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Shop the Sherwin Williams 4th of July sale and get 30% off paints and stains June 26th through July 6th. Whether you're refreshing your interior or exterior, we've got the colors to bring your vision to life. And with delivery, getting everything to your door is easier than ever. Shop online to have it delivered or visit your neighborhood Sherwin Williams store. Click the banner to learn more. Retail sales only some exclusions apply. See Store for details. Delivery available on qualifying orders. Hey everybody, welcome back to the you are Not Broken podcast. This is episode 284 and in this I am discussing the Menopause Society's 2024 conference. It was wonderful. This is a long winded episode and I didn't even go to all the talks or look at all the presentations. So of note, a lot of these are my personal opinions and my insights. I do not claim to be 100 accurate in getting all of my statistics that I'm reading off correct. This is me taking notes and thinking what would be interesting to you as I'm attending the conference. So I hope you enjoy couple housekeeping notes if you want to see me and you're in the Pacific Northwest. Couple of options October 3rd which is a Thursday from about 5:30 to 9 there is a Menopositivity conference at the tacoma in Tacoma, Washington. Me and Aoife O' Sullivan are going to be joining Dr. Aoife O' Sullivan or will be joining Dr. Marcy Mayer to talk about Ladies Night Menopositivity Expo. And I'm going to be talking about I think pelvic health, testosterone, genital urinary syndrome and menopause. And I think Dr. O' Sullivan is going to be talking about perimenopause. So it's going to be at west of the Waterway, 1901 Dock Street, Tacoma, Washington. I'll put the link in the show notes. Otherwise go to eventbrite.com you can search for Tacoma and menopause and it'll pop up. So see me there. The other awesome is the M Factor documentary about menopause I am premiering in Bellingham on Sunday, October 20 at 2pm Thor's open at 1 and following the documentary I am going to do a live discussion Q and A and I'm going to have a panel about menopause in the workplace, some experts and advocates for menopause in the and the workplace coming up from Seattle for that. So tickets are on sale now. The I'll also put the link in the bio and there'll be links in my link tree on Instagram or you can go to the Mount Baker Theater. Search for events in October. October 20th is our showing of the world premiere of the PBS documentary the M Factor. Also, the book is out. You are not Broken. Stop shooting all over your sex life. If you go on Amazon, do me a favor. If you go on Amazon, will you please leave a review because it really helps me and it really helps the algorithm and lets other people know that this is good adult sex education, high quality book and that it helped you. So thank you for that and enjoy this episode 284 of you are Not Broken. Talk to you next time. Welcome to the you 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 everybody, Dr. Kasperson coming to you on the podcast. I'm actually live on Instagram right now for a little bit of this. And this is going to be a podcast all about the 2024 Menopause Society Conference that just happened in Chicago and it's awesome. I'm currently in New York trying to fit in a podcast recording and so this will be probably about two weeks after the conference by the time it actually gets up on the podc. I'm here celebrating the you are Not Broken book. The re release. It is currently number one on Amazon under marriage and long term relationships. Which I didn't know is a category but it makes sense because people literally come to me and they're like, you saved my marriage. Had had I had this book a couple of years ago, it would have saved my marriage. All of the amazing comments that I'm getting from it. If your marriage or long term relationship is on the rocks because of money, no, this is not how I will help you. This is understanding female sexuality, female bodies, how to communicate about sex, why different people want sex, genital urinary syndrome of menopause. All of the amazing things. I told people on Instagram that I would read the table of contents and I haven't done it yet so I'll do that quick introduction. You are not Broken. Stop shooting all over your sex life. Number one Introduction Part one It's not your fault. Chapter one Society got it wrong. Chapter two the rules are Ridiculous. Chapter three Bad Sex Sucks Part two Sex Positive Sex Ed for Adults Chapter four the Female Edition Chapter five the Male Edition Chapter six Getting all Hormonal Chapter seven the Chemistry of Pleasure Chapter eight Own youn Orgasm Chapter nine Communication is Lubrication Part three Is it Actually low desire or something else entirely. Chapter ten it might not even be a you problem. Chapter eleven Desire is so two faced. Chapter twelve brakes and accelerators. Chapter thirteen get out of your head and into your body. Chapter 14 Change your mind, change your life. Chapter 15 what a pretty pink pill can and can't do for you. Chapter 16 maybe it's menopause. And the conclusion, you are not broken. So it's my baby. She's doing really well with sales and the audiobook's up. If you like my voice, I read the audiobook. If you don't like my voice, maybe read it because it's available on Kindle and paperback. So I'm currently in New York drinking a latte with you and we're going to talk about the North American Menopause Conference. Disclaimer. I took notes. That does not mean I'm 100% accurate. I'm probably going to leave you with a lot more questions than answers and I consider that a good thing. Like conferences really are an exciting time to network. Conferences are an exciting time to see what other people are doing and to keep asking more questions. So by no means is this an all inclusive map of what happened in Chicago over three days. I couldn't go to everything. I didn't go to everything. But the notes that I took are notes that I'm like, I think my listeners will find that this is useful. I'm in New York and did a workout book Q and A with an amazing personal trainer who specializes in menopause. Her name is Holly. Go tothe lifted method dot com. You can do things online and she's all about muscle and lean body mass and helping out midlife women. So it's fantastic. So again, disclosure, if some of this is wrong, I'm sorry, if I don't get everybody's name who spoke, I'm sorry, I did not take extensive notes, but just notes enough to talk to you guys. Shout out to Dr. Lisa Larkin, who is the president for this menopause Society meeting. She's now the outgoing president. Stephanie Fabian created an amazing program. Amazing to connect with so many people and shout out to people who actually organize conferences because it looks like the biggest, it seems like the job of organizing like the biggest wedding you've ever had. There's like 1500 people, 8000 members of the Menopause Society now and 2000 signed up like within the last year, which is insane growth. They have a new website now. They're doing good things for education for women. So you can check that out. And I'm so proud of them for hosting an amazing conference. And thank you to all the sponsors. We'll see how far we can get, and then I'll probably be recording this in two segments. The first lecture I took notes on was about recognizing abnormal menstrual bleeding and talking about what happens in perimenopause. That your periods can start spacing out, they can get heavier, they can get lighter and ovulatory cycle. So cycles are goofy when you don't ovulate in the middle of them. Anovulatory cycles are irregular, light or heavy, all a sign of perimenopause is not a diagnosis of perimenopause. And most menopause experts will agree that perimenopause symptoms can start before your periods get irregular. So it's not like you have to have irregular periods to be in perimenopause. Some women don't have irregular periods ever. They just stop. And a lot of people in perimenopause don't have periods. Right. They've had hysterectomies, ablations, or IUDs. So everybody freaks out about postmenopausal vaginal bleeding. And the speaker said, you know, the dogma of that in the medical field is postmenopausal bleeding in endometrial is endometrial cancer until proven otherwise. And so we tell people that because we never want to miss an endometrial cancer. If you have postmenopausal bleeding, what's the actual chance that it is endometrial cancer? 5%, 95% of people who have postmenopausal bleeding do not have endometrial cancer. I think that was a great statistic. The risk of abnormal vaginal bleeding if you're menopausal, young menopausal, and you start hormone therapy is about 26%, especially in that young perimenopause. Very recent menopause timeline, most experts will say, yep, you're giving your body some hormones, you're going to have a little bit of bleeding. The uterus is a very hormone responsive organ and most people say it'll mellow out. And indeed, 26% chance of vaginal bleeding when you start hormones mellows out to 9% of people at one year. So one of the menopause experts said, I tell women if you have bleeding, it's normal, but don't call me unless it goes on for more than four months because they're expecting this to happen and it's not concerning. Right when you start hormones, blind endometrial biopsies can miss cancer. Miss endometrial cancer. That was a good takeaway. So if you have abnormal vaginal bleeding and you get a transvaginal ultrasound and it shows abnormalities and your blind biopsy was negative, don't stop there. There are ACOG guidelines on this for any provider who wants to follow that up. And I think they recommend hysteroscopy or sono histogram, which I think is an appellic ultrasound that they put a little fluid in this through the cervix so that you actually get a better image of the uterus. So a negative blind biopsy is not a stopping point for vaginal bleeding if they keep bleeding. This expert was an expert in pelvic ultrasounds, and his opinion was to use birth control for abnormal bleeding in perimenopause because it smooths out the cycle. Not everybody agrees with that. Certainly there isn't a rule anywhere saying you have to use birth control. And perimenopause birth control can have its own side effects, including low desire and mood changes because of its blockage of your other sex hormones. Birth control works very well for abnormal bleeding in perimenopause, so that's why some people are recommended it. But I think true hormone specialists are going to say, we've got birth control to try, we've got other hormones, we've got, you know, ablations, we've got IUDs, lots of things to help abnormal uterine bleeding in perimenopause, which we know. Heavy bleeding in perimenopause is about 20% of all women. There's a couple of birth control options, and I don't certainly know all of them off the top of my head for this podcast. Slind is one of them. And then he again reminded us that perimenopause is the mirror image of adolescence. Erratic estrogen, not absent estrogen. So that was a nice good to see perimenopause being addressed at the annual Menopause conference, because everybody who is born female goes through it, and you have to go through perimenopause in order to go through menopause. Another talk was By Josh Johnson, PhD Future options for Menopause Transition, talking about the research that we have so far on why the ovary does what it does. And this is definitely a more questions than answers sort of thing. The ovarian reserve is dependent on the remaining number of follicles. So the follicle is like the little collection of cells that produce the hormones that then release one egg out of the follicle has follicles, and there's eggs. Eggs are one type of cell. Follicles are another type of cell. Follicles make the hormones. So we start with about 100,000 follicles. When the reserve of the follicles reaches 1,000, that's about when menopause happens. What accelerates ovarian aging? Smoking, history of endometriosis, chemical exposure, genetic modifiers. I looked up because there was a possible mention of the role of birth control on accelerating ovarian aging, and the data does not hold on. Birth control accelerating ovarian aging. Late menopause correlates with a longer lifespan. Now, here's the question. Late menopause, and that's. I think they define that as over age 55. Late menopause is associated with longer lifespan. It's actually true for those women's brothers as well. So there might be a overall genetic component. Right, because the brother doesn't have the ovaries. So it's not just her. There's like, she has, like, some genetic predispositions. Or like the families that live longer, they just have ovaries that live longer. Or is there something about ovaries living longer that makes you live longer? Very interesting to think about. And we have data that shows that women on hormone therapy live longer. Okay. So if ovaries naturally, if they last longer, you live longer. And if you give hormone therapy, you live longer. Many people are gonna ask the question, should hormones be considered for the longevity movement? I would argue, yes. Personal opinion arguing, yes. But there is no national society that's gonna say hormones should be used for prolongation of lifestyle. Nobody's ever gonna say that. You will die waiting for somebody to say that. For a society to. What I mean by society is like a doctor organization that cares about something. So the menopause society does not advocate hormone use for the prevention of dementia. Queen Carvania stood haloed by the morning sun. An army hung on her every word. My children. Champions. I have sold my chariot on Carvana. Twas a lovely suv. An inexplicably queenly offer. They're even coming to the castle to collect it. Tonight we feast. An offer you can feast on. Sell your car today on Carvana. Pickup fees may apply. So if we aren't advocating for the prevention of dementia or heart disease at this point. And again, this is society's opinion, not mine. But they certainly aren't gonna come out and advocate for longer life of use of hormones. But you guys are smart. You know the data. The whole point for me is for you to make the right decision for you. Cause if you sit around waiting for doctors to say, you can take this to prevent disease, they're currently not gonna do it. It'll be very interesting to see where we get with the data, both in terms of dementia and cardiovascular disease. Within five to 10 years, I think people are going to look back on certainly the WHI as the dark ages. But now is like, we're pretty conservative coming out of the WHI scare. And it's a very big thing to say a society should go on a medication for prevention of something versus an individual chooses that. So I went off on a tangent. So their conclusion was late menopause correlates with longer lifespan. That is worldwide. That is not just American data. Delaying consequences of aging will lead to improved life and health span. No shit, Sherlock. So, yeah, we've got all these things to say that. And they were like, but we're not going to tell you to go on to hormones for longevity improvement. But it's like, that's what the. There's a lot. There's good data, but not enough to tell 51% of the population to go on hormones to prevent things. This is truly an individual decision at this point, and I think you should find a clinician or prescriber who will support you. So how to delay ovarian follicle aging? Do not smoke cigarettes. Cigarettes are literally the worst things for your ovaries. So how to delay ovarian follicle aging? You either increase the number of follicles that you have and that don't die, or you have to decrease what's aging them, or you have to do both. So those are the different levers that you can pull. One question they're looking at is, what's the role of stem cells in replacing follicles? Do we do stem cell transplants? Do we take out some of your ovary, freeze it, put it in your belly later to give you two or three more years before menopause? These are the things people are thinking about. The answer is probably no to that because there's risks of having abdominal surgery. And the other question for a lot of people is for the people who want to continue to have fertility and have the possibility of babies, great if you keep having ovaries and periods. But a lot of people were like, can we just have the hormones and not have the continued worry about pregnancy and periods after 55? So it's interesting the two different avenues looking at this, right? Because you have the fertility avenue trying to preserve eggs and then you have the follicle hormone preserving people who are like, yeah, we could kind of take or leave the eggs because we're done with childbearing. Everybody agrees it's important to figure this out for the people who want to keep having kids. But not everybody wants to be like having periods and protecting themselves from pregnancy at age 59. Some people have to do that naturally. You are not good to go as far as pregnancy prevention if you have sperm in your life. If you've had a period within a year, next one. Okay, so I just looked up a little bit more about this John Locke guy. John Rock Guy, 1890-1984. He lived a long time. He was a devout Roman Catholic, groundbreaking infertility specialist, gynecologist. And he saw what unplanned pregnancies did to poverty and desperation caused by too many mouths to feed. So he was actually the pioneer in oral birth control. Very, very interesting. So then he made the birth control with a bleeding once a month. He was seeking Vatican approval. So the pill received FDA approval in 1960. And he launched a one man campaign to gain Vatican approval of the pill. Very interesting. Rock argued that using the pill was a more precise way of following the rhythm method. He strongly believed that the church should consider it a natural and therefore acceptable form of birth control. Very interesting. Dr. Rock was crushed when the Pope officially banned the pill. And then he lost his faith in the church and he stopped going to church altogether. Wow, this is so interesting. I think there is a show on pbs. This is all from a PBS website. There is a show on PBS about this guy. Very interesting. Rocks used on the pill, once daring and radical, had become commonplace among the rank and file of the church. Although he died feeling that he had failed in his mission, John Rock's contribution to the debate on birth control had a profound impact on the lives of countless Catholic women. Holy sh. I have like literal goosebumps about this guy. I remember my mom, who was raised Catholic when she was young, went to the doctor in her town. She tells this. My mom podcasted with me way back. You have to go way back in my podcast to listen to me and my mom and she tells the story on that episode of she went to the doctor to get birth control. I think she was married. I can't even remember. And the doctor said, I know who your parents are because of your last name or the last name. And he knew that was a Catholic name in the community. And did not give her birth control for that reason. That was in the 1970s in America. I would say, like, we've come a long way, and we haven't come a long way at the exact same time. That's a complex topic, but you know what I'm talking about. Okay, back to the menopause conference. Review cognition and hormone therapy. Verbal learning and verbal memory are reliable changes in the progression and diagnosis of dementia. An increase in ADHD symptoms and perimenopause. I think a lot of people know that now. We certainly need more data. But an interesting thing about ADHD is any hormone fluctuation seems to increase symptoms of adhd. So the week before your period, puberty, postpartum, perimenopause, and those are all fluctuating hormone changes. Somebody's saying psychologist here preach about ADHD and hormones. Yeah, absolutely. My feeling. Tell me if this is different. My feeling is the mental health community is picking up on the importance of, let's say, the importance of hormones in the perimenopause and menopause as far as mental health, depression, anxiety, adhd. It's very cool. There were some psychiatrists at the conference. So during pregnancy, when your estradiol level is in the thousands, people say ADHD mellows out. Super interesting. The psychologist says, yes, we are. Okay. The other cool thing about the menopause conference is, is the diversity of people that were there. There were podcasters, not just me, midwives, midlife health coaches, of course, psychiatrists, internal medicine, family medicine, ob. I was a urologist. I'm trying to think, was there another urologist there? Sorry if I missed you. If you were there, those were like the big groups. It was so cool. I met a woman at the end. I was, like, waiting for the Uber to go to the airport, and she's like. I was asking her what she liked about it, and she is not. She doesn't prescribe. She is a midlife health coach in Minnesota. And I was like, go, Minnesota for helping all the women. So, yeah, there's data showing that the brain adapts to changes in the in hormones by increasing right to left hippocampal connectivity. But the brain's efficiency goes down. 2022. NAM's position statement, they said it holds that HRT doesn't cause negative side effects to the brain. Like I was talking about earlier. We cannot wait because it's not going to happen. It might happen in five or 10 years for people to say that hormones are going to be allowed. They won't be FDA approved, but allowed for the prevention of dementia, that's going to be a very individual decision. Certainly the data is coming out stronger for people who are at higher risk for dementia, like the APO4E allele. My understanding of APO4E is it's about 25% of the population, but it doesn't even mean you're going to get dementia. It just means you're at higher risk. I think it's about 50%. So much of dementia is lifestyle, lifestyle, lifestyle, lifestyle. There is no pill that is better than exercise. No pill. Also, sleep's really important. Not sleeping increases your risk for dementia. They had said the talk on brains had said there was four randomized trials for dementia prevention. A little bird that I know says there's about 30 randomized control trials looking at hormones for dementia and prevention. And it's hard. So by the time you get diagnosed with dementia, what's been happening in your brain has been going on for about 20 years. So in order to do a study like a randomized placebo controlled study, you need to start in young, healthy people being age 50. Right. Because if you start the hormones on the 75 year olds, a lot of damage and changes has already started. So you have to start young and you have to follow them for years. So that's impossible. They didn't even do that for the whi they wanted to to study older women because they couldn't afford to study people this long. Right. So you can do longitudinal observational studies that long, which is what the SWAN study and stuff like that. But for as far as medication placebo controlled, we're not going to get the study. We have to use the data that we have. I like Dr. Lisa Moscone's 2023 meta analysis on this showing that the data strongly supports and suggest that early menopause, starting hormones early. What do I mean by Early? Within 10 years is your best bet for decreasing the risk of dementia. It's not 100% decreased risk of dementia. I think off the top of my head they're looking at 30% decreased risk of dementia. But if you look at dollars in numbers, if there was a medication that could decrease the risk of incidence of dementia by like 8% in, in our world, it would save billions of dollars in healthcare costs, long term care, hospitalizations, fallout from other people having to quit their jobs to care for these people. Oh, thank you. Somebody also said alcohol is terrible for brain health and heavy use has been linked to dementia and other diseases of the brain. Truth, alcohol is very bad for the brain. That's the other crazy shit, right, is like we're spending all this time being like, we don't have enough data for hormones and dementia. But what we do have says it could be a significant reduct, but then we've got this legal carcinogen on every fricking corner. And by the way, your carcinogen also increases your rate of dementia and a lot of other neurologic disorders, by the way. Okay, the other thing they had brought up at the menopause meeting is that the studies looking at prevention of dementia studied asymptomatic women. And they're like, maybe we should be studying specifically the big hot flesh bothered women because the hot flash itself is correlated with brain changes that look like small strokes in the brain and also associated with cardiovascular disease, which is an independent risk factor for dementia. So they're like, maybe we should be studying the super symptomatic people and seeing if they have a decreased risk of dementia. And they said that to their knowledge that study hadn't been done. Again, these are generic medications. You're not going to have pharmaceutical backings, you're not going to be able to start it young and follow these people for 20 years. There's no randomized controlled trial of medication that goes on for 20 years. And dementia takes 20 years to form. We should be thinking about dementia when we're 50, we should be thinking about dementia when we're 40, because what we do now matters for when we're 75. So my whole point is like, why with the devastation of dementia, which can affect upwards of 20% of people after the age of 80, with how much it costs, how much we're bankrupting our health care system, how much we do not have doctors to take care of us as we are, and we're aging in a way we've never aged with this amount of people before. Why are we not at least having the discussion of a risk benefit analysis of like, even if it prevented dementia by 5% of people, what that cost savings would be, let alone quality of life savings. So like, I think it's a little heavy handed to say we don't, we don't support hormones for dementia prevention because what's best for society, we don't even put everybody on aspirin, we don't even put everybody on statins, right? Like what's best for a society is different than an individual. And I think an individual should, they choose to want to be on hormones for the reason of dementia prevention should be allowed to make that these are such safe medications. Okay, so other news from the menopause conference. Hot flashes are associated with decrease in memory. That's the other bullshit hormones help hot flashes. Hot flashes are independent predictors for decrease in memory. Hot flashes are associated with decrease in memory and adverse effects on the brain. They said they make little brain changes that look like strokes. The more hot flashes a woman has, the worse her memory is. They don't know if that's correlation only or is she not sleeping because of the hot flashes and the sleep is what's associated with memory? We don't know, but it's correlated because there was an elegant study. I believe this is Pauline Mackey. Yeah, I think this is Pauline Mackey. They non hormonally blocked hot flashes in women using a stellate ganglion nerve block, which is not something that you're gonna do at home for your hot flashes. So this is in the lab setting. So non hormonally blocked the hot flashes and these women had better memories. So what's going on with hot flashes? Are they damaging the brain? Are they just correlated with what else is happening in the brain? And it's a sign. So we don't know. But it's like we have all of this information and then to make the leap that we shouldn't recommend this for dementia prevention seems like a bigger issue than us saying, like, look at, we've got all this data. It can suggest treating hot flashes has better memory. Better short term visual spatial memory is associated with long term dementia risk. So, like, all the little pebbles lead up to a path on this. And I think it's all we have. We're not going to get a study. Have I beat this topic enough? But I really want you guys to think about this and think like, why do we say what we say? The more hot flashes you have, the more vulnerable your brain is. There's issues with the vasculature of the brain and that these vascular changes increase the risk of dementia. The more hot flashes you have, the more Alzheimer's biomarkers these women have. Again, is this correlation? Is this causation? We don't know Estrogen alone, and this is the WHI data. I believe estrogen alone had a 28% decreased risk of dying from dementia. Maybe that wasn't WHI's data. This is some study they quoted. Estrogen alone has a 28% decreased risk of dying from dementia. The number needed to treat for clinicians who know what number needed to treat is. So they're saying in this study alone, you would have to give 2004 women. Estrogen in order to decrease. One diagnosis of dementia. That's a very high number needed to treat. Recent observational studies don't support use for prevention. And what to do instead is what they said is make sure you have social activities because that helps your brain. Heart health is good for the brain. Decreased alcohol and increased physical activity. Next talk was what causes depression during menopause? So a statement of most people don't know depression and anxiety are associated with menopause. In the 1960s, they said the empty nest syndrome for women, that women were getting depressed as their kids were leaving home. Which by the way is at the same time that perimenopause and menopause is happening. Who is at increased risk of midlife depression? History of trauma. Then they don't just mean physical trauma, but traumatic life events, depression, chronic health issues, socioeconomic factors, stressful life events, vasomotor symptoms, sleep problems. And people who are more sensitive to hormone changes have an increased risk in dementia. Estradiol decreases occurrence and severity of mood symptoms. Sleep disturbances are associated with increased depression and anxiety scores even in the absence of vasomotor symptoms. Then there was a JAMA paper that looked at estradiol and progesterone protecting from dementia and there was twofold decrease compared to placebo. Then the women with stressful events in their life had the most protection from depression by being on hormones. That's the other thing. I'm effing beating a dead horse at this point. So depression is an independent risk factor for dementia. Hormones help depression. Again, not all. Not all hormones help depression. You're helping the things that are independent predictors of dementia. Hormones help protect against heart disease, which is an independent risk factor for dementia. My God, the more physical symptoms of menopause that you have, the more increased risk of psychological symptoms that you have. The Mediterranean diet helps depression. That was great point that the speaker said is like they actually have data showing changing your diet improves depression scores. Like stop the processed foods. Probably, if anything, processed foods and alcohol. Mediterranean diet helps depression. 2001 study, depression improves with estradiol even without having any hot flashes. So in the women who are depressed who don't have hot flashes, because remember, the big myth is you have to have hot flashes to be treated with hormones. That's a myth. But even in women without hot flashes, depression improves with estradiol. In 2022, data show that estrogen helps mood. They made a very brief statement. So for anybody who doesn't understand testosterone as much as I understand they made a Very brief statement that testosterone does not help mood. I would argue that for a couple of reasons. Number one, libido's a mood libido's in the brain. Number two, not as primary outcomes, but we have a lot of secondary outcome data on testosterone helping mood. And then the third question is how you're tracking improvement in mood with your questionnaires. Is that actually valid in the mental changes and mood changes that women experience on testosterone? Right. If you've got a shit questionnaire for mood and then you give somebody a study drug and then nothing on the questionnaire changes, but they come back and they say, I feel more like myself. You just didn't measure that. I would say feeling more like yourself is a independent marker for mood. Right. So are you even measuring mood in the right way, which some brain experts would say we're not doing? Loss of progesterone makes anxiety worse. Role of birth control pills in perimenopausal depression. So birth control pills shut down the roller coaster of hormone changes. And it's the hormone delta change in hormones that can be the trigger. Right. So birth control will mellow that all out. It gets rid of roller coasters. Nextellis and Yaz were two of the ones that they recommended for birth control options. I am not a birth control expert. I will understand my limitations on that. Somebody's saying testosterone has been a game changer for my mood motivation and I feel like my old self again. That's what it is, feeling like yourself. And are we measuring that properly? Okay, so there's two non hormonal drugs that are coming out for hot flashes. They work in the brain. Fezalinitin and Enzalinitin. So they have Enzalinitin data saying it helps mood by decreasing hot flashes and improving sleep. I'm like, yeah, so does estrogen and testosterone. But these two brand name drugs are expensive. We don't have long term safety data. Did I mention expensive? And they don't help all the other things that hormones help with. All right, next one was on bone health. They were talking about having a lifelong bone health plan, which I loved. Talking about the role of muscle mass and aging. Women get sicker, but men die quicker. Falls cause higher burden of disease than dementia. Older women are less likely to recover than men from injury. If you are 65 in 2021, your life expectancy is 19.7 more years. And how do you decrease the need for long term care? Prevent physical frailty, fractures and falls. Only 1 in 3 patients with hip fracture recover completely. 20% will die within the first 12 months. White women age 50 have a lifetime risk of osteoporotic fracture of 4. 40%. Unbelievable. Peak bone mass achieved by age 30. And by age 50, 16.5% of American women already have osteoporosis. I think screening 20. Sorry. 16% of women by age 50 have a diagnosis of osteoporosis. Why aren't we screaming? Screening at age 50, it's crazy. Average woman loses 10 to 12% of her bone density at menopause. By age 80, about 30%, peak bone mass is lost. Alcohol use affects bone health. Who doesn't know that? Oh, somebody said, my first DEXA at 50 osteoporosis. Well, unfortunately, you're in good fucking company because it's 16.5% of women have osteoporosis diagnosis by age 50, which blew my mind. That's more than 10%. I'm like, did you know 16% is more than 10%? It's very high. Hormone therapy increases bone density by 2 to 5%. One year after you stop your hormone therapy, you have a 3 to 6% loss. Like, the bone protection stops when you stop your hormones. Oh, super excited to see you in Orlando. That is a nice segue to say. I'm going to Dr. Vonda Wright's. I want to say menopause activity, but I'm confusing all my expos at this point. Orlando, Florida, November 7th, 8th and 9th. I am like, literally flying in for Friday night, all of Saturday. I'm talking about GSM and sex. It's going to be awesome, and it's going to be Orlando. Can you reverse osteopenia or osteoporosis? I always say yes in some people. I've seen it. I've heard it. Hormones are not FDA approved for the treatment of osteoporosis, but there is good data, especially. I looked this up yesterday. There's randomized control trials looking at bisphosphonates alone compared to bisphosphonates, plus estradiol. And the plus estradiol group did significantly better than bisphosphonates alone. Why do doctors not know that if you have osteoporosis, you have 13 times the risk of sarcopenia. That's insane. And they feed off each other. Osteoporosis and sarcopenia. So osteoporosis increases the risk of sarcopenia. Sarcopenia increases the risk of osteoporosis. Muscles and bones are partners. And when one partner's affected, the other one's affected. How to prevent Sarcopenia, vitamin D, protein and heavyweights. You got to keep your muscle mass up. You got to eat. You can't try to weigh the least amount. Trying to weigh the least amount is not good for your long term health. Strong, strong, strong muscles are heavy. I've put on five pounds of muscle this year and it's helped a lot of things. But you got to work on that psychology you've gotten if you were raised in the 90s, that the lower the scale number the better. Like I'm not immune to that either. All right. There was a lecture on immunization at the menopause conference. It said, why do older adults need immunizations? Age related changes that increase risk to disease. Low grade inflammation and decreased T cells equals more risk of infection. So that was good. Okay, so a couple of things I want to do in the middle of this podcast because I don't want to forget doing it is last night we unleashed or announced. Me and Rachel Rubin in New York announced the campaign being spearheaded by letstalkmenopause.org called Unboxing Estrogen. So it is an amazing unboxing menopause, but unboxing estrogen. It's time for the FDA to remove the outdated, misleading boxed warning label on local vaginal estrogen products. Go to letstalkmenopause.org unboxingmenopause you can donate to the cause. If you are a healthcare professional, you can send a letter to the fda and if you are a the general public, you can click and send a letter to the fda. The FDA will move, I promise you this. They will move because of grassroots pressure on them taking the misinformation off of the label. So for the summary, so you understand this because I want you to understand this enough to be able to explain it to your neighbor and your sister and everybody else to do this is after the WHI in 2003, the FDA slapped a warning label, what they call a boxed warning warning label on all estrogen products. Doesn't matter if it's synthetic, doesn't matter if it's what your body naturally makes, doesn't matter if it's high dose oral, doesn't matter if it's transdermal, doesn't matter if it's a vaginal product, which we know doesn't get into your bloodstream. We actually you can put vaginal estrogen in your vagina and then have somebody with a penis have sex with you and it raises their estrogen levels. Not enough to matter, raises them a little bit still within the male levels They've done those studies. So vaginal estrogen does not increase or significantly change your serum level of estrogen, but doesn't matter. What if it's synthetic estrogen or estrogen your body naturally makes? Doesn't matter. Everybody gets the same warning label. Most things on that warning label have been debunked by follow up analysis of the WHI and subsequent studies. The most irritating thing to me and what really got me motivated to remove the box label warning is number one, my little old lady is not using this product because after they meet me and you know, they have a 10 minute connection, they go home and in the comfort of their la Z boy, they read the entire warning label and it basically says it's going to give you a blood clot, it's going to give you a stroke. Don't use if you have high blood pressure. Don't use if you have a history of X, Y and Z. But the most irritating thing, and by irritating I mean incorrect thing, is that it says probable dementia. Probable dementia. That's not true. There's no evidence that shows estrogen causes dementia or probable, not even possible dementia pro probable dementia. So that's super irritating. And that's why misinformation needs to get off of the governmental warnings. The scaring is wrong. It's okay to educate, but it's not okay to be wrong about what the risks are. So LetsTalkMenopause.org unboxing menopause. If you just go to LetsTalkMenopause.org it'll go, you know, pretty, you'll be able to find the unboxing menopause. The FDA needs to understand that we are effing paying attention. I love this advocacy. This is so good. Okay, so they have a lot of education on there you can get. But it's basically removing this label is not just a regulatory change, it's a critical step towards saving women's lives. Vaginal estrogen saves lives, decreases the risk of urinary tract infections by 50 to 60%. And urinary tract infections kill people. Not all people, but especially old, frail, vulnerable people. I tell women, you know, they're trying all these things for recurrent UTIs. It's like if there was a medication that this is how I frame it for them. For people who are prescribers. If there was a medication that decreased your risk of urinary tract infections by 50 to 60%, would you want to be on it? And then they say yes. And I say great. So that, and then the second thing I want to let you know about if you are in the Seattle area or Pacific Northwest in general and want to come see some education and me on stage. Thursday, October 3rd at 5pm it's called Ladies Night Amena Positivity Expo and that is in Tacoma. Tickets start at $25. There is a VIP section if you want to have like pre party cocktails with us. So if you go to eventbrite.com and then I'd say under search events search for menopause and under location say Tacoma and that'll pop up. It'll be like a lighted sign that says Ladies Night, a menopausitivity expo. That's going to be October 3rd, so see you there. There are still tickets available. Okay. Going back to the menopause conference, there was a lecture on hair loss and they talked about labs to order if you're experiencing hair loss, checking your zinc, your thyroid, your vitamin D, comprehensive metabolic panel. And they talked a lot because this is what we care about is female pattern hair loss, which is no longer called androgenic alopecia because that's confusing and makes you think testosterone does it. The hormone component of this is not understood. There's a huge genetic component, increased shedding of the hair and the hair follicle itself is minimized. So it shrinks. We really don't understand it, but happens more in midlife. Widening of the hair part is what you see first and then front of scalp thinning and you can see through to the scalp. They talk about prescriptions that can help. They did a minoxidil oral versus topical trial. They said it's equivalent lots of women there. So there's a topical minoxidil. You have to do it twice a day and most women don't stay consistent with it. It's not a great. It's not a pleasant product to use and you have to be on it twice a day for it to work. So they're talking about oral minoxidil at low doses, 1.25 to 2.5 milligrams daily, rare risk of edema, rare risk of decreased blood pressure. And they think it works by increasing the blood flow in the follicles. Other options are spironolactone. You have to check your potassium on that and then dutasteride and finasteride. And they tend to be higher doses than men take. Men take those for enlarged prostate. Dutasteride and finasteride block the conversion of testosterone to dihydrotestosterone. So that concern for the sex med people Sex Med people worry about the side effect because you're basically kind of blocking testosterone, which we know is good for other things. So sex med we tend to more minoxidil. I always tell women when they want to blame their hormones on hair loss. Hair loss is incredibly complex. We do not have consistent data as far as if hormones are going to be beneficial. Some. Some women say I started estrogen, my nails are stronger, my hair is stronger, my skin looks great. Some people say I started hormones and they have hair loss, I think. And I don't have a paper to back this up, but I think it's the delta change for dramatic hormone changes. So that's why the pellet people tend to be a little bit louder about hair loss, because you're dealt a change of, like, if you go from a testosterone of 10 to a testosterone of like, 250. Hair follicles are very sensitive to dramatic changes like that, whether it's thyroid or stress in general, you know, postpartum. So you go from an estrogen of like, 2000 to, like, no estrogen postpartum. That's a big change. You see a lot of the hair follicles kind of like arresting in their cycle and falling out. So I asked the lecturer if you would be on my podcast to talk about hair, because you guys absolutely loved the facial estrogen episode. And he said yes. So I just need to get that, get that scheduled. All right, now we're talking about hand grip strength and big toe strength. So they said a good hand grip strength is really, really important as far as a measure, an easy, cheap measure of your overall body strength. And they said another one was stand and pick up your big toe while standing, while keeping all the other toes down. If you can do that, you're pretty strong. Then the other one is to put a credit card underneath your big toe while standing and have somebody try to remove it. That's a good sign of good strength if you can do that one. So I thought that was great for clinicians for, like, cheap and easy. I'm thinking about getting, like, a hand grip strength thing for my clinic just to kind of see where people are with that. B vitamins are good for bones. In menopause, we decrease our gut microbiome diversity so it looks more like male. That's one theory on why risk of colon cancer is improved by being on estrogen is maybe it has something to do with the microbiome. A change of microbiome is related to depression, nutrient absorption, and carb metabolism. So I feel like we're in the dark ages with understanding gut microbiome and the role of hormones in it. But it's very interesting and fascinating and I am like eating the popcorn watching that. So things that are bad for you and increase your symptoms. These things increase your vasomotor symptoms. Smoking, alcohol, processed sugars, ultra processed foods, snacking and glucose spikes. They talk about the role of continuous glucose monitor to really understand what spikes your glucose. Things that have been proven via studies to decrease symptoms of menopause. Plant based diet, fiber, low glycemic index foods, B vitamins, magnesium and vitamin E. But of course all these, if you can get these micronutrients in your diet, a lot better than pills or supplements. Foods to avoid with poor sleep, alcohol, processed foods and high glycemic foods. Things that improve your sleep fiber and magnesium. Mediterranean diet is associated with decreased muscle catabolism. Catabolism, Catabolism, Catabolism. Oh my God. And better sleep. Mediterranean diets associated with better sleep. It's also associated with improving depression scores. Weight loss alone will not address metabolic, nutrients and physiologic needs of the body. The GLP1s are have now already been renamed NUSHES, nutrient stimulating hormones. So they're talking about GLP1s and them being called NUSHES. There are 84 million women over the age of 40. That blew me away. That statistic's now sticking in my brain. Obesity in women has a higher risk of heart disease than equivalent obesity in men. The in body scan is good and quite accurate compared to the gold standard, which is dexa. In midlife because of hormone changes, we shift. Even if your weight doesn't go up, you shift your adiposity to central adiposity, the belly adiposity, which is worse for you. So than like the outside of the abdomen. Adiposity, booty and thighs. Does your metabolism slow with menopause? The data said not until we are 60. For both men and women. Apparently there's a good book called Burn that discusses this. Decreased fat free mass controls your metabolism. So fat free mass. So lean body mass helps with your metabolism. They're saying we should no longer use the bmi, but we do because it's easy. But they should call it the body roundness index. How much central adiposity you have matters more than what your actual weight is. You need a 15 to 20% weight loss reduction for diabetes remission. You don't have to go down to whatever people think a normal weight is, just 15 to 20% weight reduction for diabetes remission and a 10 to 15% weight reduction to treat metabolic fatty liver disease. Metabolic fatty liver disease is a big problem. I think it's found incidentally on a lot of ultrasounds and CAT scans. And like, people aren't even told it's a big problem. Nobody cares about their liver until it's broke. It's a big problem. Same with bladder. Nobody cares about your bladder until it's broke. Oh, you guys side. Exciting. So I was checking my. I was watching Dr. Rachel Rubin be filmed yesterday because she is creating some amazing content and I was checking my podcast statistics while I was doing that. And the youe Are Not Broken podcast hit number 220 in America of all podcasts yesterday. Long dramatic pause. Number three in. I think it was number four in medicine. And this is on the Apple podcast rankings. And I reached out to my podcast network and they were like, this was coming. We just didn't know when it was going to hit because month on month you're up 20% and. And week by week you're up 45%. So thank you, thank you, thank you, thank you, thank you. I'm just gonna do a podcast episode where I thank everybody. Thank you to all the people who care about midlife health. Thank you to all the providers. Thank you to all of the sex med doctors. Thank you to all of the people who don't know but wanna share info and know that, like, they might never become the sex med expert. And that's okay. Just share the info. Know how to help women besides telling them to have a glass of wine, know what book to give them. That's why I wrote the book. That's why I have the podcast. Thank you, thank you, thank you for sharing this. I want to keep going because, hey, the ego feels good when you're number 220 in America. But like, we're legitimately changing the world. We're legitimately giving people education about their body that's resonating and they want to keep listening and they want to share it and it's effing amazing. And I love all of you and I'm sorry for the people who think I say F too much and I'm sorry for the people who think I don't say F too much. But I love all of you and you all mean a lot to me. Okay? The next thing at the menopause conference, which I thought was super interesting, is the repeated message that obesity is a public health emergency. And I'm like, wasn't it just three years ago where we were healthy at every age. And, like, what the F happened besides the massive promotion of GLP1s? Why couldn't we say that having an unbalanced lean body mass to adipose ratio wasn't good for you? We know it's not good for your heart. We know it's not good for your kidneys. We know it's not good for your brain. We shouldn't shame people about how their body looks and all bodies look different and there shouldn't be an ideal standard. But healthy should matter, not just number on the scale. So many women are losing their lean body mass because they just. They just think the lower number is better. That the dramatic shift from healthy at any weight to obesity is the number one public health epidemic of our time. Like, that came fast. And I think that came on a Tuesday when GLP1s broke the Internet. So it's very interesting to me, just on a big social scale, that as soon as there was a marketable drug that seems to be safe and work well, all of a sudden we have a problem. But before we had that, we didn't have a problem. Kind of like with Viagra. Before then, erectile dysfunction was all in a guy's head. And then we had a solution. So now it's like biologic. Same with SSRIs and depression. Before then it was just like, you just didn't get enough sunlight. And now we're like, no, no, no. It's a neurochemical problem. So we don't want to get too reliant on medications and not remember the basics of sleep, exercise, food. It's just amazing because now they're like, oh, my God, effing wake up. Obesity is horrible. And I'm like, I think it was like three years ago when obesity was fine because we didn't have a solution. But I think the message of that of like, don't shame, body acceptance. You are good enough at any size. Don't lose sight of that. Don't lose sight of effing. Loving yourself in the process of loving yourself to be the healthiest that you can be. Because weight doesn't make you a good person, it doesn't make you a bad person. It doesn't make you lovable or not lovable. It doesn't make you be able to enjoy sex or not enjoy sex. Don't lose sight of that. When doctors start to speak up and say there are things we can do to try to make us be as healthy as we want to be, okay, There is a study saying it's called the look ahead study. It is saying that Women greater than 70 losing weight is harmful. And I think it's because of that lean body mass. If you lose lean body mass. So getting in shape after age 70 absolutely can be done and you can change your adipose to lean body mass ratio. But just strictly losing weight is a risk factor for frailty because of your lean body masses. The more the better for lean body mass. The scale just doesn't tell you. That's why they say the in body is so nice. I'll probably be getting one of those at my next clinic because I really want one and I think it's very important. Oh, B vitamins are good for you. Meat, legumes, whole grains all have B vitamins. C women on estrogen and GLP1s had greater weight loss compared to GLP1s alone. That also has been shown with testosterone in men. Probiotics are safe. There are rare side effects. Not great data to support them, but and quality matters. Good ones don't have to be refrigerated, but there are refrigerated ones. But like, that's not the only thing you need to look for. I'm not an expert in probiotics, but it seems like they're safe and have rare side effects. Was basically the takeaway from the Menopause Conference. GLP1s and bone loss. You can see bone loss, but probably not the med's fault as any weight loss can affect it was what their takeaway was. My amazing book events in Chicago were put on by the midlife upgrade. Check them out. They are in Chicago. They do coaching and a membership program. My book saves marriages, you guys. My book saves marriages out on my book tour right now. And like that's the number one thing. Is this book saved marriages or I get the. Had I read this book years ago, I wouldn't have gotten a divorce. Okay. Emerging strategies to postpone menopause. Ovarian cryopreservation to delay childbearing has been in the works for a long time. It's invasive, right? You have belly surgery to take about 30% of one ovary, which in and of itself causes loss of eggs and follicles because it's traumatizing. But then you freeze it, get your cancer treatment or whatever and you put it back later and you can get pregnant. There are accelerated ovarian changes after the age of 37. The cause is unknown. You are born with 1 million eggs and 300,000 to 500,000 primordial follicles. Ovarian transplant. A published case was in the New England Journal of medicine in 2000. You put the ovarian follicles in your arm and your abdomen. The live birth rates are 25 to 50% and you get 100% to 76% endocrine function restored. It lasts about two years. So you take a piece of your ovary, you put it in your arm or your abdomen. It will prolong, it will give you endocrine function, it'll give you testosterone and estrogen for about two years and then it dies off. Why so short? The trauma of the process. You lose two thirds of your cells just with the process of freezing and transplanting data. On 400,000 women, 11% enter menopause greater than age 55. And those women have increased life expectancy. Women who enter menopause over the age of 55 have less depression, cardiovascular heart disease, stroke, type 2 diabetes, Alzheimer's, possible increased risk of breast cancer. But the question is, are you just living longer and then more likely to get a cancer because you're just living longer because they're not dying of other things. Mean age of natural menopause has increased by 1.5 years over the past six decades. We're doing some right? Probably. Probably healthy living, probably not stressed and starving helps. If you can figure out what ages are ovarian follicles, you can make a medicine that delays menopause. Is it a decrease in DNA repair in the testicles? The same thing happens. So if we continue to extend our life expectancy, will we see more and more testicular decline, failure andropause by age 80, how many men have testicles that don't work right? I need to look into that. Are we over medicalizing menopause? There was a great talk. $1.5 billion lost a year because of workdays lost because of menopause. A 4 billion contribution to the USA economy by 2030. So huge loss if we don't treat menopause to keep women working. And this isn't just for the economy. We got to get the women to work to help our economy of like this matters for them. Women who work are less dependent on others. Women who work are less destitute and dependent on programs that may or may not be available in the future. Health consequences to a natural occurrence 4.5 billion amount spent on aging they called the menopause penalty. Lost work productivity because of untreated menopause symptoms. People ask why do we need to delay menopause? There's an ingrained status quo bias why don't we just keep things the way they are? Not dying in childbirth is natural. Infections are natural. But we've thought to help those along. So the next thought of like, why don't we try to age well, maybe age a little bit less fast. Why not? It's just a thought paradigm change than just accepting things are the way they are because we haven't accepted things are the way they are. For a lot of medicine, I could name many, many, many things not to call anything out specifically. We don't accept the status quo for most everything in medicine. Why are we doing that for women? Aging, menopause at work. Symptoms are linked to low performance, more absence, increased unemployment and underemployment. Occupation type doesn't matter. All different types of workers experience hormone therapy. Night shifts are associated with earlier onset of menopause. Economic impact of menopause in the midlife Woman has an increased $1346 per year for health care costs compared to people that aren't in that region. Global life here, this is why this is the whole Is menopause natural? Right. From 1800 to 2018, average life expectancy in the world went from 30 years to 73 years. So yes, menopause is natural, but living so long after no ovaries is not natural. So why don't we try to effing optimize it? Women spend about nine years in poor health. Women spend 25% more time in poor health than men. People are like, too many women are suffering in silence. And then the other people are like, we're over treating menopause. And then they're like, how can we be suffering in silence and over treating menopause at the same time? Doesn't make any sense. All right, so then there's an amazing talk on gsm. GSM is a diagnosis of exclusion is what they said. I don't know if I fully agree with that. I think it's the most common thing. And then you have to rule out infections. If it's present in 50 to 85% of women, how is that the diagnosis of exclusion? But like, you have to make sure it's not an infection, not all these other things. GSM prevalence 2021 article in menopause by Dr. Milley and her associates. 92.8% of women in menopause clinics have said they experience genital urinary syndrome and menopause. 87% vaginal dryness, 66.9% dyspareunia, which is pain with sex pain and low desire dominates the midlife sex change menopause 2017 there's an article changing in sexual function over the menopause transition. They're talking about vestibular changes, changes in the entrance of the vagina, the vestibule, petechiae, pallor, thinning, dryness, redness. Women have pain because of the vulva, not the vagina. So they're like, that's why we shouldn't call it vaginal atrophy because it's a lot of it's vulvar symptoms. Are we being too late in treating gsm? I would say yes. They called it let L E T local estrogen therapy instead of vaginal estrogen therapy. I really liked that. I wanted to try to start using that more, especially on Instagram where they don't let me say the word vagina a lot. Step therapy is not mandatory. Meaning it used to be like try moisturizers first or there's no data to say that. If it's a lack of hormone problem, give them the hormones. The door is open for energy based therapy, but we need more research. Don't forget the partner. Involve the partner, treat the partner. As far as sexual function goes, when you treat sexual dysfunction, treat GSM first. That was their takeaway. Sex and sexiness is ageless, but not trouble free. I like that this is a data. This was data presented again in the sexual function 1 In 2021 a paper showed polling all ages, 25% of Americans had no sex at all in the past year. Gen Z has less sex than the other generations. And in age greater than 65, 30% have sex once a week. Don't compare yourself to other people though. This is just an effing study. This is not to say if you're normal or not. Okay, in the 20s people are having sex about 80 times a year. In the 60s they're having sex about 30 times a year. But how is this true if also they just said Gen Z is having less sex? So I'm not convinced of all the accuracy of all this data. More important than the age of the person is the age of the relationship. On if you have you know how your sexual desire is or your sexual functioning. Because remember, the brain seeks novelty at the same time loves conformity. So the brain gets habituated after about six to 12 months in a relationship. So you have to keep the desire and the intimacy alive. Desire is not how women always enter the sexual event. Your appetite may be neutral, but if you engage for other reasons, for example emotional connection, then you get aroused, then desire kicks in. But remember you have to have sex worth desiring. Responsive desire is not dysfunctional. Read my book. I'll say I talk a lot about that in the book. But some women want to want or miss wanting and we can treat that the partner as a precipitating factor for sexual dysfunction. That's interesting to think about. It's not me. I like sex. It's just my partner. Barry McCarthy, famous sex therapist Good sex adds 15 to 20% value to a relationship, but bad sex is freaking bad for the relationship. Dr. Kingsburg gave a lecture hypoactive sexual desire is the new depression in 1988. Prozac was the first SSRI that came out and the first acceptance that depression could be biologic. Depression is a loss of pleasure. HSDD is a loss of sexual pleasure desire Discrepancy between a couple is not HSDD. Testosterone position statement is supported by 12 international societies for HSDD. Testosterone helps in all domains of sex. Talked to a lot of people. Orgasm is a lot easier to. This is funny. Testosterone is a lot easier to come by. Orgasm is a lot easier to come by. When you're on testosterone, get a baseline testosterone. When you're going to do that, there's no level to get to. And don't forget about estrogen and desire. Next talk was on sleep disturbances and breast cancer. 24% excessive daytime sleepiness. A study looking at letrozole showed a 40% insomnia symptoms. Menopause relates to a decreased regulation of melatonin. There was a study looking at sleep effects on survival and breast cancer. Over nine hours of sleep, you die sooner. A lot of people have trouble sleeping, but people who sleep too much, that's associated with dying, probably fatigue, overall wellness and strength right to get out of bed. And they couldn't say, are you actually. Are these people actually sleeping for nine hours or are they just in bed for nine hours? Hot flashes predict the number of reported awakenings. Nam's 2022 statement Estrogen may have some effect on sleep independent of vasomotor symptoms. The lack of studies on progesterone is criminal. Progesterone is cheap. It's been around forever. There's no money in studying it. The effect of placebo on sleep. There's 32 studies on this. Placebo helps 63.56%. Don't forget cognitive behavioral interventions. If you get your hormones up and you still have trouble sleeping, go to a sleep specialist. You guys, reminder. On this long podcast, everything I'm saying was my takeaways or tidbits from the Menopause conference. I did not attend every lecture. I might be wrong in some of these and how I interpreted it. There's a lot of nuance in a lot of this. So don't be like, Casperson said this one sentence once on this one podcast. And this is like, no, this is a very, very high level overview. I hope you understand that no data for Trazodone or Melatonin for insomnia disorder, which is very different than like, I have a little bit of trouble sleeping. But many, many women are given that Ambien and Lunesta are GABA receptor agonists, which is basically what progesterone does, which has way less side effects and other benefits. Talked about the role of doxepin for sleep. Women 41 to 64 who slept less than six or greater than nine hours had higher odds for low testosterone than sleeping seven to eight hours a night. Does poor sleep decrease your testosterone production problem? BL testosterone's made at night, specifically during REM sleep. It's like, who's the chicken and who's the egg? Does poor sleep decrease testosterone? Or does low testosterone equal poor sleep? There's a lecture on are we over treating menopause again? Super awesome. The conclusions of the WHI were not scientifically sound. This has been repeated by many experts since the WHI trial came out in 2002. Male mortality has gone down, female mortality has gone up. If you take the WHI study at face value, as far as breast cancer goes, it was for an increased risk of four breast cancers out of 1,000 people. So very damn low. And we don't use that progestin anymore. We think that might have been what caused it. We also think the placebo arm was flawed. And we also know that the increased risk in breast cancer was not much higher than a lot of other things that have been associated with breast cancer. So this is a very short overview of why the WHI was flawed. But everybody stopped hormones because of the fear of breast cancer. It's just not grounded in significant risk. Hormone therapy is considered the gold standard for basal motor symptoms and GSM, but 60 to 70% of women will stop their hormone therapy within one year, likely because of the fear and the pressure of stopping hormones because of the risk of breast cancer. Hormone risk to causing breast cancer is about the risk of what obesity and alcohol is. I think the risk is lower. I think they were underplaying the risk of alcohol and obesity. And that also depends how obese, how much alcohol. Right. And then one of the experts who was in the who wrote the WHI has now recently wrote WHI findings should never be used as a reason to deny hormones to women in early menopause with bothersome basal motor syndrome symptoms. Empowerment is essential to shared decision making. Then they reviewed the SWAN study, which is a prospective observational study across women aging across America. Black women have the most hot flashes and the most severe hot flashes. If you ask women, do you have any problem with sex? 45% will say yes and 15% will say it's distressing. 63% of women do not feel like themselves. There's an increase in LDL of your cholesterol in menopause, not an age effect, as it would go up linearly if it was an age effect. And it goes up precipitously right at the menopause transition. SWAN study data showed us that. Other things that the SWAN study told us Profound effect of menopause on lipids increase in vascular stiffness, not just aging. Carotid atherosclerosis. Carotid atherosclerosis accelerates late perimenopause. So perimenopause. Late perimenopause is when shit starts going down. Even if your weight is stable, you will increase your fat mass and decrease your lean mass. Part of decreasing lean mass is bone density going away. Increased anxiety in late perimenopause is the worst compared to, like, years post menopause. And they think the increase in anxiety might be related to vasomotor symptoms. Increased depressive symptoms quadruple the risk of major depressive disorder post menopause. Decrease in verbal memory performance. Vasomotor symptoms are associated with increased atherosclerosis even after adjusting for age, race, education, bmi, lipids and hypertension. This is where people pick on social media, the menopausy experts for being like, you're scaring women. Like, no, I'm fucking educating women. If they choose to be scared about learning what the data says, how about being a little bit pissed that everybody thinks you shouldn't try to prevent your health from getting worse? Okay, so the Solon study was started when women were 40 and these women are now 70. Worse vasomotor symptoms are associated with increased risk of heart attack if you have persistent vasomotor symptoms postmenopause, 70% increased risk of stroke and heart attack compared to people who don't have persistent vasomotor symptoms. Insomnia is associated with increased risk of heart attack and stroke at a risk of 71% increase even when adjusting for heart comorbidities Very cool Study by Pauline Mackey, 2008. They took women with hot flashes and they studied their memory and they blocked their hot flashes with stellate ganglion block. Their memory got better. That's crazy, right? Brain don't like it. Brain don't like hot flashes. Hot flashes, stress. Brain fix hot flashes fix brain. All right. 91% of women said they don't have enough information about menopause. Share my podcast 36% of women don't feel comfortable talking about menopause to their providers. 31% obstetrics and gynecologists are trained in menopause and of those 31%, 71% had less than two lectures. 6.8% of residents of all residents. So medical school graduates who are now doing residency. This is all residents, internal medicine, family medicine. Of all the people. All the people, not ob. Right. So if you didn't go into a woman specific specialty, 6.8% of residents felt adequately trained to discuss menopause. Interesting data saying that hdl, which is considered the good cholesterol, that a higher HDL doesn't help cardio protection as much postmenopause as it does premenopause. What to do about asymptomatic women. That should be a podcast episode, don't you think? What to do about asymptomatic women. They are the ones who get the hip fractures. That's me saying that of like they're the ones who are like, well if you have, if you have symptoms, treat menopause. But like if you are lucky and don't have symptoms, you don't eat hormones. But then if you don't have hormones, you're the one getting the hip fractures. So like make it make sense that we don't treat the asymptomatic women. It doesn't make sense to me. All right, another statement of getting the men on board. Everybody needs to care about 50% of the world they're talking about. Top articles of the year Menopause hormone therapy on diabetes. They said it's bidirectional diabetes. Type 2 can affect ovarian aging and menopause can increase the risk of diabetes. So a bidirectional effect there later age menopause onset has decreased diabetes risk. Meta analysis of 17 randomized controlled trial showed menopause hormone therapy decreases insulin resistance if you have a good heart score. So atherosclerotic cardiovascular risk disease score, ASCVD score. Physicians know what that is because if you come in wanting hormones and you're a Little bit older, you've got some risk. Then they'll usually run this calculator. And if you're in the low risk category, you could consider oral estradiol, which has a stronger improvement in insulin sensitivity than transdermal. But if you have moderate cardiac risk, they don't want you to take oral estradiol. They want you to stick with transdermal semiglutide. And cardiovascular outcomes in obesity without diabetes. This is the select trial. Obesity is an independent risk factor for cardiovascular events. This is a randomized control trial looking at women over the age of 45 with BMIs greater than 27 with established coronary vascular disease. So previous stroke, previous MI, previous peripheral vascular disease. 70% of these people were male, 66% of them were pre diabetic. Semaglutide decreases all cause deaths and decreased A1C and weight compared with placebo. 17% of people discontinued the study because of the study drug side effects. 7% discontinued the placebo. This is complicated stuff. I don't want to downplay that. Do not take one sentence that I said and try to extrapolate it to you. The medicine's complex and we're not all Toyotas. Don't use the podcast as individual medical advice. The Prevent calculator. It's a new cardiac risk factor calculator. You put in your zip code for social determinants of health. This is very interesting. They got rid of race because you could be of a certain race and be wonderfully wealthy with social connections and great access, AKA zip code. Right? So zip code is associated with mortality in the United States of America. The other thing in this new heart calculator, it's called the Prevent calculator, you can Google, it includes kidney function and A1C independently predicts heart attack, stroke, heart failure and total cardiovascular disease risk. Then there was an article on changes to breast cancer screening. United States Preventive Services Task Force recommended screening between the ages of 40 and 74. They have changed their screening to Q2 years, which leads to less women being screened in general because you kind of lose them in the system and then they don't get screened. There's data to support that. Only 64% of women in the United States of America are screened for breast cancer. Screening decreases your mortality, especially in black women. False positive rate of a mammogram is 6.5%, which means you will suffer a false negative biopsy every 100 years, which means that's pretty low risk and you might get a false negative workup every 13 years. So understand every screening test we use, whether it's a colonoscopy, mammogram, chest X rays, anything that's screening for disease will have false positives, meaning it looks positive, but then on workup, it's negative. Paper on military sexual trauma. Women who have suffered military sexual trauma have two times the rate of vasomotor symptoms and vaginal symptoms. 20% of women have greater than four adverse childhood events, or ACEs. Look up ACEs if you don't know about ACEs. An internal medicine doctor in my community introduced me to ACEs and in the coffee shop on a coffee break probably 10 years ago. And it's incredibly insightful. Child abuse and PTSD increase both vaginal and vasomotor symptoms of menopause. Incredibly interesting biopsychosocial effects here of mammograms. Out of 1,000 women screened, five cancers will be found. If you do MRI, 37 cancers will be found out of 1,000. So the question is, are those cancers that we shouldn't find? And this is incredibly complex. Don't misinterpret me here. Our bodies make cancers, and then our bodies process them and let them go away. And they don't always become a true what we think of as a cancer. Our bodies are always making mistakes and correcting them. Sometimes our body can't correct them, and then it becomes clinically significant. But it's like, and I never want to get into the weeds and, like, misinform people, but there's false positives that happen. Or like, if we find something, maybe it never, ever would have killed you, but we're just so good at finding little blips now. Which is not to say don't get screened. It's just to say that the discussion over what the correct screening modality is. It's probably not a one size fits all. People at higher risk probably might need a more sensitive one because their cancers might actually be worse or more likely to find and treat them and do better. And low risk people probably don't need to be finding all these asymptomatic things. These are incredibly complex concepts of how do you find the right test to apply to an entire population? Certainly women with more dense breasts. Maybe they need a different type of screening. And then how do you get insurance to do that based upon risk at a population level? These are incredibly interesting and challenging conversations. 75% of women who get breast cancer don't have a family history of breast cancer. Super. What I want to find out on that corollary is of women with a family history of breast cancer. How many of those women don't get breast cancer because everybody's like so afraid if you have it in your family, I want to know the data to be able to help people. My job is to make you guys think. I'm here to make you think. I'm not here to tell you what to do. I'm here to make you think. I'm here to bring you news. I'm here to tell you how I like to think about things. I'm here to tell you that I love the complexity of medicine and how there isn't always a right answer and how we shouldn't just the answer to your individual health problem on a 90 second Instagram reel like that's not healthcare. It's education, but it's not healthcare. And it does things don't always apply to you. So long Podcast this reminds me of the debriefing of the Ishwish Conference that I did earlier. You know, go back and find that podcast if you want to hear about. If you like the style of like a medical conference review, go back and listen to my Ishwish Conference podcast review because it's like equally as long and entertaining. So I love you. Thank you for sharing the youe're Not Broken podcast. Go out and buy the book. It's also called you Are Not Broken. It's Saving Marriages. Give it to your adult children. Give it to your male partner. Everybody needs to understand female bodies. It's incredibly important. So love you to the moon. 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. 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