The Cleveland Clinic’s Women’s Health Specialist Dr. Pelin Batur Gives Us a Master Class on Hormones

It was a big week for women’s health.

On April 17, the Cleveland Clinic launched its new Comprehensive Women's Health and Research Center—an innovative program aimed at addressing the unique health needs of women in midlife and beyond.

“I’ve always believed our nation needed a first-class comprehensive women’s health center, and now we have one,” says Maria Shriver, chief visionary and strategic advisor of the center. “This is a place for women at every stage of life where they will feel seen, get the research they need and the care they deserve—from their brains to their bones.” 

To celebrate the opening of this first-of-its kind facility, The Sunday Paper sat down with one of the center’s clinical specialty leaders, Pelin Batur, MD, whose areas of expertise include menopause, medically complex contraception, osteoporosis, and sexual health. We asked Dr. Batur some of our most pressing questions about women’s hormones and sexual health, and her answers left us feeling more informed and empowered, better able to navigate our health with confidence and clarity.

A CONVERSATION WITH DR. PELIN BATUR

Women are bombarded with information about how to “balance” our hormones, but what does this really mean? Is this notion of hormone “balance” futile and what should we be focused on instead?

It’s the trend of the moment to focus on “balancing” hormones, but it’s not a great term for what’s actually happening. Before puberty, our hormone levels are low. And then throughout most of our reproductive years, every few days our hormones are doing something else. That’s how it’s meant to be. We get huge spikes of ovulation hormones, and they plummet if we’re not pregnant. Our hormones are meant to cycle up and down, up and down, every four weeks. 

And then you go into menopause and your hormones flatline. So, this idea that you’re going to “balance” your hormones is a complete misnomer for most women, because if you want to feel good and healthy, your hormones are meant to be out of balance.

Now that being said, there are situations where women can feel off balance. For example, during the menopause transition it can be tough, because your hormones are not doing their regular cycling. And so sometimes you don’t ovulate for many months at a time, and you have surplus of estrogen, and then other times estrogen drops. This can mean a lot of women feel out of balance, and it’s when talking to your clinician about “balancing” your hormones makes more sense. 

Another situation where we might think about “balancing” hormones in a reproductive-age woman with a medical condition that’s aggravated by hormones. For example, for women who get hormonal acne, hormonal headaches, or PMS, hormones add fuel to the fire when it comes to symptoms—and in those cases, we might want to “balance” hormones with a birth control pill before menopause. This can provide a steady hormone level, which can keep those symptoms at bay.

It sounds like the goal is to optimize our hormones for our specific needs … 

Yes. Because what might be optimized one way for one woman’s needs might be wrong for another woman’s needs. It all depends on your risk factors and your symptoms.

So many women want hormone testing to see what their hormones are doing and where they are in the menopause transition. Is this a good idea?

Unfortunately, during the menopause transition, hormone testing isn’t helpful at all because it only gives us one snapshot in time. In fact, it can be a great way to make a mistake. Let’s say a woman has six months of no bleeding and several blood tests that show her follicle stimulating hormone (FSH, the hormone that skyrockets in menopause) is high. And guess what, she gets pregnant because somebody inadvertently told her she’s in menopause.

Now, on the flip side, if you are younger—say, in your 20s or 30s—and you’re skipping cycles, then you likely do need some hormone testing to understand what’s going on. Remember, regular menstrual cycles is a sign of your hormonal health being on track. 

Now, we’re just talking about the ovarian hormones: estrogen, progesterone, testosterone. But there are other hormones outside of these ovarian hormones that can make us feel unwell. Sometimes there’s such a hyper focus on the sex hormones that people forget to take a step back and really think bigger picture: What else might be happening?

When it comes to changes happening in our sex lives, we often blame our hormones first. But sex is “biopsychosocial.” Can you explain what this means?

The biopsychosocial model really is the best place to start because hormones are just one small part of that. So, let’s break it down. 

Biology: This is the hormonal piece. Has there been a major hormonal shift? Have you just gone into menopause? Did you just have a surgery that impacted your ovarian function? Did you just have radiation treatment? Essentially, did something potentially cause a major change in your hormones? 

Psychology: Our brains are our biggest sexual organ. One of the questions on the hormonal health questionnaire I give all of my patients is this: When you’re on vacation, is your libido back on track? When they answer, “Oh yeah, on vacation my sex life was great!” Well, there’s no prescription for that. That tells me we have to focus on what’s happening psychologically. Maybe sex therapy or better stress management.

Social: How are you connecting with your partner? I feel like women expect so much of themselves that even if there’s discord within the relationship, they expect to have the same sex drive. Your upbringing is also a part of this: Was there shame surrounding sexuality that you encountered, even if in your subconscious mind?

Changes in your sexual health is not just about your hormones. The biopsychosocial model helps us look at the whole picture.   

What do you wish more patients were talking to their doctors about regarding their sexual health? 

As women, we put so much pressure on ourselves. I see women all the time who tell me some version of, “I don’t know why I have no sexual interest.” And then I start talking to them and it becomes clear that they’re having pain when they have sex. Yet they’re focused on their sex drive and on the medications they’ve heard can fix their libido—when really, they’re in so much pain when they have sex that if we focused on treating that, their sex drive would improve. 

Also, I heard someone say the following recently and found it really profound: So much of the typical female desire is wrapped up in how desirable we are to others as opposed to our own pleasure. I think this wears on our souls.

What do you want women in the menopause transition to know?

During the menopause transition, we know stress certainly aggravates symptoms. I think it’s also important to point out that the placebo effect on a lot of menopause prescriptions is 40 to 50 percent. What does that mean? If I give you a tic tac and say, “This is really going to help you with your menopausal symptoms,” up to half of the time women will get symptom relief. Translation: If you have a lot of negative energy or positive energy going to the transition, you can really change the trajectory of how your menopause experience is. 

I would say once you’re really in the menopause transition, make sure you’re getting accurate information from somebody who is trained. Right now, many clinicians are still nervous about prescribing menopausal hormone therapy and don’t know how to accurately assess and discuss the risks and benefits. On the flip side, there are people prescribing very high dose, compounded products that are not safe. So, I feel like most women are either not being listened to or being pushed down a wrong path because they’re feeling miserable. 

What do you think more of us should ask our doctors to optimize our sexual health?

Speak up. I know it can be tough to talk about your sex life, but I’d urge you to not be shy about it! Because if half of American women aren’t happy with their sex life, then it’s not just you, right? In an ideal world, you’d feel empowered to talk to your clinician about anything. 

However, it’s also important to recognize that if you bring this up at an annual visit, your provider may not have time to dive into it then. But at least you’ve brought it up, and then you can make a plan for a follow-up to discuss. 

Finally, when it comes to sexual health, there’s just so much women think is abnormal when it’s completely normal. Try to find a clinician you can really talk to about what you’re going through so you can understand your symptoms and treatment options, and know what you can proactively do to feel your best.

Pelin Batur, MD, works in the Department of Subspecialty Care for Women’s Health, within the Ob/Gyn & Women’s Health Institute at The Cleveland Clinic. Her practice is a referral resource for women with complex hormonal needs, and her areas of expertise include menopause, medically complex contraception, osteoporosis, and sexual health.