← The Curbsiders Internal Medicine Podcast
The Curbsiders Internal Medicine Podcast
#507 Swinging the Pendulum on Menopause Care With Dr Rachel Rubin
01:34:31
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- [00:00]
A
Hey, before we get to the show, I wanted to remind you to check out our patreon@patreon.com curbsiders. If you haven't signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes, and a whole bunch of other cool stuff@patreon.com curbsiders.
- [00:19]
All right, Paul, I have an unrelated pun, but I'm going to try it out anyway. On the other hand.
- [00:27]
Paul, on the other hand, you have different fingers.
- [00:35]
All right, one more.
- [00:37]
B
I got a menopause one. Okay. What's the name of the menopause superhero?
- [00:44]
C
The Hot Flash.
- [00:46]
B
Just the Flash.
- [00:50]
A
I like Hot Flash.
- [00:51]
B
It's like, all right, it could be the Hot Flash, you know. Okay.
- [00:56]
D
The Curbsiders podcast is for entertainment, education and information purposes only. And the topics discussed should not be used solely. Diagnosed, treat, cure, or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash, like more hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We aren't responsible if you screw up. You should always do your own homework and let us know when we're working.
- [01:22]
A
Welcome back to the curbsiders. I'm Dr. Matthew Frank Waddo here, my great friend and America's primary care physician, Dr. Paul Nelson Williams. Hey, Paul.
- [01:31]
C
Hi, Matt. Just a peek behind the curtain for the audience. We took that over and I wasn't sure if you're going to downgrade me in terms of friendship, so I'm glad I still remain your great friend.
- [01:39]
B
I thought you were going to be downgraded in terms of the Americas.
- [01:42]
C
Just. Just a primary care physician.
- [01:44]
A
No. In our weekly meeting, Paul's mom and I decided that he is still America's primary care physician and probably the primary care physician. Yeah, that's a running thing. Paul and I. Paul, I have a weekly phone call with Paul's mom just to see how he's going. We talk about if we're worried about him or not, how he's doing in life. Yeah, yeah.
- [02:04]
C
And yes, and badly are probably perpetual themes.
- [02:09]
A
Well, this is an episode I've been really excited to have on our calendar. We talked about menopause hormone therapy with Dr. Rachel Rubin. And we will introduce our guest in a second and our co host in a second. But Paul, first, what is it that we do on Curbsiders?
- [02:28]
C
Sure, Matt, great question. As a reminder, we are the internal medicine podcast. We use expert Interviews to bring in clinical pearls and practice changing knowledge as you allude to. We are joined by yet another co host, fan favorite, women's health expert, longtime correspondent, super producer extraordinaire all around super doctor, Dr. Molly Hoiblein. Dr. Hojblein, how are you?
- [02:49]
B
Oh, thank you, Paul. I'm doing well. Did I get a promotion to Chief of Women's Health at Cashlack?
- [02:55]
C
Let's make it official. Why not? Sure, Absolutely.
- [02:57]
A
If not you, then who? Molly, come on.
- [02:59]
E
Thank you.
- [03:01]
C
Who better than you?
- [03:03]
A
So let's hear about our guest.
- [03:05]
B
Yeah, we had a fantastic conversation with our guest, Dr. Rachel S. Rubin, MD. She is a board certified urologist and nationally recognized expert in sexual medicine. She is one of the few physicians fellowship trained in both female and male sexual health and serves as an assistant Clinical professor of Urology at Georgetown University. She was deeply involved in the development of the 2025American Urologic association guidelines for the treatment and management of genitourinary syndrome of menopause. She engages in research and advocacy to improve evidence based care and is dedicated to advancing education of clinicians on both sexual dysfunction and the care and treatment of women in perimenopause and menopause. Dr. Rubin did a great job talking us through the newer data around the safety of hormone therapy that's available today, hopefully helping us feel a little more confident as primary care providers in offering this essential care to our patients. And she really does a nice job talking us through vaginal estrogen and other products as well as systemic estrogen and progesterone testosterone and just a kind of a nice toolbox of how to start prescribing these medications. So without further ado, let's get to it.
- [04:20]
A
A reminder that this and most episodes are available for CME credit for all health professionals through VCU health@curbsiders.vcuhealth.org.
- [04:31]
Rachel, welcome to the show and we have really been excited about this for a long time because we've been corresponding via email and everyone's heard you on other podcasts at acp. So really excited to talk with you. But first they want to know what is a hobby or interest that you're currently enjoying outside of medicine.
- [04:50]
E
Well, anyone who follows me on Instagram knows that I have two brands. One is sexual medicine and the other are cute otter videos. I don't know why, but they just everyone will send me otter swag or genital swag. Those are the two things that come my way whenever anyone sees it. I will say for me, I don't like things. I realized that what makes me happy is, like, human connection, which is why I'm obsessed with my work and my job. I love deep connection with humans. So I've got my best friends from middle school. I've got friends. I like people. That's my hobby.
- [05:24]
A
Paul, you were making some faces there. Do you have any comments?
- [05:27]
E
You hate otters, Paul. Paul, what do you have against otters.
- [05:29]
C
Of your two interests? Otters are much more appealing to me.
- [05:33]
E
Genitals.
- [05:34]
C
Well, then people.
- [05:36]
A
I never heard the phrase genital swag before. Certainly not on the curbsiders.
- [05:41]
B
Ovary necklaces.
- [05:43]
E
I've got a vulva necklace on. I've got a nice array of clitoris and vulva necklaces and all sorts of signs that say, you're clitorally the best. And.
- [05:55]
A
Well, I'm all for this. I like it. I like it. Really? It's a good way to break. This is supposed to be the ice breaking part of it. And maybe I need to get on Instagram, Paul, because I need to explain, explore, and broaden my horizons.
- [06:11]
C
Yeah, no, I think this is a great place to.
- [06:12]
E
There's a lot of videos that you can watch. Absolutely.
- [06:15]
A
Okay, Paul, anything you'd like to ask before we get to our case?
- [06:19]
C
Oh, well, let's ask the meaningful advice or feedback questions. So, Rachel, any advice you've either received or advice that you'd like to give to people in training or just in their career in general that you feel is especially useful?
- [06:32]
E
So lots. Unlimited, actually. But truly, progress over perfection is one of my favorite. You do not have to be perfect to get messages, important messages out there. I always joke I have a face for radio, or I should say a face for podcasting. And so you do not have to dress up, wear lots of makeup, look perfect, and sound perfect to make giant impact. And so just do it, do it messy. Get. Build those muscles right. If you. If you listen to my first video I ever did or the first lecture I ever gave. Horrible, right? And so you can learn how to do things. That's how we learn how to do central lines and surgery and all. All of those other things. And the other really great advice I got is sometimes it's not about giving new messages to the same people, but it's about giving the old messages to new eyeballs. And that's so much of my mission is I have been on my soapbox with my colleagues talking about things like vaginal estrogen, which has been around for decades. It's not new, it's not shiny, it's not lucrative, it's not sexy. And yet we have ascended great mountains by doing it over and over and over again for just people who've never seen it before. And that's saving lives. And I love that concept of medicine. There is, yes, the unknown and the things that we're gonna learn ahead, but we're not actually doing a great job of messaging the stuff that we already know and we know to be true. And so we've gotta really disseminate those good messages out there to new people who haven't seen them before.
- [08:01]
A
I'm hyped up for this now. So let's go. Let's get to our first case. Molly, can you read it out for us?
- [08:09]
B
Hi, this is Molly here. Just a quick update between the time that we recorded our episode and when we're going to be releasing it, the FDA started the process to initiate removal of the black box warning for all hormone therapy products. So these products will still carry a black box warning for endometrial cancer with unopposed estrogen, but the black box warnings around breast cancer risk, dementia risk, and cardiovascular disease will be removed from estrogen containing hormone products. So just wanted to add that little update that occurred between the time of our recording and our release.
- [08:45]
Absolutely, I'd love to. This is this hypothetical patient I have seen about five times in the last two weeks. So very excited to get your take on it. So at Cash like Memorial Outpatient, we have Jane. She's a 60 year old woman who's coming in today to talk to her primary care doctor about menopause care or hormone therapy. She went through menopause at age 50, so 10 years ago and at the time she was discouraged from considering hormones by her provider. So she never really explored a menopause hormone therapy or mht. But now all her friends are talking about how great they feel on hormone therapy and she's interested in initiating it. She's most bothered by some ongoing night sweats, poor sleep quality, joint stiffness and low libido which she attributes to worsening at the time of menopause. She has a past medical history of high blood pressure that's well controlled on an ARB and pre diabetes. She has no history of thromboembolism, she has no prior surgeries, and she does have a family history of a first degree relative with breast cancer. So I know that was a lot in the case and we'll unpack that. But to start off, Rachel, this feels like a really pivotal time in menopause care. People are talking about Menopause much more openly. Social media seems awash with the benefits of hormone therapy, and yet many primary care providers are still operating under kind of the old model of hormones are dangerous and should only be prescribed at the lowest dose for the shortest time possible. So why do you think we're at this transition point in menopause care and why does it kind of feel so polarized sometimes?
- [10:11]
E
Yeah, I mean, I think we're at this, this moment, but I think it's more than a moment. I think it's a movement. I think it's really, there are voices that haven't really been loud before and now people are getting louder and louder and social media is allowing everybody to have their own TV show, which you can say is terrible, but everyone gets to decide which TV show that they watch. And my patients watch multiple TV shows and they get to choose the flavor of the TV show that makes sense to them. And, and to be honest, that's how medicine has always worked. It's just happening at such a quick, fast paced level and we don't have that much control anymore and that makes us all very uncomfortable. But the reality is, is the guidelines have moved way beyond lowest dose, shortest amount of time possible. It feels like such a magic blessing to watch the menopause society guidelines evolve from don't do this, it's dangerous whi scare tactics, warning labels to ooh, we're a little nervous still. But we still believe in hormone therapy. So lowest dose, shortest amount of time possible, which was not very data driven to the 2022 guidelines. Right. Which are shared decision making. It was just beautiful. What do you think about that?
- [11:24]
B
Yeah, I think that's very well said. Yeah, I think it's. Medicine has a lot of inertia and it's often hard to change things. We continue on in the same models even when there's clear data to the contrary. And I think menopause is a complicated place because we don't have as much data as we like to see in like cardiology trials or those kinds of things. And so I think people who are risk averse sometimes stick to those older, more conservative approaches, even if it's not in the best interest of our patients.
- [11:53]
C
That's, I think that's so well said about. Because it's my, my thinking is I feel like there's also some benign neglect also combined with sexism. And by that meaning just I feel like the underlying thought is I heard that these things could maybe cause harm, whereas the vasomotor symptoms are not going to Kill you. But the thing I do may potentially, because I heard this scary thing at one point that I don't fully remember. So I'm just going to actually avoid the conversation entirely. Seems to be a broader sentiment that I maybe sometimes see.
- [12:19]
E
And we're giving permission, and I think that's the challenge. These warning labels that are actually not true or fair or based in data are giving doctors permission to say, you don't have to learn this because you'll get sued anyway because of these warning labels. And patients are afraid. And so it's actually not the doctor's fault. We are set up to fail here. Right? The residents aren't taught anything about this. The fellows aren't taught anything about this. They don't learn how to write prescriptions. Then they get out into the real world and they don't actually know the data. So when you learned how to manage diabetes in Residency, you saw 20 different people do it, if not many more, and you're like, oh, I like the way doctor so and so does that one. I like the way he titrated that one. Oh, that spiel was awesome. But if you don't learn how to talk about the Women's Health Initiative or the box labeling or the doses or the nuances, guess what you're not gonna do in a 10 minute visit with your patient who just explained all of the symptoms of menopause, you're gonna say, oh, I feel much more comfortable talking to her about exercise or talking to her about her high blood pressure or her prediabetes. Cause that's a safe space for me. Cause I saw all my mentors sort of navigate that.
- [13:30]
A
Can we talk about. You mentioned the WHI and warning labels. What is your beef with the whi? Like, where do you think they steered us wrong and maybe made the risks seem more than they were? Can you talk a little bit about that?
- [13:45]
E
Yeah. So the beef is actually not with the whi. It's kind of fascinating. We can do a big, broad overview. Right. The Women's Health Initiative was looking at cardiovascular prevention with oral sex. Synthetic hormone therapy is Prempro. Right. So if you had a uterus, you took Prempro, and if you didn't have a uterus, you took conjugated equine estrogen only. And they followed these women. The average age of women were 62, and the majority did not have menopause symptoms. So not your 52 year old healthy person with hot flashes, joint pain and night switch that you, that you see every day. But the WHI just published in JAMA that looking below 70 in women who were on systemic hormone therapy on both, both kinds. Right. Had no increased risk of stroke or heart attack. No increased risk. Right. And we know those who used equine estrogen only had a decreased risk of getting and dying from breast cancer. And we know that there was reduced fracture risk and diabetes risk in both arms. We know that there was overall mortality decrease. And so even the WHI didn't show the harm that we're so worried about with systemic hormone therapy. So the WHI actually keeps showing us how safe hormone therapy is and it gets safer.
- [15:01]
In sort of expert opinion and the guidelines when you use a transdermal product. We know vaginal hormones are microdosing and are the safest thing in the world for every human on earth, which we can get into. But this idea of hormones are not all the same thing. You can no longer bucket all hormones together and say hormones are good or bad, right or wrong, yes or no, they're nuanced. And estrogen is different than progesterone and testosterone. Vaginal hormones are different than systemic hormones. Oral hormones are different than transdermal hormones. And if it feels confusing, my friends, you can titrate GLP1s, you can talk about different antihypertensive, different osteoporosis medications. Good lord, that is so confusing for my urology brain. You can do this. It just takes a couple very short explanations of knowing that transdermal products don't increase your blood clots risk or that progesterone, micronized progesterone shows no increased risk of breast cancer. And so it's knowing these things where you can actually then give really good shared decision making with your patient. And for sure there is data we don't have, of course, but the data that we do have is actually extremely reassuring and supportive of use even in this patient that you just told me about.
- [16:23]
C
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- [17:53]
This episode is brought to you by the Buxbaum Siegler Institute if you're a physician or healthcare professional who is passionate about improving patient care, you should know about the Buxbaum Siegler Institute for Clinical Excellence at the University of Chicago. The Institute supports medical students, residents and faculty who are pushing the boundaries of what great clinical care looks like through scholarship, mentorship and national programming. And right now, we're excited to highlight one of the Institute's signature programs, the Buxbaum Siegler Institute Clinical Excellence Award, a national recognition honoring a physician who has displayed exceptional dedication to clinical excellence and the advancement of the doctor patient relationship. For over a decade, the Buxbaum Siegler Institute has helped train and support physicians who consistently put patients at the center of their care. They support scholars doing innovative work in ethics, communication, health equity and patient centered care. They also run programming like the Clinical Excellence Podcast, the annual symposium, and mentorship networks, all dedicated to strengthening the way clinicians care for their patients. Among their most impactful initiatives is the Clinical Excellence Award. Each year, a committee selects a physician who exemplifies what we all want in a empathy, listening, clinical skill, and true partnership with patients. The award includes a $15,000 prize and nominations are open until January 15th. Past recipients have been leaders in obstetrics and gynecology, compassionate care, addiction medicine and primary care innovation. If you want to learn more about what the Buxbaum Siegler Institute is doing and to nominate someone for the Clinical Excellence Award, you can check them out today, visit buxbauminstitute Uchicago Edu, that's bucksbauminstitute uchicago. Edu. Whether you're a clinician, a trainee or someone interested in innovations being made in the physician patient relationship, check out their Institute. Go to BucksBaumInstitute uChicago.edu to learn more and submit a nomination.
- [19:45]
A
Can I ask just to follow up on. You said so the transdermal. Transdermal estrogen, because it's missing that.
- [19:54]
First pass effect in the liver. Right. You're not increasing clotting factors. So that's why we think it doesn't cause clotting.
- [20:01]
E
Yes.
- [20:01]
A
And then for the micronized progesterone, you said it. Can you. What was that point that you said?
- [20:07]
E
So progestins scare everybody. From the Women's Health Initiative, it was medroxyprogesterone acetate. And in the studies and actually there's some statistical questions whether this is actually true or not, which we could get into the nerd nerdiness of it. But there was a increased risk of incidence of breast cancer, but no increased risks of mortality with breast cancer. Whereas the estrogen alone arm, the conjugated estrogen alone arm, showed a decreased risk of both getting and dying from breast cancer. So to deny a woman vaginal estrogen, which is safe for every human on earth, even if women with breast cancer on the grounds of stroke, blood clot, heart attack, probable dementia or breast cancer, is insanity. Like, it's just pure, it's just pure insanity. So it doesn't take much learning of those simple facts and things to say, wow, this actually isn't so scary. I do much scarier things with much less data. Right. If we think about how many drugs that we use in women all the time that haven't really been studied in women fully, and we just extrapolate and say, well, it works in men, so let's just give it to women. And we feel comfortable with that when we probably shouldn't. Right. Right. And so hormone therapy, you say there's. There's not, there's tons of data. There's tons of trials out of Europe. There's tons. There's not WHI level data. And I don't. After the debacle that in the messaging that went so badly, I don't know if we'll ever have that again. But we do have a lot of data. And with the excitement on the Internet about menopause and the industry and the companies coming in, we could talk about them as all being grifters and snake oil salesmen, but we're Going to see money come into this space, and that is going to be important for research.
- [21:55]
A
So could we call. This is being recorded before.
- [22:00]
Any label changes were made. But just predicting, you know, just reading about this over the past several months, it seems like at least vaginal estrogen will have the label changed to say, you know, so that it removes. Because does right now have a black box? Like, what does the label say right now?
- [22:16]
E
All right, I brought the label, my friends. I don't know if you're on video, but. And if you hear crinkles, it's. Cause it's a big crinkly paper. And I prescribe so much Viagra, it is crazy. And by the way, Viagra can cause blindness. And if you take it with a nitrate, right, like, you go, you like, like bottom out and go to the hospital, right? So there's all these risks on Viagra. No one reads any box labeling on Viagra. Like, men just guzzle it like candy. And yet every woman reads the box label on estrogen. I, I really, I don't quite understand it, but that's where we are.
- [22:48]
C
This feels like a pointless correction, but I will just say sildenafil, we should say as the medication, we're sliding right here. It doesn't sound like we're showing a brand preference, but just, just for our cme.
- [22:58]
E
Overlordalafil, sildenafil, vardenafil, or even a pill, all of them. No one cares about any warning labels that exist. But we know there are risks to medications, right? There are always. The FDA's job is not to make sure a medicine has no risk. The FDA's job is supposed to make sure that the benefits are there and the risks are discussed. And so the label is this big long thing that should have lots of information on it. But a boxed label is for serious warning. This will kill you. This could kill you. And if you look at birth control, I looked recently, I am not a gynecologist. I don't prescribe much birth control. But the box labeling on birth control is just about smoking and blood clots, right? Not blood clots in general, but smoking specifically with blood clots. Whereas we all know that the risks of birth control are well beyond just a risk of smoking, you know, and getting a blood clot. And so we have to think about labels of, like, what is a serious warning label. So the labeling on all estrogen products, because it's a class labeling, if it's even like smells like estrogen and menopause, it gets the same label. It says and gosh, my 41 year old eyes are having trouble with this. But warning, endometrial cancer, cardiovascular disorders, probable dementia and breast cancer. And then it goes to say to talk about WHI data.
- [24:22]
In depth. Okay, so it makes no sense, right? This idea, like none of that makes sense, especially for vaginal hormone therapy products. But we could even argue for or systemic hormone therapy products because transdermal is different than oral, which is different than 17 beta estradiol compared to a synthetic hormone. And so there is a need to remove sort of the class of it all to actually say, hey, there's nuance here. Now that's not saying we all agree there's risks and different risks, but what about the benefits? Like this label is scaring women saying you're going to get probable dementia. If you take estrogen, you're gonna, if you take a microdose of vaginal estrogen, you're gonna get probable dementia where there is no study on earth to show probable dementia with those doses and types of hormones. And so it truly is revolutionary. This is only step one. Step one is change the labeling. Right. But that doesn't change management because you still have internists and we still have gynecologists and other doctors who are saying lowest dose, shortest amount of time possible. We're still having people take their patients off hormone therapy at 55. We are still having people stop vaginal hormone therapy before their hip replacement and then they die of urosepsis. We are still having, you know, you have migraine with aura, you can't have any estrogen product, which is not true. So it is only step one to change the labeling and to get the news to talk about it. Step two is we have to teach you all the nuances and actually how to do this to the highest level of the guidelines. And then step three is we actually have to advance the medicine and the research. Right. So it's a multi step process here.
- [26:07]
B
I really appreciate your efforts and advocacy to change the labels because I learned very early on in practice that if you don't explicitly tell women this is not gonna kill you. They'll come back and see you six months later with horrible vaginal pain, dryness, recurrent UTIs and said, you know, I picked up the medicine but the label scared me so I just wasn't feeling safe taking it. And I have to go through this whole spiel about that's for systemic, maybe it's definitely not for vaginal. And yeah, I think that'll be a big move forward.
- [26:37]
E
Yeah. And it's not even for systemic. Which is the craziest part of it all of, like, there's even nuance from that. And so it really. The challenge is getting everybody to believe that this study that happened in the early 2000s was not in turn, even that study showed the safety of hormone therapy. And so how do you. It is in the ether of the air that sex hormones are dangerous somehow, right? Or that they're harmful or damaging. So we should pick up the ssri. We should pick up the osteoporosis medication first. We should pick up the melatonin or the Ambien first. When you have a whole toolbox of these. Of these natural hormones that the ovaries made naturally, you know, that we could be using and the benefits. And I think there's all these scare tactics of the harms, but we're not talking loudly enough about the benefits of hormone therapy. The magic of hormone therapy, the incredibleness of hormone therapy, too, for me in my practice as a urologist, to watch women in their 50s and 60s say, oh, my gosh, I feel like myself. Where every time I see them, they feel better and better, that they feel like they get out of bed and they don't feel. I didn't think I'd treat so much joint pain in my practice. That's not why I'm giving them hormone therapy. But I can't ignore the fact that that's what they tell me over and over again. That their libidos come back, that their relationships get better, that they feel like they can work longer.
- [28:03]
C
Right.
- [28:03]
E
My God complex is that I keep strong women in their jobs and in power because they have the energy to keep doing it. So I think the joy. That's why I think I've been effective, is the storytelling. It's so beautiful to tell my patients stories about how good they feel. I literally had a patient, a neighbor, actually run up to me on the street. She ran with her dog to catch up to me as I was walking home, back from dropping my kids off at school. And she said, oh, my God, the testosterone finally kicked in. And I said, oh, how long did it take? Cause I usually tell patients it takes like four to six months. She goes, it took five months. She goes, I'm back. And she just kept walking. And I can't unsee that, right? I cannot unsee that. And I can't not share it because it's so powerful. It truly, like, it truly is incredible. I see these patients who you would say are unhelpable, and to watch their mental Health get restored to watch them sleep again, to watch their relationships improve. Now I do very guideline based, evidence based hormone therapy. But I'm so confident in my prescribing that it has become, I've learned so much about sort of the other unintended consequences.
- [29:18]
A
Well, let's, let's get back to our case because we, we gave a little bit of a challenging case that for me this would, this would make me a little nervous. So I want you to talk me down. Paul, does this make you anxious? Someone who's like just about 10 years from menopause.
- [29:33]
C
This is a beautifully written stem. Yeah, nice work, Dr. Hoiblein. This was plenty anxiety provoking.
- [29:38]
E
So your blood pressure is getting high because of this patient. So when I teach how to do this, whenever I go and teach sort of the basics of hormone therapy, my favorite thing to talk people through is actually to ask, take a question and ask a question in return is what are you afraid of?
- [29:58]
What gives you pause with this patient? And truly what makes you nervous? Let's talk through it.
- [30:05]
A
So the. Well, Paul, you're good at this. What makes you nervous about this patient?
- [30:10]
C
So I feel like there's a lot of cusp stuff here. So I think someone who is now 10 years out from menopause. So just to revisit the case. So someone who went through menopause at age 50 is now age 60. So there's this sort of 60 threshold and the concern for someone who already has what seems like a little bit of cardiovascular risk. So they've got high blood pressure, they have prediabetes, so there's sort of whispers of metabolic syndrome. So the idea that I might actually increase cardiovascular risk by starting hormone therapy I think would be sort of front of mind for this particular patient. That would be the first thing I would worry about.
- [30:39]
E
And I'm going to ask you a question. And what data are you using to say that you're going to increase her risk of cardiovascular disease?
- [30:46]
C
It's such a great question. It's the rich oral tradition and sort of vibe based medicine is sort of vibe, right?
- [30:51]
E
You're going on vibes. You're going on vibes. And the ether of like, I think this is bad. And so I just said a few minutes ago that JAMA published the Women's Health Initiative. They use synthetic oral estrogen progestins, which are the most dangerous that we think of for thrombotic risk and cardiovascular risk. And they wrote below 70. There was no statistically significant difference in cardiovascular disease, stroke, heart Attack all of those things. Things. So to me now, that doesn't mean we have unlimited data here. And there was an increase when you started these therapies over 70. Okay, so over. We're not starting. 70 year old on Prempro, please. Okay. If there's one message, let's not do that. But then we just said that the transdermal hormones don't have the same sort of risk, we think. And so. So the question then becomes, is the timing hypothesis true? And there are people who are questioning the timing hypothesis to say, maybe it isn't so clear cut. Your heart doesn't just explode at 60 if you give someone estrogen, right? And what if we know that actually hormone therapy can decrease diabetes, decrease fracture risk, decrease. Get people with energy and sleeping so that they start exercising again, they start having sex again, which we know is really good for their cardiovascular health. Right? So the question becomes, are you actually hurting this patient? She's coming to you with hot flashes and night sweats and like real symptoms of menopause. So are you actually hurting this patient by not offering transdermal hormone therapy that she's asking for? I'm not telling you to push it on her, but she's coming to you to say, hey, my friends told me all about this and I just saw Ruben on a podcast. And now I want you to check my hormones and I want you to, I want, you know, am I the bad guy? Am I the one who's bullying people into hormone therapy?
- [32:50]
A
And one of the things that I've seen out there, this is at conferences. There was a talk on menopause hormone therapy a couple years ago, and they were saying, sizing people up with you calculate a gale risk score for breast cancer. This patient that we gave you had a first degree relative with breast cancer. And then you could look to see if they've had a coronary artery calcium score. If they have a Moderate score like 100 or above, you might, you might think the cardiac risk is higher. And you know that that's been out there as the teaching. So I think that's part of what else gives us pause. Like, but Paul, like, I like the way Paul phrased it as rich oral tradition or whatever you said, Paul, that I think that was good.
- [33:30]
E
And I think, I think maybe this is because of my urology. My urology background is quality of life and like feeling, like feeling like themselves and feeling better. And it actually really speaks loudly to me like, I'm sexual medicine doctor, so I care about libido, arousal, orgasm, and pain. Like, those are the things that I treat all day, every day. So this idea of like shared decision making about. I believe that when you give patient the knowns, the unknowns, what are they? The known knowns, the known unknowns, the unknown unknowns. When you really talk to patients and say, hey, here's what we know, here's what the WHI showed, here's what the data on transdermal therapy seems to show. There are unanswered questions. It like, is there harm? Am I going to hurt you? I don't believe that I'm going to cause this woman to have a cardio cardiac event. Could any of our patients at any moment have a cardiac event? Of course. Do we have like this ability for people to have dignity and to say, my quality of life. This is how I want to live my life. This is what I want my sex life to look like. This is what I want my relationships to look like. And letting patients really engage in that shared decision making. And you document and you talk about it and I truly, truly again, because I'm very confident in my prescribing and I see the magic. This is when people have, their health gets better, their weight goes down, their exercise goes up, they sleep, they have better relationships and connection and social support. And so how could I not want to fight for that for my patient?
- [35:09]
A
Molly, is this resonating with you? I know you're having these conversations a lot more often than Paul and I. Yeah, definitely.
- [35:19]
B
I think this is a patient that I am seeing a lot more of and it does make me a little uncomfortable, I think, because we have that long tradition.
- [35:29]
But people are asking for it more. And so I am prescribing it more and people so far are doing fine. Do you have any absolute hard stops of this is a patient other than active breast cancer kind of situation?
- [35:43]
E
Yeah, I mean, I think there are. Right. So there's a great paper and I'm happy to send it to you if you can put in the show notes. It's called A Contemporary View of Menopausal Hormone Therapy. And it was sort of, sort of written by Barbara Levy and James Simon and it goes through sort of all of the modern day things and all the studies and the research that we have on cardiovascular risk, thrombotic risk, the difference between the synthetic hormones and the transdermal hormones, and really goes through what is the European data, what is the WHI data? Just again give you this comfort. It's not a home run. Like we don't have home run stuff here. Of like this giant warning label, this is going to kill you immediately. Even in the breast cancer population, there was just the menopause society just put out guidance to say, hey, we need to start looking at this more closely. It's not as clear cut. And if you have an early survivor who is, you know, castrate, are you actually going to do more harm? You know, with her, she's going to have cardiovascular risk with low hormones, right? These premature ovarian insufficiency patients or these early cancer patients, they're dying of heart disease. And so like this idea that hormones cause heart disease. Well, we know that not having hormones actually leads to heart disease in many of these young patients. And so it's this nuanced understanding of all of this stuff. So even in the breast cancer population, there are these heroic people who are starting to ask questions and it's becoming more talked about out. So in terms of huge, you know, I would never do. Right. If you have a complete liver failure and you are like, you have a horrible liver, then I'd be a little nervous, right? I'd be a little nervous. If you have someone who has an active blood clot issue, Honestly, I've treated, I'm. I have treated patients who have a history of blood clots with transdermal hormones and I have seen miracles upon miracles. And so this is a case of extreme shared decision making. But I'm not. I think the important thing for my message here is take the easy ones, my friends. Everyone should be on vaginal hormones to prevent urinary tract infections because it's costing our government $22 billion a year. For all of those visits that you get for UTIs, the Urosepsis admissions, they should all be on vaginal hormones. Take the easy wins of the hot flashes, the night sweats, the osteoporosis prevention, and for the hard ones, bump it up to the send them to you experts. Send them to us. Send them to that send them to the menopause society people. The reality is we have 85 million women in the country. They can't. For the 3,000 Menopause Society members, like, they can't see. We can't see 28,000 patient panels, right? We can't do it. So we need primary care to be really helping us with the very much bread and butter easy things. And then use the experts for the really tricky, complex way ones.
- [38:34]
A
I think this is a matter of reps needed. You know, like the first time you prescribe anything, the first few times, it's always a little Nerve wracking. And you usually, I would tend to talk to colleagues that are more experienced just to make sure I'm not missing anything. And then I think after a while then you just get, you get more and more comfortable and the number of cases that you're referring out becomes less and less.
- [39:00]
B
We're excited to have you. Since you said earlier you know how to break it down very simply, which is how we like to do it here. So say we, you know, we were feeling comfortable prescribing her hormone therapy, talked over the potential risks and the significant benefits, and she's decided she wants to go forward with it. How? What does that first prescription look like or what do you offer?
- [39:18]
E
Absolutely. So the first thing I do is I obviously get a really good history. That's my magic. I spend a lot of time with people and I figure out what are her goals? What does she really care about? What is really, why is she here? What's a win? Is it her UTIs or her pain with sex or her dryness? Is it her hot flashes and night sweats? Is it osteoporosis prevention? Is she most. And what is she afraid of? Is she afraid of that first degree relative with cancer? Because that's gonna tailor again, I read a room that's gonna tailor my messaging and the data that I present to her of like, here's what I think, you know, I think you should be thinking about. But it is actually rare that I'm gonna give a huge like five prescriptions out at the first visit. I'm gonna actually figure out how my patient likes to consume information. Now because I've done many long form podcasts and I'm sort of all over social media, patients come to me having watched every video that I've ever done and so they kind of do their homework before they show up into my office. But for you or if I'm doing it my busy VA clinic, I basically say, how do you like to learn things? Do you like books? Do you like podcasts? Do you like Instagram? Do you like YouTube? Do you like Curbsider's podcast? Like, what do you like? And then I tailor literally a homework assignment for them because an educated patient is a compliant patient and is a patient who has sort of the ability to decide from the menu what they want to try. So I always say, don't take hormone therapy because I tell you that you should. But I need you to do a little bit of investigation of what this means and what you're comfortable with. Oftentimes I will encourage them to use vaginal hormone therapy immediately because it's going to take two to three months to prevent the UTIs, to help with the pain, with sex, the dryness, the irritation, the arousal, and it is safe for every human on the planet. So I typically will do my gsm, my Genitourinary Syndrome of Menopause spiel at that point and we'll decide. Do you use a cream, which is the cheapest but the goopiest and the ickiest? Do you use a tablet insert twice a week, a 10 microgram tablet insert twice a week till death? Do you part? Do you use something like vaginal dhea, which is a suppository? This is what it looks like. It's a suppository that you put in every single night or a ring that set it and forget it for three months. So we're going to make that decision early on. On. I don't want to give them decision overload and like really give because they can't hear that much. I mean so much information. So then I'll have them come back if we can, right? They'll come back and I'll say, what'd you read? What you learn, what you listen to.
- [41:50]
C
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- [42:55]
A
Foreign.
- [42:59]
C
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- [43:54]
D
See.
- [43:58]
B
Can we just pause, pause real quick on the on the genital vaginal estrogen for the cream. How do you get that cheaply for patients? Because I still have Medicare patients who complain that their co pays are extremely high.
- [44:10]
E
Okay, so this is a tube of vaginal estrogen. It comes with a tube like this and it comes with an applicator like this which is non. You have to reuse it and women hate it. So they can buy disposable ones on Amazon or they can just use their finger and put a gram on their finger and put it in their vagina and rub it into the walls like you would rub sunscreen on your face. Okay, you don't push sunscreen on your face. Glop it on and walk out the door. You rub it in so that you don't see it. So you tell patients if you don't want it to be messy, goopy, gloppy, you put it a gram on your finger and twice a week rub it into the walls of the vagina completely so that it absorbs into the tissue. That's an amazing tip that I got from a colleague once that changed my practice. And so if they go to good, if you send a Goodrx, give them a Goodrx coupon. It'll be about $30 at a local pharmacy if you e prescribe it to Cost plus Drugs. Mark Cuban's pharmacy Cost Plus Drugs based in Florida is where the pharmacy is based. It'll be $13 a tube and this tube will last about two and a half months. So if this keeps your 85 year old patient out of the hospital from se sepsis. I think it's worth the $7 a month that will save her life. But she doesn't know this. You have to make those connections for her. Does that help Molly?
- [45:31]
B
Absolutely. Yeah. And I think that tip about applying it with her finger is very helpful because a lot of women who already have a dry vagina and like a sensitive skin using that plastic tube I've heard is very scratchy and uncomfortable. And then people are like, well, it hurts, so I don't want to keep using it.
- [45:45]
E
And there's a lot of mistakes my colleagues make where they'll say, just take a little dab and put it on the urethra. And it's honestly not enough because you have acidify the vagina. The vagina needs to be a ph of four and a half to fight those UTIs. And if you're just putting a little at the, you could put it on the vulvar opening and on the urethra every day. It's totally fine. But you really want to get it in the walls of the vagina to really get that ph to go down so that you can fight UTIs. Like that's the thing that's going to kill the patient. Now, creams aren't everyone's favorite and they can be irritating. And the old school Premarin cream, if Premarin is the only thing you prescribe, I encourage you to learn new ways to do this. But we have lots of free trainings all over the Internet about how to prescribe these products. And Premarin is made from horse urine. There's alcohol in it. And so it's not my favorite product. The inserts, like the generic estradiol, 10 microgram inserts. It's so easy to teach doctors on Twitter to just say estradiol, 10 microgram, one insert twice weekly till death do you part, refill forever. Like I can teach you that in a tweet and that it's not messy, it's not goopy, it's dosed out for you. It comes with an applicator. Insurance mostly covers it. Your Medicare patients mostly should have that covered. If they don't, it's a little more expensive, the cash price than the cream. So then we go to creams often for the patients where that's an issue.
- [47:10]
A
And the rings, there is a ring for the vaginal estrogen, there's a ring for systemic estrogen. Right. So is there a pitfall there with ordering the wrong one?
- [47:20]
E
Yes, it's just important that you know that there are two different kinds. Now, the E string, which is the local estradiol ring, you don't need to give the woman progestin if she has a uterus. You set it and forget it over three months. It's often. It can be covered by insurance, but it tends to be quite expensive. You can get it on cost plus drugs for about $500. And remember, that's over three months. The fem ring is the systemic estrogen. It comes in a.05 dose and a 0.1 dose dose. And that if you have someone with a uterus, they do need a progesterone or a progestin. Now, what's fun about the systemic ring is that it's a two for one because it gives you vaginal hormones to prevent UTIs and systemic hormones to prevent osteoporosis and help with the vasomotor hot flashes. And so we love that product. Although there are some caveats in that. I don't think it lasts the full three months. We just presented that data at the Menopause Society. That's expert opinion, by the way. My patients say the last couple of month they feel fatigued, their sleep gets worse, their hot flashes come back, and we'll check an estradiol level, and it will not be what the package insert says that it should be. So we will sometimes change it early, supplement with a patch. And so listening to the patients is really helpful here. What's funny is we presented that data at the Menopause Society meeting, and everyone came up to my team and said, oh, we see that all the time, too. Oh, my gosh, you see that, too. And that's how science evolves when you realize everyone's seeing the same things in their clinic. Clinic. And so now we're going to do a project with the Mayo Clinic where we're actually going to study it and we're going to actually publish on it. So it's funny because it's your observations in clinic that are so important to then fuel more research.
- [48:59]
B
I heard you talk about that on another podcast, and I was like, oh, my gosh, I have two patients who swear that it does not last. And so we write these appeal letters to try to get it covered more frequently.
- [49:09]
E
It's being curious. It's just really being so curious and having the time to be curious. I think, which is. Is a challenge in medicine right now, is I've set up my practice so that I have time to be curious. And I just wish everybody had the same opportunities.
- [49:27]
A
So we're gonna talk about systemic hormone therapy as well. But you said for this patient you would start on vaginal estrogen therapy because it takes two to three months to kick in. And talking about systemic hormone therapy.
- [49:41]
How does that conversation go with a patient like this? And are you using both for. Are you recommending that everyone be on vaginal estrogen therapy and then even if they start systemic, that they stay on both?
- [49:53]
E
Yeah, it's a great question. And this came up when we developed the GSM guidelines. And my favorite statement is number 11. It is the one I'm most proud of. And it says for patients on systemic hormone therapy, we should be screening and treating the genital and urinary symptoms of menopause. And so what we find, and we don't have this data, so clear clinical cut, we have a lot of what I'll call vibes and spidey sense of that. Many, many, many people who use a patch, an oral estrogen, any kind of systemic therapy, it's not enough for the vaginal and the bladder symptoms. So they're still going to have frequency, urgency, leakage, UTIs, pain with sex. And adding a vaginal product is adding no risk, no danger, nothing scary. So when I say, what are you afraid of? Don't be afraid of having someone on a path patch and a vaginal product at the same time. It's not scary. And it's now in the guidelines to support you. So we were very. I'm very proud of that guideline statement. Now again, back to that patient where I would be crystal clear. And I want to clarify is, again, what are her goals and what brought her to my office? What is the thing that is just so distressing to her? Because if she's hot, flash, and has no genital and urinary symptoms, I'm not going to start with a vaginal hormone and say, okay, we gotta do this for three months. I'm gonna start with a systemic hormone product. If she comes to me, she's got everything then. And she needs some education. I'll probably do education and vaginal hormones and then bring her back to start the systemic hormone therapy in a stepwise fashion. I have found, and this is sort of my gray hair, there's a lot of it. If you look up close. My experience is when you give a person all five things that we sometimes give for menopause hormone therapy, they go home and they just can't figure it out. And they don't know how to do it. And they get nervous and they kind of always end up coming back and like starting slow. I do think stepwise approach, because you, as a prescriber, you need to know what your medicines are doing as you're getting comfortable doing this. And what I encourage you to do is don't give hormone therapy prescriptions and say, I'll see you at your next annual in a year, because that is not good for your brain. As the prescriber, you need to know what these are doing because you need that positive reinforcement to say, oh, wow, she really is sleeping better. Oh, my gosh, her joint pain really is gone. That's amazing. And then it gets your brain realizing that all those patients that you're also seeing that week, that maybe there is a conversation to be had.
- [52:21]
A
What's the step wise? What does it look like? So if you're starting estrogen first, maybe what dose would you start and how long until you bring them back or think about even titrating the dose up or down? Down.
- [52:35]
E
Yeah. So again, if you have a patient with a uterus and you're talking about systemic therapy, the big three are estrogen, progesterone, and testosterone, right? And there's different medications, there's different doses, there's different.
- [52:51]
Delivery systems, there's different types of hormones. So again, you start with a couple that you feel comfortable with, and then you stay curious, you listen to podcasts, you read books, you listen to all sorts of different ways people do it. And I love it because I'm still picking up tips and tricks all the time, right. From my colleagues of, oh, you dose testosterone out that way. Oh, that's a fabulous trick. I'm going to use that in my clinic. And so that's what makes this medicine actually kind of fun. So when you have a woman with a uterus and you're going to talk about systemic estrogen therapy, and then she needs progesterone therapy to sort of protect the uterus, because unopposed estrogen will give you uterine cancer. And that does still need a big warning on it, because that is true. If you have a uterus, you should protect it with progesterone. And so progesterone is kind of easy, right? You can do micronized progesterone, and you can do 100 milligrams every night at bedtime, or you could do 200 milligrams 12 days out of the month. I'll tell you, most patients like the 100mg every night because it's easy. They remember it. We can sometimes use the cyclical ones if they're still bleeding sort of in that perimenopause phase. Sometimes it can help, but not always. And so progesterone, I usually tell them I like micronized progesterone. If you have a Mirena, a progestin based iud, you know, that's another option for five years of uterine protection there. Or I don't use much of the synthetic progestins, but there are reasons why you might go to them. But that's not my first move. Typically there are other strange medications that you could talk about like bezodoxifene that's combined with conjugated estrogen, which is a non progestin based sort of uterine protector. Because there are patients who are very sensitive to progesterone. So it gets, I feel like this is less simple and kind of crazy, but the more you know about the menu, the more you get comfortable with, okay, I'm gonna start with just 100 milligrams of micronized progesterone at bedtime and see how my patients do. You're not gonna hurt the person by doing that. And so we do find patients get sleep benefit, although not everybody and it's not a universal thing, but it's a lovely added benefit when it works. I've had patients tell me some of their joint pain gets better just with progesterone. I've had patients who occasionally get bloating with it or feeling too sleepy. And so it's not perfect for every patient. So if they have a uterus, we talk. Here's the easy one. Let's pick your progesterone. And I usually try to steer them with 100 milligrams of nightly progesterone. Is that clear? The progesterone piece?
- [55:19]
A
Yes. And for the audience, our last we did episode 409 was we talked about hormone therapy for menopause. And we had have tables with all the products listed, both the generic name and the brand name in there and the common doses. So we can link to that again for this one.
- [55:39]
E
Fabulous. And so again, keeping it kind of simple. Estrogen, systemic estrogen. Start easy. If you're starting, we've got the advanced seminar. But if you're just dabbling and you're starting to get comfortable, you got the 52 year old with hot flashes and nights and sweats. No medical problems. She's at the gym, she's, she's doing great. Patch, give her a patch, right? Or if she likes a gel, give her a gel. If she wants A ring, Give her a ring. But if patches are really easy thing to start with and I find we're still stuck in that lowest dose, shortest amount of time possible, we gotta move beyond that because if you start her on a 025 patch, she's not going to have like symptom improvement and it's, and she's going to think it doesn't work and you're going to think it doesn't work and you're going to throw, you're going to grab the, that SSRI really quickly. And so this is where it's getting comfortable and not afraid. Like again going back to what are you afraid of? My estrogen levels right now are probably between 50 and 150. Okay. Depending on where I'm in my cycle between 50 and 150. When I was pregnant it was probably 3,000. Okay. Matt and Paul, your estrogen levels are 25. Right? Like hard stop. Your estrogen is 25. If you give someone a.005 pack patch, their estrogen, what do you think their estrogen level is going to be?
- [56:57]
A
0.05.
- [57:00]
And this is someone in menopause, I would hope between 50 and 150.
- [57:05]
E
Yeah, about 50. Right. Like you might get to like 40 or 50 with a 0.05 patch, 0.1 patch. You're probably going to get more to like the 80s, 90s, 100 maybe that kind of again like maybe 70. Like you're going to get a little high, higher but you're not going to get like the 150. I'm, I'm a 150 when I'm ovulating. I'm not running around fearing my life because I'm living in the 150 space. Right. Like I'm not worried about blood clots or heart attacks or strokes or something like that. And so again it's that comfort level. So if you're giving this 50, 50 year old woman a 025 patch, you're getting her estrogen to about probably 25. Right. Which is, is not what she's used to. It's not actually, actually what's filling her sort of symptom levels. It's a low dose. So what I'll typically do is I'll do a 0.05 patch. This is sort of what it looks like. This is a twice weekly patch. If anyone's on video.
- [57:59]
And I like the twice weekly ones, they tend to stick a little bit better. But what I'll sometimes do is okay, here's the 0.05 patch. This is what it looks like. If they haven't had estrogen in their body for three years, five years, or that 60 year old woman, I might say cut it in half, right? Because if I write her for a 0.025 patch patch, then I have to write her a new prescription or have her put on two patches or something like that. I'll give her a 05 patch. I'll say cut it in half so you don't get breast tenderness. Do that for a week or two and then put the full patch on if you want. This idea of getting her estrogen up now, it's not wrong to give that 60 year old patient the 025 and see how she does with it. But just being afraid of 05, like I usually start at 05 for many people because it's not that scary to get an estrogen. I'm not afraid of getting these women to have an estrogen of 50. Like that does not scare me.
- [58:50]
B
I'm glad you said that because I recently had a perimenopausal woman in her mid-40s and someone had given her a 0.025 and she was like, oh, it didn't help at all. I think I need an ssri. And I was like, no, no, that just wasn't doing anything for you because that's nowhere near your levels when you actually are ovulating.
- [59:06]
A
This begs the question about monitoring levels and if it's useful, do you mostly go by how they're feeling and check levels if you feel like you're trying to troubleshoot things?
- [59:17]
E
So there's a lot of feelings about this topic and you're going to see a lot on social media that if you check labs, you're a grifter. If you don't check labs, you're the best person ever. And the book says this, and this is what you should do. I always joke, I said there's a book answer, there's an Instagram answer. And then I live somewhere in the middle, right? I kind of live in this like, middle zone. So I actually find labs work can be helpful in our storytelling. It just may not always be the most truthful, reliable and helpful story in the world. But it is a data point that we can use if we're trying to understand something. So again, I use it personally when people are at their low. So if you have a perimenopausal person and they're at their life, remember I said my low is probably about 50. Well, if I check a day, two or three, estrogen level. And my estrogen. Estrogen is six. And I'm having hot flashes. Right. Even though I'm cycling regularly. You could argue that the shifts in hormones might be giving me symptoms and it may be worth trying hormone therapy. Now, the book says, never check labs. You're having hot flashes, give hormones. But what I find is that doctors aren't giving hormones. They're saying, well, you've had your period, so your hormones are normal and we shouldn't ever check your hormones. And that's not to say that testosterone is not a menopausal hormone. It drops in your 30s. And so all these women saying, an FM, I'm not feeling like myself. There is an androgen component that we are gaslighting women and completely ignoring. And so this whole mantra of never check labs, you're charlatan if you check labs. I think we need to just be more curious. I think it's just, I think it's just. I think there's more curiosity and humble and humility needed there. I don't claim to have all the answers, but I have a lot of questions. Now, I don't recommend things like saliva testing or urine testing or very expensive testing, right. Check an estradiol level. Check a testost a total testosterone level. Know that they fluctuate throughout the month. The, again, the more you get comfortable with the menstrual cycle and the levels, the more you get interested and curious. And then you try things and then you get, you know, you, you, you see, start to play in this space. And I feel like I do a lot of playing in this space of really working with patients, of we're tinkering, we're seeing, like, what works for you. Because the patient who's got a mast cell issue and is clearly like an allergy patient and everything you touches or she's sensitive to, she's going to react differently than my patient who doesn't have those things. And I have done this long enough to know that I can't predict how each individual is going to respond to my toolbox. Does that help at all? Does that make sense?
- [61:57]
A
Yeah, absolutely. Now, you said there's five things you might put people on. So there's the systemically, that's estrogen and progesterone. Right. And then I think, I'm guessing the other things are testosterone.
- [62:11]
E
Let's see if you can guess the last two.
- [62:13]
A
Vaginal estrogen therapy and dhea.
- [62:16]
E
Oh, good try. So the fifth one is the, the expert level superstar one that you probably wouldn't Guess the fifth one. So the five, the five treatments we consider and we think about that doesn't mean every patient needs all five. It doesn't mean everybody needs the same dose or the same type. It doesn't even mean people need hormones at all. They just need to know that the toolbox exists. So you're right. Systemic estrogen, systemic progestin, testosterone, vaginal hormones, which could include vaginal estrogen or vaginal dhea. And the fifth one, arguably the most important, is the vulvar vestibule, which is the area that surrounds the urethra at the introidal opening. That is the cause of all the pain with sex. That is the cause of all those UTIs that have negative cultures. That is the cause of that young woman on birth control that can't put a tampon in or who has pain with sex. It's called the vulvar vestibule and is very hormone sensitive. And so oftentimes we'll use vaginal DHEA or we'll do a topical cream that this is the only place I compound, to be honest, is I take a low dose estrogen and testosterone combination to put it on this tissue to help these patients with pain with sex. The challenge is you and I didn't learn that the vulvar vestibule was even an organ or a body part during our training, let alone how to examine it, how to help it and treat it. And this is why we see so many people who have pain with intercourse. Interstitial system bladder pain syndrome. It's actually a lot of it, not all of it, but a lot of it is actually based in this part of the body.
- [63:53]
A
All right. Does this fall into the category of we would be referring to you if we think they need the fifth option?
- [64:01]
E
Well, I do think that.
- [64:04]
We can teach interested parties how to examine genitals. I think the reality is no one examines the clitoris routine. No one examines the labia routinely. Nobody examines the vulva routinely. And that's a problem. Even gynecologists don't routinely get taught how to do it. So we have a lot of work to do into teaching people how to do this. And I love doing that work. But the reality is, when we did the guidelines for genitourinary syndrome of menopause, we were very clear. We would love for you to do an exam. We would love for you to frog like a patient, open her labia and make sure there's not a giant prolapse falling out of her body or a giant thing where you need to Refer her or lichen sclerosis that can give her vulvar cancer. We would love for you to use your eyeballs on genitals. But if you're telemedicine and that patient has frequency, urgency and UTIs, please prescribe her vaginal hormones. Please liberally prescribe her vaginal hormones. And so this is where the guidelines are very clear that you don't have to do an exam. We would love for you to do an exam. And I will teach all of you how to do examination exams, but you don't have to. Is that clear?
- [65:11]
A
Yeah, absolutely. So we've talked about estrogen, talked about for systemic estrogen, not starting on the absolute lowest dose for the patch because we might underdose them. We talked about progesterone. You can start the micronized at 100 nightly or 212 days out of the month. Or if they have an iud, they could be covered by that. Let's talk about testosterone and how you. I've heard you talk about this, but I don't know if my audience has heard this. So how are you dosing testosterone?
- [65:46]
E
Yeah, I think the TLDR too long, didn't read on testosterone is it's not that serious. We want it to be serious and it just truly isn't that it feels serious, but that doesn't actually make it that serious. And so part of the problem is most gynecologists have never written a testosterone prescription in their life because why would they? Right? We teach women have estrogen and men have testosterone. You need a DEA license to prescribe testosterone. Cause it is a controlled substance, which is insanity. And Based on the 1990s doping scandals of bodybuilders, this is why your advocacy and your voice matters. I get to talk to the commissioner of the FDA and what do you think I'm saying in his ear of like, hey, why is testosterone, testosterone needing a DEA license? You have the power, make the change. And so this is why your advocacy and politics actually really matter here. So testosterone is a human hormone. It is not good or bad, right or wrong. It's not a feeling. It is a hormone that the testicles make, that the ovary makes, that the adrenals make, like it just is. And so we just don't have an FDA approved product for women. Women. It is FDA approved in Australia, New Zealand and England and I think South Africa, if I'm not mistaken. There's one other country. I might have said that wrong. But it is totally acceptable for their governmental bodies. The idea that it's dangerous or harmful or problematic. It is all politics, misogyny and loopholes and the fact that the benchmark for women is always completely made up compared to what it is for for men. Okay? It is like they just move the benchmark every single time. So we are left with no product, a controlled substance and not enough education around what the global consensus and the guidance is because y' all have a lot to read. So you're probably not reading the global consensus on testosterone for, for women, but it exists. And the too long didn't read version is it's not that serious. It works for libido. Libido. I will tell you, my patients do talk about it helping other things, but that is not why I give it. I tend to give it for libido. But I think as we have products and more research and money and funding, we are going to see that there are like many reasons why we may consider this therapy as part of menopause hormone therapy. So in my practice, I don't use high doses or pellets or anything like that. I use FDA approved male testosterone. Here's what it looks like. It's. It's a small tube of 1% testosterone gel. And I will show you it is truly not that serious. I tell them the morning you pee, after you pee, your ankle is exposed. It's on the shelf right there where you pee. And you're gonna use a blob. And that's about the size of the blob. It's kind of like a lima bean or a nickel. It's not a pea. A pea is too small. But you're gonna wanna make this tube last about a week, a week or 10 days. When I lectured at Harvard, I put testosterone on during the lecture to show everyone. I was like, do I look like I have a mustache? Do I look bald? Do I look angry? I probably look a little angry, but it's just to show again, these things are not that serious. And also there's evidence behind it. And you just need someone holding your hand, showing you how to do it. Because it's not enough to say why you should do it. You gotta teach them how. So there's a lot of logistics because for men, a 30 box, like 30 tubes per box, that's a one month supply for a man. That's a 10 month supply for my female patients. And so you give them a goodrx coupon outside of insurance. A 32 box is 100 bucks at CVS. Okay, so for 100 bucks you can get a 10 month supply of testosterone. No compounding pharmacy is gonna be that cheap. So you can compound it if you want a perfect dosing and a perfect click amount. But there's also potential risks with compounding pharmacies. So it's a very. Again, that's kind of how we do test off. Does that make sense?
- [69:57]
A
It does make sense. And you. So I've heard you say you tell them to rub it, I think maybe on the back of their calf or the inside of their calf muscles. Muscle.
- [70:06]
E
Well we say skin is skin. Like our male patients use the same thing and they'll put it on their shoulders. I think it absorbs anywhere. The thought process being is if you were to grow hair. Women are used to growing hair on their legs and they decide whatever it is they want to do on their legs. Now many people don't notice extra hair growth or darker hairs or things like that. But that's why I would say don't rub it on your face. Right. Because that wouldn't be ideal if that were to grow here hair.
- [70:33]
A
I heard something about possible voice changes with testosterone. Is that something you see?
- [70:39]
E
So let's talk about it. Say you have a trans person, someone who wants to transition, come to see you and you're gonna counsel them on the risks and the benefits and.
- [70:50]
The gender affirming hormone therapy. You're gonna tell them that they're gonna use a whole tube every single day. Okay, probably not the tube cause it's not that strong. So you're probably gonna get them on injections or another form of. Because you want to really get that super physiologic testosterone. You want their levels probably way higher than 300, 500, 1000, something like that. And you're going to tell them that, man, you got to hang in there because it takes a lot of time. It's going to take like six months, you know, for you to grow that enlarged clitoris, for you to get that deepening voice. And you may get hair loss or hair growth or more androgenized symptoms. It takes time. So we are giving people 10 times the dose for long periods of time. And yes, you see voice changes, you see hair changes, you see genital changes. And yet look at the long term data, we see so much safety. Like we don't see giant boxed warning label levels of risk when we give. What other medicine are we giving 10 times the dose for decades and watching to see. And we have a whole body of literature and evidence on the safety of that. Does that age? I think it's really Important to think about it that way.
- [72:01]
A
That's great. So we've, I think the only thing we haven't really talked about is vaginal DHEA is that is there anything different there than the way compared to how you apply vaginal estrogen?
- [72:15]
E
Yeah. One of the beautiful things about the American Urologic association guidelines on the genitourinary syndrome of menopause, which I encourage everybody to read, they really are. We did it for you. We did it for the primary care document. Doctor who needs an easy to read document about how to do this confidently. To know vaginal hormones don't cause breast cancer, to know that they are safe to use, that you don't have to monitor the endometrial lining, that you don't have to give progesterone with vaginal hormones, that this is lifelong therapy. The guidelines are there to just be your hype man, to know that this is like you should be doing this. And I think it's a beautiful, beautiful consensus document that was also beautiful about the GSM guidelines is they don't just talk about estrogen. The genital and the urinary system has androgen receptors throughout it. And that we have to start thinking about androgens a little bit more than we do when it comes to women's health. And vaginal DHEA is the only FDA approved product that we have that has androgen in it. So DHEA is the precursor to estrogen and testosterone. Now, it's not high dose systemic levels, but it's enough of that local therapy to really help with dyspareunia. We published that it prevents urinary tract infections and it really is a lovely product. Now it's a suppository that they put in every single night. This is kind of what it looks like and when you open it, it's really made of palm oil and dhea. So it's a very natural. You'll get a lot of people on the Internet complaining about the parabens in vaginal estrogen. I get, every day I get a comment about that. Why do they have to make it with parabens? So Internet, please make it without parabens so people stop yelling at me on the Internet. Internet. And they come with applicators, each individual applicator. So the woman's going to put this in the vagina and deploy the DHEA suppository. Now again, these vaginal hormones cannot hurt the penis. Remember a man's estrogen level is 25 and these are not systemic products. So there's going to Be no absorption to a partner systemically if it touches his genitals or his mouth or something like that. So the only reason, reason not to use vaginal DHEA is cost. Right. It's not always super covered, well covered by insurance, but it is a lovely, lovely product. If you have a patient who's on vaginal estrogen and she's still getting UTIs or having pain, I would definitely consider a switch to the DHEA as those androgen receptors may need a little love and that may be something that rescues that patient.
- [74:44]
A
Okay. Okay, so what would be the order back to your stepwise starting of things because now we've talked about, I think all the agents. What would be the cadence of like the visits, the titration, you know, any changes, adding new, adding new agents.
- [75:02]
E
Yeah. So let's talk, let's change your 60 year old patient because for the true starters out there, don't start with the 60 year old patient that is afraid of hormones. Like don't start with that patient. Although in that patient I would love to give her hormone, I would love to have, have evidence based discussions and shared decision making conversations about hormone therapy and I would happily write some prescriptions with that patient. I'm not afraid of that patient. But if you are, that's okay. Like I'm not here to convince you not to be afraid. I'm here to convince you. The very, very standard 52 year old person with hot flashes, night sweats, joint pain, vaginal burning pain with sex, utis. That is the home run mecca of you're going to change that person, person's life. So what I would do is I'd bring her in, we talk about all the problems, we'd give her all the resources and build our ship. Because you want to build a pit crew around it. You don't have to do everything you can, you know, sort of get other people's opinions too. And I'd give her a vaginal hormone prescription. So let's say I give her estradiol, 10 microgram inserts twice a week and I'll say come back in two months, we'll see how you're feeling. She comes back in two months and I say, oh my gosh. She says, I'm sleeping through the night, I'm not getting up to pee, my orgasm is better, my arousal is better, sex isn't painful anymore. I'm so happy. Dr. Rubin, I read a book and listened to a podcast, this Curbsider podcast that you did. And I really want to go after this menu and See what we can do. So then I'll talk to her about systemic therapy. I'll say, you know what, estrogen's the workhorse. It really does all the things right. It prevents osteoporosis. It's going to help with your hot flashes and your mood. Like, I really think estrogen, estrogen is the big one to talk about. And so I'm going to say we're going to put testosterone on the back burner for a minute. I think it's going to be great and I love it, but I don't want to give you all the things at once. So then I show her the menu of estrogen. Do you want a patch? Do you want a ring? Do you want oral estrogen? Do you want a gel? What are we afraid of? What do we like to do? What's your routine? I show her them. I have show and tell in my office and she says, you know what, a patch sounds pretty good, Dr. Rubin. It seems pretty easy. And so we show her the patch and we give her a 0.05 twice weekly patch. I'll say we may have to go up, but I think it's a really great place to start. If you got breast tenderness, we'll come down a little bit. If you bleed, don't panic. We'll likely get an ultrasound. We'll talk to you about what happens if you bleed. But anytime you start a new hormone or something like that, there's always a possibility of bleeding, which I know you're going to ask me about in a few minutes anyway. And then I'll tell her about progesterone. And we'll likely start estrogen and progesterone at the same time. Time. But I'll tell her like, you can start the patch and use just the patch for a couple weeks to see how you feel. You're not going to develop a uterine cancer so fast that takes years and years to develop. And so then we'll get her on the progesterone because it's very important that you match the estrogen with progesterone if she has a uterus. Okay. And then I'll have her come back in usually about, you know, two or three months. And she'll be sleeping, her hot flashes are better, she's feeling pretty darn good. And if her libido is low and she still feels like something's missing. Missing, we will add testosterone at that point. And I will tell her that testosterone takes four to six months to kick in. It really, you gotta stick with it, you gotta be consistent with it. And we want to see if your total testosterone is 30 or 20 or 15. I just want to see it go up. I just need to see it go up that you're absorbing this stuff. And I need you to do it for a long period of time. And then at that four to six months, something clicks. Her eyes pop out of her head. When she watches a Netflix television show.
- [78:34]
She has a moment where she's like, oh, my God, my partner initiated sex and I was actually excited about it, or my orgasm is back, my arousal is better. And the thing that I hear over and over and over again that I can't unsee is, she says, I feel like myself again. Those are the magic words. I don't hear it. With estrogen and progesterone, I get, I feel better. My life has changed. I'm super happy. Happy. It is when we add that piece of testosterone that I'm just over and over and I hear, oh, I'm back, I'm back. I feel like me again. And that, that's why I am so loud and obsessed with this, because I want everyone to have access to those decisions. I don't need everybody to take all the things, but I want everyone to have access to the, to the, the information.
- [79:21]
B
That was a beautiful run through. I'm glad you brought up the bleeding, because I, I do see that frequently and it always makes me a little nervous. The Menopause Society recommends evaluating it further if it's been more than six months since initiating hormone therapy. Is that what you follow or how do you look into.
- [79:36]
E
That's the guideline. So that, that's got you covered. But I'm a nervous Nelly too, and I'm not a gynecologist. And so I also like to look for like, like structural reasons that they're bleeding. Because if she has a huge polyp or fibroid, that's going to be, it's going to be driving us crazy, crazy this whole time. And if she has a fibroid that is bleeding, that is not a reason not to do hormone therapy. It's a reason to have a discussion of, like, what, you know, what's bleeding, why is it bleeding? And to work with your team and your pit crew to like, figure it out and let the patient decide. Does she put an iud, a progestin based IUD in. Does she consider a hysterectomy? Does she consider, like, what are the options? Because we also have to think about her bones and we also have to think about her hot flashes and her sleep. Like women are not just the bleeding uterus. Right. So it becomes this whole person conversation about what are we worried about? What are we afraid of? You know, are we worried about cancer? Do you need an endometrial biopsy? You know, those are the conversations that we're having.
- [80:39]
B
Perfect. Well, I think you've done such a nice job describing the benefits of hormone therapy and just how many different ways menopause can impact patients lives and that we do have these tools that are very approachable from a primary care perspective. So hopefully after listening to this, people are feeling a little more comfortable to give it a try. And you know, I love your approach of just asking around for advice and help and playing around with it and getting that close follow up with patients to see what that, to get that immediate feedback to see, oh, this is actually having an impact and I am benefiting their patients. Patients.
- [81:12]
A
And if Rachel, if you're willing to, I have maybe one or two more questions that I think would be high yield because the perimenopause transition and when people start to get hot flashes. But they're like you said, you know, maybe, maybe they have you check their estrogen. It's, it's low. They're in that transition, but they're still having periods. Is. But we don't know if they could still become pregnant or not. Oral contraception is higher dose estrogen and progesterone than menopause hormone therapy. How do you recommend people navigate that tricky period where someone is not fully in menopause yet, but they're having symptoms and you're wanting to put them on hormones?
- [81:57]
E
Yeah, I think this feels scary and hard because we just got done talking about the home run patient that hasn't bled, that's menopausal. That seems, and even that feels hard. There are no guidelines for perimenopause. There are no, there are no major publications that really look at it. There is not a lot of research. This is a place that feels really scary. And so I go back to again, what are you afraid of? If we're going to use very high dose synthetic hormone therapy in these patients, which is called birth control. Right. We are giving high dose estrogen, high dose progestin and we're not afraid. And we know they could get blood clots and we know that there are side effects of and risk to birth control pills. It becomes what are we worried about if we were to use more natural menopause hormone therapy? And the truth is we're afraid because we don't know how to write the prescriptions. And we don't feel as comfortable with those prescriptions as we do with birth control. Now contraception is really important to have that discussion. But again, not every patient is a contraception conversation. If her husband has a vasectomy, if she has a tubal ligation, if she, you know that not every conversation has to be about birth control. And many women feel that synthetic birth control gives them side effects, whether it's mood effects or weight effects. And there's a lot of feelings around birth control. So birth control is, I always say, when I teach about perimenopause management, I talk about sort of really three ways to do perimenopause management management. One is status quo, which is do nothing, suck it up lady, and just like ride out the waves. It's not my favorite option, but it is one that is commonly used. The most elegant option, I would say is birth control. It's super elegant because the, the, the, the, the symptom fluctuation, right, is because you're super high, you're super low, you're going, you know, you're really going, you know, full tank, empty tank, full tank, empty, empty tank. And so cut it off, just shut the ovaries down and do add back therapy. I just wish the add back therapy were a more natural form of hormone therapy that helped with the patient's symptoms without the side effects of some of those other therapies. And there are some coming out that seem promising. The less elegant option, and the one I tend to use a lot is what I sort of call the sort of the gas tank analysis is just keep a quarter to a half a tank in the gas at all times. You're still going to go high, but you're not going to crash to empty. So you can still drive wherever you're going. So it doesn't help with the symptoms. When your hormone levels are too high, you still may have symptoms, but you're not going to necessarily have the symptoms of being too low. So we'll use. This is where I love using an estrogen patch, testosterone and progestin based iud. It's fabulous. They don't bleed, their uteruses are protected, they've got their estrogen protecting their bones and testosterone keeping their libidos good. Because we know the libido drops in your. Sorry, the testosterone drops in the 30s, like age 30s. And so I love that prescription option for perimenopause. It becomes, what am I afraid of? She's got birth control, she's got bleeding control, she's got hormone support and let her ride it out. And honestly, it's a great approach through the menopause as well.
- [85:21]
A
Love it. That is a great solution. I think you're giving short shrift to number three. That's actually a really good solution, it seems, in my opinion.
- [85:30]
E
I find that it works most of the time and that people really like it. Now we'll use cyclical progesterone if they don't want an iud. And some people don't mind bleeding for. Right. So there are different sort of tinkering that you can do when you're still bleeding. But this idea of, you know, that you have to wait. We hear this all the time. Well, my doctor said I can't have hormone therapy because I still get periods, but I have all these symptoms. I really think we have to change the discussions around that because it's simply not true.
- [86:03]
A
And then I guess the final question would just be like, is this a destination therapy? Are people in their 70s, 70s, 80s, still going to be taking this? I think for the vaginal estrogen therapy, I think the answer is probably yes. But for systemic therapy, how have you handled that? And is it sort of shared decision making, case by case?
- [86:25]
E
Yeah. So the data shows shared decision making here. So when we don't really recommend taking people off hormone therapy anymore, we know the bone benefits go away and we know that there are protective elements of hormone therapy therapy when you started as early as possible in menopause. So this idea that people are hurting themselves by staying on. Now, I like transdermal products, so if I have a, a lady on Prempro at 74 and she's doing great, I'll have a shared decision making discussion with her. I actually think she's probably fine and the data actually supports her staying on it. But I may try to switch her to a patch or something like that. But. But honestly, if it's not broke, I don't necessarily need to fix it. But I really want people to stop trying to get everybody off hormone therapy because you're. They're hurting themselves because the data doesn't support that. There was a big paper, I believe it was in the Menopause Journal this year that looked at Medicare patients who stayed on hormone therapy. And it's a little muddled of the data because the data set that they use, but it is overwhelmingly beneficial and positive in that. Not, you know, it's not randomized placebo controlled data, but it really, it was reassuring to sort of look at these Big Medicare data sets about continuing hormone therapy. So again, this is where it's okay to phone friends and to ask people, look at the Menopause Society guidelines. Become a Menopause Society member. Don't just do it because I said it. Look like back, like, read the papers, look at the data, ask the questions, learn from other people. Because. Because I think even if you don't agree, I don't agree with 100% of anybody. Right. So I think the idea is you can get tips and tricks from all people, even people who maybe don't vote the same way as you or who aren't in the same specialty as you. And showing that sort of curiosity of like, what can I learn in this conversation? And we're seeing that a lot on social media, is that you can learn tips and tricks from people who you may not agree with with 100% of the things that they say on the Internet.
- [88:28]
B
I will definitely plug that 2022 Menopause Society hormone therapy guideline because it is very, very well researched. They were called NAMs at the time, but we'll link to it in the show notes. And I think if anyone really wants to dive deeper into the data, they really do a beautiful job outlining it.
- [88:44]
E
And I know you guys like puns, so I'm just going to say my daughter's name is Billy Rubin.
- [88:52]
A
That's great.
- [88:54]
E
I just needed you to know that. Thank you.
- [88:56]
A
Thank you.
- [89:00]
Before we let you go, is there like a couple take home points that you want people to remember and then we'll let you plug anything that you want to plug.
- [89:09]
E
So I think the take home points is. Oh, my God. Thank you for anybody who has listened this long and who has stuck with us and cares about, about this topic. And you are incredible clinicians. You are incredible humans. You are interested in learning and growing your practice and learning new things. And you are the people who I want to work with every single day. And medicine is so lucky to have you truly. Like, really, we don't say thank you enough at a time where burnout is high. You don't have enough time with people. The patients are not the nicest anymore. And what you do matter matters. And so if I can give you a tip or a trick or something that can improve your spiel or help you meet patients where they are and give them what they need, like, that is the thing that moves me. And so don't give up. You can do this. We'll help give you all the resources that you need to do this as good as Possible. But really thank you. And you're amazing.
- [90:07]
A
And where would you like the audience to get more information about this is any website or society places that you, you'd like to direct them. Of course they're going to follow you on all the socials.
- [90:19]
E
Yeah. So my favorite place is. Listen, if anything I said today gives you sort of the goosebumps. Oh, this is amazing. I really love this stuff. There's really two places where you want to hang out. The first is one of my homes, my biggest home, which is iSwish, the International Society for the Study of Women's Sexual Health. It's a fabulous organization, multidisciplinary, and we need you, we need your voice, we need your research and really, what does.
- [90:43]
C
That say for one more time?
- [90:45]
E
The International Society for the Study of Women's Sexual Health.
- [90:50]
C
Outstanding. See.
- [90:51]
A
Thank you.
- [90:52]
E
Thank you.
- [90:52]
C
Yeah, that's really excellent.
- [90:54]
E
Three times fast. Yeah, three times fast. They have courses, they have, they have courses, they have annual meetings. It's lovely. And then the Menopause Society, right. Which is a growing. They've doubled in size of the membership because of the Internet is talking about this so much. So we would love for you to be involved and get involved in things like the Menopause Society and, and become a practice, a clinician whose name is on these websites so that patients can find you. Because just listening to this podcast means that you know more about this than most clinicians out there. Of course, my website and YouTube channel, we have tons of educational resources, free. We've got CME resources and follow me on social media because I'm always trying to talk about new research, new data and just different messaging that's out there.
- [91:40]
A
I think people will follow you. I mean you're, you're a great speaker on this topic. You're a very clear communicator and your enthusiasm for everything I think gets people excited about talking about this. So I can see, can see why you've been everywhere right now and, and I think you will continue to be very popular and I will continue to follow you as you kind of keep educating us about this topic. So we can always have you back when future guidelines change and go over things or when you learn any new tricks that you want to share with the audience.
- [92:15]
E
Well, I will say you did have my co fellow on Ashley Winter, who she's now in my practice and she's the LA side of my DC practice and I listened to her episode and she is just so much fun and I loved that episode all about erectile dysfunction. And men's sexual health.
- [92:33]
A
Yes, and she we might have had to bleep a couple things on that episode, but.
- [92:39]
She'S quite the character. Yeah, we had a lot of fun talking to her as well. So thank you so much for all your time and teaching. I'm sure the audience has really enjoyed this as we have, so we will let you go and we will head out into our outro.
- [92:59]
C
This has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole.
- [93:03]
E
Yummy.
- [93:05]
C
Still hungry for more. Join our Patreon and get all of our episodes ad free + twice monthly bonus episodes@patreon.com curbsiders. You can find our show notes@thecbsiders.com and sign up for emailing list to get our weekly show notes in your inbox. This includes our Curbsiders Digest which recaps the latest practice change, changing articles, guidelines and news in internal medicine.
- [93:22]
A
Paul I thought we agreed it was going to be brain holes.
- [93:25]
C
From now on, until you change the copy, it's going to be brain hole buddy.
- [93:29]
B
Why is there more than one?
- [93:32]
C
All of it's gross or viscerally upsetting.
- [93:36]
A
We're committed to high value practice changing knowledge and to do that we need your feedback. So please email us@askcurbsiders gmail.com a reminder that this emotion episodes will be available for CME credit for all health professionals through VCU healtherbsiders.vcuhealth.org A special thanks to our writer and producer for this episode, Dr. Molly Hoibline, and to our whole Curbsiders team. Our technical production is done by Podpaste. Liz with Proto does her social media. Jen Watto runs our Patreon. Chris the Chumanchu moderates the Discord. Stuart Brigham composed our theme music and with all that, until next time, I've been Dr. Matthew Frank Watto.
- [94:09]
B
Well, thank you for inviting me to join today and I've been Dr. Molly.
- [94:12]
C
Hoi blind and as always remain Dr. Paul Nelson Williams. Thank you and goodbye.
- [94:32]
D
If you're a maintenance supervisor for a commercial property, you've had to deal with everything from leaky faucet to flickering light bulbs. But nothing's worse than that ancient boiler that's lived in the building since the day it was built 50 years ago. It's enough to make anyone lose their cool. That's where Grainger comes in. With industrial grade products and dependable, fast delivery, Grainger can help with any challenge, from worn out components to everyday necessities. Call clickgrainger.com or just stop by Grainger for the ones who get it done.
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C
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O'Reilly.
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Auto Parts.
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When your company earns unlimited 2% cash back on all purchases with Capital One, that's serious business. So Stephen at Sandcloud got a serious business card, the Spark Cash plus card from Capital One.
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Savvy Steven and we get big purchasing.
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C
Power so our business can spend more and earn more.
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D
The SparkCash plus card from Capital One. What's in your wallet?
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A
Terms and conditions apply. Find out more@capitalone.com sparkcashplus.