Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Why Your Symptoms Matter More Than Your Hormone Numbers
Hot flashes don’t keep a schedule, and neither do lab numbers. We sit down with Dr. Rachel Novik of Cleveland Clinic’s Center for Specialized Women’s Health to cut through the noise around perimenopause, menopause, and hormone testing—and focus on what actually helps you feel like yourself again.
We talk about why the most reliable “diagnosis” of menopause is still 12 months without a period, and when lab work like estradiol and FSH can be helpful for patients with hormonal IUDs or after hysterectomy. She breaks down common myths about the Dutch test and other urine hormone panels, explains why major medical societies don’t endorse them for menopause, and shows how chasing unvalidated numbers can drive unnecessary supplements and costs without improving outcomes.
If you’re overwhelmed by conflicting advice on “balancing hormones,” this episode offers a calmer path: collaborate with a clinician, align on goals, and judge success by how you feel, not a single number.
Welcome to the Speaking of Women's Health podcast. I'm your guest host today, Lee Clecker. I am the producer, producer of the Speaking of Women's Health podcast, and I'm so happy to be back in the Sunflower House. Today I am being joined by Dr. Rachel Novick. She is a newly appointed physician at Cleveland Clinic Center for Specialized Women's Health, and we'll be talking about her new role, her areas of specialty, and we'll dive into some important women's health topics, especially around perimenopause, menopause, and hormone testing. But first, let me tell you a little bit about Dr. Novick. She's a board-certified family medicine physician. She recently completed the specialized women's health fellowship at Cleveland Clinic under Dr. Thacker. And congratulations, Dr. Novick, on that. A lot of hard work, many years. And for our loyal followers, I'm sure you saw many of the pictures we posted on social media with all the graduation pictures of her and Dr. Cohn. And her academic journey began at New York University, where she earned a bachelor's degree in social work with a minor in child and adolescent mental health. She went on to complete her pre-medical sciences at John Carroll University here in Northeast Ohio, followed by medical school at Ohio University's Heritage College of Osteopathic Medicine. And Dr. Novick completed her residency in family medicine at University Hospital's St. John Medical Center, where she served as chief resident and helped develop a women's health curriculum. She brings a deep passion for caring for women across all stages of life with a special focus on those in their middle and later decades where care gaps often exist. And this is not Dr. Novick's first time on the podcast. She joined Dr. Thacker in season one. So without further ado, welcome Dr. Novick. You're welcome. So let's start by introducing your new role. And can you tell our audience what you'll be doing at Cleveland Clinic? Yeah, that's my side of town, so I like it. So can you share a little bit more about what your areas of specialty are? And you know, within the Center for Specialized Women's Health, what are you most passionate about focusing on as a physician? Absolutely. And there's not enough of you out there right now. So yeah. So you mentioned that you'll be at main campus, um, and then you'll be hopefully changing offices. So we can put that information in the show notes for those of our listeners who are in Northeast Ohio. Um, and as soon as we know her new locations, we'll get that posted as well. Um, so I want to kind of talk about because you will be specializing in, as we mentioned, you know, perimenopause and menopause a lot and hormones and um birth control, which doesn't always have to be for actually contraception, can be also just hormonal control. Um, but so we heard from a lot of the nurses that work with you in the Center for Specialized Women's Health that patients often ask about blood tests to determine if they're in perimenopause or menopause, you know, things like progesterone levels, the Dutch test, and other urine hormone panels. So there's a lot of talk about also this. I don't, I've never heard this, but blood being the gold standard. Um, so I want to unpack that a bit. And um, first let's start with are there any blood tests that are actually recommended? And then what those labs um are that aren't necessary for actually diagnosing menopause.
Dr. Rachel Novik:The answer is are there necessary for diagnosing menopause? The answer is no. Because the true diagnosis of menopause is 12 months or 10 period. So I don't need any of those labs to tell you, hey, you haven't had a period in 12 months. Yeah, you meet the qualification, you meet that cutoff guideline. But there are lab tests that I will check just to kind of get a baseline idea of where you are, and they can be more helpful in specific populations, such as um people who have an IUD, a hormonal IUD, and aren't getting a period. Or someone who has a hysterectomy, so we just don't know what's going on. Um, so that's when those labs can be a little more helpful. That being said, I understand that a lot of people like to know that information. So I don't think it's unreasonable to say, if you, you know, if we want those labs, we can check them, and but know that this is only one moment in time. And if you're truly pre-orper, those levels are going to change moment to moment, moment to moment, day to day, month to month, week to week, etc. So it's it gives you this snapshot that is not necessarily indicative of what the true picture is. So that is why we make these diagnoses more so based on the clinical picture as opposed to blood tests. And that's why we base our treatment and its effectiveness on how you feel and not on a blood test.
Leigh Klekar:So that's a lot of questions about the symptoms, right?
Speaker:Yeah.
Leigh Klekar:Um, and yeah, so I would imagine that you would probably tell your a lot of your patients to come prepared to their appointments with you with a list of their symptoms. And if they're not in menopause yet, right, when their last cycle was and how long and how heavy.
Dr. Rachel Novik:And exactly. Yeah, knowing your menstrual history, at least for the last few cycles, is very helpful because if you're someone that's having a monthly period, I am not necessarily going to make the same recommendation as someone who's having a period every three, four months. It it just changes what I might think about from a what is the best option for you. And that's why manopause hormone therapy isn't necessarily one size fits all. And we have to think about hormone therapy and the options as hormone therapy as opposed to birth control or contraception. It's all at the end of the day, the goal is to get you back to a better steady state from a hormone standpoint.
Leigh Klekar:Yeah, that's great. So, can you talk about these? So I mentioned the progesterone levels, the Dutch test, um, hormone panels, and the gold standard. So are those things that we should know about? Um, because you know, I've worked very closely with, you know, your team and Dr. Thacker for many, many years. And I haven't even heard of these before from the experts. So Yeah, yeah.
Dr. Rachel Novik:So the Dutch test. The Dutch test is a urine test that measures steroid, hormone, and metabolites. So this is cortisol, cortisone, estrogen, progesterone, testosterone, DHEA. A lot of the things that we think about, but it's marketed for evaluating hormone balance and adrenal function and menopause symptoms. The problem with this test is that it lacks independent verification, and there is limited peer review research regarding the Dutch test results compared to like gold standard testing, which would be serum, um, blood, labs, um, or 24-hour urine collection, salivary assays. So things that are just collected slightly different. Um, these the Dutch test tests tends to do um, it depends on which test people do. So the Dutch test is the common one, but there's a couple other urine hormone testing things where you will collect like a daily sample of your urine um over the course of a month and send that in, send them in. And while it it again, it gives you this snapshot in time, but it still doesn't, it doesn't give you the true, you know, any true data beyond what we already know based on what your body's doing. Yeah. Um, so the menopause society, ACOG, the endocrine society, and all these major medical bodies do not include the Dutch test in their guidelines for menopause, CCOS, infertility, adrenal disorders, anything like that. And that's because our hormone metabolites in dried urine don't necessarily reflect the real-time hormone activity in the body. So our hormone levels will fluctuate throughout the day, throughout our menstrual cycle, and with stress, sleep, diet changes, medication changes. So a single test snapshot is hard to interpret no matter what. But then when we're looking in a urine sample, it's even further harder to really navigate how accurate this is and difficult for interpretation. So I mentioned, you know, that when I collect the blood work, the results can always be, you know, slightly misleading and they can lead to unnecessary supplements, hormones, treatment options, you know, and and at the end of the day, money spent for something you don't need.
Leigh Klekar:Right.
Dr. Rachel Novik:Um, but like I said, I will check some blood levels. And the main levels I do look at are estrogen or estradiol, the FSH, which is your follicle stimulating hormone. And this is one of multiple labs that is that um assesses ovarian function. But this is the one that we look at specifically when we're just kind of getting that broad picture. I tend to check a TSH or a thyroid stimulating hormone. And if someone has a history of thyroid disease, I will also add in a free T3 or T4, depending on the history of their thyroid disease and if they're on medication. So that looks a little closer at not just a screening thyroid, but are you getting adequate additional thyroid hormone if you're taking a supplement? Um, I check B12, vitamin D, ferritin, which is an iron storage level. And I also check a zinc because these are all deficiencies that can lead to low energy, brain fog, fatigue, the same symptoms we all complain of hot flashes, night sweats with the thyroids. It's not good medicine, and it's not a good practice to blame everything on hormones when there could be a medical reason for why you're or an alternative reason as to why you're having these symptoms.
Leigh Klekar:Right.
Dr. Rachel Novik:Um so yeah, and so I yeah.
Leigh Klekar:Oh no, I was just gonna ask, you know, and I'm kind of um do this at home just because I've been avoiding going to, you know, getting my appointment, but I'm like, I'll just take a zinc supplement and I'm just gonna take a omega-3 supplement, and I'm just gonna take my calcium and my vitamin D three and then my magnesium. But so really, I mean, I don't know if I'm low in those. I could be getting plenty of those, you know, from my diet and the sun with vitamin D. So really, I mean, it's probably best to don't do what I do and to see your see your see an expert um because it could be more than just hormones or deficiency, it could be something else too that's causing.
Dr. Rachel Novik:Right, exactly. And with some supplements and some vitamins, you don't want to overdo it because these can lead to calcifications, they can lead to arrhythmias. They so you know, we're careful with the things that we prescribe and and the doses we recommend. Um, there's also issues when it comes to are you taking an adequate dose for optimal absorption? So there's there's more to it than just like, should we take one thing here, take one thing there? You know, it's we think about it a little bit. Um, but you also mentioned like omega fatty acids. So those I know Dr. Shacker has talked about them, but you know, those can affect your mood and inflammation. So it's just, yeah, you're right. That's one more thing that I do, I do check on occasion, not as consistently. Um, and at the end of the day, with all of these supplements, I would rather you get these things from your diet than from a supplement. Because when you're getting things from your diet, if possible, um, you know, you're getting additional nutrients that are aiding in absorption and your body's really regulating that. As opposed to a supplement, we're we're kind of just throwing a larger dose at you and and absorb and you know, you're absorbing however much you're absorbing out of.
Leigh Klekar:Right, right. Good point. It's just the supplements are just such a big trend, right? And it's everywhere. And yes, and you know, I I write the headlines for the social media for speaking of women's health. So I'm on a lot of social media and it's just it's everywhere. And and and sometimes I'm like, okay, that's what we're saying, and that's correct because I work with you know physicians, and then sometimes like that's just so not correct, but women are reading this, and so it's just scary. There's so much.
Dr. Rachel Novik:And I like it would be a lie to say we don't all fall into those marketing schemes from time to time, right? Like, I've definitely bought a vitamin that I'm like, oh, let me try this, let me see if I feel any better. And then I'm like, Well, I don't know why I spent extra money on this. This is the same thing as the target brand, you know, multivitamin I was taking before. Yeah. And it's, you know, but it's 10 times the price.
Leigh Klekar:Yeah, right. Okay, so we took we we answered this, but I just want to sort of actually get this down by. So is it even possible to test for perimenopause or menopause?
Dr. Rachel Novik:Yes. So uh yes and no. So we have these serum blood tests that give us an idea of where you are in this transition period, right? So your FSH can help us determine what your ovaries are doing. And the ovaries are where we get are getting a majority of our estrogen from. So if that FSH is high, ideally I like to see a level of at least 35, but um, or a level of 35, but at least over 25, that can give us an idea of perimenopause or menopause. But then we compare we add this into an estrogen level. So if you have an estrogen level that's undetectable, or within our Cleveland Clinic lab, it's less than 25, then we're thinking, okay, your ovaries are getting, you know, sending out this signal. We need, we, we need to be trying to make, you know, ovulate and have these eggs um pushed out to, you know, get pregnant, etc. And our estrogen level is saying we got nothing. So that picture, that balance of your estrogen level and your ovarian function come together to tell us like, are you more likely on one side of this, you know, this transition period versus the other? So if you have a high FSH and a low estrogen level, you're more likely to be in that perimenopause-menopause stage. But let's say you have a low FSH and a high estrogen level, that tells us your ovaries are doing what they should be doing from a pre-perimenopause standpoint, they're ovulating. And your estrogen level is showing that this is happening because it's nice and high. Your body's getting what it's need, what it needs. But when that, when it's not those two clear pictures, when it's a high estrogen and a high FSH, it's like, okay, at some point you had some ovulation, your body's clearly making some estrogen, you're in perimenopause. Or if both are low, then I'm like, okay, your ovaries are still telling me that they're doing something because there's still function going on, and this feedback signal is still where where I expect it to be, but your estrogen's low. So depending on where you are in your cycle, that could just again be that one moment in time, or it's telling us, yeah, you, you know, things are right, but maybe you missed the cycle this time.
Leigh Klekar:Yeah. Wow, that's interesting. I actually, I mean, I've done a lot of these interviews and listened to a lot of them, but you know, you explained that really well. Um, so thank you. Uh, can you walk us through which blood tests or labs should not be used to determine if a woman is in menopause? Yes.
Dr. Rachel Novik:So, as I've said a couple of times, estrogen and FSH are the only two like true labs that I order when I'm like, let's see where you are in the scheme of things. I don't typically order progesterone, I don't order LH, which is another um ovarian function level, and I don't order an AMH level, which can kind of tell us egg reserve levels. Um and I don't order those because number one, they don't necessarily change anything I do, but they cost you more money. Number two, the specifically the AMH, you know, the only time we ever really order it is when we're thinking about egg retrieval and IVF and those, you know, that side. And are you gonna be a good candidate for stimulation so we can get those eggs? So it's not something that I really I use even in just kind of a screening situation. But at the end of the day, your labs can tell us, like we've talked about, they can tell us whatever they want. If you're having a monthly cycle, I'm not gonna consider you menopause. Sure, we can put the label of like perimenopause, but that's you know, that's because you're having symptoms. Is it truly perimenopause, TMS? It's hard to know. It's such a gray area.
Leigh Klekar:Yeah.
Dr. Rachel Novik:But it it can be, you know, it can be nice to have a little more data and a little more information. I think we're such a data-driven society and population that we like to have those numbers, but we have to remember that not everything is number driven.
Leigh Klekar:Right. Because everyone's symptoms are so different. But like you mentioned, it would be nice to just kind of know what is actually happening with my body and what will make me feel better. Well, what will make me feel more like myself, or so, you know, it's I think it's just that like you you mentioned, we like we get a lot of data, you know, headlines, but it's just nice to know what's going on and get an answer.
Dr. Rachel Novik:Exactly. But I also, you know, I think the one the one thing I run into more these days, especially as women are coming in with regular cycles and they're perimenopause. You're having a regular cycle, but you're having symptoms. Trying to get someone on board with like a birth control pill, because a birth control pill suppresses ovulation, right? So when you're when you're having a monthly period, you're going up and down and up and down and up and down, and these estrogen, progesterone, and other hormone fluctuations are what are triggering your period every month. So when you're having symptoms and you're fluctuating, but those fluctuations and those kind of erratic fluctuations and severe fluctuations are what cause a lot of these symptoms. One of the most effective things we can do is suppress ovulation. So you're no longer going up and down, you're just going nice and steady. And then we give you estrogen in that birth control pill. And so you have a nice estrogen level because we're still giving it to you. But I think we get stuck on it's a birth control pill. But in this situation, it's truly hormone replacement therapy because we're still giving you or replacing what your body would otherwise be doing, controlling that fluctuation. So that's why there's so much, you know, it is a very individualized approach. And and it's also a collaborative approach. So if you don't like what your physician or your clinician is recommending, you have to have that conversation. Um, but it's not necessarily that we're just saying, oh, here's a pill, take it. There's a reason behind it, you know?
Leigh Klekar:Well, and yeah, and I think like you mentioned, a lot of women just think, okay, I did that, you know, we're I'm past the childbearing ages. I or, you know, and I took that birth control for so many years and had to remember to take that pill. I think they're just like, oh, really, I've got to go back to that again. Maybe some of them, right? Right, exactly.
Dr. Rachel Novik:Exactly. Feel that way. You know, my my other argument is like at the end of the day, it's often one pill versus another pill. And they tend to be at least one pill once a day. And one's typically zero dollars by your insurance, another one ranges in price. So there's not like sometimes the right answer is what is the most effective, cost-effective thing too.
Leigh Klekar:Yeah, very right. And if you're spending hundreds of dollars on supplements, I mean, and you know, right. So right, exactly. Like, I just think I, you know, I I think again, it's just getting over that, you know, WHI study and and and a little bit of that as well, right? That we need to reassure our patients that it's okay.
Dr. Rachel Novik:And it's it's the marketing, just like we keep talking about this, like, oh, we need to balance our hormones. And it's not, you know, it's not, I guess it is a balance in some ways, but it's maybe not, there's no like perfect answer to this. It's it's a especially with perimenopause, it's like this is when it becomes an art, and we're doing these like small changes just to find the right regimen for you. Yes. Um, and when we get thrown, take this test to to optimize yourself, and then take this supplement that's like cortisol balance, and then take this other thing for your thyroid. You know, it's like it gets to be very confusing, and a lot of those supplements can affect your lab values on blood work, they can affect your liver and your kidney function. You know, they nothing we do is without side effect, right? So that's why I always say like you're better off seeing someone who works, I you know, is a f you know, registered licensed physician or clinician. And we always prefer those FDA-approved prescription medications as opposed to these compounded things that you don't necessarily get that same like dose and pump to pump of the cream or click to click, whatever it is, because we know you're getting this nice steady state.
Leigh Klekar:Yes. And I mean, I think this has been said before on the podcast, but just do your research too before you see a physician. Um, my dear friend, um, I've recommended all of you to her, but she just has, you know, she needs to get in quick. So she saw someone else who said, No, I don't, I don't want to prescribe hormone therapy. And that's why she was going there. So, you know, it was basically a waste of a well visit for her and um really frustrating. And I said, Don't go, don't see her again. And I may, you know, so that's just sort of like maybe see what you can find out about the physician before you see them. Because if you're going there for, you know, hormone therapy, birth control, and they're not going to prescribe it or try and talk you out of it, then that may not be the physician for you.
Dr. Rachel Novik:Right, for sure. And and it's, you know, it's hard because there aren't a lot of physicians and clinicians out there that are comfortable with prescribing. And we're, you know, we're out there, we're educating people, we're we're doing all sorts of things at the clinic to help get our primary care docs and our residents and our, you know, all sorts of people kind of on board with hormones. But that doesn't mean that they're comfortable at the end of the day. They might be open to it, but that's why, you know, that's why you see someone that that is truly a specialist.
Leigh Klekar:Yes. Yeah. Okay. So we talked about this a little bit, but are there any other blood tests or labs that um you want to mention or that you want patients to steer away from? Um, any other sort of warnings?
Dr. Rachel Novik:Um, you know, at the end of the day, I think you can come in with whatever labs you want. Um, I've lately been getting a lot of questions about like a sex hormone binding globulin level. So I I generally say, you know, this level goes up as we go, as we age and as we go through menopause. And again, we don't treat numbers. We treat based on how you feel. So we don't, I don't order labs routinely because I don't want to, I don't want people to get so focused on that. I want you to feel good. I want you to feel so good that you're not even thinking about it that you're like, I don't need a I don't need a level. I want, I just feel good. You know, it's when when we get focused on numbers, that's when that's when things kind of get lost in the process, right? Um, obviously, if you're having issues, if you're having bleeding, if you're having cramping, things like that, then I think about do we need to check your level? Is there an imbalance in this situation where you have too much estrogen or too much tragesterone? And we need to we need to assess that and make sure that there's nothing else going on. But unless there's a problem, I don't necessarily need to check labs. Um, I will, though, especially if I, you know, if I start you on a regimen and you're like, I feel good, but maybe I'm having a little breakthrough symptom, or maybe I've been on this regimen for a couple months, a year, and all of a sudden something just feels a little different. So then we're thinking, like, is your patch in the right place? Are you changing it? Are you, you know, of the right interval, whether it's three and a half days versus once a week? Do we need to switch it based on placement? Do we need to switch from a once a week to a twice a week? Do we need to switch you from a pill to a patch? You know, there's all sorts of thoughts that go into it there. And so that's when I find that those levels can be a little more helpful because then I'm gonna say, okay, well, maybe you're not absorbing it as well.
Leigh Klekar:Great. So before we wrap up, do you have any other final thoughts or tips that you'd like to share with our listeners?
Dr. Rachel Novik:Um, I think we've touched on a lot of it just through conversation, but you know, I think just remembering menopause and especially perimenopause can be difficult to manage. And it's it's an art at some point, more than a science. And you know, listen to your clinicians. And if you don't understand why a regimen is being recommended, ask. Because if you don't ask, then you don't understand, right? So I think at the end of the day, if we can understand why something's being recommended to us, we're more likely to get on board with it. Um and then we're all on the same page and we can work together to better find what that right regimen is for you if you don't like whatever that regimen is. Um, and then, you know, I think the other big thing is like you've all heard this before if you listen to this podcast, that we don't recommend pellotherapy because you can have those unregulated hormone levels. Um, and we don't recommend topical progesterone cream because it doesn't absorb well. So and and frankly, the you know, the the last piece is I don't recommend you create your own hormone regimen, but if you're if you're going to try to, you know, work work with your clinician, make sure you guys are on the same, you know, on the same page and doing that together, because you that balance between estrogen and progesterone is a is a balance. And too much of one thing, especially too much estrogen with not enough progesterone, can have serious consequences. So we don't, you know, we don't want to put you at higher risk if if we don't need to.
Leigh Klekar:Right. Thank you. And then finally, how can patients schedule an appointment with you?
Dr. Rachel Novik:Yeah, so I think there's a handful of ways to schedule with our department. You can call the Center for Specialized Women's Health, which is 216-444-6601. You can call the Cleveland Clinic for Her Women's Health line, which is 216-4444 for her. And then there's also the Cleveland Clinic Comprehensive Women Women's Health. What is it? Cleveland Clinic Women's Comprehensive Health and Research Center, which is 444 8686.
Leigh Klekar:Great. You and we'll put that in the show notes too for our listeners. And you can actually find a lot of those phone numbers on speakingofwomen's health.com. Well, thank you, Dr. Novik. This has been great. I appreciate you joining us on the Speaking of Women's Health podcast. And thank you to our listeners for tuning in to another episode of the podcast. We're very grateful for your support and hope you will consider supporting the podcast by sharing it with your friends and family. So thank you again for listening, and we will see you next time in the Sunflower House. Be strong, be healthy, and be in charge.
