Episode 26: Transcript

"Our education in menopause is still very fear-based." - with Jackie Piasta

Doug French: You want to just come in hot with the menopause? Then come in with the hot flashes? It's the episode you've all looked forward to: The All-Menopause-All-the-Time episode.

Magda Pecsenye Zarin: You know, what's interesting is I have noticed that a lot of the menopause experts and health practitioners who specialize in menopause on Instagram are talking this week, right now, about the result of this new study that re-crunches the numbers from that 2002 study, and shows that the conclusions that everybody drew from the 2002 study were completely false, because they just looked at the numbers the wrong way. And we recorded this episode with Jackie Piasta, who is a nurse practitioner who specializes in perimenopause and menopause, and that's what we talked about. So if your interest is piqued, keep listening. There was a study in 2002 that they thought showed that going on what at the time was called Hormone Replacement Therapy or Hormone Replacement Treatment, HRT, and is now called Menopausal Hormone Treatment, MHT, that that would increase your risk for breast cancer.So they took hundreds of thousands of women off it and doctors stopped recommending it and people started... 

Doug: What did she say? It was down like 70%? The prescriptions?

Magda: Yeah. I went on it two or three years ago, because I don't have a high risk of breast cancer to begin with. And my doctor was like, the benefits outweigh any of the risks for me, specifically.

Doug: And you're an iconoclast. Let's just put that out there.

Magda: I'm a scofflaw really. The kids say I'm a scofflaw. But the whole thing is, like, I have a risk for Alzheimer's, because my grandmother died of Alzheimer's and my dad is diagnosed with Alzheimer's now, and there are studies that show that MHT is protective against Alzheimer's, especially if you start taking it before you've actually gone through menopause. And I am still in perimenopause. So I brought that to my doctor and I said, “I think I want to try out MHT.” And she said, “Oh, are you having hot flashes?” And right then I had a hot flash right in front of her. And she's like, in her late 30s and like, you know, beautiful and put together, and there am this sweaty white woman and I was like, you know, in the Elmer Fudd cartoons, when he would get mad about something, and the red steam would go up from his chest up his head and then pop out the top and like, [FSSSSSSHHHHHH!]. The steam, that's exactly what happened in her office. 

And she said, “oookay, let's start you out right now.” And I said, “I brought in this study about Alzheimer's to show you!” and she said, “Well, yeah, it's good for you. It's good for you to go on these hormones, but also clearly it's time.” That's so, yeah, that's how we started.

Doug: And only 14 years left.

Magda: Right? Because perimenopause lasts, what do they say, four to 14 years. I'm in year eight. I think I have probably three more years to go.

Doug: Yeah, based on what?

Magda: The same doctor, God love her, decided to see if I was getting any closer to actual menopause by drawing blood levels. And the thing about that is it's kind of dicey. In the past, doctors have asked to draw blood levels to see if you're in perimenopause or menopause, but you can't tell from a blood draw whether someone is in it. You can only tell if they're not, because your hormone levels vary by day and by time of day, and they vary even more in perimenopause. So if your levels are high enough, they know that you're not in menopause. But if your levels are low, that doesn't mean that you are. So they can only tell if you're not. And so my doctor, she was like, “you gotta be getting kind of close.” I'm like, “Oh, I think you are more of an optimist than we have reason for.”

Doug: Well, but the confusing thing was, I mean, the big revelation was that you don't know you're in menopause until it's over.

Magda: No, it's retroactive.

Doug: Yeah.

Magda: Yeah.

Doug: Don't you know you're in menopause if you've stopped menstruating?

Magda: Yeah, but you “stop menstruating” for any length of time, right? Like in the eight years that I've been in perimenopause, my cycle length has varied between 26 days and 93 days.

Doug: This is what women go through just because it's different with everybody.

Magda: Right.

Doug: The symptoms are different. The longevity is different. The prognosis is different.

Magda: It's nuts.

Doug: And I gotta say, when we got divorced 25 years ago, it seems, I did not anticipate talking about your menstrual cycle in our 50s.

Magda: I didn't either. And you know, the reason I didn't was because women didn't talk about it back then. They called it “the Change.” And nobody even saw perimenopause as a specific time period with its own characteristics until the 90s. Isn't that nuts?

Doug: And that's what's cool about Jackie because she was committed to specializing in this and only this at a time when more people need to specialize as we prepare for the Silver Tsunami.

Magda: Right, well, and you don't get to be silver and part of that tsunami without going through perimenopause and menopause. And if you are assigned female at birth, you will have some form of menopause. Like, we've all got to go through it. The other alternative is death. And I don't think we want that.

Doug: The whole experience makes me think of taking the Midtown Tunnel to the airport. Only you have no idea what kind of traffic will be in there. And you don't know how long it is.

Magda: That's exactly it. That's basically it. And then when you get there, you don't know if your plane's going to be there.

Doug: They may have moved the airport out to Suffolk County.

Magda: Yeah. So anyway, I think Jackie is great. She is not the age to be in perimenopause or menopause yet. And I love that she is taking us seriously. Because for so long, women this age have not been taken seriously by the medical community, even by women in the medical community. And I love it that she just takes us seriously.

Doug: She did a nice job. Yeah. She talked a lot about how to be straightforward, talk to your doctor from an informed perspective, recognize you want to have a great hand in this decision-making with someone who is flexible enough to have read a lot about menopause and recognizing that there is no one therapy for everybody.

Magda: And also, there’s no reason not to try to treat it. Just because it’s natural. I mean, cyanide is natural, too.

Doug: Yeah, but who wouldn’t want to walk around feeling like Elmer Fudd everywhere you go?

Theme music fades in, plays, then fades out.

Jackie: I married a pilot. Originally an Air Force pilot, and now a Delta Airline pilot, so I have just been moving and grooving ever since I graduated college, and I haven’t lived in one place for more than, seven years has been the longest one.

Doug: I guess you do a lot of single parenting a bit, right? Cause your husband's off on flights a lot.

Jackie Piasta: I do. It's a crazy schedule, and there's a lot of marital negotiations that go on. I think they've listed the top five professions that are the worst to be married to, and I picked someone with two of those five, a military and a pilot. I think the other one is surgeon, another one is police officer, so all these high-stress careers. But anyways, he's a lovely human being, and I think we have a good balance of things. I think it's like everything. It's always a learning process and being open to all the taking the punches as they come. And especially as a female professional, somebody that has career aspirations myself and pulled in different ways. So I think it's just an evolution of trying to figure out that dual career path and trying to “have it all” at the same time.

Magda: Yeah, and I think the meaning of that has changed as time has gone on to, you know, like women in the ‘80s were told, “you can have it all you just have to schedule correctly.”

Jackie: Yeah.

Magda: And then women my age, I'm 50, were told, “well, you can have it all, you just can't have it all at one time, you have to sequence it, and you might have to choose.” And I don't know what women who are 10 years or 20 years younger than I am are being told about it.

Jackie: You know, I think there's a lot of pressure because I think my generation is the last generation that didn't grow up with social media, right? We just, I remember in high school, just having, you know, the cell phones come out and the advent of AOL and all of that. But I think there is a lot of pressure on our generation to be the “All,” because my mother is in her mid-60s, so she was off getting her big, fancy career, and not really around for us. I think she has a lot of guilt about that. I kind of saw that. I went into the nurse practitioner profession rather than the medical profession specifically for that reason. I kind of saw her with these crazy physician hours all the time, always gone. And I'm like, well, how can I have that? I like a career in medicine, but how can I have it, but maybe a little bit more balance? And it's also a lot of the reason why I do telehealth. People ask me, why do you do telehealth? Well, I'm lucky that the space in which I treat women in menopause can largely be dealt with in a telehealth space, but it allows me to have my cake and eat it, too. It allows me a lot of balance to set my schedule and to be around for my kids, but also do what I love to do.

Doug: So specializing in menopause was part of a professional choice. It's interesting.

Jackie: Part of the master plan. It is now. It sort of has become that way as time has gone on and the kids have gotten older and they need more of us around and having a husband that travels a vast majority of the time. How do you be in more than one place at one time? And you can't. When we moved to Atlanta, we moved actually about almost two years ago now from Little Rock. And I sort of was looking around in the job market and thinking, because I was employed there in a physical gynecology practice, I would go in just your normal, what you would normally expect out of your healthcare provider at your doctor's office. And moving here, and that was in the middle of COVID, right? We were all using virtual platforms. Nobody wanted to have physical proximity. So I sort of said, okay, great. We're moving to Atlanta. My husband's going to be gone all the time. This is a new city. I don't know this place. So now I'm going to be in a medical office where I don't know the culture. I don't know the expectations. And it's hard, too, when you specialize in menopause may kind of fuel into why there's so much misinformation out there and why women don't get answers a lot of the time is because the curriculum to be in the OBGYN space is super vast. And menopause, it's like a tiny little morsel of it. So the vast majority of us are incredibly undertrained on it. And there's statistics out there that say 7% of doctors feel prepared to treat their menopausal patients. And so when we were moving here and I was interviewing for jobs, I was only doing menopause as my patient population. I fell into that. That was a kind of weird, but cool career opportunity that came upon me. So I was interviewing around. I'm like, “yeah, I do menopause.” And they're like, “well, no, you do everything. And if menopause comes across your plate, great.” And I thought to myself, oh, my God, there's so many women that need menopause and you guys are not willing to do it. Why wouldn't you be open to just hiring menopause? Well, this is the business of medicine, the business of these clinics. They're not set up to accommodate that.

So there was a number of factors that sort of kind of pushed me into opening my own telehealth business and then just sort of being like, all right, well, shit, let's just make this up. Let's just do something.

Magda: Did you explode right out of the box? Because I feel like the pandemic was when perimenopausal women really were just like, okay, I have to talk to somebody about this because I don't know if this is COVID, if this is trauma from COVID, if this is perimenopause, if this is trying to deal with the repercussions of having lived through the Trump administration, like, what is it? I have to talk to somebody about this.

Jackie: Well, and your home all the time, you're around your family. So your family's more aware of it. They're seeing what's happening. They're seeing the changes. Patients would come in and say, “Oh my God, my husband just thinks I'm a total bitch.” And I'm like, well, I don't think you are. There weren't as many distractions or things to sort of water it down. It was all front and center. I have been very, very pleasantly surprised with the reception I have received in my own practice. I'm very happy professionally, but I own a cash-based practice. So there are some barriers to that.

So I sort of, in my mind, compensate for that by having my platform on social media where I educate and offer resources and try to help advocate, you know, for women so that they can go to their providers. I also host clinician mentorships where I mentor other healthcare providers in the space and try to educate them and get them up to speed so that hopefully this information can be more widely disseminated. We don't necessarily have to have a bunch of us popping up with cash-based practices. So I do that as sort of a boundary to myself, and this is what I can do with my space. But I think that we need more. Oh my gosh, we need more. I was actually at a conference this last week and somebody stood up on the stage and said, we have the Silver Tsunami. Get ready for the Silver Tsunami that's coming. And none of us are prepared for it.

The medical space is not prepared.

Doug: I'm only picturing a movie marquee with Jackie Piasta, Millennial Gynecologist.

Jackie: Yeah. Hey, I love it. I love it. And to your point on the millennial, my mom calls us “whiny.” She's like, “you guys are so whiny about everything. You talk about your feelings,” but I think there's been a cultural shift of people not keeping things all bottled up. Right. And especially because of podcasts and social media and everybody is kind of talking and women are sitting there like, okay, wait, if I'm feeling this, are you feeling this? And are you going through this? My husband will come back from every trip he's on and his captains are usually a generation ahead of him, and they will say, “Oh my God, what does your wife do? Can my wife see your wife?” There is a general interest is wanting to figure this out.

Doug: You have a non-stop patient pipeline. Absolutely. You're all set.

Magda: My mother turned 81 and she didn't talk about perimenopause. I don't think she knew perimenopause existed. She just stopped having her period. She went through menopause and then she told me she got hot flashes for a couple of years after menopause. And that was it. So I have been having like every possible perimenopause symptom under the sun and my mom's just amazed. She had no idea that these things happened to anyone. And I think just it's the Gen Xers right now who are sort of looking at the millennials like, “wait, they talk about everything.” And we kind of right now are like, “oh, we could talk about this. Could we talk about this? Let's talk about this.”

So I ended up starting a Facebook group to talk about perimenopause with a friend a few years ago because this friend had said, “Hey, does anybody know of a group about perimenopause that isn't about bashing husbands?” Yeah. Or making those corny jokes about like, “Oh, it's a power surge.” Like, fuck you. It's not a power surge. It's I'm standing in front of a group of people that I'm supposed to be presenting to, and suddenly I'm red and sweating. You know, it's a medical issue. And we couldn't find a group that wasn't about husband bashing. And that also was trans-inclusive, because that was another thing we wanted, like a lot of people our age are going through gender stuff and are transitioning or becoming non-binary. And there were no groups that were safe for them that weren't tied into this whole heteronormative, like, “Oh, my husband's such an asshole. He doesn't understand that I'm having a power surge, right.” And so we had to form a group for ourselves. And the whole group is basically just people coming in and saying, “Oh, my God, this is happening to me. Is this a perimenopause symptom?” And yeah, putting it all together.

Doug: So tell us, when did you get started in this? What is your role? What is your title and how long have you been practicing?

Jackie: I have been a women's and gender health-related nurse practitioner for coming up on 14 years now. I graduated from Vanderbilt University School of Nursing and I initially went into just your primary, regular run-of-the-mill OBGYN space and worked in several different clinics. And about six to seven years ago, I fell into a job opportunity with a big, big, it's actually the largest OBGYN practice in the state of Arkansas, and with a gynecologist. And she specialized in menopause within this larger clinic. And she was really needing help and needing to hire an additional clinician to help with her practice. So I started there with her and we primarily saw all menopausal patients and perimenopausal patients and anyone just coming in with this sort of air quotes, “hormone problems.” “I think my hormones are off or I want my hormones checked.” So anything that could fall under that umbrella. And since then, within that space, I have done and dabbled, I guess you can say, just in about every single layer of the hormone space. I’m certified  by the Menopause Society, formerly known as the North American Menopause Society, they write all the big recommendations and guidelines on menopause therapy. I'm also an active clinician in the International Society for the Study of Women's Sexual Health. That is a huge mouthful, but they are the preeminent society that dictates and writes guidelines on women's sexual health matters, which are super common in the menopause space. And they also kind of help influence how we prescribe testosterone for women as well. Those are my primary credentials and why I can walk around and tote that I am a menopause expert.

Magda: I like that as an intro. The reason that I asked you to come on the podcast is that I've been following you on Instagram for a while. And I really like the way you educate and I like the way you're educating the people going through perimenopause and menopause, but I also like the fact that you are mentoring other clinicians, other nurse practitioners and other providers, because I don't think it's easy for them to find information about what's true and what's false, but also just how to work with us.

Jackie: Yeah. Unfortunately, our education in menopause is very fear-based, and it piggybacks off of the fact that this is a natural form of aging, so why should you have to address it? I think that our current experience of menopause is very different from older generations. I always refer to my husband's grandmother. She's 95 years old. She lives on her own in Los Angeles. I mean, she is a spitfire. She's sewing. She text messaged us today that she was making sourdough bread. I mean, she's 95 years old for Christ's sake and she's never seen a hormone in her life that I know of. I don't think she takes any hormone therapy and I don't think really she's thought much about menopause for the last 40 years. But I do think that we are living a lot differently. We have a lot of different stressors. We have a lot of different environmental things going on. And so there's, there's just the contextually, I think things are different. Whether we're just more vocal about it and it's just a cultural difference, or there's actually some real things that we still are left to figure out as time goes on, I don't know. But I do know because that's an argument that I get often. “Well, this is a normal fact of aging and my mom never needed anything or my aunt or whoever, insert, needed anything.” That’s kind of that argument. But I do feel like there is a very different lived experience. And we are seeing more people coming to us with much more severe symptoms, whether they're more severe or you're just more vocal about how severe they are, we don't know. But we do know that it's different.

Magda: Yeah, I think we today at the age of 50 have to perform at a higher level and have a lot more things going on than 50 year olds did 30 years ago. 

Jackie: Correct.

Doug:  In that vein, though, I think when we talk about the quantity of information, because even though we've established that there isn't nearly enough, there are still many, many, many, many, many, many sources of that information with differing viewpoints. And from what I understand, no two menopause stories are the same. Do you actually think that the level, the quantity of stories that are out there, is that making people more secure about learning more about this? Or is it causing more anxiety because there's so much differing information out there from which to choose.

Jackie: But then you have, what did my dad used to always say, opinions are like assholes, everybody has one. Literally everyone and their mom has an opinion out there and it's in a blog or it's in this or that. And then you, as a patient, as a regular lay person, non-medical person, go to your healthcare provider and there seems like a large gatekeeping of information or a door slammed in your face, not even willing to play ball. So then there's sort of a built up animosity I have found in the, my healthcare provider won't give me the information and I know there's information out there to receive. And so it creates this angst amongst the populace. And I feel like it's just this vicious circle. Frankly, it just creates a shit show. I mean, of just confusion. What do I do? Who can I trust? It's a mess.

Magda: Yeah, I think we should set out what are perimenopause and menopause for people who don't know what they are? And I found out that perimenopause only became a thing that in the ‘90s. Yeah.

Jackie: So let's start with menopause because that's more definite. Menopause is the cessation of your period and the definition of it is if you've experienced 12 months, 365 days with no period, then that 365 day time period is menopause, okay? And every day after that is actually post-menopause. So we look at menopause retrospectively. It's also if you have had your ovaries removed for surgical reasons, or you've, you can go through it. There's a disorder called premature ovarian failure where your ovaries stop working, or maybe you've gone through chemotherapy and that medication has actually induced menopause. Basically it's the stopping of your ovaries producing hormones. And then perimenopause is actually the time, I call it your ovaries going out of business sale. And it is where your ovaries are starting to get ready for not being fertile anymore, not producing a period, not trying to produce an egg for which there to be fertilization. And so the ovaries are starting to just kind of plan their retirement. And this is a big misconception. That's where actually the vast majority of the symptoms will start and be the worst. They tend to really rev up in that because the hormones are all over the place. I mean, it's literally, they're going everywhere. So that's perimenopause. It's anywhere from four to 14 years. It's a really long going out of business sale for some women. Four to 14 years. So this is, again, another area where women can get often dismissed because they get told, you're too young. We think menopause is for older women. And I don't want to go down the rabbit hole, but there's so much crap in our environment that influences our hormones. And we're seeing a lot more women experiencing menopause or earlier menopause, just like we're seeing earlier breast cancer diagnoses and all this other stuff.

Doug: And earlier periods in our daughters too, right?

Jackie: Exactly. A hundred percent. I know my daughter's eight and I'm just like, Oh my God, hold out on me. Hold out on me. So a lot of women get like, Oh, you're too young. No, it can start in the mid thirties. I mean, in some women it can start earlier than that, but. 

Doug: That's amazing, because you're having periods throughout perimenopause. You're not in menopause until your periods stop, and then you haven't had one for 12 months, and you're like, oh, I guess that happened. 

Jackie: Exactly. We look back on it and perimenopause, your periods, there's a whole myriad of what they look like. They can come normally, they can come all the more frequently, less frequently. So I have a lot of women that come to me and that's one of the most common complaints that women will come for is they're like, Oh, things have changed in that regard. And I'll say, well, it's kind of no woman's land. Anything goes. Let me know when it's been a year or if things get really bad and we have to intervene. Yeah.

Magda: In hindsight, I hit perimenopause hard. One month, it was after I turned 42, and suddenly my cycle just flipped. You know how you have light days and then heavy days. I had had the same pattern of light days and heavy days since I got my period when I was 11. And then suddenly one month, it just flipped. And I was like, what is going on? Well, then, you know, two years later, after I really thought I was crazy, and my entire body was falling apart. I was like, oh, that was the first month of perimenopause.

Jackie: Yeah, here it is. Ring ring ring. Yeah.

Doug: I mean, yeah, there's one thing worse than the period. It's a wonky period.

Jackie: That's for sure. Amen to that. Yes. My gosh.

Magda: Can we talk about the 2002 study that kind of has been dominating everybody's interest for the last 20 years.

Jackie: Yeah. Right. So for all those people that are listening that don't know, the 2002 study is actually when the initial findings were published. The study had been going on for several years before that, but it was called the Women's Health Initiative trial. And it was the largest randomized controlled trial. It was really trying to prove the safety of hormone therapy, which is really quite ironic now, right? Because it completely tanked hormone therapy for the next 20 plus years, and it cost about a billion dollars. So anybody that asks, well, why can't we just do that again? Why can't we just have a redo? It was the largest prospective study of its kind and it looked at a number of different factors. It was looking at how hormones function in the heart. What do they do? So breast cancer wasn't just the only kind of outcome that this was looking at, but essentially what most people focus on and what really kind of killed hormone replacement therapy was in 2002, They looked at the kind of preliminary findings and what they found was that in one arm of this study, women were randomized to either take hormones or to take a placebo. And in the women that took the hormones, you had one group of women that had a uterus and they took a medication called Prempro, which was conjugated equine estrogen. We know that as Premarin. It's an estrogen that's derived from the urine of pregnant horses. And they added, because there was a uterus, you have to take a progestin, and they added Provera, which is a synthetic form of progesterone. And the second group was just Premarin, women that did not have a uterus and did not need the progestin to offset estrogen's effects in the uterus. And then you had the placebo group. And what they found or what they thought they found was a statistically significant increase after five years of women who were on the estrogen plus the progestin. And so they published those findings and overnight prescriptions for hormone replacement therapy dropped by 70%. And yes, so it is really, really, really crazy. And so what they didn't publish was that actually the women that were in the estrogen only group, so these were the women on estrogen only with no uterus, had a reduction in breast cancer risk. And when they re-analyzed the data, there was not a statistically significant increase in the breast cancer risk in the group that they had initially thought was the increased risk. But that one statistic, I always say it's like you wore a white t-shirt and you dumped wine on it and you're never going to be able to get that wine out. I mean, and that is literally what we are doing as we are trying to unpractice this sort of notion of the increased risk of breast cancer. Unfortunately, that WHI trial also not blasted all over the news outlets is that the women that were on hormone replacement therapy had a reduction in all cause mortality. So a reduction in basically any reason you might die and there was no increased risk of death from breast cancer.

Magda: So they misinterpreted the findings to show an increase in breast cancer, but even within that misinterpretation, they still hadn't found an increase in death from breast cancer.

Jackie: Correct. And it ended up being only one additional person from the difference from the placebo group.

Magda: Wow.

Jackie: Yes. And there was a four person reduction in breast cancer in the estrogen only. And nobody was like, oh, hey, look at all these women over here on the estrogen group. They had less breast cancer. And then here's another really important point to understand, because, you know, people are very wary of hormone replacement therapy, not just for what they think is the increased risk of breast cancer, but also the increased risk of cardiac events. The patient population in this study was flawed as well. The average age of a person participating in this study was 63 years of age. The average age of menopause in this country is 51 and a half. And none of these women could be on hormone replacement therapy at the time of the study. They also could not have any active symptoms of menopause. And one of their outcome measures was did quality of life improve, but none of these women had active symptoms.

Magda: So they weren't having anything to improve at all.

Jackie: Correct. Or they weren't being keyed into what they were looking for to be improved because they didn't have any active symptoms. 35% of the women were overweight. Another 34% were obese, which we know are independent risk factors for cardiovascular disease and breast cancer in and of itself. 36% were currently being treated for high blood pressure. So we already know there was some established cardiovascular issues going on in these women. And nearly half the participants were either current or past cigarette smoking users. So again, another independent risk factor for disease and illness. 

Magda: Half were cigarette users?! Although, I mean, I guess this was 20 years ago, and they were just smokers.

Jackie: So either current or previous smokers. So any type, any history of cigarette smoking is going to increase your risk of having vascular dysfunction or cardiovascular system not being as good as it might have been if you hadn't exposed it to that. So it's a big, big, big red wine stains on the white t-shirt. The cohort was flawed. The statistics of the data were not well put together. And in addition to that, some of the positive conclusions were not amplified.

Magda: So they basically were taking women who had already gone through menopause like 10 years ago.

Jackie: Correct.

Magda: If they had had hormone treatment at the time, they weren't still on them when they started the study, all of a sudden started them on hormones and then were like, Oh, this isn't improving your life.

Jackie: Correct. So that was one of the measures that they were looking at is did it improve quality of life? But no one in the study could enter with any currently existing symptoms of menopause or anything that they would associate with menopause. Right. So again, it was just, it was a mess. It was a sloppy billion dollar bomb.

Doug: Well, just for my benefit too, the study itself is 21 years old. How old are these revelations? How old is this new assessment of that study? And how well do you think that's taking hold in your community as far as educating women who need to know how little of this study now is worthy of their trust?

Jackie: So interestingly enough, the most pioneering individual in this space that sort of initially raised the red flags is actually a cancer doctor out of California. And his name is Dr. Abram Blooming. And he wrote a book. It's at least 10 years old by now. It's called Estrogen Matters. And he basically combed through all the data. One of his chapters, actually, I think it's the first chapter of his book, is called Who Killed Hormone Replacement Therapy? Actually, within the last few weeks, he and Dr. Robert Langer, who was the principal investigator in the Women's Health Initiative trial, this 2002, came out with a rebuttal argument called, "'Tis But a Scratch." This was published in the Menopause Society Journal.

Doug: And he threw in a Monty Python reference.

Jackie: Yes, he did! He did throw in the Monty Python reference.

Doug: Yeah, now you know they're serious.

Jackie: That came out most recently, and that was really sort of exciting that the two of them, that he joined with Robert Langer, and Robert Langer spoke his voice up of being the principal investigator and saying, okay, look, we got these things wrong. There were questions about the validity of the results as early as 2004. Somewhere in between 2012 and 2014, there were some actual published statements of actually walking back. Several of these conclusions, there have been attempts to rewrite these wrongs, but they have been very poorly received or just, it's just been deaf ears, I guess. The damage has sort of been done and it's been a slow process to move back. I mean, we're 21 years and we're still having these conversations.

Doug: Why do you think that is? Is that the nature of the woefully incomplete understanding of women's health in general and the regression we're seeing now as far as understanding of what women's health is versus what certain people who legislate think it is?

Jackie: I mean, the terribly jaded answer is menopause doesn't make a lot of money and it's a systemic issue. Clinical education is not focusing on menopause. They're still teaching outdated information. There's a cognitive dissonance as well. You know, we don't want to unlearn what we already know. We have that confirmation bias because it's not their primary focus. And you might say, well, of course it should be the primary focus of any internist or any, cause it's, you know, 50% of their population. And if we look at it primarily in the OBGYN space, and I don't mean this as doctors are money hungry. I just mean that healthcare is very corporate now, and there is a focus on generating revenue. And what makes money in the OBGYN space is delivering babies and doing surgery. Sitting in an office space, talking to women about their quote unquote feelings, right, even though it's a condition, talking to them about a normal condition of aging is not the moneymaker in the medicine space.

Doug: There is an opportunity here. I mean, if you want to think like a capitalist, women who are going through this, it's an untapped market.

Jackie: I agree with you. I say the squeaky wheel gets the oil. So just like your mom never talked about menopause, never said anything about menopause, well, there's a lot more squeaky wheels right now. And so not only are we seeing the poking and the prodding and the pushing, the good pushing from our patient population as clinicians of saying, “Listen, I feel terrible and I'm not going to take these answers anymore. I need to figure this out.” And then you’re also getting a fairly loud group of clinicians, me included, who are saying, “Hello? We’re doing this wrong.” And then now you have venture capital coming in, saying, “Hmm. We’ve got something here. We can work with it.” So, yes I do think that. Are we going to see it from the corporate practice of medicine, and how medicine has now become super-institutionalized? I think that we’re seeing a lot more interest. How long is it going to take for there to be global acceptance? I don't know, but I've seen so much growth. I mean, I've been doing menopause exclusively for the last seven years. And from seven years ago to now, massive tidal wave shift in the overall acceptance and also patient advocacy, self-advocacy of, “listen, I know something about this. I want help with it.”

Magda: I think you're right about that. And I think, you know, like I've seen a huge, huge, huge change just from the beginning of the pandemic. And I think this ”Tis But a Scratch” paper is going to be a big, big deal because I've talked to so many women who find out that I'm on MHT, which is the new name for HRT. This is like when VD changed to STDs for us. It used to be called VD. And that's at some point. So it used to be HRT for hormone replacement therapy, and now it's MHT for menopausal hormone therapy.

Jackie: Menopausal hormone therapy.

Magda: Yes. So people find out that I'm happily on it. And they're saying to me, “Oh, I can't go on it because my mom had breast cancer,” or “I have a risk for breast cancer.” And I've said, “Oh, go on the NAMS website and look at their recommendations.” But if I can hand them this study that said this whole thing was full of shit. There's no reason for you not to go on it.

Jackie: Yeah. The good news is the North American Menopause Society, now the Menopause Society, they also had a rebrand of sorts. They also have great guidelines. If you have a family history of breast cancer or an increased risk of breast cancer, you are not necessarily contraindicated to take hormone therapy or menopausal hormone therapy. There are a lot of misassumptions on what is actually a contraindication to therapy. You know, there's a difference in the safety profile in different types of hormone replacement therapy or hormone therapies. Not all hormones are made alike. There's a huge kind of grassroots movement right now actually. Hormone therapy has horrible box warning on it. When you get the drug insert, it will tell you you are going to like die a slow and painful death. It's like when you watch a commercial for a drug on TV and you're like, “Oh my god, I'd rather have the disease than the side effects of this drug.”

Magda: There's one drug in there right now that has a warning that they actually say, some voice actor had to read the words, that there's a danger of a deadly infection of the perineum.

Jackie: Yeah, I know. That's probably a diabetes drug, actually. So now we know there's basically no contraindications to vaginal estrogen, even in individuals with a personal history of breast cancer. That's actually newer guidelines that have come out. But the package insert for vaginal estrogen still says, stroke, heart attack, all these things, and then I send them to the pharmacy, and that's another problem. Pharmacists are also mis- and undereducated on the safety of hormone therapy and menopausal hormone therapy as well. So I've just spent all this time painting this lovely picture for them. They go to the pharmacist. The pharmacist warns them, and that is if you still have a pretty good pharmacist that will actually educate you on the medications they dispense to you. So there's another barrier. “Oh my God, my pharmacist told me I'm going to die. What'd you give me?” Then you open up the package insert. If you can believe it, a lot of women still read those. They'll read and they'll email me and say, “Oh my God, but it says this.” So there's a grassroots effort right now. It's called Let's Talk Menopause. And they are trying to get our legislature to take off this warning because all hormones are lumped into this same sort of risk profile. We know that different hormones have different risk profiles, not all hormones are created equal. So that's another issue. That's another layer of barrier that we have of when women say, Oh my God, you're using hormones. I can't do that. Well, if our package inserts are incorrect, you know, that's like one major blaring thing to be like, okay, how do we educate these women if the literature that we're giving them is incorrect?

Doug: Well, is it incorrect or just overly corporately cautious? It's like it's a sell-by date.

Jackie: Yeah. I mean, so much of medicine is CYA. In terms of the vaginal estrogen, that has been proven in the literature pretty distinctly that it is wrong. And I think that's why they're targeting that one specifically, because we can all well prove that every statement within that is unfounded. So that one specifically needs to be incinerated, I guess you could say.

Magda: The results of that 2022 study were about estrogen, progesterone, a combo, and then just estrogen by itself, but taken orally. So it did go through your whole system. But then there's also vaginal estrogen, which is the one with the horrible warnings that are false, which is taken vaginally. And so it never goes through your system. It's just staying there locally. And the reason that people would take vaginal estrogen is because as you age and have less estrogen in your system, you start having all kinds of weird symptoms down there. You might not even notice symptoms, but increased UTIs, leaking urine, pain, all kinds of stuff like that. And you can treat it very easily with vaginal estrogen, which would be a cream, a suppository, I mean, it’s basically just like putting lotion on you down there, except that it has hormones in it.

Jackie: It really should be seen as a topical therapy. And this is honestly the most ridiculous juxtaposition in the whole medical community. And, Doug, I think you’ll get a kick out of this. We literally hand out Viagra like candy. It's cheap as dirt. It takes literally nothing for men to get a prescription for Viagra. And then you have all these menopausal women walking around with Sahara deserts for vaginas and wondering where are all these erect penises going to go? I mean, they're surely not going into their menopausal wives. Yes, the different hormones have different safety profiles. If it's in the vagina, it's not going to get absorbed into the systemic circulation, your bloodstream. If you're delivering your estrogen via a patch, it's not going to go through your liver, so it's not going to interfere. And they're doing more research on this. But right now, transdermal or a patch or a gel or anything that you don't swallow orally in an estrogen form is considered to have a better safety profile cardiovascularly. So that is the preferred method. Especially if women tend to be older when they've come to ask for hormone therapy, because if they've had many more years without any hormones, then we assume that cardiovascularly, they're not going to be as well off than a blank slate, because estrogen is very protective on the cardiovascular system.

Doug: So imagine that Big Pharma came up with a way to combine vaginal estrogen with lube.

Jackie: Yes, it would be nice, but they haven't done it yet.

Doug: I mean, wouldn't there be a huge market for that?

Magda: No, there would not. And I'll tell you why. If you follow the Instagrammers talking about vaginal estrogen, there are always people in the comments saying, “My husband is scared that if we have sex and he gets estrogen cream on his penis, something horrible is going to happen to him.” And so that is why it’s never going to be a thing.

Doug: He’s going to develop breasts or something?

Jackie: Yeah, right. Most people don’t actually realize that our reproductive hormones are not gendered. We all have progesterone and estrogen and testosterone, we just have them in different quantities. And that's what helps us develop our secondary sex characteristics. But men have estrogen. And so men, you know, exposed to vaginal estrogen via various routes, it's fine, it's not really going to be an issue. And the amount that you're getting, again, it goes back, it is so minuscule.

Doug: This speaks to the fundamental hurdle in your life. It's just you have to overturn and convince people that the consensus of medical wisdom, such as it is, is incorrect. What are your best strategies to keep talking about things so that the word gets out and people have a greater understanding of what they're doing?

Jackie: Don't get me wrong, at times it is rather infuriating, especially when you have spent a really long time with somebody and you've educated them to the best of your abilities. And it is an exhausting job to sort of steward this knowledge. And I used to get, when I first started out doing this, I used to get really irritated when patients would call up and be like, “Well, I had coffee with Aunt Sue and Aunt Sue told me this, and so I stopped taking my hormones.” And I'm like, Mother of God, oh my, you know, and I would just get so irritated, but then, you know, it doesn't work. Fear is a huge influencer, and they have to respect that. They've actually done studies on why the breast cancer narrative has been so hard to wash out of our system, and it hits a pressure point for us. It's very emotional. Dr. Bluming's book speaks to this as well. Looking at the psychology of why breast cancer has been such an iInfluence and that fear surrounding us when the vast majority of breast cancer patients will actually die of cardiovascular disease. The number one killer of all women, regardless of any pre-existing medical diagnosis, is cardiovascular disease, including breast cancer survivors. So why are we still so afraid of breast cancer?

Doug: Breast cancer has entered so much of our lifestyle. I mean, the whole idea of Pinktober, I guess that's the power of a nonstop narrative where even the NFL is wearing pink socks all month.

Jackie: Exactly. Number one cause of death in women, all women, is heart disease. Number two is cancer, all cancers. Number three is chronic lower respiratory diseases, like COPD. And number four is stroke. And number five is Alzheimer's. Heart disease, stroke, and Alzheimer's have a menopausal influence to them. And so why do we allow breast cancer to scare us more than any of these other diseases, which we know are but greatly benefited by hormone replacement therapy. I used to get way more frustrated about it. Now I just sort of bitch and moan on social media about it and try to get my message out to as many people as I can. And I think that has helped me to vent because I know that, okay, I'm out there. I'm trying to be a voice of reason in all this. If I'm not out there advocating for it, then I can't be mad when Somebody within my clinic just crosses my path for 30 minutes and then somebody important to them in their life that they see all day, every day, you know, triggers that fear within them, influences their decision making process. You know, that's another thing is healthcare providers were kind of kept in this ivory tower. You have to come in and see us. You have to wait in the waiting room. You have to be inconvenienced. You sort of get the big eye roll or the huff and puff if you call the nurse and then you have to wait three days for the nurse to call you back. I can't walk them off of every ledge as they walk to it and provide them with reassurance every step of the way. I try to do that through social media now.

Doug: You get a lot of Gen X actresses who are using their platforms to talk about menopause and bring menopause into a much more common discussion. Naomi Watts leaps to mind. And so how do you think you might be able to tap into that? And at least, again, it's a socialization issue. Fear comes from ignorance and ignorance comes from an unwillingness to talk about stuff. So you're moving the battleship here. It's a little bit at a time, but it seems to be working to some extent.

Jackie: I do. I think it is a flooding of the market. We sort of have to be more numerous. More of us out there have to be spreading the awareness in the positive direction, not overselling the product, so to speak, but just trying to provide an overall awareness. Naomi Watts has been very vocal. She went through perimenopause at 36 and was told it wasn't perimenopause. You know, Oprah's famously quoted for saying she saw five cardiologists for heart palpitations and nobody could figure out what was wrong with her heart when it was a menopause symptom. And you know that those were five of the most prominent cardiologists that the U.S. has to offer. 

Magda: Yeah. 

Jackie: So it is exciting to hear these individuals that we sort of deify and we look up to as saying, oh, I've been through this lived experience. You're not abnormal. But then it also takes those of us in the medical space to sort of validate what they're saying. And I'm all for it. A menopause dietitian on Instagram, she’s @backtothebooknutrition, I love her stuff as well. And she said, “all you NAMSfluencers.” She used that term, “NAMSfluencers.” Those of us.

Doug: No.

Jackie: Yeah, okay. It made me chuckle a little bit. We just have to do it. And every time I think that I shouldn’t put a morsel of information out there because it’s been done before, I just have to tell myself, no, no, there’s probably one or two people who are going to cross your path that have never heard this before. So be there for that.

Magda: I think a big part of the damage that the 2002 study did was that it was denying women's experiences and forcing women to kind of go away from the medical establishment because, you know, there have always been women that have been trying like, you know, wild yam cream and all of that kind of stuff. And I'm getting a zillion different supplements advertised.

Jackie: Don't get me wrong. I have had women come in with duffel bags of supplements.

Magda: At this point, I'm just saying, why don't you just go to your doctor and get hormone therapy and have it prescribed to you and your insurance will pay for much of it and it'll be a lot cheaper and it's a lot simpler. You don't have to swallow 80 pills a day. But I think because the healthcare providers weren't prescribing the hormones, people went underground. And I think by being out there, you and the other medical providers who keep providing that information, it's eventually going to converge back. And so regular women are going to be able to trust that they're going to be able to walk into their doctor and their doctor will take them seriously. I mean, I just lucked into a fantastic gynecologist who, when I said, “I've been thinking about going on hormone therapy,” she said, “Oh, okay, great. Let's talk about it.”

Jackie: Yeah. And that's, you know, not the norm, at all.

Magda: And I didn’t have to fight her at all. She said, well, let's just start here and after three months we'll evaluate how you feel and see how it goes. But I mean, I am completely lucky because I don't think everybody has a provider like that.

Jackie: Well, and just because somebody gets prescribed hormone therapy by someone doesn't necessarily mean that the journey is going to be effortless either, because I encounter a lot of individuals that say, oh, well, it didn't work for me. And then the clinician said, okay, fine. And took them off of it. Didn’t try to troubleshoot, didn’t try to change dose, didn’t try to do anything. Probably because they just didn’t know what they were doing. Or said, well you’ve been on this for this long, and now it’s time to come off. There is no established age range or number that it’s appropriate to be on or off hormone therapy. It is an individual decision made with the patient and the clinician, and most individuals are perfectly fine to be on hormone therapy for the rest of their life. It is no longer an arbitrary date set range, but we have a ton of clinicians still practicing who are saying, “Five years and you’re done.” You know where that five years came from? Because it was five-year data from the Women’s Health Initiative trial that said “after five years there was an increased risk of breast cancer.” Most women were 60 to 63, and so there you go. We’re not very creative here in the menopause space. We’re scientists here, ok? It’s so frustrating, because now not only do we have to–well, you didn’t have to–but to fight tooth and nail just to get on hormone therapy, but to then be prescribed it in an actually evidence-based way, is another hurdle. It’s really great, your experience, but.

Magda: It's not typical at all. 

Jackie: No. People who tend to be more evidence-based in our hormone teaching, some people get very irritated at patients who choose to use other modalities or compounded therapies, and we get very critical of that. But when those study results were published and 70-80% of hormone prescriptions went kaput overnight, those symptoms didn’t go anywhere. Those patients’ struggle didn’t go anywhere. But businesses were closed. Doctors’ offices were shuttered. And so where do you think those patients would go? Because the symptoms and condition was still alive and well. Those people that practice very evidence-based can be hypercritical of that, me included, but I usually just say, “Ok, so you’ve been on this.” I’ve had people who come to me from all sorts of fancy California doctors, and they’re on every cream and salve, every crazy regimen that I’ve ever heard of. I’m like, “I’m glad that this has worked for you, for this amount of time, but let’s talk about how we can do this in a more evidence-based way, and maybe let’s streamline your regimen a little bit, and make it easier.”

Doug: Is the answer the role of our more august medical institutions? I mean, can the FDA be of help? Can the DSM be of help? Can the Mayo Clinic, Mass General, what sort of esteemed organization or official evidence can be introduced that can help establish as much of a consistent through line as possible so that you at least have some kind of structure to start building your communication play?

Jackie: Yeah. So I truly believe it has to start in the clinical education piece, medical schools, nurse practitioner schools, PA schools, it has to start there. And the reason why we are doing it in the bigger platforms, we are doing it at the Menopause Society, International Society for Women's Sexual Health, these bigger societies, but there is so much confirmation bias and lack of time. And motivation to learn more, know more, do more. Medical providers have egos just like everybody else. Sometimes we don't want to admit when we don't know things and we don't know how to do them or, you know, we're not necessarily open to patients coming through our door saying, Oh my God, look at this study or look at this study that I looked at for you. Let me show you how to do your job. That's not always met with very accepting reception. Not that I want to say we have to give up on all the clinicians that are out there currently trained and practicing. Absolutely not. You know, we just sort of have to be louder and continue with these guidelines. But we also have to push the medical education. And there is an effort to do that. There's a grassroots effort to sort of push menopause content more to the forefront of the medical education. So they're getting it early. So it's not, oh my God, I never learned that.

Magda: Yeah, because not everyone assigned female at birth is going to have a baby. But everyone, if they live long enough, is going to go through menopause.

Jackie: If you're lucky enough to get to that age. It's a universal lived experience. Our focus has to be less on the reproductive value of a woman and more on just that general lived experience and what we go through. So it's an unteaching, which unfortunately is just a long, tedious, painful process. I literally, and I don't want to sound pessimistic, but I just hope and pray we'll be there by the time my kids are sort of going through menopause. But I'm more hopeful than that because I have seen such a huge shift in the narrative and the conversation and the prevalence of the conversation just in the last seven years.

Magda: I think the market is speaking in a lot of ways. I think these doctors that are just digging in and aren't curious about why people are leaving their practices. And, you know, I realized a few years ago that what I really wanted out of a doctor was not somebody that had all of the answers, because to be completely honest, I can go dig up those same studies. I wanted somebody who was curious, who knew how to talk to other human beings in a decent, respectful partnership kind of way, and who really enjoyed being a doctor. You know, my PCP is a young white man and he's super, super curious and he loves being a doctor and he's a direct pay doctor. And so he always has medical students from the medical school in there shadowing him because there's no other opportunity for them to experience direct pay medicine. And so every time he asks, “do you mind if the student comes in?” And every time I give them my like 30 seconds on perimenopause and menopause, because I want to make sure that they've heard it somewhere. “This is something that happens. It's four to 14 years. It can cause a lot of crazy symptoms. Hormone treatment is a very

straight line answer for a lot of people, just put it in your back pocket.” 

What I would really like to hear from you is if there's somebody listening to this, who was assigned female at birth, had or has a uterus, who's like, “Oh, shit, maybe that's why I think I'm going nuts. Like, what should I ask for from my doctor? And how should I ask?” Because I'm guessing not everybody can just walk in like I did and say, “Hey, hey, I think it's time to start hormones.”

Jackie: You know, but I do think that that is probably the best approach now is to go in very confident, very much sort of in command of your own health decisions because I'm a huge advocate that this is a shared process. I tell women to come in sort of with your concerns written down. My biggest pro tip as well is if you are specifically trying to do this in your gynecologist's office, do not do it at your wellness exam. Do not do it at your yearly pap smear exam. It seems crazy that that's not what that's for. If you're going to hit a red stop sign every time, so make a separate appointment to discuss these concerns and have your questions written down so you're prepared and say, look, I really think that I am going through changes that are consistent with menopause or perimenopause. I'm seeing a lot of change in my body. These are the various symptoms that I'm having, and I'm really, really interested in discussing. 

Magda: The language around it for some women is just quality of life based, right? Like if you're having all these symptoms like hot flashes, insomnia, weight gain that's intractable, random aches and pains, vision buzzing out during the course of the month so you can't see half the itchy skin, all that kind of stuff. It's quality of life.

Jackie: Most clinicians have about seven to 10 minutes if they're lucky with their patients. That's how stacked the day is. So it can be very, very overwhelming for the clinician to be bombarded. And I don't mean that in a dismissive way, but bombarded with an entire laundry list of symptoms that already we've already established that there is an undereducation in this entire space. So now you're coming at the clinician with this laundry list and say, oh, whoa, whoa, whoa, whoa, hold the phone. So I always say try not to expect Rome to be built in a day and be up front of what are your top three priorities? And those will actually help to target therapy and treatment so that it doesn't have to be, Oh my God, we have to solve all of these problems in 10 minutes, come back in or do telehealth, yay telehealth and follow up.

Magda: Good. That's very, very solid advice. I'm hopeful that women can get help, right? Like even if they walk into their own doctor and their doctor stonewalls them, there's telehealth.

Jackie: Yes. Don't be afraid to break up with your clinician. And I'm not endorsing breaking up with your clinician, but we don't have to have a lifelong relationship with somebody that we don't agree with or don't see eye to eye with. And just because they're your healthcare provider doesn't mean that it has to be a relationship set in stone. As an inconvenience as that can be, it sometimes is a necessary reality.

Doug: And in that same vein, what would you suggest to women who have been socialized not to talk about it?

Jackie: I think that the threshold for modesty is, is lower in terms of where we're at with menopause. I would say, you know, we are starting to pull back the layers of the onion a little bit on like hot flashes. What the more recent literature and data has shown us is that the severity of your hot flashes actually can correlate with severity of certain disease processes. So women that have more severe hot flashes tend to have more advanced cardiovascular disease and illness. So there's this kind of push to say it's not just about the hot flashes, that there are some true health ramifications and implications that can come with menopause. It doesn't necessarily have to be kind of this conversation shrouded in shame. It can be brought up in a broader context. Menopause isn't necessarily all about the symptoms that we see. We have bone loss, we have muscle loss, we have heart disease, memory concerns. So these things are going to pop up probably at some time. I'm probably not a great person to ask because I'm a very transparent person that is funneled to TMI, but just as best as you can, maybe putting that health spin on it.

Magda: I also think that not everybody has to talk about their own personal symptoms, right? But I do think it's important that we're all able to talk about perimenopause and menopause without, you know, the way when people talk about cancer, sometimes they go, [hushed] cancer, right? Yeah, just like the being able to acknowledge it. Not everybody's like me, right. But I, I always feel like if something bad happens to me, the way to turn it into something good, is to–

Jackie: And there are a lot of people that don't want to talk about it, and that's okay. And it is okay. You don't have to feel like you're sort of being taken on this runaway train of the menopause conversation. If you don't want to talk about it, that's more than your prerogative, and that's totally fine. But I think it's always good to kind of know what the potential outcomes might be if we don't talk about things. And so I sort of frame it that way too. I found this a lot as a clinician, I hear all the time, or gosh, anybody that finds out I'm in menopause at a cocktail party, you know, they'll say, Oh, I've been through menopause. I'm over that. And sort of like this badge of honor that they're not on hormone therapy or they're not on anything. And that's a huge misconception that we haven't actually talked about is there's no end to menopause. Once you're in a postmenopausal state, you are living in that postmenopausal state forever. So these health implications that come with it are lifelong, and everybody's going to experience them differently. Everybody has different genetics, different environments. But I just don't want us to be so complacent that we're like, oh, I'm through that.

Magda: Yeah. Oh, yeah. I mean, there's tons and tons and tons and tons to say on this. But I mean, people are writing books and plays and, you know, everything

Doug: It will be the Mondays with Jackie, and we'll just talk more about... 

Jackie: Yeah, menopause Monday, right?

Doug: Yes. Since we're talking about having transparent discussions with your caregivers and promulgating messages that are going to help people understand what's going on with their bodies, what resources do you recommend? Where can we find you online? Where's the best source of research for people who need to know as much about their bodies as possible?

Jackie: My favorite places are going to be the North American Menopause Society. There's also a fabulous resource index from one of the most prominent menopause physicians out of the UK. And her name is Dr. Louise Newson. And she has an app called the Balance App. And I love it. There's so many free resources and booklets, basically a search engine where you can type any experience, this, this, and menopause, and she's got a booklet on it. So I absolutely love that. It's all free. And then ISSWSH, the International Society for the Study of Women's Sexual Health is great for any woman that is going through sexual health issues in menopause. And then there's also another really amazing app that I love called the Rosie app. It was developed by an OBGYN. It helps women with sexual health concerns as well. As far as I'm concerned, I would love for you to give me a follow on social media. I'm at JackieP_GYNNP. And I also own my own concierge telemedicine practice called Monarch Health, where I see patients virtually. So that's where you can find me. And those are the resources that I usually like to direct my patients to.

Doug: We're going to link to all that in the show notes and thank you so much for helping spread this message, the important aspects of menopause that not just women need to know about as well. Men, if you have a woman in your life who's going through this, you need to study up a bit as well, understand what she's going through and how we can help the women in our life live through this as painlessly as possible.

Jackie: Totally agree. Well said. Yeah. Thank you guys so much for having me.

Doug: Well, thank you, Jackie, for talking with us today. And thank you, listeners, for checking out Episode 26 of the When the Flames Go Up podcast with Magda Pecsenye Zarin and me, Doug French. Our guest has been Jackie Piasta, menopause expert who puts a meno-positive spin on the big change. (Hold for applause.) 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 Friday Flames newsletter every Friday. If you listen to us on Apple Podcasts, as many of you do, please leave us a review. It really helps us a lot. Thanks again for listening. We'll be back next week. Until then, bye-bye. 

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Doug: And we didn't even get into the whole idea of what it must have been like to try and practice women's medicine in Arkansas, knowing you were, you know, that was a whole, that's another podcast.

Jackie: Well, yeah, my former boss is the current Surgeon General and I love her to death, but boy, did we not have converging political views. Let's put it that way.