Can't Take Estrogen? Dr. Corinne Menn on Who Can, Who Can't & What's Changed

So my whole thing is I want to try to find a way for women to have their cake and eat it too. Yeah. I want you to be treated for your breast cancer. I want you to stay in your medications. And if you need to be menopausal for them, either forever or for some period of time, well, we need to support you in every other way. Because it's very hard for women to hear all the benefits of HRT and all the problems when you lose estrogen, especially early. It's scary. You know, as your process risk, cardiovascular risk goes up. And so when you hear that, you're like, you're like, well, this is depressing. This sucks. Well, maybe I shouldn't be doing these breast cancer treatments. And I'm like, no, you need to do your treatments. But we need to find a way to make them tolerable, to improve your quality of life. The views and opinions expressed on unpause are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Today on unpause, I am joined by someone who feels like she's been in my life forever. Honestly, I can't even remember when Dr. Karen Men and I first connected probably through a social media post. But from that very first exchange, she's become one of the closest people in my professional circle. She's one of the women I literally text with every single day in our group chat. And I can't imagine this work without her. Dr. Men is a board certified obstetrician gynecologist, a certified menopause practitioner, and a medical advisor in prescribing doctor at Alloy Health, a menopause telehealth platform. She's also a 24 year survivor of breast cancer and premature menopause. Her story of loss, survival, and resilience is one of the most gut-wrenching and compelling I've ever heard. And beyond her story, she has taught me and so many others what true survivorship looks like, what risk reduction really means, and why sintering the patient experience is just as important as the medicine itself. She's also shown me how quality of life is not a luxury, but the very heart of patient care. I am so excited to share this conversation with her today. If you've ever been told you can't take estrogen, or if you've been labeled high risk because of a family history, a genetic mutation, or you're a pre-viber or survivor yourself, this is an episode you cannot miss. I'm Dr. Mary Claire Haver, a board certified obstetrician gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics gynecology at the University of Texas Medical Branch. Welcome to Unposed, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. Dr. Men, welcome to Unposed. Thank you for having me. So give me some backstory. Where did you grow up? I grew up in upstate New York in a pretty rural place with my younger brother. And then did you know right away you wanted to be a doctor? Absolutely not. The famous thing is I remember sitting like in a diner with my mom when I was in high school and thinking like what am I going to be? I kind of went through this I know some career inventory list at the high school guidance counselor. I was like I was so nervous about that. But I always liked more the social sciences. So social studies, anthropology, English writing and so I was not the science girl. In fact, like when they talked about the cardiovascular system in like whatever science class, I would feel a little faint. Like I was going to pass out. So then I you know fast forward, I went to George Washington University in DC and I went in as a political science major and then pretty soon after knew that wasn't for me. And then sophomore year I'm like I'm going to be a double major in French and art history. And I was like yay. And then I was like no. And then I was like oh psychology is interesting. And then some one day I got a little brochure in my like student mailbox or whatever for this this biology and medical technology major. I just went and I was taking a required biology class and I really liked it. And I said well maybe you know women's health is interesting. Like I could do that. And I was like I'm just going to be pretty mad. And everyone was like what? You hate science. They're like what? I was like yeah I'm just going to do this. And that's it. And there you went. I liked that if I studied this I could do this and there was a clear path. Yes. My mom didn't go to college and my parents got divorced and I saw kind of where that left her in some ways. And I felt a real burden but it really made me want to have a path where I knew I was going to get a job and be able to take care of myself. But really looking back if that had not been a concern what I really wanted to be was a teacher. But there was this attitude back then and sometimes still now like oh you're not going to make any money. Why would you do that? Yeah. But that's what I liked and it's really funny because I feel like life has come full circle. Same. And now I'm a teacher. Same. And just in a different way. So my parents had they're still married. They were married. You know my father passed away but you know they made it through all the things. But my aunt several of them divorced on the young and and I kind of watched one of my aunts like had to move into like government sponsored housing because she was so destitute from her divorce. And I like remember that. So when I was growing up and making choices I'm like I have to do something where I'm not dependent on someone else for my livelihood and I can take care of any of my kids. And so I get it. Like I've got to be in the med school. I loved that. They take all the guesswork out. You just show up and here's your books and here's your classes and the biggest decision is what do I want to specialize in. So what made you pick OBGYN? So I think very early on even when I was in undergrad I says well I'm going to do this premed thing and I didn't have like a love of chemistry or physics. I just did those classes that I had to get through it. But I was really like okay I could see myself in a caring field. So that's why I was attracted to medicine. And I thought well if I'm going to be in medicine I think maternal health, women's health that just always spoke to me. So it was just very early on I just knew I was going to do something in women's health and so just OBGYN seemed like the natural thing even though I knew it was a really tough specialty. But for me it was really the only one. And then you start your residency. Your mother had a variant cancer. Yeah so I start residency in 2000 right after getting married. And so sometime in my first year residency my later in the year my mom was diagnosed with a variant cancer. Now what kind of symptoms was she having? I don't even really know. At the time it's a long story but the time my mom was not living in this country and she had called me and was like oh just to let you know tomorrow I don't know they think I have these I don't know fibroids it feels like I can actually feel it like there's a creep fruit. And my mom is very petite and thin and I suspect for a number of reasons she just let her symptoms go. So she has a surgery not in this country and she tells me everything's okay and I believed her. And what was really interesting is right before residency I got married. And when she got off the plane when I went to go pick her up before our wedding I don't know what it was as soon as she got off the plane I saw her and my very first thought and my mom is goodness she looks like she has cancer like I don't know why that thought came in my mind. I just think she was a little thinner she looked a little gonson her face but otherwise she appeared healthy. It was just this weird sense. I was not even a resident at that time finishing at medical school but you've seen enough patients to kind of know when someone's not right. So a little thought passed my mind and I let it go. So fast forward then I start residency. You know I get this call at the end of my first year and she said she had masses removed from her ovaries but everything was okay and she didn't need any further treatment. It was just a benign cyst and I was like okay and I was busy. I was in residency and she was just like you're good you do your thing girl because she was supportive of me and she wanted me to I don't think she wanted to pull me or my brother down with any burden of taking care of her. So then fast forward next year, second year of residency. I get a call September of 2001 that she's got recurrent ovarian cancer and so it was obviously spread. It was stage four and so we were kind of trying to coordinate how to get her home and what to do and all of that and it was very stressful and she was supposed to my brother was supposed to fly down and bring her back. She was in Costa Rica and the morning that she was supposed to come back. I was on call on the labor floor and my husband shows up with security from they wouldn't let people just up up to the labor from like, David, what are you doing here? And he's like come in the call room. I've got to tell you something your mom died last night. So she she she knew she was ill. She knew she was dying. She wanted to get home to us and she just didn't make it but the thing is is a week before that I thought to lump in my breast and I was just a busy resident and I was like, it's probably just a little sest, right? Right. I'll just watch it and then I get this news that my mom has passed away. And so then I go into the mode of like I was the eldest daughter. My mom is not married. She was divorced and so I had to arrange the funeral and call the relatives and get it all in order while being a resident. Yeah. And so I kind of let this little breast thing go. To let our audience understand who don't understand medical residency. This was the years before duty hour restrictions. And we were working. We trained at the same time in different institutions. We didn't know each other but we're you know, 100 hour weeks were the norm. Very normal. Yes. So huge patient loads, you know, incredibly aggressive training programs. And that's just what was built into the system. And to layer on your mother's illness, her sudden death, her funeral, all of the arrangements. She's living in Costa Rica. I didn't know this part of the story. All I knew was complicated. Your mom had died and right around that time, you found a lump in your breast. Yeah. So you were just boss to the wall. I mean, David, your husband, he is my savior. He's always been my savior. He's amazing. And he's my backbone. And you know, he helps get me through it. But you know what, when you're so busy, you don't have time to grieve or deal with anything. So I was just like, this is what I have to do. My program gave me a week off to deal with my mom's funeral. How nice of them. They were very supportive looking back. My residency program director and all my co-residents were actually incredible. And so then I, you know, came back a week later. And you know, when I came back from my mom's week, I said to myself, I was like, damn, cyst is still there. And I had had my GYN feel it. And she says, let's just watch it with a few cycles. You're too young for breast cancer. You have no family history. Wait, did she know your mom had a variant cancer? No, this was like before I felt it. And then we knew that my mom had. So like, but even back then, this was 2001. There still wasn't a lot of widespread knowledge, even in the medical community of like this hereditary breast and a varying cancer syndrome. So a lot of times people didn't put the pieces together so much. And I was like, you know what, I still feel this. My fellow residents and some of the younger attending. So I was friends with who were women. I had them check. They're like, yeah, just, you know, watch it for a couple cycles. You know, you know, it's probably a five-room and a noma. If it's still there, get it checked out. I really need to do this. So finally, December of 2001, I go in for an ultrasound. And they're like immediately want to do a biopsy. And still then I was like, I literally wasn't scared looking back. I'm like, it was like crazy. And I just kind of went home and I forgot about like them even calling me with the biopsy report. And then I was in the middle of prenatal clinic, seeing a woman, you know, for her pregnancy. And she didn't speak English. And the poor woman, you know, I get a page. There's no cell phones. And so I get the call. I answer it and the radiology resident who was sweet, got your report crin like it's, it's breast cancer. And I threw my page across the room, screamed, started hysterical crying, the poor patient. I had no idea it was going on. The nurses and doctors come running into the exam room and, you know, they whisked me away and go and comfort me. But it was a shock. And a very, very first thought was not that I was going to die. Nothing. It was that I might never be a mom. And damn, David married a lemon. No, that's what I thought. So first three days of this, like, did you go home? Did you take time off? Did you dry your tears and try to around and pick up the page again and start seeing patients? It took a very little brief time off. But I knew I had to save my time off because I knew I had a lot ahead of me. And luckily, again, I had a supportive, supportive colleagues. And remember, this was right before the holidays. It was like mid-December. And so luckily, my contacts in the medical world got me in to see the top breast surgeons and, you know, plastic surgeons in New York City. So I got a lot of access really fast. So it was a big whirlwind. And I just had to go in and and make my decisions and move forward quickly. But they gave you multiple options. They gave me multiple options because there's a young woman with breast cancer. You know, there's a lot to think about. And we've come a long way since then. But at that time, breast conserving surgery. So having a lump back to me was definitely a choice on the table, having a mastectomy on just one side was on the table, having both done. And so I got like four opinions, kind of four slightly different treatment plans. And it was the surgeon who said to me when I sat across the table and I said, what would you do if this was your sister? And she said, Corinne, I would very least do a mastectomy. But she goes, before you make a decision, I want you to go see the radiation oncologist. And I will always remember this. It was a young radiation oncologist because if you make this choice to have say a lump back to me, you're going to have to have radiation. So you should really know what that means for you. Normally, you wouldn't go see the radiation oncologist told like later. And so then I met with that radiation oncologist and she says, Corinne, you're young. You've got many years to deal with a radiated breast and that skin. If you ever wanted reconstruction, there are late side effects of radiation on on heart, et cetera. And so she's like, just think about that. And she got a lot of pushback. She told me they presented my case at grand rounds and she got a lot of pushback for like saying that to me. But I'm so glad she did because it was because of that that I was like, you're right. And I also knew myself psychologically. I was not really interested in lots of mammograms, et cetera. But I did start with just one side, even though my gut said do both because everybody kept on saying, but you could get pregnant one day and maybe breastfeed. So there was that hope. I was like, okay, well, I'll save the other breast, right? But as soon as I was done with chemotherapy, I was like, taking both off because I am not dealing with the stress of repeated screenings. And I'm not saying to anybody listening that that would be the right decision for them. But for me at the time, it just felt like the right decision. And remember, I was tested genetically and it was negative for the BRCA one and two gene at that time. And we can circle back to that. But so I wasn't under the impression that I carried this, but my mom was only 54 when she passed. I was 20 to diagnosis. I was like, something's not right with my genes. That's how I felt. So you're still a resident. You're still working all those hours. You are still managing these major surgeries. You did an outpatient mastectomy. Is that right? Yes. So I chose my breast surgeon partially because I loved the center that she was associated with. And they had this beautiful comprehensive cancer center where they had ambulatory surgery center. And she's like,, Karin, we can do your mastectomy as an outpatient. And I was like, I love that because I'm not sick. I don't need to be in the hospital. I'm not one of those sick people, right? Like, literally, that's how from a psychological standpoint, I liked that idea. It sounded great on paper. But my case was long. It went for a long time. And by the time I got out, it was like the evening. And David and I were, you know, we lived in Manhattan and we didn't have a car. And we had a ton of money at the time. They wheeled me out. And there was a yellow taxi cab to like, they shove me in there. And they brought me home. And, you know, anyone who's had surgery, especially that one that was hours long, your pump was fluid. So I had to like get up to go to the bathroom so frequently over that night. And it was in so much crushing pain on my chest, totally shell shocked. And I didn't have a mom there to take care of me. Thank God I had my my amazing mother-in-law who is like a mom to me. And so she was there to help me. It was really, really hard. And fast forward years later, when one of my friends had breast cancer, and she stayed overnight for two nights in the hospital with her mastectomy, I actually cried because I was like, wow, it was really screwed up how they treated me. And you went back to work. I went back to work. I took like a week and a half off. And I went back to work because I knew that I might need to take more time off. But I was crossing my fingers. Initially they said my lymphite was negative. But two weeks later, I got the phone call that there was a tiny area of cancer spread in my lymph node and that I was going to need someotherapy, which was very devastating. So that's why I was was trying to be efficient with my time off. So yeah, went back to work. Now let's go through the post care. The top thing on your mind when you got the diagnosis was, am I going to be a mom? Yeah. And how did that shape your future decision? So you've had your mastectomy, you're getting your chemo. And are they recommending having your ovaries removed? No, no. So before chemo, I was really lucky. So this is where I was hurt as a patient because there was a lot of times where I was dismissed. But in this I was hurt and my doctors did really value my choice to preserve fertility, which you know, for 2001, let me ask, do you think that's because you were so young? And you were so young. And because I was a doctor and because I was in New York City and luckily my oncologist is like, I'm going to get you in immediately with Dr. Octay, who fast forward presented at the Menopause Society conference last year. And he at the time was doing groundbreaking work on creating a protocol of how young or breast cancer survivors, patients who were about to undergo chemotherapy could safely, right, stimulate their ovaries and collect eggs and fertilize embryos because there was a concern, right? Like I had estrogen, so they're positive breast cancer. I was about to start chemotherapy. I knew what to follow was going to be a variant suppression. So they're nervous about IVF. We've got a lot more data and have safe fertility preservation is in that setting. But at the time, they were nervous about it. And so he had this protocol where I was given to Moxifen and that's what was used to stimulate my ovaries. So I was able to have a few embryos saved in case chemo killed my ovaries, which was a huge blessing. So I was able to enter chemo. That's not cheap. Who paid for this? Insurance. Oh, thank God. Yes, but they probably, well, I'm not going to even get started insurance now. But it was interesting. We like, you know, it was a long time ago. This is almost 25 years ago. And my husband was at a big bank. So we had a really good insurance policy. But we never saw a dime. We never saw a bell. And we all know, I think in the past 25 years, that's all changed for the worst. So I was very lucky. I never had any problems with insurance. But now I think a lot of the things might have been barriers. So you have some embryos frozen and then you go back to work. I go right back to work, start my chemo. And the beginning of chemo was hard, but I kind of, I was okay with it at first. And my program director allowed me to not take call. So I did as much clinic time and daytime work as I could. And my fellow residents picked up the call, which I'm forever grateful, because it was a huge burden on them. But it really became after months and months of chemo. So as I was making that six month mark, it was just, it was getting so brutal, the side effects of chemo. And at the time, I thought it was the chemo. But I know now is, it was the induced menopause from the toxicity of chemo on my ovaries. I didn't realize that me calling my husband at one o'clock in the afternoon saying, I feel like I'm calling out of my skin and I want to jump out a window and I'm having a panic attack or the very low mood and depression, because I'm a pretty resilient upbeat person for people who know me. I could roll with a lot. But this was the first time in my life where I felt so. And of course, I was depressed about cancer, of course. But it was more than that. It was as dark as in gloom paired with a lot of insomnia, horrific hot flashes and eight sweats. Did anyone whisper the word menopause to you? No, they're just, no, I mean, they said, oh, it might show your ovaries might, you may not get your period. And they'll probably recover your ovaries because you are so young. And then at some point, I can't even remember some point in the middle of my chemo. They're like, you know, there's some studies showing that if we give you Lupron to really shut down your ovaries, that it might protect them from the chemotherapy. So on top of like the chemo kind of slowly shutting them down temporarily, then they gave me Lupron injections, which then I think just put me over the edge. Yeah. So Lupron is the medication that we give in a lot of fertility treatments, and they give in certain cancers, where it basically completely, it's a chemical menopause, and it's immediate. Immediate. Yeah. So. And I just honestly, I just really didn't know. I mean, I know it sounds silly that I'm an obituary. But remember, I was a second year resident. So I was still young in training. And that's when the W.H.I. came out. It was 2002. There was no talk about premature menopause, menopause, and all the other side effects. And if anything, I was like, it was the hot flashes. I didn't realize it was everything else. So when did chemo end? And it's sometime that's like late summer, I actually refused my last chemo. I could not take it anymore. And like a crazy person, I like called up the preeminent person in the world at the time who was like an expert in young women and breast cancer. And I cold call them. I'll never forget it. I think he was at the University of Michigan. And he took my call. And I was just like, I know this was really weird. But I just want to tell you this. And I'm so scared that, you know, I'll never be a mom. And I want my ovaries to come back. And do you think I need that last dose of taxate here? And he's like, no, you, it's okay. You don't need that one. It's okay. And I was like, oh, okay. So I went to my oncologist. I'm like, I'm not doing the last one. She was just the biggest pain. But she's supporting me on that. And then they're like, okay, let's kick you while you're down. And now let's put you onto a moxifen and a variant suppression. So my new line is that, listen, we have got to think about someone who has had breast cancer or some other complicated medical thing. But in breast cancer, they've been through surgery. They've been emotional stress of being diagnosed with cancer. They've had all these treatments, chemotherapy. And then when they're done, they're like, okay, now when you're really low, now we're going to put you on prolonged estrogen deprivation for five to 10 years. But we're not going to prepare you for any of it. To me, it's like kicking a dog when they're down. That's how I felt. And in retrospect, I'm like, whoa, whoa, when we are embarking on that, we really need to empower women so that we can optimize things. Be like, come on, come on, girl, we gotta get you ready for the marathon. Right. Because it's a marathon. It is not a sprint. And that conversation isn't always happening. And there's so much rush. Yeah. It's to get the chemo rush to get the surgery rush. I understand that. And that's important. But there are times where I say it's okay to just like take a pause and be like, we've got a regroup reboot for this next phase. And I never really had that chance along the way. So you talk about all this stuff they gave you before chemo prophylactically stuff for nausea. Yeah. Talk about that. Yeah. So when you go, the listeners are taking notes right now. Yeah. So when you go in for chemotherapy, they give you a steroid, a dose of prednisone, they give you anti-nauget medication, multiple different traces. They gave me injections, nupogen to keep my weight, blood cell counts up. They give you out of hand wall, you're getting the red devil, Andrew Mison to help like keep you from like having a panic cut spitting out. Doring that, you know, crashing out, is the case. Yeah, crashing out, during that chemo infusion, but they didn't give me anything or offer anything to help me cope with the induced menopause that was about to happen and was happening. So for instance, I didn't know it at the time at all. Anything about genitalia and recentral menopause, that was like a foreign thing. I didn't know what never said that. So for our listeners, what is genitalia and recentralia? Yeah. It's when loss of estrogen, the vagina, vaginal dryness, vulvar, atrophy, clitoral atrophy. Like, yes, it's more than vaginal dryness. Everything is drier, shrinking, thinner, poor quality tissue, decreased lubrication, pain with sacs, decreased sensation, but it's a urinary syndrome too. So urinary tract infections, urinary urgency and frequency. So of course that was happening to me. So that's just one example of I didn't even get like use of moisturiser or lubricant or these are the things you can do. No, we gave you a tub of coconut oil. No, because this was 2001 into 2002. Like no one was talking about sexual health with cancer treatments. I mean, we've come a long way and we're doing better, but we got to remember at the time it was not at all addressed, right? And so now I say like, okay, if I could have looked back, I would have said, oh, let's pre-medicate her. Give her like the lowest dose of vaginal estrogen, like twice a week to prevent the downward decline. Yeah. Because we know we know the hot flashes are coming. Let's offer this woman something. We know she's likely at very high risk for mood issues and anxiety and depression. But I was never offered an antidepressant or even the talk of it until years later, like literally years later when I don't even know. It was like probably five years into treatment on to Moxfin. And finally the nurse practitioner, the new medical oncologist that I went to, she was so lovely. She's like, you don't need to suffer. She wrote me a prescription for the necessary. I was like, okay, maybe that will help my hot flashes. I mean, it was crazy. Five years of it. And I actually have, I pulled my medical records. I have the note from the middle of chemo when I was almost about to just like lose my mind and like stop taking the chemo. And in the note, it says the doctor wrote like horrible hot flashes, hasn't slept in months. She's terrified of premature menopause. That was the line. And then I looked at the plan, and the plan was prescription for Ambien. That was it. That basically sums it up. So you did have a baby. I did. So walk me through that. Yeah, we're allowed. Yeah. So I finished a chemo. And then at the time, they just, that I started to Moxifen. And to Moxifen does not cause you to go into menopause. It just blocks the nurse's symptoms. You feel like you're menopausal. Yeah, you do. Menopausal symptoms. But because I was very young. And at that point, they stopped the loop run. They stopped the forced menopause. Really, let's just see what happens with your ovaries. And so I started to Moxifen. And I actually tolerated it. Okay, because slowly over the months, my ovarian function came back. Right. And so I was doing okay on it. Right. And at about the 18 month mark, I decided sort of on my own. I was a little bit of a cowgirl about it. I was like, yeah, I'm going to just stop this. I'm going to get pregnant. And then I'll go back on it. And that is what we tell patients they can do now. So there was recently something called the positive trial that looked at young women like me where they would pause their adjuvant endocrine therapy. So to Moxifen or Romantic inhibitors for up to two years to get pregnant, either naturally or use IVF, have the baby even breastfeed if they could. So this to your pause, then you go back on to complete your treatment. So I basically did the positive trial on myself back then. And my doctors were sort of supportive of it. Because at the time, there was observational data that pregnancy after breast cancer didn't seem to increase their recurrence risk or change the prognosis. And so I was like, I'm going to do this. And we didn't need to use our frozen embryos. We were really lucky. Like literally, we had sex 11 days later. I was a crazy person in a dream. I owned blood in the call room and I ran it down to the lab. And an hour later, I go on to the computer. And like my HCG was like, I don't know. It was like 47. No, not even that high. No, it was like 16. It was so low. I think I just like, you wouldn't even have a positive pregnancy test. Oh, yeah. No, it was like, yeah, it wasn't like urine. I had a need a must have 25. I didn't even disappear yet. And I was crazy. And then like 36 hours later, I dream I blood again. And I did it again. And that's Eva. And that's Eva. Yeah. And she's 20 minutes. The new LinkedIn hiring pro can't undo your last hire, the lone wolf, who you thought was a good collaborator because you didn't have the right candidate insights. But once you hired them, it was all hoarding, info, declining meetings and howling at the full moon. But LinkedIn can find you a perfect fit by using insights from the LinkedIn network to give you a short list of the best fit candidates. 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And you deserve a clear roadmap for a transition that medicine has ignored for far too long. The new Perry menopause is now available for pre-order everywhere books are sold. Learn more and pre-order your copy at thepaslife.com. You've had multiple surgeries since then. Too many. Lots of reconstruction. You have become a leader in this space in medical communication, especially around survivorship and pre-vivership. What is the, and I hope I've pronounced it correctly, what is the Young Survival Coalition? So the Young Survival Coalition is the premier nonprofit organization worldwide that addresses breast cancer in women 40 and younger. Because our knees are different, they're unique and more impactful in ways that aren't in someone who is menopausal say when they have breast cancer. My DMs constantly, constantly. Every time I post about menopause are estrogen. There's at least 10 or 15 people. What about me? What about me? Nits, the survivors, the pre-vivers. People have just been told you're too high-risk. You can't take estrogen. Yeah. And they just feel like they're left in the dust. Absolutely. And so that feeling of left in the dust, I felt it not in terms of the menopausal conversation HRT at the time. But even when I was diagnosed, I felt left in the dust because I was the youngest person in the chemo room. And I didn't relate to the support group women who were much older than me. So the YSC became a real lifeline. And I feel like it's a similar reflection of the community that I have now in the menopause space. And they were really like my sisters in arms at the time, advocating for what we needed. But now full circle now me being a menopause specialist. Now I'm trying to speak to the needs of those young survivors. You like me are dealing with premature menopause. They're dealing with GSM, genital coronary syndrome, sexual health stuff, stuff. And they're not getting answers from their doctors. What they're allowed to do is get pregnant. But no one is talking to them about, oh, well, does it hurt when you try to get pregnant? Because the sex is so painful. Yeah. You have a choice as an adult woman to make a risk-benefit decision for yourself to pause aage of an endocrine therapy to attempt pregnancy. So most women don't understand this. It's really a radical concept, especially in the oncology space, that a patient would have as much input into the decision-making around her care. It's almost like it's like medical school here. Here you go. Here's your plan. Here's your chemo. Dada, and you're lucky to be alive. Like you've described stories of people coming to you after they find you on the internet and talking about their experiences. Like give me these, again, they're taking notes. You know, what should they not hear? Well, does that I think most medical oncologists out there. I am so grateful for them. And they do want shared decision-making. They're so smart. They know all the ins and outs of these things. But the reality is they're working in the same medical system that you and I worked in. And they are pressured for time. They're pressured from a hierarchy of an institutionalized like protocol. They're afraid of all the medical legal stuff, the insurance things. So I think even with the best intentions, it's very, very, very hard for women to get individualized care. And then when this elephant in the room of like the fear of death, I mean, I feared it for years. I mean, it's still sitting in the back of the mind recurrence and mortality. When that enters the room, it really gets in the way. It's like, you know, if a medical oncologist or increasingly, there's a lot of, you know, there's just practitioners and PAs who are also seeing these patients. If they don't have that clinical expertise or interest in helping with sexual health or the menopausal symptoms or premature or the mental health and stuff that's going on, all these other things, it's just easier to be like, wow, you know, you don't want to risk your occurrence. You have to stay the course and do the most. And sometimes doing the most leads to people's stopping treatment, not completing treatment or just really suffering. So my whole thing is, I want to try to find a way for women to have their cake and eat it too. I want you to be treated for your breast cancer. I want you to stay in your medications. And if you need to be menopausal for them, either forever or for some period of time, well, we need to support you in every other way because it's very hard for women to hear all the benefits of HRT. And all the problems when you lose estrogen, especially early, it's scary. You like, as your process risk, cardiovascular risk goes up. And so when you hear that, you're like, you're like, well, this is depressing. This sucks. Well, maybe I shouldn't be doing these breast cancer treatments. And I'm like, no, you need to do your treatments, but we need to find a way to make them tolerable, to improve your quality of life. And there's lots of ways we can support your long-term health, even if we can't do systemic hormones. And this is why it is maddening and it's sickening to me that we would ever deny women safe things like local lotus vaginal hormones, vaginal estrogen, because I like to picture there's all these bricks on your back, as a cancer survivor. You're dealing with all of these struggles. And if you just take one or two of the bricks off that woman's back, she could stand a little strider and she could feel a little bit more like herself. So I might not be able to give her systemic estrogen in many cases. Yeah, although maybe down the road, we can talk about that. But I can give her local vaginal estrogen. And maybe she could have sex with her partner and keep with the intimacy. Maybe she doesn't have to go to the bathroom five times a night, maybe riding a bike or hiking doesn't hurt because it's so painful and dry down there. Maybe she could have a pap smear. I had two patients in the past couple weeks who can't have pap smear anymore because your rheumatism inhibitors have made their volvas, the vaginas, so atrophic and stenotic that they can't tolerate a speculum, so they can't have cervical cancer screening. That's not okay. Yeah, it's insane. And these are women who are already past treatment. Stage one, like the lack of knowledge in the oncology community about the importance of just this one little thing I hate to hurt myself. No, but it's everything. Like this one thing affects intimacy relationships. You're you're in a hurry how that it affects like your ability to have a damn pap smear to get several cancer screening like come on people. These are now as I've come to learn I did not learn this in residency or training, but the mental health, the cognitive changes, the general year, I did know about some of the general year and area changes, but not all are expected and we're dictable. This is not it's not like it's not going to happen. It's going to happen. Yes, every woman in menopause and every doctor involved in this care like we're failing. The medical system is failing women because we are not training these clinicians. They're good people. They want to do the right things. And the bias that is just built into this. You're worried about your vagina. Yeah, I how dare you actually my medical oncologist who is still practicing. I'm so one of my patients and she didn't know that it was one of my patients. The patient found me afterwards and when the patient asked have vaginal estrogen and the patient is a complicated she had recurrent breast cancer. She's at high risk for not a good outcome, but her GSM was incredibly severe. Her 20-year marriage collapse and her husband left her and she was really just like, please can I consider some vaginal estrogen and you know I'm really worried about my heart health and my oncologist slammed my old oncologist, slammed her hand on the desk and said, is this about your goddamn vagina? Use some coconut oil and if you're worried about your heart, how go see a cardiologist, I'm here to save your life. And so that's an extreme example. Some things have changed, some things have not. There's much more awareness. There's a lot of medical oncologists. All the AUA guidelines. AUA guidelines. American Eurological Association. Yes. And ASCO is having more of this kind of American study clinical oncology. There's leaders, my friend Dr. Eleanor Teplinski, shout out to her. She's a leading voice out there trying to bridge this gap and help communicate with the the menopause specialists need to communicate with the oncologist. As all this, the psychiatry is need to communicate with the menopause specialists. The orthopods need to communicate because we're all seeing the impacts of menopause. And I use the breast cancer patient as the most extreme example, but everything we talked about also applies to no woman with endometriosis, the woman with premature ovarian insufficiency for a reason that we don't even know why it happened. For the woman who just had a complicated menopausal situation, because maybe she has some other comorbidity. I don't know, she's got hypertension or something. Someone told her she couldn't have this or a family history of breast cancer. So these tellers she can't have that or that, right? So this is the most extreme example, but it applies to really all women I find. Yeah. So you finish residency, you make it through. Yeah. And then you work, you go to work. Yeah. And a traditional OB-GYN practice. Yes. Yeah. So my first job is actually in a community health center because it was really close to my house. So I can like come home for lunch to see my daughter, Eva. And so I did that for a little bit. And then my friend from the Young Survival Coalition who became like a sister to me, she had a recurrence of her breast cancer. Our breast cancers were very, very different. She had a recurrence when she was pregnant. And she delivered her baby and she died two weeks later. And while we were in the hospital there, my husband said to me, he's like, you're not getting pregnant again. You're going to stay in your to-moxifen. It's here. Him so bad. Yeah. And you know what? He was right because Nicole's situation was very different. And I can't compare our medical diagnoses in terms of our breast cancers were very, very different. But at the time, I just said, I have a daughter. She's healthy. A wonderful husband. I'm going to stick on my medication. I'm going to do what I need to do. I can't pause again. And then that's when, because I make decisions like literally two weeks later, we have an agency. We're going to do an international adoption. And we adopted Lucia from Guatemala. She was born in 2006. And she came home at the very end of 2006. And she was sophomore in college. She's a sophomore. She's 19. Yeah. And so, yeah. So I say, Eva saves me emotionally because I was in a very dark place and can never be a mom. And then Lucia, I say, saved me physically because because of her, I was allowed to stay on my my my to-moxifen. Yeah. When did you decide to make the switch to menopause care? So after I got back from taking your Lucia's adoption, I chose to have my ovaries removed at that time. So I was like, I'm not going to have another baby. Well, I'm not going to have another baby. I was brought a negative. And so the doctor like, you don't have to do this, Chris. Well, I was like, I'm going in for a new reconstruction. They were fixing my my breast implants. And I says, well, I'm under just damn things out. I don't want them anymore. My mom died at 54. I know you all tell me I'm rocking negative. But there's something I write with my jeans. I said, they're like, you don't have to. I'm like, no, it's okay. I'll do I don't even I'm glad I did it. The audience why in a little bit. But again, Clueless, I didn't really realize what surgical menopause was going to mean for me. And bam, talk to our listeners about the differences between abrupt menopause, surgical, but you know, induce menopause and natural menopause surgical menopause is abrupt because you walk in to the OR with ovarian hormones being produced. And then you walk out those ovaries are removed. There's no more production, estrogen, progesterone, and you're losing a big source of your testosterone. Just estrogen is made in other places. And so from a symptom standpoint, it's more abrupt and more severe and it's permanent. And I think I didn't realize it because my other menopause times were temporarily and chemo kind of gradually put me in. And then you know, and then again, the loop run. So I don't think and I was like, I weathered that. And you were older. And I weathered that and I was just like, I was in a better place. I had my two kids. I'm like, I can handle this, right? But it was really hard. So when I realized, we're like, wow, over two months, I got like, I gained weight, I gained like at least 10 pounds really quickly. The sleep, all the things, right? All the stuff. And then I was in a private practice. I was starting to see more women coming in with paramedicause and menopause complaints. I'm like, I need to figure this stuff out. I'm like, because I am not capable of taking care of my own patients with these complaints much less. Someone like me who is very complicated. And so then I got involved in the menopause side. And I got certified and just started to like slowly tailor my practice in that kind of way. And when did you make the switch to you're working with alloy health now with a telemedicine platform? Yeah, I stopped doing OB around that time of switching towards menopause. That's delivering baby. A lot of us do eventually because babies come when they want to come. And we have to sleep. Exactly. So it was, I don't know, it was probably some time around 2010, 2011. I stopped OB switched to GYN office-based practice only and then COVID hit. And I just started to do a little bit of telehouse just for my established patients during COVID because in New York, you know, no one was coming into the doctor. And by that point, my daughters were in high school and I was trying to be there for them and supportive of them with their high school years. And I was like, you know, with this telehealth thing kind of works for a lot of education. Menopause is a lot of talking. Breast cancer survivorship is a lot of talking. It's a lot of like education. Digging menopause is not going to cut it. Yeah. And also, I didn't need to examine these patients in the same way. Like they can still have their GYN. I'm not replacing their kind of colleges to do their in-person exams. But I says this works. And then I was at a menopause society conference in Washington, DC and Monica, Malinar and Anne Follinwider, the co-founders and co-seos were there. They had a little booth. And I met them. I'm like, I do telehealth and I do menopause. They're like, oh, we're going to start coming to the post telehealth company. I was like, we should talk. And so we, we see it in contact. And then I joined them and got a lot of medical licenses and started to see patients in a lot of states through alloy. But also still maintained my own small telehealth practice. So, you know, over, so fast word over the last like, it's like, you know, three, four years, I've really, I've learned a lot because the more you see, the more you learn. Yeah. So I've learned a lot by really only focusing on this. You know, it makes you a better menopause doctor. And so now I'm like really on my mission to because I have all this experience now to really help the most dismissed, the most complicated. And so I'm coming back to what I always wanted to be, which was a teacher. There's a lot of I can't take estrogen. I've been told X, Y and Z. What are some legitimate reasons? Because there's so much misunderstanding, even amongst clinicians. Yeah. As to who can and cannot take? So in medicine, we call it an absolute contraindication. What are the absolute contraindications to someone taking estrogen? So I'll be bold and say, I don't believe in medicine. There are any absolute. Yeah. I think as as Dr. Blooming said, yeah, it's not cyanide. Yes. And I think so what I like to say is like, listen, yes, we have some general contraindications that we're always going to talk about. You've unexplained bleeding, postmenopausal bleeding. We've got to work that up and figure out. It's meaning you're having vaginal bleeding, not you're normal, right? Now you don't want to start hormone therapy in that case because there might be something there that estrogen would feed. And we have to figure that out. Absolutely, especially postmenopausal bleeding, we're really new onset of very heavy, very abnormal bleeding into the pariamenopause. You have some real active liver disease, complicated active liver disease. You've had a recent thrombosis, so a blood clot or a blood clot that goes to your lung called the pulmonary embolus, right? We're going to be very careful there. You've complex cardiovascular disease, like a massive heart attack, a bypass, something significant, hypertension, high cholesterol is not serious. Right. I'm under being told if they have any risk factors for heart disease, they can't take it. Yeah. No. If they have any family history of breast cancer, they can't take it even with negative gene testing. Exactly. And then the last one, you personally have an estrogen dependent breast cancer, new diagnosis in the middle of breast cancer treatment, right? Those are the big ones. But like we can find things in really most of those scenarios where there might be situations where we could consider it in the right context, right? So those are the big things. But notice none of those were a family history of anything. Right. So the biggest one, the biggest barrier that we get is family history of breast cancer. That is not a contraindication hormone therapy. I tell patients, I want to know your family history and I want to know your other because it's not just family history. We need to look at all of your risks for breast cancer so that we can personalize your screening, talk to you about preventive measures, both lifestyle, sometimes medication, even surgery, depending on you're the most high risk, like you carry a BRCA mutation, for instance. But it's it's it's to do those things. It's not to deny you a conversation about your choices on hormone therapy. And the menopause society makes this very clear. So don't take my word for it. Look at the experts and the guidelines that are generally on the more conservative side. And it says that the preponderance of evidence does not show that menopausal hormone therapy further adds to your risk of breast cancer. Your risk is elevated. It's elevated. We're going to address that with your screening surveillance, but adding menopausal hormone therapy isn't going to significantly increase that risk more. That's how you have to think about it. And so that family history is often used as like a gate routine. Yeah. To say absolutely no. You talk a lot about weird Barbie. It is weird Barbie. So the weird Barbie is this is the idea that like doctors now are coming to the place where they're like, okay, we got it. This menopause train is happening. We've got to get along the ride. Okay, I'll learn how to prescribe hormone therapy for the ideal perfect candidate like this ideal stereotypical thin, perfect occasion, healthy, you know, no risk factors like yes, you can have it. Exactly. Like your breast density is zero. There's no family history, etc. But we're all weird Barbies. We're all unique and different. We all bring different things to the table whether it's like 80% of us by the time we're 50 will have some other medical condition migraines with or hypertension and to be true. We're right now. I get blowing up. Yes. Oh, I have fibroids. I've been told I can't take it. Oh, I have endometriosis. I've been told I can't take it. Yeah. Oh, I have autoimmune disease. I've been told I can't take it at migraines with aura. Yeah. Dr. Five Liden. It's like the Benemias existence. Dr. Five Liden. It was a nature far. So these inherited clotting situations, Perthrom and Factor Five Liden. Great example of individualization matters. We can give you transdermal estrogen. We would just avoid oral. Right. It doesn't mean you can't. Yeah. So we do not increase the risk of a blood clot with a non oral estrogen formulation. Exactly. Let's talk about some statistics that you love to throw out there. One in eight women lose ovarian function before natural manopause. Yeah. That's a inconvenient one in eight. And I say, the one in eight, everyone thinks, oh, one in eight women will get breast cancer and then I'll live to him. And that is true. If you live to 80, it's not one in eight women in each decade. Yeah. No one talks about that one in eight women are going to lose their ovarian function prior to the age of natural menopause average ages about 51, right? Range is 45 to 46. So that's a lot of women. So premature menopause is under 40 early menopause is under 45. Okay. And there's some specific risks associated with early and premature menopause that a lot of women don't know. I mean, I can't tell you people coming into my office who had ovaries out with surgery electively at 45 and no one counsel them as to the earlier loss of hormones and what that would do to her long-term risk of chronic disease. I mean, it is it's shocking and in my mind, it is medical malpractice to remove somebody's ovaries prematurely and not have preop counseling, preop plan. There are many good reasons why we move over to early. I removed mine. I am so glad I did because fast forward years later, I found out on update testing that I do carry a BRCA to mutation. My gut was right. I'm glad I did it. What is update testing? This is important. I guess most a lot of women don't understand. A little cyber here. So family history of breast cancer use get tested for a gene or you say, oh, my mom is tested for that because she had breast cancer and it was negative. Anybody listening? If you had testing really prior to 2014, 2013, 2014, you should speak to a certified genetic counselor or your physician or as a referral to genetic counselor because prior to that time, we didn't do panel testing. So we didn't include other genes because it's not just BRCA. There's other genes that can raise the risk of a variant and breast cancer. But they didn't even do the full sequence of the BRCA gene. They just did like the most common mutations and my mutation is in something called the BART sequence, which is the larger your range rate of the gene. It's less common, but it exists. So if you had a negative rocket test in your family prior to that time, you need update testing. And when I called my unconscious, I think I need update testing because I was doing all this like continuing medical education and I read about it and it's like, oh, you don't probably need it. It's really rare. I was like, just do it. And then three weeks later, he's like, oh, I've got bad news. I'm like, no, it's good news because now I know why because now I could have my family members tested and you know, they can take proactive steps, right? So that gets back to why would someone remove their ovaries early and with enhanced, there's more women having genetic testing out there, which is good. So we know. And then they're done with their babies having babies. Okay, you don't need your ovaries anymore in terms of the fertility perspective so we can remove them surgically. You could have your kidney to two. You can lower your risk of a varying cancer. You will wake up in the recovery room with that estrogen patch on you. We can give you pregesterone. We can give you testosterone. We can manage it. So you've lowered your risk and you get your hormones back. And that confuses a lot of women. Why would you remove my ovaries and then give me hormones back? Isn't that going to increase my risk? So first of all, with BRCA carriers in particular, there are risk of breast cancer and a varying cancer. So you remove the ovaries physically in the tubes. You're dramatically lowering your risk of a varying cancer. It doesn't matter whether we give you the hormones back there. And with so fascinating, and we can't explain this necessarily, but you remove the ovaries. You actually also lower her breast cancer risk, even if she still has intact breasts. Many of these women will have a prophylactic mastectomy. But what the studies have shown is giving back hormones doesn't negate the risk reduction in breast cancer. We don't know why. That's another question. But it's really interesting. So basically, the guidelines are actually quite clear. This is NCCN guidelines, as well as ACOC menopause society is that if you are a BRCA pre-viber, meaning you've not had cancer, you've removed those ovaries. Whether you've had your prophylactic mastectomy or not, you can and really should have those hormones given back to you up until at least the age of natural menopause, when you can have that same discussion that every average age menopausal woman has about what do you want to do now going forward? And what's really shocking is many of these women have already had her bile fat on the spectamase. There is literally no reason to be withholding hormones from them because of all the risks that you were alluding to. So you did a study, you co-authored a study, and you found that 94% of breast cancer survivors report moderate to severe menopause symptoms. And 89% felt that the care was inadequate. How groundbreaking was that? With my co-authors, Dr. Layla Agrawal and Dr. Elinor Tupelinsky, and this is the positive power of social media, right? So we did a study looking at, we called it Wish, women's insights in sexual health breast cancer. So what kind of information were they getting and access to care for their sexual health concerns after breast cancer? We focused a lot on sexual dysfunction, GSM, we asked a few questions about like their menopause symptoms as well, other menopause symptoms. And within three weeks, we got over 1,800 people who completed the survey. Normally, it takes months and months and months to recruit that many people. But we had this outpouring of participation. And the results were profound, you know? 85% said that they had significant moderate to severe impact on their sexual health. And almost 90% said it caused them moderate to severe amounts of distress. Which is important. So the dysfunction was there and it caused them a lot of distress. And close to 80% says it greatly impacted their relationships with their partner. And we allowed patients to be in comment to all the questions. So we have literally thousands of comments on their experiences. And it is, I like to call it shock and awe. So we were really proud to present it at Asco. And it got published because we really want like this to be a wake up call, right? It wasn't actually surprising that women had these things. But I think it was jarring to see how explicit they wrote about how much it hurt them and how little information they got. Like basically nobody got referrals. Nobody was offered all the things because it's vaginal estrogen. Yes. But there's a lot of things we can do for sexual health. Basically, they weren't getting much. Yeah. I'm going to call myself out here because you fixed my semi-broken vagina. You know, we're friends. We talked quite a bit. And I was on HRT early in the game within nine months of when we figured out it was menopausal because I was on birth control pills. I came off. I was immediately off hormones and figured out, oh god, my ovaries quit somewhere back there. And here we are. But I never started vaginal estrogen. I wasn't having any symptoms. So I thought I wasn't having much dryness or anything. And I was like, well, when I get there, I'll get there because I often prescribed them together. But I never thought about prophylaxis. Like, why would I wait till something breaks? But I was we were chatting and I was symptomatic because I was struggling with orgasm. I was literally like, why is this taking so long? Like this used to not take so long. Like I am frustrated here and trying all the different techniques and different vibrators. And we go to these conferences and they're throwing vibrators. So I feel like I have to try them all so that I can talk to patients about the different methods. And I think this is taking forever. And Karin just casually goes, I think we were texting. You guys, you're like, girl, I don't know what's going on with the acid ring clear. How much vaginal estrogen are you on? And I was like, I was like, I'm going out you on social media that the menopause queen isn't using vaginal estrogen. Me, me, the woman who talks about this stuff all the time. And then really within a month or two, everything was kind of back to normal. So thank you. My distress is much lower. Yeah. And now I, you know, if I lay off, I immediately have urgency and frequency and stuff. So like that keeps me on track. But it's interesting that you mentioned like the decreased or, you know, diminished orgasm or it gets harder to orgasm. It's because this is the one area that we don't say it that much with GSM. It is literal atrophy people. You don't atrophy the vagina and the vulva and the clitorisities robots magically. Yeah. And also like, and our friend Dr. Rachel Rubin is always like saying that like guys like vaginal estrogen is like viagra, for women in terms of it's not exactly the same but the idea is that her brings blood flow to the genitals. And that's what vaginal estrogen does. And blood flow is a clitorisist's best friend. So did you ever imagine that in all of this, you'd be a medical communicator or an influencer or some people like to refer to? No, we're, we're, we're, we're thought leaders were medical experts were medical educators and we are medical communicators because I'm not in the clinic doing like seeing 30 patients a day anymore. Now, many and God bless. And I'm so grateful for my colleagues who are on the ground providing that excellent care in this very, very broken medical system that does not value patients. And it doesn't value doctors either. When we complain about what's happening out there with women getting information or getting men of positive care, I don't want the doctors to feel attacked. Right. Get it. We understand. We did that job. We did that job. And, and we, we need you to do that job. And so we're trying to educate patients so that they're more empowered so that when they get to you, you don't have to spend an hour explaining the difference between transdural and vaginal estrogen is safe, right? The day that we're recording this, you posted a video that I shared and it was a very, very popular medical influencer, medical communicator, Dr. Mike. And he was speaking on a panel at a large conference. So tell me and you reposted it and do edit it and you put in your thoughts about it. Let's go through that right now. Yeah. So I just, you just got back from a big conference where something similar had happened. Yeah. So, yeah. Dr. Mike was honest, this panel and they were talking about the role of how do we communicate health messages to the public. Yeah. They were talking about it in the framework of what happened with COVID and public health officials and doctors and communicating to the public. So that was a theme. But then it kind of got a little bit deeper and kind of talking about what does the role of social media play and what does the responsibility of people whose job it is to tell people information from a public health standpoint or anything. How do you communicate? And there is attention in this world now between the people who are publishing and in the research and the people who are on the ground doing the really hard work and the clinics and the people who are out there publicly facing and talking to people on social media, right? This is the new newspaper. It's the new radio. It's the new this and it's not going away. But people are a little uncomfortable with it, and I get it. It's very, very frustrating as a doctor and we see it too. There's a ton of misinformation out there. It's a huge amount. And I can't imagine being in that clinic every day and having patients say, look, I heard this. I heard that. I heard that. I get it. And sometimes it can make you roll your eyes when you hear, oh, you heard this on social media. Okay. Great. But that can be a bit dismissive to the patient and it can be a bit dismissive to the colleagues who are out there. Like it's hard doing this. It's a lot of work. I do it because I love talking to people on social media about being empowered because I lived all these things. If you listen to my reels, it's I'm very emotional about it. I really believe in telling patients. And it's it's work. It's my role that I'm giving back to the medical world. But what I see sometimes at medical conferences or you know, within these professional societies is a little bit of a role of the eyes. Oh, the doctor influencer, which I don't guess we have influence. But I'm not an influencer like someone who does not have any medical training. I'm actually a medical expert who's communicating. That's why like call ourselves medical communicators, right? And so Dr. Mike was talking particularly about something with the AMA and some kind of messaging that they sent out in a rebuttal to some public health information that wasn't right. So he said the AMA sent out a strongly worded tweet that got 5,000 views. And he's like, and then they put their president on camera with a, you know, a webcam that was like, didn't work well and the microphone was not great. I'm like, no, no, we we we have to be better at communicating because this is the world, right? And so when people roll their eyes and be like, oh, you probably heard that on social media or some doctors on social media are talking about progesterone or talking about that women should consider you know, menopausal hormone therapy for XYZ. We can't be dismissive of our colleagues who are out there. We should build bridges because I love to bring the research to the public. Like, I'm not doing all those research studies. So I love to read them and then communicate them to the public. So I'm grateful for them for doing the research. Yeah, I want them to be grateful for us to do. So it's like a translation service. We do backdrops of the studies behind us to like share the new information. Yeah. And so we need to line updates. Anything we think would would enable a patient to make a better informed. Yeah, decision for herself. And I think some physicians and I hear this, there's like, oh my god, I feel so like stressed that, I know, I have to get up there and do that on social media. I'm like, no, no, you don't got to do that. You could reshare stuff. You can give a little list of the doctors that you really like in your specialty that speaks to your patients concerns and say to your patient, yeah, I don't want social media, but here they account that I think are providing high quality information. Tell your patients that. Or if you are in social media, you don't have a big account. It's okay. Just reshare other good content. Direct your patients to credible sources. Right. And be careful about battling in the comments, misinformation from people who are not experts who go so much of it is bots. No, because you feed and you give that person more power when you retention. Better is to shine light in the darkness. So lead with good information or direct your patients to the people who are giving good information. And together, physicians can drown out all the crap that's going on. We've got some pre-vivors. We've got survivors, you know, a lot are going to be listening to this. What are some top resources for them? What would you recommend? So if you are a breast cancer survivor listening to this, my favorite sources, menopause and cancer.org, because she has information on managing all aspects of menopause and cancer, because it's not just breast cancer. It's calling cancer, it's cervical cancer. It's a variant, GI and cancer is lung cancer. There's lots of women out there dealing with that. She's an amazing source. She has physicians. She's got a podcast. She's got a book. Tons of free resources. No, I'm not. That's one of my favorite. If you're young and just diagnosed with breast cancer, the young survival coalition, of course, any books. I do like this one book called The New Medicine. I don't do a lot of, I don't cover a lot. I always refer out, you know, no, no, but I think it's really important. Because that's a whole nether book. Yes, you know, so nuanced. Yes, but no, no, I think it's really, really important for manifesting your book for you. Oh, well, thank you. But I think it's really important that women actually understand the basics of what's happening from a hormonal standpoint. Put the HRT question aside for a second. Like you have to name the problem and understand the problem, understand the physiology so that then you can say to your healthcare team, okay, doctor, I understand why I need to do a hormone blocker or have my over removed or whatever the case is. So how are you going to then address the estrogen deficiency? The British menopause society has a very lovely guideline called the management of estrogen deficiency in breast, you know, breast cancer survivors. And it's a really simple checklist of all of the things. One of the leading things they say is that women should be referred to a menopause specialist preemptively. Get them involved early. That's not happening. Let's face it. So you need to take charge and really say like, okay, I'm going to do these things, but you need to support me with all of my body systems on how that's going to be impacted by this menopause. So hormones are off the table for her. What are some of those resources? We talked about vaginal estrogen. So we've covered that. Yeah, vaginal estrogen, of course, if you have phesomotor symptoms, I'll have just nice bits and insomnia, you must address it. I know many people don't want to take another medication. And there are some, you know, yes, you could sleep in a cool room in layers. I get it. But you know what? If a medication and there are non-hermonal medications, both off-label medications, as well as specific FDA-approved medications, the guidelines are clear on that. The menopause society has a whole list of the non-hermonal evidence-based approaches. You must do that. Don't try to ride it out, stick it out, because if you are not sleeping at night and your quality of life is poor, it is very, very hard for you to do the lifestyle pillars of nutrition and exercise and sleep and community and, you know, your mental health and all of these things. So, you know, my friend, a new friend, Dr. Shannon Klingman, who created a new me. She's an amazing entrepreneur, physician, and she is now fighting breast cancer. And so, she's gone public with it, and I've helped her with things. And she was on HRT, living her best life, and she loved it. And listen, I love HRT too. Look, we want to prescribe it to the people who we can prescribe it to. But right now, she's having to use an aromatase inhibitor. And so, she says, you know what? I am feeling better than I ever have in my life, because when I was taking my patch, which I did love, it gave me in some ways a little false sense of like, health, where she's like, I wasn't leaning into the lifestyle pillars, which you and I always preach about. It has to be not negotiable, not negotiable. The HRT is like a nice ingredient. But you've got to do these other things. And so, she goes, now she's exercising and doing all these things like her life depends on it, because she says it is. And she says, I feel better. I'm stronger. I have more muscle. My bone is going to be healthy. I'm sleeping better. I'm eating a cleaner diet. I've gotten rid of alcohol. She feels great. So, I tell patients, I know that it's a lot of pressure when you've just been hit with all these treatments to be like, oh, I've got to become like the superwoman now. No, I say, but you could take like one brick off your back. Like, I was alluding to you. So, you could say, okay, well, you know what? For the next three months, I'm just going to eat clean or the next three months, I'm going to like invest in that group exercise class or that personal trainer, or I'm going to speak to my nurse practitioner or my medical oncologist about getting something for those hot flashes. Because then we slowly piece everything together and we can really improve your quality of life. And then there's some women and the conversations moving forward, there are some women within this breast cancer survivor world who may consider men, apostle hormone, there be in the future. Sometimes it's not right for them at that time. Sometimes it's never right for them. But there's subsets of them who might consider it because breast cancer is not one disease. It's heterogeneous. Each cancer can't lump a DCIS, someone who had DCIS and a mastectomy. Or what they call stage zero. Yeah, with someone who has more advanced breast cancer or someone who has triple negative and we never shut down our ovaries before. So, like, why can't we talk about her? We can. So it's opening up. There's a paper being published in January that's talking about a trial that we're going to hope support worldwide. I'm called the Menoebic trial where they're going to enroll women who are breast cancer survivors and collect observational data about their outcomes. Dr. Larkin and a team had a wonderful editorial in the Menoebic Society guidelines journal and there was just recently a practice pearl by Dr. Holly Peterson about how we need to approach this difficult conversation because there's more than four million women in the US alone. These women want some answers. So how would you advise a partner if they're listening to be supportive and lean in because women take on all these roles, right? Mother could organize her head child, you know, whatever. And then all of a sudden they get these diagnoses and they have to pull back from all those other roles. And someone has to step up to fill the gap. It's a huge burden on the partner in your life, your husband, your wife, partner because they do often have to take on other responsibilities. But if they really want to be supportive of some of the collateral damage that's happening, I'm going to really beg them to like get educated. Like you got to know what's happening to your, to your, you know, the woman in your life. You have to understand like she may not want to have sex with you, not because she doesn't love you, but because it hurts or because it's just less, it doesn't feel as good. And so her brain doesn't want it as much or maybe she's so exhausted because her hot foshers are keeping up her at night that by the time she hits the bed, she don't think about sex, she just wants to try to desperately go to sleep. Or if her muscles are hurting or joint pain or all the men and pulsos, so get educated, read a book like yours, get information, read our friend's book, you are not broken. It's another great one because I think it really helps with intimacy and talking about how to communicate when it comes to like maintaining that relationship and that connection. That goes a long, long way. And tell her she doesn't always have to put up such a happy face. I always wore a mask in terms of I had the perfect way. My makeup was always on. No one knew I had cancer. We kind of didn't tell a lot of people about it. I put up a good, good front and I didn't have to. So tell her it's okay for her to be a little vulnerable and break down sometimes. And guess what? When chemo ends, that's when the sadness and the grief sometimes kicks in because everyone's like, you're done. Yay, pink ribbon. Let's go on like a five K walk. I'm like, no, I can't be around. This is depressing. I have so much fear of recurrence and all the collateral side effects and people don't realize women are in breast cancer treatment for years. It doesn't end when the hair grows back. How was your mom? My mom was 54 when she died. And we were born on the same birthday. So next December, I'll be 54. Yeah, I did. It'll be 25 years. And that's a big day for you. This is 57. And the year I outlive all three of my brothers who died. So I get it. But you do say that the last 30 year life should be the best third. Yeah. It only gets better. And your great relationship, healthy kids thriving. You've got this incredible career that you need to get it pivot and you're teaching. You've got this incredible following community. And it's just such an inspiration. I think to our listeners. So so much in menopause is expecting women to be quiet and to fade away and to become invisible. But unposed is about really taking the reins back on this part of our life. What are you unposing in your life? What am I unposing? I think this part of my life has given me now this freedom to kind of finally really focus on myself, my development and let my wings fly. Like I let my birdies fly. They've flown the coop. They're always welcome back to the to the nest, of course. But I'm unposing. You know, worrying about everybody else and focusing here and and leading, right? So that my daughters won't have to face the same struggles in accessing quality health care and making hard decisions in the women's health space. Because no one has it easy. Sometimes I look back and think like, why me? Why did this happen to me? I went through so much. But now when I talk to all these women out there, every woman is dealing with their own challenge. You don't, you don't know until you walk in her shoes. We're all at some point in our life as a woman going to have to deal with something difficult within our health, right? And so I'm excited to empower women to not have to face the barriers that we all had to face. Well, thank you for coming on unposed. We loved having you. Thank you for having me. Menopause made me do it. Oh, she gave me this button. Yeah, menopause made me do it. Menopause made me do it. It's my new mantra. Thanks very clear. As a reminder to our audience, you can find out more information from Dr. Men at her website, drmen.com, or you can follow her on Instagram, TikTok and substack at Dr. Men, OBGYN. For more information, check out her CME course, managing menopause and breast cancer at Heather Hersheycademy.com. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness and navigating midlife at the pawslife.com. Also, my new book, The New Perry Menopause, is currently available for preorder on Amazon. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Mary Claire. Unpause is presented by Odyssey in conjunction with Pod people. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on unpause are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment.