00:08:26.400This is very reassuring because, you know, I wasn't expecting the whoosh and it actually
00:08:32.740really started while I was on book tour last year for Sicilian Inheritance and I no no I sat in
00:08:39.880this chair until the whole crowd left like I didn't get up to hug people and then I just like
00:08:44.260quietly cleaned it up and slipped out of there by like backing out of the book tour it was at
00:08:49.340Birch Tree Books they know about it now they read my sub stack and they're like that was our event
00:08:52.400wasn't it I was like yes I like just like murder scene all over my book event at Birch Tree I love
00:08:58.000them they're having me back for everyone is lying to you so they didn't mind what happened but yeah
00:09:02.220I mean, I think it's surprising. And, you know, this is just one of the many things I feel like we're not prepared for like what's going to happen to our bodies because no one really tells us.
00:09:11.740Well, see, this is the thing. And I, I was actually thinking about doing a post on this
00:09:17.220today because a friend of mine made me aware of, she said she didn't think I was doing it,
00:09:22.420but you know, there's a lot of doctor bashing that's happening on social media. And I don't
00:09:26.460think it's actually not, I mean, from doctors on doctors, but it's, it's not because doctors have
00:09:33.600a hard time explaining things in today's current situation. And I used to be in the situation where
00:09:39.180I was being asked to see, I was seeing 30 to 32 patients a day and I was being asked to see more
00:09:44.220patients. And it's partly that it's partly that we are given 10 minutes or less to see patients.
00:09:49.680And we're trying to handle the problems that you come in with at the time. Like if you're coming
00:09:53.480in for an annual and we need to get your pap smear done and we need to do your mammogram and things
00:09:56.680like this. And then the, and there's another whole part of it, which is actually just the lack of
00:10:02.620thinking of what, what do I need to say now to prepare my patients? Because I'm so caught up in
00:10:06.640the moment of what needs to get done in this time period. And I was almost I was so glad to be doing
00:10:11.400this podcast because I do think you have a little bit of a younger audience. And my audience now is
00:10:16.840in the full thick of perimenopause already. That's usually why they come see me. And and the and I0.95
00:10:23.240always I said, I just wish I could get a hold of these women when they're in their 30s, even 20s,
00:10:28.340just to tell them what they're going to what they can expect, what they're going to experience
00:11:46.100You can have your PMS symptoms become exacerbated.
00:11:49.420You can have all different sorts of changes in your periods.
00:11:52.200You can have decreased libido, muscle aches and pains and all these things.
00:11:55.780not that you're necessarily going to experience them all, but they're all normal and it doesn't
00:12:00.880mean that anything is wrong with you. And especially the cognitive change. I would make
00:12:05.480sure that everyone knows that when you start feeling a little bit forgetful or you can't
00:12:09.240remember why you walked in the room, this does not mean that you're going to develop Alzheimer's
00:12:13.520or dementia. This is a normal cognitive change that is transient during perimenopause and you
00:12:18.540will be yourself one day. I don't know when. We don't know when. Yeah. It's different for everyone,
00:12:23.860but it does not last. They have seen that in research and studies. It does not last.
00:12:29.820And the best way to prepare for perimenopause, other than just having that knowledge under your1.00
00:12:34.240belt, because I find that when women really know what to expect, they handle that change so much
00:12:38.300better, to be honest with you, without the fear, is really nothing mind-blowing, Joe. It's just
00:12:44.700really kind of healthy living, healthy eating. We do have to change a little bit about how we eat
00:12:52.060and how we exercise in perimenopause to really optimize our health. But the way we do that in
00:12:57.920perimenopause is the same way we should try to prepare for that premenopausally. You know what
00:13:02.260I mean? Just making sure we're, we're exercising to whatever degree we can, making sure we're
00:13:07.920cutting out the ultra processed foods and including more whole, like whole foods in our
00:13:13.260diet as much as we can. I never say eliminate because I, I believe that we have to, you know,
00:13:18.840make things make our lives livable. And, you know, the more strict and restrictive we are,
00:13:23.920the less successful we are. But really just thinking ahead as much as we can about what's
00:13:29.860optimize our health forever, like going forward and increase our health span. And that really is
00:13:35.980somewhat of a cumulative effect from the time we're in our mid 20s. It doesn't mean it's too
00:13:42.560late once we hit our mid 40s or mid 50s or even mid 60s to make changes that will be really that
00:13:48.480will be lasting, but it never hurts. And I found that my patients that are exercisers and have
00:13:54.900always eaten a healthy diet and keep their weight and their BMI normal, they actually sail through
00:14:00.040that menopause transition much smoother than the others do. Okay. That's good to hear. That's good
00:14:06.960to know. Yeah. I mean, my big symptoms so far have been bad sleep. My sleep has gotten crappier. I
00:14:14.280wake up in the middle of the night at like 3 a.m. with the sweats, lower libido, and then the brain
00:14:19.160fog. Well, see, you said you're 42, right? 44. Oh, 44. So, you know, you are at this prime age.
00:14:28.340The average age of perimenopause early transition is 45. Late transition is 47. And, you know,
00:14:34.740that range is, you know, so you're right in that range where you should be feeling all these
00:14:38.680symptoms. And you don't have to. I mean, women that are experiencing symptoms actually can go
00:14:45.260on hormone therapy, even if you're still getting your period. And sometimes a really good form of
00:14:50.580hormone therapy is actually, you know, at your age is actually the birth control pill. And there
00:14:55.780are certain kinds of pills that work better than others. And if women don't want to go on the1.00
00:14:59.420birth control pill or they can't for some reason, there are the more traditional forms of birth
00:15:04.000control that have a hundred percent shown to alleviate those symptoms. Like if you're waking
00:15:09.320up from night sweats, the answer and the cure to that is really estrogen. If you're having brain
00:15:15.160fog, there are estrogen receptors in your brain. There are estrogen receptors everywhere in your
00:15:19.760body. And a lot of the symptoms that you could be experiencing could be from estrogen deprivation.
00:15:24.940And the cure for that would be, you know, an S little estrogen patch. Yeah, no, I mean,
00:15:29.980And it's it's so funny because I actually I wanted to get off the pill after I after I stopped breeding because I thought that maybe, you know, the additional hormones would be bad for me in menopause.
00:15:42.660And I think it's because I was getting so much of this like mixed information online.
00:15:48.600I do think that, you know, social media can be a rabbit hole.
00:15:54.120You never know, you know, and there are doctors saying there's doctors saying one thing.
00:15:58.960And then there's doctors saying the exact opposite.
00:16:01.060So I do think it's hard to know what to listen to and what to trust.
00:16:03.780And I definitely think that, you know, for the last over two decades, we have been misled
00:16:09.580by research that has told us over and over again that hormone replacement therapy and
00:16:16.100And they're going to give us breast cancer and dementia and heart attacks.
00:16:19.340And, you know, being off hormones is the most natural and the best thing for us.
00:16:23.520And, you know, really, it's different for everyone.
00:16:26.840If you're someone that took hormones and didn't feel well on hormones and feel better off them, then maybe you are one of those people that shouldn't be on them.
00:16:35.480If you're feeling like if you feel like you're having symptoms and you're the age you are and your estrogen is lowering, you might want to try it.
00:16:44.960Like we know now, like the one of the main studies that was that is responsible for all this hormone misinformation is called the Women's Health Initiative.
00:16:53.920And this was like a landmark research study that was done and released in 2002.
00:16:59.260And there's been a lot of media coverage in the last year or so, really debunking all
00:17:05.640of these myths that told us that, you know, it was going to give us breast cancer and
00:17:10.980And it's a much longer story than I think you have time for.
00:17:15.140But, you know, really now it's coming to light that the fear, the fear mongering that's going
00:17:20.820that has gone on with women's health and hormones in particular has actually been is actually
00:17:26.080unfounded. And there is just so much data and research out there that actually will prove
00:17:30.680the benefits of hormones, not to say they're without the risk, but actual health benefits,
00:17:35.760cardiovascular health benefits, the fact that estrogen may not really be causing breast cancer
00:17:40.720at all, you know, so things like this. So, you know, and the fact that like a lot of women in0.95
00:17:45.800this actual study that scared everyone, women that used hormones in their lives had a decreased risk
00:17:50.400of mortality. Some had a decreased risk of cardiovascular disease, you know, all when
00:17:55.560started young as opposed to old. And that was the key, one of the key reasons why the study was,
00:18:00.440you know, actually it was done on a subset of older women, but extrapolated and applied to
00:18:07.420younger women like you or someone going through menopause at the time versus someone out of
00:18:11.880menopause for 15 years. You know, you can't, you can't extrapolate results. So I think that I'm
00:18:18.860glad that it's in social media now that, you know, hormones are getting some presses and getting some
00:18:23.360good press. And it's opening up the conversation now for women to come in the office. And instead1.00
00:18:27.520of being scared and not treating their symptoms, coming with more of an open mind and we can have
00:18:32.640this conversation about what the actual risks and benefits are and really make decisions not
00:18:38.280based out of fear, but on out of education. Yeah, I love that. I do. I do. And I feel like
00:18:44.400the conversation has just been cracked so wide open. But then also maybe there's too much
00:18:50.900information. I've got to say my personal story is, and it is time for me to find a new doctor,
00:18:57.760but also, yeah, you know very well that finding doctors is very difficult in America. Doctors
00:19:03.440that you like, that are accepting patients. But every time I bring it up, I get the speech that
00:19:08.460menopause is when your period has has ended and has been over for, you know, 12 months or whatever,
00:19:14.580and that it's not impacting me right now. And there's nothing to do. I mean, that's literally
00:19:18.680what she has told me three or four times now, which means she's probably not the right doctor
00:19:23.020for me. But I also like finding the doctor that is right for me just feels so daunting. And I know
00:19:30.380so many of my friends feel the same way. I have heard this over and over. So I hear this story
00:19:35.400all the time because you know what I am doing right now is starting a menopause practice purely
00:19:40.680for perimenopause menopause people that are suffering through this and it is not based and
00:19:46.900this is the it's not based it's not an insurance-based practice so women would actually
00:19:51.600because they have such a hard time finding a provider that's well-versed in menopause
00:19:56.000that can actually understand what they're going through and know how to treat them
00:20:00.500is not an easy thing, not only just in this country, but anywhere in the world.
00:20:06.340And it all really does go back to this study back in 2002, which scared patients off from
00:20:13.600taking hormones. Taking hormone replacement therapy, it used to be 80% of women going
00:20:18.740through menopause used to take hormone replacement therapy. And now it is less than 4% of women that
00:20:23.660take hormones. So it scared doctors from prescribing. It scared further research from
00:20:29.660being done. So we didn't get the education we need. You know, I'm going to speak for myself
00:20:33.300personally. I did not get the education in my residency that I needed. And I know a lot of
00:20:37.140people, you know, a lot of OBGYNs feel the same way. And so there's basically over 20 years of
00:20:42.560a gap in our knowledge. And so when patients like yourself go to your doctor, you know, I'm not
00:20:47.400surprised that you, you know, that you're told this because I hear the story every day, patients
00:20:51.420reaching out to me to join my practice. And they've been to see three providers, four providers,
00:20:56.020and they've been suffering for years and there's a problem with the knowledge and there's a problem
00:21:01.000with the availability of doctors. You know, when I, I, the only way that I found that I'm going to
00:21:06.560be able to give the quality of care that I need and the time and devote the time that menopause
00:21:11.480actually needs to each patient is to go outside of an insurance model, unfortunately, and really,
00:21:17.000and it's only then that I can spend 60 minutes with you, 90 minutes with you and really do a
00:21:22.160comprehensive, holistic job explaining to you about what menopause is, about what your options
00:21:27.820are, all the risks and benefits, going through the literature, talking about exercise and sleep
00:21:32.220and nutrition and stress and your community that's so important, the people you surround
00:21:36.720yourself with and really, you know, do more preventative care than, you know, putting out
00:21:41.640fires and slapping Band-Aids on cuts. Yeah, no, I mean, it just it speaks to how broken the whole
00:21:48.460healthcare system is that it's not possible to do this in an insurance-based model. And that does
00:21:54.660mean that it's going to be really difficult to get this kind of information and this kind of care
00:21:59.340to people in certain socioeconomic brackets. But this is just, I mean, this is how our healthcare
00:22:06.040system is set up right now. It is so sad. And don't think that I don't actually have a good
00:22:12.080deal of guilt about it and that I don't think about it. It is, you know, I worked under the
00:22:16.140insurance model my whole life. I've been an OBGYN for over 20 years. And, you know, this year would
00:22:21.120be the first year that I changed my model up because, you know, my personal stories that I was
00:22:25.660in, I belong to a very, you know, it was a large group that had been a very longstanding group here
00:22:31.480in the suburbs of Philadelphia. And we were bought by private equity, you know, in 2017. And little
00:22:38.460by little, it just became an intolerable situation where we were being forced to see more and more
00:22:43.240patients in less and less time. And, you know, when you and we were starting to have to make
00:22:49.640decisions that I don't think were in the best interest of patient care. And if you don't feel
00:22:54.120good about the kind of medicine you're delivering, really, what's the point? So, you know, then I
00:22:59.580quickly realized that it's not just private equity. It's even in nonprofit institutions where
00:23:04.340doctors are just really being forced. It's like a numbers game. It's just see more patients,
00:23:08.500see more patients. And, you know, it's why more and more doctors are now leaving the system and
00:23:14.020going concierge, which is unfortunate, but it's the reality. And there are ways like, you know,
00:23:21.240there are definite ways, like next week I'm giving a lecture to all the doctors in the four
00:23:26.220hospitals of my healthcare system on menopause and hormone replacement therapy and prescribing
00:23:31.160and going through all the literature. So I think the education is trickling down. I don't think
00:23:37.000this is, you know, this, this void in education is going to last forever. Like I educate other
00:23:41.420doctors. I teach classes to, you know, for $35, you can have six hours of my time for, you know,
00:23:46.860mainline school night and things like that. So, you know, there are a lot of people out there
00:23:50.720giving that information. It just is unfortunately not always your doctor in the office. And I wish
00:23:57.120it was, but I do think that that is changing. I do see like, you know, some of the residents I
00:24:01.320work with have a renewed interest in learning about menopause, which warms my heart. And I
00:24:05.480think that the fact that menopause is getting more attention, it's sparking more interest in
00:24:11.320the younger generation of doctors. No, I totally agree. And my doctor is perfectly fine, but she
00:24:17.020is definitely from a different generation that is very much like, I went through this, you should1.00
00:24:21.580too, as opposed to how can we make your life a little bit better right now? I do agree that you
00:24:29.640need a new doctor. As I would say with any specialty, if you're going to a doctor and you
00:24:34.580feel like you feel in your heart of hearts that you're having an issue that has a solution or
00:24:39.560you're having an issue that isn't being heard. I do tell women all the time, just get a second0.90
00:24:45.000opinion on surgery, on your menopause, on any symptom. Get a second opinion. Go to another
00:24:50.100doctor. Even if it takes months, make that appointment. There are ways to get menopause
00:24:55.580care covered through your insurance. If there are like telemedicine companies that I tell women to1.00
00:25:00.960try like Genev and Midi Health do telemedicine menopause. And I'm pretty sure I know Genev takes0.92
00:25:07.540insurance. And there are there are people out there. If you go to menopause.org, you can find
00:25:12.140a lot of menopause providers and you can search via your zip code and see if you know what comes
00:25:17.320up there. You know that some take insurance, some do not. But there are ways and you and you really
00:25:23.420do have to search for that provider because menopause and perimenopause really are it's a
00:25:28.660pivotal time. It's a pivotal time in your health where you have to make those changes. And I do
00:25:34.000think that women that have taken hormone therapy and started it at the age, at the appropriate age
00:25:39.460when you're having those symptoms, really do have significant health, long-term health benefits from
00:25:45.040it. Well, let's take one more quick break. And when we get back, I want to hear about those
00:25:49.800long-term health benefits and also the nitty gritty of the hormone therapy. Like when I go
00:25:53.880to the doctor, what should I be saying? Okay, we are back. Let's start with what I should ask my
00:26:07.840doctor for when it comes to hormone therapy. Should I be asking to go back on birth control0.96
00:26:12.620or should I be going straight to hormone therapy? Well, so birth control is a hormone and the
00:26:18.040difference between birth control pills and traditional what we call hormone therapy,
00:26:21.400it's actually now called menopause hormone therapy, MHT. But the difference between
00:26:26.380traditional birth control and MHT is that birth control is much higher of a dose, much, much
00:26:33.160higher of a dose than what you're going to get in menopausal hormone therapy. Menopause hormone0.73
00:26:38.700therapy is really just geared to alleviating your symptoms with small doses of estrogen and
00:26:43.400progesterone, whereas birth control pills basically needs you to stop ovulating and has to be much
00:26:48.120higher doses. Now, sometimes in perimenopause, when women are still cycling and they still do
00:26:55.180have, you know, a certain amount of hormones being produced by your ovaries, sometimes that
00:27:00.080menopause hormone therapy is not going to be a high enough dose to A, control your symptoms or
00:27:06.160B, control your bleeding. So a lot of menopause experts actually do think that the birth control
00:27:11.580pill, like let's just say a low dose birth control pill, is going to be the best thing to control all
00:27:17.400your symptoms and not cause problematic bleeding. So for my patients that are open to it, especially
00:27:22.760if they need a form of birth control, if my patients that are open to it, you know, want to
00:27:26.700try a low-dose birth control pill, I actually do try that first. And there are certain types of
00:27:32.280estrogen, like there are certain types of birth control that I think do that a little bit better.
00:27:37.320For instance, there's one called Nextelis, and that has an estrogen and a progesterone component
00:27:41.420that really do well at suppressing symptoms and hot flashes and controlling the follicular activity
00:27:47.480that can be problematic for bleeding. And if they're not, like I do have a number of patients
00:27:52.640that, you know, really weren't comfortable on the birth control pill when they were in their 20s or
00:27:56.38030s and are looking for something. They just have it in their head that they want to try something
00:28:00.660else or they've tried the pill and it doesn't work and it makes them gain weight or they feel
00:28:04.100bloated. Then we go to hormone therapy. And really the hormone therapy is, you know, the things that
00:28:10.060we start patients most on is a transdermal form of estrogen, like a patch, a gel, a spray. And
00:28:17.220it's very easy. The transdermal form really has low side effects. It doesn't have that blood
00:28:22.800clotting risk that we worry about with oral estrogens and the birth control pill. And then
00:28:27.420we give a pill form of progesterone at night, which is lovely because it helps women sleep and1.00
00:28:32.780has a sedative effect. Oh, I love that. I know. And even that pill form of progesterone, given0.99
00:28:39.300in higher doses has been shown in studies to help both hot flashes and sleep. But the estrogen is
00:28:46.680known to really be the one that's going to be the one that the gold standard for knocking out most
00:28:51.420of the symptoms that you're having with perimenopause, because it's the estrogen that
00:28:54.480you're really lacking and and causes all these downstream effects. So, you know, it's what we
00:29:00.380usually start with is, you know, a transdomal form of estrogen and an oral progesterone that we can
00:29:04.700take at night. And that's the benefit of hormone therapy as opposed to the pill. The pill you take
00:29:09.400in the morning and it does not make you sleepy, but most women really have trouble sleeping in
00:29:13.020perimenopause and, you know, and they love the progesterone pill for that. Oh, yes. I just want
00:29:19.200more sleep. That's the thing. I just love sleep so much and I want more of it. And when you're
00:29:25.100not getting it, you know, that has its own downstream effects. You know, your chronic
00:29:30.620fatigue is going to affect your mood. It's going to affect your libido. It's going to affect your,
00:29:36.800you know, even cause metabolic changes, like increase your cortisol level, make you more,
00:29:41.660you know, you're going to increase your leptin. So you can be more, you can be more hungry. You
00:29:45.260can find a bit more appetite. It can cause weight gain, insulin resistance, like all these things
00:29:50.580that are downstream effects of sleeplessness. Yeah, no, exactly. Exactly. I love, I love all
00:29:56.480of these ideas. Are there tests that you can run to check your estrogen levels?
00:30:01.100There are tests. I, you know, the most, the most effective, or I should say the most accurate test
00:30:07.400would be a blood test. I do talk a lot about, you know, I don't really believe in the Dutch testing
00:30:12.640or the saliva testing or the urine testing, but, you know, because really what, when we want to
00:30:16.500know what your blood, what your levels of estrogen are, blood is the gold standard. So you can do
00:30:22.880blood tests to see what your estrogen level is, what your FSH level is. FSH is the hormone that
00:30:29.000is secreted from the pituitary gland that acts on the ovaries to cause the ovaries to secrete0.92
00:30:33.920estrogen. So they are helpful once you're in menopause or like, for instance, some women
00:30:40.280don't get their periods because they have IUDs or they've had a hysterectomy and they really are,
00:30:46.420we need a little bit more clues than just what are your periods doing to know what,
00:30:51.180If you're in menopause or perimenopause, the problem with lab tests is that they're very poor diagnosing perimenopause, which is why I tell my patients, I don't usually need to take your blood to diagnose perimenopause.
00:31:02.940I can go strictly on your symptoms alone and sometimes what your periods are doing.
00:31:06.980And the reason why they're not accurate is because your hormones in perimenopause are in, I call it a roller coaster.
00:31:15.660One day they could be high, like higher than they ever were in premenopause.
00:31:20.220And then the very next day or the next week or the next month, they could be low, like you're in a total menopausal range.
00:31:26.820And it goes up and down until you are actually in menopause and sometimes a couple of years into menopause.
00:31:33.420So, you know, I could check your labs one day and you'd be menopausal range.
00:31:37.060And the next day you would be told by your doctor, nothing's wrong.
00:31:59.140I mean, I would routinely be in rooms running an hour late because we, you know, doctors, I'm convinced that doctors do not get into medicine to not listen to their patients and to not serve their patients and help them.
00:32:56.860So there's no way that I can do a really good job for you and not keep my next 10 patients waiting for an hour to fully discuss menopause at the time of your annual.