April 27, 2023 • 47 mins
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
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
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 1 (00:35):
Have experienced joint pain.
Speaker 3 (00:37):
It's definitely moodiness, it's crankiness, it's stress.
Speaker 4 (00:41):
Sleep deprivation, brain fog, irritability.
Speaker 3 (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.
Speaker 5 (00:52):
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
(01:16):
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 Up
Call by going to Katiecouric dot com.
Speaker 3 (01:41):
So to be here.
Speaker 5 (01:44):
Have you been on the show before?
Speaker 6 (01:46):
On the podcast?
Speaker 2 (01:46):
I have not done her podcast.
Speaker 1 (01:47):
We've done like we are really going to be getting
down and dirty here today, ladies.
Speaker 2 (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 2 (02:06):
Very excited. It's a big deal. 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 unbelievable, 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. 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
(02:36):
to be talking about nights, wets. We're going to be
talking about all sorts of fun things. So you too,
pretty jazzy.
Speaker 5 (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 7 (03:03):
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 and 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
(03:48):
and it had just gone up. And that was what
we started hearing over and over and over again that
every woman who was in some big group text thread.
I clearly am not in enough of those, but they
were getting them from all side that it was just circulating,
and the comments started pouring in and on the one
as I said, it seems sort of like, yes, of course,
that people would be relieved and surprised to see all
(04:09):
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 5 (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 obg yns.
Speaker 2 (04:35):
What was your reaction. I was so excited. I met
Susan att list falls NAMS meeting. Well, explain what North
America Menopause Society meeting in Atlanta. I knew she was
working on the article and the morning I think came
out initially online and then it subsequently was in print
a couple days later. It is the greatest article. It
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 7 (05:38):
I actually really 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 5 (05:49):
Wow, I'm amazing. I'm addressed the presence I now.
Speaker 7 (05:53):
He came to me and said I think we, and
my wonderful editor, Elna Silverman as well said, I think
we should do an article about METAP, but was a
very big, baggy topic. I didn't know where to begin.
Speaker 1 (06:03):
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 of sleep every night, disruptions that chipped
(06:24):
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 that she sat her twelve year
(06:46):
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 just want to say that
(07:07):
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 7 (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 5 (08:04):
Absolutely?
Speaker 2 (08:05):
And It's interesting. 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 7 (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, but 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 that was the cause. It wasn't you know,
(09:10):
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 5 (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 5 (09:37):
So as hormone.
Speaker 2 (09:39):
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 women there will
(10:02):
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 no discussion. They're
(10:23):
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 been
so impacted by the inability to sleep, brain fog, and
(10:47):
people say, what, it's not me, it's not me. 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 this CBS evening News and
I didn't want to have like a brain fart in
the middle of the even 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 5 (12:12):
You have to think, and it does.
Speaker 7 (12:14):
You can't help but think that it is about a
discomfort with not just female sexuality, but aging women's sexuality.
Speaker 5 (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 7 (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 guynecologists 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.
Speaker 5 (13:11):
Know, it's completely disrupting her life.
Speaker 7 (13:14):
I think increasingly they're 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 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.
(13:36):
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, it might just be
easier to move on. I mean, that's sort of the
impression I get.
Speaker 2 (13:52):
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 for you. 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. So it's tough. And I also think doctors
don't necessarily, you know, want to take the time. They
(14:14):
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 vatinal 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 7 (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 it'll never stop. So I think that it's not
(14:55):
something that in general kind of collegist sir excited to
talk about it.
Speaker 1 (14:58):
That quote made me laugh out last. 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 3 (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, but there's this
ring of gray haired ladies in the back and they're
not really saying anything other than we're so happy for you.
But there's like this black box that happens of like, Okay,
(15:33):
you're gonna have to figure this out for yourself.
Speaker 5 (15:35):
It kind of feels like that. It feels like a frontier.
Speaker 1 (15:39):
We'll be right back.
Speaker 4 (15:47):
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, deper to depression, to vaginal dryness,
and with being so transparent, you just don't feel alone
(16:09):
in all of this. You know you're not the only
one going through this.
Speaker 1 (16:12):
To say the very 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. Let's talk now about
(16:36):
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 director who started
(16:56):
the WHI. So let's start by talking about what that
trial was designed to do.
Speaker 7 (17:03):
So it was the largest all women trial, as you say,
and it was trying to answer a couple of different 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.
(17:23):
But there had been a lot of observational studies that
suggested that when women went on hormones they saw lower
rates of cardiovasculars.
Speaker 1 (17:31):
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 7 (17:45):
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 (18:00):
But there was some concerns about estrogen. I guess doctor
Brightman where maybe this breast cancer question was kind of
looming large.
Speaker 2 (18:08):
Right, 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,
(18:30):
and that really has to be teased apart before we
talk about it getting halted. 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.
So what happened is it was finally realized that you know,
women were using just estrogen alone, and then it became
(18:51):
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
earning prest risk of getting endometrial cancer cancer of the
uterine lining. So by the addition of progestogen progesterone being
one of them, you can medigal reculate and you can
mitigate the increased risks. So in women with the uterus
(19:13):
who were going to use metopausal homown 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 (19:24):
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. Why it was stopped.
Speaker 7 (19:42):
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 (19:52):
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 use estrogen alone.
And it's so interesting because estrogen is what gets the
bad rep but in the group that again estrogen alone
no increased risk.
Speaker 1 (20:08):
So it got changed mid stream.
Speaker 7 (20:11):
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 (20:31):
I remember covering this back 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 7 (20:45):
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
scared right.
Speaker 1 (21:00):
In fact, the coverage was pretty breathless, and I would say,
in retrospect, unintentionally alarmist. You talk about an interview that
Ann Curry did on the Today Show.
Speaker 8 (21:10):
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
the study. Sylvia good Night.
Speaker 1 (21:29):
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 8 (21:39):
The effects were, what made it ethically impossible to continue
the study?
Speaker 6 (21:44):
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
for heart disease.
Speaker 8 (22:00):
Disease, 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 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.
Speaker 5 (22:18):
So what are we.
Speaker 8 (22:18):
Telling women the six million women in America today who
are taking HRT.
Speaker 1 (22:24):
So how did these numbers get so misunderstood or misreported?
Speaker 7 (22:29):
Well, they were definitely not misreported.
Speaker 5 (22:31):
They were accurate.
Speaker 7 (22:32):
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.
Speaker 1 (22:41):
And what did it translate into?
Speaker 7 (22:43):
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 means now you've elevated it to a two point
nine to four percent. So you know that in the
grand scheme of things, everybody can have their own comfort
level with a two point nine to four percent risk
(23:03):
and how much you've increased it. But that's not I
don't think how women heard it at the time.
Speaker 1 (23:08):
And in fact, you say smoking, by contrast, increases cancer
risk by two thousand and six hundred percent.
Speaker 5 (23:14):
That's a risk.
Speaker 1 (23:16):
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 it for the last thirty years.
Speaker 2 (23:28):
Living it and continue to live it. It was unbelievable.
For the second I walked into the office, the phones
were ringing like crazy, and 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
(23:49):
still get to face women who say this to me
all the time. But it was quite remarkable. It really
was something else.
Speaker 1 (23:55):
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 that carried on throughout the
decades they've been practicing medicine.
Speaker 5 (24:13):
Right, that is exactly right.
Speaker 7 (24:14):
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
(24:35):
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 (24:41):
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 (24:52):
The most important thing is for women to realize that.
I think women take this information they say, how does
it affect me well. The truth of the matter is
the 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. So it
(25:14):
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 olds. 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 and thought,
(25:38):
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 (25:43):
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 (25:53):
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.
Speaker 5 (26:05):
We still use them.
Speaker 2 (26:07):
However, there was a really you know, the number of
prescriptions that were being written for the combination dropped dramatically,
and unfortunately it 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
proved wonderful bioidentical options. You can get them through any
(26:30):
commercial pharmacy. But I think people were so worried about
safety that they started going to physicians who would prescribe
lotions and potions, 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
(26:50):
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. And there were safer bioidentical options, but you
needed to discuss it with your physician.
Speaker 1 (27:03):
Right, But also, what about synthetic hormos. Haven't they been
vastly improved since this study?
Speaker 2 (27:09):
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 layup.
We don't pick them from a tree. Interesting.
Speaker 1 (27:21):
We're going to take a break, but when we come back,
we're going to answer some 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 3 (27:33):
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.
Speaker 5 (27:51):
It's something to respect.
Speaker 1 (27:52):
But I feel like the way I was raised, it
just wasn't.
Speaker 3 (27:55):
Talked about and it's sort of met with a shrug.
Speaker 4 (27:58):
Definitely, society could certainly be more tolerant, more mindful of
all of the issues that women have to face from
the very beginning of our lives to the very end.
(28:19):
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 (28:32):
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
(28:52):
small risks but a bigger reward. Is that a safe
thing for me to say.
Speaker 2 (28:58):
I feel so I've always felt this way. And what's
really interesting. In the United States prevent a 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. But I
think we've come a long way.
Speaker 6 (29:14):
You know.
Speaker 2 (29:14):
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 a need, and they also
may serve a role with disease prevention.
Speaker 1 (29:27):
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 (29:38):
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
(29:59):
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're only disgust to
discuss it. But if there were an increase, it would
be minuscule.
Speaker 1 (30:16):
What if you're at a high risk for breast cancer
is another question? Is HRT absolutely out of the question?
Speaker 2 (30:22):
No? No, And it depends again on family history, again
on genetic predispositions. What has to again look at the
symptoms and with appropriate counseling. It's a very individualized, personalized decision.
Speaker 1 (30:35):
Should women take hormones if they're only experiencing slight symptoms.
Speaker 2 (30:40):
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. I'm cruising through this.
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 woman.
(31:02):
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 and think, h she didn't talk to
me about this.
Speaker 1 (31:10):
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 7 (31:21):
Especially one of the doctors I interviewed, Nannette 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,
(31:41):
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 5 (31:51):
Stay on them.
Speaker 7 (31:52):
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 (32:14):
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
(32:35):
you know, I couldn't help but wonder, as Carrie Bradshaw
would say, did the patch result in my breast cancer?
Speaker 2 (32:43):
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 eight women in their thirties, forties,
or fifties. But by the time we live our lives,
(33:04):
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 (33:19):
But now that I have gotten breast cancer, I can't
go back on the patch, can I not?
Speaker 4 (33:26):
Really?
Speaker 2 (33:26):
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 (33:41):
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
(34:03):
have that causes hot flashes. Can you explain, doctor, I can.
Speaker 7 (34:09):
Explain what doctor has explained to me, which is that
the hypothalmis regulates body temperature and very rich in es.
Speaker 1 (34:16):
I'm not getting in a hot flash.
Speaker 5 (34:17):
I'm taking my sweater arouf.
Speaker 2 (34:19):
It just happens to be hot in the air appropriately enough.
Speaker 7 (34:22):
It's very sense. So the hypothalmus is rich in estrogen receptors.
It is 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,
(34:42):
and 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
(35:03):
it's 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 (35:20):
Is it the same with night sweats I got? 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 (35:37):
It's the same mechanism of action, the lack of estrogen
and the firing away of neurons in the hypothalamus.
Speaker 1 (35:44):
That's why it's so important to be able to talk
to your doctor and to really be able to share
your individual symptoms.
Speaker 2 (35:51):
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
inflammatory relationship. Estrogen changes everything. It can change the bacteria
(36:13):
that's in our gut. There's some thought that 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
(36:33):
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.
(36:55):
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 a try.
Speaker 1 (37:04):
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 (37:16):
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
(37:38):
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 down the road.
Speaker 1 (37:56):
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 do that.
Speaker 2 (38:18):
Setting that's so upsetting? 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
(38:38):
we have many options in different ways in which we
can treat our patients. So you know, whoever feels dry
as a sahara, we can make that better.
Speaker 5 (38:45):
That's the good news.
Speaker 1 (38:46):
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 (39:02):
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
(39:24):
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.
They need to be evaluated for palpitations, but that's also
(39:45):
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 (39:57):
When should women start talking to their doctors about this?
Speaker 2 (40:01):
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
(40:21):
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 7 (40:32):
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
(40:52):
who are going through you know 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 well,
which I will matterfer to doctor Brightman to discuss.
Speaker 2 (41:02):
So it's interesting because we don't we have many things
we can do after menopause. And the issue is you
can't necessarily put younger women on these these therapies because
they will probably menstruate around them and have all sorts
of bleeding that that 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 surgery. It creates hormonal neutrality. For many women,
(41:28):
that 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.
It really depends. But many women who have a hormonal IUD,
we can layer on a little estrogen through a patch,
which is it works really, really nicely. The other thing
(41:50):
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 FT proved option, peroxetine
in our country right now. The FDJA is on the
brink of approving another medication called a phesesilinit tant It
also it targets the hypothalamic thermo what we call the
(42:14):
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 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
(42:35):
to use, but the studies that are out there are
very small. Many of them are 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 (42:46):
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.
Speaker 2 (43:08):
Buyer beware, 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
(43:29):
the fact that, you know what, I'm a sexual being.
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. 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
(43:51):
can do and taking advantage of women suffering. Oh, it
breaks my heart. It breaks my heart. I have a
group of friends, fellow docs from NORTHMA 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
(44:11):
time job. So it breaks my heart because we don't
have great access to healthcare providers 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 (44:26):
I think some of the things I've learned in this
conversation and through reading your great articles, Susan, 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, which
(44:51):
makes me wonder is this indicative of how women's health
issues have been treated historically?
Speaker 2 (45:00):
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 NAA has designated money that
will go into researching women women's healthcare. But this is
(45:23):
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 (45:42):
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 7 (45:50):
You know, I think I would just quote Rebecca Thurston,
who's a metapausal 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
(46:12):
population for women suffering and it was a really grim assessment,
but it's very hard to argue with it.
Speaker 1 (46:19):
Well, hopefully things will change thanks to articles like yours
and conversations like this. Doctor Becky Brightman and Susan Dominus,
thank you so much. This was great.
Speaker 2 (46:30):
Thank you.
Speaker 5 (46:30):
Thanks so much having me on. It's been wonderful.
Speaker 1 (46:34):
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 oh nine five point two five
to five oh 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 Couric Media.
(46:57):
The executive producers are Me, Katie Couric and Courtney Ltz.
Our supervising producer is Marcy Thompson. Our producers are Adrianna
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,
(47:20):
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 1 (00:35):
Have experienced joint pain.
Speaker 3 (00:37):
It's definitely moodiness, it's crankiness, it's stress.
Speaker 4 (00:41):
Sleep deprivation, brain fog, irritability.
Speaker 3 (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.
Speaker 5 (00:52):
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
(01:16):
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 Up
Call by going to Katiecouric dot com.
Speaker 3 (01:41):
So to be here.
Speaker 5 (01:44):
Have you been on the show before?
Speaker 6 (01:46):
On the podcast?
Speaker 2 (01:46):
I have not done her podcast.
Speaker 1 (01:47):
We've done like we are really going to be getting
down and dirty here today, ladies.
Speaker 2 (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 2 (02:06):
Very excited. It's a big deal. 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 unbelievable, 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. 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
(02:36):
to be talking about nights, wets. We're going to be
talking about all sorts of fun things. So you too,
pretty jazzy.
Speaker 5 (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 7 (03:03):
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 and 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
(03:48):
and it had just gone up. And that was what
we started hearing over and over and over again that
every woman who was in some big group text thread.
I clearly am not in enough of those, but they
were getting them from all side that it was just circulating,
and the comments started pouring in and on the one
as I said, it seems sort of like, yes, of course,
that people would be relieved and surprised to see all
(04:09):
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 5 (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 obg yns.
Speaker 2 (04:35):
What was your reaction. I was so excited. I met
Susan att list falls NAMS meeting. Well, explain what North
America Menopause Society meeting in Atlanta. I knew she was
working on the article and the morning I think came
out initially online and then it subsequently was in print
a couple days later. It is the greatest article. It
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 7 (05:38):
I actually really 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 5 (05:49):
Wow, I'm amazing. I'm addressed the presence I now.
Speaker 7 (05:53):
He came to me and said I think we, and
my wonderful editor, Elna Silverman as well said, I think
we should do an article about METAP, but was a
very big, baggy topic. I didn't know where to begin.
Speaker 1 (06:03):
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 of sleep every night, disruptions that chipped
(06:24):
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 that she sat her twelve year
(06:46):
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 just want to say that
(07:07):
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 7 (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 5 (08:04):
Absolutely?
Speaker 2 (08:05):
And It's interesting. 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 7 (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, but 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 that was the cause. It wasn't you know,
(09:10):
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 5 (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 5 (09:37):
So as hormone.
Speaker 2 (09:39):
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 women there will
(10:02):
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 no discussion. They're
(10:23):
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 been
so impacted by the inability to sleep, brain fog, and
(10:47):
people say, what, it's not me, it's not me. 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 this CBS evening News and
I didn't want to have like a brain fart in
the middle of the even 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 5 (12:12):
You have to think, and it does.
Speaker 7 (12:14):
You can't help but think that it is about a
discomfort with not just female sexuality, but aging women's sexuality.
Speaker 5 (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 7 (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 guynecologists 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.
Speaker 5 (13:11):
Know, it's completely disrupting her life.
Speaker 7 (13:14):
I think increasingly they're 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 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.
(13:36):
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, it might just be
easier to move on. I mean, that's sort of the
impression I get.
Speaker 2 (13:52):
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 for you. 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. So it's tough. And I also think doctors
don't necessarily, you know, want to take the time. They
(14:14):
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 vatinal 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 7 (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 it'll never stop. So I think that it's not
(14:55):
something that in general kind of collegist sir excited to
talk about it.
Speaker 1 (14:58):
That quote made me laugh out last. 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 3 (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, but there's this
ring of gray haired ladies in the back and they're
not really saying anything other than we're so happy for you.
But there's like this black box that happens of like, Okay,
(15:33):
you're gonna have to figure this out for yourself.
Speaker 5 (15:35):
It kind of feels like that. It feels like a frontier.
Speaker 1 (15:39):
We'll be right back.
Speaker 4 (15:47):
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, deper to depression, to vaginal dryness,
and with being so transparent, you just don't feel alone
(16:09):
in all of this. You know you're not the only
one going through this.
Speaker 1 (16:12):
To say the very 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. Let's talk now about
(16:36):
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 director who started
(16:56):
the WHI. So let's start by talking about what that
trial was designed to do.
Speaker 7 (17:03):
So it was the largest all women trial, as you say,
and it was trying to answer a couple of different 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.
(17:23):
But there had been a lot of observational studies that
suggested that when women went on hormones they saw lower
rates of cardiovasculars.
Speaker 1 (17:31):
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 7 (17:45):
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 (18:00):
But there was some concerns about estrogen. I guess doctor
Brightman where maybe this breast cancer question was kind of
looming large.
Speaker 2 (18:08):
Right, 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,
(18:30):
and that really has to be teased apart before we
talk about it getting halted. 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.
So what happened is it was finally realized that you know,
women were using just estrogen alone, and then it became
(18:51):
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
earning prest risk of getting endometrial cancer cancer of the
uterine lining. So by the addition of progestogen progesterone being
one of them, you can medigal reculate and you can
mitigate the increased risks. So in women with the uterus
(19:13):
who were going to use metopausal homown 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 (19:24):
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. Why it was stopped.
Speaker 7 (19:42):
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 (19:52):
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 use estrogen alone.
And it's so interesting because estrogen is what gets the
bad rep but in the group that again estrogen alone
no increased risk.
Speaker 1 (20:08):
So it got changed mid stream.
Speaker 7 (20:11):
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 (20:31):
I remember covering this back 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 7 (20:45):
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
scared right.
Speaker 1 (21:00):
In fact, the coverage was pretty breathless, and I would say,
in retrospect, unintentionally alarmist. You talk about an interview that
Ann Curry did on the Today Show.
Speaker 8 (21:10):
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
the study. Sylvia good Night.
Speaker 1 (21:29):
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 8 (21:39):
The effects were, what made it ethically impossible to continue
the study?
Speaker 6 (21:44):
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
for heart disease.
Speaker 8 (22:00):
Disease, 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 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.
Speaker 5 (22:18):
So what are we.
Speaker 8 (22:18):
Telling women the six million women in America today who
are taking HRT.
Speaker 1 (22:24):
So how did these numbers get so misunderstood or misreported?
Speaker 7 (22:29):
Well, they were definitely not misreported.
Speaker 5 (22:31):
They were accurate.
Speaker 7 (22:32):
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.
Speaker 1 (22:41):
And what did it translate into?
Speaker 7 (22:43):
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 means now you've elevated it to a two point
nine to four percent. So you know that in the
grand scheme of things, everybody can have their own comfort
level with a two point nine to four percent risk
(23:03):
and how much you've increased it. But that's not I
don't think how women heard it at the time.
Speaker 1 (23:08):
And in fact, you say smoking, by contrast, increases cancer
risk by two thousand and six hundred percent.
Speaker 5 (23:14):
That's a risk.
Speaker 1 (23:16):
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 it for the last thirty years.
Speaker 2 (23:28):
Living it and continue to live it. It was unbelievable.
For the second I walked into the office, the phones
were ringing like crazy, and 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
(23:49):
still get to face women who say this to me
all the time. But it was quite remarkable. It really
was something else.
Speaker 1 (23:55):
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 that carried on throughout the
decades they've been practicing medicine.
Speaker 5 (24:13):
Right, that is exactly right.
Speaker 7 (24:14):
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
(24:35):
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 (24:41):
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 (24:52):
The most important thing is for women to realize that.
I think women take this information they say, how does
it affect me well. The truth of the matter is
the 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. So it
(25:14):
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 olds. 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 and thought,
(25:38):
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 (25:43):
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 (25:53):
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.
Speaker 5 (26:05):
We still use them.
Speaker 2 (26:07):
However, there was a really you know, the number of
prescriptions that were being written for the combination dropped dramatically,
and unfortunately it 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
proved wonderful bioidentical options. You can get them through any
(26:30):
commercial pharmacy. But I think people were so worried about
safety that they started going to physicians who would prescribe
lotions and potions, 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
(26:50):
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. And there were safer bioidentical options, but you
needed to discuss it with your physician.
Speaker 1 (27:03):
Right, But also, what about synthetic hormos. Haven't they been
vastly improved since this study?
Speaker 2 (27:09):
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 layup.
We don't pick them from a tree. Interesting.
Speaker 1 (27:21):
We're going to take a break, but when we come back,
we're going to answer some 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 3 (27:33):
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.
Speaker 5 (27:51):
It's something to respect.
Speaker 1 (27:52):
But I feel like the way I was raised, it
just wasn't.
Speaker 3 (27:55):
Talked about and it's sort of met with a shrug.
Speaker 4 (27:58):
Definitely, society could certainly be more tolerant, more mindful of
all of the issues that women have to face from
the very beginning of our lives to the very end.
(28:19):
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 (28:32):
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
(28:52):
small risks but a bigger reward. Is that a safe
thing for me to say.
Speaker 2 (28:58):
I feel so I've always felt this way. And what's
really interesting. In the United States prevent a 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. But I
think we've come a long way.
Speaker 6 (29:14):
You know.
Speaker 2 (29:14):
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 a need, and they also
may serve a role with disease prevention.
Speaker 1 (29:27):
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 (29:38):
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
(29:59):
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're only disgust to
discuss it. But if there were an increase, it would
be minuscule.
Speaker 1 (30:16):
What if you're at a high risk for breast cancer
is another question? Is HRT absolutely out of the question?
Speaker 2 (30:22):
No? No, And it depends again on family history, again
on genetic predispositions. What has to again look at the
symptoms and with appropriate counseling. It's a very individualized, personalized decision.
Speaker 1 (30:35):
Should women take hormones if they're only experiencing slight symptoms.
Speaker 2 (30:40):
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. I'm cruising through this.
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 woman.
(31:02):
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 and think, h she didn't talk to
me about this.
Speaker 1 (31:10):
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 7 (31:21):
Especially one of the doctors I interviewed, Nannette 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,
(31:41):
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 5 (31:51):
Stay on them.
Speaker 7 (31:52):
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 (32:14):
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
(32:35):
you know, I couldn't help but wonder, as Carrie Bradshaw
would say, did the patch result in my breast cancer?
Speaker 2 (32:43):
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 eight women in their thirties, forties,
or fifties. But by the time we live our lives,
(33:04):
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 (33:19):
But now that I have gotten breast cancer, I can't
go back on the patch, can I not?
Speaker 4 (33:26):
Really?
Speaker 2 (33:26):
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 (33:41):
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
(34:03):
have that causes hot flashes. Can you explain, doctor, I can.
Speaker 7 (34:09):
Explain what doctor has explained to me, which is that
the hypothalmis regulates body temperature and very rich in es.
Speaker 1 (34:16):
I'm not getting in a hot flash.
Speaker 5 (34:17):
I'm taking my sweater arouf.
Speaker 2 (34:19):
It just happens to be hot in the air appropriately enough.
Speaker 7 (34:22):
It's very sense. So the hypothalmus is rich in estrogen receptors.
It is 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,
(34:42):
and 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
(35:03):
it's 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 (35:20):
Is it the same with night sweats I got? 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 (35:37):
It's the same mechanism of action, the lack of estrogen
and the firing away of neurons in the hypothalamus.
Speaker 1 (35:44):
That's why it's so important to be able to talk
to your doctor and to really be able to share
your individual symptoms.
Speaker 2 (35:51):
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
inflammatory relationship. Estrogen changes everything. It can change the bacteria
(36:13):
that's in our gut. There's some thought that 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
(36:33):
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.
(36:55):
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 a try.
Speaker 1 (37:04):
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 (37:16):
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
(37:38):
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 down the road.
Speaker 1 (37:56):
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 do that.
Speaker 2 (38:18):
Setting that's so upsetting? 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
(38:38):
we have many options in different ways in which we
can treat our patients. So you know, whoever feels dry
as a sahara, we can make that better.
Speaker 5 (38:45):
That's the good news.
Speaker 1 (38:46):
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 (39:02):
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
(39:24):
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.
They need to be evaluated for palpitations, but that's also
(39:45):
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 (39:57):
When should women start talking to their doctors about this?
Speaker 2 (40:01):
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
(40:21):
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 7 (40:32):
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
(40:52):
who are going through you know 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 well,
which I will matterfer to doctor Brightman to discuss.
Speaker 2 (41:02):
So it's interesting because we don't we have many things
we can do after menopause. And the issue is you
can't necessarily put younger women on these these therapies because
they will probably menstruate around them and have all sorts
of bleeding that that 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 surgery. It creates hormonal neutrality. For many women,
(41:28):
that 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.
It really depends. But many women who have a hormonal IUD,
we can layer on a little estrogen through a patch,
which is it works really, really nicely. The other thing
(41:50):
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 FT proved option, peroxetine
in our country right now. The FDJA is on the
brink of approving another medication called a phesesilinit tant It
also it targets the hypothalamic thermo what we call the
(42:14):
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 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
(42:35):
to use, but the studies that are out there are
very small. Many of them are 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 (42:46):
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.
Speaker 2 (43:08):
Buyer beware, 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
(43:29):
the fact that, you know what, I'm a sexual being.
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. 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
(43:51):
can do and taking advantage of women suffering. Oh, it
breaks my heart. It breaks my heart. I have a
group of friends, fellow docs from NORTHMA 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
(44:11):
time job. So it breaks my heart because we don't
have great access to healthcare providers 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 (44:26):
I think some of the things I've learned in this
conversation and through reading your great articles, Susan, 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, which
(44:51):
makes me wonder is this indicative of how women's health
issues have been treated historically?
Speaker 2 (45:00):
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 NAA has designated money that
will go into researching women women's healthcare. But this is
(45:23):
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 (45:42):
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 7 (45:50):
You know, I think I would just quote Rebecca Thurston,
who's a metapausal 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
(46:12):
population for women suffering and it was a really grim assessment,
but it's very hard to argue with it.
Speaker 1 (46:19):
Well, hopefully things will change thanks to articles like yours
and conversations like this. Doctor Becky Brightman and Susan Dominus,
thank you so much. This was great.
Speaker 2 (46:30):
Thank you.
Speaker 5 (46:30):
Thanks so much having me on. It's been wonderful.
Speaker 1 (46:34):
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 oh nine five point two five
to five oh 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 Couric Media.
(46:57):
The executive producers are Me, Katie Couric and Courtney Ltz.
Our supervising producer is Marcy Thompson. Our producers are Adrianna
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,
(47:20):
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,
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Host
Katie Couric
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