August 1, 2024 • 47 mins
This episode is presented by Midi Health, a virtual care clinic dedicated to providing expert menopause and perimenopause care to women in midlife.
For so many women, menopause is a mystery. Its symptoms can be wide-ranging and last for years, and information about treatments can be confusing - where it exists at all. To make things even more challenging, healthcare providers are often less-than-helpful when it comes to finding solutions. Our guests today are here to help: New York Times writer Susan Dominus’ recent article, “Women Have Been Misled About Menopause” was an immediate viral sensation, becoming a valuable resource on the latest research and treatments. Her reporting also resonated for another reason: the symptoms women experience are finally being taken seriously. Dr. Rebecca Brightman, a gynecologist from New York City specializing in menopausal medicine, joins the conversation to share what she’s learned throughout her years of treating women facing this life-altering transition. Plus: our guests answer questions submitted by you, our listeners.
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Episode Transcript
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Speaker 1 (00:04):
Hi everyone, I'm Katie Couric, and this is Next Question.
If you're a woman of a certain age, or if
you even know a woman of a certain age, I
think this episode of Next Question is for you because
when it comes to menopause, which according to Webster's Dictionary,
is quote the natural cessation of menstruation that usually occurs
(00:26):
between the ages of forty five and fifty five, people
have a lot of questions.
Speaker 2 (00:33):
I got terrible hot Flashesn't I.
Speaker 3 (00:35):
Had experienced joint pain?
Speaker 4 (00:37):
Definitely, moodiness, it's crankiness, it's stress.
Speaker 3 (00:41):
Sleep deprivation, brain fog, irritability.
Speaker 5 (00:45):
Because of where I am with husband and kids, it's
hard to tell how much of that is my body
and hormones versus just normal life.
Speaker 1 (00:54):
Susan Dominus wrote a groundbreaking and really long overdue cover
story for the New York Times magazine called Women Have
Been Misled About Menopause. So we invited her, along with
doctor Rebecca Brightman, a New York City gynecologist who specializes
in menopausal medicine, to get real about what to expect
(01:17):
when you're no longer expecting. By the way, if you
want to get smarter every morning with a breakdown of
the news and fascinating takes on health and wellness and
pop culture. Sign up for our daily newsletter, Wake Upcall
by going to Katiecuric dot com.
Speaker 6 (01:41):
So to be here.
Speaker 7 (01:44):
Have you been on the show before?
Speaker 8 (01:46):
On the podcast?
Speaker 6 (01:46):
I have not done her podcast.
Speaker 1 (01:48):
We've done like we are really going to be getting
down and dirty here today, ladies.
Speaker 6 (01:53):
Sounds good.
Speaker 1 (01:55):
We're going to really be talking about menopause. And I'm
so excited that we're doing this, and I know doctor Brightman,
you're pretty jazzed as well.
Speaker 6 (02:06):
Very excited. It's a big deal.
Speaker 2 (02:07):
It's great to see you and Susan, I am so
excited to see you again and to discuss this because
you have really hit it out of the park.
Speaker 1 (02:14):
She blew the lid off of menopause to.
Speaker 2 (02:16):
Unbelieva unbelievable, and it's really it affirms what I've been
discussing with my patients for decades, and it's really helped
women understand that they are not alone.
Speaker 1 (02:27):
We're going to be talking about menopause, perimenopause. We're going
to be talking about vaginal dryness, We're going to be
talking about hot flashes, We're going to be talking about nights, wets.
We're going to be talking about all sorts of fun things.
So you too, pretty jazzy.
Speaker 7 (02:43):
Yeah, it's pretty much all I do lately. Anyway, it's
been my career.
Speaker 1 (02:48):
Okay, perfect, Susan, Let's start with you, because I feel
like you are a hero to so many women out
there who read your cover story in the New York
Times magazine. What was your reaction to the reaction?
Speaker 9 (03:04):
I have to say I was stunned. I mean, of course,
the reason we did the article was to address this
gap that seemed so apparent, just based on the conversations
I was having with a fairly wide circle of friends.
I mean, most of my women friends now are in
their early fifties, and you know, I'm kind of a
I'm not a shy person. I ask a lot of
(03:25):
questions of my friends a reporter, and it was amazing
to me the range of confusion and how common it was.
So we knew that there was a total need for
them some kind of information. And at the same time,
I would say, within an hour of it going up,
I had one friend text me and said that she
had already had the article texted to her on four
different girlfriend group threads that she was on and it
(03:49):
had just gone up.
Speaker 7 (03:50):
And that was what we started.
Speaker 9 (03:51):
Hearing over and over and over again that every woman
who was in some big group text thread.
Speaker 7 (03:56):
I clearly am not in enough of those, but.
Speaker 9 (03:58):
They were getting them from all side that it was
just circulating and the comments started pouring in. And on
the one hand, as I said, it seems sort of like, yes,
of course, that people would be relieved and surprised to
see all this information in one place in the New
York Times because there had been such a hunger and
confusion about it. On the other hand, you never expect
that kind of reaction.
Speaker 7 (04:18):
You just can't.
Speaker 1 (04:19):
Doctor Brightman, who full disclosure, is my doctor, who has
said I could call her Becky. During this podcast, you
were doing backflips when you read this article. I think
you and I talked about it. You were talking about
it with your fellow obgyns.
Speaker 2 (04:35):
What was your reaction. I was so excited. I met
Susan att list falls Nam's meeting. Look explain what North
American Menopause Society meeting in Atlanta. I knew she was
working on the article and the morning I think it
came out initially online and then It subsequently was in
print a couple of days later. It is the greatest article,
is so affirming to what I do. I feel it
(04:58):
is such an uphill battle trying to discuss some of
the things we're going to talk about now and to
explain to people and reassure them that what their experience
is normal, but it's part of the menopause transition and
women need to be heard. And I think it was
the most validating article. And it also really went to
discussion of the statistics and why menopause hasn't received enough attentions,
(05:19):
and why hormones have received such a bad rap.
Speaker 1 (05:22):
We're going to talk about the bigger picture about women's
health in general in a little while, but first I
want to really do a deep dive into the article. Susan,
how did this piece heard around the world come about?
Was it because you were going through this, your friends
were going through it, and you all were confused?
Speaker 9 (05:38):
I actually, really I am glad you asked that, because
the reason this article came into being is really due
to the vision of my male editor in chief, Jake Silverstein.
Speaker 7 (05:49):
Wow, I'm amazing. I'm impressed the presence I now.
Speaker 9 (05:53):
He came to me and said I think we and
my wonderful editor, Eliana Silverman as well said, I think
we should do an article about METAe, but was a
very big, baggy topic.
Speaker 1 (06:02):
I didn't know where to begin, and your writing is
pretty vivid, Susan, I wondered if I could just quickly
read this paragraph. For the past two or three years,
many of my friends, women mostly in their early fifties,
have found themselves in an unexpected state of suffering. The
symptoms they've experienced were varied and intrusive. Some lost hours
(06:22):
of sleep every night, disruptions that chipped away at their mood,
their energy, the vast resources of goodwill that it takes
to parent and to partner. One friend endured week long
stretches of minstrel bleeding so heavy that she had to
miss work. Another friend was plagued by as many as
ten hot flashes a day. A third was so troubled
by her flights of anger, their intensity new to her
(06:44):
that she sat her twelve year old son down to
explain that she was not feeling right, that there was
this thing called menopause and that she was going through it.
Another felt of pervasive dryness in her skin, her nails,
her throat, even her eyes, as if she were slowly calcifying.
By the way, you're a really great writer, Susane. I
(07:05):
just want to say that it's so evocative. Susan. The
more you looked into this, were you surprised at how
significantly menopause was affecting women in their daily lives.
Speaker 9 (07:20):
Well, you know, you start to hear about it first
from your older friends. So I was already thinking about
it a little bit. But when I got together with
my college friends, that was when I really started hearing
about how drastic it had been. And it was interesting.
Is also the range of reactions that my women friends had.
I would say that some of my friends were looking
for answers and somehow could not find them or did
(07:41):
not know what information to trust. And then there was
a whole other cohort of friends who I think just thought,
this is just my lot in life, you know, to
suffer like this is what happens when you get older.
And I think they thought, well, if there was something
that could be done, surely somebody would have said something
about it.
Speaker 1 (07:57):
And doctor Brightman Becky, you see patients all the time.
Do these symptoms sound about right to you?
Speaker 6 (08:04):
Absolutely? And It's interesting.
Speaker 2 (08:05):
When I practiced obstetrics, I used to say, well, hormones
of pregnancy, which are the hormones that change during menopause,
affect every organ system in the body, and the same
is true with menopause, so it's not just night sweats
and hot flashes. And honestly, it is really the disrupted
sleep and the night sweats initially and once forties, that
sort of you know, precipitate mood changes and difficulty focusing,
(08:29):
and you know, cognitive changes and all the things women
talk about.
Speaker 1 (08:34):
I'm glad you mentioned cognitive changes. Susan. Tell us about
that conversation you had, which you include in your piece.
When you're at a cocktail party and you see an
older writer. This actually broke my heart. Honestly.
Speaker 9 (08:48):
There was a writer whose work I had always admired,
and she had precipitously retired, and I'd always wondered what happened.
And I saw her at a party and I just said,
you know, I just loved your writing. I always wondered
why did you stop? And without even hesitating, she just said, menopause.
I couldn't find the words, and she is sure that
(09:08):
that was the cause. It wasn't you know, as if
she was on the path of dementia. It was just
completely timed to this phase in her life and it was,
you know, really agony for her, I think, and I
think that always stuck in my mind as well as
a writer. It sent a chill down my spine at
the time.
Speaker 7 (09:26):
I remember.
Speaker 1 (09:27):
First, I just want to ask you about brain fog, Becky.
I mean, do doctors know what causes this and how
it's associated with menopause?
Speaker 2 (09:38):
So as hormone levels start to fluctuate, their super high
levels of estrogen and super low levels, and it's the highs,
it's the lows. It's really the disruptive sleep and the
fact that women can't focus and feel foggy. They're looking
for words and for many women and there's there have
been studies that show that many women will return to
baseline with respect to word finding incognitive function. For some
(10:01):
women there will be some age related decline. But it's very,
very scary when it happens to you, and I think
that you know Susan's article is so eye opening for
women because as doctors, those of us practice menopausal medicine,
we know this, but for many women will be eye
opening because it can be one of the earlier signs.
Someone can be having regular menstrual periods but start to
(10:22):
no discussion. They're not sleeping, they're drenched at night, you know,
they're exhausted during the day, they can't make it through work.
And I think now that we have so many women
in the work force, so many women, we have very
you know, set the bar for ourselves. It's very high bar,
and we want to keep achieving, and one wants to
be their best self, and it's very hard when you've
(10:42):
been so impacted by the inability to sleep, brain fog,
and people say, what, it's not me, it's not me.
Speaker 6 (10:48):
I've never been like this before.
Speaker 1 (10:49):
Why parenthetically, I started doing the patch, a hormone patch
when I think I went through menopause at around fifty
four because I was anchoring the CBS evening News and
I didn't want to have like a brain fart in
the middle of the evening news, or forget the question
I was supposed to be asking a correspondent. We're going
(11:10):
to get into the Women's Health Initiative and the hormone
study in a moment. But I think you raised this,
Susan and your piece, and you do wonder if men
were going through this experience, if we wouldn't have a
lot more solutions. In fact, you write, imagine that some
significant portion of the male population started regularly waking in
(11:32):
the middle of the night drenched in sweat, a problem
that endured for several years. Imagine that those men stumbled
to work, exhausted, the morale low, frequently tearing off their
jackets or hoodies during meetings and excusing themselves to gulp
for air by a window. Imagine that many of them
suddenly found sex to be painful, that they were newly
prone to urinary tract infections, with their penises becoming try
(11:55):
and irritable, even showing signs of what their doctors call atrophy.
I've said lately when I've been talking about women's health issues,
if we had focused as much attention on these issues
as we had on the development of viagra, imagine where
we'd be.
Speaker 9 (12:12):
You have to think, and it does have to You
can't help but think that it is about a discomfort
with not just female sexuality, but aging women's sexuality.
Speaker 7 (12:21):
It's just not seen as a priority.
Speaker 1 (12:24):
I can say from personal experience that Becky Brightman is
an excellent doctor who talks to her patients about pretty
much everything, including menopause and a whole host of issues.
We don't have to get into detail. But Susan, you
found in your reporting this just isn't the case.
Speaker 9 (12:42):
I think it is pretty unusual, you know, And you
can talk about the different kinds of doctors who see women.
You know, some women stop seeing gynecologists and they only
go to family medicine or internists, and those doctors obviously,
you know, need to be well versed in so many topics,
but they really are under informed. I do believe about
menopausal symptoms and about hormone therapy in particular. I do
(13:04):
think that many obgyns. You know, if a woman comes
in and she is absolutely gutted by symptoms and is
you know, it's completely disrupting her life. I think increasingly there,
you know that people are moving away from the older fears,
and they do recommend menopausal hormone therapy. But if it's
not that extreme, I think it's easier just to move
(13:26):
on because it is a kind of complicated conversation. People
do want to understand what the risks are. They are
kind of individualized. It's hard to explain the history. It's
hard to overcome people's hurdles. It's just time consuming it,
you know, in the defense of many obgyns, now they
have fifteen minutes, they have other things they have to
get through, and unless the person is completely wiped out
and useless and you know, in a state of extreme suffering,
(13:49):
it might just be easier to move on. I mean,
that's sort of the impression I get.
Speaker 2 (13:53):
It's a very long discussion, and it's not a one
size fits all when it comes to deciding whether or
not menopausal hormone therapy is free. There are many different
types of menopausal hormone therapy, and there's certain tests that
I need to make sure someone's had. We have to
go through family history. You can't do that in fifteen minutes.
Speaker 6 (14:09):
So it's tough.
Speaker 2 (14:10):
And I also think doctors don't necessarily, you know, want
to take the time. They don't find it really interesting.
And again it's opening up a can of worms.
Speaker 1 (14:19):
When one of your friends, Susan, expressed concerns about a
lower libido and bachinal dryness, she could tell her doctor
was uncomfortable talking about both. You write about this and
you quote her as saying, I thought Hey, aren't you
a vagina doctor?
Speaker 9 (14:33):
I use that thing for sex, yes, But I think
sex also is a complicated subject. It has to do
with like emotional relationships and is anybody on an antidepressant
and you know, how's your marriage? I mean, I think
people feel, doctors must feel it opens up a huge
can of worms that like, you know, if you open it,
it'll just it'll never stop. So I think that it's
(14:55):
not something that in general kind of called is sir
excited to talk about?
Speaker 1 (14:58):
That quote made me laugh out. It is a great quote.
When we come back, we're going to talk about the
Women's Health Initiative, which really screwed things up for everyone.
We'll do that right after this story.
Speaker 5 (15:11):
But there's this this distinct memory of being pregnant at
my first baby shower and all the young gals are
upfront and they're giving you like fun gifts and things,
and they're so cute and everything's awesome.
Speaker 4 (15:23):
But there's this ring of gray haired ladies in the
back and we're not really saying anything.
Speaker 7 (15:28):
Other than we're so happy for you.
Speaker 5 (15:30):
But there's like this black box that happens of like, Okay,
you're gonna have.
Speaker 7 (15:34):
To figure this out.
Speaker 5 (15:34):
For yourself if it kind of feels like that, it
feels like a frontier.
Speaker 3 (15:39):
My friends, my loving friends. I have shared, they have shared.
But what a wonderful support system I have in that area.
Everything is discussed sleep deprivation, to depression, to vaginal dryness,
and with being so transparent, you just don't feel alone
(16:00):
in all of this. You know you're not the only
one going through this. To say the very.
Speaker 1 (16:04):
Least, We're back with doctor Becky Brightman and also Susan
Dominus of The New York Times talking about menopause and
all sorts of fun things like vaginal dryness. How often
can I say vaginal dryness in one podcast? Not often enough, apparently.
(16:26):
Let's talk now about the Women's Health Initiative. So, Susan,
there was a nineteen ninety one National Institutes of Health
hormone trial. It was the first clinical trial involving all women.
Thanks to Bernadine Healy may she rest in peace. I
always feel like she doesn't get enough credit, the NIH
(16:46):
director who started the WHI. So let's start by talking
about what that trial was designed to do.
Speaker 9 (16:54):
So it was the largest all women trial, as you say,
and it was trying to answer a couple of diferent questions,
but I would say the question that drove its initiation
in the first place was are hormones in fact good
for women's health, specifically cardiovascular health. And there was a
concern that there might be some elevated risk of breast cancer.
(17:15):
But there had been a lot of observational studies that
suggested that when women went on hormones they saw lower
rates of cardiovascular.
Speaker 1 (17:23):
Because we should mention they do have lower rates until
they go through menopause, and then their rate of cardiovascular
disease equals men correct. So they were thinking estrogen had
some kind of protective quality for the heart.
Speaker 9 (17:36):
That's exactly right, And in fact, one of my favorite
quotes in the piece came from a doctor Hadeen Joffrey,
who said, you don't understand. I had a slide that
said we should have estrogen in the water. It should
be like fluoride. That's how good for women. People thought
that estrogen was.
Speaker 1 (17:51):
But there was some concerns about estrogen. I guess doctor
Brightman where maybe this breast cancer question was kind of
looming large.
Speaker 2 (18:00):
So the WHI was designed as a prevention trial to
see whether or not hormones actually prevented disease, what happened
with breast cancer? Did it prevent carnary artery disease, cardiovascular disease,
did it help bones? And then it was abruptly halted,
as we know, because there was a signal that perhaps
it did increase the risk of breast cancer, and that
(18:22):
really has to be teased apart before we talk about
it getting halted.
Speaker 1 (18:26):
I read that, I think in your article season that
estrogen had been around for decades, right, and women were
getting a lot of positive results from it, Becky.
Speaker 2 (18:37):
So what happened is it was finally realized that you know,
women were using just estrogen alone, and then it became
apparent I think in the seventies that women really that
estrogen would stimulate the lining of the uterus, and when
you have too much stimulation of the uterine lining, women
are an increased risk of getting endometrial cancer cancer of
the uterine lining. So by the addition of progestogen progesterone
(18:58):
being one of them, medical reculate and you can mitigate
the increased risks. So in women with the uterus who
were going to use metopausal homoonn therapy they needed if
they were taking estrogen, they had to use some sort
of progestine. For women without uters, they could just be
on estrogen alone.
Speaker 1 (19:15):
So this was the first big study to determine, like scientifically,
what are the pros and cons of hormone replacement there
exactly all right. So suddenly, as Becky intimated, the trial
was stopped.
Speaker 7 (19:32):
Why it was stopped.
Speaker 9 (19:33):
After five years because they found in the group that
was taking both estrogen and progestine, which is to say,
women who have uteruses, that they were seeing an increased
risk of breast cancer.
Speaker 2 (19:44):
In that group, there was an uptick in breast cancer,
but they continued it the study and they did not
see it in the group of women using estrogen alone.
And it's so interesting because estrogen is what gets the
bad rep but in the group that again estrogen alone
no increase risk. So it got changed mid stream.
Speaker 9 (20:03):
It was supposed to last for eight and a half years,
and the idea that they halted it unexpectedly after five
years was very big news. They also held a very
big press conference. And you know, when people understand that
a study has been stopped unexpectedly, I think they think
that translates into and therefore, you too, must stop using
this medication.
Speaker 1 (20:23):
I remember covering this back in that day, by the way,
and you write what happened next was an exercise and
poor communication that would have profound repercussions for decades to come.
What did happen.
Speaker 9 (20:36):
Basically representatives of the WHI very well intended but not
particularly media trained when on television shows and started, you know,
engaging in conversations in which a lot of statistics were
rattled off, and some of those statistics sounded very, very scary.
Speaker 3 (20:51):
Right.
Speaker 1 (20:52):
In fact, the coverage was pretty breathless, and I would
say in retrospect, unintentionally alarmist. You talk about an interview
than Ann Curry did on the Today Show.
Speaker 10 (21:02):
An important medical story making news this morning. The government
has abruptly ended the country's largest study of a type
of hormone replacement therapy that found long term use of
estrogen and progestin can increase a woman's risk of breast cancer, strokes,
and heart attacks. Sylvia Smuller is a principal investigator in
this study. Sylvia good Night.
Speaker 1 (21:21):
I was working on the Today Show back then, and
I remember all of this pretty well, and it was
with one of the chief investigators with the Women's Health initiative, What.
Speaker 10 (21:30):
The effects were, what made it ethically impossible to continue
the study?
Speaker 11 (21:35):
Well, in the interest of safety, we found that there
was an excess risk of breast cancer which had passed
the prespecified monitoring boundary lines. And there was also no
benefit for heart disease, and in fact some excess risk
of heart disease.
Speaker 10 (21:52):
And it'd be very specific here. You actually found heart disease.
The risk increased by twenty nine percent, the risk of
strokes increased by forty one one percent, it double the
risk of blood clots, invasive breast cancer risk increased by
twenty six percent, and cardiovascular disease increased by twenty two percent.
So what are we telling women the six million women
in America today who are taking HRT.
Speaker 1 (22:16):
So how did these numbers get so misunderstood or misreported?
Speaker 9 (22:21):
Well, they were definitely not misreported.
Speaker 7 (22:22):
They were accurate.
Speaker 9 (22:23):
Those numbers were accurate, per the WHI I just think again,
it takes a little bit more time to say, Okay,
so what does that actually translate into for the average
woman And what did it translate into? Well, though, the
math that we did was that if a woman's risk
of having breast cancer between the ages of fifty and
sixty is around two point three three percent. Let's say
if you increase that risk by twenty six percent, that
(22:45):
means now you've elevated it to a two point nine
four percent. So you know that in the grand scheme
of things, everybody can have their own comfort level with
a two point ninety four percent risk and how much
you've increased it. But that's not I don't think how
women heard it at the time.
Speaker 1 (23:00):
And in fact, you say smoking, by contrast, increases cancer
risk by two thousand and six hundred percent.
Speaker 7 (23:06):
That's a risk.
Speaker 1 (23:07):
So we're talking about a very very small uptick. If
you're on HRT. What was the impact of all that coverage, Becky,
You've been living in it for the last thirty years.
Speaker 2 (23:19):
Living it and continue to live it. It was unbelievable.
For the second I walked into the office, the phones
were ringing like crazy.
Speaker 10 (23:26):
You know.
Speaker 2 (23:26):
I heard of stories where women were sent letters by
their kind of colleges of the time being told to
stop hormones. I will tell you that my patients, who
if I ever mentioned it they were symptomatic, they were like,
absolutely no, don't I know that they could get cancer?
It's amazing and I still get to face women who
say this to me all the time, but it was
quite remarkable.
Speaker 6 (23:45):
It really was something else.
Speaker 1 (23:47):
There have been other long term ramifications medical students who
graduated around this time, and you point this out as well, Susan,
we're thinking HRT bad and carried on throughout the decades
they've been practicing medicine.
Speaker 7 (24:04):
Right, that is exactly right.
Speaker 9 (24:06):
I mean, I think the statistically quote in there is
that something like half of practicing obgyns graduated from medical
school or finish their residencies after the WHI. So that's
a huge percent of the population who basically never really
learned about hormone therapy in medical school. And also I
gather in clinics it doesn't come up very often in
(24:27):
part because of the population that's being treated, so there's
not a lot of opportunity to learn it on the
ground either.
Speaker 1 (24:33):
The study was flawed in a whole host of ways,
it seems. Can you all talk about why this study
really wasn't accurate.
Speaker 2 (24:43):
The most important thing is for women to realize that,
you know, I think women take this information they say,
how does it affect me? Well, the truth of the
matter is the average age of the women in the
study was between sixty two and sixty three. You know,
many of these women did have some comorbidities. Many of
them on average were twelve years beyond their final period,
and the majority of these women didn't even have menopausal symptoms.
(25:05):
So it was a lousy population to study. You know
what we really need to go back and do is
look at the fifty to six year old how did
they do? And you know what, they did pretty well.
And then once things are teased apart and we look
at it a decade by decade, it's very very different.
But essentially one just extrapolated all the findings to themselves
(25:29):
and thought, oh no, I'm going to get breast cancer,
I'm going to get heart disease, and my bones may
be good. But that's about it.
Speaker 1 (25:35):
There were other flaws though, to the formulations of the hormones.
We're kind of off. Now we have better hormones that
more mimic a woman's natural biology.
Speaker 2 (25:45):
It's not as that the hormones were flawed and those
poor hormones counticated estrogen and medroxy progesterone acetate, which was
a progestogen, received such a bad rap, a really really
bad rap and we still use them. However, there was
a really you know, the number of prescriptions that were
being written for the combination dropped dramatically, and unfortunately it
(26:06):
gave rise to some very unsafe options. But it opened
up the world of what we call bioidenticals, many of
which are great because there are several FDA approved wonderful
bioidentical options. You can get them through any commercial pharmacy.
But I think people were so worried about safety that
they started going to physicians who would prescribe lotions and potions,
(26:30):
as I say, compounded forms of hormones that made people
believe women believe that these were safer options. Yet they
weren't studied. So essentially they were trading something that they
thought was horrible for them because of what they looked
at the data, they looked at the WHI results going
to what was what they perceived to be safer options.
(26:50):
And there were safer bioidentical options, but you needed to
discuss it with your physician.
Speaker 1 (26:55):
Right, But also, what about synthetic hormones. Haven't they been
vastly improved since the study? Yes, And one has to
realize all hormones are synthesized. You know, many of them
are derived from plant products, but they are all synthesized.
They are made in a lab. We don't pick them
from a tree. Interesting. We're going to take a break,
but when we come back, we're going to answer some
(27:15):
listeners questions because we got the doctor here, we've got
the expert there. Let's take advantage of you. We'll be
right back.
Speaker 4 (27:25):
My mom was pretty modest and old fashioned, and I
feel like that really has changed the way I parent
my kids, all of them boys and girls. I feel
like they need more bracing truth about, like this is
what goes on and it's not something to be scared of,
it's something to respect. But I feel like the way
(27:45):
I was raised, it just wasn't talked about and it's
sort of met with a shrug.
Speaker 8 (27:50):
Definitely, society could certainly be more tolerant, more mindful of
all of the issues that women have to face from.
Speaker 3 (28:08):
The very beginning of our lives to the very end.
Of course, society could be a heck of a lot
more empathetic and supportive, and hopefully we'll see that at
some point.
Speaker 1 (28:23):
Hopefully we're back with doctor Becky Brightman and Susan dominis
talking about menopause and really perimenopause and maybe a little postmenopause,
which I am officially in ladies and gentlemen. I think
one of the bottom lines here is that HRT has
(28:44):
small risks but a bigger reward. Is that a safe
thing for me to say.
Speaker 2 (28:49):
I feel so I've always felt this way, And what's
really interesting. In the United States Prevented Service Task Force
would say, no, no, no, we are not supposed to
talk about hormones and the benefits they may have in
terms of disease reduction and everything else.
Speaker 6 (29:04):
But I think we've come a long way.
Speaker 8 (29:06):
You know.
Speaker 2 (29:06):
It used to be hormones were strictly for night sweats
and hot flashes, and they had to be really, really,
really bad. But we know that they improve the quality
of one's life greatly if in need, and they also
may serve a role with disease prevention.
Speaker 1 (29:19):
All right, Well, we got a lot of questions about
HRT hormone replacement therapy. One question asked, can HRT be
used if you have a family history of ovarian cancer?
Speaker 2 (29:29):
So that's a great question. There is a tiny bit
of data that there may be a minuscule increase in
ovarian cancer in women who use menopausal hormone therapy MHT
or hormone replacement therapy. Again, it really needs to be individualized.
I think much more goes into counseling a woman with
a family history of ovarian cancer, and there's certain things
(29:51):
one can do to reduce risks, and certain genetic testings
that can be offered. But it would not mean that
someone with that family history can't be on hormones, but
they would need to discuss it. They'll all discussed it
to discuss it. But if there were an increase, it
would be minuscule.
Speaker 1 (30:07):
What if you're at a high risk for breast cancer
is another question? Is HRT absolutely out of the question?
Speaker 6 (30:13):
No?
Speaker 2 (30:14):
No, And it depends again on family history, again on
genetic predispositions. One has to again look at the symptoms
and with appropriate counseling. It's a very individualized, personalized decision.
Speaker 1 (30:26):
Should women take hormones if they're only experiencing slight symptoms.
Speaker 2 (30:31):
Yes, I think so they should be offered hormones and
it should be part of the discussion. And I find
I'm backpedaling with my patients, like those who have said
years ago, my symptoms aren't terrible.
Speaker 6 (30:41):
I'm cruising through this.
Speaker 2 (30:42):
I'm now revisiting it because many of their eyes have
been opened by Susan's wonderful article. So I feel that
if I don't discuss it with them, I need to
discuss it again. So again, it depends on the women.
And even if I'm somebody with mild symptoms, of course
I talk about it because I don't want them to
leave my office.
Speaker 1 (30:59):
And think, hh, she didn't talk to me about this.
And also in your article, Susan, you talk about like
what is significant exactly? How do you measure if something
is bothersome or not right?
Speaker 9 (31:12):
Especially one of the doctors I interviewed, Nanette Centaurro, who
was pointing out to me that when her patients say
to her, I don't know, I feel I'm not sleeping
well and I'm really moody, and I'm getting these incredible migraines.
I don't know is it menopause or just stress? You know,
she would say to them, well, you could try hormones.
You don't have to marry them, you can date them,
(31:32):
and if you don't see an improvement in your symptoms
in three months, we'll take you off. If you do
see an improvement. I think we can bet that it
was estrogen deprivation, and you may choose to.
Speaker 7 (31:43):
Stay on them.
Speaker 9 (31:44):
So she was sort of saying, you know, every patient
is going to weigh their own personal tolerance for risk
with the benefits to their lifestyle of going on the hormones.
But you don't actually know the benefits necessarily until you've
tried them. So first, you know, look, if you're sailing
through and you're completely symptom free, then maybe it's not
something even to think about. But if you're wondering about it,
there's very little harm in trying.
Speaker 1 (32:06):
And speaking of that, I had to ask a personal
question because I was diagnosed with breast cancer, as doctor
Brightman knows in June, and I have been on HRT
the patch probably gosh, ten or eleven years maybe now,
and I loved it. Didn't look great with bikinis, but
that's okay, I'm kidding. I don't wear bikinis anymore. But
(32:26):
you know, I couldn't help but wonder, as Carrie Bradshaw
would say, did the patch result in my breast cancer?
Speaker 2 (32:34):
I would say, no, it didn't. And this one of
my friends was told by her breast surgeon. When my
friend asked, why did I get breast cancer? She got
breast cancer because she's a woman. And if we think
about it, one in eight women will get breast cancer
during the course of their lifetime. And this, you know,
we're not talking about one in eight women in their thirties, forties,
or fifties. But by the time we live our lives,
(32:56):
life expectancy for women now is about eighty one one
and eight women we'll get breast cancer. And my feeling
is that is why. And I think for many women,
if appropriately counseled, the benefits outweigh any potential risk.
Speaker 1 (33:11):
But now that I have gotten breast cancer, I can't
go back on the patch, can I not?
Speaker 6 (33:17):
Really?
Speaker 2 (33:18):
No, There are certain situations with appropriate counseling where women
have resumed hormones, but they are few and far between,
and I venture to say the majority of physicians would
say it's a hard no.
Speaker 1 (33:32):
Let's move on to some other questions we got from
our daily newsletter, wake up Call, Shameless Plug sign up
at Katiecurrek dot com and social media. We got a
lot of questions Susan about hot flashes, and I thought
we would just take a moment because I thought it
was fascinating. You talked about this internal regulator we all
(33:54):
have that causes hot flashes. Can you explain doctor that
you're not doctor.
Speaker 9 (34:00):
I can explain what doctor has explained to me, which
is that the hypothalmis regulates body temperature and very rich in.
Speaker 1 (34:08):
Ester I'm not getting a hot flash.
Speaker 7 (34:09):
I'm taking my sweater. It just happens to be on
in heir appropriately enough.
Speaker 9 (34:14):
It's very sense. So the hypothalmus is rich in estrogen receptors.
It's also somehow connected to the reproductive system. So if
it regulates body temperature and suddenly it's not getting the
estrogen that it used to, it starts to get a
little bit wonky, and it over interprets little cues internally
about rises in core body temperature, really infinitesimal rises, and
(34:34):
the body responds as if there was some kind of
catastrophic oven, you know, from within, and it dilates all
the blood vessels, and it sends sweat rushing to the
surface of the skin, and the surface of the skin
actually the temperature there really does rise. But what's so
interesting to me about hot flashes is that women feel
as if they do have an oven within but it's
(34:55):
kind of almost like a phantom limb sensation. Like obviously
your inner core is not suddenly steaming, you know, there's
very little change there. But that's where women really do
experience that heat. So it's a purely cognitive brain chemistry.
It's a brain, it's a brain phenomenon, it's a neural phenomenon.
Speaker 1 (35:12):
Is it the same with night sweats?
Speaker 7 (35:14):
I got?
Speaker 1 (35:14):
I mean, people are like, we really don't care what
you had, Katie, But I relate a lot to this conversation.
I don't think I had hot flashes, but I did
have night sweats where I'd wake up not bad, but
you know, my pajamas would be kind of soaked.
Speaker 2 (35:28):
It's the same mechanism of action, the lack of estrogen
and the firing away of neurons in the hypothalamus.
Speaker 1 (35:36):
That's why it's so important to be able to talk
to your doctor, to really be able to share your
individual symptoms.
Speaker 2 (35:42):
The other thing is estrogen has anti inflammatory properties, and
we really see an uptick in rheumatologic diseases, arthritis and
all sorts of skin related phenomenon after menopause. And I
don't think anyone ever thought about estrogen having an anti
anti inflammatory relationship. Estrogen changes everything. It can change the
(36:04):
bacteria that's in our gut. There's some thought that gut
bacteria plays a role with inflammation. Also, it's all interrelated.
I mean, it's a super hormone. Estrogen is also like
a natural antidepressant. And we haven't talked about this, but
a lot of women who go through menopause become depressed
(36:25):
because of the decrease in estrogen, right, Yes, absolutely they do.
They do, and they don't realize it. They don't realize that,
their doctors don't realize it. It's one of the most
upsetting things to me. Nuance at anxiety, nuancet palpitations. Women
will go to their physicians and talk about it, and no,
people do not draw a correlation between those symptoms and menopause.
(36:47):
And I'm not saying that hormones are first line for
treating anxiety and depression, but if it's part of the
whole picture, absolutely it's worth it try.
Speaker 1 (36:55):
I wanted to bring up something that's so important is
that these symptoms are often worse in women of color.
Why do these symptoms sometimes affect women of color even
more severely?
Speaker 2 (37:07):
So, we really actually don't know, but there really seem
to be some racial disparities amongst you know, who tends
to have more what we call vasomotor symptoms or VMS
night sweats, hot flashes. Women who are Black definitely have
been noted to have worse symptoms. Women who are Asian
fewer symptoms. And what's very concerning is we want to
(37:29):
make sure people are getting the appropriate care because now
it seems like the worse the vaso motor symptoms, the
greater the risk of cardiovascular disease. So women need to
be offered some education about it, information and the option
to treat their symptoms, particularly because they may be at
risk of what lies.
Speaker 6 (37:47):
Down the road.
Speaker 1 (37:48):
We want to get in a couple more questions from
women who wrote in who are dry as the Sahara
just say what you were talking about calcifying This is
pretty much happening to a lot of women. One says,
I've experienced extreme dryness and I've had to take a
three year break from sex. What can I take such.
Speaker 6 (38:09):
Setting that's so upsetting?
Speaker 2 (38:10):
Like I have to tell you, I really try to
be proactive with my patients and once they stop menstruating,
talk about are you having this symptom, that symptom, and
they're like, no, no, no, I said, just be aware.
Now with menopause, there can be an increase of vaginal dryness, itching, burning,
painful sex. You know, mostly it's reversible. I think that
the nice thing is we have many options in different
(38:31):
ways in which we can treat our patients. So you know,
whoever feels dry as a sahara, we can make that better.
Speaker 6 (38:36):
That's the good news.
Speaker 1 (38:38):
I don't want to give short shrift to perimenopause because
we really haven't mentioned that at all. Becky, is there
something that you can talk about when it comes to
perimenopause that will help women who may be in that
phase of life.
Speaker 2 (38:53):
When we talk about menopausal symptoms, these are largely the
symptoms women start experiencing during perimenopause. Menopause is a transition,
and there are different stages of going through this transition,
but what we describe as perimenopause can last. It can
last like up to seven years, and many women can
have regular menstrual periods. But the first thing they may
notice might be getting warm at night. Then they may
(39:16):
notice that they're just not sleeping well. And you know,
these symptoms can then snowball into heavier periods or regular periods, moodiness,
just a whole constellation of symptoms, palpitations, which we haven't
talked about. Many women are seeking out, you know, cardiologists,
and they need to be evaluated for palpitations, but that's
(39:36):
also a symptom, so they're frequently symptomatic of other things
that are frequently brushed off. Some women during perimenopause have
vaginal dryness, so again it's very varied. People's experiences are
very varied at the time.
Speaker 1 (39:49):
When should women start talking to their doctors about this?
Speaker 2 (39:52):
I start now that I have a large menopause practice,
I would say, and as women get into their forties,
I do you know, early early forties, certainly mid forties.
And I think the hardest thing for my patients is
when they're on the earlier side. No one wants to
be the first one to go through it, whereas I've
other patients who are fifty six. But you know, for
the forty four year old, the forty five year old
(40:13):
where things are starting to change, and for some women
they're younger, it's hard to discuss and acknowledge the fact
that some of the things they are experienced may be
linked to the menopausal transition.
Speaker 9 (40:23):
I was just going to add that I think a
lot of women under the impression that you start menopausal
hormone therapy when you are officially menopausal, which is to say,
a year after your last period, and they think that
there's nothing they can do during perimenopausal I'm still getting
my period, so I'm not going to get treated. But
in fact, for women who are experiencing heavy bleeding or
(40:43):
who are going through you know that their periods are regular,
they know that they're in perimenopause, they're having brain fought.
There are treatments that they can consider as well, which
I will now defer to doctor Brightman to discuss.
Speaker 2 (40:54):
So it's interesting because we don't we have many things
we can do after menopause. And the issue is you
can't necesscessarily put younger women on these these therapies because
they will probably menstruate around them and have all sorts
of bleeding that then needs to be evaluated. But if
one is a candidate for birth control pills, low dose
birth control pills are a beautiful thing. They can use
them continuously without even.
Speaker 6 (41:16):
Urgery.
Speaker 2 (41:17):
It creates hormonal neutrality for many women. It just helps
them sleep, They just feel better, and it's a great
way to transition them through menopause. And I'll keep them on,
you know, depending on any underlying medical factors. I'll keep
them on birth control pills until you know, the early
fifties or sometimes even mid fifties.
Speaker 6 (41:33):
It really depends.
Speaker 2 (41:34):
But many women who have a hormonal IUD, we can
layer on a little estrogen through a patch, which is
works really really nicely. The other thing is there are
some non hormonal options. Again, not everybody's a candidate for hormones,
and everyone can be on hormones. So unfortunately, we only
have one FDA proved option, peroxetine in our country right now.
(41:56):
The FDJA is on the brink of approving another medication
called a phesilinit tant. It also it targets the hypothalamic
thermo what we call the thermoregulatory center of the brain,
so that offers tremendous promise. It's non hormonal. It will
be great for women who are not candidates for hormones
or who choose not to go on hormones. The good
(42:16):
news is there's several other medications we can use off label.
Some antidepressants, anti anxiety medications. There are non hormonal nutritional
supplements that many women opt to use, but the studies
that are out there are very small.
Speaker 6 (42:30):
Many of them are.
Speaker 2 (42:31):
Self funded by the companies that manufacture them, so if
a woman is going to take a supplement, they should
discuss it with their healthcare provider.
Speaker 1 (42:38):
Speaking of that, there is a whole new group of
companies that are addressing these symptoms with creams and vibrators
and lubricants and all kinds of things, which I think
is a welcome addition to the marketplace. But I know, Becky,
you're of the school of buyer, beware, buy.
Speaker 2 (43:00):
Or be aware, and I think, much the way it
is for adolescent women, women should not get the wrong
impression that they're being left out. Everyone's swinging from the
chandeliers and you know, the women are missing out and
they need to buy these products. Just because somebody has
come up with a concept for a product doesn't mean
one needs necessarily buy it. That's on one hand, but
the other hand, it's really nice to be able to
embrace the fact that, you know what, I'm a sexual being.
(43:22):
I want to remain as sexual being, and there are
products that are out there that are really geared towards me,
you know, not towards a younger woman. So I actually
think it's fantastic.
Speaker 1 (43:33):
But I know you're worried about all the stuff on
social media, on TikTok, on Instagram, with these companies kind
of overstating what some of these things can do and
taking advantage of women suffering.
Speaker 6 (43:45):
Oh, it breaks my heart. It breaks my heart.
Speaker 2 (43:47):
I have a group of friends, fellow docs from North
American Menopause Society, and they send around bad tiktoks. There's
misinformation out there. It's so upsetting. I think I could.
I would love to dispel some of the myths. It
would be a full time job. So it breaks my
heart because we don't have great access to healthcare providers
(44:08):
who are well versed in menopausal medicine. So women are
turned to social media. And there's some great things on
social media, but there's some things that are potentially very detrimental.
Speaker 1 (44:18):
I think some of the things I've learned in this
conversation and through reading your great article, Susan, and through
my conversations with Becky Brightman, is that a lot of
doctors are not particularly knowledgeable about this. They don't have
time or they're uncomfortable. This is something that has been
kind of ignored by large swaths of the medical establishment,
(44:42):
which makes me wonder is this indicative of how women's
health issues have been treated historically?
Speaker 2 (44:51):
Absolutely, you know, certainly in the past with respect to medicine,
women were small men. Certainly when I was in medical school,
no one differentiated cardiac disease in women as being any
different than cardiac disease in men. And we've learned so much.
But now, you know, the NAAH has designated money that
will go into researching women women's healthcare. But this is
(45:14):
all recent and I think we do need more studies.
And again, we have observational studies. There's certain things that
I feel very comfortable doing for my patients, but there
is so much much more research that needs to be done,
and education of physicians needs to be accelerated on a
grand scale.
Speaker 1 (45:33):
What did you learn, Susan about how did you feel
about women's health and the attention paid to it after
reporting out this article?
Speaker 9 (45:42):
You know, I think I would just quote Rebecca Thurston,
who's metopausal researcher out of the University of Pittsburgh, whom
I interviewed for the piece. You know, she's thought about
this for many more years than I have, and her
basic conclusion about the lack of treatment for women suffering
from menopausal symptoms all these years, it's just a reflection
of what a high tolerance you have as a population
(46:05):
for women suffering and it was a really grim assessment,
but it's very hard to argue with it.
Speaker 1 (46:11):
Well, hopefully things will change thanks to articles like yours
and conversations like this. Doctor Becky Brightman and Susant Dominus,
thank you so much. This was great.
Speaker 6 (46:21):
Thank you so much having me on.
Speaker 7 (46:23):
It's been wonderful.
Speaker 1 (46:26):
Thanks for listening everyone. If you have a question for
me or want to share your thoughts about how you
navigate this crazy world reach out. You can leave a
short message at six h nine five point two five
to five five, or you can send me a DM
on Instagram. I would love to hear from you. Next
Question is a production of iHeartMedia and Katie Kuric Media.
(46:49):
The executive producers are Me, Katie Kuric, and Courtney Ltz.
Our supervising producer is Marcy Thompson. Our producers are Adriana
Fazzio and Catherine Law Our audio engineer is Matt Russell,
who also composed our theme music. For more information about
today's episode, or to sign up for my newsletter, wake
Up Call, go to the description in the podcast app,
(47:11):
or visit us at Katiecuric dot com. You can also
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For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts,
or wherever you listen to your favorite shows,
Hi everyone, I'm Katie Couric, and this is Next Question.
If you're a woman of a certain age, or if
you even know a woman of a certain age, I
think this episode of Next Question is for you because
when it comes to menopause, which according to Webster's Dictionary,
is quote the natural cessation of menstruation that usually occurs
(00:26):
between the ages of forty five and fifty five, people
have a lot of questions.
Speaker 2 (00:33):
I got terrible hot Flashesn't I.
Speaker 3 (00:35):
Had experienced joint pain?
Speaker 4 (00:37):
Definitely, moodiness, it's crankiness, it's stress.
Speaker 3 (00:41):
Sleep deprivation, brain fog, irritability.
Speaker 5 (00:45):
Because of where I am with husband and kids, it's
hard to tell how much of that is my body
and hormones versus just normal life.
Speaker 1 (00:54):
Susan Dominus wrote a groundbreaking and really long overdue cover
story for the New York Times magazine called Women Have
Been Misled About Menopause. So we invited her, along with
doctor Rebecca Brightman, a New York City gynecologist who specializes
in menopausal medicine, to get real about what to expect
(01:17):
when you're no longer expecting. By the way, if you
want to get smarter every morning with a breakdown of
the news and fascinating takes on health and wellness and
pop culture. Sign up for our daily newsletter, Wake Upcall
by going to Katiecuric dot com.
Speaker 6 (01:41):
So to be here.
Speaker 7 (01:44):
Have you been on the show before?
Speaker 8 (01:46):
On the podcast?
Speaker 6 (01:46):
I have not done her podcast.
Speaker 1 (01:48):
We've done like we are really going to be getting
down and dirty here today, ladies.
Speaker 6 (01:53):
Sounds good.
Speaker 1 (01:55):
We're going to really be talking about menopause. And I'm
so excited that we're doing this, and I know doctor Brightman,
you're pretty jazzed as well.
Speaker 6 (02:06):
Very excited. It's a big deal.
Speaker 2 (02:07):
It's great to see you and Susan, I am so
excited to see you again and to discuss this because
you have really hit it out of the park.
Speaker 1 (02:14):
She blew the lid off of menopause to.
Speaker 2 (02:16):
Unbelieva unbelievable, and it's really it affirms what I've been
discussing with my patients for decades, and it's really helped
women understand that they are not alone.
Speaker 1 (02:27):
We're going to be talking about menopause, perimenopause. We're going
to be talking about vaginal dryness, We're going to be
talking about hot flashes, We're going to be talking about nights, wets.
We're going to be talking about all sorts of fun things.
So you too, pretty jazzy.
Speaker 7 (02:43):
Yeah, it's pretty much all I do lately. Anyway, it's
been my career.
Speaker 1 (02:48):
Okay, perfect, Susan, Let's start with you, because I feel
like you are a hero to so many women out
there who read your cover story in the New York
Times magazine. What was your reaction to the reaction?
Speaker 9 (03:04):
I have to say I was stunned. I mean, of course,
the reason we did the article was to address this
gap that seemed so apparent, just based on the conversations
I was having with a fairly wide circle of friends.
I mean, most of my women friends now are in
their early fifties, and you know, I'm kind of a
I'm not a shy person. I ask a lot of
(03:25):
questions of my friends a reporter, and it was amazing
to me the range of confusion and how common it was.
So we knew that there was a total need for
them some kind of information. And at the same time,
I would say, within an hour of it going up,
I had one friend text me and said that she
had already had the article texted to her on four
different girlfriend group threads that she was on and it
(03:49):
had just gone up.
Speaker 7 (03:50):
And that was what we started.
Speaker 9 (03:51):
Hearing over and over and over again that every woman
who was in some big group text thread.
Speaker 7 (03:56):
I clearly am not in enough of those, but.
Speaker 9 (03:58):
They were getting them from all side that it was
just circulating and the comments started pouring in. And on
the one hand, as I said, it seems sort of like, yes,
of course, that people would be relieved and surprised to
see all this information in one place in the New
York Times because there had been such a hunger and
confusion about it. On the other hand, you never expect
that kind of reaction.
Speaker 7 (04:18):
You just can't.
Speaker 1 (04:19):
Doctor Brightman, who full disclosure, is my doctor, who has
said I could call her Becky. During this podcast, you
were doing backflips when you read this article. I think
you and I talked about it. You were talking about
it with your fellow obgyns.
Speaker 2 (04:35):
What was your reaction. I was so excited. I met
Susan att list falls Nam's meeting. Look explain what North
American Menopause Society meeting in Atlanta. I knew she was
working on the article and the morning I think it
came out initially online and then It subsequently was in
print a couple of days later. It is the greatest article,
is so affirming to what I do. I feel it
(04:58):
is such an uphill battle trying to discuss some of
the things we're going to talk about now and to
explain to people and reassure them that what their experience
is normal, but it's part of the menopause transition and
women need to be heard. And I think it was
the most validating article. And it also really went to
discussion of the statistics and why menopause hasn't received enough attentions,
(05:19):
and why hormones have received such a bad rap.
Speaker 1 (05:22):
We're going to talk about the bigger picture about women's
health in general in a little while, but first I
want to really do a deep dive into the article. Susan,
how did this piece heard around the world come about?
Was it because you were going through this, your friends
were going through it, and you all were confused?
Speaker 9 (05:38):
I actually, really I am glad you asked that, because
the reason this article came into being is really due
to the vision of my male editor in chief, Jake Silverstein.
Speaker 7 (05:49):
Wow, I'm amazing. I'm impressed the presence I now.
Speaker 9 (05:53):
He came to me and said I think we and
my wonderful editor, Eliana Silverman as well said, I think
we should do an article about METAe, but was a
very big, baggy topic.
Speaker 1 (06:02):
I didn't know where to begin, and your writing is
pretty vivid, Susan, I wondered if I could just quickly
read this paragraph. For the past two or three years,
many of my friends, women mostly in their early fifties,
have found themselves in an unexpected state of suffering. The
symptoms they've experienced were varied and intrusive. Some lost hours
(06:22):
of sleep every night, disruptions that chipped away at their mood,
their energy, the vast resources of goodwill that it takes
to parent and to partner. One friend endured week long
stretches of minstrel bleeding so heavy that she had to
miss work. Another friend was plagued by as many as
ten hot flashes a day. A third was so troubled
by her flights of anger, their intensity new to her
(06:44):
that she sat her twelve year old son down to
explain that she was not feeling right, that there was
this thing called menopause and that she was going through it.
Another felt of pervasive dryness in her skin, her nails,
her throat, even her eyes, as if she were slowly calcifying.
By the way, you're a really great writer, Susane. I
(07:05):
just want to say that it's so evocative. Susan. The
more you looked into this, were you surprised at how
significantly menopause was affecting women in their daily lives.
Speaker 9 (07:20):
Well, you know, you start to hear about it first
from your older friends. So I was already thinking about
it a little bit. But when I got together with
my college friends, that was when I really started hearing
about how drastic it had been. And it was interesting.
Is also the range of reactions that my women friends had.
I would say that some of my friends were looking
for answers and somehow could not find them or did
(07:41):
not know what information to trust. And then there was
a whole other cohort of friends who I think just thought,
this is just my lot in life, you know, to
suffer like this is what happens when you get older.
And I think they thought, well, if there was something
that could be done, surely somebody would have said something
about it.
Speaker 1 (07:57):
And doctor Brightman Becky, you see patients all the time.
Do these symptoms sound about right to you?
Speaker 6 (08:04):
Absolutely? And It's interesting.
Speaker 2 (08:05):
When I practiced obstetrics, I used to say, well, hormones
of pregnancy, which are the hormones that change during menopause,
affect every organ system in the body, and the same
is true with menopause, so it's not just night sweats
and hot flashes. And honestly, it is really the disrupted
sleep and the night sweats initially and once forties, that
sort of you know, precipitate mood changes and difficulty focusing,
(08:29):
and you know, cognitive changes and all the things women
talk about.
Speaker 1 (08:34):
I'm glad you mentioned cognitive changes. Susan. Tell us about
that conversation you had, which you include in your piece.
When you're at a cocktail party and you see an
older writer. This actually broke my heart. Honestly.
Speaker 9 (08:48):
There was a writer whose work I had always admired,
and she had precipitously retired, and I'd always wondered what happened.
And I saw her at a party and I just said,
you know, I just loved your writing. I always wondered
why did you stop? And without even hesitating, she just said, menopause.
I couldn't find the words, and she is sure that
(09:08):
that was the cause. It wasn't you know, as if
she was on the path of dementia. It was just
completely timed to this phase in her life and it was,
you know, really agony for her, I think, and I
think that always stuck in my mind as well as
a writer. It sent a chill down my spine at
the time.
Speaker 7 (09:26):
I remember.
Speaker 1 (09:27):
First, I just want to ask you about brain fog, Becky.
I mean, do doctors know what causes this and how
it's associated with menopause?
Speaker 2 (09:38):
So as hormone levels start to fluctuate, their super high
levels of estrogen and super low levels, and it's the highs,
it's the lows. It's really the disruptive sleep and the
fact that women can't focus and feel foggy. They're looking
for words and for many women and there's there have
been studies that show that many women will return to
baseline with respect to word finding incognitive function. For some
(10:01):
women there will be some age related decline. But it's very,
very scary when it happens to you, and I think
that you know Susan's article is so eye opening for
women because as doctors, those of us practice menopausal medicine,
we know this, but for many women will be eye
opening because it can be one of the earlier signs.
Someone can be having regular menstrual periods but start to
(10:22):
no discussion. They're not sleeping, they're drenched at night, you know,
they're exhausted during the day, they can't make it through work.
And I think now that we have so many women
in the work force, so many women, we have very
you know, set the bar for ourselves. It's very high bar,
and we want to keep achieving, and one wants to
be their best self, and it's very hard when you've
(10:42):
been so impacted by the inability to sleep, brain fog,
and people say, what, it's not me, it's not me.
Speaker 6 (10:48):
I've never been like this before.
Speaker 1 (10:49):
Why parenthetically, I started doing the patch, a hormone patch
when I think I went through menopause at around fifty
four because I was anchoring the CBS evening News and
I didn't want to have like a brain fart in
the middle of the evening news, or forget the question
I was supposed to be asking a correspondent. We're going
(11:10):
to get into the Women's Health Initiative and the hormone
study in a moment. But I think you raised this,
Susan and your piece, and you do wonder if men
were going through this experience, if we wouldn't have a
lot more solutions. In fact, you write, imagine that some
significant portion of the male population started regularly waking in
(11:32):
the middle of the night drenched in sweat, a problem
that endured for several years. Imagine that those men stumbled
to work, exhausted, the morale low, frequently tearing off their
jackets or hoodies during meetings and excusing themselves to gulp
for air by a window. Imagine that many of them
suddenly found sex to be painful, that they were newly
prone to urinary tract infections, with their penises becoming try
(11:55):
and irritable, even showing signs of what their doctors call atrophy.
I've said lately when I've been talking about women's health issues,
if we had focused as much attention on these issues
as we had on the development of viagra, imagine where
we'd be.
Speaker 9 (12:12):
You have to think, and it does have to You
can't help but think that it is about a discomfort
with not just female sexuality, but aging women's sexuality.
Speaker 7 (12:21):
It's just not seen as a priority.
Speaker 1 (12:24):
I can say from personal experience that Becky Brightman is
an excellent doctor who talks to her patients about pretty
much everything, including menopause and a whole host of issues.
We don't have to get into detail. But Susan, you
found in your reporting this just isn't the case.
Speaker 9 (12:42):
I think it is pretty unusual, you know, And you
can talk about the different kinds of doctors who see women.
You know, some women stop seeing gynecologists and they only
go to family medicine or internists, and those doctors obviously,
you know, need to be well versed in so many topics,
but they really are under informed. I do believe about
menopausal symptoms and about hormone therapy in particular. I do
(13:04):
think that many obgyns. You know, if a woman comes
in and she is absolutely gutted by symptoms and is
you know, it's completely disrupting her life. I think increasingly there,
you know that people are moving away from the older fears,
and they do recommend menopausal hormone therapy. But if it's
not that extreme, I think it's easier just to move
(13:26):
on because it is a kind of complicated conversation. People
do want to understand what the risks are. They are
kind of individualized. It's hard to explain the history. It's
hard to overcome people's hurdles. It's just time consuming it,
you know, in the defense of many obgyns, now they
have fifteen minutes, they have other things they have to
get through, and unless the person is completely wiped out
and useless and you know, in a state of extreme suffering,
(13:49):
it might just be easier to move on. I mean,
that's sort of the impression I get.
Speaker 2 (13:53):
It's a very long discussion, and it's not a one
size fits all when it comes to deciding whether or
not menopausal hormone therapy is free. There are many different
types of menopausal hormone therapy, and there's certain tests that
I need to make sure someone's had. We have to
go through family history. You can't do that in fifteen minutes.
Speaker 6 (14:09):
So it's tough.
Speaker 2 (14:10):
And I also think doctors don't necessarily, you know, want
to take the time. They don't find it really interesting.
And again it's opening up a can of worms.
Speaker 1 (14:19):
When one of your friends, Susan, expressed concerns about a
lower libido and bachinal dryness, she could tell her doctor
was uncomfortable talking about both. You write about this and
you quote her as saying, I thought Hey, aren't you
a vagina doctor?
Speaker 9 (14:33):
I use that thing for sex, yes, But I think
sex also is a complicated subject. It has to do
with like emotional relationships and is anybody on an antidepressant
and you know, how's your marriage? I mean, I think
people feel, doctors must feel it opens up a huge
can of worms that like, you know, if you open it,
it'll just it'll never stop. So I think that it's
(14:55):
not something that in general kind of called is sir
excited to talk about?
Speaker 1 (14:58):
That quote made me laugh out. It is a great quote.
When we come back, we're going to talk about the
Women's Health Initiative, which really screwed things up for everyone.
We'll do that right after this story.
Speaker 5 (15:11):
But there's this this distinct memory of being pregnant at
my first baby shower and all the young gals are
upfront and they're giving you like fun gifts and things,
and they're so cute and everything's awesome.
Speaker 4 (15:23):
But there's this ring of gray haired ladies in the
back and we're not really saying anything.
Speaker 7 (15:28):
Other than we're so happy for you.
Speaker 5 (15:30):
But there's like this black box that happens of like, Okay,
you're gonna have.
Speaker 7 (15:34):
To figure this out.
Speaker 5 (15:34):
For yourself if it kind of feels like that, it
feels like a frontier.
Speaker 3 (15:39):
My friends, my loving friends. I have shared, they have shared.
But what a wonderful support system I have in that area.
Everything is discussed sleep deprivation, to depression, to vaginal dryness,
and with being so transparent, you just don't feel alone
(16:00):
in all of this. You know you're not the only
one going through this. To say the very.
Speaker 1 (16:04):
Least, We're back with doctor Becky Brightman and also Susan
Dominus of The New York Times talking about menopause and
all sorts of fun things like vaginal dryness. How often
can I say vaginal dryness in one podcast? Not often enough, apparently.
(16:26):
Let's talk now about the Women's Health Initiative. So, Susan,
there was a nineteen ninety one National Institutes of Health
hormone trial. It was the first clinical trial involving all women.
Thanks to Bernadine Healy may she rest in peace. I
always feel like she doesn't get enough credit, the NIH
(16:46):
director who started the WHI. So let's start by talking
about what that trial was designed to do.
Speaker 9 (16:54):
So it was the largest all women trial, as you say,
and it was trying to answer a couple of diferent questions,
but I would say the question that drove its initiation
in the first place was are hormones in fact good
for women's health, specifically cardiovascular health. And there was a
concern that there might be some elevated risk of breast cancer.
(17:15):
But there had been a lot of observational studies that
suggested that when women went on hormones they saw lower
rates of cardiovascular.
Speaker 1 (17:23):
Because we should mention they do have lower rates until
they go through menopause, and then their rate of cardiovascular
disease equals men correct. So they were thinking estrogen had
some kind of protective quality for the heart.
Speaker 9 (17:36):
That's exactly right, And in fact, one of my favorite
quotes in the piece came from a doctor Hadeen Joffrey,
who said, you don't understand. I had a slide that
said we should have estrogen in the water. It should
be like fluoride. That's how good for women. People thought
that estrogen was.
Speaker 1 (17:51):
But there was some concerns about estrogen. I guess doctor
Brightman where maybe this breast cancer question was kind of
looming large.
Speaker 2 (18:00):
So the WHI was designed as a prevention trial to
see whether or not hormones actually prevented disease, what happened
with breast cancer? Did it prevent carnary artery disease, cardiovascular disease,
did it help bones? And then it was abruptly halted,
as we know, because there was a signal that perhaps
it did increase the risk of breast cancer, and that
(18:22):
really has to be teased apart before we talk about
it getting halted.
Speaker 1 (18:26):
I read that, I think in your article season that
estrogen had been around for decades, right, and women were
getting a lot of positive results from it, Becky.
Speaker 2 (18:37):
So what happened is it was finally realized that you know,
women were using just estrogen alone, and then it became
apparent I think in the seventies that women really that
estrogen would stimulate the lining of the uterus, and when
you have too much stimulation of the uterine lining, women
are an increased risk of getting endometrial cancer cancer of
the uterine lining. So by the addition of progestogen progesterone
(18:58):
being one of them, medical reculate and you can mitigate
the increased risks. So in women with the uterus who
were going to use metopausal homoonn therapy they needed if
they were taking estrogen, they had to use some sort
of progestine. For women without uters, they could just be
on estrogen alone.
Speaker 1 (19:15):
So this was the first big study to determine, like scientifically,
what are the pros and cons of hormone replacement there
exactly all right. So suddenly, as Becky intimated, the trial
was stopped.
Speaker 7 (19:32):
Why it was stopped.
Speaker 9 (19:33):
After five years because they found in the group that
was taking both estrogen and progestine, which is to say,
women who have uteruses, that they were seeing an increased
risk of breast cancer.
Speaker 2 (19:44):
In that group, there was an uptick in breast cancer,
but they continued it the study and they did not
see it in the group of women using estrogen alone.
And it's so interesting because estrogen is what gets the
bad rep but in the group that again estrogen alone
no increase risk. So it got changed mid stream.
Speaker 9 (20:03):
It was supposed to last for eight and a half years,
and the idea that they halted it unexpectedly after five
years was very big news. They also held a very
big press conference. And you know, when people understand that
a study has been stopped unexpectedly, I think they think
that translates into and therefore, you too, must stop using
this medication.
Speaker 1 (20:23):
I remember covering this back in that day, by the way,
and you write what happened next was an exercise and
poor communication that would have profound repercussions for decades to come.
What did happen.
Speaker 9 (20:36):
Basically representatives of the WHI very well intended but not
particularly media trained when on television shows and started, you know,
engaging in conversations in which a lot of statistics were
rattled off, and some of those statistics sounded very, very scary.
Speaker 3 (20:51):
Right.
Speaker 1 (20:52):
In fact, the coverage was pretty breathless, and I would
say in retrospect, unintentionally alarmist. You talk about an interview
than Ann Curry did on the Today Show.
Speaker 10 (21:02):
An important medical story making news this morning. The government
has abruptly ended the country's largest study of a type
of hormone replacement therapy that found long term use of
estrogen and progestin can increase a woman's risk of breast cancer, strokes,
and heart attacks. Sylvia Smuller is a principal investigator in
this study. Sylvia good Night.
Speaker 1 (21:21):
I was working on the Today Show back then, and
I remember all of this pretty well, and it was
with one of the chief investigators with the Women's Health initiative, What.
Speaker 10 (21:30):
The effects were, what made it ethically impossible to continue
the study?
Speaker 11 (21:35):
Well, in the interest of safety, we found that there
was an excess risk of breast cancer which had passed
the prespecified monitoring boundary lines. And there was also no
benefit for heart disease, and in fact some excess risk
of heart disease.
Speaker 10 (21:52):
And it'd be very specific here. You actually found heart disease.
The risk increased by twenty nine percent, the risk of
strokes increased by forty one one percent, it double the
risk of blood clots, invasive breast cancer risk increased by
twenty six percent, and cardiovascular disease increased by twenty two percent.
So what are we telling women the six million women
in America today who are taking HRT.
Speaker 1 (22:16):
So how did these numbers get so misunderstood or misreported?
Speaker 9 (22:21):
Well, they were definitely not misreported.
Speaker 7 (22:22):
They were accurate.
Speaker 9 (22:23):
Those numbers were accurate, per the WHI I just think again,
it takes a little bit more time to say, Okay,
so what does that actually translate into for the average
woman And what did it translate into? Well, though, the
math that we did was that if a woman's risk
of having breast cancer between the ages of fifty and
sixty is around two point three three percent. Let's say
if you increase that risk by twenty six percent, that
(22:45):
means now you've elevated it to a two point nine
four percent. So you know that in the grand scheme
of things, everybody can have their own comfort level with
a two point ninety four percent risk and how much
you've increased it. But that's not I don't think how
women heard it at the time.
Speaker 1 (23:00):
And in fact, you say smoking, by contrast, increases cancer
risk by two thousand and six hundred percent.
Speaker 7 (23:06):
That's a risk.
Speaker 1 (23:07):
So we're talking about a very very small uptick. If
you're on HRT. What was the impact of all that coverage, Becky,
You've been living in it for the last thirty years.
Speaker 2 (23:19):
Living it and continue to live it. It was unbelievable.
For the second I walked into the office, the phones
were ringing like crazy.
Speaker 10 (23:26):
You know.
Speaker 2 (23:26):
I heard of stories where women were sent letters by
their kind of colleges of the time being told to
stop hormones. I will tell you that my patients, who
if I ever mentioned it they were symptomatic, they were like,
absolutely no, don't I know that they could get cancer?
It's amazing and I still get to face women who
say this to me all the time, but it was
quite remarkable.
Speaker 6 (23:45):
It really was something else.
Speaker 1 (23:47):
There have been other long term ramifications medical students who
graduated around this time, and you point this out as well, Susan,
we're thinking HRT bad and carried on throughout the decades
they've been practicing medicine.
Speaker 7 (24:04):
Right, that is exactly right.
Speaker 9 (24:06):
I mean, I think the statistically quote in there is
that something like half of practicing obgyns graduated from medical
school or finish their residencies after the WHI. So that's
a huge percent of the population who basically never really
learned about hormone therapy in medical school. And also I
gather in clinics it doesn't come up very often in
(24:27):
part because of the population that's being treated, so there's
not a lot of opportunity to learn it on the
ground either.
Speaker 1 (24:33):
The study was flawed in a whole host of ways,
it seems. Can you all talk about why this study
really wasn't accurate.
Speaker 2 (24:43):
The most important thing is for women to realize that,
you know, I think women take this information they say,
how does it affect me? Well, the truth of the
matter is the average age of the women in the
study was between sixty two and sixty three. You know,
many of these women did have some comorbidities. Many of
them on average were twelve years beyond their final period,
and the majority of these women didn't even have menopausal symptoms.
(25:05):
So it was a lousy population to study. You know
what we really need to go back and do is
look at the fifty to six year old how did
they do? And you know what, they did pretty well.
And then once things are teased apart and we look
at it a decade by decade, it's very very different.
But essentially one just extrapolated all the findings to themselves
(25:29):
and thought, oh no, I'm going to get breast cancer,
I'm going to get heart disease, and my bones may
be good. But that's about it.
Speaker 1 (25:35):
There were other flaws though, to the formulations of the hormones.
We're kind of off. Now we have better hormones that
more mimic a woman's natural biology.
Speaker 2 (25:45):
It's not as that the hormones were flawed and those
poor hormones counticated estrogen and medroxy progesterone acetate, which was
a progestogen, received such a bad rap, a really really
bad rap and we still use them. However, there was
a really you know, the number of prescriptions that were
being written for the combination dropped dramatically, and unfortunately it
(26:06):
gave rise to some very unsafe options. But it opened
up the world of what we call bioidenticals, many of
which are great because there are several FDA approved wonderful
bioidentical options. You can get them through any commercial pharmacy.
But I think people were so worried about safety that
they started going to physicians who would prescribe lotions and potions,
(26:30):
as I say, compounded forms of hormones that made people
believe women believe that these were safer options. Yet they
weren't studied. So essentially they were trading something that they
thought was horrible for them because of what they looked
at the data, they looked at the WHI results going
to what was what they perceived to be safer options.
(26:50):
And there were safer bioidentical options, but you needed to
discuss it with your physician.
Speaker 1 (26:55):
Right, But also, what about synthetic hormones. Haven't they been
vastly improved since the study? Yes, And one has to
realize all hormones are synthesized. You know, many of them
are derived from plant products, but they are all synthesized.
They are made in a lab. We don't pick them
from a tree. Interesting. We're going to take a break,
but when we come back, we're going to answer some
(27:15):
listeners questions because we got the doctor here, we've got
the expert there. Let's take advantage of you. We'll be
right back.
Speaker 4 (27:25):
My mom was pretty modest and old fashioned, and I
feel like that really has changed the way I parent
my kids, all of them boys and girls. I feel
like they need more bracing truth about, like this is
what goes on and it's not something to be scared of,
it's something to respect. But I feel like the way
(27:45):
I was raised, it just wasn't talked about and it's
sort of met with a shrug.
Speaker 8 (27:50):
Definitely, society could certainly be more tolerant, more mindful of
all of the issues that women have to face from.
Speaker 3 (28:08):
The very beginning of our lives to the very end.
Of course, society could be a heck of a lot
more empathetic and supportive, and hopefully we'll see that at
some point.
Speaker 1 (28:23):
Hopefully we're back with doctor Becky Brightman and Susan dominis
talking about menopause and really perimenopause and maybe a little postmenopause,
which I am officially in ladies and gentlemen. I think
one of the bottom lines here is that HRT has
(28:44):
small risks but a bigger reward. Is that a safe
thing for me to say.
Speaker 2 (28:49):
I feel so I've always felt this way, And what's
really interesting. In the United States Prevented Service Task Force
would say, no, no, no, we are not supposed to
talk about hormones and the benefits they may have in
terms of disease reduction and everything else.
Speaker 6 (29:04):
But I think we've come a long way.
Speaker 8 (29:06):
You know.
Speaker 2 (29:06):
It used to be hormones were strictly for night sweats
and hot flashes, and they had to be really, really,
really bad. But we know that they improve the quality
of one's life greatly if in need, and they also
may serve a role with disease prevention.
Speaker 1 (29:19):
All right, Well, we got a lot of questions about
HRT hormone replacement therapy. One question asked, can HRT be
used if you have a family history of ovarian cancer?
Speaker 2 (29:29):
So that's a great question. There is a tiny bit
of data that there may be a minuscule increase in
ovarian cancer in women who use menopausal hormone therapy MHT
or hormone replacement therapy. Again, it really needs to be individualized.
I think much more goes into counseling a woman with
a family history of ovarian cancer, and there's certain things
(29:51):
one can do to reduce risks, and certain genetic testings
that can be offered. But it would not mean that
someone with that family history can't be on hormones, but
they would need to discuss it. They'll all discussed it
to discuss it. But if there were an increase, it
would be minuscule.
Speaker 1 (30:07):
What if you're at a high risk for breast cancer
is another question? Is HRT absolutely out of the question?
Speaker 6 (30:13):
No?
Speaker 2 (30:14):
No, And it depends again on family history, again on
genetic predispositions. One has to again look at the symptoms
and with appropriate counseling. It's a very individualized, personalized decision.
Speaker 1 (30:26):
Should women take hormones if they're only experiencing slight symptoms.
Speaker 2 (30:31):
Yes, I think so they should be offered hormones and
it should be part of the discussion. And I find
I'm backpedaling with my patients, like those who have said
years ago, my symptoms aren't terrible.
Speaker 6 (30:41):
I'm cruising through this.
Speaker 2 (30:42):
I'm now revisiting it because many of their eyes have
been opened by Susan's wonderful article. So I feel that
if I don't discuss it with them, I need to
discuss it again. So again, it depends on the women.
And even if I'm somebody with mild symptoms, of course
I talk about it because I don't want them to
leave my office.
Speaker 1 (30:59):
And think, hh, she didn't talk to me about this.
And also in your article, Susan, you talk about like
what is significant exactly? How do you measure if something
is bothersome or not right?
Speaker 9 (31:12):
Especially one of the doctors I interviewed, Nanette Centaurro, who
was pointing out to me that when her patients say
to her, I don't know, I feel I'm not sleeping
well and I'm really moody, and I'm getting these incredible migraines.
I don't know is it menopause or just stress? You know,
she would say to them, well, you could try hormones.
You don't have to marry them, you can date them,
(31:32):
and if you don't see an improvement in your symptoms
in three months, we'll take you off. If you do
see an improvement. I think we can bet that it
was estrogen deprivation, and you may choose to.
Speaker 7 (31:43):
Stay on them.
Speaker 9 (31:44):
So she was sort of saying, you know, every patient
is going to weigh their own personal tolerance for risk
with the benefits to their lifestyle of going on the hormones.
But you don't actually know the benefits necessarily until you've
tried them. So first, you know, look, if you're sailing
through and you're completely symptom free, then maybe it's not
something even to think about. But if you're wondering about it,
there's very little harm in trying.
Speaker 1 (32:06):
And speaking of that, I had to ask a personal
question because I was diagnosed with breast cancer, as doctor
Brightman knows in June, and I have been on HRT
the patch probably gosh, ten or eleven years maybe now,
and I loved it. Didn't look great with bikinis, but
that's okay, I'm kidding. I don't wear bikinis anymore. But
(32:26):
you know, I couldn't help but wonder, as Carrie Bradshaw
would say, did the patch result in my breast cancer?
Speaker 2 (32:34):
I would say, no, it didn't. And this one of
my friends was told by her breast surgeon. When my
friend asked, why did I get breast cancer? She got
breast cancer because she's a woman. And if we think
about it, one in eight women will get breast cancer
during the course of their lifetime. And this, you know,
we're not talking about one in eight women in their thirties, forties,
or fifties. But by the time we live our lives,
(32:56):
life expectancy for women now is about eighty one one
and eight women we'll get breast cancer. And my feeling
is that is why. And I think for many women,
if appropriately counseled, the benefits outweigh any potential risk.
Speaker 1 (33:11):
But now that I have gotten breast cancer, I can't
go back on the patch, can I not?
Speaker 6 (33:17):
Really?
Speaker 2 (33:18):
No, There are certain situations with appropriate counseling where women
have resumed hormones, but they are few and far between,
and I venture to say the majority of physicians would
say it's a hard no.
Speaker 1 (33:32):
Let's move on to some other questions we got from
our daily newsletter, wake up Call, Shameless Plug sign up
at Katiecurrek dot com and social media. We got a
lot of questions Susan about hot flashes, and I thought
we would just take a moment because I thought it
was fascinating. You talked about this internal regulator we all
(33:54):
have that causes hot flashes. Can you explain doctor that
you're not doctor.
Speaker 9 (34:00):
I can explain what doctor has explained to me, which
is that the hypothalmis regulates body temperature and very rich in.
Speaker 1 (34:08):
Ester I'm not getting a hot flash.
Speaker 7 (34:09):
I'm taking my sweater. It just happens to be on
in heir appropriately enough.
Speaker 9 (34:14):
It's very sense. So the hypothalmus is rich in estrogen receptors.
It's also somehow connected to the reproductive system. So if
it regulates body temperature and suddenly it's not getting the
estrogen that it used to, it starts to get a
little bit wonky, and it over interprets little cues internally
about rises in core body temperature, really infinitesimal rises, and
(34:34):
the body responds as if there was some kind of
catastrophic oven, you know, from within, and it dilates all
the blood vessels, and it sends sweat rushing to the
surface of the skin, and the surface of the skin
actually the temperature there really does rise. But what's so
interesting to me about hot flashes is that women feel
as if they do have an oven within but it's
(34:55):
kind of almost like a phantom limb sensation. Like obviously
your inner core is not suddenly steaming, you know, there's
very little change there. But that's where women really do
experience that heat. So it's a purely cognitive brain chemistry.
It's a brain, it's a brain phenomenon, it's a neural phenomenon.
Speaker 1 (35:12):
Is it the same with night sweats?
Speaker 7 (35:14):
I got?
Speaker 1 (35:14):
I mean, people are like, we really don't care what
you had, Katie, But I relate a lot to this conversation.
I don't think I had hot flashes, but I did
have night sweats where I'd wake up not bad, but
you know, my pajamas would be kind of soaked.
Speaker 2 (35:28):
It's the same mechanism of action, the lack of estrogen
and the firing away of neurons in the hypothalamus.
Speaker 1 (35:36):
That's why it's so important to be able to talk
to your doctor, to really be able to share your
individual symptoms.
Speaker 2 (35:42):
The other thing is estrogen has anti inflammatory properties, and
we really see an uptick in rheumatologic diseases, arthritis and
all sorts of skin related phenomenon after menopause. And I
don't think anyone ever thought about estrogen having an anti
anti inflammatory relationship. Estrogen changes everything. It can change the
(36:04):
bacteria that's in our gut. There's some thought that gut
bacteria plays a role with inflammation. Also, it's all interrelated.
I mean, it's a super hormone. Estrogen is also like
a natural antidepressant. And we haven't talked about this, but
a lot of women who go through menopause become depressed
(36:25):
because of the decrease in estrogen, right, Yes, absolutely they do.
They do, and they don't realize it. They don't realize that,
their doctors don't realize it. It's one of the most
upsetting things to me. Nuance at anxiety, nuancet palpitations. Women
will go to their physicians and talk about it, and no,
people do not draw a correlation between those symptoms and menopause.
(36:47):
And I'm not saying that hormones are first line for
treating anxiety and depression, but if it's part of the
whole picture, absolutely it's worth it try.
Speaker 1 (36:55):
I wanted to bring up something that's so important is
that these symptoms are often worse in women of color.
Why do these symptoms sometimes affect women of color even
more severely?
Speaker 2 (37:07):
So, we really actually don't know, but there really seem
to be some racial disparities amongst you know, who tends
to have more what we call vasomotor symptoms or VMS
night sweats, hot flashes. Women who are Black definitely have
been noted to have worse symptoms. Women who are Asian
fewer symptoms. And what's very concerning is we want to
(37:29):
make sure people are getting the appropriate care because now
it seems like the worse the vaso motor symptoms, the
greater the risk of cardiovascular disease. So women need to
be offered some education about it, information and the option
to treat their symptoms, particularly because they may be at
risk of what lies.
Speaker 6 (37:47):
Down the road.
Speaker 1 (37:48):
We want to get in a couple more questions from
women who wrote in who are dry as the Sahara
just say what you were talking about calcifying This is
pretty much happening to a lot of women. One says,
I've experienced extreme dryness and I've had to take a
three year break from sex. What can I take such.
Speaker 6 (38:09):
Setting that's so upsetting?
Speaker 2 (38:10):
Like I have to tell you, I really try to
be proactive with my patients and once they stop menstruating,
talk about are you having this symptom, that symptom, and
they're like, no, no, no, I said, just be aware.
Now with menopause, there can be an increase of vaginal dryness, itching, burning,
painful sex. You know, mostly it's reversible. I think that
the nice thing is we have many options in different
(38:31):
ways in which we can treat our patients. So you know,
whoever feels dry as a sahara, we can make that better.
Speaker 6 (38:36):
That's the good news.
Speaker 1 (38:38):
I don't want to give short shrift to perimenopause because
we really haven't mentioned that at all. Becky, is there
something that you can talk about when it comes to
perimenopause that will help women who may be in that
phase of life.
Speaker 2 (38:53):
When we talk about menopausal symptoms, these are largely the
symptoms women start experiencing during perimenopause. Menopause is a transition,
and there are different stages of going through this transition,
but what we describe as perimenopause can last. It can
last like up to seven years, and many women can
have regular menstrual periods. But the first thing they may
notice might be getting warm at night. Then they may
(39:16):
notice that they're just not sleeping well. And you know,
these symptoms can then snowball into heavier periods or regular periods, moodiness,
just a whole constellation of symptoms, palpitations, which we haven't
talked about. Many women are seeking out, you know, cardiologists,
and they need to be evaluated for palpitations, but that's
(39:36):
also a symptom, so they're frequently symptomatic of other things
that are frequently brushed off. Some women during perimenopause have
vaginal dryness, so again it's very varied. People's experiences are
very varied at the time.
Speaker 1 (39:49):
When should women start talking to their doctors about this?
Speaker 2 (39:52):
I start now that I have a large menopause practice,
I would say, and as women get into their forties,
I do you know, early early forties, certainly mid forties.
And I think the hardest thing for my patients is
when they're on the earlier side. No one wants to
be the first one to go through it, whereas I've
other patients who are fifty six. But you know, for
the forty four year old, the forty five year old
(40:13):
where things are starting to change, and for some women
they're younger, it's hard to discuss and acknowledge the fact
that some of the things they are experienced may be
linked to the menopausal transition.
Speaker 9 (40:23):
I was just going to add that I think a
lot of women under the impression that you start menopausal
hormone therapy when you are officially menopausal, which is to say,
a year after your last period, and they think that
there's nothing they can do during perimenopausal I'm still getting
my period, so I'm not going to get treated. But
in fact, for women who are experiencing heavy bleeding or
(40:43):
who are going through you know that their periods are regular,
they know that they're in perimenopause, they're having brain fought.
There are treatments that they can consider as well, which
I will now defer to doctor Brightman to discuss.
Speaker 2 (40:54):
So it's interesting because we don't we have many things
we can do after menopause. And the issue is you
can't necesscessarily put younger women on these these therapies because
they will probably menstruate around them and have all sorts
of bleeding that then needs to be evaluated. But if
one is a candidate for birth control pills, low dose
birth control pills are a beautiful thing. They can use
them continuously without even.
Speaker 6 (41:16):
Urgery.
Speaker 2 (41:17):
It creates hormonal neutrality for many women. It just helps
them sleep, They just feel better, and it's a great
way to transition them through menopause. And I'll keep them on,
you know, depending on any underlying medical factors. I'll keep
them on birth control pills until you know, the early
fifties or sometimes even mid fifties.
Speaker 6 (41:33):
It really depends.
Speaker 2 (41:34):
But many women who have a hormonal IUD, we can
layer on a little estrogen through a patch, which is
works really really nicely. The other thing is there are
some non hormonal options. Again, not everybody's a candidate for hormones,
and everyone can be on hormones. So unfortunately, we only
have one FDA proved option, peroxetine in our country right now.
(41:56):
The FDJA is on the brink of approving another medication
called a phesilinit tant. It also it targets the hypothalamic
thermo what we call the thermoregulatory center of the brain,
so that offers tremendous promise. It's non hormonal. It will
be great for women who are not candidates for hormones
or who choose not to go on hormones. The good
(42:16):
news is there's several other medications we can use off label.
Some antidepressants, anti anxiety medications. There are non hormonal nutritional
supplements that many women opt to use, but the studies
that are out there are very small.
Speaker 6 (42:30):
Many of them are.
Speaker 2 (42:31):
Self funded by the companies that manufacture them, so if
a woman is going to take a supplement, they should
discuss it with their healthcare provider.
Speaker 1 (42:38):
Speaking of that, there is a whole new group of
companies that are addressing these symptoms with creams and vibrators
and lubricants and all kinds of things, which I think
is a welcome addition to the marketplace. But I know, Becky,
you're of the school of buyer, beware, buy.
Speaker 2 (43:00):
Or be aware, and I think, much the way it
is for adolescent women, women should not get the wrong
impression that they're being left out. Everyone's swinging from the
chandeliers and you know, the women are missing out and
they need to buy these products. Just because somebody has
come up with a concept for a product doesn't mean
one needs necessarily buy it. That's on one hand, but
the other hand, it's really nice to be able to
embrace the fact that, you know what, I'm a sexual being.
(43:22):
I want to remain as sexual being, and there are
products that are out there that are really geared towards me,
you know, not towards a younger woman. So I actually
think it's fantastic.
Speaker 1 (43:33):
But I know you're worried about all the stuff on
social media, on TikTok, on Instagram, with these companies kind
of overstating what some of these things can do and
taking advantage of women suffering.
Speaker 6 (43:45):
Oh, it breaks my heart. It breaks my heart.
Speaker 2 (43:47):
I have a group of friends, fellow docs from North
American Menopause Society, and they send around bad tiktoks. There's
misinformation out there. It's so upsetting. I think I could.
I would love to dispel some of the myths. It
would be a full time job. So it breaks my
heart because we don't have great access to healthcare providers
(44:08):
who are well versed in menopausal medicine. So women are
turned to social media. And there's some great things on
social media, but there's some things that are potentially very detrimental.
Speaker 1 (44:18):
I think some of the things I've learned in this
conversation and through reading your great article, Susan, and through
my conversations with Becky Brightman, is that a lot of
doctors are not particularly knowledgeable about this. They don't have
time or they're uncomfortable. This is something that has been
kind of ignored by large swaths of the medical establishment,
(44:42):
which makes me wonder is this indicative of how women's
health issues have been treated historically?
Speaker 2 (44:51):
Absolutely, you know, certainly in the past with respect to medicine,
women were small men. Certainly when I was in medical school,
no one differentiated cardiac disease in women as being any
different than cardiac disease in men. And we've learned so much.
But now, you know, the NAAH has designated money that
will go into researching women women's healthcare. But this is
(45:14):
all recent and I think we do need more studies.
And again, we have observational studies. There's certain things that
I feel very comfortable doing for my patients, but there
is so much much more research that needs to be done,
and education of physicians needs to be accelerated on a
grand scale.
Speaker 1 (45:33):
What did you learn, Susan about how did you feel
about women's health and the attention paid to it after
reporting out this article?
Speaker 9 (45:42):
You know, I think I would just quote Rebecca Thurston,
who's metopausal researcher out of the University of Pittsburgh, whom
I interviewed for the piece. You know, she's thought about
this for many more years than I have, and her
basic conclusion about the lack of treatment for women suffering
from menopausal symptoms all these years, it's just a reflection
of what a high tolerance you have as a population
(46:05):
for women suffering and it was a really grim assessment,
but it's very hard to argue with it.
Speaker 1 (46:11):
Well, hopefully things will change thanks to articles like yours
and conversations like this. Doctor Becky Brightman and Susant Dominus,
thank you so much. This was great.
Speaker 6 (46:21):
Thank you so much having me on.
Speaker 7 (46:23):
It's been wonderful.
Speaker 1 (46:26):
Thanks for listening everyone. If you have a question for
me or want to share your thoughts about how you
navigate this crazy world reach out. You can leave a
short message at six h nine five point two five
to five five, or you can send me a DM
on Instagram. I would love to hear from you. Next
Question is a production of iHeartMedia and Katie Kuric Media.
(46:49):
The executive producers are Me, Katie Kuric, and Courtney Ltz.
Our supervising producer is Marcy Thompson. Our producers are Adriana
Fazzio and Catherine Law Our audio engineer is Matt Russell,
who also composed our theme music. For more information about
today's episode, or to sign up for my newsletter, wake
Up Call, go to the description in the podcast app,
(47:11):
or visit us at Katiecuric dot com. You can also
find me on Instagram and all my social media channels.
For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts,
or wherever you listen to your favorite shows,
Host
Katie Couric
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