February 12, 2025 • 37 mins
Unlock the mysteries of why autoimmune diseases disproportionately affect women with insights from the distinguished Dr. Ahmed Elghawy, who brings his wealth of knowledge as a triple board-certified physician. You'll learn about the complex interplay of hormonal, genetic, and environmental factors that could explain this disparity.
Listen for more insights and updates in the ever-evolving field of rheumatology.
To learn more about Dr. Elghawy, follow him on X @AhmedElghawyDO.
Welcome to the Fit, Healthy and Happy Podcast hosted by Josh and Kyle from Colossus...
Listen on: Apple Podcasts Spotify
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Welcome to the Speaking of Women's Health
podcast.
I'm your host, dr Holly Thacker, the Executive Director of
Speaking of Women's Health, andI am glad to be back in the
Sunflower House for a newepisode.
For a new episode.
(00:30):
Joining me on today's newpodcast episode for Speaking of
Women's Health is Dr AhmedEl-Gawi, and I'd like to tell
our listeners a little bit abouthim.
Very interesting guy.
He completed his undergraduateeducation at Yersinus College,
where he graduated cum laudewith a Bachelor's of Science in
Psychology.
And then he went on to medicalschool and earned his degree at
(00:54):
Nova South Eastern UniversityCollege of Osteopathic Medicine
in Fort Lauderdale, florida,fort Lauderdale, florida.
And then he went on to completean internal medicine residency
at Mount Sinai Medical Center inMiami Beach, florida.
And then he went on to completepostgraduate fellowship
(01:14):
training in rheumatology at SUNYStony Brook University Hospital
in Stony Brook, new York.
And then he did a fellowship inprimary care sports medicine at
University Hospitals atCleveland Medical Center in
Cleveland, ohio.
So that makes Dr El-Gawi one ofthe few physicians in the
(01:37):
entire nation who is tripleboard certified in internal
medicine, rheumatology andsports medicine.
And I met Dr Elgawi when he wasworking at the Cleveland
Clinic's Department of Rheumaticand Immunologic Diseases, where
he practiced both rheumatologyand arthritis, and
(01:58):
musculoskeletal health.
He's got a special interest inpracticing musculoskeletal
medicine, treating systemicrheumatic disease,
rehabilitating athletes withsports-related injury and
performing musculoskeletalguided procedures.
He's a girl dad and he got abig promotion and he has left
(02:23):
and he is now in sunny MiamiBeach, florida, the head of
rheumatology.
Welcome, dr Elgawi, and tell uswhere you're at right now and
thank you so much for joining uswith your move and new baby.
Speaker 2 (02:40):
Oh, what an introduction.
Thank you so much.
Yeah, it's, yes, I just movedfrom Cleveland Ohio where we
both practiced together atCleveland Clinic.
I moved actually back to whereI did my residency at Mount
Sinai Medical Center and will bethe chief of rheumatology at
that department there.
So a little bit of a move forus and I'm still in the process
of that move and that's why myoffice is still being built.
(03:00):
So that's why I'm kind of inthe hallway right now.
But yeah, so far it's beenreally, really nice and I'm
really excited to talk with youbecause we've shared patients
before and I think it's reallyimportant to talk about
rheumatology when we talk aboutwomen's health.
I mean, I think rheumatology islike a key focus on that.
It's kind of missed frequently.
Speaker 1 (03:22):
It is.
In fact, when I came to theCleveland Clinic, I initially
came to do my internal medicinetraining because I was going to
be a cardiologist and didn'twant to move my husband twice.
But my second love wasrheumatology and I spent a lot
of time in the rheumatologydepartment, had my clinic there
A lot of my mentors wererheumatologists, was really
close with Dr John Clough whowas a chair for a long time, and
(03:43):
it always struck me that reallyrheumatology in a lot of
respects is a woman's healthfield, because so many
autoimmune diseases occur inwomen.
And why are women more likelyto develop autoimmune diseases
compared to men?
Speaker 2 (03:59):
It's really, really strange because probably 20
years ago I probably would nothave really had an answer at all
.
We just we just noticed that inthe data there's a clear
disparity of leaning towardswomen, especially premenopausal
women, that they are much moreprone to developing autoimmune
diseases.
There's a there's a fewtheories.
One could be that there mightbe potentially like a hormonal
(04:20):
component to it, and thenspecifically estrogen, and
that's why you maybe see womenwho develop these diseases in
their childbearing years andspecifically it could be the
surge of hormone changes,specifically around puberty or
pregnancy, postpartum and thenaround menopause, which are kind
of areas where we see a littlebit of an uptick in these
(04:43):
diseases, and then, when they'repostmenopausal, we start to see
that the risk of developingautoimmune diseases gets a
little bit closer to a man's.
So we do think that there'spotentially a hormonal component
.
There's also the thought thatthis could be genetic, that
women have two X chromosomes menreally only have one, and when
it comes to X chromosomes, oneof them is active and one of
(05:05):
them is deactivated, and ZIST isthe RNA molecule that
deactivates that, and there's athought that potentially that
deactivation could cause animmune surge, and so that's why
you may potentially see anautoimmune increase in women.
The reality is, we're not 100%sure.
We know that there is a geneticcomponent.
(05:28):
For sure People who have familymembers with autoimmune
diseases tend to have themthemselves.
We've seen this in identicaltwins.
There's definitely a geneticcomponent, but there's
potentially an environmentalcomponent as well.
Let's think about rheumatoidarthritis, for example.
Rheumatoid arthritis we knowthat smoking is linked to
rheumatoid arthritis and that'sbecause we've seen the antibody,
(05:48):
the anti-CCP antibody, which isvery specific for rheumatoid
arthritis, being released in thelung and those who smoke, and
we see it also released in thegums and those who have poor
dentition or a lot of gingivaldisease.
It's probably a perfect storm,like the right genetics, the
right environment, the rightfamily history, being a woman,
all those things combined givewomen a much higher risk, and
(06:11):
it's not every disease is likethat.
If you look at rheumatoidarthritis, probably 70 to 80% of
those cases are women, but ifyou look at lupus, for example,
90 plus percent.
There's a clear disparity.
But if you gave me one reason,I'm like I can't give you one
specific reason.
I think I think it's acombination.
Speaker 1 (06:30):
And tell our listeners what's the difference
between a rheumatic disease andan autoimmune disease.
Speaker 2 (06:37):
That's a great question.
It's, you know, an autoimmunedisease is a disease where you
have your immune system that'sacting inappropriately on itself
.
Like your immune system is kindof built to fight things that
are foreign, like infections.
Sometimes it makes a mistake,so then it starts attacking
itself.
And whether it's autoimmune,where there's an issue of the
(06:58):
adaptive immune system, whereyou make memory B cells and you
kind of save it for later, orautoinflammatory disease, which
we think of like the periodicfevers, we think of it more like
kids developing, like familialMediterranean fever, but the
difference between an autoimmuneand a rheumatic condition is it
sometimes are synonymous,because we take care of so many
(07:19):
autoimmune conditions.
But I kind of think ofautoimmune as more of an
umbrella, and then rheumatic isonly one piece under it.
Because if you look at otherautoimmune conditions like
Hashimoto's, like Graves, likeinflammatory bowel disease, like
Crohn's or ulcerative colitis,you see other specialties manage
those diseases.
You wouldn't typically think ofthem as rheumatic conditions.
Speaker 1 (07:39):
Okay, so more musculoskeletal.
Speaker 2 (07:41):
Yeah, by far the most common complaint for our
patients is some sort of likejoint or musculoskeletal
complaint.
But the reality is that ourdiseases, they infiltrate every
system in the body, whether it'sthe heart.
You can develop interstitiallung disease, you can develop
pericarditis, you can developnephritis.
All these things probably havean autoimmune component as well.
(08:03):
Inflammatory bowel disease weknow that a lot of those
patients develop extraintestinal manifestations like
uveitis or even like psoriasis.
So autoimmune is like the bigoverarching umbrella term for
these, and then rheumatic isjust one part, but it's probably
the biggest part.
We collaborate with all theother subspecialties when it
comes to that, so you could saythat they're somewhat synonymous
(08:26):
.
But when you work at a placelike the Cleveland Clinic, for
example, we're all sohyper-specialized that you
typically will all collaboratetogether.
Speaker 1 (08:36):
So what are some of the more common autoimmune
conditions that might affectwomen?
Speaker 2 (08:43):
Well, the big one is lupus, for sure.
I mean, like I said, there's ahuge disparity between men and
women when it comes to lupus.
Like I said, if I line up 10people with lupus, nine of them
are women, for sure, andspecifically premenopausal women
.
We do see disparities inrheumatoid arthritis as well,
like anywhere between 70% and80% are typically leading
(09:03):
towards women.
We do have some ones that doaffect men more, like things
between 70% and 80% aretypically leading towards women.
We do have some ones that doaffect men more, like things
like ankylosing spondylitis,which typically affect men in
their 20s and 30s, but the ratiois not as strong.
It's like a three to two ratio.
So it's still like there's asignificant portion of women who
are affected by ankylosingspondylitis.
Speaker 1 (09:20):
I have several patients.
Speaker 2 (09:38):
Yeah, for sure, and a lot of them.
I have several patients way,and that's where that delay gets
, that care gets delayed.
When you think of like moremale, like male men leading
diseases you're thinking of,like the crystal arthropodes and
gout is by far the most commonautoimmune crystal arthropody
that we see but interestingly,once men, once women are
(09:58):
postmenopausal, the risk isalmost one to one.
Yes, yes, and then in advancedage, one to one, yes, yes, and
then in advanced age womenovertake them, overtake men,
right, yes, like an advancedstage they can, yeah, especially
like, like you know, startgetting into like the 70s and
80s.
You can.
We think that potentially,estrogen is protective, uh,
against gout and it can helpwith your gastric excretion, or
(10:21):
maybe that just matters, notjust much poorer, like you know,
part of it is is that we're allvery poor at handling uric acid
excretion through the kidney.
You know, when you think ofgout, you think of like king's
disease, you think of likedrinking alcohol and eating red
meat and you think of guys.
Speaker 1 (10:39):
A lot of times, but there's plenty of women who do
this moonshine alcohol yeah,exactly.
Speaker 2 (10:43):
And or you think of like the, the Moonshine alcohol
yeah, exactly.
Or you think of the guy who'sgoing to a wedding eating the
serpent herb and has a coupleextra drinks than he normally
would.
But the reality is that's onlya very small fraction of
patients with gout.
Most of it is probably underexcretion, and women are just
better at it than men are tosome degree, but once they're
(11:05):
postmenopausal again, their riskgoes up significantly.
Speaker 1 (11:08):
And then the other big.
Speaker 2 (11:09):
I'm sorry.
Speaker 1 (11:10):
No, I was just going to say.
It's so interesting thatestrogen can affect the immune
system to make younger womenwith higher estrogen levels more
prone to some of theseconditions, whereas testosterone
seems to modulate that.
On the other hand, then thelack of estrogen brings on its
own problems, includingosteoporosis, which isn't
considered classically.
(11:31):
It's not autoimmune orrheumatic, but it is the
skeleton, and so that's such ahuge hit to women.
I see a lot of women, both preand post-menopausal, with lupus,
and a lot of times the previousconventional thinking was well,
don't use any hormone therapyor birth control in them.
(11:51):
But the Salina trial showedreally that we can prescribe in
women with lupus as long as it'snot active disease with clots
and active lupus nephritis,which is pretty serious.
Speaker 2 (12:06):
Yeah, and a lot of these lupus patients are
hypercoagulable in general.
And because lupus is such aheterogeneous disease, you don't
know if a patient, even if theydon't appear to have a
hypercoagulable state, they maydevelop one in the future.
And to me they are similar tosomeone who is a smoker or
someone who is on oralcontraceptives or someone who is
sedentary.
(12:26):
So we have to be extra carefulin those patients.
Even if their workup looksrelatively okay now, it doesn't
mean in the future that they'renot going to develop more
manifestations of lupus later.
And that's a really interestingthing about women with
autoimmune conditions is a lotof times we get young women who
are in their early 20s who havethese symptoms and their workup
comes back negative.
And a lot of times where wetell people like, oh no, this is
(12:50):
not autoimmune, but they have astrong family history, they
have the right symptoms.
And to me you know, most of thetime the serologies, the blood
work, precedes the symptoms.
But that's not always the case.
A lot of sometimes the symptomsprecede them and those are
patients that we have to watchvery closely.
Speaker 1 (13:05):
Oh, that is really fascinating.
And what are your commentsabout seronegative rheumatoid
arthritis versus seropositive?
Is it harder to treat?
Is it overlaps with othersyndromes?
Speaker 2 (13:18):
Yeah, I mean seropositive is easier because
we pick it up earlier.
I think that's the biggestthing is that when the workup
comes back negative, a lot ofpeople think, well, they don't
have the disease.
But I like to tell peoplethere's not one rheumatic
condition that we can diagnosebased on just serologies alone.
It has to be a combination ofthe blood work and the symptoms.
(13:39):
A lot of times we use imagingas well, with x-rays or MRI or
ultrasound.
It's got to be a combination ofthese things together and the
right clinical picture.
If your suspicion is highenough, you got to treat.
And there are plenty ofpatients who come in with
swollen, like you know, theirhands full of synovitis, like
(14:00):
polyarticular synovitis.
In the right distribution, rightfamily history and the workup
is negative, I treat itSeronegative rheumatoid
arthritis.
To me the damage is we stillhave to treat these patients
because if you don't they can goon to develop erosive, damaging
, deforming disease in theirjoints.
But also, if you leave thesepatients with a high
inflammatory state, it's verytaxing on the body.
It puts a lot of stress on theheart and these patients can die
(14:20):
earlier of heart disease thanthey otherwise would have.
So it's not it doesn't alwayshave to fit perfectly.
Rheumatology does not fitperfectly in any box.
I like to say that thesediseases, they don't read our
textbooks.
Speaker 1 (14:33):
Exactly that's, I think, one of the reasons why I
was so attracted to the field ofrheumatology, because it really
seemed like you had to be anexpert diagnostician and you
really had to kind of go aboveand beyond.
It's certainly not somethingthat's just cookbook and
straightforward and and andsimple pathways, and then you
layer the whole complexity ofthe female life cycle on top of
(14:54):
it.
Is someone pregnant?
What's going to happen withpregnancy?
And then all the side effects,potentially with steroids.
The one thing I'll say over myvast career, I remember early on
seeing so much more deformingarthritis, subluxation of the
joints, really terrible jointdamage, and I have to say that
in recent memory I don't seem tosee patients with such
(15:16):
deformity.
Is that because all of yourtherapeutics has just advanced
so much and there's so muchchange therapies that you have
at your fingertips?
Speaker 2 (15:25):
That's exactly why.
So, whenever we have a patientwith a rheumatic condition, it's
the immune system that's actinghaywire.
And so what we have to do is wehave to modulate the immune
system and suppress the immunesystem.
And so we use medicationscalled DMARDs or
disease-modifying anti-rheumaticdrugs, and what they do is,
some of them areimmunomodulatory, some of them
are immunosuppressive, and theyprevent the body from basically
(15:49):
attacking itself.
And so, you know, since theadvent of these
disease-modifying agents youknow, methotrexate, the hallmark
one back in the 80s, wasactually a chemotherapy
medication that was brought overto rheumatology, and then also
with the advent of the biologictherapies in the late 90s and
early 2000s, I mean it'scompletely revolutionized the
(16:09):
field.
It's, you know, these patientsthat we once would see like with
horrible erosive changes orankylosing changes in the spine.
We just don't see thosepatients like that anymore.
We're catching patients earlier, so we're diagnosing these
patients earlier, we're startingthem on treatment earlier and
we're really saving them from,from these these really horrible
um things.
It's not just the, the jointsthemselves, but it's like we're
(16:32):
also preventing these extraarticular manifestations of
diseases, like, like thepericardite kid, you know,
nephritis and pericarditis anduvitis in the eyes it's, it's
all these other manifestationsthat are late stage diseases
that we're just not seeing asmuch anymore.
I think part of that is thatwe're just catching it and we
have much better medications.
I like this.
I like to say that rheumatologyis almost like a young he monk.
(16:54):
A lot of medications that weuse are very much like you know.
Here's a good way to explainexactly what rheumatology is.
My program director at StonyBrook I says this on my very
first day of fellowship.
He's like what is rheumatologyis?
My program director at StonyBrook asked us this on my very
first day of fellowship.
He's like what is rheumatology?
And we didn't know anythingback then.
We're like you know, we'refellows first day fellows.
We're like study of arthritisor autoimmune diseases.
(17:16):
He's like no, it'sinterventional immunology.
We are intervening on theimmune system to some degree and
with these medications, and Ilove that definition of
rheumatology.
Speaker 1 (17:26):
Yeah, that is fabulous.
And are you doing any kind oflike genetic assessments in
terms of trying to?
Because I know in the wholecancer field there's a lot of
genetic profiling of either thetumor or the person's own
germline mutations as to what isthe best kind of chemotherapy.
Speaker 2 (17:43):
So we're not quite there yet.
So we do some genetic testingfor diagnosis for some of our
autoinflammatory diseases likethe periodic fevers.
There's another disease calledvexus that we're also checking
genetic testing for.
Then there's also an overlapwith some of the hypermobile
diseases like Ehlers-Danlos thatwe'll do genetic testing for as
(18:04):
well, but nothing in terms oftreatment modalities yet.
I think that part of it will besynovial biopsy.
They've talked about doingsynovial biopsies that can tell
us what is the primaryinflammatory cytokine that's
really playing a role in thisspecific patient and then that
way we can gear the therapytowards that patient.
But we're not quite there yet.
But that could potentially bethe future of rheumatology.
(18:26):
They've talked about that beingthe future of rheumatology for
a while.
A lot of these new medicationscome out are essentially
different stopping points alongthat inflammatory pathway to see
which works.
But some patients you stop atTNF and it works really well,
and some patients it works atIL-6 or some patients it works
at interferon and we're not surewhy some people benefit from
(18:47):
one drug over another drug andthen they don't all have the
same response.
But I think that's the future.
It's more individualizedrheumatology, similar to the way
that oncology is where it'smuch more individualized.
Speaker 1 (18:58):
Than it used to be.
Well, you're listening to theSpeaking of Women's Health
podcast and I'm your host, DrHolly Thacker and I am
interviewing one of the onlyrheumatology, sports medicine,
internal medicine trainedphysicians in the country who is
the chief of rheumatology andat Miami Beach, Florida.
He's formerly a colleague ofmine at the Cleveland Clinic, Dr
El Gawi, and we have beentalking about autoimmune
(19:21):
conditions.
Now we're going to switch gearsand talk a little bit more
about regenerative medicine.
I've had several podcasts onanti-aging.
We've certainly focused a loton nutrition and exercise and
nutraceuticals and functionalmedicine, which I think all
potentially have a role in beingsupportive.
So I wanted to ask Dr Al-Ghawiand get your opinion on PRP,
(19:43):
platelet-rich plasma.
It seems like thedermatologists are using it for
hair loss.
The sports medicine people areusing it in athletes.
Can you talk to us about whatPRP is and where you see that
fitting in in just sportsmedicine and just rheumatic
diseases in general?
Speaker 2 (20:02):
Sure, sure I mean.
So PRP is platelet-rich plasma,and so what it is is
essentially separating plateletsfrom autologous, like whole
blood, and the way to do that isto draw the blood from the
patient, spin it in a centrifuge, separate it out and then you
inject it to wherever you needto put it.
And the idea is that it's notwe think of platelets, we think
(20:23):
of like clotting and plugging,and that's not the reason why
that's not what we're looking atwhen it comes to PRP.
We're actually looking at thegrowth factors within the
platelets, and there's a lot ofdifferent growth factors, like
ones that will help withrevascularization and ones that
help with cell regeneration, andso the idea is that all these
growth factors work together andhelp the body try to fix an
(20:43):
area that maybe had beenforgotten about, and so, like
you said, a lot ofdermatologists would use it on
like alopecia.
You know, sports medicine, andthat's the context where I use
it the most is sports medicineis we use it on osteoarthritis,
we use it on chronictendinopathy.
Those are like the two bigreasons to do it, but it's
interesting because there's nota lot of data on it in
(21:04):
rheumatology.
And so, actually, about a yearand a half ago, myself and a few
colleagues put together areview because we were
interested Like what's the dataon rheumatology using PRP?
It's an autologous bloodproduct.
There shouldn't be any sideeffects to it.
But one of the bigcontraindications to using PRP
is that in order to let the bodykind kind of repair itself, you
(21:26):
can't use anything that's goingto act as an anti-inflammatory,
like things like NSAIDs orsteroids or or steroids or our
DMARDs, and so historicallywe've always thought like, hey,
we should stay away from PRP andrheumatology.
But I wanted to see what thedata showed, and so we put
together a review and kind ofbroke it down by different
diseases.
And again, these are very smallrandomized control trials, case
(21:49):
series, case reports, so theseare not the most robust, but
there is something to glean overthis and to see hey, maybe in
the future we can get biggertrials on this.
But it seems to work.
In some of our diseases likerheumatoid arthritis they had
done almost like lacrimal glandinjections of PRP that really
help with dry eyes and Sjogren's.
It seemed to work in likediscoid lupus, with those with
(22:12):
alopecia.
It actually seemed to work onlike vasculitic ulcers of the
skin.
It seemed to repair those likevasculitic ulcers of the skin.
It seemed to repair thoseulcers as well.
Um, it actually also seemed towork on on just skin elasticity,
you know, and making the skinlike a little bit more elastic
in terms of like scleroderma,where the skin becomes a bit
more fibrotic.
It could potentially work theretoo, um, but on the other side
(22:33):
of it it actually may make somethings worse.
It looked like worse.
It looked like it triggeredpseudo-gout flares in some
patients when they got it intheir joints.
So the verdict is still out tosee how useful it is in
rheumatic disease, but it seemspretty promising and, like I
said before, side effects areminimal because it's your own
blood.
You're not going to have areaction to your own blood.
(22:54):
So I think it's very promising,especially in those really
refractory diseases where, likealopecia is historically very
difficult to treat.
In lupus, it can be reallyuseful in cases like that.
Speaker 1 (23:06):
Oh, that is so exciting to hear.
Since it's consideredexperimental, I imagine a lot of
insurances won't pay for it, soit is self-pay.
Speaker 2 (23:16):
It's self-pay, it's not FDA approved and the reason
why it's not is because it's astandardization formula.
So every person who uses it,they have their own standardized
protocol.
And when you look at thestudies, the number of platelets
are always different, whetherit's leukocyte rich or leukocyte
poor.
There's no standardizationprotocol that will unify to say,
hey, this is consistentlyworking.
(23:36):
There's a lot unify to say that, hey, this is consistently
working.
There's a lot of data to showthat, hey, prp is no better than
placebo.
In some of these cases, theregenerative orthopedic
community seems to think thatthose studies just have the
platelets are just too low, thecounts are way too low.
We should be boosting thosecounts significantly.
And in those in that newerliterature it seems to be
(23:57):
working a lot more.
So I would say, ask me thatquestion in like five years and
I think that We'll have you back.
Yeah, I think that there's goingto be a lot of, there's going
to be more data coming outthat's going to seem to work
more consistently, and then,when it works more consistently
and there's a standardizedprotocol, I think it will get
FDA approved.
Speaker 1 (24:16):
Now what about patients that have platelet
disorders Like I?
Have a fair number of womenwith essential thrombocytosis.
Their platelet levels arereally high.
Would that mean it's better toget their platelets because they
have more or because they'rediseased and have something,
some myeloproliferative problem,that you wouldn't use their own
platelets?
Speaker 2 (24:36):
I don't think that there's necessarily.
If it's thrombocytosis, forexample, I don't think that you
would necessarily have an issuewith that.
I don't know the data behindthat, but it's again, it's the
growth factors.
So you may just need less PRPin general to get the same
number of growth factors.
I'd probably stay away in thosewho are thrombocytopenic
because you'd have to draw a lotmore and maybe the growth
(24:56):
factors might not be as robust.
But I don't know the databehind using PRP in those with
thrombotic disorders.
I'm sure that a lot of thosepatients in those studies are
probably excluded.
Speaker 1 (25:11):
Probably as usual, and then you just have to get
more experience with widespreaduse.
Now in my patient populationmost of the patients I see have
degenerative arthritis.
We certainly see a lot offrozen shoulder in women, which
we think may in part be relatedto changes in low estrogen, as
well as diabetes or trauma, andthat can be very painful, and
(25:34):
different tendinopathies who askme about PRP and different
tendinopathies who ask me aboutPRP and I would imagine if it's
bone on bone then you're notgoing to get into regeneration
and then you're talking aboutorthopedic surgery referrals.
Speaker 2 (25:48):
Yeah, Women definitely have an increased
risk of developingosteoarthritis.
Men have an increased risk ofdeveloping traumatic
osteoarthritis than women do.
But women have moredegenerative primary
osteoarthritis than women do.
But women have moredegenerative like primary
osteoarthritis than men do,especially in the weight-bearing
joints.
And I think part of that is theQ angle you know women tend to.
Their hips tend to be a littlebit wider, so the vector of
(26:08):
their weight doesn't go straightdown through their knee and
their ankle so there might bemore stress on the knee and
ankle and hip compared to men.
I think a big part of it ismuscle mass.
I think that women, especiallypostmenopausal women, they lose
bone and muscle mass a littlebit quicker than men do,
especially bone mass.
And so women who, let's say, donot do a lot of resistance
(26:31):
training, they developosteoarthritis for sure faster
than the men do, developosteoarthritis for sure faster
than the men do.
Speaker 1 (26:37):
I think women have less cartilage than men too, so
that puts them at another risk.
And then the whole bodyshifting and tendon shifting
with pregnancy, I imagine isquite a stress yeah.
Speaker 2 (26:50):
Yeah, I mean, I think , especially when it comes to
just laxity in general, likewomen's ligaments and the
tendons and the and and and thecartilage tends to be a little
bit more lax, and that part ofit is to accommodate, uh, the
changes in a woman, in a woman'sbody.
Um, men, just we, just ourbodies just don't change to the
same degree that women's dothroughout our lifetime, and so,
(27:10):
uh, our, our, our tendons andour ligaments tend to be a bit,
a little bit more stable and,like I said, the vector of the
weight tends to go a little bitmore through the whole joint
instead of off to the side alittle bit.
So I think that thatcontributes to it as well.
I do think that losing thatmuscle mass, especially as we
get older, plays a very big role.
Speaker 1 (27:31):
And of course men have so much more testosterone
like 10 times the amount womendo which of course affects the
immune system and makes themless likely to get autoimmune
conditions but maybe more likelyto have other problems, because
the immune system is nothyperactive.
Do you think that thetestosterone has a modulatory
effect at all at the cartilagelevel, or do you think it's just
muscular?
Speaker 2 (27:53):
I'm not sure.
I think that just having moretestosterone will lead to more
muscle mass in general and willtake less stress off the joint.
A lot of the movement that wedo should be muscle maintained
and the joint should really bemore for motion.
The muscle should be doing thework, not as much as the joint.
When the muscle's not there,the joint has to take over and I
(28:14):
think that's what leads toearly arthritis in a lot of
these patients, especially thosewho do not take care of
themselves later in their life.
Speaker 1 (28:20):
So all the more reason listeners, strength
training, stretching, aerobics,excellent nutrition, boosting
your vitamin D I certainly Ihave a lot of referrals from the
rheumatologist for joint painthat there's no cause and they
send them to me for hormones andsometimes there's dramatic
improvements in joint pain.
And a lot of times I find thatso many patients in northern
(28:43):
climates maybe not as much atMiami Beach, but certainly low
vitamin D seems to propagate alot of joint and autoimmune and
other conditions.
Speaker 2 (28:55):
I agree with you.
I totally agree and otherconditions.
Speaker 1 (29:01):
I agree with you.
I totally agree, and one of myfirst podcasts in season three
was all about vitamin D.
Now what other treatments doyou like to recommend for joint
disease in women?
Speaker 2 (29:12):
So from a lifestyle perspective, I think that the
gut is intimately related to therest of the immune system as
well, so eating a lot of natural, healthy, whole foods.
Our body's not meant to eatultra-processed food.
You can have it every once in awhile, but it's just not very
digestible and so it puts a lotof stress on the body and
hyper-inflammation in the gut.
(29:32):
So I do think that that is apart of it as well, and when it
comes to certain diets, Itypically tell patients try to
eat whole foods, stay on theperiphery of the grocery store,
try to stay away from the aislesthemselves.
That's where all thehyper-processed or
ultra-processed stuff are.
When it comes to certain diets,the autoimmune or
auto-inflammatory diet isessentially the Mediterranean
(29:53):
diet, and I think the reason whythat one's a good one to do is
because it's easy to adhere to.
I think because it's a lot ofleafy greens, it's a lot of lean
meats, it's a lot of olive oil,lemon water and it tastes good.
It's easy to adhere to, asopposed to going low carb or
paleo, which a lot of patientsafter a few months really hit a
wall and they just can't stickto it.
(30:13):
After a little while, I thinkdiet is a huge part of it.
Like you, you touched on vitamind.
I think I, I, I, I very muchagree.
I've seen patients in thesingle digits with vitamin d
levels and uh who are who arejust you, have chronic pain
everywhere and you correct thatlevel and they feel so much
better.
I think it also plays a role inin in terms of uh, their immune
(30:34):
system, in terms of justinfectious disease.
These patients tend to developless infections in general.
So I think that that plays abig role too.
I think turmeric is a nice mildanti-inflammatory that's also
good in your diet.
And then I think thatresistance training taking care
of your body, making sure thatyour muscles stay really strong
(30:55):
I think resistance training isone of the best forms of
exercise.
I think yoga and flexibilitytraining is really useful in our
rheumatic patients, especiallyones like with ankylosing
spondylitis, where the spinestarts to become more rigid.
But resistance training isparamount, I think, especially
for women, especially as theyget close to menopause.
I think there's nothing thatwill help a woman with her bone
(31:16):
health more than making her bodystronger.
Speaker 1 (31:20):
Yeah, that is excellent and that is our motto
be strong, be healthy and be incharge.
And so do you ever recommendfish oil or omega-3s, I know,
for sometimes people use it fordry eyes.
Do you think there's a role inthat?
I've been increasingly checkingomega-3 levels in my patients
and I'm hardly finding anyonewho's normal.
And so getting that omega-3,omega-6 balance, getting the
(31:43):
seed oils out of the diet, Ithink there's probably something
to that.
Speaker 2 (31:47):
There could be, and I do recommend omega-3 fish oil,
but in terms of the data behindit, in terms of rheumatic
disease, it's just not there.
We're just not sure.
But I think it's good.
Even if you don't have arheumatic condition, I think
it's useful.
Speaker 1 (32:01):
And one old, forgotten, cheap treatment that
I know they use a lot inveterinary medicine DMSO, which
I think officially in allopathicmedicine.
We just have been using forchronic interstitial cystitis
locally, but it's a solvent thatI know is used a lot in
veterinary medicine and a lot ofathletes claim that when they
have muscle injury they rub thaton.
(32:22):
Just wondered if you had anythoughts about that.
Speaker 2 (32:26):
Not for our rheumatic patients Again, maybe for the
athletes, but in our rheumaticpatients it's very rare with
swollen joints, with theimmune-related swollen joints, I
don't see a role for it.
Speaker 1 (32:40):
And so, for typical injuries, it's the RICE, which
is rest, ice compression,elevation, those physical
maneuvers and I would even takeice out of it.
Speaker 2 (32:51):
I think even the person who invented that term.
Even they say ice is probablynot that helpful.
It may give you some reliefwhen you have the ice on, but
the moment you take it off therelief goes away, and I do think
that when it comes to muscularpain, it'll actually tighten
your muscles up and make iteasier to develop muscle spasm
from it.
Speaker 1 (33:11):
So more heat especially after 24 hours.
Speaker 2 (33:16):
Yes, I think heat probably works better, but again
, these are in injuries.
I would not use it in arheumatic patient with a warm
swollen joint.
Speaker 1 (33:24):
Oh, no, you know what I mean.
Speaker 2 (33:27):
I mean, the heat will probably make it worse.
The ice will give you reliefwhile it's on there, but what
you really need is you need some.
You usually need a DMARD.
You usually need a short-termof corticosteroids to bridge
with one of our rheumaticmedications.
Speaker 1 (33:39):
And DMARD is disease-modifying rheumatic
anti-inflammatory drugs.
Speaker 2 (33:45):
Disease-modifying anti-rheumatic drugs, or DMARDs.
Yeah, so those are themedications that you see.
If you see commercials on TV ofpeople flying kites and dancing
on the beach, probably one ofour medications in rheumatology.
So, yes, and if you see thelist, the entire long list of
all the side effects, probablyone of our medications.
(34:06):
They are historically prettysafe, but whenever you're going
to get one of these medications,you've got to talk to your
doctor about is it right for youor not, if you have a different
condition that could make thismedication difficult to
metabolize we need to know.
Speaker 1 (34:22):
So really, with these kind of serious rheumatic
conditions, you really need tosee an expert rheumatologist as
well as see your primary carephysician and kind of get
regular and close follow-upbecause, like you said, it is
like chemo chemotherapy.
Speaker 2 (34:34):
So tell us to some degree, yeah we're so grateful
um you joining us.
Speaker 1 (34:39):
How can people make an appointment with you, because
I know we have people inFlorida who listen to our
podcast.
Speaker 2 (34:46):
Yeah, so if you want to make an appointment with me,
I'm going to be starting off asthe chief of rheumatology at
Mount Sinai Medical Center inMiami Beach, florida, so you'll
be able to find all mycredentials online to find that
I'm still working on getting anoffice number and once I do, I
can always send that to you toattach to this podcast if you'd
like to.
Speaker 1 (35:05):
But yes, they could go ahead.
This will air in 2025 in ourseason three.
So, yeah, we will include allof that in the show notes and
any personal or professionalsocial media you have that we
want to link up to at all.
Speaker 2 (35:20):
Yeah, sure, you can follow me on X, formerly known
as Twitter, I think at Ahmed ElGawi DO, or I may have to look
exactly and see what I wrote onthere, but I can also include
that as part of it as well, ifyou want to connect and follow
me.
A lot of times I do kind of youknow, retweet a lot of the
(35:42):
newer data coming out inrheumatology.
So, yeah, you can follow me onthere.
Speaker 1 (35:48):
Well, that is great, and I would just like to thank
our listeners for tuning in tothe Speaking of Women's Health
podcast.
We're so grateful for yoursupport and your listening.
Please share our podcast withothers, leave a five-star rating
and to catch all the latestfrom us, you can subscribe on
Apple Podcasts, spotify, tuneinor wherever you listen to
(36:08):
podcasts.
You can bookmark our websitespeakingofwomanshealthcom.
We have free treatmentguidebooks, we're on all the
social media and all of this isfree.
So thanks again for listeningand we look forward to seeing
you next time in the SunflowerHouse.
Be strong, be healthy and be incharge.
Welcome to the Speaking of Women's Health
podcast.
I'm your host, dr Holly Thacker, the Executive Director of
Speaking of Women's Health, andI am glad to be back in the
Sunflower House for a newepisode.
For a new episode.
(00:30):
Joining me on today's newpodcast episode for Speaking of
Women's Health is Dr AhmedEl-Gawi, and I'd like to tell
our listeners a little bit abouthim.
Very interesting guy.
He completed his undergraduateeducation at Yersinus College,
where he graduated cum laudewith a Bachelor's of Science in
Psychology.
And then he went on to medicalschool and earned his degree at
(00:54):
Nova South Eastern UniversityCollege of Osteopathic Medicine
in Fort Lauderdale, florida,fort Lauderdale, florida.
And then he went on to completean internal medicine residency
at Mount Sinai Medical Center inMiami Beach, florida.
And then he went on to completepostgraduate fellowship
(01:14):
training in rheumatology at SUNYStony Brook University Hospital
in Stony Brook, new York.
And then he did a fellowship inprimary care sports medicine at
University Hospitals atCleveland Medical Center in
Cleveland, ohio.
So that makes Dr El-Gawi one ofthe few physicians in the
(01:37):
entire nation who is tripleboard certified in internal
medicine, rheumatology andsports medicine.
And I met Dr Elgawi when he wasworking at the Cleveland
Clinic's Department of Rheumaticand Immunologic Diseases, where
he practiced both rheumatologyand arthritis, and
(01:58):
musculoskeletal health.
He's got a special interest inpracticing musculoskeletal
medicine, treating systemicrheumatic disease,
rehabilitating athletes withsports-related injury and
performing musculoskeletalguided procedures.
He's a girl dad and he got abig promotion and he has left
(02:23):
and he is now in sunny MiamiBeach, florida, the head of
rheumatology.
Welcome, dr Elgawi, and tell uswhere you're at right now and
thank you so much for joining uswith your move and new baby.
Speaker 2 (02:40):
Oh, what an introduction.
Thank you so much.
Yeah, it's, yes, I just movedfrom Cleveland Ohio where we
both practiced together atCleveland Clinic.
I moved actually back to whereI did my residency at Mount
Sinai Medical Center and will bethe chief of rheumatology at
that department there.
So a little bit of a move forus and I'm still in the process
of that move and that's why myoffice is still being built.
(03:00):
So that's why I'm kind of inthe hallway right now.
But yeah, so far it's beenreally, really nice and I'm
really excited to talk with youbecause we've shared patients
before and I think it's reallyimportant to talk about
rheumatology when we talk aboutwomen's health.
I mean, I think rheumatology islike a key focus on that.
It's kind of missed frequently.
Speaker 1 (03:22):
It is.
In fact, when I came to theCleveland Clinic, I initially
came to do my internal medicinetraining because I was going to
be a cardiologist and didn'twant to move my husband twice.
But my second love wasrheumatology and I spent a lot
of time in the rheumatologydepartment, had my clinic there
A lot of my mentors wererheumatologists, was really
close with Dr John Clough whowas a chair for a long time, and
(03:43):
it always struck me that reallyrheumatology in a lot of
respects is a woman's healthfield, because so many
autoimmune diseases occur inwomen.
And why are women more likelyto develop autoimmune diseases
compared to men?
Speaker 2 (03:59):
It's really, really strange because probably 20
years ago I probably would nothave really had an answer at all
.
We just we just noticed that inthe data there's a clear
disparity of leaning towardswomen, especially premenopausal
women, that they are much moreprone to developing autoimmune
diseases.
There's a there's a fewtheories.
One could be that there mightbe potentially like a hormonal
(04:20):
component to it, and thenspecifically estrogen, and
that's why you maybe see womenwho develop these diseases in
their childbearing years andspecifically it could be the
surge of hormone changes,specifically around puberty or
pregnancy, postpartum and thenaround menopause, which are kind
of areas where we see a littlebit of an uptick in these
(04:43):
diseases, and then, when they'repostmenopausal, we start to see
that the risk of developingautoimmune diseases gets a
little bit closer to a man's.
So we do think that there'spotentially a hormonal component
.
There's also the thought thatthis could be genetic, that
women have two X chromosomes menreally only have one, and when
it comes to X chromosomes, oneof them is active and one of
(05:05):
them is deactivated, and ZIST isthe RNA molecule that
deactivates that, and there's athought that potentially that
deactivation could cause animmune surge, and so that's why
you may potentially see anautoimmune increase in women.
The reality is, we're not 100%sure.
We know that there is a geneticcomponent.
(05:28):
For sure People who have familymembers with autoimmune
diseases tend to have themthemselves.
We've seen this in identicaltwins.
There's definitely a geneticcomponent, but there's
potentially an environmentalcomponent as well.
Let's think about rheumatoidarthritis, for example.
Rheumatoid arthritis we knowthat smoking is linked to
rheumatoid arthritis and that'sbecause we've seen the antibody,
(05:48):
the anti-CCP antibody, which isvery specific for rheumatoid
arthritis, being released in thelung and those who smoke, and
we see it also released in thegums and those who have poor
dentition or a lot of gingivaldisease.
It's probably a perfect storm,like the right genetics, the
right environment, the rightfamily history, being a woman,
all those things combined givewomen a much higher risk, and
(06:11):
it's not every disease is likethat.
If you look at rheumatoidarthritis, probably 70 to 80% of
those cases are women, but ifyou look at lupus, for example,
90 plus percent.
There's a clear disparity.
But if you gave me one reason,I'm like I can't give you one
specific reason.
I think I think it's acombination.
Speaker 1 (06:30):
And tell our listeners what's the difference
between a rheumatic disease andan autoimmune disease.
Speaker 2 (06:37):
That's a great question.
It's, you know, an autoimmunedisease is a disease where you
have your immune system that'sacting inappropriately on itself
.
Like your immune system is kindof built to fight things that
are foreign, like infections.
Sometimes it makes a mistake,so then it starts attacking
itself.
And whether it's autoimmune,where there's an issue of the
(06:58):
adaptive immune system, whereyou make memory B cells and you
kind of save it for later, orautoinflammatory disease, which
we think of like the periodicfevers, we think of it more like
kids developing, like familialMediterranean fever, but the
difference between an autoimmuneand a rheumatic condition is it
sometimes are synonymous,because we take care of so many
(07:19):
autoimmune conditions.
But I kind of think ofautoimmune as more of an
umbrella, and then rheumatic isonly one piece under it.
Because if you look at otherautoimmune conditions like
Hashimoto's, like Graves, likeinflammatory bowel disease, like
Crohn's or ulcerative colitis,you see other specialties manage
those diseases.
You wouldn't typically think ofthem as rheumatic conditions.
Speaker 1 (07:39):
Okay, so more musculoskeletal.
Speaker 2 (07:41):
Yeah, by far the most common complaint for our
patients is some sort of likejoint or musculoskeletal
complaint.
But the reality is that ourdiseases, they infiltrate every
system in the body, whether it'sthe heart.
You can develop interstitiallung disease, you can develop
pericarditis, you can developnephritis.
All these things probably havean autoimmune component as well.
(08:03):
Inflammatory bowel disease weknow that a lot of those
patients develop extraintestinal manifestations like
uveitis or even like psoriasis.
So autoimmune is like the bigoverarching umbrella term for
these, and then rheumatic isjust one part, but it's probably
the biggest part.
We collaborate with all theother subspecialties when it
comes to that, so you could saythat they're somewhat synonymous
(08:26):
.
But when you work at a placelike the Cleveland Clinic, for
example, we're all sohyper-specialized that you
typically will all collaboratetogether.
Speaker 1 (08:36):
So what are some of the more common autoimmune
conditions that might affectwomen?
Speaker 2 (08:43):
Well, the big one is lupus, for sure.
I mean, like I said, there's ahuge disparity between men and
women when it comes to lupus.
Like I said, if I line up 10people with lupus, nine of them
are women, for sure, andspecifically premenopausal women
.
We do see disparities inrheumatoid arthritis as well,
like anywhere between 70% and80% are typically leading
(09:03):
towards women.
We do have some ones that doaffect men more, like things
between 70% and 80% aretypically leading towards women.
We do have some ones that doaffect men more, like things
like ankylosing spondylitis,which typically affect men in
their 20s and 30s, but the ratiois not as strong.
It's like a three to two ratio.
So it's still like there's asignificant portion of women who
are affected by ankylosingspondylitis.
Speaker 1 (09:20):
I have several patients.
Speaker 2 (09:38):
Yeah, for sure, and a lot of them.
I have several patients way,and that's where that delay gets
, that care gets delayed.
When you think of like moremale, like male men leading
diseases you're thinking of,like the crystal arthropodes and
gout is by far the most commonautoimmune crystal arthropody
that we see but interestingly,once men, once women are
(09:58):
postmenopausal, the risk isalmost one to one.
Yes, yes, and then in advancedage, one to one, yes, yes, and
then in advanced age womenovertake them, overtake men,
right, yes, like an advancedstage they can, yeah, especially
like, like you know, startgetting into like the 70s and
80s.
You can.
We think that potentially,estrogen is protective, uh,
against gout and it can helpwith your gastric excretion, or
(10:21):
maybe that just matters, notjust much poorer, like you know,
part of it is is that we're allvery poor at handling uric acid
excretion through the kidney.
You know, when you think ofgout, you think of like king's
disease, you think of likedrinking alcohol and eating red
meat and you think of guys.
Speaker 1 (10:39):
A lot of times, but there's plenty of women who do
this moonshine alcohol yeah,exactly.
Speaker 2 (10:43):
And or you think of like the, the Moonshine alcohol
yeah, exactly.
Or you think of the guy who'sgoing to a wedding eating the
serpent herb and has a coupleextra drinks than he normally
would.
But the reality is that's onlya very small fraction of
patients with gout.
Most of it is probably underexcretion, and women are just
better at it than men are tosome degree, but once they're
(11:05):
postmenopausal again, their riskgoes up significantly.
Speaker 1 (11:08):
And then the other big.
Speaker 2 (11:09):
I'm sorry.
Speaker 1 (11:10):
No, I was just going to say.
It's so interesting thatestrogen can affect the immune
system to make younger womenwith higher estrogen levels more
prone to some of theseconditions, whereas testosterone
seems to modulate that.
On the other hand, then thelack of estrogen brings on its
own problems, includingosteoporosis, which isn't
considered classically.
(11:31):
It's not autoimmune orrheumatic, but it is the
skeleton, and so that's such ahuge hit to women.
I see a lot of women, both preand post-menopausal, with lupus,
and a lot of times the previousconventional thinking was well,
don't use any hormone therapyor birth control in them.
(11:51):
But the Salina trial showedreally that we can prescribe in
women with lupus as long as it'snot active disease with clots
and active lupus nephritis,which is pretty serious.
Speaker 2 (12:06):
Yeah, and a lot of these lupus patients are
hypercoagulable in general.
And because lupus is such aheterogeneous disease, you don't
know if a patient, even if theydon't appear to have a
hypercoagulable state, they maydevelop one in the future.
And to me they are similar tosomeone who is a smoker or
someone who is on oralcontraceptives or someone who is
sedentary.
(12:26):
So we have to be extra carefulin those patients.
Even if their workup looksrelatively okay now, it doesn't
mean in the future that they'renot going to develop more
manifestations of lupus later.
And that's a really interestingthing about women with
autoimmune conditions is a lotof times we get young women who
are in their early 20s who havethese symptoms and their workup
comes back negative.
And a lot of times where wetell people like, oh no, this is
(12:50):
not autoimmune, but they have astrong family history, they
have the right symptoms.
And to me you know, most of thetime the serologies, the blood
work, precedes the symptoms.
But that's not always the case.
A lot of sometimes the symptomsprecede them and those are
patients that we have to watchvery closely.
Speaker 1 (13:05):
Oh, that is really fascinating.
And what are your commentsabout seronegative rheumatoid
arthritis versus seropositive?
Is it harder to treat?
Is it overlaps with othersyndromes?
Speaker 2 (13:18):
Yeah, I mean seropositive is easier because
we pick it up earlier.
I think that's the biggestthing is that when the workup
comes back negative, a lot ofpeople think, well, they don't
have the disease.
But I like to tell peoplethere's not one rheumatic
condition that we can diagnosebased on just serologies alone.
It has to be a combination ofthe blood work and the symptoms.
(13:39):
A lot of times we use imagingas well, with x-rays or MRI or
ultrasound.
It's got to be a combination ofthese things together and the
right clinical picture.
If your suspicion is highenough, you got to treat.
And there are plenty ofpatients who come in with
swollen, like you know, theirhands full of synovitis, like
(14:00):
polyarticular synovitis.
In the right distribution, rightfamily history and the workup
is negative, I treat itSeronegative rheumatoid
arthritis.
To me the damage is we stillhave to treat these patients
because if you don't they can goon to develop erosive, damaging
, deforming disease in theirjoints.
But also, if you leave thesepatients with a high
inflammatory state, it's verytaxing on the body.
It puts a lot of stress on theheart and these patients can die
(14:20):
earlier of heart disease thanthey otherwise would have.
So it's not it doesn't alwayshave to fit perfectly.
Rheumatology does not fitperfectly in any box.
I like to say that thesediseases, they don't read our
textbooks.
Speaker 1 (14:33):
Exactly that's, I think, one of the reasons why I
was so attracted to the field ofrheumatology, because it really
seemed like you had to be anexpert diagnostician and you
really had to kind of go aboveand beyond.
It's certainly not somethingthat's just cookbook and
straightforward and and andsimple pathways, and then you
layer the whole complexity ofthe female life cycle on top of
(14:54):
it.
Is someone pregnant?
What's going to happen withpregnancy?
And then all the side effects,potentially with steroids.
The one thing I'll say over myvast career, I remember early on
seeing so much more deformingarthritis, subluxation of the
joints, really terrible jointdamage, and I have to say that
in recent memory I don't seem tosee patients with such
(15:16):
deformity.
Is that because all of yourtherapeutics has just advanced
so much and there's so muchchange therapies that you have
at your fingertips?
Speaker 2 (15:25):
That's exactly why.
So, whenever we have a patientwith a rheumatic condition, it's
the immune system that's actinghaywire.
And so what we have to do is wehave to modulate the immune
system and suppress the immunesystem.
And so we use medicationscalled DMARDs or
disease-modifying anti-rheumaticdrugs, and what they do is,
some of them areimmunomodulatory, some of them
are immunosuppressive, and theyprevent the body from basically
(15:49):
attacking itself.
And so, you know, since theadvent of these
disease-modifying agents youknow, methotrexate, the hallmark
one back in the 80s, wasactually a chemotherapy
medication that was brought overto rheumatology, and then also
with the advent of the biologictherapies in the late 90s and
early 2000s, I mean it'scompletely revolutionized the
(16:09):
field.
It's, you know, these patientsthat we once would see like with
horrible erosive changes orankylosing changes in the spine.
We just don't see thosepatients like that anymore.
We're catching patients earlier, so we're diagnosing these
patients earlier, we're startingthem on treatment earlier and
we're really saving them from,from these these really horrible
um things.
It's not just the, the jointsthemselves, but it's like we're
(16:32):
also preventing these extraarticular manifestations of
diseases, like, like thepericardite kid, you know,
nephritis and pericarditis anduvitis in the eyes it's, it's
all these other manifestationsthat are late stage diseases
that we're just not seeing asmuch anymore.
I think part of that is thatwe're just catching it and we
have much better medications.
I like this.
I like to say that rheumatologyis almost like a young he monk.
(16:54):
A lot of medications that weuse are very much like you know.
Here's a good way to explainexactly what rheumatology is.
My program director at StonyBrook I says this on my very
first day of fellowship.
He's like what is rheumatologyis?
My program director at StonyBrook asked us this on my very
first day of fellowship.
He's like what is rheumatology?
And we didn't know anythingback then.
We're like you know, we'refellows first day fellows.
We're like study of arthritisor autoimmune diseases.
(17:16):
He's like no, it'sinterventional immunology.
We are intervening on theimmune system to some degree and
with these medications, and Ilove that definition of
rheumatology.
Speaker 1 (17:26):
Yeah, that is fabulous.
And are you doing any kind oflike genetic assessments in
terms of trying to?
Because I know in the wholecancer field there's a lot of
genetic profiling of either thetumor or the person's own
germline mutations as to what isthe best kind of chemotherapy.
Speaker 2 (17:43):
So we're not quite there yet.
So we do some genetic testingfor diagnosis for some of our
autoinflammatory diseases likethe periodic fevers.
There's another disease calledvexus that we're also checking
genetic testing for.
Then there's also an overlapwith some of the hypermobile
diseases like Ehlers-Danlos thatwe'll do genetic testing for as
(18:04):
well, but nothing in terms oftreatment modalities yet.
I think that part of it will besynovial biopsy.
They've talked about doingsynovial biopsies that can tell
us what is the primaryinflammatory cytokine that's
really playing a role in thisspecific patient and then that
way we can gear the therapytowards that patient.
But we're not quite there yet.
But that could potentially bethe future of rheumatology.
(18:26):
They've talked about that beingthe future of rheumatology for
a while.
A lot of these new medicationscome out are essentially
different stopping points alongthat inflammatory pathway to see
which works.
But some patients you stop atTNF and it works really well,
and some patients it works atIL-6 or some patients it works
at interferon and we're not surewhy some people benefit from
(18:47):
one drug over another drug andthen they don't all have the
same response.
But I think that's the future.
It's more individualizedrheumatology, similar to the way
that oncology is where it'smuch more individualized.
Speaker 1 (18:58):
Than it used to be.
Well, you're listening to theSpeaking of Women's Health
podcast and I'm your host, DrHolly Thacker and I am
interviewing one of the onlyrheumatology, sports medicine,
internal medicine trainedphysicians in the country who is
the chief of rheumatology andat Miami Beach, Florida.
He's formerly a colleague ofmine at the Cleveland Clinic, Dr
El Gawi, and we have beentalking about autoimmune
(19:21):
conditions.
Now we're going to switch gearsand talk a little bit more
about regenerative medicine.
I've had several podcasts onanti-aging.
We've certainly focused a loton nutrition and exercise and
nutraceuticals and functionalmedicine, which I think all
potentially have a role in beingsupportive.
So I wanted to ask Dr Al-Ghawiand get your opinion on PRP,
(19:43):
platelet-rich plasma.
It seems like thedermatologists are using it for
hair loss.
The sports medicine people areusing it in athletes.
Can you talk to us about whatPRP is and where you see that
fitting in in just sportsmedicine and just rheumatic
diseases in general?
Speaker 2 (20:02):
Sure, sure I mean.
So PRP is platelet-rich plasma,and so what it is is
essentially separating plateletsfrom autologous, like whole
blood, and the way to do that isto draw the blood from the
patient, spin it in a centrifuge, separate it out and then you
inject it to wherever you needto put it.
And the idea is that it's notwe think of platelets, we think
(20:23):
of like clotting and plugging,and that's not the reason why
that's not what we're looking atwhen it comes to PRP.
We're actually looking at thegrowth factors within the
platelets, and there's a lot ofdifferent growth factors, like
ones that will help withrevascularization and ones that
help with cell regeneration, andso the idea is that all these
growth factors work together andhelp the body try to fix an
(20:43):
area that maybe had beenforgotten about, and so, like
you said, a lot ofdermatologists would use it on
like alopecia.
You know, sports medicine, andthat's the context where I use
it the most is sports medicineis we use it on osteoarthritis,
we use it on chronictendinopathy.
Those are like the two bigreasons to do it, but it's
interesting because there's nota lot of data on it in
(21:04):
rheumatology.
And so, actually, about a yearand a half ago, myself and a few
colleagues put together areview because we were
interested Like what's the dataon rheumatology using PRP?
It's an autologous bloodproduct.
There shouldn't be any sideeffects to it.
But one of the bigcontraindications to using PRP
is that in order to let the bodykind kind of repair itself, you
(21:26):
can't use anything that's goingto act as an anti-inflammatory,
like things like NSAIDs orsteroids or or steroids or our
DMARDs, and so historicallywe've always thought like, hey,
we should stay away from PRP andrheumatology.
But I wanted to see what thedata showed, and so we put
together a review and kind ofbroke it down by different
diseases.
And again, these are very smallrandomized control trials, case
(21:49):
series, case reports, so theseare not the most robust, but
there is something to glean overthis and to see hey, maybe in
the future we can get biggertrials on this.
But it seems to work.
In some of our diseases likerheumatoid arthritis they had
done almost like lacrimal glandinjections of PRP that really
help with dry eyes and Sjogren's.
It seemed to work in likediscoid lupus, with those with
(22:12):
alopecia.
It actually seemed to work onlike vasculitic ulcers of the
skin.
It seemed to repair those likevasculitic ulcers of the skin.
It seemed to repair thoseulcers as well.
Um, it actually also seemed towork on on just skin elasticity,
you know, and making the skinlike a little bit more elastic
in terms of like scleroderma,where the skin becomes a bit
more fibrotic.
It could potentially work theretoo, um, but on the other side
(22:33):
of it it actually may make somethings worse.
It looked like worse.
It looked like it triggeredpseudo-gout flares in some
patients when they got it intheir joints.
So the verdict is still out tosee how useful it is in
rheumatic disease, but it seemspretty promising and, like I
said before, side effects areminimal because it's your own
blood.
You're not going to have areaction to your own blood.
(22:54):
So I think it's very promising,especially in those really
refractory diseases where, likealopecia is historically very
difficult to treat.
In lupus, it can be reallyuseful in cases like that.
Speaker 1 (23:06):
Oh, that is so exciting to hear.
Since it's consideredexperimental, I imagine a lot of
insurances won't pay for it, soit is self-pay.
Speaker 2 (23:16):
It's self-pay, it's not FDA approved and the reason
why it's not is because it's astandardization formula.
So every person who uses it,they have their own standardized
protocol.
And when you look at thestudies, the number of platelets
are always different, whetherit's leukocyte rich or leukocyte
poor.
There's no standardizationprotocol that will unify to say,
hey, this is consistentlyworking.
(23:36):
There's a lot unify to say that, hey, this is consistently
working.
There's a lot of data to showthat, hey, prp is no better than
placebo.
In some of these cases, theregenerative orthopedic
community seems to think thatthose studies just have the
platelets are just too low, thecounts are way too low.
We should be boosting thosecounts significantly.
And in those in that newerliterature it seems to be
(23:57):
working a lot more.
So I would say, ask me thatquestion in like five years and
I think that We'll have you back.
Yeah, I think that there's goingto be a lot of, there's going
to be more data coming outthat's going to seem to work
more consistently, and then,when it works more consistently
and there's a standardizedprotocol, I think it will get
FDA approved.
Speaker 1 (24:16):
Now what about patients that have platelet
disorders Like I?
Have a fair number of womenwith essential thrombocytosis.
Their platelet levels arereally high.
Would that mean it's better toget their platelets because they
have more or because they'rediseased and have something,
some myeloproliferative problem,that you wouldn't use their own
platelets?
Speaker 2 (24:36):
I don't think that there's necessarily.
If it's thrombocytosis, forexample, I don't think that you
would necessarily have an issuewith that.
I don't know the data behindthat, but it's again, it's the
growth factors.
So you may just need less PRPin general to get the same
number of growth factors.
I'd probably stay away in thosewho are thrombocytopenic
because you'd have to draw a lotmore and maybe the growth
(24:56):
factors might not be as robust.
But I don't know the databehind using PRP in those with
thrombotic disorders.
I'm sure that a lot of thosepatients in those studies are
probably excluded.
Speaker 1 (25:11):
Probably as usual, and then you just have to get
more experience with widespreaduse.
Now in my patient populationmost of the patients I see have
degenerative arthritis.
We certainly see a lot offrozen shoulder in women, which
we think may in part be relatedto changes in low estrogen, as
well as diabetes or trauma, andthat can be very painful, and
(25:34):
different tendinopathies who askme about PRP and different
tendinopathies who ask me aboutPRP and I would imagine if it's
bone on bone then you're notgoing to get into regeneration
and then you're talking aboutorthopedic surgery referrals.
Speaker 2 (25:48):
Yeah, Women definitely have an increased
risk of developingosteoarthritis.
Men have an increased risk ofdeveloping traumatic
osteoarthritis than women do.
But women have moredegenerative primary
osteoarthritis than women do.
But women have moredegenerative like primary
osteoarthritis than men do,especially in the weight-bearing
joints.
And I think part of that is theQ angle you know women tend to.
Their hips tend to be a littlebit wider, so the vector of
(26:08):
their weight doesn't go straightdown through their knee and
their ankle so there might bemore stress on the knee and
ankle and hip compared to men.
I think a big part of it ismuscle mass.
I think that women, especiallypostmenopausal women, they lose
bone and muscle mass a littlebit quicker than men do,
especially bone mass.
And so women who, let's say, donot do a lot of resistance
(26:31):
training, they developosteoarthritis for sure faster
than the men do, developosteoarthritis for sure faster
than the men do.
Speaker 1 (26:37):
I think women have less cartilage than men too, so
that puts them at another risk.
And then the whole bodyshifting and tendon shifting
with pregnancy, I imagine isquite a stress yeah.
Speaker 2 (26:50):
Yeah, I mean, I think , especially when it comes to
just laxity in general, likewomen's ligaments and the
tendons and the and and and thecartilage tends to be a little
bit more lax, and that part ofit is to accommodate, uh, the
changes in a woman, in a woman'sbody.
Um, men, just we, just ourbodies just don't change to the
same degree that women's dothroughout our lifetime, and so,
(27:10):
uh, our, our, our tendons andour ligaments tend to be a bit,
a little bit more stable and,like I said, the vector of the
weight tends to go a little bitmore through the whole joint
instead of off to the side alittle bit.
So I think that thatcontributes to it as well.
I do think that losing thatmuscle mass, especially as we
get older, plays a very big role.
Speaker 1 (27:31):
And of course men have so much more testosterone
like 10 times the amount womendo which of course affects the
immune system and makes themless likely to get autoimmune
conditions but maybe more likelyto have other problems, because
the immune system is nothyperactive.
Do you think that thetestosterone has a modulatory
effect at all at the cartilagelevel, or do you think it's just
muscular?
Speaker 2 (27:53):
I'm not sure.
I think that just having moretestosterone will lead to more
muscle mass in general and willtake less stress off the joint.
A lot of the movement that wedo should be muscle maintained
and the joint should really bemore for motion.
The muscle should be doing thework, not as much as the joint.
When the muscle's not there,the joint has to take over and I
(28:14):
think that's what leads toearly arthritis in a lot of
these patients, especially thosewho do not take care of
themselves later in their life.
Speaker 1 (28:20):
So all the more reason listeners, strength
training, stretching, aerobics,excellent nutrition, boosting
your vitamin D I certainly Ihave a lot of referrals from the
rheumatologist for joint painthat there's no cause and they
send them to me for hormones andsometimes there's dramatic
improvements in joint pain.
And a lot of times I find thatso many patients in northern
(28:43):
climates maybe not as much atMiami Beach, but certainly low
vitamin D seems to propagate alot of joint and autoimmune and
other conditions.
Speaker 2 (28:55):
I agree with you.
I totally agree and otherconditions.
Speaker 1 (29:01):
I agree with you.
I totally agree, and one of myfirst podcasts in season three
was all about vitamin D.
Now what other treatments doyou like to recommend for joint
disease in women?
Speaker 2 (29:12):
So from a lifestyle perspective, I think that the
gut is intimately related to therest of the immune system as
well, so eating a lot of natural, healthy, whole foods.
Our body's not meant to eatultra-processed food.
You can have it every once in awhile, but it's just not very
digestible and so it puts a lotof stress on the body and
hyper-inflammation in the gut.
(29:32):
So I do think that that is apart of it as well, and when it
comes to certain diets, Itypically tell patients try to
eat whole foods, stay on theperiphery of the grocery store,
try to stay away from the aislesthemselves.
That's where all thehyper-processed or
ultra-processed stuff are.
When it comes to certain diets,the autoimmune or
auto-inflammatory diet isessentially the Mediterranean
(29:53):
diet, and I think the reason whythat one's a good one to do is
because it's easy to adhere to.
I think because it's a lot ofleafy greens, it's a lot of lean
meats, it's a lot of olive oil,lemon water and it tastes good.
It's easy to adhere to, asopposed to going low carb or
paleo, which a lot of patientsafter a few months really hit a
wall and they just can't stickto it.
(30:13):
After a little while, I thinkdiet is a huge part of it.
Like you, you touched on vitamind.
I think I, I, I, I very muchagree.
I've seen patients in thesingle digits with vitamin d
levels and uh who are who arejust you, have chronic pain
everywhere and you correct thatlevel and they feel so much
better.
I think it also plays a role inin in terms of uh, their immune
(30:34):
system, in terms of justinfectious disease.
These patients tend to developless infections in general.
So I think that that plays abig role too.
I think turmeric is a nice mildanti-inflammatory that's also
good in your diet.
And then I think thatresistance training taking care
of your body, making sure thatyour muscles stay really strong
(30:55):
I think resistance training isone of the best forms of
exercise.
I think yoga and flexibilitytraining is really useful in our
rheumatic patients, especiallyones like with ankylosing
spondylitis, where the spinestarts to become more rigid.
But resistance training isparamount, I think, especially
for women, especially as theyget close to menopause.
I think there's nothing thatwill help a woman with her bone
(31:16):
health more than making her bodystronger.
Speaker 1 (31:20):
Yeah, that is excellent and that is our motto
be strong, be healthy and be incharge.
And so do you ever recommendfish oil or omega-3s, I know,
for sometimes people use it fordry eyes.
Do you think there's a role inthat?
I've been increasingly checkingomega-3 levels in my patients
and I'm hardly finding anyonewho's normal.
And so getting that omega-3,omega-6 balance, getting the
(31:43):
seed oils out of the diet, Ithink there's probably something
to that.
Speaker 2 (31:47):
There could be, and I do recommend omega-3 fish oil,
but in terms of the data behindit, in terms of rheumatic
disease, it's just not there.
We're just not sure.
But I think it's good.
Even if you don't have arheumatic condition, I think
it's useful.
Speaker 1 (32:01):
And one old, forgotten, cheap treatment that
I know they use a lot inveterinary medicine DMSO, which
I think officially in allopathicmedicine.
We just have been using forchronic interstitial cystitis
locally, but it's a solvent thatI know is used a lot in
veterinary medicine and a lot ofathletes claim that when they
have muscle injury they rub thaton.
(32:22):
Just wondered if you had anythoughts about that.
Speaker 2 (32:26):
Not for our rheumatic patients Again, maybe for the
athletes, but in our rheumaticpatients it's very rare with
swollen joints, with theimmune-related swollen joints, I
don't see a role for it.
Speaker 1 (32:40):
And so, for typical injuries, it's the RICE, which
is rest, ice compression,elevation, those physical
maneuvers and I would even takeice out of it.
Speaker 2 (32:51):
I think even the person who invented that term.
Even they say ice is probablynot that helpful.
It may give you some reliefwhen you have the ice on, but
the moment you take it off therelief goes away, and I do think
that when it comes to muscularpain, it'll actually tighten
your muscles up and make iteasier to develop muscle spasm
from it.
Speaker 1 (33:11):
So more heat especially after 24 hours.
Speaker 2 (33:16):
Yes, I think heat probably works better, but again
, these are in injuries.
I would not use it in arheumatic patient with a warm
swollen joint.
Speaker 1 (33:24):
Oh, no, you know what I mean.
Speaker 2 (33:27):
I mean, the heat will probably make it worse.
The ice will give you reliefwhile it's on there, but what
you really need is you need some.
You usually need a DMARD.
You usually need a short-termof corticosteroids to bridge
with one of our rheumaticmedications.
Speaker 1 (33:39):
And DMARD is disease-modifying rheumatic
anti-inflammatory drugs.
Speaker 2 (33:45):
Disease-modifying anti-rheumatic drugs, or DMARDs.
Yeah, so those are themedications that you see.
If you see commercials on TV ofpeople flying kites and dancing
on the beach, probably one ofour medications in rheumatology.
So, yes, and if you see thelist, the entire long list of
all the side effects, probablyone of our medications.
(34:06):
They are historically prettysafe, but whenever you're going
to get one of these medications,you've got to talk to your
doctor about is it right for youor not, if you have a different
condition that could make thismedication difficult to
metabolize we need to know.
Speaker 1 (34:22):
So really, with these kind of serious rheumatic
conditions, you really need tosee an expert rheumatologist as
well as see your primary carephysician and kind of get
regular and close follow-upbecause, like you said, it is
like chemo chemotherapy.
Speaker 2 (34:34):
So tell us to some degree, yeah we're so grateful
um you joining us.
Speaker 1 (34:39):
How can people make an appointment with you, because
I know we have people inFlorida who listen to our
podcast.
Speaker 2 (34:46):
Yeah, so if you want to make an appointment with me,
I'm going to be starting off asthe chief of rheumatology at
Mount Sinai Medical Center inMiami Beach, florida, so you'll
be able to find all mycredentials online to find that
I'm still working on getting anoffice number and once I do, I
can always send that to you toattach to this podcast if you'd
like to.
Speaker 1 (35:05):
But yes, they could go ahead.
This will air in 2025 in ourseason three.
So, yeah, we will include allof that in the show notes and
any personal or professionalsocial media you have that we
want to link up to at all.
Speaker 2 (35:20):
Yeah, sure, you can follow me on X, formerly known
as Twitter, I think at Ahmed ElGawi DO, or I may have to look
exactly and see what I wrote onthere, but I can also include
that as part of it as well, ifyou want to connect and follow
me.
A lot of times I do kind of youknow, retweet a lot of the
(35:42):
newer data coming out inrheumatology.
So, yeah, you can follow me onthere.
Speaker 1 (35:48):
Well, that is great, and I would just like to thank
our listeners for tuning in tothe Speaking of Women's Health
podcast.
We're so grateful for yoursupport and your listening.
Please share our podcast withothers, leave a five-star rating
and to catch all the latestfrom us, you can subscribe on
Apple Podcasts, spotify, tuneinor wherever you listen to
(36:08):
podcasts.
You can bookmark our websitespeakingofwomanshealthcom.
We have free treatmentguidebooks, we're on all the
social media and all of this isfree.
So thanks again for listeningand we look forward to seeing
you next time in the SunflowerHouse.
Be strong, be healthy and be incharge.
Popular Podcasts
40s and Free Agents: NFL Draft Season
Daniel Jeremiah of Move the Sticks and Gregg Rosenthal of NFL Daily join forces to break down every team's needs this offseason.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
Las Culturistas with Matt Rogers and Bowen Yang
Ding dong! Join your culture consultants, Matt Rogers and Bowen Yang, on an unforgettable journey into the beating heart of CULTURE. Alongside sizzling special guests, they GET INTO the hottest pop-culture moments of the day and the formative cultural experiences that turned them into Culturistas. Produced by the Big Money Players Network and iHeartRadio.