m not rocking on a boat. I’m not the room is not spinning. It is it’s something I know it’s something in my brain, but it’s it’s something you know, it’s exacerbated by, you know, fluorescent lights in big box stores, highways, where there’s, you know, signage, that’s like going back really fast, particularly if it’s night and there’s like a reflection. So, you know, the linkage to stopping nursing, I think is interesting. And then kind of seven years go by. And then I’m 39, right. And this easily could be the beginning of shifting hormonal patterns, as I look back. And also as I look back at these, I hadn’t even thought about it until I was kind of preparing to kind of share this two to three weeks is about a menstrual cycle, right? If you if you take out the the menses itself, and, you know, the way these things happen, right, there’s, I think there’s the sort of seismic shifts, and then our body tries to get back into homeostasis, and then you know, something else go. So it’s very interesting. I’m 53 now. And last week, I had, I mean, I spent a lot of time on the computer all the time. And last week, I was watching doing this all day webinar, and doing some other stuff at the same time. And all of a sudden, I was like, Oh my gosh, here it is, again, like I could just I was like, I gotta look away, I’ve got to get away from my screen. And so I left the webinar. And I’d say for the last four or five days, my eyes are again in this it’s like a vulnerable sensitive time. And so you know, I, I’m going to be hitting I gotta be getting towards minimize it sometime sometime soon. And because I do all this other sort of tracking of my sleep and my hormones, I know that things are very erratic for me. So that’s kind of the kind of history of the of the intermittent and it’s mostly been sort of that you know, I call it sort of a visual dizziness, like, when you have a drink or two and it’s the first bit of a buzz or you know, in your head sort of feels good. It’s caused me to not drink because for a long time, because it’s like that became very unpleasant. And I remember initially sort of sighting around being like wait a minute, like what’s going on, like trying to just make sure that nothing was moving like in the background, you know, it’s visual, definitely a visual thing for me a couple of times I felt lightheaded, but it’s, I’d say 90% of it has been like a visual We’ll just kind of thing.
Kimberly Warner – Unfixed Media
I love how well you’ve tracked this. I think this is really I want to hear my what you have to say about this because it’s it’s absolutely fascinating. And I too, I don’t know if I told you, Nina but my first Dizzy episode started at 39. So I was definitely experiencing some hormonal changes, not just female hormones, but thyroid changes as well. So anyway,
Cynthia Ryan – VeDA
let’s let’s, I’m interested to hear from Dr. Rakesh, how, how did you get involved in researching the effects of menopause on vestibular patients?
Dr. Maja Svrakic
Well, I think mostly for me, it was just the experience of the amounts of patients that I was seeing with dizziness. And I don’t want to fool anyone I actually might training was purely surgical. You know, as some of you may know, narratology is a surgical field, it’s not actually a medical field. And so I didn’t have a lot of experience with dizziness. But what I ended up seeing was just a wide array of patients, I see both pediatric adults, and then geriatric patients, at the span of their life, both women and men. And what I was seeing was the patients with dizziness that I was getting that sort of peak was at this sort of Peri menopausal or menopausal time for women specifically. And so I just realized there is a very large underserved population, basically, where they’re coming in for dizziness, people not really understanding where this dizziness is coming from, or how the hormones influence this. And then what what they can do for treatment. So it was more sort of the curiosity of how do I help the patients even in the case that I don’t have formal training and this and so then my research might mainly became sort of clinical in a way that I was looking at the trends in my patients and the kinds of treatments that worked, and then sort of correlating that to the basic science research to understand the effects either way. So that’s sort of how the interest was there because of the need, it wasn’t something that I personally, you know, started with, this isn’t why I entered neurotology or why I started doing this, but it was sort of where I was needed. And I think, you know, just from a doctor’s perspective, your your job we are calling is to help people and if this is what’s coming through your resort and you do what needs to be helped. Right. So I think
Kimberly Warner – Unfixed Media
it’s it is coming from the need. And even though there isn’t a lot of research out there, I can can’t tell I can’t I don’t have enough fingers to count the number of women that have said, it gets worse during ovulation. It gets worse before my period get got worse during I mean, there’s there’s definitely in our own lived experience that there is a correlation here. And like you said, Nina, as well, you’ve you have suspicions about this in your research and the things that you shared on women living better. I know that this hypothesis is something that’s very real for you. When you did it ever come up with your care provider? Because the you know, you were having these suspicions. Did you bring it up with them? And if you did, how did they were? So
Nina Coslov
you know, the initial whole workup? I mean, I’ve been through so many crazy, not crazy tests, but some crazy tests like the flip table, I mean, really like trying to try to figure out figure out what this is allergy, heart monitor, you know, all types of stuff, but the whole first episode where I was in the vestibular, you know, lab or whatever it was, that was before I had any suspicions and I wasn’t on to this whole idea of perimenopause. But the way that it I think, from a provider perspective has been linked was to migraines. Now I never had really really severe migraines, but I sort of have a little bit of family history. I had a grandmother that had really bad migraines, I’ve had a couple but not like many of my friends that have migraines that carry around you know, prevention I never had that I could always kind of you know, go to bed, turn the lights off, put something cold on my head and it would be gone the next day. But that became the default diagnosis after seeing lots and lots of providers I think it was sort of like the absence of a of something else which I was fine with. There are a lot worse things it could have turned out to be but you know, I It’s the absence of the headache but the dizziness but in a lot of my notes and actually last week too. I do feel like a head pressure sometimes when I have the dizziness, so it’s not that killer migraine like on one side that makes you want to like close an eye or not walk up the stairs, but there is a little bit of a headache. So I think that in a way because we do know from research that that migraineurs have Worst migraines in perimenopause, and then they subside after your final menstrual period. And so that to me is a kind of consistent story. It was never discussed with the provider like, Hey, this is hormonal, but I think you know, just it certainly in the later episodes, I think that was kind of like, you know, you’re a woman of a certain age and this could be happening and if you had a history of migraine, so it wasn’t explicit. In terms of talking to my providers.
Kimberly Warner – Unfixed Media
That makes sense. Let’s
Cynthia Ryan – VeDA
let’s talk about hormones, specifically. Dr. psychische. Some research suggests that low estrogen levels may put vestibular may put patients at risk for developing vestibular disorders or trigger symptoms, and otherwise predisposed people. Can you? Can you explain why this occurs? What is that connection?
Dr. Maja Svrakic
Yeah, so let’s talk a little bit about sort of the, the actual hormones and then let’s talk about the kinds of disorders you know, that are going to be giving vestibular symptoms. So first things first, the major hormone that’s driving menopausal changes is going to be the drop in estrogen. And so what happens sort of on the physical level, or the woman is that there’s going to be some changes in menstruation, that’s usually the beginning of the drop of estrogen. And at some point in time, you will have your last period. And that period where the the estrogen is dropping is really the perimenopause. As estrogen drops, there is a hormone inside your pituitary gland that is alerted, to try and keep the estrogen levels up. So that hormone, the luteinizing, hormone starts secreting. And then it makes your ovaries try and secrete more estrogen, but there’s not a lot of stuff there to secrete anymore. So it’s kind of like a, like a faulty hormonal factory at that point. But it’s sort of driving it to produce more. And so you’re basically on this roller coaster, where you have a depletion of estrogen, and luteinizing hormone secretes more, it goes to your ovaries to kind of squeeze out whatever they can, and then they kind of keep, you know, dying out and in that way. And so I think it’s important not only to understand what that hormonal changes to then think about, what what are we really looking at, but you also want to look at this disorders. And you also want to look at, what is the goal of your body in this in this drop of estrogen? And I don’t want to get too philosophical. And if you need to cut me off on this one, you can. And then I think Nina probably is with me on this one. But it’s really thinking about why is this happening? What is the role of a post fertile woman in society? Right? Why are we still alive, and not being able to produce for half of our lives? That is a very unusual thing for a species to have. And so why is that? And the reason why is there is an advantage of having older, wiser women, they’re the keepers of wisdom. And again, to just go a little bit off tangent, when we look at primates. The reason why primate groups are more successful are the ones that have older females who are post fertile, who hold the wisdom of society, who then know where the best food is, who have experience, if you get into a war with this competing ape, troop, this is what’s going to happen. So I think it’s important for women to understand why these changes are happening. They’re happening because you are unable to reproduce anymore, but you’re still valuable. And let’s talk about what those changes are. And those changes again, if you just think about, well, what, what, what effects that it has. Well, it has neurological effects, why does it have neurological effects. When you need to be childbearing and child rearing, you need to have certain behaviors that are conducive to that. Let’s talk about the immune system. When you’re growing a baby inside your body when you’re breastfeeding, you have to have immune system changes that allow literally an alien thing to live in your body and not to reject it, right. So there is immune system changes that happen. There’s major metabolic effects on your bones on your musculoskeletal system, because you have to somehow reprogram your body to say, I will now draw out all the nutrients that I need for me into this fetus, right? So of course, they’re going to be major changes, and estrogen and progesterone are the major drivers of all these changes. And so if you think about, you know why the hot flashes happen, it’s a vasomotor symptom. It’s a symptom that causes your heart rate to increase your radiant temperature to rise. And that’s all happening because there’s like this sudden bursts of estrogen and why is it happening? Well, if you think about, well, if I need to have just evolutionary a fetus or to protect the young, right, like you need to be alert, you need to have an alert system to protect your babies or to protect your family. And so these changes and these hormonal changes are ancient, and they exist for a reason. But they mess with us, right? They mess with our whole bodies, they mess with our brains, they mess with our immune system. And then you have to sort of understand well, what disorders are we talking about, and then I’ll just jump to the disorders, so many years disease, it’s a disorder, technically of electrolytes and fluid and your inner ear. But if you think of the amount of fluid changes that have to have to happen during pregnancy, during exchange of fluids during breastfeeding, all of these things hormonal hormonal influences will influence the inner ear. If you think about this tubular migraine, what Nina was talking about, it doesn’t have to be a headache, migraine can also be an alteration of sensation. So all the things that affect you neurologically are going to affect that. If other disorders such as BPPV, benign positional vertigo has been linked to estrogen levels, and there is a thought because estrogen increases bone resorption. So basically, as you age, some of the bone loss happens, that bone resorption can happen in the inner ear, and then you can form the little oral lips and otoconia that cause crystals in the inner ear. Maldon Embarkment syndrome is also the thing that can happen more menopause, it’s a very specific syndrome of feeling like you’re on a moving object without actually being on there. And that can also happen because of hormonal changes, again, in your neurological processing. So, I know I spoke for a long time. But my point here is to say there’s a reason why these hormonal changes happen. And there’s also a reason how they influence each of those different disorders. And then when you’re trying to treat or trying to figure out why it’s happening. That’s sort of where you should be looking
Nina Coslov
- Oh, one thing I just like to add to that I spend a lot of time sharing the there’s a chart from a 20 I think 17 paper that looked at one woman 180 days her her daily urine, and actually in perimenopause, your estrogen is really fluctuating. So it ends up declining, right, but it’s like going up and down and up and down. And I think a lot of what like the study of women’s health across the nation and other research is learning is that it’s this drop in estrogen, but it’s happening so many times. So it’s one of the reasons that this but so many other things in perimenopause are really hard to treat, because it’s a moving target, right? And so, you know, even like hormone therapy for perimenopause is tricky because you can, you can treat hot flashes, but then your ovary might kick in and produce normal periods for another six months or a year. So it’s interesting to think about, I wish I had been tracking all this time to kind of correlate these six year periods where things were relatively stable, and then all of a sudden, you know, it’s like, you know, a perturbation to the system right and then again, something comes up and then back to homeostasis. I send people I have it on the site because so many people look at that and say that’s the way I feel this like up down and up and down right progesterone is declining estrogen is going up and down. And it’s it’s it’s a very kind of tumultuous time hormone.
Kimberly Warner – Unfixed Media
And that makes so much sense now that the way you both explain that and the this the fluctuations, whether it’s breastfeeding or whether it’s you know, preparing for a fetus or whether it’s preparing for the next phase of your life where you’ll be more doing more nurturing and wisdom sharing those fluctuations are you know, unlike a man they we don’t have this homeostasis and until maybe I’m even wrong but until menopause, or are there fluctuations still even happening in during menopause? But I’m assuming that it flattens out a little bit is that right? Yeah it
Dr. Maja Svrakic
menopause it it just levels off basically. Yeah, that’s I mean their post menopause technically is a term to describe once your estrogen has come to a full low and then you’re just calm time
Nina Coslov
able to be wise there are women though who continue to have hot flashes into into posts after their final menstrual period postmenopausal because right some estrogen is still produced in fat tissue and other places and so but for most I my and my hope is and I tried to you know, give that good message that migraines and things related to migraines. Most things calm down postmenopausal.
Kimberly Warner – Unfixed Media
Wow. So So is it a matter, Nina? I mean, is it a matter of just waiting it out? Because if there’s all I mean, how do we do hormone therapy, if the you know, you’re getting these surges? And E, we can’t track
Nina Coslov
that. Well. Hormone therapy is my least favorite topic. And since I’m not an expert, I’m going to be kind of careful there. But I think from a woman’s perspective, it’s it It’s understanding that those fluctuations and built being willing to trot, try and tweak things and know that you’re going through these different times. So something may start, it may not work the whole way. I think it’s why many providers use the birth control pill again for women, because that basically just takes over the system and kind of stops, you know, shuts down your normal production of hormones and you don’t ovulate. And so it’s a way to kind of dampen all of this. I think the Mirena IUD is also a way that kind of calms the system. But, you know, I personally, I, I wish I knew what kind of pulled me out of these things. We talked about it a little bit can really before. But the thing that I have done consistently is kind of take the, you know, more sleep, you know, less alcohol, like all of those things to kind of, I think of it as like helping my body get back to homeostasis, right. If it’s working to get back to homeostasis, what can I do to help that right? I mean, reducing stress, like, good luck. You know, I mean, this is a really tough time of life. perimenopause meets life is like, ah, you know, so. But there are some things we can control. And I’ve done a lot of those. And I sort of watch my sleep more closely and see what things affect that so I, I don’t have any great answers. And it’s, it’s tricky. Treating perimenopausal women on many dimensions is really tricky. I always say like, but it’s so much better to know, it’s better to know that that’s what this is. Because there’s so many other things, this is a normal life transition, it will come down, there are things you can do in kind of the self care realm. You talk to other people, you know, it’s not just you, because there’s a lot of other right, like the mental health component for those of us that have, you know, grandmothers or aunts that have dealt with really severe mental health crises, like that’s really scary when you have the first mood changes, when you just stop sleeping out of nowhere, right, knowing that it’s normal. And that’s really been the most all of what I’ve created as a non medical person. It’s it’s normalizing and validating. What people
Kimberly Warner – Unfixed Media
hear you, normalizing invalidating, it’s, it’s invaluable to know that you’re not alone and that you’re not losing your mind.
Cynthia Ryan – VeDA
Yeah, it definitely feels that way. Sometimes I can tell you that. Dr. Triggers, can you in your practice? Can you tell us what the role hormone therapy does play from a medical perspective and moderating or treating vestibular symptoms? Or I guess, I guess, let’s just say in the, in the menopause, and perimenopause process.
Dr. Maja Svrakic
Yeah, again, it No, it’s menopause is not a it’s not a disorder. It’s not a disease. It’s a normal sort of process of aging for women, for human women, right. But what it what it does is it influences all these different disorders. So you have to really think about what disorder a patient has to understand that what is the role of hormone therapy going to be in that I don’t prescribe hormone therapy. But I have many patients who obviously have their OBGYN who do that. And then we talk about sort of the effects and sometimes I would advise them to either stop or start start the therapy. So again, the major one is the estrogen replacement. All those there are combination products that also focus on the progesterone replacement, as well. And as I think all of you have commented on, it’s really the fluctuation so you’re really sort of trying to level the patient off. The problem is, again, it’s not the same for every patient. So what research has found, and what I’ve seen is that if a woman is experiencing a lot of vasomotor symptoms, and that’s defined as hot flashes, then hormone therapy may help not just with, with the vasomotor symptoms, but also with the dizziness symptoms. But if that is not a part of their experience, even though the hormones are fluctuating, hormone replacement therapy won’t help. And then the other problem is that for every study than every patient that you have, one thing is true, you will find the study, they will say the opposite is true. So just to give you an example for that is they tried to do hormone replacement therapy for women who are postmenopausal, so their estrogen levels are depleted. And what happens in older people, not just women, but in general is that your balance decreases and you have an increased risk of falls. So they said well, is estrogen the key in this? Can we just increase estrogen give women estrogen and then see how they do? While on the one hand, you have a study that shows that something called posturography. But basically a way to sort of measure people a person’s balance by either having them close their eyes or moving a platform to try and see how they sort of deal with that challenge. And on the one hand on this short study where they gave two weeks of estrogen transdermally and then a little combo estrogen progesterone product Women had less falls and had better balance if their estrogen was maintained. On another study. So this was one done in Europe, this one was done in America, the one that was done in America, they didn’t show that effect at all. It said it was not protective in any way. People still had the same amount of falls and the crease in balance, whether or not you give him estrogen. And I think it’s hard because there’s some things that happened in the lab. And then there’s other things that happen in real life. And what happens in real life. It’s not just the menopause, that also is the aging process that happens to men and women and everyone else. And sometimes it’s hard to discern. Is it just the estrogen and progesterone level? Or is it all the other things that happen with aging, your cognitive abilities to slow down your vision decreases, the sensitivity of your ears to the outside environment decreases. So it’s not it’s not a cookie cutter approach. But again, for patients that have vasomotor symptoms, hormone replacement therapy can help. But for patients who don’t, it’s likely not going to help. And there is no clear data that it will help with balance. Just on its own, I think balance exercise that or other therapies would help with that. So
Kimberly Warner – Unfixed Media
just to clarify my mic, because I know people are everyone that’s listening to this if dizzy. So if they don’t have any hot flashes, you don’t recommend hormone therapy. If they’re experiencing dizziness in their perimenopause slash menopause phase.
Dr. Maja Svrakic
Correct. If they do not have the hot flashes, just to put it plainly, if they don’t have hot flashes, hormone replacement therapy will like likely not help their dizziness symptoms. So I would not advise him to do that. And any new and any new I just recently had a patient who just started hormone replacement therapy mix mixture of estrogen and progesterone. Immediately after that, hypersensitive to light motion, headache, dizziness, cannot go to work. She’s a school teacher, you know, and I said, you know, it’s it’s, it’s clearly that was the change, you started this therapy on Sunday, it’s Monday, and you have these symptoms. But she was really sort of adamant about keeping the hormone replacement therapy. And so what I’m saying is, you know, you got to sort of be careful, because he can certainly worsen symptoms as well, again, depending on what kinds of symptoms are bothering them.
Cynthia Ryan – VeDA
So there can be downsides to the hormone replacement therapy.
Dr. Maja Svrakic
100%. Yeah, you have to don’t wed yourself to that as with treatment at all.
Kimberly Warner – Unfixed Media
That’s, that’s very important to hear, I just finished reading the upgrade. And the author who also wrote it was women, I’m forgetting the first book that she wrote, but she’s a neuro psychiatrist, I believe, and I think she highly recommended hormone replacement, specifically to protect late later in life dementia, that there was that period of time where the estrogen can really protect the brain. But it’s important for the vestibular community to hear what you just said. So we don’t all run out and get that for the later in life dementia. Meanwhile, we might be exacerbating our symptoms in the interim. So
Nina Coslov
Kimberly, I’ll just add, again, there are just like my head said, there are equal studies that show that hormone therapy causes harm in, in the cognitive realm. People are getting very excited about, you know, again, there’s this pendulum that swings between hormone therapy is the best thing ever. And it’s, then it’s the worst thing ever. And on the cognitive front, I know that there are some really big population studies that show harm to in terms of dementia, and there’s other people saying it’s the best thing. So, again, I think you just have to look at all the data. And I what, what drives me crazy about this discussion and work on behalf of women I get so frustrated is the people who love it only talk about the studies that show benefit, and the people who don’t like it only talk and it’s really, really confusing. You know, I did an interview with a woman named Pauline Mackey, who I think offers a pretty balanced perspective. And so I tried to find those people that will talk about both and say, well, in this study, just like just like minded in this study, it showed this, but in these studies that showed harm, and we don’t know, and there’s different regimens, and there’s different formulations, there’s, there’s estar, you know, they’re desperate dial, and there’s conjugated estrogens, and there’s progestins and progressed, you know, progesterone anyway, all of those things have a factor and I would say we don’t know yet nobody should, you know, it’s I don’t know how you feel my you’re probably reading this, but it’s
Dr. Maja Svrakic
Yeah, I think not only is it hard to control again, for what are the effects of aging on the human being versus what are the effects of menopause. The other thing that people largely sort of don’t want to talk about because I think ends up being kind of political is really the length of time that women are a birth control. When you’re on birth control, you’re really are suppressing your endogenous hormones. And you’re just sort of taking exogenous hormones for the purpose of birth control for the purpose of women having control over their bodies for the purpose of all these things that are good. And so I think once you touch birth control, you’re very politically sort of attacked. And I think no one talks about the bad effects of birth control. And perhaps, if you’re living constantly suppressing, or your hormone levels to, you know, to be flat. Once you come to this perimenopausal period where things are fluctuating, you don’t deal with fluctuations as well. And so, again, I think that when you do these studies, you know, you’re not really controlling for the population, the certain the people that you’re studying, what was the length of their birth control? What kind of birth control was it, you know, and that definitely has affected your hormonal axes throughout your life. And women are commonly in birth control for 30 years of their life, right? So we can’t say that there’s no effect. Yeah.
Kimberly Warner – Unfixed Media
So that’s Nina, going back to what we can control. And you talked about lifestyle, I know that sleep is a huge one. For me, I found that even like I mentioned, before that we started recording, I was just at a birthday party in Colorado, and I was not going to bed at nine like I religiously have done since I started getting dizzy. And I ended up taking hope for me. hydroxyzine is like an Anna histamine. And it is it’s a temporary fix, but it really helps me just secure that good night’s sleep. And if I don’t get that, I can guarantee you it’s going to be harder to recover from the dizziness, the you know, the subsequent days. So what else Nina, have you found? yourself in? In your race? Yeah, I
Nina Coslov
mean, so it mostly the research, I mean, what I will say is like, when we when we did this really big study I did include when we looked at like 82 different symptoms I was all keen on putting in I put in Dizzy in three ways I did the like rocking on a boat, I did the feeling like I’m gonna pass out I gave and you know, about 20% of people endorsed that both in the late reproductive stage. That’s kind of before you’ve entered perimenopause, officially but it’s sort of while you’re having regular periods. That’s sort of the focus of my my research. And the website is really normalizing and validating that all of these things can start before your periods are irregular, right? Because that’s sort of where I think women are getting most the word is dismissed by and I don’t want to throw healthcare providers under the bus because they we don’t have the research to tell them that it’s happening either. But it’s it’s traditionally that’s where the rub happens on. So a whole bunch of things start happening, whether it’s mood or dizziness or sleep, and then you go to your health care provider and like, are you still getting a regular period? And you say, yes. And they say, well, then that’s not perimenopause. And that is sort of the whole genesis of where this happened for me, and why I wasn’t thinking of anything hormonal, because we discount that this could start at 40. You know, if you’re still having regular periods, so, um, but in terms of, you know, sleep, I think height, you know, hydration, and again, I don’t know what, like less alcohol. I don’t know what exactly kind of takes me out of these. But I also want to just mention, there’s, for me, the dizziness. And then there’s the anxiety about the dizziness. And I that for me has I really, really had to decouple those. So I also began some different meditation practices. And you know, like just more walking and yoga, I’ve tried so many things, and I do them for a short time, but I always kind of kind of come back around because I really do think it’s sort of like, my default network. My default mode network in my brain is when I can’t control something to be very act to get anxious about it, right. And at the time, when this first started, I have like three young kids at all of these, you know, now they all drive but it was always like, Oh, my gosh, three of them have to be in three different places. I’m driving for carpools. Like what if I’m dizzy, right. And so that became such an anxiety producing thing. And so winding back of that part of it for me, and I think that just exacerbated my disease. i It’s hard to again, unwind those but I think finding ways to kind of calm your sympathetic nervous system, I think throughout perimenopause, particularly with respect to vestibular things, but other symptoms as well. You know, taking the step back, it is a normal time in life. And it’s good for all of us to have ways to kind of unwind our anxiety for whatever is kind of a trigger for us. So and again, I’ve tried so many different things that it’s hard for me to say this is the thing and I don’t think there is one thing for everyone. I think you have to sort of, it’s a time of real it’s been a time of really kind of getting to know myself and getting to know my body much better. I really never paid attention to my periods or my cycles or understood how they worked. And now I pay so much close attention. And I feel like I’ve learned so much. And that’s given me some kind of sort of an element of control and knowledge. It doesn’t make it all go away. But I just feel kind of more knowledgeable about it and accepting of this, like this tumultuous time again, I go back, I just picture that graph. And I’m like, yep, that’s how I feel. You know, that is that’s sort of what’s going on in my body and my brain and it will end and how can I help it kind of, you know, calm down.
Kimberly Warner – Unfixed Media
And that acceptance you talk about is so key to allowing the anxiety to not exacerbate the dizziness. We did an episode with Dr. Yoni Arthur. And she talks a lot about how, you know, patients that have higher panic disorder, anxiety, that accompany the dizziness, tend to have longer episodes or Angeles episodes, whereas the ones that are like a doozy, you know, whatever. That’s
Nina Coslov
fascinating, because I would say my worst one was, I did develop some panic around it. And it was around this driving thing. And I had a couple of dizzy episodes while I was driving. And then I think they sort of can they started connecting for me, like my brain started, like, oh, you know, I was like, I’d be in the car thinking like, My, oh, am I getting dizzy? Oh, no, like, right? And then I’m sure I was I was exacerbating it. And that was the one like, at the height of, you know, everybody had a carpool going. And you know, driving other kids, I started thinking like, I can’t drive other kids like, this is not safe, you know. And so that also definitely spun things up. So that’s fascinating that like, the more you worry, the more that dizziness lasts, because that, you know, if all of mine were kind of two to three weeks, and then this one here was like eight or nine weeks, right? It’s like, oh, maybe that’s exactly what I had done there.
Cynthia Ryan – VeDA
So you know, when I was going through menopause, I was seeing a nutritionist, and I was I was on hormone therapy, and she was trying to get me to wean myself off hormone therapy through nutritional management, you know, managing my diet. Dr. Dr. Rakesh, can you do you have any thoughts about nutrition or other types of lifestyle changes that you recommend to patients during this change during this time?
Dr. Maja Svrakic
I do and I think you should separate and sometimes they come together. But the two real sort of components of dizzy disorders is something called hyper reactivity and then hypersensitivity. And I’m glad that Nina touched on both but hypersensitivity means, think of what a trigger could possibly be for you say that a trigger for your either a headache or dizziness symptom would be bright lights, that’s a simple one to think about. So that your threshold is very low, right? That’s what hypersensitive means that for you. Even if you see a little bit of a brighter light than normal, you become sensitive to that and you start having symptoms. So that’s hypersensitivity, whether your threshold of activation is low hyperreactivity is and then what happens to your body is that say that you saw a little bit of a brighter light, and then you something happened in your body where their response was a little bit out of proportion than what you would expect. If you think of it as a startle reflex or something like that, right? Like that many things startle you, but then you just sort of calm down versus not just the many things startle you, but what they startle you, you work yourself up so high that it’s really hard to sort of calm down. So if you think of the stimuli or disorders in an hypersensitive inner ear, and brain’s sort of organ system, and then the hyper reactive, this adrenaline sort of axis, then you can really sort of think about, well, what lifestyle changes would help either one of those or both, if that’s what you’re dealing with. So it’s for the hypersensitive is sort of what we talk about the migraine diet, but it really I just use it for any sort of hypersensitivity disorders including Malden bereavement, but that would be very specifically changes in caffeine intake and keeping the caffeine intake very regular. If you do do caffeine, being very careful of hidden caffyns Alcohol is a really big one, any kind of alcohol but especially anything that has to do with food degradation. So that will be wine would be or beer yeast would be one of those chocolate nuts, peanut butter, all the good stuff. Avocados, onions, citrus, fruit, bananas, processed meats, any of the artificial sweeteners are really sort of a big on this. So really anything that you think of like cheese’s aged cheese’s, anything that has the aging process in there, so that will be yeast, cheese, wine, beer, those kinds of things. And anything that it has a mimics a neurotransmitter that’s particularly pleasurable. So unfortunately, bananas, avocados, chocolate, they mimic neurotransmitters in their brain. And actually those are the things that can make you more sensitive. So you can really go down the diet diet list. And it’s readily available. It’s called the migraine diet. And I know there’s a lot of people on Vita who talk about this as well. But basically, that’s to decrease the sensitivity. And then dietary wise for decreasing sort of the hyperreactivity is just things that are good for the heart. So you can really think about what that is, you know, low sodium, healthy fats, sort of the Mediterranean diet will be things that would help with that sort of hyperreactivity. But then what helps with other like other things that would help so sleep always good, right, so sleep keeping sleep consistent, a really important aspect of sleep and both hyperreactivity. And hypersensitivity is exact timing of sleep, like when you go to bed, like Kimberly was saying nine religiously and when you wake up, really key here is that you get the same amount of hormones, dose through your sleep, right, because your sleep cycle is every hour they have because you get release of your growth hormone, you get release of all these other hormones in your body that you’re not thinking about not just female hormones. And so if you’re not sleeping in these hour and a half intervals, you’re actually missing some of those doses. So what does that mean hour and a half intervals for you know, women are age six is the really bare minimum, you should be sleeping seven and a half is like golden, like that is the time. But if you have the option of sleeping seven hours or six, go down to six, do not sleep, do not sleep the seven hours, because of that hour, they have sort of 90 minute hormonal cycle that happens. So sleep is if you regulate sleep, you can really fix a lot of problems. The problem is sometimes it’s really hard to regulate sleep. And a lot of sort of, I know for me, very menopausal and hot flashes, I can’t fall asleep, anxiety through the roof. I’m just like I’m struggling. So sometimes just this consistency of sleep is the thing that you have to sort of work back and figure out what is it it’s going to get me to sleep. So consistent sleep, dietary changes that we talked about magnesium is a big one that’s overlooked. magnesium glycinate is a pretty popular one. But increasing not that your magnesium deficient, but just increasing magnesium helps a lot of the vestibular disorders. And then stress is a big one. And again, sometimes you have to really think about like, is it just sort of everyday stress? Can they remove myself from these situations? And what are my coping mechanisms? And if you can’t, then you have to figure out how to deal with stress. So mindfulness meditation, even sometimes going on medications that deal with stress, you know, would be helpful.
Nina Coslov
I just I just struck a thought, when you were talking about the hyper react the hypersensitivity and hyper reactivity. Is there like a and then can we add there if it’s like a Venn diagram like that the fluctuating estrogen is also a, like a vulnerable window, right? When when your hormones are doing this, I mean, that is like, as I’m like thinking about this, and going back, like what was different about last week, like I sit on webinars all the time, but there was something about and what I didn’t say is this, so this was like Thursday. And then I got my period and my shortest cycle and like yours, two days later, so definitely hormones were dropping for me. And that that kind of intuition that I have now, because I’m tracking all these things so closely, like, that’s becoming part of my story here, right? That it’s like, it’s the fluctuation, it’s the drop in estrogen. So it’s not low all the time. But it’s the the drop that makes me more sensitive to light. I mean, I’ll go I’ll go a couple years, and then I’ll walk into a target and be like, Oh, my God, these lights are driving me crazy. And so it’s not always but if there’s some kind of vulnerability that happens, right, and then it kicks on the sensitivity, and then my reactivity. So I think, as you said, like, you can work on all of those things. You know, there’s some level of a little bit of control there.
Kimberly Warner – Unfixed Media
It’s almost like certain things line up. And for those two years, they’re not lining up like your cycle and the target shopping aren’t lining up and then one day you do
Nina Coslov
something else. I’m like, What is going on here? You know, and I know it I know that feeling and then it happens and then what you know, I think again, this goes to the like, the the perspective of like, this is not going to last forever. Here it comes in here comes from dizziness, like right, again, you have to have these like ways of saying to yourself, like, here’s what I’m gonna do, I’m gonna go outside for a walk these things work. I have some control. But when this first happens, you’re thinking, Oh, my gosh, like this, you know? It’s, yeah,
Cynthia Ryan – VeDA
it’s easy. It’s not easy. It’s not easy to say this isn’t going to last forever. And you know, this too, will pass. And I can tell you, you know, looking back, you know, having, as I said, been paused and looking back. Now I can say oh, yeah, it that. That was something that was temporary. And now you know, life is back to what we call normal but I can also say I think one of the difficult things is not just experiencing but it but communicating it with the people, the other people in your life, you know, your, your, your spouse, your partner, your family, your friends and people that you’re working with. Because especially, you know, an opposite sex partner is not going to get what you’re going through. And, you know, we, again, we can look, my husband and I can look back at it and kind of laugh that that was my, you know, my crazy period. Going through, it wasn’t so fun.
Dr. Maja Svrakic
So I want to just give a shout out to the men, men go through a vestibular migraine disorders of veneers, disease and all the other problems, but why it’s easier for them is they don’t have their hormonal fluctuations in the background. That’s one variable that they don’t have to deal with. So that, you know, it’s not that men don’t get these disorders they do. But as exactly as you pointed out, Cynthia’s they just don’t get the fluctuations. And then they’re like, well, like, What do you mean, if you control your diet and your sleep? Like, shouldn’t you be fine? And you’re like, Well, no, because I got this, like, crazy.
Kimberly Warner – Unfixed Media
So one of the things my I’m actually curious about this. And I know a lot of other patients, including those that have MdDS, like myself are on Effexor, and I’m on so I’m on Effexor, and it’s been about two years now. And it’s greatly helped. And I’ve, my physician told me that there is an off label property to Effexor that actually helps increase estrogen. I want to know, have you heard that? And what or is it correct? Or what do you what are your thoughts about that? I
Dr. Maja Svrakic
don’t know that, like particular study offhand. But I can certainly tell you from experience that a very large subset of my patients does well, in Effexor, and a very large subset of again, my practice is everyone, but I do see a lot of middle aged women with vertigo, and they specifically see women with this sort of both hypersensitive and hyper reactive. And the reason why Effexor is a really nice thing that works is because it works for the hyperreactivity part, that’s when it’s also used for anxiety and panic disorders. But it also works really well for the hypersensitivity part, which is why it’s used surface tubular migraines, and so Effexor to me is, you know, definitely can work and women, but it’s also a, I don’t know, its effect on estrogen, but I can assume, and tell you that there’s no like nothing definitive. And if you sort of looked at studies that looked at it looked at a different hormone, they may sort of show effect on that, too. So I wouldn’t pay too much credit to that one particular study, I would just say that effects are is very effective in treating both hyperreactive and hypersensitivity, certainly
Nina Coslov
as anything that I can add can really is effects or that venlafaxine. venlafaxine has been studied for hot flashes. And it is you know, if you look at the MS flash studies, you can also just I have this on the website, if you go to the MS flash studies, and you look at the curves of what is called the closest to hormone therapy, but not hormonal therapy. This was before the new this new class of drugs came out last May these NK three inhibitors and eurocon inhibitors. But venlafaxine is does does pretty well. So you may be getting an X and added bonus. So that might be where somebody was linking it to estrogen. I don’t actually think that it’s increasing anyway. I bet that’s the tie in in somebody’s mind, because venlafaxine has shown to do pretty well with hot flashes.
Kimberly Warner – Unfixed Media
That’s fascinating.
Nina Coslov
I can send that I can give you that one.
Cynthia Ryan – VeDA
Yeah, is there is there other research either Nina or my other research out there that that you’re aware of that you could share that might be you know, in the future, something that will help vestibular patients as they are transitioning through menopause.
Nina Coslov
I’m not aware of that much in the vestibular world Honestly, I was hoping my was because I I’ve done some some searches and in PubMed and I don’t I don’t see much that’s tied to perimenopause with hormonal fluctuations except that with lots of women present at this time of life with dizziness and
Dr. Maja Svrakic
so yeah, exactly. So that’s the problem is that basic science research is lacking. And then you have to sort of think about, well, what are you going to gain from basic science research and if it says, Well, if you give this up since two guinea pigs are going to be going through, I don’t know more dizzy or less dizzy spells. It’s not really translatable into into human research right and Then when you think about human research, again, it’s very hard to sort of parse out like, what changes are exactly happening. Like I said, variables such as well, your age could be a factor, but also how much you’ve used birth control, or how other metabolic disorders such as diabetes are affecting all of this. So there’s a lot of confounding variables, and you’re not going to find that research. So what you sort of have to do is step back, instead of trying to like look at like one molecule affecting this other molecule, you have to kind of step back and figure out, what is it that we’re trying to treat? Right? Like, what are we? Are we trying to treat numbers like in hormone, like hormone numbers? Are you trying to treat the person as a whole? Like, what is it that’s affecting them? How do you get them to be most functional? How do you get them to drive their three kids around and not be dizzy at the same time, right? Like, that is the thing that you’re trying to fix. And so, to me, looking at every single study individually is really not going to help this I think what’s going to help more, is having a more holistic approach. And what’s unfortunate is that you’re not going to find a lot of practitioners that do that, because in the way it’s also like a behavioral therapist or a cognitive behavioral therapist problem, or think to solve but it’s also a medical doctors think, to Folman, an endocrinologist and an OB GYN and then you have the neuro otologist, who, you know, I’m, I think I’m running a reputation now the of the inner ear psychologist or whatever you want to call it. But I basically am dealing with three symptoms that people don’t want to deal with ear fullness, dizziness, and tinnitus. And the reason why you don’t want to deal with is because these are non surgical problems. And because there are problems that are affecting you as a whole and no one, no practitioner is dealing with you as a whole. And so, again, the you’re not going to find like this cutting edge research on one medication it’s going to be I think, just acceptance that it’s a complex problem, and that you need to have a lot of people sort of solving it at once.
Cynthia Ryan – VeDA
Yeah, I think thank you for taking a holistic approach. It’s really refreshing to hear and I think that the good news about that, you know, people, people, when they’re not feeling well, they want a pill to make it better. But the good news about the holistic approach is that it empowers you to do that you can do something to improve your well being now and into the future by you know, by all of the lifestyle changes that we’ve talked about that there, there is hope and and you have the power to, to control that to some extent. Yeah.
Kimberly Warner – Unfixed Media
And even if the research isn’t there, yet, even what Nina has created with women living better, there are at least there’s a place to go for women to read survey results, and hear about people’s women’s reported symptoms and know that they’re not alone and know that this is common. And then they can you know, see it as a phase and relax their nervous systems, all of that. So I think Nina, you know, the work the two of you are doing together is actually they really complement each other. Well.
Cynthia Ryan – VeDA
Absolutely. This has been one of the most educational conversations that we’ve had.
Kimberly Warner – Unfixed Media
Oh my gosh, I just I want to like, listen to it again. As soon as it’s the recording done. I learned so much. So thank you. Yes.
Cynthia Ryan – VeDA
Thank you so much. Nina, Maya, thank you so much for sharing your experience and your expertise and with our community. I know that we’re gonna we’re gonna have a lot of people commenting on this one. Yeah,
Kimberly Warner – Unfixed Media
I think this might go viral.
Dr. Maja Svrakic
Oh, no. Oh, no.
Nina Coslov
blessing and a curse.
Dr. Maja Svrakic
Yeah, I’m glad that you’re recognizing in general vestibular disorders as disorders that are so common and very commonly under treated and mistreated. And also that it’s such an important role in women’s lives, especially during these hormonal changes. It’s so great to even have these conversations.
Cynthia Ryan – VeDA
I’m just going to do one more, call out for those of you who are out there listening who are going through, you know, hormonal changes or just have questions. There is an article on VITAS website about hormones and how they affect the vestibular system. So just go to the stapler.org Use the Search button, put in hormones, and you’ll find that there. Thank you so much again for joining us today. Good night. Thanks for tuning in to ICU this month. We hope
Kimberly Warner – Unfixed Media
this conversation sparked a new understanding of the vestibular journey. And for all of our patients out there, leaves you feeling just a little more heard. And a little more seen. I see You