← BETTER! with Dr. Stephanie Estima | Strength, Body Composition & Perimenopause
BETTER! with Dr. Stephanie Estima | Strength, Body Composition & Perimenopause
HRT, Breast Cancer Risk & Vaginal Estrogen: Risks & Myths Explained with Dr. Corinne Menn
01:36:20
Navigating menopause after breast cancer? Join Dr. Corinne Menn as she discusses overcoming fears and misconceptions around hormone therapy. Your health journey is unique! Watch the full episode at https://youtu.be/ZNeVWBocxd0
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- [00:00]
A
The vast majority of women and doctors are making their hormone therapy decisions based on fear and, you know, misconceptions. And the fear of breast cancer is largely driving women's access and decision making as well as doctors. And that's all because of the Women's Health initiative. And that has left a legacy of fear and misinformation that has left a generation of women and doctors feeling really uncomfortable and nervous.
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It isn't about being perfect, it's about being better. Hello, My name is Dr. Stephanie Stima and I host expert discussions with thought leaders in all facets of health, including nutrition, fitness, hormones, stress management, performance, recovery, longevity, healthspan and energy production. On this show we discuss complex science, but then we also alchemize it into actionable everyday living. The ultimate goal with the show is to assist you in making informed decisions about your health and to catapult you into being the hero in your own life. Hey Betty's. Welcome back to better with Dr. Stephanie. It's me, your host, Dr. Stephanie Estima. Today I am talking with Dr. Corinne Men and we are talking all, all about hormones, breast cancer, vaginal estrogen, you name it. Dr. Men is a board certified OBGYN and Menopause Society certified practitioner. She is a 20 year survivor of breast cancer and premature menopause. She's a b BRCA carrier, bra carrier and she uses her experience to help women navigate their own health challenges. She has dedicated her medical practice to menopause management, the unique healthc care needs of female cancer survivors and those at high risk for for breast cancer. She now practices exclusively through telehealth through Alloy and she provides women's health consultations and patient education via her private practice at Alloy. So what did we talk about today? As you might guess, we talked about the Women's Health Initiative, the WHI and we get into some of the shortcomings that happened from or conclusions that came from that study. We also moved into breast cancer risk and hormone replacement therapy. So this is a, it's sort of niche. But I feel like this is an important conversation because every woman, maybe their mother, family member, community member, you're going to know somebody who deals with breast cancer in your lifetime. So knowing how to navigate it, especially if you are perimenopausal and menopausal, I think is very important. We talk about best case scenarios for use of hormones, worst case use for hormones and much more. And then we move into vaginal estrogen and the genitourinary syndrome of menopause. It's not just for lube ladies, you'll want to listen to what she has to say about that. And then we also get into the timing hypothesis. Those of us who maybe have missed the window of opportunity or the best time to get on HRT. What is available to our 60s, 70 and 80 year old women. I really feel like this is an important conversation. Dr. Men did not disappoint. If you want to hang out until the end of the show, I what I'm calling the after party, you are going to hear my best takeaways, my favorite parts of the conversation and maybe not so favorite parts of the conversation. So without further delay, please enjoy this episode with Dr. Corinne Men. Ladies, if you are exercising a lot and in perimenopause, minerals are going to be required to optimize your hormones without sending them for a loop. Have you ever hit a wall in the middle of the day, like it's 2pm you're feeling good and then out of nowhere you're exhausted, you're hangry, and then you end up raiding the pantry? Well, there's a simple reason for why this happen. And the good news is, of course it's an easy fix. You need to give your body more minerals. If you struggle with fatigue, cravings, headache, hunger, brain fog or any of the other very common side effects that can happen during perimenopause, I recommend trying Beam minerals. They make one of the best mineral supplements on the market and all you do is take a single shot of the mineral rich liquid every morning. And that's exactly what I do on an empty stomach. It just tastes like water and contains every mineral that your body needs. And they don't contain fillers, sweeteners or any of that other stuff. So it won't disrupt your gut or add any hidden calories to your day. Head over to beamminerals.com and use code better for 20% off your first order. All right. Dr. Corinne Men, welcome to the show.
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Thank you for having me. Excited to be here.
- [04:42]
B
Yeah. We're going to talk about hormones and menopause and we're going to really focus in on breast cancer today because this is maybe a very common question that I get. Probably one of the more common questions that you get or one of the more common issues that you have advocating for the patient that you see. And I think maybe to orient ourselves, it might be useful just to think about where this misconception or overly cautious, we'll say philosophy around hormones and breast cancer came from. So we have to talk about the wh, the Women's Health Initiative. So I'll let you start the conversation off by talking about maybe some of the shortcomings in terms of population selection for the whi. So who was included in the study and then some of the different arms that they looked at in the study. So the estrogen only arm, and then the type of interventions that were used and why those are a little bit different, very different than the hormonal interventions typically offered to patients today.
- [05:36]
A
Of course, I always say this, that the pink elephant in the room is that, you know, the vast majority of women and doctors are making their hormone therapy decisions based on fear and, you know, misconceptions. And the fear of breast cancer is largely driving women's access and decision making as well as doctors. And that's all because of the Women's Health Initiative, which was a very important study. We're not about to throw the baby out with the bathwater. We learned a lot of good things, important things from the Women's Health Initiative, which was the largest to date study ever done on hormone therapy in women. But there are huge problems with the way the results of that study were messaged to the general public as well as to the physician community back in 2002. And that has left a legacy of fear and misinformation that has left a generation of women and doctors feeling really uncomfortable and nervous about using hormone therapy, primarily because the message that went out, kind of the soundbite was that estrogen causes breast cancer and it also caused all these heart problems. So it's dangerous. You should only use it if you absolutely have to. And because of that message, you know, physicians who were in training at that time, I was a second year ob gyn resident at the time, really just didn't get any education on actually the science of hormone therapy. And there was already a lack of education on the physiology of menopause in general. And that was like the nail in the coffin. There was just literally no interest in really pursuing them. So here we are now, fast forward over 20 years later, right, where just a generation of doctors and women are misinformed. But here's the facts about the WHI study that are really important for women to understand. First of all, it was already established that estrogen and hormone therapy was FDA approved for the treatment of hot flashes and night sweats. So vasomotor symptoms lowered the risk of osteoporosis, we knew, treats the genit urinary syndrome of menopause and, you know, was also used for women who went through menopause. Early, and it had been well established and, you know, used for decades. Right. It was one of the most commonly prescribed medications. The interest arose because there was a lot of data, a lot of observ observational data showing that hormone therapy may be also protective from the cardiovascular on the cardiovascular system. And so they wanted to test that hypothesis. So essentially, the WHI study was not whether hormone therapy was safe or not. It was already determined to be safe. It was whether this would be something that we can use for primary prevention for heart disease. So it was really, that was the primary outcome that they were looking at. And so in order to get that outcome and, you know, and get some meaningful results, they had to recruit older women. Right. And they had to recruit women who no longer had hot flashes or night sweats because otherwise they would know whether they were on hormone therapy. Right. Because otherwise it couldn't be placebo controlled because you would know if you were getting the hormones if your hot flashes went away. So it's important to keep that in mind. The population of the WHI was, you know, in general, an older population than the average woman seeking menopause therapy, which is women in the late perimenopause stage. And normally women within the first five, certainly 10 years from, you know, menopause. That's the average kind of woman who's seeking it now. Right. So these were older women. And on whole they were, you know, they did have elevated cholesterol and elevated blood pressure. They were, they were older, they were less healthy. Right. But even with this older population, and we should say they, they separated these women in two arms. If you had a uterus, you took an estrogen plus a progestin. And if you didn't have a uterus, you didn't have to use a progestin. So you used estrogen alone. And fast forward, they stopped the study short and they held a big press conference that said it causes breast cancer and there was an elevated risk of cardiovascular disease. And that went out like a lightning rod to the world. Everybody got scared. But the facts are that the in the estrogen only arm of the study, okay, never showed an increased risk of breast cancer at that initial press conference in 2002 and on subsequent follow up and at the 20 year mark, they were found to have a lower risk of ever getting breast cancer by roughly about 23% and up to a 30% decreased risk of dying of breast cancer. Okay, so let that sink in. The estrogen only arm, no increase, actually a lower risk of dying of breast cancer, estrogen only Arm, the progestin only arm. They, those women had a. I'm sorry, the other arm was estrogen and a progestin. And that arm of the study showed a slight increase, statistically not significant. Reaching. Reaching statistical. Not, not quite reaching statistical significance. But they reported it as though it was statistically significant. But let's just take them at face value and say we even believe that it was actually increased risk. The increase was an increase in incidence of breast cancer. Okay. And it was less than an additional 1 additional breast cancer for every thousand women taking it. Right. And on the 20 year follow up, it showed there was no increased risk of dying of breast cancer. And that increased risk was similar to modifiable lifestyle risks like being, you know, having obesity or, you know, drinking, you know, excessive alcohol intake. Right. And so that is really not the message that was sent out to the public. The message was that estrogen causes breast cancer. Right. And that is not what the WHI study found. And in fact, the WHI primary investigators have now walked back all of their, you know, original claims. And, you know, they say, like, we should never use the WHI to withhold menopausal hormone therapy access to women out of fear of breast cancer, but old habits die hard. And, you know, so that's kind of the background. If you want to learn more about this, the best thing you could do is pick up the book Estrogen Matters by Carol Taverson, Avoid Pluming. And that really explains it in detail for the layperson out there or the doctor out there who's kind of confused by all this kind of different arms of the study. And that will, that really puts it in clear perspective. And then, you know, alluding to what you, you know, you alluded to the different formulations. And so it's important to remember, in the WHI study, they used conjugated equine estrogen, all right, That's Premarin. And they used a synthetic progestin, medroxyprogesterone acetate. And remember, we should not fear conjugated equine estrogen. And I know for a variety of reasons, which we can talk about these days, we prefer, really FDA approved bioidentical estradiol. That's what we generally prescribe in hormone therapy. But conjugated equine estrogen is frankly the only estrogen that's been studied in such a large, large study like the WHI that actually showed a significant decrease in getting breast cancer or dying of breast cancer. So we should not fear conjugate equine estrogen when it comes to breast cancer risk. And we shouldn't fear estradiol because neither have ever shown to cause or increase your risk of breast cancer. Now, the medoxyprogesterone acetate was an old synthetic, you know, progestin, but it's still used and is useful in very, in specific cases, can thin out the lining of the uterus, well, can help control bleeding. So we use it for specific things. But in general, we don't use medroxyprogesterone acetate in hormone therapy anymore. And in fact, we now use bioidentical FDA approved progesterone in the vast majority of cases or one of the other synthetic progestins. And when we compare those progestins, we see that medroxyprogesterone is probably the least beneficial on breast tissue. Right. There's more inflammatory response to it. There's other aspects of medroxyprogestron acetate that are kind of less ideal on breast tissue. So I always like to always come back. What is the worst case scenario in terms of risk? If I prescribed you a combined, basically what Prempro is the conjugate equine estrogen with a synthetic progestin. What does the data tell us? It tells us that even with that old school formulation, your risk of breast cancer incident appears to be similar to modifiable risks like I mentioned, like alcohol intake or unhealthy lifestyle or having obesity. And that risk is less than one additional person for every thousand women taking it. And we must weigh that against the many benefits of hormone therapy, including prevention of osteoporosis. Right. One in two women will suffer a fracture in their lifetime. Right. And we can get into those details. Symptom relief, quality of life, better sleep, all of these things. Right. So you're more than just your breasts. That's the other thing to remember. And then the last thing that gets a little bit into the weeds. But there is serious criticism of even that risk associated with the synthetic progestin. Dr. Avrim Blooming published an incredible piece along with colleagues and many other leaders in this space have been, have deeply criticized how the WHI interpreted their own statistics and that it didn't actually reach statistical significance. So that's why I say worst case scenario. If we even believe them at face value, it's still such an incredibly low risk. And we can modify that by choosing to use progesterone and you know, and really looking at the full picture of the woman. Right.
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B
Beautiful. Beautifully said. Let's just again, just for definition's sake. I get a ton of questions on what is the difference between a bioidentical. So you've mentioned now bioidentical estradiol, bioidentical progesterone. What is the difference between that and a synthetic hormone? And I know that there are some educators in the space that feel like bioidentical is a marketing term. They sort of dismiss it. Can we, can we give some, some verbiage into what, how, how we distinguish between those two camps?
- [16:09]
A
Well, I think it's dismissive to say that it's only a marketing tool, but I understand in part why they say that. So let's just talk about what is bioidentical mean? It just means from a biological structural standpoint, it's literally the same hormone as what your body's producing. So estradiol, right. Looks exactly the same that's produced in your body as an estradiol patch spray gel, vaginal cream and then progesterone. Right. Is looks the same as what your body is being produced. Right. So that's all it means, is that it looks the same. Right. Now the reality is none of these hormones that we're prescribing to you magically just appear out of nature in a pill form. They're all.
- [16:55]
B
You don't pluck it off the progesterone tree dog.
- [16:57]
A
No, we don't pluck it out. The progesterone trait. Right. We are harvesting it from women. Right. So they're all made in labs. I mean, are they natural? I mean, they're made in a lab. Right. And typically they do use plant based molecules that help them generate this in a lab. Now the marketing thing, the important thing is that some women are led to believe that the only way that they can get bioidentical hormones is if it's compounded from a compounding pharmacy. Compounding pharmacies have important roles and there are hormones that are available from a compounding pharmacy as well. There other medications and then there's FDA approved, really well studied quality controlled hormone therapy and other prescriptions available. Right. And so when women are led to believe that the only way for them to get bioidentical hormones is through a compounding. Right. Or through a pellet. That's not true. And I think that's where the criticism about marketing is. And so you can go to your local CVS or regular pharmacy and get bioidentical estrogen and or estradiol and progesterone. Okay. So that's important. And I also think it is important we need to recognize that in general from a safety, safety, tolerability and probably efficacy in terms of getting the best results in terms of symptom relief and maybe other things like bone protection and such. It appears in the literature, although we need more studies that the bioidentical estradiol and progesterone are probably going to do the best job overall. That being said, I never want women to fear if they need to use a synthetic progestin for whatever reason. Some women don't tolerate progesterone. We need to use an alternative progestin and we don't want women to be afraid of, you know, safe, well studied hormonal contraception and birth control pills have to be synthetic at this point in time. That's what we have because it has a different job. It has to suppress ovulation. Right. And it's also can be used to control heavy menstrual bleeding and such. And sometimes things, you know, these tweaks that are made in these synthetic hormones help it do a better job. If we had to give you very, very large doses of bioidentical estradiol and progesterone enough to suppress ovulation, you probably wouldn't tolerate the side effects. Right? So let's not. We don't want to vilify the right appropriate use of synthetic hormones. But also we need to recognize and be honest that there's a reason why we now these days prefer bioidentical. And in my opinion, we try to use FDA approved options when we can. And when we need to compound things, you know, we lean on, you know, a reputable combating pharmacy and make sure that we're, you know, we're choosing good products.
- [19:41]
B
So noticing your hair isn't as full as it used to be. One of the absolute keys to thick full hair is scalp health. Good hair starts with your scalp. So instead of wrinkles and sagging skin, poor scalp health affects your hair, causing thinning of the hair shaft and a shorter growth cycle, which means that the hair is going to fall out sooner, which is why you see clumps of hair after your shower. Oneskin, the company that I trust for my skin, has just launched their new peptide scalp serum OS1 hair. It is the first scalp serum with the OS1 peptide, which is scientifically formulated to target cellular senescence, which is a primary cause of age related hair loss and thinning. Now I've been using this for about four weeks with the one Skin Derma roller. So I derma roll the areas where I'm seeing thinning hair and I apply the serum afterwards and I have already noticed in just four weeks, less shedding. And I have new little baby hairs in the areas on my scalp where there was thinning hair. Get to the root of hair loss and thinning with One Skin's new peptide scalp serum. OS One Hair. Use code better for 15% off of your first order of hair products at OneSkin. CO better. That's O N E S K I N CO better and use code better to get 15% off. The One thing that every time we discuss the whi on the show, one of the feelings that I constantly get is I'm overwhelmed with the. What appears to be an. Just like a disinterest for whatever reason. And I don't. I can't. I. Maybe you have some insight that I don't, but there just seems to be this disinterest in caring for women. Well, I. I know that there's always been jokes and I've said this myself that, you know, if a man. If the sim. If the similar. If there was ever. If there was an equivalent in a male, in the male population, and we just said, well, honey, it's just because you're 45. It's just because you're 55. Like, that's just what aging is, you know, like, eat less and move more. Like, if we, if, you know, go, maybe you just need like a. Just pottery. Like, do you want to take a pottery? You know, like, I feel like this. And I'll ask you, maybe I'll ask you to elaborate on this, but I just get this overwhelming sense that there's this disinterest in serving women. Well, I don't know if it's intentional. Maybe it is. But managing menopause and believing women, when we say, hey, we're suffering, there are, you know, and it might not necessarily be the hot flashes of the night sweats, like sort of that classic symptom cluster of perimenopause. It could be just mood and affect changes. It could be, you know, burning, itchy skin. Like some of these sort of, you know, atypical, we'll say, are not common, not commonly accepted symptoms of menopause. What. What do you.
- [22:23]
A
What say you listen. You know, we have to recognize that for centuries, you know, women's health has not been, you know, elevated or respected in the same way as men's health. We know that women were not included in. Required to be included in trials of medications in the US Right until recent years. And, you know, the emphasis in women's health. Right. I'm an ob gyn. So the emphasis in women's health in my training is on pregnancy, on reproduction, and then on obviously, the surgical management of things that cause suffering, like endometriosis, fibroids, cancer. Right. That is the primary focus of an OBGYN residency. And I think in general, we have to admit that in society, women's sexual, sexual health heroes, her kind of wellness and her health after her reproductive capacity ends has never been really valued. We're kind of sent up to pasture, you know, kind of this, this older woman menopause. And in fact, I think that's where there is a lot of shame around women even admitting or talking about menopause, because it seems like, kind of like, I hate to say it, but women feel embarrassed to talk about it. Shameful. Oh, you're old, you're dried up, you're, you're not sexy anymore. Right. And we'll talk about this in a little bit. I, we're going to get into breast cancer. But, you know, and this is why for women who deal with premature menopause due to cancer treatments or for any other reason of having premature menopause, there's lots of reasons why it can happen early. It's particularly shattering because imagine being in your 20s or your 30s and identifying as menopausal, like, that's really uncomfortable because in your mind, you picture someone old and no longer kind of valued as a woman in terms of what society thinks. Now, luckily, that narrative is shifting, thank goodness, to powerful leaders and women in this space and women rising up and saying, hey, I've got another 50 years to live. I deserve to live. Well, I'm not dried up. I'm just getting started. Right. But it really comes, I think, down to just admitting societal biases on women and aging and the lack of training. Listen, I had zero, zero education in menopause in my residency training. None. Right. There was no menopause clinic. We didn't, I mean, we touched on premature menopause and, you know, some little basics here and there, but there was nothing about managing menopause. And then, you know, I, I, it was the second year of my residency when the WHI hit. And so if there was any interest in prescribing hormone therapy or even talking about menopause, it was halted then. Right. So I think that's, you know, but this is the first generation of women who are in their 50s who are coming into that menopause transition, and they're in positions of power. Right. They're physician leaders. They're leaders in media, you know, in. In and in. In television and in. In, you know, in Hollywood. And, And. And so they're speaking up. They're like, I've got a voice. I've got leadership roles. You know, I'm an entrepreneur. I'm a business person, and I'm not going to take this, like, you know, so. And it's the first generation of women going through menopause during social media. So we have now a way to democratize getting the word out. We've got podcasts, we've got social media. And so women, the change is happening, I say, from the ground up. It's women becoming knowledgeable about their bodies and what they want for their health. And they're rising up and they're demanding of their physicians, like, hey, you need to address this. And then the physicians are like, ooh, I need to learn about this. Right? And so that's what's happening, really.
- [26:15]
B
Okay, so let's shift to breast cancer, because I think even though you very eloquently explained the results from the whi, there's two problems. One is, I think, patient understanding. And then two, I think, is the onco, like the. The oncologist's understanding of what's going on. So with breast cancer and HRT or mht, so hormone replacement therapy or menopause hormone therapy, a lot of people will say, and I've heard people. This is questions that people ask. Well, my cancer was estrogen positive. That's sort of the, you know, the vernacular, like the nomenclature that they'll use to describe their cancer. So I just want to spend a moment talking about language, if we can, because language is important. Does that mean when someone says, well, my cancer was estrogen positive, does that mean that. That it's estrogen that caused the cancer?
- [27:08]
A
No. You know, and I think it's important to understand this. So all breast cells, all cells in your body have estrogen receptors on them. And I think this is important for women to understand. And this really is something that is never explained to breast cancer survivors. So every cell in your body has receptors to estrogen, to progesterone, to androgens, like testosterone. Right. So that's just a normal part of your cells. Okay. And it's not just your breast tissue. It's your uterus, it's your brain, it's your skin, everything. Right? Lungs, lungs, everything. All right? And so normal, healthy breast cells have these estrogen receptors and progesterone receptors. Right. And from the time you're a little girl through puberty, pregnancy, lactation, perimenopause, menopause, those cells in every part of your body, not just your breast, you know, those cells, those little estrogen receptors are responding and changing and doing different things depending on and fall of estrogen, right? So estrogen receptors are a very important integral part of the physiology of your cells, right? So now fast forward, you get diagnosed with estrogen receptor positive breast cancer. Okay? It's very important to understand that receptor is important and it's, it's very important that we have discovered that some breast cancer cells, actually the majority of breast cancer diagnosed in, in the world is er, positive. So estrogen receptor positive or. And those cancer cells, right, your cancer has maintained, it's retained that estrogen receptor. And so now it's a cancerous cell. It's not a normal cell. It's rapidly dividing, it's doing things that, you know, allow it to grow, invade local tissue, you know, kind of recruit blood vessels. Right. And so one of the ways that we can manipulate, kill, you know, target that cancer cell is by targeting the estrogen receptor. So it's one of the tools. So I want, you know, patients who have diagnosed with cancer, you know, they understand there's lots of ways the oncologist tries to, you know, treat their cancer. Lots of tools, right? They're going to target the cells by cutting it out, right? They'll have the breast surgeon cut it out, remove it. You have the radiation. Oncologists use radiation to impact the cell, right? We have things you've heard of herceptin maybe or HER2 positive breast cancer. So that means there's receptors on those breast cancer cells that, you know, we can do targeted therapy like Herceptin. And with estrogen receptors, we can target it in a number of ways. We can lower estrogen levels. We can give medications like tamoxifen that don't actually lower estrogen levels. Tamoxifen blocks the receptor so that receptor can't get any signals about growth. Right? We can do something called, you know, using aromatase inhibitors. So that is used for women who are in menopause naturally, or they got put into menopause surgically, or if they're younger, we can give them medications like Lupron or Zoladex, which quiet down the ovaries, stop your ovaries having estrogen production and then aromatase inhibitors go in and further lower the estrogen even more, basically putting your estrogen like sub physiologic. Right.
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B
And so blocking testosterone to estrogen is.
- [30:24]
A
What Aromatase is doing, that's what aromatase, temperature is doing. So yeah, so those are ways that we're manipulating the cancer cell. That is a very different idea than telling somebody or having this notion that estrogen caused your breast cancer. That's not true. And in fact, younger women, okay, so premenopausal women have a higher chance, you know, they're the ones who are more likely to get triple negative breast cancer. Okay. Which means those are breast cancer cells that have become so abnormal, so different looking than a normal breast cancer, than a normal cell, that they don't have any receptors to estrogen or to progesterone. Right? So it's triple negative. So that's interesting. These are women, younger women are more likely to have triple negative breast cancer. So these are women who are bathed in estrogen, right. Every month, they're still getting their periods, but they're more likely to develop triple negative. And in fact, estrogen receptor positive breast cancer is more likely in the postmenopausal women. Right. When they don't have estrogen around. And so why you get one form or another, we don't know exactly. Some genetic mutations may predispose women to certain types of breast cancer, but we don't really know why anyone gets one form form of breast cancer. And it's also important for listeners to know breast cancer is not one disease. It's many diseases. There's many different types of breast cancer and kind of permutations of like how that cancer expresses, whether it's triple negative, triple positive, ERPR positive, HER2 negative, there's other markers that we look at. And so just like we treat any individual human being, we treat every breast cancer very specifically and it's targeted and it's individualized. The reason why I'm making that point is breast cancer is not one disease. Like DCIS is not the same as advanced multiple positive lymph node triple negative breast cancer. For instance, we treat those very differently. So hence, follow me through on this. When women then, as a survivor, or they're in the middle of their breast cancer treatment, present with debilitating menopause symptoms, sexual symptoms, other side effects, we should not treat them with the same blank answer of I can't do anything with you. We can't talk about any kind of hormones or we don't have any strategies for menopause because you had breast cancer. We, we have to individualize it. But sadly, what happens is, and this gets back to the whi in these fears that are ingrained. Breast cancer, estrogen like literally, that's the only thing that goes off in people's heads. So then when a breast cancer survivor presents and is seeking care for her estrogen deprivation symptoms, and that's what we have to call it because these women are being put into a state of severe estrogen deprivation, either surgically or medically, chemotherapy, these medications like aromatase inhibitors and tamoxifen, we can't just knee jerk or say sorry, like exercise and use some coconut oil. Like literally, that's what they get. And here's an antidepressant. Like we need to be more nuanced. Just like we're nuanced in treating their cancer, we need to be nuanced in managing their long term estrogen deprivation symptoms. Because goodness, obviously this is something I'm passionate about. But there's 4 million plus survivors of breast cancer in the US alone. Every year, roughly 300,000 new women are added to their ranks. Over 60,000 or more women are diagnosed with stage zero DCIS breast cancer. And then even more are being diagnosed and screened for carrying like BRCA one or two mutations or other hereditary mutations. And they're having ovaries removed early to prevent neo ovarian cancer. So we have this kind of like ever growing population of previvers and survivors and we have to stop with this knee jerk like reaction that we can't have any discussion of hormones after menopause with any of these women. I mean, it's unsustainable, frankly.
- [34:42]
B
Yeah, that's a big population.
- [34:43]
A
That's just in the US alone. I mean, women are suffering profoundly by the lack of individual nuanced menopause care after breast cancer or after being diagnosed with just being at high risk of breast cancer. Because, you know, we're forgetting about like, you know, we're talking about breast cancer survivors. But remember, there's, you get it all the time, I'm sure. Questions. There's huge amounts of women who are at higher risk for breast cancer, right? They have a family history, they carry a mutation or they have things like dense breasts or they had, you know, a benign breast biopsy that raises their risk of breast cancer, right? And so there's a huge population out there who is also not a cancer survivor. But they have a lot of fear about how do they navigate menopause and how do they address sexual symptoms and such. And so because the whi fears and misinformation that were propagated, a lot of doctors don't even know how to deal with those patients, right? Which is, you know, this is like becoming unacceptable.
- [35:46]
B
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- [38:06]
A
Such an important question. And so first of all, we have to respect what oncologists do. Every day is so incredibly hard and they're in the trenches taking care of both women who survive, but also women who have recurrences and they see metastatic cancer, and they see death from breast cancer. Over 40,000 women still die every year in the US of breast cancer. And the oncology field is constantly changing. There's so much for them to stay up to date with. But we have to recognize that if the average OB GYN has less than 4 hours of training in their residency in general menopause, do you think that oncologists or breast surgeons or radiation oncologists, do you think they have menopause training? No. So let's just recognize that doctors aren't trained in menopause, just plain old benign menopause, much less menopause after cancer. Okay? Number one. So we have to understand that's where we're starting from. And yes, there are some oncologists who are understanding of this, but the vast majority just have not been trained, just like the vast majority of OB GYNs. And not only are they not trained in hormone therapy, what I find, sadly, is they're not even trained or really grasped the full extent of menopause. So when I. And we can get into my personal story if you want, but in a little bit, but we'll come back to in a minute. But like, when I was diagnosed, no one told me about the menopause symptoms that were to come. And most women who tell me, like, what guidance did you get from your breast cancer team? Right? Cause it's not just the oncologist, the breast cancer nurses and the. And the surgeons and, you know, everybody who's, you know, and their gyns, and they say, well, I might have some vaginal dryness and I might have some hot flashes, right? And night sweat, guts. Like, literally, those are the two things. And to me, that's a huge disservice to not inform a woman of what is about to happen when she begins five, 10 years or a lifetime of estrogen deprivation with not. And it may just be that you're going into menopause and we're not giving you further medications like aromatase inhibitors or tamoxifens, but the women who are prescribed those medications, their menopause is even more profound and really much more serious. And we really need to inform these women that it's not just hot flashes and night sweats. It's an increased risk of cardiovascular disease, cognitive decline, obviously, the bone loss, mental health impacts, insomnia, increase in anxiety. I mean, the list goes on. And so. So I think this first step in communicating with your oncology, your breast cancer team is to say, like, hey, can we have a separate appointment because there's a lot to fit in. These doctors are all overworked and stretched for time and say, all right, we're here for my checkup or my follow up or talking about my treatment or my chemo or this. I need a follow up appointment so that we can discuss and you can inform me of what does it mean for me, symptom wise, as well as my health span, lifespan, chronic disease risks with menopause and breast cancer treatment. And what are you going to do to help mitigate some of those things if I truly can't take estrogen? Right. And so we have to be honest with certain breast cancer patients, we may never consider adding back systemic hormones to them. We may add back local vaginal hormones, which we can talk about. There are lots of safety data showing that. But I always want women to first hear the message that if you can't use systemic hormones, you have to demand, how are you going to manage this beyond just giving me an antidepressant? Because that's all that they get these days. And the reality is we actually have a toolkit of non hormonal things that can work from prescription standpoint, from lifestyle, diet, other kind of other alternative complementary therapies that we can use. And then for some women, we can have a nuanced conversation of balancing risks versus benefits of adding back systemic hormone therapy at some point in time when they're done with their treatments. Right. And so I advise women that you have to start by actually making sure you're being educated on what, you know, what menopause is going to mean for you and your treatment, what treatment options you have that might help mitigate some of those, like tamoxifen versus aromatase inhibitors, or you know, kind of individualizing your treatment so you can manage it better. And then, you know, what are you going to do about it? And if your oncologist is. Can't explain that to you or doesn't know, then that's when you have to say, I respect that you don't know that. Can you please refer me to a menopause specialist or someone who is able to help me with this? Because they can't just tell you it's not acceptable and you cannot just, you can't accept that. So then what do you do when you, the problem is patients do this, they try to advocate and then they're met with like, sorry, like this is the best we can do. So then you really need to, unfortunately, with all the burden of being a breast cancer survivor, I always say you're really worth it. You have to act like the CEO of your health. You have to come in prepared and educated. So I, you know, I advise women that you, you really do have to do the work yourself and bring it to your, you know, your physician and say, well, I've read the non hormonal physician statement from the Menopause Society and I see there's not just an antidepressant, there's all these other medications that I can use to help me with my vasomotor symptoms. And I've read the position statements on treating the genitourinary syndrome of menopause in breast cancer survivors. And we can, I can provide links to your listeners for these, these guidelines. I have a Google document, my link in bio, my Instagram that's become very popular and it's, it's an ongoing, it's a Google document where I just keep on adding all of the studies that show the safety of vaginal hormones from breast cancer survivors, even er, positive. Right. So you go with that and say, okay, well I want to discuss this and I'm happy to kind of report that this menopause movement is trickling down to breast cancer survivors. And just last month I spoke with two esteemed breast oncologists and a fellow OB GYN with. We had over 200 medical professionals there and we had a two evening session discussion about using hormone therapy after breast cancer. Which patients are candidates for. How can we have shared decision making on risks and benefits. And we reviewed, there's over 25 published studies of using hormone therapy after breast cancer. They're not perfect, some of them are old, they're small. There's things you could pick apart in all of the studies, but it's a start. And so we reviewed all of that data and the consensus was really refreshing at the end of these two evening sessions that we did. I think we all felt together as oncologists and menopause specialists that yeah, we can have individual nuanced discussions and it's not a one size fits all approach. I think the book Estrogen Matters, they have a whole chapter on Dr. Blooming, Dr. Tavares have a whole chapter on reviewing those 25 studies. And I'd say there's more and more interest in how we can individualize this. Now, will every medical oncologist be open to hearing this? Probably not. But I say to the breast cancer survivor out there, you're worth, at least, you know, you are worth pushing and having the discussion. And I do see breast cancer survivors and sometimes I tell Them for you, this is not the best choice and that's okay. I'm going to help you manage your menopause in other ways. So I never want anybody to listen to me and think that, like everybody after breast cancer, hrt, no problems. No, that's far from my message. But everybody after breast cancer deserves a conversation on how we're going to manage our menopause and that you do have options. And in the end, there's something called patient autonomy, body autonomy. It's your body, your choice, and you get to decide what risks you take. If your risk, say, of breast cancer recurrence is extremely low, you understand that the data suggests that it likely doesn't cause an increased risk of recurrence, but we don't know for sure. There are some studies that showed there was an increase of local breast cancer recurrence when women used hrt. But you can make that risk benefit decision for yourself, just like we allow you to make that risk benefit decision when you choose chemo or aromatase inhibitors or mastectomy versus lumpectomy or any other medical treatment in the world. We give you choice and informed consent. This should be no different. You're a big girl. You can, you can interpret and understand the information when given to you in a clear manner and make decisions.
- [47:08]
B
Let them write whatever they want in the chart. It's like you can take the drug, like, you can make the decision to do the HRT or whatever it is and you can let them write whatever they want in the chart. Because I know they're going to say, well, we're going to write this in your chart. Which I know can also be really scary. It's like, oh, okay, well, if you're going to write it in the chart, then yeah.
- [47:25]
A
And so I say, listen. Like, you know, and like, I can, I've worked with oncologists and I'll say, listen, I had this patient, we did a very thorough, you know, review of her history. She's tried xyz. This hasn't worked. She's at this point in her survivorship, she's really suffering. And at this point she's decided she'd like to try low dose, you know, menopausal hormone therapy. We're gonna start on this and, you know, we'd like your input. And they may say, well, in general, I don't recommend this and I don't advise that. And I say, okay, we respect that. She's been informed, she's signed an informed consent, we're going to follow her closely and in the end, this is the patient's decision. Right. But I find that most of the time patients are surprised when you are the squeaky wheel and you actually present in a clear manner your reasons for what you're interested in pursuing and you're well counseled and you sign informed consent. I'd say more times than not, I find the medical oncologist is willing to have a discussion. They're not going to be the one to prescribe. I don't want them to. I don't prescribe chemo like we all have. I'm not doing knee surgeries. You know, it's okay, you know, and it's important for your oncologist to be part of the discussion and the team, and it's important for us to respect women's values, right. And how they want to live.
- [48:46]
B
So let's put on our clinical hats here and maybe you can give me two different scenarios. We have a woman who has survived breast cancer. Maybe she's going through perimenopause, menopausal changes in mood affect, sleep, all the things that we've been talking about. Maybe she's noticing some brain fog, memory issues, what have you, Body issue, body composition issues. Who would. I'll ask you the same question, but in two different ways. The best candidate that you might say for that would be a candidate for hormone replacement therapy. And then maybe, you know, you mentioned sort of in passing, you know, there are, there are patients where you say, listen, this is not the best, this is not the best strategy for you. So can you paint a picture of like, like best candidate in that scenario, worst candidate or someone who you might advise, like, hey, this might not be the best route for you.
- [49:31]
A
Absolutely. So best candidate would be, let's start with like easy things. You've had dcis, you've had a bilateral mastectomy, you had no invasive disease. Your breast cancer, which some might not even call it breast cancer, stage zero dcis, it's pre invasive, right. Has been completely treated. Hormone deprivation, tamoxifen, aromatase inhibitors. That was not part of your treatment plan ever. Some of these women have their DCIS and they go on to have normal periods for a number of years and plenty of estrogen in their bodies. Now suddenly they go through menopause and suddenly we can't discuss hormone therapy. So that's, that's an easy camp, that, that's an easy example of someone who, I think low hanging fruit, right? We, we can talk about that. Dcis. With the bilateral mastectomy, your lifetime risk of Recurrence is not zero because theoretically there can still be breast cells that are left over. But particularly in BRCA negative patients, patients who have had, like I said, the bilateral mastectomy, that risk isn't very, very low and much, you know, and we have to think about the risk of not treating their symptoms. Right. So that's one easy. Then we have, I'd say then the other thing to think about is did you complete your breast cancer treatment? Right. So it's, it's best for you to get treated for your breast cancer. Right. And you know, whether, you know, you, you know, were triple negative and you, you know, you have to get through your chemotherapy, you finish that, or your estrogen receptor positive, and you've been recommended 5 years or 10 years of adjuvant endocrine therapy. And we can talk about how we navigate that. But ideally you've completed your treatment and now we're kind of, you know, all right, what's next? Right. So that's important. And then I think we have to understand breast cancer is not an individual, it's not one disease as we alluded to. So a triple negative of breast cancer is most likely to recur in the first five years and probably the recurrence risk peaks around three to four years. So when I am, you know, counseling estrogen receptor negative patients, I say for the first three to five year time frame, we're going to be more cautious with you. Right. Not because I actually personally think that giving her back a low dose of hormone therapy is necessarily going to cause recurrence, but it certainly is going to complicate it in everybody's minds. Right. And so that's a time where we want to maybe be more cautious. We can certainly give her vaginal hormones for local vaginal estrogen treatment and we would try to manage her menopause, you know, non hormonally, although there are exceptions that can be made. Right. A very low stage, low risk, triple negative patient who's maybe three years at this point. Some of these women are premenopausal. So I give an example, here's a good example. One of my dear friends, and she's been on Instagram lives with me and she's very active out there publicly, so she won't mind me telling her story. But she had triple negative breast cancer at the age of 28. She had her chemotherapy, she went on to have many years of normal menstrual periods. She was only 20 in a diagnosis. She went on to even have a healthy twin pregnancy in her mid-30s. And then at age, right before age 40, she got her ovaries removed because she carries the broncho1 gene and suddenly, suddenly nobody would talk to her about hormones. Meanwhile, she had over 12 years of high levels of estrogen every month because she had monthly menstrual cycles. So now that's just like nonsense, right? To deny her access. Her, she had surgical menopause and overnight her life changed. Severe symptoms, super sexual symptoms, hot flashes, nights with sweaty. So that is like a no brainer example, right, of where she should have access. Now a trickier example, where we going to be more cautious is someone who is estrogen receptor positive. Who, you know, those women still can have the discussion, right? But we're going to think about it in a little bit more nuanced. We have to recognize estrogen receptor positive breast cancer tends to be slower growing and it is the one that can have late recurrences at five years, at 10 years, at even 20 years. Right? So we have to tell these women like breast cancer can come back even early stage, er positive breast cancer. The preponderance of those studies I mentioned show that even er, positive breast cancer, when we give them back hormone therapy in these studies, it doesn't appear to increase their risk of recurrence. But we don't have perfect studies on that. And there was one study that showed they had an increased risk of recurrence locally in their breast or to get a new primary in the other breast. Right. And so those are the patients that were more nuanced. We want to look at what is your absolute baseline risk of recurrence. Did you have extensive disease, how did you respond to therapy? But those patients can still have that conversation, right? So basically in general lower risk disease, estrogen receptor negative, outside of the first three to five years. Those are like, you know, kind of general ideas. And then women who are in the middle of breast cancer treatment, er, positive breast cancer patients, these are tricky, right, because they may have five to 10 years where the oncologist is recommending things like aromatase inhibitors or tamoxifen. And so the way I approach that patient is different, right? They're still in the middle of treatment. So we have to individualize it. We want to make sure that she's actually getting a lot of benefit from her adjuvant endocrine therapy and weighing the benefits versus risks. So an example I give here is someone who's completed four years of aromatase inhibitor. They were a stage 1A breast cancer, they have low risk of recurrence. And they are debilitated by the aromatase inhibitor. It's reasonable to talk to them about individualizing their treatment, changing to tamoxifen, taking a drug holiday, discussing with the oncologist if the benefits aren't really outweighing the risks of the detriment to her quality of life. Right. So sometimes the treatment for their menopause symptoms is to reevaluate the need for their estrogen deprivation. Now, other patients might come to me and they're at, say, four years of tamoxifenrin aromatase inhibitors, but they had a large tumor with multiple lymph nodes and other markers of a higher risk of recurrence. I'm going to kind of help them manage things in a different way. Right. And so I think sometimes the answer is kind of just individualizing their treatments and recognizing that these treatments have really serious side effects. And in fact, up to 50% of women quit tamoxifen and aromatase inhibitors because no one is addressing their side effects. And sometimes just addressing side effects allows them to stay on these medications. But when we don't recognize the menopausal side effects for what they are, it's very hard for these women to get adequate care. Right.
- [56:38]
B
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- [58:09]
A
Yeah, I mean, I think tamoxin is a fascinating drug. It's a selective estrogen receptor modulator. So in some tissue it blocks the estrogen receptor. In other tissue, it actually promotes the estrogen receptor. But one thing it doesn't do is tamoxifen doesn't lower your estrogen levels. Okay. In fact, premenopausal women who use tamoxifen have higher levels of estrogen circulating in their body for the most part. Right. So it's just competing with estrogen at the receptor level. Right. And so it's, it's, it's blocked, but it's not, it's not blocking the production of estrogen. Right. And that's important. Right. Because it's so silly that we, like, deny women access to local vaginal estrogen to treat vaginal atrophy, painful sex, urinary symptoms. They are on tamoxifen. It is a medication that is blocking the receptor in the breast. We use tamoxifen in premenopausal women and we use it in these women without estrogen suppression. So we can give it. It's like a low risk for recurrence. Breast cancer patient who's say 40 years old, she still has her period, she's still getting periods. We give her tamoxifen without suppressing her ovaries. We don't also put her into medical menopause, so she gets her ups and downs of her periods. She's got estrogen being produced, but tamoxifen is there and it's blocking estrogen receptors. And tamoxifen works in like 10 other ways, if you read about it. There's all sorts of immune impacts that tamoxifen has. It's actually fascinating. And actually people who actually understand tamoxifen understand that that's probably one of the more important ways that tamoxifen works, rather than just the estrogen receptor blocker. And so I use it as an example of these premenopausal women because they have plenty of estrogen in their body. So if they're suffering from some vaginal dryness, you can give them vaginal estrogen. Right. There's a lot of, you know, misconceptions about tamoxifen. And I also want to just say that some women can manage tamoxifen okay. And aromatase inhibitors. Okay. With help. So if you're out there hearing this and you're about to start this medication and you're afraid to start it, I'd say don't be afraid to start it. It's an important part of cancer treatments. But don't be afraid to be a squeaky wheel and say, I'm going to start this, but I want help. And I want you to recognize that these side effects are going to happen to me. And I know I can have vaginal estrogen, and I know there are things you can do to help me with my hot flashes and night sweats and other symptoms. So don't throw me to the wolves.
- [60:45]
B
I want to move to vaginal estrogen. But I just have one question that, as you were talking, I was, I was thinking is when we're thinking about these, er, positive cancers, are we also. And maybe for all cancers, whether they're, er, positive, negative, progesterone receptor positive or negative, do we, do we take lifetime exposure of estrogen into account when we're thinking about who may or may not be a candidate for hormone replacement therapy? So, for example, if someone suffered for years, let's say with pcos, maybe they're put on the birth control pill to control it, but it never actually really fits, fixed the, you know, they. They were, or whether or not the birth control pill is in the picture or not, that pcos, where they've had years or months, at least months of anovulatory cycles, where they've had a lot of exposure maybe to estrogen in the absence of progesterone, let's say, or if someone is obese. Of course, we know that adipose tissue is not just like, annoying, you know, subcutaneous fat. It's an, it's an. It's an endocrine organization where we know that there is production of estrogens, right? So estrone, but estrogens, do we take that into account when we're thinking about the prognosis or whether somebody is a candidate for HRT as well?
- [61:58]
A
I would not use it. There is no guidance out there that says lifetime exposure to estrogen might preclude you from being offered safe menopausal hormone therapy to treat your menopause symptoms? Symptoms, I think, and this is a bigger discussion, I think these, these risk calculators that are very overly simplified, where they only take into account your periods when you went through menopause, how many babies you had if you breastfed, and they don't take into Account things like alcohol intake or family history or genetic status or, you know, or metabolic. Metabolic health. And I actually think this, this, I think it's totally oversimplified. And I think this idea with obesity have a higher risk of breast cancer because they're more estrogenic is really way oversimplifying. What you alluded to really is what is really happening in people living with and struggling with obesity is profound metabolic dysfunction. Inflammation in the impact systemic. Yeah, yeah, that systemic inflammation that has insulin resistance and all of these things have. On cancer development, on immune function, on cellular repair and to break it down to estrogen exposure or not is really way oversimplified. And I think missing the boat almost. It's missing the boat. Yeah, it's missing the boat. And so I don't really love the breast cancer risk assessment tools that are overly simplified. I think you can use them like the GAIL model, for instance. It could be a useful starting point perhaps, but you need to look at the woman whole picture. And I think it's really important for women to know their risk of breast cancer by the age of 30. All women should have a basic risk assessment. Why? Because it's a great opportunity, one to talk to women about modifiable risk factors like how we can improve their overall health and risk reduction for not just breast cancer, but other cancers with obviously lifestyle and exercise and diet modification, but also helps identify which women might be referred for genetic screening for hereditary cancer and which women might be good candidates for enhanced surveillance. Because we don't treat all breast cancer the same ways and we shouldn't be doing breast cancer screening as a one size fits all. There are some women who need more intensive screening and there are some women who need more like average screening. Right. There's a. Your audience should note there's a wonderful study called the Wisdom Study. It's a nationwide study, it's free. Anybody could participate. I think you starting at age 30, I think, and basically, you know, you put in all this history and they, they do a risk assessment. You get a free genetic test, test for it and then they give you their recommendations for screening for you. So that's important. But none of that, none of that should preclude whether you get hormone therapy or not. So my example is you have a higher risk of breast cancer because you have a strong family history, say, and you have dense breast. So your risk is here versus the average risk, which is lower. Giving hormone therapy for the appropriate reasons. Right. For symptom relief, for the prevention of osteoporosis. Right. Does not further increase your risk. Okay? Your risk is still elevated. And I want to know about that elevated risk so we can screen you and, you know, talk to you about lowering your risk in terms of other lifestyle things. But it's not going to stop me from giving you hormone therapy. And that's what the Menopause Society position statement clearly states. Yet let's get back to the pink elephant in the room. The fear of breast cancer precludes those women from getting access to hormone therapy because there's a knee jerk reaction. The OB gyn, the primary care doctor says, oh, you're crazy for doing this. You have a family history of breast cancer. We can't give that to you. And I'm like, did you actually ever read any of the science or the data or the recommendations, which it's not true, right? And then one step further, BRCA carriers. So women who carry the mutation who have not had breast cancer, who choose to take their ovaries out to lower their risk of ovarian cancer. And there's thousands of these women now, right? Tens if not hundreds of thousands, millions of these women who lose their ovaries before the age of natural menopause. Right. So their ovaries are coming out before age 45, before age 40, sometimes younger, and they're in surgical menopause, premature surgical menopause, very high risk risks of cardiovascular disease, diabetes, cognitive decline. These women need hormone therapy given back. And in the past, and still many people, knee jerk reaction. You're a BRCA carrier, we absolutely can't give it to you. But even in women who have not had their breasts removed prophylactically, even in these women who are BRCA carriers who have their ovaries removed, they can safely be given back menopausal hormone therapy at least up to the age of natural menopause and then at that point beyond, because it does not appear to further increase their risk and it doesn't negate the risk reduction that having those ovaries removed gave them. So, you know, so I always tell women, so we have clear clinical guidelines, published guidelines that BRCA carriers can have hormone therapy. So don't tell me you, as an average risk woman or someone who is not a carrier should be denied it because we're giving it to the most high risk women.
- [67:38]
B
All right, let's talk about vaginal estrogen. Why should every woman be thinking about vaginal estrogen as a. Whether they're sexually active or not? Why do we want to be thinking about the genital urinary Syndrome of menopause. And why is it important? Maybe. Actually, let's just define GSM for the listeners, and then, then we can move into vaginal estrogen. It.
- [68:01]
A
So gsm, genitourinary syndrome, menopause, it's more than vaginal dryness. So basically, when estrogen levels decline, you know, due to menopause, for whatever reason, you're in menopause, natural, surgical, premature, you have a loss of estrogen at the tissue level of the vulva, the vagina, the labia, the clitoris, the urethra, and your bladder. And so with the loss of estrogen, and I use the example of, of the skin on our face as we age, right? Gets drier, it gets thinner, you know, more wrinkles, it's less elastic, less moisturized. Well, the same thing is happening in all of those tissues that I just named. Loss of collagen, loss of support tissue, loss of blood vessels there, and less sensation, you know, changes in the nerve endings. And so it's a. It's a syndrome that is not only going to cause, you know, dryness and decreased lubrication, but also urinary health. So increase in urinary urgency frequency, increased risk of urinary tract infections. Okay, so if you are like, okay, I'm menopausal, I'm noticing some vaginal dryness, but it's not really bothering me. I'm not sexually active. I'm not having pain with sex. I'm not going to do anything about it. It's really important for women to know. GSM basically affects all women going through menopause at some point in time. Some women have more of a pronounced effect than others, but it's progressive. So that's an important thing for listeners to know. It's not something like that. You just kind of get over. There's a progressive decline in the tissue quality. So you might not be sexually active right now, and you might not be having any symptoms now, but at some point in time, you are going to be at risk as you get older for all of these urinary symptoms. Urinary incontinence, urgency frequency, UTIs. And the number one reason why women who are older wind up at urgent care emergency room is for urinary symptoms. You know, urinary tract infections, which then can become a kidney infection, can lead to sepsis, pneumonia. You can have cognitive changes when you're having an infection. You could slip and fall and break a head hip. I know it sounds like, outrageous to say it, but it's actually just true. And so I Like to think of it as just preventative skin care for the vaginal skin as well as the skin quote unquote of, you know, the, the urethra, your, you know, and the, the lining of your bladder. And so just from a preventative standpoint, as we age, I think, I think personally all women should be 100 and you know, vaginal estrogen and it's really safe to start it if you are hearing this message for the first time and you're 70 or you're 80 or you're whatever age and you either are having symptoms or you want to prevent them. You know, the thing about GSM is it's treated with local vaginal hormones, not, we don't need to do systemic hormone therapy for these women. And that the local hormones work really, really well. And even if you've had a lot of decline in either sexual function, urinary function, you know, symptoms, we can really get it back. We really, really can. I've seen women who had terrible symptoms and you know, consistent use is really safe, really effective. And there is really hardly any contraindications out there. I don't care whether you had a stroke, a massive heart attack. I don't care if you have advanced breast cancer. I don't care if you had ovarian cancer or lung cancer or colon cancer. We can give you back, I don't care if you've had a history of blood clots. We can give you vaginal hormones. There are a few rare sarcomas, some certain advanced GYN cancers that we might be slightly more cautious with. Or if you are on an aromatase inhibitor, there's certain vaginal estrogen formulations and instructions and how I would have you use it, but in the outside of those circumstances, everybody can have it.
- [72:19]
B
I love that you're saying this because I think that a lot of women will say, oh, well, I'm not sexually active or, or maybe I am sexually active and I'm using lube. So is it, isn't it just fine? And we've had, obviously Kelly Casperson's been on the show and she, I, I'm gonna quote her here because she needs her own Netflix special because she's so comedic in her delivery. But she said something like, do your orgasms feel like, you know, you know, like you have in order to get there. It's like you're, you know, masturbating or self pleasuring like through a blanket. Because if it is or a caf can or something, I can't remember what she said, but it's something like that if it feels like your orgasms or your tissue sensation is changing. And I think the, the stat that she dropped on the show was like 80% of women will experience some degree of clitoral atrophy. Yeah. Which is, I mean, I had to pull my mouth like my jaw was on the floor when she dropped. And she's like. And I actually think it's higher because we don't actually track it because it's so cloaked in shame that we don't even talk about it. So it's sexually active or not, lube user or not, you know, this is going to, and to your point, this can lead to, in the extreme sepsis, like this can literally kill you. Yes, I think it's important, I think it's so important. Some of the points that you made around it being progressive like this gsm, it is progressive as you are estrogen deficient. It just gets worse over time. The tissue gets thinner and thinner over time. The atrophy continues over and over. And I think that this works really well into sort of this like timing hypothesis because a lot of women will say, oh, well, I missed the window. Like I was menopausal in like, you know, 20, you know, 2004 or 2002 or whatever taken. I was denied hormones. So now I'm 70, now I'm 75. Can I still take it? And this is one of the ways that we can potentially alleviate and improve a woman's quality of life, irrespective of her age.
- [74:12]
A
Yes. And I think absolutely, I mean, yes to everything you just said. And this is why when we only talk about it as vaginal dryness, we're doing women a discernment service. About a year ago, I was on Dr. Mary Claire Haver's menopause cruise. It was so much fun. We had a bunch of experts and we were, you know, we had amazing women that we got to hear from. And there was a lawyer who was on the cruise and she said, you know what, I've been a divorced lawyer for over 30 years. And she says, honestly, and I don't want anybody to be offended by me saying this, and part of, part of her was joking, but not joking. She goes, if vaginal estrogen was routinely handed out and discussed with perimenopausal women, I think that half of the of the divorces would have been saved because it's a really slippery slope. And so, you know, let's paint this picture of a 40 something year old woman who's been juggling life pretty well. Had a relatively happy marriage. We all know, you know, marriage is not easy. But over the last few years, not only does she have all these like vasomotor symptoms and hot flashes and insomnia, she feels more anxious, put on weight gain, her body's changed. Her doctor says, there's nothing I can do with you. You're not menopausal yet. And you know, and the husband is getting ED meds because 50% of men have erectile dysfunction by the time they're 50. So the husband's penis is optimized.
- [75:38]
B
Ready to go.
- [75:39]
A
Ready to go.
- [75:39]
B
He's ready to go.
- [75:40]
A
And as Kelly says, is anybody asking the partners of these men with, with these, you know, really robust erections? Yeah. How they're, how, you know, the recipient of that penis feels right. And so if your tissue is all right, you take care of the dryness, you use lube, you're able to get through the act, you have sex, but it's a blood flow issue. Erectile dysfunction meds give enhanced blood flow to the penis, helps make it erect. Guess what helps helps blood flow to the clitoris? Vaginal estrogen. Rachel Rubin, amazing doctor you have to follow. And she's amazing. She talks about, you know, vaginal estrogen being kind of like Viagra for women, you know, kind of in a backdoor way. And that vaginal estrogen improves tissue quality, keeps it thicker, more blood flow to the clitoris, less atrophy. So then the sensation is good. So now maybe that woman not only just tolerates that sex, but actually wants it. Because your brain does not want something that feels, hurts, not even hurts, but just feels like mid, right as the, as the team say, right as my.
- [76:53]
B
14 year old boy, like, that's mid. Yeah, yeah, yeah.
- [76:55]
A
And so like you don't crave mid sex, especially when you're having hot flashes at night. Switch. And you're tired, you just want to pass out at night. Right. And so you could see how this could create a lot of tension in a relationship because the husband perceives the wife as not desiring him and not wanting to be in it. Her brain is just not motivated because your brain is only motivated by things that feel really good. And what I find is women forget what sex is supposed to feel like because they're in long term relationships, say, and they kind of got used to it just being kind of blah. And let's also remember that a large number of perimenopausal women are put on birth control pills to manage, obviously contraception which is great. I prescribe birth control pills all the time. I'm not against them. But birth control pills, one of the things side effects is vaginal dryness and lowering testosterone levels. So a known side effect of birth control pills is lower libido. A known side effect is vaginal dryness. And so here we have a perfect storm. We've got a woman who has lower libido because she's also probably been put on Prozac or an ssri, which we know has sexual side effects. So she's on the SSRI and the birth control pill. No one offers her vaginal estrogen, which is safe to take with both of those things, by the way. Her husband is on ED meds, and she's also not sleeping. So you can really see these ripple effects. And that's why vaginal estrogen, like, is so important and empowering. But, you know, because there's. It's shrouded with shame and fear and all these misconceptions. There are lots of doctors out there who literally don't even know how to prescribe vaginal estrogen. And they think a family history of breast cancer or because she has some other medical complication, but she can't use it. Right? And so then take it a step further, and you can see the devastating effect that breast cancer treatments have on women's relationships with their sexual partners, their sense of intimacy. And when we deny even discussion about vaginal hormones and breast cancer survivors, these are women who are already struggling with all sorts of sexual and body image issues and loss of, you know, loss of everything. Right. I mean, there's so much going on here that when we tell these women that just lube and coconut oil is what they need to stick with, meanwhile they have poisonous, profound clitoral atrophy from aromatase inhibitors. It's one of the main side effects that no one informs these women on. And I don't want to say be afraid to take these medications. You can take them. And we have ways to help treat and prevent that downward decline of your sexual health, even if we're not doing systemic hormones. So, like, my favorite thing, I could talk about vaginal estrogen all day because there's really so many people who everyone's a candidate and. And there's so many more ways it helps besides just vaginal dryness. And when you give women with breast cancer some control of one aspect of her health because everything's been taken out of her control, don't discount the power of that meaning. Like, I see women who have horrid menopausal symptoms. And I say, okay, let's pick one or two things and let's work on that. And it may not be that I'm giving you HRT back yet, yet, you know, but just the power of a little vaginal estrogen can give her hope back and intimacy and control of her body. And maybe she won't be peeing five times, you know, at night and be woken up. Like, there's so many profound ways that we can help these women, but they're not being helped.
- [80:33]
B
I, I, I, I struggle with this too, because I think that talking about sexual health for women still, still very, very shameful. Like, you know, you mentioned that we were talking before about incontinence, like urge incontinence and frequency. And I think that nobody, you know, it's like, you don't want to end up in diapers, right? Like, you have to, this is something that we just have to get, we have to just get rid of the shame.
- [80:56]
A
Men aren't embarrassed. I mean, for God's sake, they all get ED medications. Like it's going out of style. It's easy for them to get testosterone as well for their low libido. You know, those are easy. And it's not shameful. It's kind of like, okay, I'm staying robust and manly as I age. And that's cool. And our medical world supports that, right?
- [81:19]
B
Yeah, but so how can we make it cool for women?
- [81:21]
A
Well, it's becoming cool, it's getting there. But we just need to level up the clinicians knowledge because we now have women who are demanding access to care and we have clinicians who aren't prepared to give it. That's, there's a mismatch there. And so that's why I, you know, you and I do podcasts, right, to get the message out. I, Anybody listening? I have a course for physicians and clinicians who take care of breast cancer survivors on managing menopause and how to prescribe them hormone therapy or make those decisions. So I'm doing like CME classes. I think that's like a step in the right direction. And there's more and more doctors who are interested in that. And I think all of us out there speaking at professional medical societies and conferences, because really, I think the solution is we really need to level up the education of the clinician at this point because, you know, the word's getting out on the street to the women, but they're kind of faced with not getting access to care. Right. That's a big problem.
- [82:25]
B
So in wrapping this up, I wanted for you to share part of your story or however much you would like to share with our listeners. You are obviously a breast cancer survivor. Tell us a little bit about what happened with you, what interventions you were offered, what you ended up doing about it and where you are. I mean, obviously you're still here with us today, thank goodness. But tell us, tell us a little bit about your. Tell us a little bit about your.
- [82:50]
A
So in 2001, I was a second year OBGYN resident. I was newly married. I was 28 years old. We had no family history of breast or ovarian cancer and my mom died of ovarian stage 4 ovarian cancer suddenly. It's a terrible story, but she died and six weeks later I was diagnosed with breast cancer. Right before her death, I had felt a small lump in my breast and was dismissed. I dismissed myself. I was like, I'm too young for breast cancer. We have no family history of breast cancer. My physicians, who I was training with as well as my gyn, they all said, just watch and wait for a couple of cycles. You're too young. Which my first experience of being gaslit and dismissed. But then fast forward right after my mom died, I was like, I gotta get this checked out. So I was diagnosed with ERPR positive HER2 negative stage 2A breast cancer. Very devastating because I was, you know, we were thinking about starting a family, getting pregnant. I was middle of my medical training, but I went ahead and wound up getting through multiple surgeries, wound up getting eventually a bilateral mastectomy. I went through six months of chemotherapy with some hormone suppression. I did fertility preservation prior to starting chemotherapy in case chemo, you know, killed my ovaries, which it didn't. Then was on tamoxifen for a few years and then paused. My tamoxifen was able to have a natural pregnancy. I have a almost 21 year old beautiful daughter, went back on tamoxifen with some ovarian suppression for a period of time. But that was really, really rough then.
- [84:26]
B
And that was for reoccurrence. What was the reason for that?
- [84:28]
A
No, no, no, no. So, er, positive breast cancer. The standard of care is 10 years of adjuvant endocrine therapy. So I was able to do tamoxifen for a couple of years. And we support women, this is interesting. This is a whole nother podcast, but we support women who are breast cancer survivors, who are even er, positive people to pause their adjuvant endocrine therapy, which can be for up to 10 years to get pregnant. So I was young. So they said, okay, you could stop everything, get pregnant, have lots of estrogen, right? Deliver a healthy baby. And then I went back on tamoxifen to finish these 10 years. And so I realized early on that I was not prepared as a OB GYN to even understand or treat my own. Now severe, abrupt, surgical, or at first medical menopause, and then subsequently down the road, I had my ovaries removed. Then surgical menopause. I had no idea how to treat myself with all my awful symptoms, much less the average menopausal woman. So that kind of personal experience got me involved in the menopause society and I continued, you know, to focus my practice on that. And so. And it really evolved over time. So I tell patients for literally Almost, you know, 18 years or more, almost 20 years, I managed horrific menopause symptoms, sexual side effects, the whole thing really, without much help. I mean, like, because I was a bad menopause doctor, right? Because I was not trained, right. And then even after I got trained in managing other people's menopause, I still had a lot of fear about how to deal with my own. And so I did not do anything optimally, I didn't do things the way I would have. You know, all the stuff I talked about today. So it took me a really long time to get to a place where I treated myself.
- [86:14]
B
I always say, bless my first patients for letting me practice on my own.
- [86:17]
A
Yeah, exactly. Yes, exactly. And so it took, you know, a long time. So I really relate to women who have been dismissed, been gaslit, who didn't, you know, get proper care. And I buried my hand in the sand in terms of the sexual side effects and all of the, all of the kind of quality of life side effects. And so along the way I found an honorable things that helped to a point, lifestyle things that I should have done earlier. Right. And then finally, after many, many, many, many years, I, you know, made the decision actually with the support of my medical oncologist, to stored hormone therapy. So I've personally experienced what it's been like to be a late starve. I was past the ten year window by far, and I have started very low dose, not very high dose, low dose. Transdermal estradiol, progesterone. At bedtime, I added in testosterone eventually for libido. Game changer. And game changer.
- [87:19]
B
Game changer. I was gonna say how, like, how did all those things, how did you feel? Was it night and day getting the.
- [87:24]
A
Estrogen not so I'll say. And again, my choice is not for everybody and I did it in lots of ways and I think that you don't have to do what I'm doing. But you know, when I speak about this and making these hard decisions, I speak from personal experience, right. And I second guess myself through the years and it's been messy and not easy. So there is no one clear path. But I will tell you what was the most devastating looking back at all those years was, is the loss of sleep. Years and years of chronic insomnia, terrible nighttime hot flashes that really nothing, you know, antidepressants through the years helped, you know, effects or I was on for a long time. Once I was able to restart just I started with nightly progesterone and then I added back really the lowest dose. I'm on like one to two sprays of Eva mist. Very, very low dose. My serum estradiol level is like, is around 35, very low. But for me that's all I need to have relief of my symptoms. So it's very low dose. Within a few days of progesterone and the estrogen, it was like a aha moment. I finally slept through the night. That kind of low grade anxious feeling, little, you know, common heart palpitations. The hot flashes that you I told so they went away. I had more energy, my joint pain improved. I mean I had tried all the things and I did was doing exercise and all those things and it helped. But I will say I noticed a big difference. I was really lazy about using vaginal estrogen and then I got better at it. And after a few weeks, game changer in terms of sexual function as well as urinary symptoms. And then after a period of time and learning more and getting more educated on sexual health, being part of Ishwish, the Menopause society decided, all right, I had my ovaries removed years ago. My testosterone level was 2, very, very, very low. And I just didn't have drive or interest. And, and, and sexual response. Orgasm was definitely not as, not what it used to be. And so I added back very low, very conservative using the Ishwish global position statement guidelines. And I'd say I had a response very early. Some patients it can take 6 to 12 weeks to like notice response and desire. For me it was a huge game changer in overall sexual function from arousal to desire to interest to performance and function. So that was really life changing for me personally. And I think that the lessons I learned from just being my own patient is that it really can have huge improvements in quality of life. And it is more than just vaginal dryness and hot flashes and night sweats. And I think that you can take all those tools and some women only need one thing or they, you know, they need the whole kitchen sink. And looking back, like, when I did use non hormonal things for my hot flashes, it did help me. I wish, I wish I had investigated all the different non hormonals because there are more than just antidepressants to use. We've got other, you know, prescription medications that we can use and vios as a new medication on the market that can be helpful. So I'm very optimistic that we do have non hormonal things for hot flash and night sweats. And I wish and I didn't always use them. And in retrospect, treating those things and sleeping through the night is really damn important because you can't do the lifestyle things that we ask you to do as a cancer survivor unless you're sleeping and having those things controlled. So don't be afraid to do something even if it's not hormonal. And I really wish I would have years ago consistently used vaginal estrogen. And I also really, really wish years ago someone would have educated me and I would have been up to date on adding back in low level of testosterone. And an example, mine was two. And when I checked it recently, my Testosterone level is 17. It's crazy low. Okay. But let me tell you, I'm a responder. Like I don't need high level levels. Just a little bit on my little STAR receptors. I think just it has a profound impact on me. I notice a profound difference. And so it's not about chasing down a blood level. The guidelines are clear when it comes to testosterone. We can find the balance of giving back. We start with low transdermal doses and we find do you get a response and do I care what my number is per se? I don't need it to be super high. It's working for me. Other women need it to be a little bit higher. They may start at 20. And so when we get theirs to 50 or 60, they feel better. Right? But for me, I use an example is I'm using very modest doses and I feel really good on them. So that's my little personal thing.
- [92:16]
B
I love it. I love it. And I have to thank you for sharing that because, you know, your honesty and your transparency, there will be other women who are listening, who are going to see themselves in you and this is, is the value of being, you know, you mentioned a couple times, so I'll just reflect it back to you being that squeaky clean, you know, advocate for yourself, like learning all of these things. And certainly you can have regrets, but I, I, I would love to reframe it as like, it's your, it's your learn. That was your path, that was, whatever it was supposed to be was, you know, what happened for you. And now you can take what you've learned. And the contrast, right? Sometimes we need that contrast. We need the crescendo of the, of the play along with the, you know, know, the very soft, you know, melodic parts of a, you know, a music piece. Let's say we need the, we need the night and day contrast in order to understand how truly valuable, like you said, sleep is to be able to show up and do some of the things that, you know, you need to in order to live well. And now I think, you know, and I've seen you do this, I've seen you walking on your treadmill on Instagram, like, I see you advocating and doing all the things, and I don't think that that would have been possible if you didn't have the experience that you have and, and, or had. And I think that, yeah, I just, you did not disappoint. This has been such a fantastic conversation. I'm so happy that you came on and I know that this is going to help so many of my, my listeners to make better, to have better conversations with their PCPs, with their primary healthcare providers and to make better decisions for themselves. So I just can't thank you enough.
- [93:41]
A
Thank you. And I want to give, like, my favorite resource, shout out is menopause and cancer. So if you're a cancer survivor of any type of. My dear friend Dani in the uk, she has an incredible podcast, an incredible website, free resources for all cancer survivors. Menopauseandcancer.org there's incredible resources on hormone therapy after breast cancer as well as vaginal hormones and breast cancer. So if you're needing to listen and read and hear these stories, I think that's an incredible source. That's why I always want to, you know, I always want to shout out to her because I know women who have had cancer, no matter how many podcasts they hear, they still are just desperate for more information. Right? Really, really important. And also, you know, just understand that if you are getting a brick wall when you're trying to get answers for, you know, hormone therapy, know that there are educated clinicians out there. This is why I do telehealth. You know, I'm a medical advisor at Alloy and we see patients there and we're physicians who are trained in menopause. And so I think, you know, don't let yourself be limited. If your, your in person GYN who you loved and has served you well for the years is just not up to par when it comes to the menopause piece, it's okay to seek a second opinion because you're, you're worth it. So speak up. Be a squeaky wheel.
- [95:06]
B
Fantastic. Thank you so much. And we'll have make sure that all those are in the show notes as well.
- [95:10]
A
Well, amazing. Thank you so much for having me.
- [95:12]
B
You are so welcome. Hey, if you're listening this long into the podcast, welcome to the Betty afterparty where I tell you what I loved or didn't love about this conversation. So couple things here. I thought that first I loved Corinne's explanation of the whi she was. She actually got into quite a bit of detail with the two arms of the study, the estrogen only and the estrogen plus progestin study, which is not something we've actually discussed on the show before. So it actually added a little bit more nuance, a little bit more color as to why people were freaking out over the estrogen only arm or the pro. At the estrogen and progesterone progestin, pardon me, arm of the show or of the study?
- [95:58]
A
The.
- [95:58]
B
There were a couple big highlights for me in this entire conversation. First and foremost, obviously, we spent most of our time talking about breast cancer. And I really love this idea of that. Just because you've had breast cancer, irrespective of the type, because we know that breast cancer is not just one thing. It can be many things, just like menopause can be many things that you at least deserve the opportunity to have the discussion with your primary healthcare provider or several healthcare providers, your oncologist, maybe a menopause specialist, your primary, you know, your, your medical practitioner, whomever, naturopathic doctor. I think that this is an important, how should we say it, taking back of our power. Whereas I think in, in past years and decades we just sort of delegated, like whatever the doctor said is what we did. I think it's important for us to be going at a squeaky clean wheel, as she was referring to a couple times in the show, going and saying, hey, I've read the position statement, hey, can I have this conversation? So I really, really love that. And maybe my most favorite part of our conversation was this idea that vaginal estrogen is like skin care. Right. We've, we've seen people, myself included, using vaginal estrogen on the face for the anti aging properties that it has. And why don't we use this for every woman in perimenopause and menopause, irrespective? Like there's so few contraindications to vaginal estrogen. It's not systemic, it's very local. And I loved that she talked about this idea that it's not just lube. Like we're not just taking vaginal estrogen just for lube. Like you can just use coconut oil for that. Right. It's really about overall health of your vagina, your vulva, your clitoris, the labia, all of the anatomical parts that are literally starved of estrogen. That gets progressively worse. It gets pro, it doesn't get better with time, it gets worse. So I loved that she talked about that and, and thinking about vaginal estrogen, you know, in the extreme as something that can be possibly life saving. Like, we don't want more UTIs. Like, I can tell you I've never had a UTI, but I know my girl. Like I've had friends who've had UTIs and it's just the worst. So can we prevent UTIs? Yes. Can we avoid getting a kidney infection and eventually sepsis? Yes. So vaginal estrogen FTW for the win. And then the other piece that I thought was really important was this idea of, hey, guys are getting at least they have easier access to therapies for sexual dysfunction. So maybe they're being given Viagra or something that's going to improve blood flow to the penis. And now we have a very happy penis. Is there, I'm totally getting explicit, by the way, on this particular episode. But you know, we have a very happy penis. But is there a way to also have the recipient of that penis also very happy and excited for what's about to happen? Right. She mentioned there was a lawyer on a cruise that she went on who, a divorce lawyer who said, I wonder how many divorces could have been avoided if we just gave these women vaginal estrogen. Like just imagine that. And Corinne did a really good job of painting that picture. We have like a really excited guy ready to be with his wife. And the wife has like brain fog, she's not sleeping. It, it hurts when they have sex. You know, like, can we just allow our women the same access to care as we are? Our beautiful men, like both our beautiful women and men getting the same access to care and then, you know, low divorce rates. Right. And the, and the sort of socioeconomic changes that can, that can come with it. That was such a great conversation. As I mentioned, I met her at a conference that we were both speaking at and I knew I wanted her on the show. Show. I have included all of the show notes for you, clickable links, all the resources for her. She's a wealth of knowledge. And I'm so glad that you stayed to the after party to get the Easter egg that we kind of put put in every show. So if you are a dark rose, Betty, you're probably listening. Thank you so much. I hope you appreciated it. Let me know in any of the reviews that you give, whether it's itunes or you want to make a comment on Spotify. Love to hear. Love to hear from my beta community. And until next time. All right, all right. I hope you enjoyed today's episode and I must give you the obligatory legal and medical disclaimer here. This podcast, Better with Dr. Stephanie, is for general information only and the advice recommendations we discuss do not replace medicine, chiropractic, or any other primary health care care provider's advice, treatment or care in the consumption of this podcast. There is no doctor patient relationship that has been formed and the use and implementation of the information discussed are at the sole discretion of the listener. The information and opinions shared on this podcast are not intended to be a substitute for primary care diagnosis or treatment. In other words, guys, be smart about this. Take it with a grain of salt. Take this information to your primary healthcare provider and have a discussion with him or her to make the best choice. That is for you. Remember, I am a doctor, but I am not your doctor, and these conversations are meant for educational purposes only.