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- [00:04]
A
Welcome to the youe Are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a board certified urologist, thought leader, and conversation starter on midlife living, hormones and sexuality. Enjoy the show. Hey, friends. Welcome back to the you Are Not Broken podcast. I have The Amazing Jane, Dr. Jane Morgan on today. Who. This is a long time coming. Me and Dr. Morgan chatting today. So I have not had a podcast episode about the heart, the midlife heart, hormones and heart. I've never had a cardiologist on before. And I'm super excited that you're here. Thank you for coming.
- [00:39]
B
Oh, thanks, Kelly. I'm so happy to finally, finally get here. Right. Fourth time is the charm. So, yes, let's jump into it.
- [00:46]
A
I met you. So I was sitting next to Dr. Sharon Malone at the New Pause conference in New York when you were on the stage, and I was like, what? Who is this? And she's like, I went to medical school with her. We've been friends for years. And I'm like, she's gonna be on my podcast. And she's like, yes, she does. That's how we met.
- [01:05]
B
And that's how I ended up at the conference. Sharon. Sharon is the one who said, you gotta come to this conference.
- [01:11]
A
Sharon's amazing. So how did you. How did. You were a cardiologist, you were doing research. How did you get into menopause from cardiology?
- [01:20]
B
Oh, my goodness. So I was. I like to say I was doing research and innovation. I like to say I was just kind of minding my own business, right? Publishing papers. And if you were to see me as a patient, you had to be within a clinical trial. I really was a clinical trialist researcher. And then Covid hit. And just like many other doctors and hospital administrators, I got redeployed, specialist stepped away from the front lines because if you can remember, we didn't have PPE in that first wave. All the primary care and emergency room physicians, we were pushing all the PPE forward. I was asked to lead the COVID task force. I asked sort of one question, what does that mean? And everybody was scrambling, was just kind of figure it out. And so I started opening vaccine clinics in the communities. And because I was so steeped in the biotech and innovation space in Georgia and really throughout the country, because we had been working on creating this Atlanta specifically as the southeast hub for biotech and innovation, I started to contact all of my sources that had PPE that really hadn't had an opportunity to get into hospitals because big vendors, right, took up the space and So I was doing all those kinds of things, opening vaccine clinics and running. And then there was one wave after the next after the next. And it was supposed to be sort of a three or four months assignment. You're going to do this for three or four months and then get right back to your research that you love. In my little corner of the world where I sat and enjoyed teaching and having interns and having residents and working clinical trials, and it just kind of went on and on and on. And during those four years, I began to develop a series, a social media series called Stairwell Chronicles. Again leading the COVID task force and now trying to combat misinformation. And so I created this social media. Really, I didn't plan on it going as long as it did. I originally did it just to show people that I was getting the first vaccine, to record myself getting the vaccine, and then to record myself every couple of days thereafter the show. I didn't get three heads. I can still speak. You know, my skin didn't slough off. Here I am, I'm still, you know, doing it. And naively, naively, I, I thought that would be it. People just needed to see a doctor getting the vaccine and having confidence. Oh my gosh, it exploded into a million other questions and people were writing. So then I said, oh, okay, people have questions. Still naive. Let me do a few more and just answer the questions. Okay? And then that was more questions. And then there was just, you know, and then, you know, how crazy social media was and misinformation and the right versus the left and the politicization. It just became crazy. And so I started to work on being a calm within the storm, recording Stairwell Chronicles. They're just one minute videos on social media where I answered originally about COVID one single question about COVID and the vaccines, kind of in and out, do a strike. And started to do that as we got to the end of COVID Surprisingly, I didn't go back to research and innovation. I was asked actually to join our marketing and brand growth team and to continue a lot of the media. During that time, I started doing a lot of the media also related to Covid and vaccines. Continue the media, the community outreach, the community engagement, people seem to trust me. The communication was working. The Stairwell Chronicles were building a cult following. And so here I am. I left research involuntarily on a whim in an emergency, a global pandemic, and never went back. So there you have it, here I am. So I don't know if that's the Path that everyone should take Cake. So in that, I started to. I was following my friend Sharon Malone, of course, And Sharon had just kind of stepped away from her practice during COVID and was really showing a lot of delicious cooking recipes and things on her page. And I was following her. I was like, oh, my gosh, that chicken cacciatore looks great. Sharon is really killing it. But meanwhile, unbeknownst to me, she had started working with this company called MyAlloy. So then, of course, when she started to make that public, I could see what she was doing while I was doing the Sterile Chronicles. And then she contacted me one day, Actually, I may have contacted her first, I'm not sure, to come onto my Sterile Chronicles to talk about MyAlloi. First I became a client of MyAlloi, and then I asked Sharon to come on. And then Sharon said, you know, Jane, you do all of this cardiology, and I'm kind of learning every time I talk with you about the heart aspect. And we started doing a couple of webinars, and that's really how I started to be drawn into the menopause space, really, because I was watching Sharon in retirement do cooking shows, and it transitioned to my alloy and what I could offer from the cardiac space when she and I were kind of talking offline. And so then I was invited to the swell, the PAWS conference. And it's kind of gone on from there. You know, I'm a big proponent of women's health, and health equity is a big space, space that I was in as well. Clinical trials. Who's in clinical trials, who's not in clinical trials? So it's been a really good fit. It's a very seamless transition from the efforts that I was making in clinical trials with regard to representation and why it's important. It's been a seamless transition to menopause.
- [06:59]
A
Amazing. I think what's so shocking about heart disease is that it's the number one killer of women. And I get the feeling that nobody knows that and nobody cares.
- [07:10]
B
Why are we not talking about it? You know, it's kind of like who gets the biggest platform, and breast cancer has the biggest platform. And we've got to be able to associate heart disease with women as well as breast cancer, not to minimize breast cancer, to join breast cancer. You know, there's room for more than one, and so we're not trying to push anything away. All of these things are important, but heart disease, the fact of the matter, is the number one killer of women. And it gets worse during Perimenopause and menopause and we don't talk about it. Menopause, you know, I was in a conference recently with hello Heart. And they asked if menopause was a dirty word at work. And I was on a panel. My response was, we aspire for menopause to be a dirty word at work. It's not even a word, it's not even spoken about. We are hoping to get to that bottom rung where it's a dirty word. We haven't even reached that yet. Menopause and perimenopause in the workplace.
- [08:15]
A
Well, I think, you know, perimenopause is. Can be in your 30s, in your 40s. We think of heart disease as maybe an old person's thing, but really perimenopause and menopause is tied to, to heart disease. My cousin died of heart disease and she wasn't even 40. And so like, you know, that's a reminder of like, heart disease is not just old people. How we treat our bodies and what's going on in midlife is profoundly important to the long term health of the heart.
- [08:43]
B
And heart disease doesn't just start the moment you have a heart attack. It is a progression of 10 or 20 years of your habits and your exposures and your choices and your decisions and your genetics. Rarely there's someone who just throws a thrombus or clot and has a heart attack or has some weird vasospasm, oftentimes from drug use or something. But for the most part it's been something that has been developing over time. And it's why hypertension is called the silent killer. Hypertension is one of the main reasons that leads towards heart attacks. And women are not excluded from that, and certainly not women during perimenopause and menopause, when our risk of heart disease really doubles. And even cardiologists don't necessarily address that and treat that with the seriousness with which they should. And I work to sort of elevate the communication and the visibility for that as well.
- [09:43]
A
Love it. Let's back up for people who might not know because I think even for a lot of physicians it's very vague, like, what is heart disease? How do you get diagnosed with cardiovascular disease? It's kind of nebulous for me. Can you start there?
- [09:57]
B
Yeah. It is nebulous because a woman's symptoms of heart disease can be different from those of a man. It doesn't mean that she doesn't have what we call these classical symptoms. I hate these terms. I'M still looking for terms. So maybe what I will say is the learned symptoms, how we've been taught, because the classic symptoms, really, it's kind of up in the air whether or not these are classic symptoms or not. But we do have another constellation of symptoms that are lesser known. But more frequently we see them in women and they may not be this crushing chest pain, as you well know, and the shortness of breath and you start to get sweaty. And it may be things that are more subtle. Chronic fatigue or back pain or jaw pain or flu like symptoms or even right sided chest pain. All these kinds of things that might be a little bit different from what we have learned. It doesn't mean that they are not normal. In fact, they are normal. But we haven't learned that. We've got to begin to normalize them. Because not only do women and men not recognize them for what they are, which causes a delay in medical care and seeking medical treatment, but physicians as well do not recognize them for what they are.
- [11:11]
A
Love it. So how do you, if you go to your doctor, do they use screening tests to tell you you have heart disease? Is that blood pressure, cholesterol, the calcium score? Now that we're doing right?
- [11:23]
B
Yeah. Okay, so let's talk about that. So if you were to come to the physician, let's say with these types of symptoms, you know, I'm just kind of run down, I'm not myself, I'm taking a nap every afternoon. I kind of have a little bit of back pain. It maybe goes away with Motrin. Sometimes it does, sometimes it doesn't. An astute physician will get an EKG if you're in the office or in the emergency room. Now, I don't want to call other physicians non astute, but the symptoms that I just described can also be attributed to other things. Let's be fair. And that's why we need to have this interest and focus on menopause and perimenopause. Because if you have a woman who comes to you within this age range, 35 to 55, and she's complaining of these vague symptoms, number one on your mind should be is this going to be a cardiovascular event in a woman who's in this right age range and I want to make sure I don't miss it, that's not what the thought is now. And so we've got to begin to think about that. So you asked about a calcium score. Calcium score can be helpful. But remember, a calcium score does not predicate treatment. A calcium score is a Risk tool. It assesses your risk of developing heart disease. And so a calcium score can be very helpful in a woman who does not have symptoms, I want to be clear, kind of asymptomatic, but in that right age range, you may want to get a calcium score to assess this female's risk who's sitting in front of you. If someone is symptomatic and you have recognized those symptoms, let's be clear, you have recognized that these symptoms of maybe hypersomnolence, meaning sleeping a lot or feeling rundown, might be a cardiac equivalent, then a CAT scan for the heart would be better because oftentimes women have soft plaques that have not yet calcified and you don't want to miss those. And that is a test that will move you towards treatment as opposed to your calcium score and gives you your risk. And those plaques have to be calcified. So I hope I've made that clear. Both can be used and you need to assess who's sitting in front of you.
- [13:44]
A
Interesting. What about cholesterol? I've read some that cholesterol, elevated cholesterol is not as strongly correlated with concern for cardiac disease as it is in men. And furthermore, statins haven't been found to be useful for primary prevention in women.
- [14:00]
B
So the cholesterol has been shrouded a bit in controversy with statins and whether or not high dose statins actually worsen heart disease, as opposed to whether women should just be on low dose statins. And again, we're back to what's my bread and butter? Clinical trials and whether we've got the right information and whether we have the right patient group and whether we're just extrapolating data and do we really know what's going on? Now, what's not controversial is that statins are good and women should be on them and women are offered them less often than men. Even though women's risk of heart disease is increasing during perimenopause, they're offered statin therapy less often. That should absolutely not happen. The controversial area is whether high dose versus medium to low dose statins, what is the difference in that? That's the controversy. But whether you should be on statins really is not refutable. Currently in the literature, when we look at men and women and we talk about testosterone levels as well, women actually make more testosterone than estrogen from their ovaries. And so women who undergo oophorectomies, meaning your ovaries are taken out maybe with your uterus, that's sometimes it's part of a hysterectomy, your fallopian tubes, the tubes, the ovaries and the uterus may come out for whatever reason, and then you have a sudden loss of not only estrogen, but testosterone that suddenly seen those women who have surgical. It's called surgical menopause, seem to have higher risk of heart disease and cholesterol. And it may not only be related to the loss of estrogen, it may also be related to the loss of testosterone as well. And so we're starting to understand and take a look at that to see what it means. Most of the trials on testosterone and formulations of testosterone were made for men, by men, of men, to men. And we're kind of extrapolating a little bit with that. I mean, we don't really treat testosterone by measuring levels, but it's something to understand that testosterone loss also goes along with perimenopause and menopause. And the other thing about testosterone is that starting from the age of 25, women gradually lose it as we get older. So it's not really predicated in perimenopause and menopause unless you have a surgical menopause, meaning you had a hysterectomy where your ovaries were removed. Other than that, it's kind of declining from the age of 25 in women. And so we've got to really begin to take a closer look at that to make sure we understand what the heart effects are of testosterone, especially low doses of it. And we want to make certain that we're safe. But it's something really, especially myself and others are starting to take a really close look at. When we talk about the heart, we talk about cholesterol. We've got to also begin to talk about testosterone, because in men, testosterone is cardioprotective. So we are assuming that it also has some cardio protection for women. But listen to the word I use. Assuming. We don't know, and we need to find that out. And so here are all the areas. If you're listening to this today, you're right on the cusp of research, like listening to stuff where we don't have the answers and we're looking for them and we're digging all the time. And so you're out there way ahead of maybe even many of your doctors. So listen up and take the information back.
- [17:35]
A
I love that. I mean, we do have observational studies looking at older women post menopause, those with higher natural testosterone. These are not being treated or supplemented, but women with higher natural testosterone levels seem to have a lower risk of major cardiovascular events. And that's published.
- [17:54]
B
You make a good point. It's really low testosterone, closer to your endogenous levels, meaning your natural. What your natural levels were in your body as opposed to high levels. So it's a great example of more doesn't mean more, it doesn't mean better. And so we want to make certain that we understand kind of what that level is. And so far, the data does seem to be showing that high levels is not what we should be aiming for in women.
- [18:23]
A
Yeah. A physiologic dose certainly lower above zero, which some women do have. Zero testosterone. I love this. I love that you brought it up because it just. It just reinforces that testosterone's not just for libido, which is kind of like the only acceptable container. We've put weed and not me.
- [18:42]
B
Well, it's an important. That's one important container, though, because that's what.
- [18:45]
A
It's an important container. And certainly heart health behoove sexual health. Right. If you don't. If you don't have endurance, it's hard to be athletic in any sport, you know, and you.
- [18:55]
B
And I would agree with that. But there might be some listeners who don't agree, and they might. They might put it in the opposite. But because we've got two doctors on today, we're. And one is a cardiologist. We're going to put heart health first before sexual health.
- [19:08]
A
Dude, I take care of bladders and prostates, and heart always comes. You can't get your bladder and prostate surgery if your heart's not good. I always tell them, I'm like, heart always comes first.
- [19:17]
B
Yeah, yeah. You got to get a cardiac clearance to get this surgery.
- [19:21]
A
Yeah. Even if you can't pee. Okay. So in the 90s, cardiology was really on board with the protective effects of hormone therapy. To the point of. In the 90s, they were saying hormones can be used as prevention for heart disease. We have multiple observational studies reflecting the clinical practice of hormone therapy reduces the rate of cardiovascular disease in these users. And a 1991. I like to go back because it's like, dude, we have to come back to this old stuff after the WHI. But a 1991 analysis of prospective observational studies reported an overall summary relative risk of Cardiovascular events at 0.5 on the hormone users, meaning it reduced your risk by 50% to continue taking these hormones. And then we had this big hormone scare. Is cardiology kind of coming? Because I see. I read a lot of the cardiovascular literature on this. Some cardiologists know how protective hormones are for the heart. Are we getting back to that?
- [20:25]
B
Slowly. I would say that cardiologists and also breast health physicians are still slow to come to sort of the. The table. And it just goes to show you, once the horse is out of the barn, it is hard to put the horse back in the barn, because what are all physicians trained? First do no harm. And in the back of people's minds, because this is how everyone has been trained. Is there enough data on this yet? Should I be doing this or. I was always taught that this was bad. I don't want to harm my patients. You know what's interesting? I went to the American College of Cardiology conference this year. It was in Atlanta. And there was one lecture on menopause in the whole conference. I mean, these are huge conferences. I don't even know how many people are there. 20,000, 30,000 from all over the world. That was one lecture on menopause. And I was so excited because the year before there had been none. So look at the progress we were making. There was one like, woo. It was in a side room. It was not in the main theater. You know, we had to look for it. We went in and there were maybe a total of 12 people in there, and that included the four panelists. So I had my choice of seating. But the lectures were very good. And they took a look at carotid intimal media thickness. So these arteries on either side of your neck, that. Those are the carotid arteries that feed the brain. And if those arteries are blocked, sort of like the arteries of your. Your heart, you can have a stroke, you know. So there was some good literature on interval media thickness and carotid arteries in relation to vasomotor symptoms. And women who had up to. This is. I know it's a small number, but this was a study. Up to six hot flashes or hot flushes per week. Now, don't jump on me. I know it can be 12 a day, but this is the study. So they went from zero per week to six per week. And those who had six, six per week or more had more of that intimal media thickness, meaning an increased risk of stroke. So they gave a lot of very nice, carefully, well designed trial data. It was poorly attended. Not many people were there. It was in a side room. It was hard to find. And yet, Kelly, that was kind of a win. Like, oh, we're here. We made it to the acc, you know, and so I'm hoping that that will continue to grow with voices like yours and voices like mine. And I'm starting to see even commercials on mainstream television about menopause and, you know, take these vitamins for your menopause and are you having hot flashes in the elevator? And I thought, oh my gosh, you know, we're starting to see some visibility to it now, whether or not that's going to translate to the scientific world, which is important to you and I, not just the commercials on television. I want to see the data, I want to see things presented. I want there to be interest. I want to see clinical trials, I want to see women in clinical trials. I want there to be an acknowledgement that menopause is more than just uterus and ovaries, that it affects the brain, affects the heart, affects the skin, affects the bladder, affects the bones. I want to hear all of that. And that's what I'm not hearing. I know you are looking to hear for it too. That's why we comb the literature. And yet we have to admit a little progress is being made. So we gotta take it where we can get it. Right.
- [24:04]
A
I mean, it's crazy. I love your optimism, but I'm like, this is 50% of the population. What's wrong with medicine at this point?
- [24:10]
B
Well, because medicine, the leaders and the leaders of medicine and Doctors are not 50% women. So medicine is still very male dominated area. And if you want to talk about cardiology, it's really super male dominated. So there's not a lot of impetus or interest to move this along.
- [24:33]
A
Yeah, the only data that's stronger than the cardio protective data for hormones is, I'd say bones on hormones being protective and beneficial. Because, you know, again, the other problem I think is medicine is so disease state focused, Wait till you have a disease, then we'll try to reverse it or stabilize it. Where western medicine is not in the preventative world. And like hormones are preventative, once you have the disease, they don't help as much.
- [25:03]
B
Right, Yeah. I often say we don't, we don't, we're not in healthcare system, we're in a sick care system. And so that's another topic about food and everything else.
- [25:12]
A
Yes, totally. So hot flashes. Let's talk about that. Because a lot of people are like, oh, it's the thermal regulatory center of the brain and the hypothalamus and there's something that estrogen, you know, works on. So that's why you can't tell what temperature it is. So you get a hot flash. Why Aren't we saying. Which I'm like, yes, and people who have hot flashes have way worse cardiovascular disease. Why are we saying hot flashes are a sign of cardiovascular disease?
- [25:38]
B
There's no data yet to say that. But.
- [25:41]
A
But can we just start saying it?
- [25:44]
B
Yeah, we can say whatever we want, but we can say this. We can say that hot flashes increase your risk of stroke because they increase the carotid intimal media thickness. You know, I think as we continue to look at correlations and links, which is clearly a correlation between vasomotor symptoms and cardiovascular disease, and that the worst vasomotor symptoms. I say vasomotor symptoms. I mean, hot flashes and hot flashes and nice sweats. And I'm saying that for your audience, Kelly, you know, often are suffered by black women as well. And so there's an even further increased risk of heart disease in minority populations, specifically in black females. And that concerns me as well because there's so little representation of people just like me who look like me. I mean, when we talk about cardiology being dominated by males, there are so few black females. Until I think myself as a cardiologist, I probably only know three or four. And I mean black Americans, and I certainly do know some Africans as well. Even when you include the African population of black females, we still don't even make it to 1%. And then if you slice off just, you know, American born, you know, people like me, you've never even really seen me. You never met me, you never even heard of me. And what's interesting is people don't even think about it. Oh, that's right. I've never. I really have never. You know, it's not even part of the consciousness of what anybody would think. And I live it and breathe it every day. And the number of people that I know are probably on one hand, which is sad. That's how few, you know, that's how few we are. Now, I've probably seen more. I'm a member of the association of Black Cardiologists, and it's few and far between. And so it's hard to get that message out there that it's black women as well who are suffering the most from these vasomotor symptoms and therefore have an even further higher risk of heart disease and stroke.
- [27:51]
A
Would you say the additional challenge on that, because this is what I hear, is that that group of people also have a distrust, mistrust of the medical system. So to say, go in and get on hormones is kind of a big ask.
- [28:07]
B
Just as they go in. That's a big ask. And it's one of the reasons why 80% of the black population is seen by black physicians. It's not by happenstance. People specifically choose somebody where first they're going to feel safe, that we're the only race that picks a doctor by safety. Where am I first going to be safe? Where I can just take a deep breath and not think either this person's going to purposely do something to me, or they're going to do it by neglect or lack of concern for me. And I'm going to be injured. And even after I'm injured, they're not going to really care. And not only will they not care, the world's not going to care either. So what do you do? You end up going to black physicians who then are steeped in working in the community and all of their patients and serving them. And what does that mean? That means that they're away from large medical centers, they're out in the community. They're not being trained to be principal investigators of clinical trials, and yet they're the ones who are controlling most of the population. But they're not being identified for clinical trials. They're out in the community. And so this whole thing has to be unraveled. People like me are not leading research programs. They're not leading research centers. And so you don't have that leadership and that congruence and that voice at the table and that lens on what needs to happen in clinical trials. And so there are just so many different areas where this needs to be sliced and diced and see if we can kind of do a reset. So I spent a lot of time, you know, I spent a lot of time as an advisor to Moderna and to other companies as well, working with them to improve the recruitment of minorities into clinical trials, such that everybody can be confident that drugs and compounds that go before the FDA for approval are relevant to every single population. I'll tell you where that is a great example of that. We talk about the Women's Health Initiative and what a disservice it did. Yet there was still a group of women, black women, a subpopulation who had had hysterectomies, who therefore were only taking estrogen. They were not also taking progesterone. And that subpopulation showed a decreased risk of breast cancer and a decreased risk for heart disease. That data was never published or known because that wasn't the group that was studied. But when you brought those women out and looked at that particular group. That's what it was and that's what research should be. We should be looking at the different populations. And it's a great example as well. I can have a lot of criticism of the Women's Health Initiative, but another example of the disregard for black women in that study. Yet that group of women later, when you looked at the data, actually shone the light on how we were going to get out of this. Because here, unbeknownst to them, they didn't try to do it. They ended up with a, with a population that was actually showing different data than the way they wanted to interpret it. And then there's another conversation about why black women even have hysterectomies in the first place. Why are we having more hysterectomies than the rest of the population? And so that just goes on and on and on. With regard to, back to your original question, why do we don't go to the doctor? Why? We're very careful about it. Who's going to see us? Who's going to touch us? Who really has our best interest at heart? Who's advising surgery that's necessary? Who's advising surgery that's unnecessary? Who can we trust? Maybe we're just better off at home. I was reading a study today about drinking beet juice and whether beet juice reduces nitrates. There's a big study out on beet juice reducing nitrates and therefore reducing endothelial activity and improving heart disease over time. And so I said that maybe go home and drink beet juice. You know, kind of tongue in cheek. But again, food is medicine and we're learning about foods and we're learning about plant based diets and which foods have more antioxidant potential and which ones have more anti inflammatory. So today I was reading about beet juice, so it might be on the menu.
- [32:26]
A
I love that. I mean, another big part of the perimenopause, menopause and cardiology is the heart palpitations. And from what I hear, word on the street is cardiologists are missing it. They do the workup to make sure it's not a heart attack. They do the Holter monitor to make sure it's not an arrhythmia. And then they look at the woman and they say, nothing's wrong with you.
- [32:50]
B
They put you on a beta blocker or a calcium blocker or something, you know.
- [32:54]
A
But heart palpitations in the hormone transition of perimenopause and menopause is very common, but not talked about.
- [33:01]
B
Not Talked about, and I had them, and I didn't even know what they were. And I had heart palpitations. And I went to the doctor, and, you know, I had the whole big workup. I was so anxious. I didn't know why I was having this. I was so healthy. Why is my heart beating? And at the time, I was going through a divorce, and I thought, I'm just totally stressed. I'm, like, going to keel over and die. And I was eventually put on a beta block, which made me feel miserable and dropped my pressure too low, and just. I was dizzy, and I just. I basically took myself off of it and lived with it. Didn't know what was going to happen.
- [33:37]
A
The cardiologist takes herself off of the beta blocker.
- [33:40]
B
I just took myself off of it. I'm done with this. There was no answer. So here's what I learned years later, so I didn't know. Later, we began to talk about menopause and learn about menopause. And I have an aha moment as to, oh, my God. That's what was happening to me way back then, and nobody could figure it out. So, yes, I have personal experience in that. And what should have happened in an ideal world is I should have been offered hormones or at least been referred to a menopause specialist to have the conversation about what it is that I wanted to do after they realized that I didn't have heart disease. Once you come up with the. There's nothing wrong with you. The doctors are kind of like, I've run all my tests. I don't have anything else in my arsenal. There's nothing else in my black bag. I did everything. All I can say is, you're fine. Here's a beta blocker, maybe an antidepressant. I don't know what to tell you. Maybe you need to see a psychiatrist. You're under stress with your divorce, you know. But as it turned and I accepted all of that, maybe I am under stress. Maybe it was a divorce. Maybe I am losing my mind. Maybe I am, you know? And it was only years later, as I began to teach myself and learn about menopause, that I thought back and said, oh, my God, that was me. I had all those palpitations. That's right.
- [35:04]
A
I think it's gonna just to normalize it for women, because I think they get. You know, they get told. Because people. Nobody's thinking about hormones. We think about hormones for periods and for maybe bones now.
- [35:16]
B
Right.
- [35:16]
A
But we don't think about it with the heart. Is it the estrogen's effect on the sinoatrial node in regards to why the heart palpitations happen. Is that your understanding? It's the electrical conductivity of the heart.
- [35:27]
B
You're absolutely right. So the stabilization of that SA node. And again we are back to. We have got to do clinical trials and have randomized clinical trials and really good information. Not observational data, pathophysiologic data, animal data. We've got to be begin to get data such that we can speak definitively because if we don't have that data, that is really the only way we're going to penetrate the medical world. The medical world will practice based on evidence based medicine, period. They're not going to practice based on trends, on popularity, on correlations, on associations. They're not going to do any of that. And if the data's not there, they're not going to practice even on data that's not there. They're not going to step in and fill the void. They need to wait for the void to self populate. So that's really where we are.
- [36:29]
A
Heart palpitations, to my understanding, you know about it. We don't have data. A randomized placebo controlled trial looking at estrogen and the reduction in heart palpitations, we don't have that, do we? And since hormones are generic, they're not going to. Hormones are not going to be, there's not going to be a sponsored unless an institution pays to do it. A drug company is not going to pay to do these studies.
- [36:51]
B
You know, I wouldn't say that really. I would say that people are starting to understand women's financial power and that women make most of the health decisions for themselves and others around them and that this is a good business decision to invest in women and invest in women's health because they will turn around and reap that benefit. And so I think when you're talking dollars and cents, when people sit down to look at it, it is an excellent business proposition. So I would never say, never, I would not be surprised, surprised at all if drug companies got into it. This is a huge market. Huge market.
- [37:47]
A
Well, it's a huge market, but hormones are, they're generic.
- [37:50]
B
Yeah, they're generic. But who will begin to develop different compounds and different formulations and different, you know, how are you going to make it easier? Maybe I can combine all these things together.
- [38:02]
A
I do want that, but I don't want more expensive medications for my women and I don't want five medications that all do what estrogen can do. Right? Like to me, I'm like, sometimes just giving the body back what it had is the cheapest and most effective.
- [38:20]
B
But we have to get new indications for estrogen. So estrogen is not indicated for these things. It doesn't have FDA approval and indications. And that's also going to go a long way to have the medical community accept it, to make certain that you are not prescribing things off label. And so I understand, as you do as well, our colleagues, I understand them like, I've got to follow all the guidelines. If it's not listed on the guidelines, it's hard for me to justify it. And then what else do we have to deal with? All the medical legal stuff and would I be sued? And if I'm sued, do I have any. Do I have any support? Can I back this up? I can back it up if it's got an improved indication. I can back it up if it's X, Y and Z. But I can't back it up if I'm using it off label. If the data is trending that way. But we don't really have randomized clinical trials. The FDA hasn't approved it for these specific indications. It starts to get more challenging. That being said, everybody's a thinking person, especially physicians, and we see the errors of the world of the women's health initiatives. We see those errors. People are starting to think about it, talk about it. Doctors are even beginning to refer their patients to menopause specialists to say, you know what? You're in the right age range. I haven't been able to find anything that is related to my specialty or as far as I've gone. But I think that you need to talk to a menopause specialist to see if it's time for you to begin to have these discussions on hormone therapy. And quite frankly, that's all we're asking. That's fine. That'll work, too.
- [39:59]
A
Yep. Yeah, absolutely. I mean, to me, I'm like, the data's so strong on that hormone replacement therapy or menopause therapy decreases your risk of a cardiovascular event, saving trillions of dollars in healthcare, if we believed in prevention as valid way to spend our money. But it's like, you know, this vagueness of cardiovascular disease. How do you know if you have it? But a hot flash is pretty damn obvious. And as we link hot flashes to cardiovascular risk, decreased sleep is also a
- [40:28]
B
known risk factor for heart disease. So, you know, let's be real. We've got decreased sleep, we've got hot flashes, we've got high Cholesterol, we have hypertension. On their own, they are all related to an increased risk of heart disease. And then during perimenopause, you get them all at the same time.
- [40:48]
A
Yeah, totally. And we do have an FDA approved indication for vasomotor symptoms for estrogen. So it's all there. You just have to put the puzzle pieces together. Before we wrap up, I want your opinion on fasting glucose and cardiovascular disease. Because we, we look in the data I've been reading, it's like we know what, we know what diabetes level glucose is, we know what prediabetes glucose levels is, but there's this elevated glucose that's not yet diseased that seems to be correlated with your future risk for cardiovascular health. Would you agree like that? There's, we should, everybody should be caring about their glucose levels because it is bellwether canary in the coal mine.
- [41:29]
B
Something that is an indicator, these pre diabetes numbers. And oftentimes they are related to your weight management and the types of foods that you're eating. So we're back to kind of how are you managing your life and your lifestyle if you've been told that you've got early numbers and not quite diabetes, but you know, we want to start to take a look at this. Especially if you have other people in your family who have diabetes, you need to give that a serious, serious consideration. Diabetes is a cardiovascular equivalent, meaning it does incredibly increase your risk of heart disease. And over time that doesn't get better. In fact, nothing gets better over time in the body. Let's be real. It doesn't really just get better. Right. No disease process just cures itself. So I want you to think about that. And if you have been told those numbers, get serious about what you're going to do about your weight if you are overweight and be honest with yourself, begin to consider maybe more of a plant based. And when I say a plant based diet, you know, there can be a lot of processed and ultra processed foods in a plant based diet. So think about that. You know, I, I'm still not sure what's in this meat that's plant based. It's artificial meat. Seems very processed to me. What is it called?
- [42:53]
A
It sounds very processed.
- [42:55]
B
It sounds very pro. I mean, I wouldn't eat this meat, but when I say a plant based diet, I would say real plants and fruits and things and not necessarily substitutions because when you begin substituting meat and substituting cheese, these are all processed foods that have all types of chemicals and things in them that you may or may not be able to pronounce. And that's actually a really good indicator. If you look at the package and you can't pronounce all the ingredients, you probably shouldn't eat it. It's probably not all foods. And so begin to think about what you need to do with your body to start to dial back these glucose numbers, glucose meaning sugar, and dial those back, including little artificial packets of sugar that we add to our coffee and tea that have the xylitol, the saccharin, the sucralose, all of those kinds of things in them equal nutriset, nutrasweet and sweet and low. And all of those kinds of things because they really raise your sugar levels almost a thousand fold. And it also increases your desire, retrains your taste buds to crave more and more and more of that sugar. So if you're one of those people shaking one of those colored packets, blue, yellow, pink, all those colors, let's put those down and use either natural sweeteners or use to. Or begin to try to retrain yourself to drink beverages without any of those sweeteners at all. Or believe it or not, we're trying to get away from real sugar. That's what you're doing to lose weight. Actually, the raw sugar, the real sugar, is better for you than these artificial packets. And remember, there's always honey, vanilla, cinnamon, all these kinds of things where you can sweeten your foods naturally and dial your numbers back away from that threshold line if your glucose numbers are getting close.
- [44:43]
A
I love that. Before we leave, I'm going to be respectful of your time, but apob and little L. Lipoprotein A lipo. That's got a weird name. The insurance doesn't always cover these things. They're newer. Do cardiologists like them? Are they meaningful? Again, this is apob and lipo A. Yeah.
- [45:01]
B
So LP is actually gaining a lot of interest. I'm actually on the steering committee of big pharmaceutical company running clinical trials looking at lp. What is that? Lipoprotein Little A. It is a genetic component of cholesterol for which we don't really test. We can, but we don't. And the reason we don't is because if it turns out you have a high lp, we have no treatment for you. There is no treatment available. Now, what would we do if we test for? We would aggressively try to get you to modify your behaviors, increase your exercise, decrease your weight, make sure you're controlling your blood pressure, controlling your cholesterol, getting good sleep, all those kinds of things, quitting smoking. Because if you have a high LP level, it really increases your risk not only for heart disease, but early heart attacks. So in your family, if you have. If you see people that have sudden death early or heart attacks early, you may have lp, little A. It's lowercase L, lowercase P, parenthesis, lowercase A, parenthesis. So lipoprotein little A. But hopefully we will have something coming for you soon. It's not as rare as you think. What's rare is testing for it. I think once we start testing for it, we're going to find out just how prevalent it is in our society and what happens. People who get tested for it. Unfortunately, talking again about sick health. If you were to come into a health system, you're in your 20s or 30s with a heart attack, you might get your LP check as part of kind of the doctors need to know kind of what's going on. But the fact of the matter is you should already know what it is and have already been implementing either some therapies before you come in. But early heart attacks are often a signal that this may be somebody with lp. It is cholesterol. Think of it as cholesterol for which we don't check because we have no therapy for it. But we're working on it. I am part of a group we've been working on.
- [47:08]
A
I'm so glad I asked you. And then what about apob?
- [47:12]
B
Yeah, so apob, kind of the same thing. And we are going to be looking at all of these different types of cholesterol levels. You know, how can we splice them to be more personalized and more individualized? And the more we understand, the more we can develop therapies. Very specific to that and very specific to you. So this is part of what's coming with this personalized medicine.
- [47:39]
A
I love it. Dr. J. Morgan, the heart is very important, so thank you. Thank you for coming on. Any final words you want women to know about their heart disease, Heart health, menopause?
- [47:51]
B
Yeah, listen, you know, midlife is hard, and we don't have to make it harder by kind of, you know, grinning and bearing it. Make certain that you are getting support, you're doing what you need to do. That's suffer is removed from your vocabulary. You do not have to suffer that you feel good. You're bringing your best self forward. And in addition to following Kelly, you guys can follow me as well. I'm at Dr. J. Morgan. D R J A Y N E M O R G A N on all the channels including Instagram. I do a number of things. I talk about menopause and heart disease, but I do a lot of media interviews as well. But I'm always, always, always focused on health, focused on you, focused on the community. When I make certain you guys can always find trusted voices to follow. If I don't know, I say I don't know. Right? Research is not here. Here's what I think, but I don't have anything to support it with or I'll tell you where we have real data and ultimately you make your own decisions. So we want good health for women. We are most of the population. We must own that and begin to understand what our real focus, financial strength is in pushing this industry forward.
- [49:05]
A
I love that. Thank you so much for joining me today.
- [49:09]
B
I'm so happy to finally get here. Kelly, Me too.
- [49:13]
A
Thank you. All right, thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment and you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and adult Sex ed Masterclass members. Get the Master class for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests including on this podcast are not giving individual medical advice or practicing medicine. See and consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time, remember, you are not broken.