Dr Kelly Casperson You Are Not Broken Episode 259
S2, E22
May 15, 2024

This week, we’ve got a bonus episode for you - an episode from Dr. Kelly Casperson's podcast You Are Not Broken: Episode 259: Lancet Menopause Article Rebuttal - the Menoposse.

Dr. Casperson and a panel of menopause expert physicians and nurse practitioners discuss the recent four-part article series on menopause published in The Lancet.

In the episode, Dr. Casperson and her guests address the agenda behind these articles and the implications for menopause care. The panel strongly disagrees with the claim that menopause is being over-medicalized and emphasizes the importance of hormone therapy in managing menopausal symptoms and preventing long-term health issues. They also criticize the suggestion that cognitive behavioral therapy should be the first-line treatment for menopause symptoms, highlighting the barriers to access and the lack of evidence supporting its effectiveness. The panel advocates for a comprehensive and individualized approach to menopause care. The conversation methodically identifies the principal themes discussed in the Lancet article on menopause.

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Hello Menopause is a podcast from the national nonprofit Let’s Talk Menopause. Produced in partnership with Studio Kairos. Supervising Producer: Kirsten Cluthe. Edited and mixed by Justin Thomas. Artwork by Stacey Geller.

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Stacy: This week, we're thrilled to offer you an episode of Dr. Kelly Casperson's podcast, You Are Not Broken. We love Dr. Kelly's show, and on this episode, she welcomes a panel of menopause expert physicians and nurse practitioners to discuss the recent four part article on menopause published in The Lancet. Enjoy the episode.

Kelly: I'm super excited to have part of the menopause on today. These are all menopause prescribing physicians, nurse practitioners who are passionate about educating the lay person on the facts and the truth. about perimenopause and menopause, and our goal today is to have a conversation about the recent four part article series that came out in The Lancet.

For people who don't know who The Lancet is or what The Lancet is, it is a British medical journal, prominent, I'd say it's a prominent one, Not to mention they did do the article saying vaccines caused autism, which they then had to rescind. But that was like the one oops of the lancet, but they're otherwise well respected.

And very recently they came out with a four part series on menopause, and a lot of professional organizations have written responses in saying this is probably not number one up to date and number two medically accurate. So what I'm going to do is I'm going to go around and just have people introduce themselves and say where they practice and why they care, uh, in case you guys want to come and see these amazing women.

And then we're going to dive a little bit deep into the Lancet article and give you our thoughts. So Dr. Sullivan O'Sullivan start with you. I'm so happy that you're here. Where are you coming to us from and why do you care?

Aofie: Morning everyone. Thanks for having me on Kelly. I am up in Portland, Oregon. I'm a family physician and I work in Portland, um, at a fantastic healthcare clinic called AIM Health.

And then on Mondays I work with Heather Hirsch, who's a menopause specialist. And I also specialize in menopause care. So trying to

Kelly: change things person by person. Thank you for being here. Dr. Flagg, coming in from New York City, why are you here and why do you care?

Heidi: Oh my gosh, I care so much, uh, yeah, you know, it's, I'm Dr.

Heidi Flagg, I'm based in New York City, a founder of Spring OBGYN and a menopause specialist, and I care because I see so much suffering, uh, in the 40 year old patients, even late 30s, end of their 50s. And I listen, uh, as Dr. O'Sullivan does, one patient at a time to all the symptoms and, and all the challenges that they have, uh, with the symptoms of perimenopause, uh, that hit them all at different times and, uh, in a very challenging time of life when lots of other things are going on, uh, with young kids at home, with their families.

partners with big jobs. Uh, and, uh, we, we just, we just try to break it down and, and figure out how they can optimize this time of life. Uh, and, um, I'm a big fan of hormone therapy. Uh, I think it has lots of benefits and I think we're going to talk more about that here.

Kelly: Awesome. Thanks so much for being a part of this today.

Dr. Quayle. Welcome. I'm so glad you're here. Introduce yourself. Tell us where you're from and why do you care?

Heather: Hi, thank you so much for having me, Kelly. Excited to be here. I am Heather Quayle. I'm a women's health nurse practitioner. I've been practicing for about 23 years. I'm in the Atlanta, Georgia area.

I have my own practice called the show center sexual health optimization and wellness. Why do I care? I am that boots on ground clinician. I, um, have kind of been everywhere, a little bit in academia, nonprofit, all the worlds, but I really am. I like to call myself that boots on ground, hear the stories day in, day out from my patients.

Um, not heard, have a glass of wine. It's in your head. You're crazy. No, that can't be a symptom. Um, all day, every day. I'm crazy passionate about this, not only in the menopause space, but also sexual health. Um, I feel like we have done such a horrible, women. Um, and I think that this whole menopause see that I'm so honored to be a part of is trying to get so much louder so that we can get the information out.

But I don't think we're getting loud enough because we're only a little small army and we need to get it out to the masses. So I'm so excited when we have podcasts like this, where hopefully it reaches a much larger army.

Kelly: Thank you for being here. And pulling in, putting her on the spot is Dr. Lauren Stryker.

Dr. Lauren Stryker, we are doing introductions, so if you wouldn't mind jumping in, telling us where you're coming from, who you are, and why do you care?

Lauren: I love being put on the spot. I'm Lauren Stryker. I'm here in Chicago. I'm a professor of OB GYN at Northwestern University and the host of Dr. Stryker's Inside Information podcast.

And why I care about perimenopause and menopause is the impact it has, not just on the quality of life day to day, but I'm really looking at the big picture, the impact that it's going to have on women. And down the road. Everyone here knows very well that pot flashes are not harmless, that the impact on cardiovascular disease and bone health and length of life is enormous and that's why it is so important that as health care clinicians that we are on top of this.

We are not ignoring this. We are not just brushing this off like it's no big deal and let's think the symptoms away.

Kelly: Raise of hand probably if whoever wants to tackle this because I think I'm going to ask the hardest question first. The question is, Why did these four articles in The Lancet get written and why did they get published?

Do any of us know what kind of what the agenda was behind these articles? And does anybody want to grab the hardest question first?

And we're speechless.

Lauren: Even Dr. Stryker. No, I've never, you've ever seen me speechless. I've

Kelly: never seen you speechless.

Lauren: No. I mean, you know, look in the academic world, and this was written from someone in the academic world, we've all heard the term publisher parish. You need to make a name for yourself. You need to get out there.

You need to put a stamp on something and call it yours. And. You know, job done. This accomplished that. This person, everyone's talking about this article. Everyone's responding to this article. It's had a big impact. And unfortunately, it's going to live on for a long time. You know, one of my naive optimistic.

Reactions to this was, well, maybe nobody will notice, you know, maybe it's just us that we saw this article and we're getting all upset about it, but I'm sure just like I have had a number of queries from the media in the last 48 hours about this, I'm sure you have as well. So it is getting noticed.

People are asking about it. I did a webinar with a bunch of women the other day. And the first question that came up was, well, I heard that this thing that we're over medicalizing. So, you know, people are reacting to it. And so when you say, what was their agenda? Why did they do this? It's exactly this, to get out there, to be the spokesperson for something new, for something different, to put their banner on menopause, because that's the thing that people are doing these days.

Heidi: I just want to add, I mean, I think we were talking about boots on the ground, right? I think one thing that this article misses completely is it is written by, and, and all respects, uh, to this group of, of people, but you know, they are PhDs, they're actually not folks that are in the field like all of us here practicing day in and day out, talking to patients every 15 to 20 minutes and hearing their stories and hearing the extent of the suffering and listening.

And acknowledging the symptoms, right? So I think that was a major swing and a mess on this particular article that these are PhDs, uh, and, uh, and not people that are really, that are really have a handle on what the, the, the forefront issues are. So I think that's a major point that we should, that we should bring up.

Kelly: When you're looking at a town from an airplane, everything looks pretty peaceful and calm, right? You're like, this town is fine. You're like, if you're on the ground talking to people, there's can be incredible problems and you don't see it when you're not boots on the ground.

Lauren: Not one of these PhDs has ever looked at a dry vulva or vagina, just saying.

Heather: 100%. I mean, it was epidemiologists for the most part that wrote this. And I think These are also people that use their own data from the WHI. I'm sure you're going to get into that, but I think that that also is incredibly relevant that we need to point out that we've debunked so much around it, but I think that again, um, they're trying to be relevant again.

So lots of flaws.

Lauren: I don't think we'll ever know what the agenda was. But now we're dealing with the downstream effect of it. And that's really not fair to us as clinicians who already have a very difficult job to get out there and educate not only our colleagues, but to give the right information to our patients.

And now they've just made our job a whole lot harder. Thank you very much.

Aofie: A hundred percent agree. I'm on a Facebook group called Oregon Physician Women, and it's a collection of physicians all through Oregon and Southern Washington. And there's about 1700 doctors on there. And I go on as often as possible and spread some awareness about menopause hormone therapy.

And I felt like when that article came out, it just, it's like going two steps forward, one step back all the time, um, because those are doctors and they're looking for papers to read and study and go by. And you think something coming out of the Lancet would be a good. paper to kind of practice by, but there were just so many points through that paper where you could go, Oh, so you've never seen the menopausal patient then you, you don't deal with this at all.

I mean, the whole way through it comes up time and time again.

Kelly: Yeah, absolutely.

Heidi: Contradictions within the piece itself. Right. There's so many things we could talk about.

Kelly: The first thing I want to start with, because I think it's, to me, the biggest dirty band aid of this, is the statement that we're over medicalizing menopause.

And part of that is I don't even think that people these authors understand what menopause is that it is a decline in hormones. It is an endocrine apathy. It is the ovaries running out on their timeline, right? And just saying like, oh, it's just the hot flash and not understanding the pathophysiology behind what happens.

Let's start a conversation about your thoughts on if, if are we. In 2024 over medicalizing menopause and what that means to you.

Lauren: I think we're under medicalizing menopause, quite frankly, you know, here we have this going on at the same time that Drew Barrymore puts out this nonsense of supplements that are supposedly going to help with your brain fog, sleep, hot flashes, again, ignoring the consequences of all these things.

And this is an exact example of note. These women don't need to take worthless, unproven herbs and spices. They need people who are going to give proven, effective, safe hormonal and non hormonal options. And I think we would all agree that if men stopped making testosterone at age 50 and couldn't sleep and couldn't think and were having all day and all night hot flashes.

Nobody would talk about over medicalizing the fact that they would be getting testosterone supplementation. So this is offensive and sexist on every level.

Aofie: I mean, they actually say it, Kelly. They say, rather than focusing on menopause and some endocrine deficiency, we propose an empowerment model. You know, I mean, I just try to imagine myself whenever, I know we've all said this now, and Dr.

Stryker just there, always try to flip it and think, would I say this to my male patients? If I had a man sitting in front of me, I checked his testosterone and it was undetectable. He was in tatters as a man, couldn't sleep, um, had just no quality of life. Would I say to him, now, rather than focusing on this as an endocrine deficiency.

Let's, let me empower you. I mean, it's just, it's ridiculous. Do some yoga. It will help. Be empowered. Empowered. Exactly. Let's try some cold plunges and some, uh, acupuncture. You know, acupuncture's great, but not for menopause. It's just laughable.

Heather: I think when you said it on your Instagram, Dr. O'Sullivan, it cracked me up actually.

Cause you're like, you know, I decided I was going to read this from the side of a man. So everywhere it said female, I replaced it with male. And when you read it, it was brilliant. And when you read it that way, I said, what man in God's green earth would put up with this?

Heidi: I

Heather: think the over

Heidi: medicalization statement is it's absurd, quite frankly, to say that in our country where four to 6 percent of menopausal perimenopausal women are medicated.

Four to 6%. How can you possibly say that they're over medicalized in that scenario? I think maybe 6 percent in England are treated, right? We're, we're under treating as Dr. Stryker just said, and let's talk about over medicalization for a second. All the things that this, all of us here, and many of us do know is that the preventative benefits of hormone therapy, what, how, where, and how estrogen plays a role, we have estrogen receptors from our head down to our toes, It works as a neurotransmitter.

It binds receptors in almost every tissue in our body and plays, plays an incredible role there. And when we don't, when we don't treat people and they start getting diabetes and they, their blood pressure starts going up, their LDL goes up. When, as a result of not having their estrogen sources, these are all the things that we see happen to women when they hit 50, 51 and a half and stop getting their periods.

And then we start treating with antihypertensives and how let's talk about depression and anxiety. We start treating with SSRIs. We start, we just start treating with diabetic medications, all these medications that we start treating with that's over medicalization. When in fact,

Lauren: Exactly. We have

Heidi: something that is in your body.

It's, it's, it's in your system. Your, your, your body's used to seeing it and knows how to use it, which is hormone therapy, right? We weren't meant to live past a certain time. We're lucky enough to be alive during this time. Our estrus receptors want to stay bound.

Lauren: And Heidi, to your point, I mean, we all know the statistic that by age 60, one out of four women are taking an SSRI, one out of four.

Talk about over medicalization, and that's twice as many as we see in the men. 50 percent of those are prescribed when? During perimenopause, because this is how they're told that they should treat. their hot flashes, their insomnia, their mood swings instead of getting hormone therapy. So it's not just as you correctly said under medicalization, it is over medicalization in the wrong way.

And that was something that I loved about this group that put together this response because we were all in total agreement on that point.

Kelly: Viagra has been out since 1998. Literally nobody ever has said we're over medicalizing erectile dysfunction, right? And it's like, low estrogen is all the things.

It's not just sexual dysfunction. For the people who feel like sex is extra, which I know none of us feel like sex is extra. It is a human right. It is part of healthy living. But nobody's ever said we're over medicalizing low testosterone. Nobody's ever said we're over medicalizing erectile dysfunction.

And so when you flip it, this is about equality and how we're dismissing 50 percent of the population.

Heather: Absolutely. And the thing is, is that I think another thing that's a really hard point for me is that There is a place for SSRIs, don't get me wrong, but to offer it as a first line or to talk about cognitive behavioral therapy as first line, I really have a problem with that.

You're talking about meds that alter the brain and that help with brain and cognition and functioning and all that, but why are we not looking at hormones as that first line? It sounds a lot less risky, a lot less scarier to me, um, that some than something that's working on our central nervous system, but that is my personal bias on that.

I'm not against. mental health treatment, but just not as first line for menopause.

Heidi: Heather, I think you've got some data backing you up on that. Formal therapy should be first line, right?

Kelly: The thing I want to mention on SSRIs, which I think is not explained to people in, you know, consent discussions, is SSRIs are linked to bone fracture and not just through the osteoporosis pathway, right?

Serotonin is in bones and we know there is an increased risk of fracture, not just osteoporotic fracture, in people who take SSRIs. Now, estrogen decreases bone fracture and helps with mood. So I'd say the, a better medication for Some mood changes in menopause again, we're not talking about extreme depression that does need to be treated aggressively There is a caveat for SSRIs, but as a medication that can help both bones and mood Nothing, nothing is what estrogen is in that in that department.

Let's talk about the cognitive behavioral therapy statement that they said and tying into that, uh, them saying that they did not believe there is enough data saying depression and anxiety is correlated with the menopause transition.

Heidi: You know, Kelly, what I say, then you are not giving, if you don't acknowledge the mental health changes that are present in perimenopause, you are not listening to your patient.

You're not giving them a safe and comfortable space in which to reveal their, what they're undergoing, what they're going through. I am convinced of that. You have to give time and space and attention, and you have to listen. And if you listen, you will hear how incredibly impactful The mental health changes are in perimenopause, but you've got to listen and hear them.

Uh, and I'm, I'm just convinced anybody that's it, that denies it or says it's because of something else is not. And also doesn't understand the biology behind it. It's not just about our

Lauren: clinical experience. I mean, the data is there and that's what was the most striking to me is this is not new data.

This data has been around for a very long time that looks at the impact of hypoestrogenemia Transcribed by https: otter. ai in the brain in terms of our levels of serotonin, dopamine, and other neurotransmitters, which has been well documented and well studied, not to mention in Dr. Lisa Muscani's new book that just came out this week.

She spells it out for people who aren't familiar with that data. So they have no excuse.

Heidi: It's so good. The other thing this article emphasized was that CBT was new and that this should be first line therapy. And, uh, first of all, you know, I think not new, right? We've known about it, that it helps with sleep.

It's good. There's good data behind it, right? For sleep and for hot flashes, uh, menopause society recommended it or, or suggested it as a, as a, as a treatment option in 2015. This is not new, right? Right. Um, CBT. In my population, in my women here in downtown New York, and I'm sure all of yours as well, they are busy women.

They, they have huge jobs. They've got families. CBT takes six months to kick in. It's expensive and it takes extra time out of your schedule to go do it. It's untenable. It's not something that it's. It just, and they, they put the Lancet put it as a forefront treatment for hot flashes. That's what they talked about.

They completely de emphasized hormone therapy. Uh, I really, the whole tone of that article, it just, I immediately reacted to all of you do that too.

Heather: I always am thinking of our marginalized or the people that can't afford things. So hormone replacement therapy is affordable for most use a good Rx app.

You can get it probably a six month supply for 30 to 60 bucks. So not crazy off the charts to go into cognitive behavioral therapy. Most insurance sadly is not covering it anymore. It's a cash based business. It's 100 plus or more dollars, and that's at a minimum for a 50 minute consult. That's going to take six months.

No one has, like you said, that kind of time for a lot of people, especially when I, again, think of the marginalized who have to work, when are they going to do this? And again, it's just not an option for everybody because it's, there's a huge barrier to cost. And that's some of the things being that boots on ground clinicians that we all are, is we have to kind of balance out what patients can do, what's feasible and what's affordable.

Aofie: One of the really infuriating things about that article, one of them, was the thread the whole way through that clinicians who prescribe hormone therapy just do that. We don't think to prescribe pelvic floor therapy or cognitive behavioral therapy or to, um, um, you know, support our patients with nutrition and diet and exercise that ran through the whole article as if we don't, that doesn't occur to any of us.

I mean, we all use all those tools.

Lauren: Well, not only was it insulting, but the other thing that ran through the entire article was the idea of, and if your patient is having a hard time, It's her own fault. She just needs to buck up and do some CBT and start thinking positive thoughts, and then she's going to wish away all of these symptoms.

It's interesting that they did not say she could wish away her vaginal dryness, even though they were not willing to go that far. I'm waiting for it, you know.

Kelly: Yeah, I think from a sheer numbers game, women are 50 to 51 percent of the population. Our medical system's already jam packed. Now you're going to have, let's say, let's say 80 percent of them are symptomatic from perimenopause menopause.

Uh, you're going to push 50 percent of the population, 80 percent of them to a cognitive behavioral therapist. Like, we simply can't, even if we said, yes, that should be the gold standard, we do not have enough training schools to dump out that many a cognitive behavioral therapy providers to help this sheer amount of humans.

I always say this is not an autosomal recessive, you know, genetic disorder. This is 50 percent of the population and to help the majority of them, we, we need to really follow the evidence.

Aofie: They really went out of their way not to mention any of the benefits of hormone therapy on bones and brain and heart.

I mean, they went out of their way. There was one line that said, um, MHT might improve sleep, memory and concentration in women taking it for vasomotor symptoms, but it is unlikely to have any effect in women without vasomotor symptoms. I totally reacted to that. It's insane. It's

Lauren: just not true. It's just, you know, it's just just simply not true according to every piece of data that we have.

Kelly: Jumping in from Galveston, Texas is now Dr. Mary Claire Haver. Welcome. We're going to put you on the spot real quick. Tell us who you are, where you're from, and why do you care?

Mary Claire: My name is Dr. Mary Claire Haver. I am a board certified OBGYN physician. I'm also certified by the Menopause Society and I have a culinary medicine specialization as well.

I care and I practice solely menopausal care. I'm sitting in my clinic right now between patients and I care because patients deserve better that we have left an entire generation of women and females bereft, um, without the option or the discussion of hormone replacement therapy for the wrong reasons.

And I think that we can do better.

Kelly: Love it. I'll put you on the spot to answer this question. So one of the statements in the Lancet article said most women navigate menopause without the need for medical treatment. Would you like to comment on that?

Mary Claire: So the interesting twist. That's an interesting twist on a fact when most women navigate the menopause without the option for menopause hormone therapy, which is a very different statement than without the need that we have overwhelming evidence to support the need for menopause hormone therapy for patients, not only for treatment of their basal motor symptoms, but prevention of disease in multiple organ systems and categorically denying a patient that just saying to chin up and suck it up and get through it is outrageous.

Kelly: Yeah.

Heidi: I

Mary Claire: wonder if they even got the basis for that statement either, right? Yeah,

Kelly: that statement was not cited.

Mary Claire: It was not cited. And I found citations to prove the opposite.

Kelly: One of the things I think that was, uh, interesting was also, we'll start with the word interesting, is that there are many, many, many, many papers on perimenopause and menopause that said we need more research.

What they tended to do was cite their own studies. And that makes for a very biased review article.

Lauren: I think it's okay to cite your own studies. I've cited my own studies on occasion, but you have to cite other studies too. When you're limiting it to that, you know, as we've all talked about the fact that they cherry pick the data and talk about the ultimate in cherry picking is to only list your own studies.

Mary Claire: For several of the points they were trying to make, they were citing their own research. Instead of looking at a balanced view, which is what most good review articles do, is present both sides of the equation, studies that prove a point, studies that disprove a point, and trying to meet in the middle somewhere, this fell far short of it.

Aofie: Which is so ironic because their whole point at the beginning was, let's have a balanced view. And as you read through, then you could see, yeah, no, that was not your goal at all.

Heather: And for being such a well respected journal, I mean, I, I know we're all floored. Like how did this meet the dot all the I's and cross all the T's to even get through, you know, when it was so unbalanced.

Mary Claire: I mean, I can know we can only speculate. I think it's a bit of thinner washing where the Lansing came out very clearly that they were going to have a women's health focus and they really wanted to. You know, and here they were kind of gifted this, this article of series of four, you know, um, of articles that would kind of fill that gap for them.

And I can't imagine it underwent the rigorous review that they typically do, because perhaps in my mind, the only way that justifies it, they were maybe in a bit of a rush and it sounded good. The headline sounded amazing. And they felt like, you know, here's a way for us to show that we really are going to try to switch our focus to more female centered research.

They stall the

Lauren: headline. They stole the headline from the New York Times. I mean, come on. And of course they saw how well that one did. So they just used it again. I don't think we give them credit for that.

Aofie: If you were an editor and you read through that article, you might not think it was crazy. It's because we practice menopause medicine and we see these women and the hell that they go through.

Um, that's so glaringly obvious to us, but I wonder who read that. Um, and who had a hand in,

Lauren: you know, I mean, I'm on the editorial board for the journal menopause. So I know exactly how these things work. And if I had read through that as an editor, I would have said, no, this is biased. This is opinion. They don't support these facts.

So I have to assume that the vetting process at the Lancet is very similar, but to your point, how did this even get through? This never would have gotten published in menopause. Never.

Heather: No. I had some colleagues that actually read it, and this is where I was, and again, it goes back to our education that I, that said, Heather, I don't see anything wrong with the article.

And they don't pause day in day out, but that's the frustrating thing right there that I think all of us keep pointing out is that most people do not go back for further training. We got very little training if you graduated in the two thousands because they, the whole WHI. So if they keep with that same WHI mentality, maybe they don't see a problem with it, but it's like, come on, come up with times you debunked everything.

But. I think that was very eyeopening to me as some of my colleagues saying like they didn't think anything was welcome or that it wasn't patronizing or misogynistic or those things.

Heidi: I heard that too. And I thought it was deeply upsetting because But it just supports what they believe, what they believe for the last 20 years, right?

Since 79. Um, but gosh, it, you know, to, to make it challenging to convince our colleagues that the data driven facts don't exist, it's just, it's hard enough. And it also

Mary Claire: validates the clinical experience of what most women are going through right now. They are getting those same answers. They are getting the suck it up.

They are getting the, because of this exact mentality, this is not representing clinical data fact. This is representing. how we are supposed to think about women and how they age.

Lauren: Exactly. Because it really is ageism. Because we talked earlier about how, of course, if this was happening to men, the response would have been completely different.

But even if we just look at women, If you look at the fertility data, for example, anyone who's practicing fertility or was referring to fertility, they are looking at the data, they are changing their protocols. They are, you know, going with what is new. Why are we not seeing this? Because we're talking about older women.

And even if you look in the gynecologic literature, if you look at things that are not specific to menopause, you see very little about anything over the age of 50. And in the menopause literature, it's not unusual for a study to end at 55 or 60, as if at 60, you just die, you know, so the problem is a bigger global problem in terms of not just being sexist, but also being ageist.

Kelly: Yeah, if you look at early menopause, right, we know the devastating effects for not putting those women on hormones till average age of menopause. I would argue we're under treating those women. We are not getting them the treatment they need. And then all of a sudden, poof, when you turn 51, we're over medicalizing you.

That makes no sense to me.

Heidi: That's the other thing about this article is they focus so much on menopause, right? When the suffering is happening the 10 years prior. And that was the other thing that, you know, just embrace it once you've stopped your period, enjoy the fact that you don't have your period anymore, that you don't need birth control, but the suffering is happening the 10 years prior, it completely ignores

Lauren: this.

Finally, the suffering is setting the stage for cardiovascular disease and osteoporosis down the road. And that to me is.

Aofie: Yeah. And it was such a good opportunity to talk about perimenopause. My GYN doctor would not start me on hormones because she said I had to wait until I had been a year without period.

So great doctors believe that. So we need this information out there. And it was such a great opportunity and they totally blew it.

Kelly: One of their statements was over medicalization can lead to disempowerment and over treatment. Now, I know you guys have the same experience as me, but when a woman comes back with the proper amount of hormones in her body, No way in hell is she disempowered.

Lauren: No. And I'll get to talk about earlier. Yes. The over medicalization by giving them the wrong treatments, things that don't work, the SSRIs, the antihypertensives. That's what disempowers people. And we know that, you know, Kelly, as you say, these women do not feel disempowered. They feel like, oh, my God, now I can think now I can work.

Now I can function.

Heidi: I call it like the seventh lifestyle lifestyle pillar because It's to start somebody in hormone therapy. They can then just have the wherewithal to continue, you know, to get through life, to actually go exercise, to actually work on your nutrition. It actually, for many of my patients, that's the starting point to help them feel well enough so that they can actually get these other things done, right?

You can, you can talk about the six pillars of, of a healthy life, but until you get them, their hormones back, uh, many of them are just sitting there. So upset and suffering that they can't even wrap their heads around those other things. It's all too overwhelming. So the starting point is often hormone therapy for me with my 40 something.

Kelly: Yeah. Once you get them to a better level of functioning, then they can exercise, then they can start doing the other, like you've got to get them off the couch.

Lauren: Sleep is a beautiful thing.

Kelly: You got

Lauren: to

Kelly: sleep.

Lauren: Gotta sleep. Hot question, you're not sleeping.

Kelly: Just the statement that like over medicalizing leads to disempowerment, where else do we say like we shouldn't, we shouldn't treat diabetes too much because we don't want to disempower people.

Like it doesn't make any sense if you think about, you know, treating other conditions and how that could possibly be dispowering to somebody.

Lauren: Forget those eyeglasses, you don't really need to see. Think positive thoughts. We

Kelly: don't want to disempower you by treating your hearing loss. It makes no sense.

Mary Claire: It's just the history of medicine and the way females are treated, assigning a psychological cause to a biological event. And we've all seen it. We've all seen it in medical school and our trainings and it's all in our head. You know, we have beautiful books written on the subject. I mean, this is real and it is, I think it's very much pervasive today, especially for the aging woman.

Kelly: All right. We're going to let one more person in because now Jackie is here. Jackie is an amazing nurse practitioner coming to us from. Oh, man, I want to say Atlanta. Can you introduce yourself? Tell us where you are and tell us why you care.

Jackie: Hi, Jackie Fiasco here, women's health and key menopause clinician coming from Atlanta, Georgia.

Why I care? Well, because I'm willing to do a wild goose chase for the piece I just got off the phone for. I'm literally on good Rx right now, Mark Cuban pharmacy and Amazon pharmacy trying to find the cheapest price for vaginal estrogen for a pizza, um, is the key. Five with terrible GSM symptoms, saw her gynecologist and have no, no solutions for her.

So I feel like we just need to band together and make this better. So I'm here. Sorry I'm late to the party everybody.

Kelly: Ah, thank you so much for coming and lending your support to this amazing discussion that we're having. Uh, another thing I wanted to bring up before we wrap up with final thoughts is they stated in these articles that estrogen, uh, can cause breast cancer.

Uh, so perpetuating the myth again, um, not only that the, in the WHI, the placebo arm was flawed that we now know that there is no significant increase in breast cancer. And the other fact that gets washed over, which is insane to me is that in the estrogen alone arm. Estrogen decreased the risk of breast cancer.

Why aren't we breaking the internet as estrogen as prevention for breast cancer? Um, we're not there yet, but it's exciting that that could happen at some point. Can you guys talk about how this article is not up to date with what we currently know and is perpetuating the fears of hormones?

Lauren: This is, I think just made my blood boil because as you said, Kelly, not only does it decrease the risk of breast cancer, but we know that women who are taking hormone therapy and get a breast cancer diagnosis, they have a 40 percent decreased risk of dying from that breast cancer.

So it is protective. And there are now studies going on in multiple university settings of do a bay, which is a combination of estrogen and basal doxepin, which breast oncologists are giving to their patients. Because they are quite sure that this is going to shrink away ductal carcinoma inside too. And if that doesn't tell you that estrogen is protective, I don't know what does.

But here we are, now, again, you know, making, as I said earlier, more work for us. Now we have to continue to scream and yell and educate others. And get rid of this myth, which will not go away.

Jackie: Well, I think what's so cool, too, about that study, uh, Lauren, that you mentioned, was there, it's U of A, U of A's primary.

I mean, and there's, there's also a lot of spirits that surround everybody, you know, people that come to me with hormones, they always say, I want castles. What

Lauren: could be more natural than horse piss?

Jackie: Yeah. I know. Well, I agree with you.

Lauren: Those are worse than plants. I'm just saying.

Heidi: Also, Kelly, let's talk, let's talk about breast cancer risk.

And I know this is always a subject that nobody wants to talk about, but alcohol intake, right? Um, there are things from a lifestyle perspective that we can do to mitigate our risk for breast cancer. And it's, you know, not drinking, not over drinking, like not drinking too much alcohol, right? Or going to zero.

Although that's not in our culture. Really, uh, something that is feasible, I don't think, but I, you know, just lay off the cocktails, um, and be reasonable about that.

Mary Claire: We can mitigate our. Breast cancer. It's a bigger impact than only HRT has ever been shown. Have any

Lauren: of you ever been at dinner with, with women who say, Oh, I won't take hormone therapy because it's going to give me breast cancer.

But then when the waiter comes around with a bottle of wine, they say, no, no, that's going to give me breast cancer. It doesn't happen.

Heather: It's too hard to change your lifestyle. That's always the thing. I think people just don't know. They do not

Lauren: know.

Kelly: Anybody want to do another, uh, any final comments on the breast cancer statement in the Lancet articles or the perpetuation of the fear of hormones that I'd like to put behind us but seems to keep popping up?

Aofie: Yeah, it was inexcusable. With all the information that we have now, uh, it was inexcusable to put that in our newest article in the Lancet. I don't know how they rectify that in their minds.

Kelly: All right. Well, you guys, thank you so much for joining in our last few minutes. I'm just going to have us go around and kind of give your, whatever you want people to know either about menopause or hormones or this article, we'll kind of go around and uh, get everybody's final opinion.

Let's see. Dr. Kate White, can you want to give us your, your final thoughts on the Lancet article or menopause? What you want women to know?

Kate: Oh, absolutely. The person we're seeing, and you really need to go and get them from someone who will be supportive. And there are people out there you can find.

Kelly: So for people who missed Dr.

Kate White's statement there for the audio. It's okay to get a second opinion. It's okay to ask somebody else if hormones are right for you. If you're not getting the help you need. Dr. O'Sullivan, let's start with you. Any final thoughts or wishes that you want to tell women?

Aofie: I would say, um, if you are going through peri menopause or menopause, find yourself a menopause specialist and go and talk to them.

No one is going to push anything on you. We can help you, uh, figure out what lifestyle changes might be helpful. And talk to you about hormone therapy and then, um, just help guide you. There's no pressure at all, but every woman deserves this information and it has been withheld for the past 20 years.


Kelly: Heather Quayle, any final parting thoughts you want us to take away?

Heather: So if you're feeling like you're being dismissed from your provider, they're not hearing you, they're not seeing you, they're telling you it's in your head. I want you to feel advocated enough, hopefully after hearing this, following many of us that you see on here on Instagram to go find another provider.

Um, I know that can sound a little bit harsh, but it's time and you need to advocate for yourself so that you are heard and that you get optimal treatment.

Kelly: Thank you. Dr. Heidi flag parting

Heidi: thoughts. I'm going to just repeat what everybody else is saying, that it's just really important that if you're, if you're suffering with symptoms or you just want to talk about preventative treatments, so to find somebody that you can speak with and, and share all the things that you're, that you're going through, um, the menopause society has a menopause certified specialist, but there are other practitioners out there that, that, uh, that are not on the list that, that do, uh, treat menopause.

If you are not being heard. Find someone that will listen, and I know that's not easy, but, um, there, there are many of us out there that that do and and

Kelly: care. I want to, I love that. Thank you. I mean, I, I want to give a shout out to the women who have to do extra work to find a different provider. This is the extra burden on women because.

Health professionals have not stayed up to date on what is safe and effective and the burden is on the woman at this day and age until our health system changes. And I want to apologize for that, but it's the current state as it is.

Lauren: So, the average age of menopause in this country is 51. With current life expectancies, women are going to live at least one third if not half their life after the menopause transition.

This is too important to say, suck it up. Live with it and to everyone's point where we talk about the challenges of finding a menopause expert. I hear you We all know this because we are one of a handful quite frankly of menopause experts And when you do find one sometimes quite frankly, they've got a six month to one year waitlist or their concierge And, and that's really challenging.

We do have some very good telehealth companies that are going to improve access for women. I, um, and I'm very transparent. I work with MIDI who is a telehealth, uh, medical care that takes insurance and is available in all 50 States for true menopause experts. So if not MIDI, there are plenty of other ways to find someone, but the point is find someone

Kelly: beautiful. Jackie, any final thoughts you want to leave people with?

Jackie: I am going to ping right off of Dr. Warren, who is about telehealth. That's just a huge, like advocate, reach out to your representatives, to your people in government and, and push them to advocate for more access. And I think Kelly, you talked about this, about the testosterone telehealth companies now prescribing testosterone?

We have restrictions and laws, um, that don't allow us because it's still a Um, certain restrictions are going to, you know, are going to, so just advocate, right? Write the people that have the power to make these changes, to continue to expand access to telehealth, to expand access to, um, hormones that are currently on the controlled substance list.

And that, like you said, we have extra work to find, okay, it's not so easy. Like we say, it's easy to say, go find another provider, go find another provider, but there's a lot of barriers there. I mean, most women, like, um, Warren said, most women are. What's 20 percent of our workforce is women in menopause. Um, so a lot of these women have a lot of, a lot of shit to do.

Sorry, excuse me. So finding a doctor is another provider is hard. So anyway, telehealth, telehealth, telehealth. I have to put a plug in for that because. That, that helps expand our access.

Kelly: And my big takeaway for the women to hear for the, for the people who love the women who want the women to get the help is there are people who care.

There are people who are up to date on the science. There are people who care about your health and even in preventing your, you know, preventative health to help you live and thrive the best you can. As the years go on, hormones don't prevent aging, but they can decrease the risk of many, many things. Bye.

Everybody, thank you so much for your time, for your thoughts, for all the training you had to do on your own because you didn't get it in school, for being here today, and to helping get the word out for the millions of women that need to hear this. Thank you so much for joining me.