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- [00:04]
A
Welcome to the you are not broken podcast.
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I'm your host, Dr. Kelly Casperson, a
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board certified urologist, thought leader and conversation starter on midlife living, hormones and sexuality.
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Enjoy the show.
- [00:18]
A
Hey everybody. Welcome back to the you are not broken podcast. Today I have Jennifer Lanoff, who's a board certified women's health nurse practitioner and attorney. And we're going to hear all about that journey. But we're not just talking about hot flashes and hormones today, we're going to talk about ethics, access and advocacy with the brilliant Jennifer Lanoff. Thank you so much for joining us today.
- [00:38]
C
Yes, I'm so happy to be here.
- [00:39]
A
Okay, first, your story. Not many lawyers go back to take care of humans. What happened?
- [00:46]
C
Well, it's only funny. Well, it's funny for a lot of reasons, but I have resisted for so many times doing anything lawyerly because you know, everyone when I went back to school is like, oh, you can be a great med mal lawyer. Oh, you can start. You know, you're going to really know it. And I just have been like, nope, I want to see patients. I want nothing to do with this. So I was a public defender for 25 years. Ish. Including, you know, sort of during law school representing the poorest of the poor, hanging out at the jail, working on prison conditions for kids and adults, trying murder cases. During 9 11, I was like the only person trying a case because I was nine months pregnant and the entire courthouse was empty. But the judge was worried that I would go into labor, so we had to finish our trial. It was crazy. But I, you know, I did it for a long time and it's a lot of fun fighting with people. And it's also hard, hard work. Although I have to say this is hard work too, but in a different way. It just tugs at your heartstrings. My son is an investigator that now at the public defender service in D.C. and he sees it right, because there's no happy ending. Right. The clients are just as much victims as the victims. So it's a hard job and I couldn't really figure out what I wanted to do next. And I've always loved reproductive health. So given that I was old, I decided that I would. I interviewed everyone. I said, should I go to med school, Should I do this, Should I do that? And every doctor I talked to said, do not go to med school. It's a waste.
- [02:03]
A
It's long, it's a 20. I mean, no offense to the people who went to med school older, but it is a 20 year old game for sure. Not just length of years, but it's grueling physically.
- [02:14]
C
Yeah. And I also realized, like, I didn't want to do surgery. I don't need to do surgery. I don't. So then I thought, oh, I'll become a midwife, and I'll just do, like, some very low stress, you know, because GW has this great. Or they used to have this great midwifery program. You could deliver in the hospital. If it became complicated, the doctors would come in. So. And so I thought, you know, this is easy. And so. Well, not easy. But then I went to school, I went to Hopkins, drove back and forth to Baltimore every day. Cause I live in D.C. and then I just was on that path. And then I did my first rotation when I started Georgetown, the master's program at a home birth clinic. And I. I hope I'm not insulting anyone, but I was basically like, oh, my God, I don't like pregnant people.
- [02:52]
A
Way to be honest with yourself, though, ahead of time.
- [02:54]
C
Well, it was just funny. Cause I. My whole path was midwife, midwife, midwife. And I had been doulaying, and I had been doing all this stuff, but I was measuring bellies every day. And I realized that I always looked forward to the Wednesday, which was the day they only did gyn, because those were the most interesting days. And of course, at that clinic, I already knew Rachel Rubin, So I had been involved with nams. Rachel's my neighbor, so I have known her forever. And I had already sort of started down this path, so I knew some stuff. And then, of course, they were like, we don't mention the E word in our meetings with our patients, which is estrogen. And so I really spent a lot of time trying to educate them that, you know, that group of clinicians about hormones and all of that. But, yeah, then I realized that. And then. So, as luck would have it, Jim Simon was willing to take me on as a student or, you know, for a clinical rotation. And so I worked with him for a year, and with his amazing pa, Lucy Trin, who is a quiet genius, I mean, she's amazing with all of this stuff. So. And then I just. I fell into it. So, you know, it's hard to say. I think I really wanted to do direct patient care. I didn't want to go to, like, work for Plan Planned Parenthood or National Women's Law Center. I wanted to actually help patients. You know, if there's Armageddon, being a lawyer is not that helpful. So I thought, you know, I'm just Gonna learn. I'm gonna. I'm gonna learn some skills. So I guess that's my story. I don't. There are probably other versions of it
- [04:12]
A
that I say, but it's very unique. I mean, there's some combo MD JD programs, but people don't really practice law.
- [04:19]
C
Right.
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A
Like, the fact that, like, no, no, no, that was your career and then you pivoted is very unique.
- [04:25]
C
I still sometimes identify myself as Jennifer Lana from the Public Defender Service. I just. It's so part of my.
- [04:31]
A
It like comes out and you're like, hold on.
- [04:34]
C
So one of the other things I did when I was a lawyer was I was. I was on. I worked for the Board of Professional Responsibilities. So we heard a lot of attorney ethics cases. So that always sort of interested me sort of defining what's ethical and, you know, the med mal stuff. I always thought about that because I always felt so, you know, I was on lower side. I saw these poor clinicians who had tried to make good judgment decisions and then were getting sued. So. So I've sort of always been interested in that whole world, but I have put it off until this year when I feel like I'm. I feel like we have to start talking about it some more.
- [05:02]
A
I think that's the magic of anybody who brings in like, very disparate pieces of themselves and then they have like a superpower that you're like, I didn't go in this to have a unique lens on advocacy ethics and like menopause. But you do now because you have that background and that, like, deep, deep understanding that if you just went into medicine and went straight into medicine, you wouldn't have that. You don't even have the language, really. Like, to me, I'm like, jen, can you define ethics for us? Like, it sounds stupid, but, like, we better start there.
- [05:39]
C
Yeah. Well, it's interesting because when we all take ethics, I mean, I took it in school, you took it in school. I think it was all the course we hated the most. I don't think that any of us. Professional responsibility, you know, it's sort of like, let's get through this. Maybe it's a light class. I feel the same way. When I gave a lecture at ISSWISH this year, I was looking over the schedule and every time I would see my own lecture, I'd be like, oh, that's boring. I'm skipping that. And then I'd be like, oh, that's what I'm doing. It's not the most exciting or sexy part of it, but I think it is really interesting. So historically it used to be autonomy, justice, beneficence. And I think it was really coded in a way that we were not supposed to harm our patients in the same way we think of medical malpractice, right? We shouldn't be doing things that will hurt them. And I think that's sort of the way we've always thought about it, right? Don't give them medicines that are unsafe. Don't give them treatments that have terrible side effects. But I think given our political world, and it's maybe even not the political world, it's just the world we live in right now because it's clinical and political. But, you know, we are starting to deny patients. So I think we have a new definition of ethics. I really think it needs to be changed. It has to be, we do no harm. Has to be also the harm of doing nothing. Because I think it was always a very active way of talking about harm, right? Doing something to hurt your patient. Now I think we have to really consider and take a long, deep breath and look at how harmful it is to not do anything, right? I mean, you think of abortion, right? You think of the woman in Georgia with her brain dead and being forced to carry the fetus. You think of young children who are incest survivors. I mean, and you think of gender affirming care, right? So, I mean, these are, this is not doing that. Not treating those patients with what they need and at least engaging in shared decision making, I think is sort of a new ethical world. I think we have to really focus. And you know, of course, this, this, we're talking about this, but like goes through menopause, which feels like a little crazy, but I think it's true there as well. But yeah, there's. I think we need to have a new framework for how we view ethics medically, legally.
- [07:36]
A
Correct me if I'm wrong, a clinician is much more likely to get sued for doing something and having a side effect or a consequence of it than be sued for not doing something. With the exception of failure to diagnose,
- [07:50]
C
I think that's probably right. Although, you know, I do think we're in this new world, we don't know. Can people who have been denied gender affirming care start to sue when they're not allowed to make their own autonomous decisions? If I were a lawyer, I would. I mean, actually I am a lawyer.
- [08:06]
A
Nobody, not many people are allowed to be like, hold on, yeah, I am a lawyer. But to switch to, you know, I think where many People are starting to talk. Whether or not it's going to materialize is can we sue? Can there be a class action, something against the WHI and more against like the media.
- [08:23]
C
Right.
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A
Like who actually did, who actually did the harm in the WHI and can you. Do we have a big enough case to prove correlation equaled causation on there?
- [08:33]
C
I mean, it is so interesting, right? When we went. I don't know if you want to talk about it now, but one of the things I, when I gave a lecture that was similar to this, what we're talking about a couple weeks ago and you know, when I first started thinking about harm in menopause, it sounded kind of silly because I was like, you know, of course abortion's harm, not giving birth controls harm, not giving gender affirming therapy. All of the things that's harm but like, is not giving someone some estrogen harm?
- [08:54]
A
I had this amazing post by a personal trainer on Instagram and they were like bros at the gym doping testosterone to get the look that they want to get is gender affirming care. Isn't all of this gender affirming care, we've, maybe we've politicized that, but it's like it's actually all humans need gender affirming care.
- [09:17]
C
Yeah, I mean, I don't know about you, but I have to do prior authorizations every day. It's a little strange for progesterone for my patients who want it, not even estrogen. But I have to, I have to sort of like say it's not being used for gender affirming care. But also I'm like, why am I even saying this? Why? It's such a strange exercise that insurance companies will only give it if we say it's not being used for gender affirming care.
- [09:37]
A
And on the flip side, insurance companies will only pay for testosterone if it is for gender affirming care. So like that's the double edged sword of it is like, when can we just call all of this gender affirming care to get rid of all this insurance bullshit?
- [09:51]
C
I know, I do wonder that like, are patients coming in and they, you just want some testosterone? They're saying they're transitioning. I don't know. They could. You know, a patient could show up and say anything, right? They could say I'm having hot flashes 100 hours a day and you'd be like, okay.
- [10:02]
A
But I mean, I think that's the slippery slope of all of this is the erosion of trust in the medical system because people are Lying to get the care that they need, whether they're lying to the pharmacist or they're lying to the insurance company, or they're lying to the doctor and nurse practitioner. It's like the erosion because we don't treat people as the individuals who have valid concerns, who have valid requests and they have to do all these loopholes.
- [10:28]
C
Yeah. And you know, it's just all about. It's nothing more complicated than shared decision making. Right. I just think that is informed consent.
- [10:36]
A
Can we define those things for people?
- [10:37]
C
Yes. I mean, I think I overwhelm my patients sometimes with studies because I'm always like, I promise this is true. Let me send you my Google Drive. Because I, you know, maybe just don't have enough self confidence that they'll actually believe me. I mean, they love it. I mean, of course we have to have an appointment to discuss all of it, but I say to like, here is the evidence or you know, for breast, you know, breast cancer. I'm sure we're going to talk about this. I don't know if you want to talk about now, but that's the ultimate situation where I think, and this is what bothers me the most, where someone will just say, an oncologist will say no to a patient. There is nothing more that drives me crazy than when someone just says no to a patient. Because. And this is the whole sort of regret, which I talked a little bit about. I think a lot of the time we don't do things is because we're worried that someone might regret it. Right. Gender affirming care. I think we make these decisions, you know, they're 16. What if they regret it someday? But is that our choice to make? If the patient is advised of all the consequences and what this means and gives their consent. So I think consent is a deeper conversation. It's not just someone signing it is talking to them about the side effects, talking about the pluses, talking about the minuses. I mean, taking the time to really explain to patients what the evidence is. And by the way, if there's no evidence, which there are a lot of situations like that, then saying like, we don't know there hasn't been enough. And for our breast cancer patients and men said all the time, like, we can't wait for a randomized controlled trial. These women are really suffering. But if a patient understands that and knows that and then reads the habits trial and reads the data, then I feel like we get to decide together what they think is best. And I think people, even if they Decide in the end not to do it. I think people feel so empowered by the fact that A, you are listening to what they are saying and not just saying no to them, and B, that you are offering them some hope that maybe their symptoms can be addressed. So, I mean, I don't know. Consent is much more than just signing a piece of paper. I think we are all quick to do it. I'm a lawyer, I know more than anyone. I just signed the thing. But I think when it comes to really important decisions, we should be really sitting down with our patients and going through it. And when our, when we're done with conversations, we throw all this stuff at our patients. You know, a meeting with them, and then we say, okay, any questions? I think we got to say, what are your questions? You know, it's as simple as that. Like, what are your questions? Because they're overwhelmed.
- [12:55]
A
Yeah. I mean, I think what percentage of the degradation of the ability to listen, the ability to answer questions, the ability to have a true informed consent is because of the 10 to 15 minute patient visit that is the current medical system. Because to me, I'm like, listen, people who go into health care, they've got big hearts, they're smart people. Otherwise they wouldn't be accepted into the schools. They don't lack a moral failing. They're usually in it for the best of the patient. What eroded it? And to me, I'm like, it's not the people in the system, it's the system.
- [13:28]
C
Yeah, it's the time. Right.
- [13:29]
A
It's the time constraints in the system. You don't, you know, when people are like, you know, what should you ask your doctor so you can learn in the doctor's office? I'm like, you can't learn diddly squat in the doctor's office anymore. In addition, information, besides what's behind paywalls, which I think is unethical in the first place, that's your tax dollars going to research that then gets locked behind something you don't have access to.
- [13:50]
C
Or maybe not anymore, given what's going
- [13:52]
A
on in the country. Right.
- [13:53]
B
Yeah.
- [13:53]
A
Or lack of research. But is the ability for the average person to truly get a lot of knowledge now. Right. And I see that is like, it's a different conversation. The doctor doesn't know it all. They don't know all the studies. They don't. They've been figuring out diabetes, heart disease, slee apnea, and like osteoarthritis. While 20 years after the WHI has been going on, they did learn about Hormones. And a lot of women know more than their practitioners now.
- [14:21]
C
Right, but where are they getting educated? No, I love that. I love. I think patients are really grateful when you say, you know what? I have no idea. Let's talk about it. Let's do the work, let's do the research, and let's figure it out if it's right for you instead of just, you know, echoing what they. Parroting what they learned 20 years ago. I mean, if I walked into a courtroom and I said, oh, here's my case from 2001. It's binding, that's it. I mean, people would think I was ridiculous. And our patients are smart and they're really trying to educate themselves, and it's so important to make sure that we are pointing them in the right direction for what they should be reading and learning about.
- [14:51]
A
Yeah. I mean, part of what happens behind closed doors that you and I know about is like, some physicians are, I don't want to put the words into their mouth, but I would say feeling threatened or annoyed by patients coming in, being educated, advocating. Because now people like us are like, this is how you talk to doctors. This is how you ask for trial of medication. These are the papers you need to know. We are getting the information out there. And then the backlash from the. And again, not all healthcare providers, but, you know, I was having this conversation with somebody else. They were shocked that a doctor was, like, annoyed and upset that women are coming in asking for stuff. And it's like, yeah, we're giving them more burden. Right. They're already completely overwhelmed with their day and their job. And now it's like, people are coming in wanting to talk and wanting to discuss and, like, wanting to advocate. And it's like, I'm sorry, it's the system, not the people in the system. I will. I'll die on that sword.
- [15:45]
C
Yeah. And when, you know, I always say to my patients, like, this is not me. It's not you. Your insurance company has given me 15 minutes. So I'm going to do my best to say what I need to say. I'm going to give you some reading to do, and then maybe we come back and talk about it. But. And I agree, it's so much. And then again, there's so much information now on social media. How do people even know where to go and why? You know, patients. Like, I looked on Reddit, and I'm like, Reddit is not. Reddit is not a reliable source. So we have to really be careful to point them to the right things.
- [16:15]
A
I'M happy to take tips, but it's tough because it's like, why is AI still wrong about vaginal estrogen? Because the Cleveland Clinic website's wrong. The Mayo Clinic website's wrong. You know, like, the big health care places, data is wrong on their websites about hormones causing cancer. Or you can't use vaginal estrogen because it'll cause a stroke. And then here we are being like, watch out where you get your information from. It's a big, tricky thing.
- [16:42]
C
So tricky. And the whole social media world is crazy. And, you know. Yeah, I don't know. It's hard.
- [16:49]
A
Yeah. I mean, to me, it's like, I sympathize because it's like sometimes you just want a quick answer to something, right? And, like, most things in healthcare are not a quick answer. And really, it is, dude. Your body's one of a kind, my friend. Right? Like, we're not Toyotas. But if you start seeing themes, you know, trickle up on social media and, like, themes of like, okay, are doctors saying this? What are they saying? And I think the other thing, just for the layperson to understand is, like, we don't have it all figured out. We will never have it figured out. Had we always had it figured out, we would have, like, started by washing hands instead of having to discover that the earth would still be flat, we'd still be using leeches. The practice of medicine is never static. It's never static. And that's a tough pill to swallow for a lot of people who just want the answer to be like, dude, we could figure out 10 years from now that we should have been giving 10 times the estrogen levels. We got no idea right now.
- [17:48]
C
Right? And, well, the problem right now is we're research. I mean, I live in D.C. like, I mean, NIH has been decimated. And even more than that, these people are taking early retirement. So even if we tried to recreate it, those people are gone.
- [18:00]
A
Brain drain. Well, plus, it's like. It's like trust, and people want stable jobs, you know, and it's like, if they're gonna leave and not come back because they've gone somewhere else.
- [18:11]
C
It's interesting that you said the thing about the Cleveland Clinic, because look at what, you know, Hallie Peterson just did in that menopause note. This is someone who has dedicated her life to breast cancer treatment, and she's. She is now out there saying, like, this we have to talk about with this with our patients, because it may not be as dangerous as we think. And it is all about Shared decision making. And are our patients. You know, I think oncologists and everyone just look at it that no breast cancer. No breast cancer. No breast cancer. But are they more likely to die of a broken hip when they're 80 and never come out of the hospital?
- [18:40]
A
Right?
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C
Like, is their marriage ruined because they can't have sex because they are sweating? Like, there are just so many different things that cardiovascular health, right? Like, we know all these things, and that's why I feel like it's harmful. It's because we're not addressing all the other things and then we make people afraid.
- [18:57]
A
But, I mean, you have to look at the goalposts. The goalpost for cancer care is cure. What are the fricking signs on the side of the highway for? MD Anderson say, it's cure, it's cure, it's cure. And that's what you go to them for. You go to them for cure, right? And the good news is a lot of this is very curable. Like, that's the thing that annoys. One of the things that annoys me about the breast cancer thing is like, this is you guys, by and large, 95% survivable now. That's not how it was 20 years ago. Incredibly survivable now. So the goal post has to change. It's like, we won that game for most people now they need to live and not just be like, let's keep you cured. We don't know. So let's keep you cured is like, move the goalpost. And until oncology cares more or equal to something else besides just cure rate, you're not going to see that coming from. That's their goal post.
- [19:54]
C
There are two things I always show my patients they are blown away by. One is something I put on Instagram all the time because I just need now I need to be able to see. It is the rates of what people actually die from osteoporosis up here, breaking your hip, mortality huge when you're 80, cardiovascular disease and then breast cancer. Breast cancer's all the way down here. And so I always. I want to talk to them about that. Then there's another thing I say to them, which I also, they can never believe, is that actually hot flashes are not good for you. I think people feel like they really have to get through these hot flashes because there's no other thing that we actually have to get through, right? We can't see, we wear glasses. We can't walk on hot ground, we wear shoes. And it's just funny how people have These attitudes. But once I start talking to them, like, it leads to later life dementia. If you're waking up 100 times at night because of a hot flash, you're going to have increased risk for cardiovascular disease. And I think that is the harm, right. That when we are not giving our patients the information that they actually may be hurting themselves by not doing this, it's more than just breast cancer. It actually is brain health, it's bone health, it's cardiovascular disease prevention. I mean, these are. We are not using them for prevention, but they should know what the rules are in terms of what the numbers are. Incredible.
- [21:02]
A
Yeah. I was like, for one hot minute I thought I had invented something new. And I was like, oh, it's called the doctor patient relationship. Because I'm like, I'm like, I want to create a clinic where I have like an hour with somebody and we just talk and I just hear them tell me what they're worried about and how. I want to see how women are processing this.
- [21:24]
C
Right.
- [21:24]
A
Because I want to see what they think is important and have they considered these other things and blah, blah, blah, blah, blah. And I'm like, yeah, I want a relationship with them. Thinking this was like this novel thing because it didn't exist in my insurance based medical practice. Right. And I'm like, oh, wait, that was like how this all started was like a relationship with a doctor and it is completely gone. And that's why, you know, so many people, they're like, the doctor only cares about keeping me alive. The doctor only cares about curing the breast cancer. The doctor, blah, blah, blah, blah. And it's like, well, yeah, when you have 10 minutes, you've got to have one goal post. But I was like, I was like super humbled by my like discovery. I'm like, you know what I want? I want a relationship. Oh, I think that's called the doctor patient relationship. Which was like a thing.
- [22:07]
C
Yeah, that used to be a thing.
- [22:08]
A
I don't know why it used to be a thing. Let's go back. Just so people know, the Menopause society puts out menopause pearls. And the big thing that came out recently was that a breast oncologist wrote the pearls. And that's meaningful. It wasn't not an oncologist.
- [22:24]
C
She's an ass. Yeah. Breast cancer surgeon and oncologist, but like the head of breast cancer surgery at Cleveland Clinic.
- [22:28]
A
Yeah. And so that's powerful in and of itself. Basically saying we need to rethink this. Absolute no on breast cancer survivors and hormones. The Other thing that like totally annoys me about the breast cancer hormone thing, this is my other pet peeve is people are like, doctor said I can't have hormones or I can't have estrogen. And I'm like, well, you can have vaginal estrogen, progesterone, testosterone. None of that's ever been written off.
- [22:57]
C
I know. And it's going to be hurting people. Like, we're not taking your ovaries out when you get breast cancer and you're still getting estrogen. So that doesn't seem to be more like, you know, you're getting pregnant. But. Yeah, no, I know. I love that.
- [23:07]
B
Yeah.
- [23:07]
A
That's the thing is like breast. Young breast cancer survivors, again, I like to explain it to people. Young breast cancer survivors are allowed to get pregnant. Allowed. Air quotes, right? Like they're like this copulation may proceed. Right. Like they're in your bedroom. But like they did and they studied that and they were like, let's let these people get pregnant. Let's see if their breast cancer comes back. Keep in mind your estradiol level when pregnant is 2000. We bring it with postmenopausal hormones is usually around 50 to 100. So they're allowed to have an estradiol of 2000, but then they're not allowed to have postmenopausal estradiol. That's gonna put em to like 50.
- [23:43]
C
It was like, right, 25. Yeah. I mean, the same is true of migraines now too. I feel like so many of my patients come in and they say, well, I can't have any estrogen because of migraine. You know, I had migraine. And first I say, first of all, like, do you actually have migraines? Do you know what a migraine is like? Has anyone ever defined that for you? Do they just see it in your chart? You said it and now you can't have estrogen. Go to the reading. Like Palin Bator is doing some incredible work about how safe estrogen, even birth control pills are when it comes to migraines. And so bring that to your. We should be doing this research. Patients shouldn't have to be doing this themselves. Right. People should be who are giving birth control pills or contraceptive prevention should be looking at this stuff every day so that they know the. No makes me crazy.
- [24:26]
A
Let's talk about informed consent. So informed consent is a big thing in medicine. It basically says you have to sign papers before surgery, before you get treated. It says informed consent, blah, blah, blah. But a lot of medical malpractice hinges around was there a breach in informed consent? So I think it's important, but a true informed consent is I understand the risks, I understand the benefits. I understand what might happen if I don't choose this intervention. I don't think that can happen in 10 minutes.
- [24:56]
C
No, I agree. It's very hard to make people understand. But I think if we start breaking it down, because sometimes we get in these very clinical modes and talk about the data and the numbers and the risk reduction, I think if we really break it down a little bit better for our patients, they will understand a little bit better. Like if you say 50% reduction, but it just reduces it one. The way we say numbers now can be really meaningless. People, you know, in terms of tamoxifen and aromatase inhibitors, right. Patients are suffering with the AIs. And then we're like, well, tamoxifen. Taking the tamoxifen will only. It's only gonna GQ to your survival rate by like 1%. And, you know, I. No one knows that. They just listen to what their person says, but no one sort of talked to them about all the other alternatives and what that means.
- [25:39]
A
Yeah, I think the. The. My big recent bugaboo on informed consent is antidepressants, because, number one, the risk of bone fracture on antidepressants, nobody knows about that. The risk of not being able to come off the damn things ever, or a very slow wean. The risk if nobody's told that, like, hey, if I start this, you on this, you might never be able to come off of this again. That should be something you think about if we do try to get you off of it. There's withdrawal symptoms, there's issues. And then number three is the rate of sexual side effects, which is like upwards of 80%. That's not zero.
- [26:15]
C
And.
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A
And most people aren't told about that. And then they're like, I have low libido. I have low blah, blah, blah, blah. And it's like, well, how long have you been on this SSRI? 20 years. And I'm like, did you have a plan to ever want to try to get off of that? Antidepressants are like, so under informed consent in my world. And I get it. The person in front of you suffering, I get it. But those medications are not benign. They're not zero risk.
- [26:40]
C
No, of course not. Tamoxifen, right? Endometrial cancer risk, blood clots, stroke. I mean, that. That's dangerous too, but I don't think anyone ever really knows that, Right? Chemotherapy can cause all kinds of damage. Radiation, immunosuppressants. I mean, we. We don't really talk about all those things with our patients. For some reason, the hormone therapy is the one where we're like, the risks outweigh the benefits.
- [27:02]
A
Isn't that wild?
- [27:03]
C
I don't. I do. I really spend so much time trying to figure out why.
- [27:07]
A
The other really weird thing about hormones is this, like, insistence on them being natural. But no, like, by definition, no other medications you take are natural. I know.
- [27:17]
C
That makes me crazy, too.
- [27:19]
A
It's very weird.
- [27:21]
C
Yeah. I feel like we should talk about social media. What do you think? I mean, I don't know.
- [27:24]
A
You're like, I don't know. Social media just seems to be everywhere. We should probably talk about it.
- [27:28]
C
Well, I just feel like there are a lot of ethical issues that none of us have really thought about when it comes to it. I mean, people are dming us with questions. People are really uncertain about what state laws apply to them if they're in one state and you're in another one. People are unprofessional in terms of, like, how they attack other clinicians on social media, and they undermine people's relationships with their own clinicians. This is a whole world of ethics. I think we all. We all need to be talking about because we have to navigate it both as clinicians and as patients, and try to figure all that out. But it's hard.
- [27:58]
A
It's super hard. And just the way that social media is built, I mean, if anybody's read Nexus, the book Nexus, it is frightening, big time frightening about how social media is built to put forward inflammatory things for Clickbait. Clickbait. Yeah. But what's very interesting to me on social media is the amount of people who DM me for my opinion on something they're on, which, like, I get the fact that, like, I'm a hormone expert and I say that I am. Like, that's not weird, but. But what's weird to me is ask the person who prescribed it with you. That's what's fascinating to me is, like, you have that relationship already. You have the product already. Ask that person this question. Not a stranger who doesn't know your history.
- [28:46]
C
Yeah, but maybe they don't have confidence in that.
- [28:48]
A
That's what social media does. It creates a familiarity. It creates a closeness. It creates a. Like, people have spent so much more time listening to me than their clinician. Right. Like, especially podcasts. Like, they're very intimate. But to me, I'm like, it's very interesting that I'm like, ask the person who prescribed you. And if you don't ask that person what are the reasons why.
- [29:10]
C
Yeah, exactly. And you have to choose who to trust. And then, you know, then you. We all have to be careful. Do we have a lot, you know, someone really does want to have us be their clinician. Do we have licenses in the place? How is it, you know, so confusing for everyone with telehealth?
- [29:22]
A
And people don't know that telehealth relies on state licensing. They want a remote phone call and it's like, dude, the telehealth companies that invest the money and being able to see all 50 states, people don't understand. That's thousands and thousands and thousands of dollars to state licensing committees. And to me, I'm like, I got 7 million people in Washington state. Another state does not need my money. I've got people.
- [29:46]
C
Yeah. I mean, and what about the EHRs and like these period apps and all, you know, where people are saying when they're having their cycles? I mean, I worry so, you know, all of our patients are saying don't put this in my chart or what are you saying in my chart? Or how can this be used against me? That's a whole other minefield. Right. We have to be so careful. Who even knows who's. Who has access to these things? So that's, you know, do you show your patients this? Do they get the results early? Like there's a lot of information out there that, you know, our patients don't want to be shared to the public, but who knows? And so I. Gosh, all of it?
- [30:17]
A
Yeah, it's all the DE identified data that the EHR sell that like that's happening. Nobody's talking about that. I mean, I'm wearing a whoop band. I fricking love it. And you can log on there because it'll like, it'll tell you what's eating late at night is not great for my sleep. Turns out guess I need an app to tell me that. But like you can log when you have sex. And I'm like, well that might be interesting to see if an orgasm helps you sleep better, but hell if I'm putting that on the Internet, right? I was like, I don't think you should even have your phone in the room when you're having sex. No, probably not. You know, like they're, they did a study where like a. Not a small majority of people check their phone while having sex.
- [30:56]
C
Oh, come on. I know that's not some that's some bad sex.
- [31:00]
A
No, it's crazy. It's like 20 or don't quote me, but it's not zero. Okay, that's crazy. Yeah, it's great. It's like take your phones out of the bedroom when you're doing all things. But yeah, like the apps will be like, when are you having your period? When are you doing pms? When are you blah, blah, blah. And it's like, that's a lot of super data that you actually, I mean, Instagram, it's free for us to access, but it's like all these other apps, like you're paying for the privilege of giving them all of your intimate knowledge,
- [31:25]
C
your medicine charts, right? Someone sees you're doing Lupron for Endo, but you also can do Lupron to block when you're younger and want to block your hormones. So like, you know, everyone knows what you're doing and all of it can be suspect if, you know, if it's not understood in the right context. So so much of our information is out there and just need to be careful in this political arena. It's, it's a little scary.
- [31:46]
A
Totally. Oh, I just, just in case people missed it. But you gave an amazing talk to like a group of, you know, there's a group of menopause providers, they meet on Mondays. It's a great gathering of minds. And you basically gave a talk of not treating menopause with hormone therapy can be construed as doing harm. With the overwhelming data that we have that the risk of osteoporosis, the risk of heart disease, I would argue the risk of depression, the risk of disordered sleeping, I would argue the risk of diabetes. The data is so profound. And this is like, that's, this is the book that's coming out that I wrote that's coming out in September is like the data at this point is so overwhelming that hormones are preventative medicine 100%.
- [32:34]
C
I mean, I say this a lot. I need to find my statistics and I'm sure you have them all over the place. But I mean, we, what medicine would come out for a man, right? Reduces osteoporosis by up to 37%. Lower diabetes by 30%. Cut coronary heart disease risk 50%. You know, colon cancer, lung cancer, LDL, decreases blood pressure, decreases triglyceride. It's pretty unbelievable. I mean, I think the cardiovascular disease is a little bit of a no brainer in my view. You know, there's some great stuff from John Stevenson, who gave some really good lectures at the International Menopause Society conference about how this should absolutely be used for cardiac cardiovascular disease prevention. I think the data's still a little bit out with dementia. I think that's a little bit of a harder one.
- [33:19]
A
It's like Dr. Crin said with breast cancer, the day you get diagnosed with dementia, it's been going on in your body for 20 years.
- [33:25]
C
Right? Well, same with breast cancer, it's been seven years. Right?
- [33:27]
A
Yeah, exactly. So to me, I'm like you, you need a 20 plus year study with the placebo controlled proving that is not going to happen. And I think people who are going to die on that sore, they're like, we don't have a placebo controlled trial showing decreased risk of dementia. And I'm like, that's right. It's a deadly disease with no cure. The medicines we have are crap with significant side effects. Why wouldn't you do everything you can if you have pretty good data that it's not going to cause harm? That's my bubble with hormones and dementia. When you shorten that and you're like, hormones prevent dementia, that's when people will poke holes, they'll poke holes in that. But if you build that argument properly, I think it stands.
- [34:11]
C
But I mean, I think, you know, Pauline Mackey and Rebecca Thurston, two of, you know, they're incredible, they say things like when you're waking up at night, you know, night sweats a hundred times, there is no question that that leads, you know, you are laying down more white matter hyperintensities in your brain and that leads to later life dementia. Now of course this link hasn't been made. If we stop those night sweats, will you have less likely to develop dementia? But I mean that evidence is, you know, not controversial at all. This is what happens. They put these little things on people and they see what happens to them when they're having night sweats. They may not even realize. So I mean, you know, that is just a no brainer to me. It is really interesting. I mean, I think it's why I think it worse at worse when it comes to dementia neutral. But the bone stuff is pretty amazing. I mean, estrogen is used to treat osteoporosis in Europe. I am so aggressive about making my patients, or at least trying to convince them to start some estrogen in their mid-50s. And I really love to do dexas because why are we not preventing osteoporosis? I mean, it's a deadly disease.
- [35:09]
A
I mean it really is deadly and expensive, right? Like if death doesn't matter because death actually saves Medicare dollars, let's argue that the rehab, the hip fracture, the ortho bill, the hospitalization costs Medicare money. And now, I mean, look at, look at Rachel Rubin's data with vaginal estrogen saving Medicare approximately 6 to 13 billion a year just in decreased urinary tract infection costs.
- [35:34]
C
I know. It saves lives. I love it. I mean, it's true. I'm literally going to my mom. I was put. My mom's in assisted living. And I was like. We were doing our interview. I was like. I said to the guy who was like, the guy. I was like, okay, we are putting everyone on some vaginal estrogen, all these 80 year olds. And he was like, please do not talk to me about vaginas. But I'm like, this is serious. We can prevent a lot of problems by just getting all these 80 year olds on some vaginal estrogen. Easy.
- [36:01]
A
And it's fun to be the thought leaders and be at the forward because, like, you actually do see the culture changing of it. Right. It's like, how quickly have we gone from fear to prevention?
- [36:14]
C
Yeah.
- [36:15]
A
You know, and prevention's a big high stick in American medicine. Like, there's. We don't tell everybody to take baby aspirin. We don't tell everybody to take a statin. Like, prevention's a big stick. And I don't think. I personally, I don't think we're gonna say all American females should take hormones. I don't think we're gonna do it. But I think for the people who want to do it, they should be allowed to do it again because harm is minimal and gain is large.
- [36:40]
C
But we just need to share that with patients. Right. Like, I'm not even saying we have to persuade them to do it or put everyone on it. I just think people need to know the data and say, see that osteoporosis is a risk. So if they have low bone density, they'll realize the risk of whatever estrogen risks are. The benefits are far away, outweigh when it comes to the bone health. Like, I just think people need to be able to make decisions in an informed way. And I just don't think. I just don't think we're doing it because we think somehow think it's. It's not good for you. It's so interesting to me because I always thought of harm as doing something to hurt a patient. It's like a tort in law school. It's flipped. Now I really do think it's a whole, it's. We have to view it from differently. All these sort of old guard clinicians who are saying, well we don't have the evidence, but they don't think they're harming, but that is harm. And so they can't stand behind first do no harm because the, the harm of doing nothing is even more harmful sometimes.
- [37:31]
A
Yeah. It makes me think about the studies we have looking at decreased incidence of breast cancer in women who are on testosterone pellets. Yeah, a couple of studies. There's like a three year study and there's a five year study comparing it with national SEER database incidence of breast cancer. Off the top of my head, it's looking like in these studies testosterone decreases the risk of breast cancer by about 30%. Might be a little bit higher, not 2%.
- [38:01]
C
Right.
- [38:01]
A
It's like if there was a drug that decreased, especially a woman at risk, her breast cancer risk by 10%, she would be on it, insurance would cover it, there'd be a Super bowl ad. And so to me this is tying back to ethics and harm. Is it unethical to not be researching that because it like we've got prelim studies. What do women and clinicians fear more than breast cancer? Als maybe, but. But not much.
- [38:28]
C
It's pretty, and I know that's pretty crazy. Yeah, but I mean that makes sense, right? In the Women's Health Initiative, the conjugated equine estrogen, when women were not alone, it decreased their risk of breast cancer. So testosterone aromatases into estrogen and it all makes perfect sense. But you're right, we cannot, we have to share that. We can't just wait for there to be randomized controlled trials because they're never going to happen. And then all of our patients are not going to be alive anymore.
- [38:49]
A
That's the thing is under, people are like, there needs to be trials. And it's like with generic medications that aren't patentable, you need to understand that there will not be trials on these things.
- [38:58]
C
There's not enough money. Who. Pharmaceutical companies don't care.
- [39:01]
A
Right?
- [39:01]
C
Especially things the drugs that are cheap. One thing if you know testosterone's cheap, super cheap.
- [39:06]
A
Right. I mean it's super interesting because it's like what can they patent? They can patent a synthetic androgen receptor modulator. Guess what they're making for the treatment of breast cancer to research selective androgen receptor modulators. Once you know too much, you're like, oh my God, you can't make this up. The low hanging fruit is right in front of us and it gets dismissed, it gets fear mongered, it gets withheld, it gets gatekeeped. You, you can't have this unless you're transitioning. Women can't access the cheap, safe generic stuff.
- [39:40]
C
And pharmacies are refusing sometimes. Yeah, that I can't, I can't get over the pharmacist saying they're not going to give people miso when they're having an IUD and they have stenotic service because they think it's an abortion drug. Right. Like the, the overreaching in the pharmacies and not giving people these meds is pretty crazy.
- [39:56]
A
I mean, I have a lot of pharmacists now who listen. Thank you for listening and who follow. Thank you for following. By their bylaws, I don't call them laws, but bylaws, as best as I understand it, that they do have to put any hormone in a biohazard bag because it can be teratogenic and it can cause cancer. In all fairness, if you give people synthetic high doses of estrogen, you can cause uterine cancer.
- [40:19]
C
Right.
- [40:19]
A
That means we have to put a cancer warning label on all types of estrogen, no matter what the dose, no matter if it's bioidentical. They, the pharmacists need hoods for packaged hormones. Talk about increased cost. I can't advocate for that. I can't advocate like the pharmacists have to change their bylaws. So they don't. They're literally handing women their bioidentical hormones in biohazard bags with inaccurate boxed warnings on them like it's insane.
- [40:49]
C
Yeah, their ethical minefields everywhere we go, especially with the politics and HIPAA and what we're allowed to protect and now and whether, you know, all these things that we're going to, the rights that we're going to lose. I mean, I'm worried about.
- [40:59]
A
Do you think HIPAA is going to go away? Have you seen, have you seen talk of HIPAA going away?
- [41:03]
C
I wouldn't be surprised that there will be exceptions. I mean, I think it's all about pregnancy terminations. So I wouldn't be surprised if there were exceptions made. Right. Or exceptions made for certain situations where that, you know, someone has a miscarriage and you're allowed to look and see what they're. I, I wouldn't be. At this point, Kelly. Nothing surprises me anymore. I never thought we would be here. Right. I never thought I would be saying like you need to get your 16 year old and IUD because I don't even know what's going to happen to birth control, you know, and who even knows if Paragard will be around anymore because it's only. At least you can say with the Mirena and the Nordestral IUDs that they're also bleeding control. Like the Paraguard is only birth control.
- [41:42]
A
Right.
- [41:42]
C
And conceivably it's. You can take it right after you have. Get it inserted right after you're pregnant. It can be emergency contraception. That's terrifying too. Right. So I don't know. Yeah, we could talk about this.
- [41:53]
A
Everybody needs a good doctor patient relationship. Everybody needs a good lawyer on speed dial. But I want to close it out not by scaring people, but to be like, hang on to the precious clinicians that you have who are in your corner who do advocate for you. Hang on to them or find them. They're out there. At the end of the day, I do fully understand, like not everybody has access to that. And especially people, you know, with state insurance and I was talking to a doctor the other day. They see 50 people in a day. How is that not unethical?
- [42:26]
C
Yeah, that's insane. I don't know how they do that, those poor clinicians. Yeah, it's like being a public defender and representing 100 people at a time. It's impossible. I mean, documentation. Right. Making sure that as clinicians we are really careful about remembering that our notes can be on the front page of the Washington Post. Remembering that our clients personal information is now in an electric system and can be seen anywhere. I think we all just need to be very mindful of the public nature of these electronic records and then remembering what we're saying in our, you know, the way we say things and the way we document them for clinicians. That's what's, that's very important. Not legal advice, of course, but you
- [43:02]
A
know, I think if I was a lawyer.
- [43:03]
C
If I was a lawyer. Yeah, I just, you know, I think that's what it all comes down to.
- [43:08]
A
Like the question was going to be like, is your lawyer brain in there? When you're like crafting a note to somebody, I'm like, how could it not be? We were doing it for 20 years.
- [43:17]
C
Because in the end I feel like, for example, we talk about this a lot like hormone therapy with someone's history of a blood clot. You know, we know the transdermal estrogens are safe. We know there's not a drop of evidence that that's going to increase people's risk of blood clots. Right. The transdermals are very safe. Factor V Leiden, whatever. And, you know, I send these letters, we write these letters to these hematologists. I have been able to persuade them that it's safe because they have enough cya. You know what I mean? They have enough to say, this is what the data said. So my patient wanted this, we talked about the evidence and this. I want to just give them enough information so that they feel comfortable that that's what the evidence says. And even if they say, I'm not going to do it, it's okay if you do it, because I think these are persuasive. So, yes, I do. I feel like every time I write one of those letters, I'm like, I'm just cyaing it. Like, you know, I just want people to have enough cushion that they don't feel scared either about us doing it or even about them doing it.
- [44:11]
A
Yeah, I mean, it makes me think about hormones as preventative medicine. When you have United States Preventative Services Task force saying, don't do it. Now, granted, their data is flawed, it's based upon the whi, but not everybody knows how weighted their meta analysis is. It gets into the point of like at the beginning of our conversation, it's like the patients inform, informed. That's what they want to do even if guidelines don't support it. You want a supportive clinician, but the clinician at the end of the day is always thinking about getting sued. In the United States of America, there's never two people in that doctor's visit.
- [44:46]
C
So what if you said so say an oncologist said, okay, I don't feel comfortable with doing this. Let me refer you to someone I know who has talked about this a lot and who knows a lot about this, right? Instead of just saying no, saying here, I don't feel comfortable, right? I don't know the answers. I haven't done enough research. But here's Kelly Casperson and moved to Seattle and then maybe she'll see you, you know what I mean? Like, I think that's almost 50% of it, right? Admitting that you don't know something and then referring, that's important, right? Instead of just saying no.
- [45:15]
A
I think that's a good answer. And I think what you're saying is how many times do you hear it on social media? A woman says, my doctor said no, It's a red light stop sign, no questions asked. It's just a no. And they don't give her any other avenue or they don't be like, no to oral estrogen, but yes to vaginal estrogen. No to estrogen, but yes to progesterone and testosterone. But whenever I'm on stage and people are like, my doctor said no to blah, blah, blah, I'm always like, it's never no. There's always something more.
- [45:46]
C
Well, maybe you guys can come to a no together, right? You can decide. Let's talk about it. Let's see if it's worth the risk. Risk. But just saying no is so. Is patronizing the right word? It's dismissive. Right. It's like. It's like someone's making a decision for you about. It's you. This is you, your body, and yourself. And so if your quality of life is such that you think it is worth it to take some hormone therapy, then you should be allowed to at least talk about it or find someone who will talk to you about it.
- [46:09]
A
Yeah, I found out in, like, the actual amazing privilege we have in America that you can get a second, a third, and a fourth opinion in British Columbia, at least the physician you have is the physician you have. You can't go get another one for an opinion.
- [46:24]
C
Oh, my goodness.
- [46:25]
A
Yeah.
- [46:25]
C
Yeah.
- [46:25]
A
You're locked into what that person knows.
- [46:28]
C
That's crazy.
- [46:29]
A
So the good gift in America is, like, what is as onerous as it is to get a second opinion? It's a privilege to be able to be like, let's go see what somebody else thinks about this.
- [46:39]
C
But we also have to be really careful, because I feel like a lot of times we undermine each other. Right? If I give someone hormone therapy who has a family history of breast cancer, and then they go to their oncologist, and the oncologist is like, oh, my God, is she crazy? What is she doing? You have to stop that right now. I think we all need to be a little bit respectful of each other. And, you know, instead of saying, oh, my God, get off that right now, reach out to us and say, like, okay, you know, explain this to me. What's your data? Why are you doing this? That's the. It's the undermining of other people that also is a problem, because then these poor patients, they have no idea where to go or what to do or who's right.
- [47:13]
A
And like we said at the beginning, our patients are smart. If they've done their job right and we've done our job right, they know why they're on hormones. They know the risks and the benefits. And I know it's scary to speak up to a doctor. I know that. But I do believe that the more educated you are, you'll be like, I'm on it for this reason. I understand there's risk, benefits and controversies, and I've decided with my clinician that I will continue. And I think there's not enough of that happening. I know.
- [47:38]
C
I arm them with their talking points. I'm like, okay, you've had a dvt. This what I want you to bring to your hematologist. Bring this. And then if they want to talk to me, they can talk to me.
- [47:47]
A
That's what I was saying. I'm like, have them call me.
- [47:49]
C
Yeah. Oh, well, please.
- [47:50]
A
I don't see 25 people a day now. Have them call me. Like, that's like, I'm literally here to be your advocate as this clinic that I've built because it's not just a 10 minute visit anymore. Like, there will be people. And again, I want to arm you against Aunt Susie too. You know, like, Aunt Susie still believes the whi. So it's like that you have to be smart enough in what you choose. And I always say, I'm like, I never want somebody to say, I'm on this because my doctor told me to. I hate that. I hate those words. Yeah, I'm on it because we. We decided they'll say like, oh, I
- [48:21]
C
was just at a mom's group and all these people didn't know anything about hormones. And I told them, hot flashes can lead to later life dementia. Just being able to say to people who are like, you're on hormones. And then they say, yes. Did you know this? It's like, it's so empowering.
- [48:33]
B
Yeah.
- [48:33]
A
Because it's their choice that, like. And there's like, that's just sexy.
- [48:39]
C
Unlike ethics in general. Unlike ethics, which is not sexy.
- [48:43]
A
Owning what you're choosing to do with your body is sexy as hell. So do you think you're gonna do more advocacy with this lawyer background, like, what's in the works, or are we just working on what's next for you in 2025?
- [48:55]
C
Well, I know I am. We're. I'm starting a new practice with a bunch of endosurgeons in dc. We're going to really, like, just focus on pelvic pain. I mean, I'm going to do all the GYN stuff, so I'm really excited about that. I love talking about it. As you could tell. I could probably talk all day about everything. I love also seeing patients, so I don't want to take away too much from that. But, you know, one of my husband's partners used to say, I'm a pigeon lawyer. Which means whatever the pigeon brings me, I'll do. You know, the pigeon comes, I'll do it. So yeah, I love talking about it. I do feel like I'm in this weird, unique role.
- [49:26]
A
Even just your ability to write like a lawyer though, like has incredible power in crafting advocacy and, and rebuttals and stuff like that.
- [49:35]
C
It's just like an appellate argument. You, you see one case and you're like, oh my God, this is so bad. And let me distinguish it. It's the same thing with all these, you know, studies that we see. We see, right? All the time. We're like, oh my God, it causes dementia. Oh my God. And then we're like, okay, let's read it. Let's see what it says. Let's notice that it's observational. They're, they're actually very similar, which I did not expect.
- [49:53]
A
That's super interesting. I'm going to give like one more shout out to like the menopause. I was meaning to like do a blog about this of like the uniqueness of the people in the space because we all love reading. Not just like clinical trials, but basic research. And I'm like, I've read more basic research in the last few years. And the level of understanding human physiology when you're like, and it's replicable in rats and it's replicable in the petri dish and it's like I, I mean I have to think of these poor basic science researchers who like, they don't see patients ever. Like they literally do petri dishes in mice. And to them it's such a no brainer that hormones help the nervous system and hormones help nerves. Like there's reams, reams and reams of data on how hormones help nerves and brains.
- [50:42]
C
Such little nerds too. Like, we love our little stuff. We're always like, I want to read this. Have you read this? This?
- [50:48]
A
Yeah.
- [50:48]
C
No, it's, it's great. It's so empowering. I mean there's so much good stuff out there. We cannot rely on something that's from 2001.
- [50:54]
A
Totally. Yeah, yeah, yeah.
- [50:55]
C
I love it.
- [50:57]
A
Jen, thanks for sharing your brain and your magic. Thanks for doing the, the tough. I don't think it's boring. I mean, I think ethics was boring when I went, but it was not more boring than statistics.
- [51:06]
C
I always said that I was going to become an osteoporosis expert because no one wants to become an osteoporosis celebrity. I sort of feel that way about ethics. Like no one really wants to be an ethics expert celebrity. But I do think these conversations are important, especially as I see more and more people saying, no, I love it.
- [51:21]
A
I posted in the group today just to go off on one final tangent, if we can, is that women are allowed to take off breasts and ovaries in the reasoning of prevention of cancer. And we see these women who are like, I love my estrogen patch, I need my estrogen, I can't tolerate any sort of progestin, including an iud. I think the conversation is going to start moving to elective laparoscopic hysterectomy for these women.
- [51:49]
C
Yeah. But also, Kelly, I was going to respond to you and I totally forgot to. But my mother in law, I should end on this because this is really interesting. She was one of the original scientists who worked on the Women's Health Initiative, which is like, I didn't even realize when I went down this path. But she has never been able to tolerate progesterone. She's 80, she gets an ultrasound every three months. And if her lining is thick, which it really has, maybe only been once, she gets an endometrial biopsy or hysteroscopy, but she's never taken progesterone and she does not have endometrial cancer. So like we could, you know, we can work with our patients as long as they're, you know, they come in.
- [52:17]
A
I think that's a golden calf. I don't know if that's the right word or the right metaphor. But the set in stone that estrogen causes uterine cancer unless you oppose it with progestin is not true.
- [52:30]
C
Well, it's not 100% by any strength.
- [52:32]
A
Exactly. So that's why you can't say estrogen causes uterine cancer because that means 100% of estrogen causes 100% of cancer in uteruses. And it simply does not. It is not true, actually. Like that's in my next coming book because I'm like, you need to actually see what the data shows. And yes, unopposed, higher dose, especially the synthetics, but low. Do a 0025 patch, never been studied, never been showed to cause. And the other thing is endometrial proliferation does not mean it's going to turn into cancer.
- [53:02]
C
Right.
- [53:03]
A
And people freak out.
- [53:04]
C
I think it takes a year. I was trying to look this up because I was like, because sometimes I tell people, okay, if you're still having your period, you don't need to really worry about the progesterone. You're still shedding your lining. Something becomes strange if you go more than three months. Let's revisit it. I was looking to see how long you could go with an unopposed estrogen before we start to worry. Whatever. And they don't even start studying over a year of unopposed estrogen. Like, it's a month or a week. People freak out. And our perimenopausal patients, oh, my God, I've got to have progesterone. No, you're still shedding your lining. So it's not. It's not crucial if you don't tolerate it.
- [53:33]
A
Yeah. And that's the thing. Nobody said, like, the perimenopausal people who are still shedding their lining, first of all, never been studied, but certainly biomechanically seems to be very safe.
- [53:43]
C
Right.
- [53:43]
A
Because you're not built. You're not building up. You're automatically shedding. And then. So I get these messages all the time on Instagram. My doctor took me off my hormones because I had some vaginal bleeding.
- [53:54]
C
Yeah.
- [53:54]
A
And I'm like. We very quickly went from, like, hormones are fearful and scary to people doing hormones poorly, which makes us all cringe. But it's still better than no hormones. So, like, it is. It is as cringy as we are with like, oh, my God, the river's moving.
- [54:13]
C
Yeah. Oh, well, it's. It's spinning. Right. When I first went to the menopause conference, I. I think it was like, 400 people. And. Yeah. Right. The rooms are already sold out. I don't even. The conference was sold out for this year. But it's great. I never thought people would be so interested in menopause, and I love it. It's great.
- [54:25]
A
It's Gen X100.
- [54:28]
C
Well, it saves me a lot of time because I don't have to sit there, persuade people it doesn't cause breast cancer. Like, it's kind. You know, I. Maybe I can do my appointments, 50 minutes. Because everyone's like, have you met. Have you heard of Mary Claire Havert?
- [54:39]
A
Oh, yeah. I'm like, dude, my podcast and my book, they make my. They make your clinic a lot fat. Like, because they just come in there, like, give me all the things.
- [54:46]
C
Yeah. Love it. Right.
- [54:47]
A
Like, they're educated people, and it is an absolute pleasure to work with them. Jennifer, the people in D.C. are lucky to have you.
- [54:55]
C
Ah, thanks. It's. I mean, this podcast is life changing. I. I just love everything that you do.
- [55:00]
A
Thank you. We get feisty and we. And we watch the river move. Basically, we mix our metaphors.
- [55:06]
C
I mean, that's. Yeah, I love that.
- [55:07]
A
We try to have a good time. The. Hold on. There is a conference in D.C. in 2026. I mean, I'm sure there's a million of them, but there's actually one I'm interested in. Is it ishwish?
- [55:17]
C
Is it the Bone Health and Osteoporosis funding? That is the fun one.
- [55:23]
A
No, I was just. Is it NAMS? 2026 is in D.C. there's something in D.C. oh, American urological Association. Oh, I'll see you there. I know.
- [55:33]
C
I love. Oh, you're kidding. I love that stuff. Because everyone's peeing on themselves. I'm always like, you should. This is one of my five golden rules. No peeing on yourself.
- [55:45]
A
Excuse me. Here's another ethical. God. We could talk forever if we have two association studies. So they're not. These are not strong studies. They're association studies looking at women who are on testosterone have less stress incontinence. And we have zero other medical. We have surgical, but zero other medical options for stress incontinence. Why are we sitting on our hands with that? I don't know.
- [56:09]
C
I'm behind on that one too. I need to start doing that for my patients. Is it top. You mean vaginal or just like systemic? Really?
- [56:15]
A
Yeah. With the theory being likely increased core muscle mass.
- [56:18]
C
I love it. No, I think because testosterone is not going to hurt you as long as you're making sure you don't get into, you know, seven thousands.
- [56:26]
A
A testosterone of 7,000 is bad for any. Any gender.
- [56:30]
C
Right. If you're watching it and not giving people these super physiological doses like, try it, it's not gonna hurt you.
- [56:36]
A
That's the whole thing. Just it's. And it's cheap. You might have to lie to your insurance company or pay cash.
- [56:41]
C
You can make your male partner get it for you and then they just, you know, they get it for free.
- [56:46]
A
Yeah, it's pretty. It's pretty darn cheap, for sure. But I'm very excited for there to be an FDA approved female testosterone product. Very excited. I'm cheering on everybody who's doing it because it's going to normalize this conversation. And then number two is, but if it's 400 and in a pink box, I'm still going to use the cheap
- [57:03]
C
shit that I'm still using 100%.
- [57:04]
B
Right.
- [57:05]
A
Like, it'll. It'll normalize the conversation though.
- [57:07]
C
Yes. But if people are gonna be on these medications forever. They have to be cheap.
- [57:10]
A
I'm planning on 40 years. Post menopause would be nice. Give me. Can I be on these hormones for 40 years? Yes, please.
- [57:16]
C
I tell the joke that I told my sister to crawl into my coffin and put my estrogen on me in case I'm a little bit alive.
- [57:23]
A
The neurons need the final whiff.
- [57:24]
C
Just that little final.
- [57:26]
A
The final little bit of moisture.
- [57:28]
C
Hot flashes in the coffin.
- [57:29]
A
I love it. All right, well, we'll let people know where to find you in the show notes and thank you for coming on. This has been. I hope if anybody's stuck on this long and think we're as a good enough time as we think we are, we've got. We've got at least a couple of fans. Yeah, if you're still here, we love you. Thank you for going for taking a ride with our tangents. All right, till next time. Thanks, Jen.
- [57:50]
B
Okay, thank you for listening to this week's episode of you 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
- [58:21]
A
and get them immediately without advertising.
- [58:24]
B
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. 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.