Episode 58: Transcript
"How to start HRT for menopause (even in Florida)" - with Dr. MaryBeth Lewis-Boardman
Magda Pecsenye Zarin: You want to know what happened to me yesterday?
Doug French: Of course. This is what the banter is for.
Magda: I got stung in the lip by a bee.
Doug: You look fine.
Magda: I feel very fortunate that I'm not a person who's allergic to bee stings. Everyone was aware of the fact that it had happened, but I didn't have any untoward swelling.
Doug: Well, I mean, did it swell up? It looked fine.
Magda: There's definitely a red mark there. You could see the puncture of where it was.
Doug: Were you still able to digest your lobster roll?
Magda: I did not have a lobster roll. I had Maine lobster stew. And I asked what the difference was between a stew and a bisque. Maine lobster stew is a bisque with chunks of lobster in it. And, yeah, Mike and I split a pumpkin-themed beer that wasn't that great, so I'm not going to tell you what brand it was. And Mike got sunburned.
Doug: Pumpkin-themed beer with lobster?
Magda: Yeah. It was September 29th in Maine. I don't know what I'm supposed to do in Maine.
Doug: There's got to be some kind of kosher standard that precludes that.
Magda laughing: Yes, the pro-lobster kosher standard.
Doug: I mean, seafood and caramel sauce. I mean, come on. [Laughs]
Magda laughs: I don't know what to tell you. And I didn't realize until the last time we went to Maine [laughing] that you drive across part of New Hampshire to get from Massachusetts to Maine.
Doug: Eleven miles of it. Yeah.
Magda: I didn't realize that.
Doug: You do.
Magda: And so we actually counted the miles last night, and the route that we go, on 95, there’s no “Welcome to New Hampshire” sign from Maine, because it switches in the middle of a bridge across a river.
Doug: Yeah, there isn't time. By the time you read the welcome sign, you're gone.
Magda: There is a welcome sign when you go from New Hampshire into Massachusetts.
Doug: Well, there is a sign in New Hampshire when you leave Massachusetts and it says, “God damn it, go back.”
[Both laugh]
Magda: We did notice that there was a lot of police activity of people being pulled over and seemed like a preponderance of Massachusetts license plates.
Doug: Well, these municipal budgets don't balance themselves.
Magda: They do not, especially for these small, small, small towns in Maine.
Doug: Well, my big story of the day is that I learned pickleball today.
Magda: Oh, my God. Oh, my God! A year early! You learned pickleball before you were 60 years old.
Doug: Well, and I learned it from a bunch of 70-year-olds too, which made me feel especially special. It made me flash back to cardiac therapy when I was surrounded by people 20 years older than I am, giving the kid the business. I went to Monday morning pick-up pickleball and learned the rules. I wanted to learn more of the etiquette more than anything else, like where you're supposed to put your racket that says you're next. And I learned from the exact perfect woman, my teammate. She reminded me a lot of your mom, actually, because she talked about like, “All right, now don't stand in the kitchen. Now, no, that's in, you see. Now you have to come up more. No, no, now you can go back. No, no.”
Magda: So like encouraging but scolding at the same time?
Doug: Yes, exactly. Encouraging but officious.
Magda: That's my mom's way.
Doug: Lovely but teaching second grade. Anyway, it was very pleasant and now I feel much well-versed in the etiquette of it. You know, I got to find my zone with this because I'm familiar with tennis and I'm familiar with squash and racquetball and ping pong and they all are different skill sets.
Magda: Well, yeah, I mean, I think ping-pong, the skill set is being ferocious, not caring about your life.[Laughs] Ping-pong is cutthroat.
Doug: And being Scandinavian or Asian, right? Those are the only two geographic areas that bring...these amazing ping pong-ulars.
Magda: Yeah.
Doug: Well, let's talk about areas of expertise, then. Speaking of which, right, we should talk about Dr. MaryBeth Lewis-Bordman, whose name I know already will not fit on the damn... It's going to run off the side of the placard that we run for the...
Magda: I know, because she's got two first names and two last names.
Doug: Yeah, it's overkill. I mean, she's a lovely person, but she's overnamed. It was another episode about The Change. Another woman who was advocating for...
Magda: This is our second episode with a medical professional about perimenopause and menopause. We did an episode last season with Jackie Piasta, who is a Nurse Practitioner who specializes in perimenopause and menopause care. And with Jackie, we really talked a lot about the WHI study, which was that horrible, unethical, horrific study that was done in 2002 that was just set up in a preposterous manner and then quote, unquote, “demonstrated” that Hormone Replacement Therapy and estrogen primarily would cause breast cancer, which turned out to be false from many, many different angles. But in the meantime, doctors stopped prescribing Hormone Replacement Therapy to this entire generation of women who then got screwed. So that has since been disproved. And they now say that you should go on Hormone Replacement Therapy. So we talked to MaryBeth and the question was, “I would like to go on hormone therapy. How do I do that?” Right.
Magda: And so we talked about a lot of the practical aspect of it. And also her physical practice is in Florida. So we talked a little bit about the state of practicing medicine as a whole in the state of Florida. And yeah, a lot of that stuff.
Doug: I did ask a bunch of questions because I am curious about these things because men need to know about this stuff too. Just like men need to elect a woman president. But, you know, I do think they're related though.
Magda: The bottom line is if men are just like, “Oh, I don't want to know anything about this.” Well, I mean, A, tough shit. You should. But B, perimenopause and menopause actually affects men a whole lot because you're interacting with women all the time. And some of the symptoms of perimenopause and menopause are life-altering for women. And that affects men, too. Right.
Doug: But at least when you are postmenopausal, you can hang around the gym and teach a young whippersnapper like me how to stay out of the kitchen.
[Theme music fades in, plays, and fades out.]
Magda: We are recording on the day that Helene is hitting Florida. And we're talking to somebody who is in Florida right now. So if it just ends up being just Doug and me, it's because you were washed away, weren't you?
[All laugh]
Magda: We are talking to MaryBeth Lewis-Boardman. You are a board certified OBGYN.
MaryBeth Lewis-Boardman: Yes.
Magda: And you have been delivering babies for a long time in the state of Florida and you recently switched your practice to focus on…
MaryBeth: Menopause.
Magda: Hooray!
MaryBeth: I have to take a pause before saying menopause.
Magda: Yes. Exactly. So what made you decide to switch?
MaryBeth: I actually started practicing in private practice in July of 2002, which was about a month or so after the initial publication of the Women's Health Initiative, which is the big study that said hormone replacement is bad. And that study obviously was using conjugated estrogens or Premarin, progestin or medroxyprogesterone acetate. And there was the big hubbub of, “Oh my gosh, if you're on hormones, you're going to get breast cancer and die!” which was essentially how it was presented in the media. So my first month in private practice, I primarily saw a large proportion of 50-some-year-old women who went off of their hormone replacement and were miserable and came to me to see if I thought that they should go back on it or if it was safe to go back on it. And so that was something that was kind of a poignant moment in my career because my training was all about “hormones are good.” And literally I graduate, go into private practice, and hormones are bad.
MaryBeth: And just being the person that I am, I had to see for myself, well, which one is it? So it prompted me to actually read through the entire WHI study publication so that I could really discuss risks and benefits with my patients and understand really what was behind why they stopped the study prematurely. And so that I could treat my patients coming in to see me fairly and appropriately, and as safely as possible with this new information that we now had. So that was kind of the start of my career and it never really went away. But when you go into OBGYN and you're practicing general OBGYN, and you're a younger physician, it's the younger patients that really want to come to you and identify with you. So I had a bit of that touch of I'm seeing women who are already menopausal, followed by just the influx of younger patients that I saw for a really long time. But that little passion and what I've learned about menopause didn't go away at that point. It was still there.
MaryBeth: As my practice grew and I started hiring new docs, I started to see that the newer docs that were being hired knew a lot less than what I had learned throughout my residency training. And as a physician, if you don't know very much about something, you don't really want to deal with it because you're already dealing with so many other different illnesses, diseases, processes that you have the information for, that you're mastering, that you're spending a lot of time with.
Magda: Well, you just don't have the time to be doing all that research.
MaryBeth: Correct. So if you get out of a program and somebody's coming to see you for a menopausal hormone consult, and you didn't really, after the WHI and everything got quiet and hormones are bad, you didn't really get that aspect of your education…
Magda: Right.
MaryBeth: …as much as you learned about gestational diabetes in pregnancy or screening for sexually transmitted infections and how you manage abnormal pap smears and HPV and HPV vaccinations. I mean, the list goes on and on. In the meantime, you also need to master doing robotic surgery and minimally-invasive techniques and making sure you're up to snuff on all of the available contraceptives that are coming out on the market and how they're used. So all of that stuff was such a big part of training, regardless of where you were in the country or what, you know, what year it is. But menopause just wasn't like that. It wasn't automatic. And even now, a lot of the OBGYNs coming out of residency don't feel adequately prepared to take care of menopausal women.
MaryBeth: You know, I'm seeing younger docs that I'm hiring who are like, “I'll see your preconception consult if you'll see my hormone consult. Can we switch?”
Magda: Oh, wow.
MaryBeth: And, you know, I embraced it because it was already something that I knew quite a bit about, more so than I would say the average OBGYN. I had a vested interest in it. I had no choice because of how I went into practice. Within my family, there's also interest because my grandmother, I was a sophomore in college when her doctor started her on PremPro. And then two weeks later, had a pulmonary embolism and ended up in the ICU.
Magda: Oh my gosh.
MaryBeth:: She was 65 years old. What do we know about the WHI? If you start a woman on hormone replacement after 10 years from the time that they've gone through menopause, you are increasing risk in terms of cardiovascular health, that kind of thing. And if you are starting it before 10 years after menopause has occurred, you're potentially giving them the benefit of improved cardiovascular health. So my grandmother happened to fall into the, you know, having hormone replacement prescribed when it was the gung ho, everybody should be on it. And we didn't know this information.
Magda: Do you know why they prescribed it for her so far out? She didn't have symptoms that were troublesome enough to her until then? Or do you think she was asking for it and they just were like, no, no, no, until that point?
MaryBeth: In the 80s, there was a study that came out that suggested that there was such a cardiovascular benefit to estrogen that the automatic response was that a lot of physicians started women on it.
Magda: Oh, oh, oh! Okay. So they weren't prescribing it because of symptoms. They were prescribing it because this study came out that showed cardiovascular health.
MaryBeth: Correct.
Magda: Okay, that makes sense.
MaryBeth: And then the WHI came out and then basically counteracted what that other study said. But part of it is because the Women's Health Initiative, the average age of women who were started on hormone replacement were 63, which is not a normal age at starting.
Magda: It seems like such an elementary thing to be like, why are we doing this in a way that isn't the way it's going to be done in the wild. It just seems so strange to me.
Doug: Is there a preponderance of data for women aged in a higher bracket than there are women who start going into perimenopause in their late 30s? I mean, is the data that we have for older women compatible with the younger ones? Or to what extent is that even possible?
MaryBeth: There are a couple of studies done after that, one in France and another nurse's study that was done that gave us a little bit more information. And the women in those studies were significantly younger than in the WHI.
Doug: Well, just one of the great revelations from my point of view about menopause is how It affects every woman differently, sooner or later in your life, longer or shorter in duration. The symptoms are all over the place.
MaryBeth: Correct.
Doug: And that's just not something that I don't think a lot of people know about and that you know what's coming, but you have no idea how long it'll last and how it will affect you.
MaryBeth: Well, I mean, once you're menopausal, you're menopausal for the rest of your life. So what happens to you is kind of, it's not like you reverse back to what you were like when you were 40. It's a total progression. It just keeps changing.
Doug: Oh, so it's like alcoholism. It's like you're an alcoholic forever.
[All laugh]
MaryBeth: Well, I mean, you're menopausal.
Magda laughing: I would like to be a recovering menopause.
Doug: Is there a such thing? I mean, women I've talked to call themselves post-menopausal. They've been called post-menopausal. Is that a misnomer?
MaryBeth: When you're post-menopausal, you're still menopausal. Menopause is defined as not getting a period for a year. The rest of your life after you're not getting a period anymore because your ovaries have ceased to have that reproductive function. That's the rest of your life. So I think what women are saying is “I had hot flashes and night sweats for six years and now they're done. So I'm post-menopausal.” You know, it's just a different phase in their life, but I wouldn't say that it's two separate entities.
Magda: I kind of think of it as like, some people will say, “I'm divorced.” And then after a certain number of years have elapsed, they're just like, I'm single.
MaryBeth: Single.
Magda: Right?
MaryBeth: Yup.
Magda: You technically were divorced at a certain point. It's just you're not centering the divorce.
MaryBeth: Correct. It's not your identification with that part of your life anymore.
15:25
Magda: Yeah.
15:25
MaryBeth: What is amazing to me is how many symptoms women can have, like the breadth of the symptomatology of perimenopause and menopause that most women don't even realize is related to that change in their hormonal status. So we know joint pain absolutely can be worse. I mean, it's one of the biggest things I will hear in women who have recently started on Menopausal Hormone Therapy is, “oh my gosh, my joint pain went away. I didn't even realize it was that bad.” And women tend to be raised to accept that the natural reproductive processes within our body are normal. So we normalize all of the symptoms that may be related to that. You know, it's, it's just like, well, “pregnancy is natural. So don't get an epidural. That's not natural.” Well, labor hurts. Why wouldn't you get an epidural? You know, why wouldn't you have this option? [Magda laughs]
MaryBeth: You know, if a man has a kidney stone, we don't look at him and say, “hey, that kidney stone is natural. When you pee it out and it feels like you have knives coming out of your urethra, it's okay because it's natural.”
Doug: I would like an epidural for that if that ever happens to me.
MaryBeth: Of course, who wouldn't? Or at least a little Pronox that you can get some laughing gas in there when it's really bad. But menstrual cramps, “they're natural.” Sure, you can take ibuprofen or what have you. Well, how many women who have menstrual cramps really have a disease like endometriosis that isn't being treated? We normalize women to associate
pain with their reproductive function and so when we start losing some of that hormonal effect of our that our ovaries are producing and we're having these symptoms “well that's natural.” What is it about us women that think that we have to do everything natural and
Magda: We're not living a life that's natural, right? We're not like out on the prairie in a group of 30 people.
MaryBeth: We’re not farming. Most of us aren't growing our vegetables out the back. We're going to a grocery store.
Magda: Yeah. Yeah.
Doug: So here's a question that I think I'd love to hear the answer to this because we've established there's a wide spectrum of symptoms and permutations and so forth. To what extent is the permutation of treatments matching up with that?
MaryBeth: I think that's a great question. There's so much research going on right now in terms of how menopause affects all different things, depression. Women who have never had a history of depression can have depressive symptoms while going through this menopause transition. Why is that? And it's not an automatic that if you give a woman estrogen therapy
that it's going to go away, you know? So I think that we have a lot of different treatments that can really focus on specific symptoms and not all of the treatments are hormonal. So somebody who's really struggling with depressive symptoms may actually do better with a combination if they're a candidate for hormonal therapy, because they're having horrible vasomotor symptoms, meaning night sweats, and they're waking up at night and potentially their sleep deprivation is also related to their mood changes, you know? So estrogen would be helpful there, but potentially so would an SSRI as an antidepressant to work on that other aspect of, you know, their function.
MaryBeth: For a woman who specifically has vaginal dryness, you know, she's at the point where it's like, “well, when I go on vacation, I need to bring my roll of Charmin because the hotel toilet paper feels like sandpaper.” She's somebody that would benefit potentially from just local topical therapy with vaginal estrogen or vaginal testosterone, which is DHEA.
Magda: I feel like everybody who has a vagina should use vaginal estrogen, like just default when they turn 30. [Laughs] I mean, I started it because I started getting UTIs.
MaryBeth: Some women have no symptoms. But absolutely.
Magda: Like I hadn't noticed any symptoms at all. I just got this UTI out of the blue. I don't think I'd had one in 20 years! Nothing in my life had changed except I was going through menopause. I was on systemic estrogen and progesterone for HRT and suddenly just got these intractable UTIs. And thank God my young, white, male, straight doctor said, “Oh, you know, that's a symptom of menopause.”
MaryBeth: Urinary syndrome of menopause.
Magda: “The cure for that is vaginal estrogen cream. Are you okay with that?” And I was like, oh God, yes. I will slather this all over anything I need to slather it all over. And like within two weeks, suddenly I just felt entirely rejuvenated. It was like getting a new pair of underwear that fit better.
MaryBeth: Right. So, Magda, let me ask you this. Two weeks into that, were you like really surprised by how symptomatic you were without realizing it?
Magda: Oh, yeah! I had just thought it was normal. I just thought, you know, I was like getting close to 50, and whatever. You're just not as juicy and dewy.
MaryBeth: Just like my skin on my face. I need more lotion there.
Magda: Yes.
Doug: We need more goop as a culture, I think.
Magda laughing: Right. Right. And then when I discovered that the itchy ears that I thought were some kind of allergies that I had never experienced before, the itchy ears are lack of estrogen in the ear canal. So the estrogen cream fixed that too.
MaryBeth: Well, here's another thing. So as we lose our estrogen production from our ovaries, our voice also deepens because of the changes in our vocal cords.
Magda gasps: Oh, my God. So that's why all these 65-year-old women sound like [does smoker’s raspy voice] they are rampant smokers like this.
MaryBeth: Not always. Some of them may have been rampant smokers and may still be. What is the other big thing that women do in this day and age? Oftentimes, because, you know, we love a fix that is going to make everything magical and give us the fountain of youth and somebody promising it to us. Exogenous testosterone therapy that is super physiologic.
Magda: Oh, interesting.
MaryBeth: A big side effect of that. And if you have a woman who is like, my friend is 55. She went on hormones. I want to go on Hormone Replacement Therapy. And she goes to a GYN who then decides to, well, if you would like that, you can't go on estrogen because that's like practically against the law.
Magda: Right. Because of the WHI.
MaryBeth: She's aged up beyond it. “We know that it would increase your risk, but I can offer you this testosterone pellet that's going to give you very high super physiologic levels of testosterone and you'll feel the same, but it's safe.” Is it? We don't know. But it's very easy to spin it in a way that it's safe because we don't have the data definitively saying that it is going to make you drop dead of a heart attack or what have you.
MaryBeth: Testosterone converts to estrogen in our body through an enzymatic reaction in our fat cells. There's an enzyme called aromatase. So if you're giving high levels of testosterone, secondarily, you're bumping somebody's estrogen levels slightly. And that's in somebody who's older, who probably shouldn't really be on it, but their voice will get deeper and they can start having some receding hairline and acne and hair growth on their face and other places that they'd rather not have it on their body, but they also get a lot of energy, little buzzwords. So anyway, that's another thing that we can see with voice deepening is exogenous testosterone therapy that's in super physiologic ranges, which is very sadly common without having a full array of what the, if there are true benefits and what the true risks are.
Doug: So Magda, you mentioned your GYN said, “are you okay with that?”
Magda: No, it wasn't my GYN. It was just my PCP.
Doug: When your PCP says, “are you okay with that?” I'm curious, why is that a question?
Magda: Well, because I'm an adult human being and he wants...
Doug: Oh, there's nothing specific about the treatment? There's nothing specific about the pushback?
Magda: No, I mean, anytime he prescribes me anything, he always wants to know, am I okay with it? Do I have questions with it? Am I actually going to comply and take it? That kind of stuff.
MaryBeth: From a physician perspective, I'm going to add to that answer. It sounds like your PCP is great, especially if those are the kinds of questions that he asks with every treatment. But it wouldn't surprise me if part of the reason that he asked that is because there is so much resistance among women to even think about any type of estradiol or estrogen therapy because of that ingrained fear that is passed along to us. Number one, “you should not give in. You're strong enough. It's natural. Suck it up. Deal.” That's one. Number two, and he may know this as well, and this to me is sort of a crime of the FDA and what they require on labeling of vaginal estrogen, but vaginal estrogen itself has a very low systemic absorption. You cannot use vaginal estrogen for the sake of treating your hot flashes and night sweats or other systemic symptoms of menopause because of that low systemic absorption. Well, if you're not absorbing very much of that estrogen at all, and it's negligible, then really what are the risks of using it? Now, unfortunately, whether you're using a very small dab of vaginal estrogen externally or you're taking an oral estrogen pill, which most people do not get written for in this day and age as appropriate Menopausal Hormone Therapy. It's a last line, not a first line. Or you're on a systemic hormone therapy patch, you know, in that package insert where it talks about estradiol, you get the exact same statement of risks, benefits of that estradiol on the non-systemic form as you do the systemic form that carries potentially those increased risks.
MaryBeth: You know, I will prescribe it for patients. I will literally drill through. “You do not have an increased risk of blood clots, strokes. You know, there are very few contraindications to using vaginal estrogen because of that low systemic absorption. There's not an increased risk of breast cancer. There's no increased risk of breast cancer.” If they didn't hear it again, I'll say it a third time. There's no increased risk of breast cancer. And I will see that patient in three months because I will schedule a two to three month follow-up because either we need to titrate it. Do they need a little bit more than what I gave them? Or the 50% of them decided not to start it, but they'll come back in for their visit and say, “Doc, I was really scared. I read the package insert. Is there something else that I can do because I don't want to die from that medication?”
Magda: And that's crushing.
MaryBeth: And so that is something that your primary may have dealt with and other women who may have come back in with another UTI and said, well, I didn't start a doc. It says that I could get a stroke or a blood clot. I might have cancer and my vagina is not worth that. I mean, this is natural anyway.
Magda: I'm lucky enough that I go to a pharmacy that is an independent pharmacy owned by these guys. I think they're two sets of brothers that are cousins. I don't know. It's fantastic. They are amazing.
Doug: Seems legit. Yeah. Sounds like a really top drawer outfit.
Magda: I mean, they're all pharmacists.
Do they sell out of the back of a car by any chance? [Magda laughs hard]
Magda: You know, if your doctor prescribes something and your insurance won't pay for it, but they know there's another formulation, they'll just call your doctor and be like, hey, let's figure out what we can get covered. That kind of stuff. Right. They're fantastic. And so when I went in to get the vaginal estrogen cream filled, they said to me, “Hey, there's some weird stuff in the insert here. Don't worry about it. It's not evidence based.” And I was like,
MaryBeth: Oh my gosh, you found the right PCP and the right pharmacist!
Magda: You know, I feel like finding a good pharmacist is like having another set of eyes on your care from your doctor, you know, because pharmacists are the ones who figure out if there's an interaction, if there's any kind of stuff going on.
MaryBeth: It's avoiding the Swiss cheese model. So we oftentimes will have patients who will come in and they need something and for whatever they came in for, but they forgot to tell us that they're on new medication A, new medication B, and new medication C. They said, oh yeah, there's no changes in my medications. So it's literally like if you look at the Swiss cheese model, you never want the holes to line up. So having somebody who is going to be that next level where there's no hole below that hole that that patient just fell through, and that's good.
Magda: I also want to say that there is a campaign right now where they're getting people to write in to whoever it is that puts that box label in the vaginal estrogen cream, asking them to reconsider
MaryBeth: It’s the FDA.
Magda: and consider aligning at the FDA. So we're going to put a link to that information about that petition in the notes for this episode so people who want to sign on can. Again, it’s all connected. I heard today about a friend whose mother is showing signs of rather sudden memory loss. And she's like in her late 70s. And it seems very sudden. And to me, that pings the, “oh, this may be an infection” thing. Because, you know, systemic infection sometimes causes memory loss. And in older people, especially women, you can be sort of wandering around after a lifetime of feeling uncomfortable constantly and have an infection and not even process it anymore because you’re desensitized to your own pain.
MaryBeth: Or to a brain tumor, cancer. Cancer is another thing to think about.
Magda: Yeah. And older women, because of the drop in estrogen, if they are not on vaginal estrogen, are really prone to UTIs. And so it's entirely possible that somebody can be misdiagnosed and mistreated for dementia simply because they get UTIs because they're not on vaginal estrogen cream. So I'm like, I'm on a tear. I'm like, I don't, you know, I would love for you to try systemic if you can, because I think you'll probably feel better and your heart will be thankful for you. But just, oh my God, go on the vaginal estrogen. You'll be so happy you went on the vaginal estrogen now and 30 years from now.
MaryBeth: And for women who are either adverse to any estrogen or if they've had any particular diseases, you know, whether it's a blood clot, a stroke or something like that, that really makes them cautious about anything hormonal that is thrombogenic. There are other options to also treat vaginal atrophy or the symptoms of GSM, whether it's using hyaluronic acid suppositories to increase the moisture in the vaginal area, whether it's using vaginal DHEA. or Intrarosa is the brand name. It's Prasterone. It converts to a little bit of estrogen, a little bit of testosterone on the vulvar vaginal surface, but again, much lower absorption. I just think that it's so incredibly under-talked-about partly because women up until now haven't been nearly as vocal as our generation is. And I think that the upcoming millennials, it'll be the nail in the coffin because they are vocal.
Magda: Oh yeah.
MaryBeth: They're going to be saying enough even more and they're going to be demanding it. They're not just going to be saying, “Hey, this is how I'm feeling.” They're going to be saying, “This is how I'm feeling, and I want to know what you're going to do about it.”
Doug: Now, we've talked about vaginal cream before and particularly how it affects male partners. I don't know if your clients have male partners who have even taken an interest in vaginal creams and vaginal therapy.
MaryBeth laughs: I think their interest is wanting to remain sexually active with their partner.
Doug: Right. And I think there are some male partners who have, based on fear and ignorance, they're like, “You're putting extra estrogen down there? How will that affect me?”
MaryBeth: I have never had that happen.
Doug: Interesting.
MaryBeth: Ever. Not a single woman who has been accompanied by her partner to discuss this issue, which I can tell you women, especially older women, are very good about bringing their partners in when the discussion is libido.
Magda: Oh, that's interesting to me.
MaryBeth: Not a single one of them, when there was a component of an anatomical change that was leading to her to not enjoying sex or having painful sex, not a single one of them ever questioned it.
Doug: Well, that's good to hear. That may have self-selected, right? I mean, anybody who accompanies their partner to a GYN is probably pre-selected to be open-minded about the health of their partner. I just want to be mindful of what men can learn from this so that they can learn what their partner is doing and be informed because that's a really important part of this.
Magda: The bottom line is it absorbs really quickly. So, I mean, unless you were actually using it as a lubricant?
MaryBeth: Lubricant, correct. So here's the other thing. There's three different forms of vaginal estrogen that are FDA approved on the market right now. There's Estrace or Estradiol cream. There are vaginal tablets that literally look like the tiniest little pills that are inserted in an applicator. So there's no worry that it's like, you know, spreading everywhere. And there are vaginal suppositories of estrogen in coconut oil. The important thing is most people aren't going to insert them and then have sex. And the regimen in terms of using them is only twice weekly. And it's at night that you're using it. So there's a lot of wiggle room around that. So in terms of having some sort of worry about developing gynecomastia, which is breast development, or something like that in a man, none of that is likely unless he decides to use it himself.
Magda laughs: You'd have to use a lot!
Doug: Right. Well, that's just, I mean, men are socialized to fear crap like that because female health to a man is, it's Fangorn Forest.
MaryBeth: It's like a no-no score. Like, you just don't go for it.
Doug: Yeah, exactly.
Magda: Well, I mean, one thing we, as a group of people in our 50s, I think are discovering is that AFAB people, assigned female at birth people, naturally produce estrogen but also testosterone. Right. And that people assigned male at birth naturally produce testosterone, but also estrogen. So, you know, it's not like if estrogen touches a dude, he's going to like go up in flames. There's already estrogen in his body.
MaryBeth: Correct. It's not like somebody who has a peanut allergy who then eats a peanut.
Magda: Right.
MaryBeth: You know, it's absolutely, there's no reaction.
Doug: Oh, good, so there's no anaphylactic shock involved in coming in contact with it.
MaryBeth: Nooooo. Definitely not. [Magda laughs]
Doug: All right, guys, take a note. You don't need an EpiPen.
MaryBeth: Penis will remain intact in that vagina.
Magda: Yeah. Yeah. Well, but I mean, again, to MaryBeth's point, there's just not enough of it in there that even if it got on you and soaked into you, there wouldn't be enough to do anything to you.
There's such little systemic absorption that there's no worry. I mean, unless you're applying it to your chest or something like that.
Magda: Yeah. I mean, you're probably in more danger if you apply like DEET mosquito spray.
MaryBeth: Probably.
Magda: And now the National DEET Council is going to come after me.
Doug: Yeah, there goes that sponsorship. [Doug and MaryBeth laugh}
Magda: I don't have any idea how much DEET absorbs into your skin if you're using a DEET-related mosquito stuff.
MaryBeth: I don’t, either.
Magda: For mosquito stuff, I prefer Avon Skin So Soft.
MaryBeth: I was going to say Skin So Soft is the way to go.
Magda: Oh my God, that smell.
MaryBeth: The smell!
Magda: I said that and I'm betting every single person who's listening to this immediately got the smell of Avon Skin So Soft in their head.
MaryBeth: The power of suggestion is amazing.
Magda: Yeah. So, okay, MaryBeth, here's what I really wanted to get out of this episode with you.
Doug: Well, thank God we're finally getting around to it.
Magda: I know. We're like, “holy crap, I want to go on HRT to see if it makes me feel any better. And also because my grandma and my mom had horrible osteoporosis, and I know that it's going to protect me against osteoporosis.” You do telehealth appointments through Gennev, so if somebody...
MaryBeth: Correct.
Magda: …does not have a gynecologist who will prescribe anything for them and they live in the states that you're eligible for, they can sign up for an appointment with you through Gennev and you're going to say, okay, let's go, let's talk about your symptoms, right? But let's say they go into their gynecologist that they've been seeing for years, have never had any conversation with this about, so they don't even know how much their gynecologist knows about it, if they have a regular routine of prescribing. And what even, like they don't even know what it is that you get prescribed. Is it a shot? Is it a suppository? They don't even know what it is to ask for.
MaryBeth: So what I would first recommend because of the way things work with appointments and insurance and all of that is as a woman who wants to know more information about Menopausal Hormone Therapy, whether she's a candidate for it, what it's about, if it's going to help her particular symptoms. I would absolutely make a separate appointment than trying to throw it in when she's there for her annual exam, getting her pap smear and having her you know, mammogram script given to her. Because those appointments typically are strictly kind of confined to that. And having that conversation of Menopausal Hormone Therapy can be a long one, and
insurance won't cover both.
Magda: Oh!
MaryBeth: And most people don't want to end up paying out of pocket for the discussion of Menopausal Hormone Therapy when their insurance is already paying for the well woman exam.
Magda: Right.
MaryBeth: So if you want your doctor's attention to really see, number one, what do they know about menopause and what are they comfortable with,
then making a separate consult for that would be really important. I have had patients in my own previous brick and mortar practice that I had in Florida who would come to see me every single year for 18 years straight for their annual exams. And on year 18, they would come in and they're on this whole slew of hormones. And I'm like, I just saw you last year and you said you weren't having any issues. Who are you seeing? How did this happen? “Oh, well, I didn't know you did that.” [Magda laughs] And then it's kind of like reinventing the wheel. And I think a big part of that is that disjunction between what is real evidence-based menopausal medicine and what is out there as I'm going to promise you the menopausal fountain of youth with all of these extra labs and extra hormones. And I'll do your own, you know, the combinations that we can come up with, and then you're going to see me every three months and you're going to pay out of pocket for this.
Magda: Well, I think that's a legacy of the WHI study that people did not anticipate because the WHI study made gynecologists stop prescribing plain old HRT and we live in the United States of America, so the market's going to provide a solution.
MaryBeth: Correct. And it's going to be a solution that makes somebody money.
Magda: Yam creams and pellets and all kinds of weird crap that people are taking to try to feel better because they weren't allowed to take the actual studied prescriptions.
MaryBeth: Right. Or they didn't know if they could.
Magda: Right.
MaryBeth: And if you end up walking into an office where somebody says, “I'm cash pay, and this is what you're going to pay me. And I'm going to promise you all of these things. And I can't tell you that there are risks because nobody's actually ever studied them.”
Magda: Right.
MaryBeth: You have the doctor that is struggling with the fact that cost of practicing goes up. The reimbursements are going down. They're already used to a certain way of life. And so how do you get more income into your practice? And then on the flip side, you have a woman who feels kind of lost with symptoms that have not ever been talked about or addressed. And she feels like she's the only one. And in general, as a society, we tend to feel like if we are paying more for something, we must be getting more in return.
Magda: Right.
MaryBeth: And I do think that the WHI kind of shutting everything down that was in the evidence-based direction and and made physicians who were prescribing very leery to continue prescribing. It just left this open hole, this void that needed to be filled somehow. And sadly, that's how it got filled.
Magda: So, okay, one way to find out in the positive direction if your gynecologist knows anything about menopause care is if they are certified by Menopause Society. And you can go to menopause.org.
MaryBeth: Correct.
Magda: And everybody who's gone through the certification process, which is just like, how much do you know about it? You have to, what, you take an exam or something to get certified to show that you know enough about it. And they're listed there. So if you go to menopause.org and you look and your gynecologist is there, things are looking good, right? Just make your separate appointment and walk in and you can start talking about it.
MaryBeth: Correct. And another caveat is they will list people, physicians who are members of (Menopause Society) that aren't certified. And even that, if you have one person in your area that is there and they're not certified, but they're a member, they probably have some vested interest in evidence-based menopausal care. If you don't find a local physician, because not everybody lives in an urban area with a lot of access to different physicians, then looking at a company like Gennev, which I'm part of. And shout out to Gennev. I mean, we're licensed in just about every state. And these are physicians who are absolutely dedicated to giving evidence-based menopausal care.
MaryBeth: If you're not a candidate for hormone therapy, they will let you know and they will let you know why, but then take that next step to talk about other menopausal therapies that can be helpful for the particular symptomatology that that patient has, so that they don't feel like they're just tossed out. “Oh, you've had breast cancer, so you can't have estrogen.” Door shuts. That shouldn't be where it stops. There are many more things that we use at times for various symptoms. It's off-label usage, but they're also things that have been studied. We know what the risks are, we know what the benefits are, and they're all essentially FDA approved medications. You know, there are a lot of other things that can be done within that realm of being a candidate versus not being a candidate for hormone therapy.
Magda: Okay, so you go in, you've scheduled a separate appointment, your doctor's listed on menopause.org. So you know, she's cool with it. You walk in, you're just like, I would say a regular person without any like specific risks, like maybe one of your female relatives had breast cancer at some point, but you don't have any particularly escalated risk. You're maybe having some symptoms, but they're not completely severe. And you have some concerns about heart health.
MaryBeth: Severity of symptoms is relative. So current guidelines recommend that if you're going to initiate Menopausal Hormone Therapy in a patient who is a candidate, it's for the treatment of her menopausal symptoms.
Magda: Interesting.
MaryBeth: So that's important to know. That is the current guideline. We wouldn't start Menopausal Hormone Therapy specifically because of an increased risk of heart disease in a family.
Magda: Huh.
MaryBeth: We know that there's some protective benefit there, but it wouldn't be the reason to start it, that we're not there yet in terms of the evidence saying that that's what we should do.
Magda: Interesting.
MaryBeth: Now, so going back to symptomatology and how I like to approach each consult is to go through kind of all the organ systems. First of all, background information. When was your last period? Are you still getting periods? If you are, how often? If it's been over a year, tell me a little bit about your symptoms and when they started. And what has made you make this appointment today if it's been two years? What's different now than two years ago? Are you feeling like your symptoms are in any way worse? Is there something that you've read? Are you just so incredibly tired because you can't sleep at night and you know that it's related to menopause and you've just had enough and you need to get some sleep? Well, if you're losing sleep, why is it that you're losing sleep? Are you having night sweats? Are you getting up in the middle of the night and urinating frequently? Are you having your mind racing? Like, so all of those things, even though they're not the trigger, what we think of automatically as menopausal symptoms, because we all know mostly about the vaginal dryness, some women more than others. We know about night sweats and hot flashes, but there are a lot of other symptoms that really are menopausal symptoms. And most women who will come to me and say that they have mild symptoms, when I start breaking it down, Do you experience this? Do you experience that? And go down with each system. [Magda laughs] They are like, oh yes, oh yes, oh yes. But they're all mild. wow, I didn't really think about that. Actually, it's been driving me bonkers that I have night sweats three nights out of the week. And those days after that, because I'm not sleeping well, I'm really struggling. And as a result, I'm also dealing with my, I've got this tire around my waist of weight gain that I never had before. And what's that from? And it literally just starts to escalate because we are so good at normalizing our symptoms.
Magda: Mm-hmm.
MaryBeth: Now, every once in a while, I will have a patient who has no symptoms whatsoever. Have I used Menopausal Hormone Therapy off-label for somebody who has two parents with osteoporosis? Her sister has osteoporosis. She has no other risk factors, but she really doesn't want to go from osteopenia, the start of bone loss, to osteoporosis. Did I start her on estrogen? I kinda did. She had a hysterectomy already, so she did not need progesterone to protect the lining of her uterus. And what we do know is taking estrogen alone does not increase the risk of breast cancer. So I knew that was okay. She didn't have increased risk factors for blood clots, stroke, that kind of thing. She wasn't hypertensive, no other real risk factors. And I talked to her about risk benefits and told her it's not, you know, this is not necessarily indicated, but if you would like to start it, let's follow up in three months.
44:53
MaryBeth: Maybe there are symptoms that we're going to be treating that you don't even realize that you had. And you're like, “Whoa, I feel back to normal.” And part of it is because they didn't have those classic symptoms. And everything else they expected was unrelated.
Magda: Right. Well, I mean, it's like the itchy ears. Who knew itchy? Like, nobody knows, right? Like, yeah.
MaryBeth: Tinnitus, restless leg. Right. Joint pain with, you know, this random joint in the hand being one that can be the most affected. Ironically, I learned about that when I was studying for my Menopause Society certification exam. Right. And it was like arthritis and, you know, joint pains. “And these are the joints that are mostly affected.” And I was on week three of pain in the joint that they said is the one that was most affected. [Magda laughs] And I was like, I can't do anything with my left hand. It's like left hand, I'm right handed.
Magda: That’s amazing.
MaryBeth: Why the heck does this joint hurt? And I was like, I was like mind blown. And I'm an OBGYN that's been practicing this for years. And I feel like I've had a pretty good background education. We're still learning. And we're still learning because so much hasn't been done up until this point. And it's exciting to know that there are so many different researchers, whether it's PhDs, MDs that are totally dedicated to advancing care of menopausal women. And not just related to their sexual function and not just related to hot flashes and night sweats, but really related to how a woman's body functions and how it's different than how a man's body ages and functions.
Doug: When the treatment starts, how much of that initial aspect is kind of experimental, like with depression meds, you've got to prescribe a cocktail and then tweak and see how the symptoms come and go.
MaryBeth: That's a great question. So there's a lot. I think most of us do kind of the same thing in terms of the start. So if you have a patient who has a uterus, she's a candidate for Hormone Replacement Therapy, which means starting estradiol. Why? Because it's an estrogen that is the same structure as the majority of estrogen that was produced from her ovaries when she was still producing estrogen and we will start progesterone, which is just like the progesterone that her body produced. So kind of looking at what “bioidentical” means, it has the exact same structure. So when we start Hormone Replacement Therapy, it's important to know that doing laboratory values to look at where their starting estrogen is or progesterone is, is not indicated because there is absolutely no scale or level of hormones, estrogen or progesterone, that correlates to optimal symptomatology. So there's a wide range of what's normal, and it's recommended, and it's been seen that treating the patient's symptoms and her symptomatology with the levels of estrogen replacement therapy that we have from our FDA-approved regimens is the way to go. So if we look at the formulation of estrogen, the most common one that we'll use is transdermal, meaning giving estrogen through the skin.
MaryBeth: We give estrogen through the skin because there are studies showing that it is actually safer with respect to blood clots, so what we call thromboembolic events, And that is because if you take estrogen orally, it starts getting metabolized through the liver, which is also where your coagulation enzymes are processed, what have you. There are gels that are available. And the most common thing that we'll start with is a patch. Most women will ask right away, especially with me living in Florida, where it's hot all the time. We have a lot of, I have a lot of patients who are athletes, for example. “I swim all the time. Is it going to stay on?” It stays on pretty darn well. Some of it can be finding the exact place. Like I've learned that putting my patch on near my C-section scar crease is not a good idea because I will sweat that darn thing off. And I didn't even know I sweat there. [Magda laughs]
MaryBeth: So finding the right place where it's going to stick can be helpful. Now, when you look at a patch or the gel packs that you can use on a daily basis, there's five different hormone levels that we start with. We start with 0.1, 0.075, 0.05, 0.0375, and 0.025. The majority of women feel significantly better and have resolution of their menopausal symptoms on that middle dose, the 0.05. So it's a really good place to start. In terms of using progesterone, we have two doses that are available, 100 milligrams and 200 milligrams. If I am starting a patient on that 0.05 level, that middle of the range, I will start on 100 milligrams. A small subset of women may develop a little bit of spotting related to that, and then we need to bump up the progesterone to make sure that she has adequate protection of her uterus from the estrogen that she's on.
MaryBeth: If I have a patient who comes in and it's been nine months since her last period and she is ready to drive into a tree because she feels so miserable, I will start her on a higher dose because I wanna knock those symptoms out of there. She's really struggling. She's not the, “I have mild symptoms and I wanna protect my bone health.” She's the, “I am about ready to hurt my family and drive into a tree. What can I do to stop all of these symptoms? It's awful.” And so I will start her at a higher level with the higher level of progesterone.
Magda: How long do you wait to adjust? Is it like a month? Is it like three months? Is it?
MaryBeth: I say two to three. And that is because that first script is going to be an 84 day supply, 12 weeks, because that's how they're packaged. One month is eight patches and there's two a week. And I like patients to kind of follow up in that eight to 10 week window because they should have really reached their optimal expectation of what treatment's going to give them. So if they come back in at eight to 10 weeks and they're like, “I am so much better. I'm only having night sweats twice a week now.” I'm bumping their dose up to the 0.075. You know, OK, great. I'm glad you're feeling better, but you deserve not to feel those if we can knock those out. If we have somebody who comes back in and she's like, “Oh, my gosh, I feel like a million bucks. You know, this is the best thing since sliced bread. If I knew your address, I'd send you flowers.” I've been told that before with this initial start. Then we just keep them where they're at.
Magda: So if somebody hits a dose that's great for them, does that mean that's what they're going to stay on until they decide to go off or they die? Because I feel like my perimenopause process, my hormones seem to have shifted in one way or another about every 18 months. And there was a point in which my HRT dosage was great. And then like over the course of two or three weeks, suddenly I could tell it wasn't right anymore. And I think it was just because my hormones shifted. Does that happen after you go through menopause?
MaryBeth: So there are different things that can affect what your endogenous hormone levels are beyond what you're taking. So if you're starting on Menopausal Hormone Therapy when you are not yet menopausal, that means that you're still going to have some fluctuations.
Magda: Right.
MaryBeth: So when I have a patient who comes to me who has gone through the periods of gotten closer together, now they're spacing out and she has a majority of symptoms related to lower estrogen and say she has an IUD with progestin in it. So she doesn't need progesterone, but she definitely seems to be suffering and needs some estrogen. I will start her on estrogen with the caveat that if her ovaries start functioning again and she's going to get a period, she now has the ovaries functioning and the extra estrogen from the patch. And she may feel worse that cycle in that PMS kind of phase than she did before. She would potentially feel better to take the patch off until she gets her cycle and moves on and kind of goes back to normal and slap it back on.
MaryBeth: Now, once you're menopausal and you're not producing any more estrogen whatsoever, I mean, you're going to be stable. The likelihood is you'll find something that is going to work for you that's stable. Now, what are the caveats? Do you have thyroid dysfunction where you have hypothyroidism and you're on a thyroid medication? Starting on Menopausal Hormone Therapy can affect your thyroid treatment. So it's important once you start that to have it assessed to see if there's any change needed in your thyroid medication. There's a lot of crossover between symptoms of thyroid deficiency and and menopause flashes, night sweats. You know, when I have a patient who comes to me and says, “Doc,
I have been on the same regimen for three years. It's been great, but now I'm having night sweats every night. So can you up my estrogen?” I'm not going to up their estrogen first. I'm going to check their thyroid first, especially if they haven't had it done recently. And nine times out of 10, it's related to that.
Magda: Wow.
MaryBeth: So it's tough. I mean, we're dynamic structures, you know, and creatures. So it's hard to know how many different things can affect it.
Doug: You know, I've never heard women referred to as dynamic structures before, but I dig it. [Doug and Magda laugh]
MaryBeth: I love it. That makes me feel better. That was, I just pulled that out of my butt, but you know, I, we are, we're dynamic structures.
Doug: Some of the best aphorisms came out of somebody's butt. So by all means, fantastic. [Magda laughs]
MaryBeth: Structure just sounds strong and prominent and important.
Doug: You counsel your patients not to tolerate the kind of pain or other symptom that they might feel they should just tolerate because that's the way it is now.
MaryBeth: Correct.
Doug: For any woman who wants to approach a doctor and say, this is what I want to do, perhaps they're getting some pushback from the doctor, perhaps they're not sure how to advocate for themselves. How would you counsel a woman to kind of advocate for herself during these first stages?
MaryBeth: I think it's a matter of really reaching out again, going back to finding a physician that's going to be supportive and knowledgeable, going back to menopause.org, for example. And it's important to also know that there are some definitive things. You know, if we have a patient who has had a deep vein thrombosis, that's a DVT, a blood clot in the leg. And it was found that she has an underlying blood clotting disorder. She's going to be very hard pressed to find a doc that is very comfortably going to put her on estrogen.
MaryBeth: That doesn't mean that her symptomatology isn't important. And that's where finding somebody who's knowledgeable, who can go over the other options for treatment of her symptoms besides estrogen. So we don't want to increase somebody's risk when they have that underlying risk factor. But I also don't want her again to have the door slammed shut and say, “good luck with that.”
Magda: There's a huge difference between saying “there's nothing we can do about that” and saying “we can't use this first line treatment because it's not safe. Let's find something else.”
MaryBeth: It's really validating the symptoms and letting her know, look, you're not imagining this. Right. You know, I mean, there are times when I'll see, you know, through Gennev, we talk about menopausal care, but the big elephant in the room is perimenopause. I'll be honest, I think menopause is a lot easier to treat than perimenopause. And perimenopause is even less studied than menopause.
Magda: They didn't even give it a name. It wasn't even called “perimenopause” until after you and I were out of undergrad.
MaryBeth: Absolutely.
Magda: That’s nuts to me!
MaryBeth: Because if a woman was getting periods regularly, she was supposed to just deal with the symptoms that were happening. And it's, I think a big reason is because we really didn't understand that just getting a period didn't mean that everything was totally perfect.
Magda: Right.
MaryBeth: You know, your periods in your forties are not the same as your periods in your thirties or your twenties.
Magda: No, not at all.
MaryBeth: And neither are your symptoms like PMS. Right. Oh my God. Like I didn't even really understand what PMS was until I was in my forties.
Magda: Yeah.
MaryBeth: And then I was like, this is for the birds. You know, this sucks.
Magda: I was just always one of those women who just had a period. And sometimes I had some mild cramps and whatever, you know, it like, it was fine. I didn't ever feel like it was a particular burden in any way. To me, it was just more of an indicator. It was like, you know, okay, system test. Right?
MaryBeth: Yeah, exactly.
Magda: And my first perimenopausal symptoms were that suddenly I had the kinds of periods that I had heard women complaining about.
MaryBeth: Very heavy, very crampy, irregular at times. Why did I just get two in a month? And why do I feel so irritated that I'm irritating myself? I wish I could walk away from my own head. No wonder my family's looking at each other like I've lost my mind. I feel like I have.
Magda: Right.
MaryBeth: I mean, those are the things that are like, whoa, those fluctuating hormone levels are crazy.
Magda: Our age group, Gen X, like we had the joy of playing The “Is it perimenopause or Donald Trump or COVID” Game, right?
MaryBeth laughs: True.
Magda: Yeah. I hate the world. Why is that? Why? It's one of these three.
MaryBeth: And did all of these, did these other two things have to happen when I'm perimenopausal?
Magda: Right.
MaryBeth: Like, thanks for the salt in the wounds there.
Doug: I think I know what the answer to this question is going to be, but I want to ask it anyway, just because you mentioned that periods change as women age. Is there any correlation to the pathology among your patients who've had children versus those who have not? Does that have any material effect on the menopause they're experiencing? Has there been any discussion about that?
MaryBeth: I'm going to say this from the view of just an observation of all of the patients that I've had. I've never specifically really thought about that. But I think women who don't have children seem to maybe go through it a little bit easier because they don't have as many people in their lives that their mood changes are affecting. [Doug laughs] And so many women who have children have spent their entire lives putting those kids first. And so that adds a whole other dynamic
Doug: The stress aspect?
MaryBeth: …on top of how they feel. You feel miserable, but you're supposed to just keep going because your kids come first and you have to suck it up and just deal.
MaryBeth: The other thing is that women who don't have kids have more flexibility in the, “Wow, I don't really feel good. Maybe I need to work out more.” What women who's busy with a lot of kids goes, “Wow, I feel miserable. I'm so busy. It means I must need to work out more”? We don't have time.
Magda: I think our generation was the first generation in which men understood that they were going to have to pick up the slack in some areas when a baby was very young. Right. That a mother had specific duties related to the baby and the men were just going to have to pick up the slack in some other areas. And I think most men, I mean, Doug was the man that I parented with when our kids were little. And Doug very much understood that he had to pick up the slack in a lot of areas that he might not have had to if we hadn't had kids or, you know what I mean?
MaryBeth: The hard part, though, Magda, is as an obstetrician, I've seen how often that isn't happening now, despite our generation. So me, like you, I have co-parented for the last 23 and a half years. You know, my husband is, he's a general surgeon. I was a full-time OBGYN. And I can tell you there were weeks where he did 80% of everything in the home and there were weeks that I did 80%. And there were a lot of times where we were 50-50, but it was never a “that's your job.” But I also recognized even within my female OBGYN colleagues that what I had was an exception.
MaryBeth: I do think that there are more of us who have that, but I absolutely don't think it's the majority yet. So I'm going to pull up a slide that was, I took a screenshot of it at the Menopause Society Conference in Chicago two weeks ago, and it blew my mind. Okay, so here we go. “The economic impact of menopause. Cost associated with lost work productivity associated with menopause symptoms in the United States is at least $1.8 billion annually.”
Magda: That's nuts.
MaryBeth: That's just the workplace.
Magda: THAT’S NUTS.
MaryBeth: So we're talking about what men need to do at home. How about women who are not yet menopausal or perimenopausal, and men in the workplace. “Costs including direct and indirect medical costs is estimated at $26 billion annually.”
Magda: Direct and indirect MEDICAL costs. Wow. HRT is pretty cheap compared to that.
MaryBeth: So, you know, what are the things that could be helpful in the workplace?
Magda: Uh, not having to clock in every day at exactly 8 o'clock.
MaryBeth: How about having a looser dress code so you can wear something that's maybe a little bit more comfortable than the pencil skirt, the heels, and the sweater? How about adequate ventilation? How about having access to maybe like a cool room or something like that? Almost like the work version of a chili pad that you can use at night to keep yourself cool. There's so many things, just having the access to care so that women can get this kind of care. So that's one of the nice things about, not to mention again, Gennev, but getting insurance contracts with particular companies where HR is supporting menopausal care and making sure that women in their workplace have access to services specifically, you know, dedicated to menopausal health so that the word is getting out there. I mean, that's the smartest thing in the world.
MaryBeth: Like if you have a woman who's not sleeping at night because of night sweats and what happens during the day, you're less productive when you're not sleeping.
Magda: Right.
MaryBeth: So say it's $250 out of pocket for the company. You have her get a visit. She starts on medication. Her night sweats are gone. She's now sleeping well. You've improved her productivity tremendously.
Magda: Oh, yeah. A lot more than 250 bucks.
MaryBeth: Exactly. Exactly.
Magda: Well, menopausal accommodations in the workplace would be better for all employees, not even just the women, and for the employers also. It's all a piece, right? Because if we had the idea that human beings had needs and that, you know, it would be okay to slot out of the paid workforce for a little while to take care of your own needs and this other complicated structure that you had created.
MaryBeth: Right, this complicated structure who's eventually going to be in the workforce if you can raise them appropriately with the adequate resources without worrying that you're going to lose your job if you go back too soon or whatever it is, you know. Adding stress to the postpartum time, you know, doesn't help anybody. It doesn't help the baby. It doesn't help the rest of the family and it doesn't help anybody at work.
Doug: You're in Florida.
MaryBeth: Correct.
Doug: And I'm very curious about how your career has been affected over the last few years by the change of political scenery down there. Under these current circumstances, how has your practice changed as far as advice you can give to women and what concerns do you have? How many lawyers do you have on speed dial, et cetera?
MaryBeth: I mean, so I stopped delivering babies in 2021 and the change in terms of abortion restrictions did not necessarily impact that, but it has an impact on my field that I'm dedicated to. And I think the biggest issue, and actually very recently, I think it was this week, there was a statement that was put out to physicians to not delay care for patients who have pregnancies in which there is a complication that is going to lead to baby not living, et cetera, regardless of gestational age, you know, with the 15 week rule, the six week rule, all of these bans that are, that keep popping up. You know, the pendulum always swings. When you start with a law that says, oh, if you terminate a pregnancy after 15 weeks, somebody comes in, breaks her water at 16 weeks and the baby still had a heartbeat, we were kind of stuck waiting. Do we wait for sepsis in the mom?
Magda: Oh, God.
MaryBeth: So we can say, oh, look, now we have to do something. What I think a lot of people don't realize within the state of Florida, who are kind of focused on that “abortion bad, killing babies bad,” or however they put it all together, is that these kinds of laws that are restricting access to patients are restricting access to patients who need vital care, even within the realm of having a pregnancy that was very desired. So you're actually injuring people that potentially are aligned with what your viewpoints are anyway. Why would you do that?
Magda: Right.
MaryBeth: I mean, there's so many other complications related to it, but the pendulum kind of swung to the everybody's afraid to do anything because they don't want to be prosecuted because they were such a push of, if you don't follow this law, you're going to be prosecuted. To now, a week or two ago, they had to put out a statement that said, “do not risk a woman's life if she is falling out of that 15 weeks and has something going on in which she needs to have care to terminate that pregnancy.”
Magda: It's insane that they had to say that!
MaryBeth: It's pathetic. No, it shouldn't have to be said but it's being said in response to having a poor outcome that was associated with this original law going into effect that then again makes people scared to act. You know, physicians are very, very fearful of litigation and getting sued. And so they're sitting there going, “I don't know what to do. What's the law? It changed. I don't know. What do I do about this?”
Magda: And the laws are being made by people who don't have any fundamental understanding of medical care. The laws are being made by people that have the idea of a hypothetical baby.
MaryBeth: Well, and by people who want a certain contingency of votes.
Magda: Right. They won't even get that hypothetical baby, but they will create older kids who have no mother.
Doug: Plus, we know “in six states it's legal to bring the baby to term and then kill it,” apparently. [Magda laughs]
MaryBeth: Yeah, I can't even. Like, I can't even. I have no words because it's just preposterous. And like, again, it is amazing to me the ridiculousness that will come out of other people's mouths for the sake of a vote. No matter how ridiculous it sounds, there are people that are listening to this and believe it.
Doug: Right, because Trump is going to be your protector, MaryBeth, don't you know?
MaryBeth: I need a protector, definitely. It's obvious.
Doug:He's going to make your life wonderful, marvelous. Your hair will be soft. All your clothes will fit perfectly.
MaryBeth: And it'll stop falling out because I won't be as stressed.
Doug: Yes. And wow, how many women just swam into the ocean once they heard that?
MaryBeth: I think honestly, you know, under this gubernatorial path, that was a big thing that really affected OBGYNs and was very frustrating just because I think the masses just didn't quite understand the potential impact. You know, to have to see somebody who has a ruptured ectopic pregnancy that's risking her life and to then tell her, a layperson, “You're not having an abortion. You're not breaking the law. You're not killing a baby” because this law has made everybody think that in any way, if a pregnancy is ending in the first trimester, second trimester, whenever it is, that must mean that it's an elective termination of pregnancy. I mean, an ectopic, a ruptured ectopic pregnancy, any woman can die of that. You know, when you have somebody who's sitting there bleeding internally and you want to do surgery to save her life and she's arguing with you, because of the changes in the laws more recently, that's a barrier to appropriate care. That is a risk to her life.
MaryBeth: Now, the other place that I've really seen an issue is having patients, I have a lot of patients who work at local colleges and universities. One patient in particular who was a head of a department at a local, big local university, and she spent 15 minutes of her 30-minute appointment telling me how horrendous it is to feel like she has a target on her back because of the classes that she teaches. Now, she is not a philosophy professor. She's not a sociology professor. She's not a professor in a medical school talking about you know, things related to abortion. She's a business professor.
Magda: Wow.
MaryBeth: You can't talk about business with respect to sociocultural differences. You know, this whole book ban, you know, don't talk about any LGBTQ+ issues. Don't talk about any gender issues. DEI can't exist. So seeing that from people who are teaching and seeing how pained they are that they are afraid of actually teaching our state students. You know, I mean, there's a reason I have two kids who were raised in Florida who both decided they were going to school outside of Florida when they left high school.
Doug: And so how do you counterbalance that? How would you like to advocate in your state to at least help as many professionals like yourself know as much about their legal footing, so that they know that they can practice with impunity.
MaryBeth: So here's the other hard part is living in a state that tends to have a large proportion of followers and supporters of these politicians and these laws. I mean, I take care of everybody who walks in my door, who comes in to see me. She could be somebody who had a termination of pregnancy and now she feels really awful and she feels scared for anybody to know. But basic things within her life, you know, whether it's decisions she's made, procedures that she's had, these are relative to me taking care of her.
MaryBeth: So I make sure that I'm taking care of each of my patients in a very nonjudgmental way and supportive way and in a very private way. You know, earlier on, I've never really talked openly on social media or in my community about my specific views on abortion or anything like that, because I didn't want to have to worry about my kids making it home safe from school or me making it out of my office and making it home.
Magda: Wow.
Doug: America really is the best country in the world. [Magda laughs bitterly]
MaryBeth: You know, I'm not shy about educating my patients, especially if I have a patient who comes to me and says, “Well, I just don't believe in killing babies.” You know, I can address that on some level. Even just to say, hey, there's another side of this that you're not realizing is that I don't know that anybody is pro-killing babies, but we are also pro-other women.
Doug: Yeah, it's pro-choice. I mean, choice does not mean anti-life.
MaryBeth: Right, exactly. My patient who was in a car accident who is now bleeding and broke her water and it's pre-viability and the baby doesn't have a chance of surviving, she's suffering because of this.
Doug: Well, Magda, I mean, I know I've taken this onto a political bent, but if you have anything else medical you'd like to ask, by all means.
Magda laughs: I think it was going to get political since we had an OBGYN in Florida.
Doug: Exactly.
Magda: I really just wanted to talk about Is it okay to go on HRT and how do you ask for it? Right? I think the other thing for people to know is if they don't feel like they can talk to their gynecologist about it, or they talk to their gynecologist and the gynecologist just shuts them down, there are services that do telehealth. I will promote Gennev because one of the founding doctors of it is friends with MaryBeth and me.
MaryBeth: She’s phenomenal.
Magda: We went to school together, Dr. Rebecca Dunsmoor-Su. She's writing a book right now, isn't she?
MaryBeth: Yes.
Magda: Yeah. When her book comes out, we'll have to have her on. But if you're in certain states, you can get care from MaryBeth.
MaryBeth: And honestly, just don't hesitate to find out. If a woman has questions or concerns about how she's feeling, then it's absolutely appropriate to have them assessed. And I'll give another quick aside to that. I have a patient that came to me for a hormone consult, discuss menopausal therapy. Is it an option for her? And her big reason was worsening joint pain. It had been going on for about three years. The first person she saw, because it started in like her hand, she saw an orthopedic surgeon and kudos to him, like her hand was fine, but he did initiate a workup for autoimmune disease, like lupus, rheumatoid arthritis, this kind of thing. All of her markers at that time came back normal. One marker of inflammation was borderline, but it was still in the normal range. And she was like, okay, well, you know, my joint pain's still there.
MaryBeth: And then she had joint pain elsewhere. She had a regular primary care. They kind of was like, ah, you know, take an Advil, you're getting old, life goes on. But she just felt like it was something more than that. And she then ended up going to a naturopathic physician who ordered a bunch of labs, including a repeat of the labs that the other physician, the orthopedic surgeon had ordered. And this time her inflammatory marker was a little bit elevated. So that tells you there's an inflammatory process somewhere within her body. Now, if her only symptom is worsening joint pain, and there's been a progression in the joint pain. And now there's a progression in that inflammatory marker. They're probably related. This particular physician focused on a lot of supplements and kind of “you need more selenium” and some other minerals and stuff like that. And she was like, she didn't feel any better. She kept feeling worse. So then she went to the second naturopathic physician. And her inflammatory marker was increased again.
MaryBeth: And the focus was on all of her electrolytes and her minerals and vitamins and supplements. And she was like, “Okay, and now I'm on an anti-inflammatory diet. Nothing is helping.” That is how she ended up with me to discuss menopause. So I said to her, “If this is just menopause and I see all of your labs, you have a marker for inflammation and it keeps increasing, that's telling me something. But I don't have a problem knowing that you don't have any risk factors of putting you on Menopausal Hormone Therapy and seeing if you improve. Let's follow up in two months and see how it is.” And her joint pains kept getting worse.
Magda: Interesting!
MaryBeth: Repeated her inflammatory marker, and it is now three times, four times more than normal. So I start looking into what could be going on. I'm like, she's got something. Now I have an underlying autoimmune disorder. I'm a little bit in tune to that, but her autoimmune screen is negative. What could be causing that? Gosh, darn it, if she doesn't have seronegative rheumatoid arthritis! Which has an increase in diagnosis, like increase in that curve of when women are diagnosed in the perimenopause to menopause transition. So you always have to think out of the box. And I'm a gynecologist. I mean, the easiest thing would be, hey, I put you on hormones. It's not better. Go to another doctor.
MaryBeth: But here's somebody who already went to three other people. And even though she had this inflammatory marker, it was ignored for the sake of looking at other normal minerals, electrolytes and other things. Oh, let's just optimize your diet. Okay. I mean, that's a good thing, but it's not everything because she kept getting worse.
Doug: I'm watching Magda listen to you while you say all these things. And I know you're heating up the parts of her brain that make her the diagnostician she is.
[Magda and MaryBeth laugh]
Doug: Because your role, when a new person comes and sits down, there's so many factors that you've got to cross-reference in this enormous Rubik's cube of mayhem that is a woman's reproductive system.
MaryBeth: It's the reason I'm going to die a poor physician because I spend way too much time with my patients and get paid the same amount as if I spent 15 minutes with them. But I feel like I have to.
Doug: I would think so. I mean, the more communication, the better. And I think that's, the best place to start both from doctor to patient to patient to patient, word of mouth, recognizing that as our awareness of menopause grows and many Gen X celebrities embrace that as something they want to talk about a lot, like Naomi Watts and like Julia Louis-Dreyfus who are saying this needs to be studied.
MaryBeth: Mm-hmm.
Doug: And that goes for all the male partners who are concerned about what their AFAB partners are going through.
MaryBeth: Right.
Doug: We're going to link to menopause.org and to Gennev, of course. But what other resources are there to find both you or other important information online?
MaryBeth: If a woman wants to know just more about menopause, there is a book called The Menopause Manifesto. It's by Dr. Jen Gunter, G-U-N-T-E-R.
Doug: Manifesto, man. [Laughs] It's got a pejorative term to it, but I'm glad it exists.
MaryBeth: It's a good resource. I think it's a fairly easy read for anybody. It's not like you need to have an MD or a PhD, which is really nice to have an idea of the basics. It feels good to have an understanding that you're not imagining what you're going through. And it might actually help some women kind of put it together.
MaryBeth: Most of us as women in the Gen X time, we don't know that much about the female sex drive. Nothing's really been presented to us. It's never been available. There's a book called Come As You Are, the author Emily Nagoski. It's one of the first books written about the female libido from the female perspective. And that's kind of nice. It's been helpful for patients who feel like their only real knowledge of libido is that their sex drive is less than their partner's, and that's distressing to them.
MaryBeth: And then there's another book called The Tired Woman's Guide to Passionate Sex by Laurie Mintz, M-I-N-T-Z. That's another really good resource, again, related to libido, desire, sex, where do we find time in our lives when we're going through all of this and we're busy at the same time and have to keep everything else going at work and home? The word of caution is beware of the, “I'm going to give you all of this menopause information and then you're going to buy all my supplements.” It's hard when financial gain is connected to the information that's given.
MaryBeth: So I think social media is really great in a, so starting with some of these resources means that women and men, if they want to read it as well, if they want to kind of start with getting more factual information that they can trust, this is a good way to start. Then it's easier to filter out what's real and what's not when they go to social media, whether it's TikTok or Instagram or, you know, Facebook, you know, with advertisements and all of that.
Magda laughing: Doug's making a big face. He hates Facebook.
MaryBeth: Excellent.
Doug: Well, it's just the level of misinformation on it. I don't think you should use Facebook for any sort of information harvesting whatsoever. I mean, you should talk to your friends.
1:19:52
MaryBeth: I was just going to say that. I'm like, it's great for connecting with people that you haven't seen in a long time.
1:19:57
Doug: Right. [Magda laughs] But everything else is just, all the marketing behind it is less than dreck.
1:20:03
MaryBeth: Mind-boggling. As a physician, a knowledgeable patient is absolutely one of my most favorite patients. And I definitely want to thank you guys for this opportunity because I am a chicken when it comes to doing stuff like this. But this was actually really a lot of fun. And knowing that it's something that I'm so incredibly passionate about has made it so much easier. And really the menopausal services that we give, it's nothing like what most people in an office in a corporate healthcare structure are able to do. So it really is an accessory. We're doing the hard work by putting the talking and the listening in that they don't have the time to do.
Doug: And thank you for this extra long session. And I always feel better informed about things. I really think it's important for men to understand what women our age are going through just for the sake of maintaining any kind of relationship.
Magda: I was saying this to you earlier, just because you don't have cancer doesn't mean you don't understand how chemotherapy works, right? Like it's just part of being a human.
MaryBeth: Or that you don't want to have the knowledge of what to expect because you never know when it's going to be you or a loved one or...
Doug [deadpan]: Well, if you don't have kids, then you don't have a vested interest in this country, as you know. [Magda laughs] Just like, you know, if you're postmenopausal, your best role is to care for other people's kids.
Magda: Oh, my God.
MaryBeth: You're funny.
Magda: I finally got done caring for my own kids. Now I'm supposed to care for someone else's.
Doug: But yeah, I think you're a natural, MaryBeth. Thank you so much for coming on. This is your first podcast. This is the first of many. I hope there's a bunch in your future.
MaryBeth: Oh, good. Well, if you know of anybody or you think of another topic that you want to get more specifically involved in, just let me know. I'll even do preparation.
Doug: I feel it's interesting too that I learned so much more about marriage now that we're not married anymore. [Magda and MaryBeth laugh] You know what I mean?
MaryBeth: You guys are so interesting. I think that's actually really pretty cool.
Doug: I'll take interesting. Well, doctor, it's been great to talk to you about this. Reproductive healthcare is an evergreen topic and one that we're only scratching the surface about what can be discovered about this. And so every chapter helps and I appreciate your adding one.
MaryBeth: Well, and I really appreciate the invite to talk about something that I'm incredibly passionate about that I've used to change the trajectory of my career. So much appreciated.
Doug: And thank you, listeners, for checking out episode 58 of the When the Flames Go Up podcast with Magda Pecsenye Zarin and me, Doug French. Our guest has been Dr. MaryBeth Lewis-Boardman. When the Flames Go Up is a production of Halfway Noodles, LLC and is available on all the usual platforms and at whentheflamesgoup.substack.com. Please subscribe there for our weekly episode every Wednesday and our newsletter, Friday Flames, which comes out every other Friday. Thanks again for hanging out with us this week and we will see you next time. Bye-bye.
[Theme music plays]
Magda: All right.
MaryBeth: Thank you again, you guys. I really appreciate it. Thank you for coming on. That was so fun.
Magda: Good. I'm glad.
MaryBeth: I'm not even that sweaty. I'm shocked. I put the extra deodorant on beforehand, you know, but I'm good.
Magda: Just in case we could smell you.