Ep. 550 Most Women With Dense Breasts Are Missing This!” – The Shocking Truth About Breast Cancer Risk, Imaging & Prevention with Dr. Lisa Chism

Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. Today I have the honor of connecting with Nurse Practitioner colleague Dr. Lisa Chisholm. She is the Clinical Director of the Oakland-McHome Center for Breast Health in Michigan, and she has over 25 years of experience specializing in breast health, menopause, sexual health, and breast cancer survivorship. She is also an author and faculty at a local university. Today we spoke about risks for women with dense breasts and specific information about family history or prior biopsy, the impact of supplemental imaging, including MRI and ultrasound, specific risk factors for breast cancer, and lifestyle modifications that Lisa thinks are really important, including alcohol, abstinence, or reduction. HRT in the context of breast risk, especially for someone at elevated risk that has not yet had cancer, what changes after a breast cancer diagnosis and recurrence fears, the genitoyernary syndrome of menopause and screening, permanent versus non-permanent changes that occur in the genitoyernary area, as well as anticipatory guidance in informed care in patients with a history of trauma. This is one of these conversations you want to listen to more than once. Lisa is an incredible advocate for women and just has so much thoughtfulness in her approach to patient care. I think after you listen to this conversation, you will understand why I felt like it was critically important to help amplify not only her platform, but also her message, truly a privilege to connect with Lisa, as I know you will be able to listen to very soon. Lisa, I've so been looking forward to this conversation. Welcome to Everyday Wellness. Thank you so much for having me, Cynthia. Thank you for the work that you're doing. I was saying to my community that we were going to have this conversation and I can't think of a better clinician, fellow nurse practitioner to talk to you about breast health and helping us understand and unpack terminology like dense breasts. Because there's so much, I don't want to say misinformation, but there's not a lot of clarity for a lot of patients about how did they determine whether or not they actually have dense breasts prior to their first mammogram. Whether it's dense breasts, a family history, or a prior biopsy, how do you explain breast cancer risk in a way that's accurate, but not terrifying for your patients? Yeah, so great questions and something that I feel it's a privilege to do every day with folks. Now, I think one of the things I think about that resonates with me when we talk about how scary it can be for folks to hear about dense breast tissue, I tell folks right away, dense breast tissue is normal tissue. Your breasts are made up of dense tissue and fatty tissue. They're both normal. And we all have some variation ratio between the two. Dense breast tissue while it is normal is busier, more glandular tissue. So we see more things going on. We may see more cysts, which are benign, physiologic. I think of cysts as a physiologic finding, packets of fluid that can develop, do not increase your risk for breast cancer. Sometimes in dense breast tissue, we see more findings like fibroidonomas, which are also benign findings that are breast tumors that are made up of dense tissue, the same type of tissue, the type of tissue is the actual term stromal epithelial tissue. That's what fibroidonomas are made of. So I help folks understand that dense tissue is normal tissue, but the ratio is what we're paying attention to. Everyone may have some degree of density. Some women won't have any dense tissue and their tissue will be fatty. That's about 10% of folks. Some women will have about 20 to 50%. That's when we call someone scattered densities. And then the next level heterogeneously dense, I help people understand that means about 50 to 75% of your breast tissue is dense. The rest is fatty. And then finally, extremely dense breast tissue is when all of your tissue for the most part is dense. Now the tissue is normal, but the reason why we pay attention to it is one, like I mentioned, it's glandular tissue. And we see more physiologic things developing like breast cancer, more cell turnover, more cell division. The second reason we care is dense breast tissue is white on imaging on mammogram in particular. And so is cancer. So with fatty tissue, we're going to be able to see everything pretty clearly with scattered densities. We're still going to be able to see quite a bit in that tissue with heterogeneously dense or 50 to 75% of the tissue being dense, we may miss about 25% of cancers. And with extremely dense, we may miss about 40% of cancers. So regardless of your risk for breast cancer, which is something that we also will talk about when we're talking about breast health with patients, regardless of your risk, we are paying attention to density. And one, mammogram still going to be gold standard. It's the only modality, the only breast imaging modality that we're going to be able to see calcifications, asymmetries, architectural distortions. Some of these findings radiologists are specifically looking for can only be seen on mammogram that can't be seen on ultrasound or MRI, but we'll see those findings on mammogram. And those folks, when that happens, we'll get called back or brought back for additional imaging, looking specifically at that area that may turn out to be a benign finding, but that's how we screen in the first place. So mammogram remaining gold standard for that reason. However, when we talk about moving beyond mammogram into supplemental imaging, supplemental to the mammogram, that's when we're talking about your level of breast density, which by the way, you mentioned, how do we know dense tissue isn't a physical finding. So some women will feel that their breast tissue is more less pliable, more rigid, so to speak, or thicker. That may be an anatomic finding, but it may not correlate with what we're seeing on mammogram. Mammogram is truly the only imaging modality where we can assess the level or ratio of density. Supplemental imaging choices we have are whole breast ultrasound, which by the way, the data on whole breast ultrasound is mixed and no actual societies or guidelines actually endorse whole breast ultrasound, but it remains an option for some women with a conversation about what can we see with whole breast ultrasound. It is a tool, MRI on the other hand, we do have guidelines, and we do have recommendations from societies such as the American College of Radiology, Society of Breast Imaging, National Comprehensive Cancer Network, that if your overall risk for breast cancer is 20% or greater, MRI is going to be the supplemental imaging modality that is recommended at a six month interval in addition to mammogram. And when we figure out your risk for breast cancer, that's when we can make recommendations about the supplemental imaging. I think for a lot of women, there's so much, I think when we're on social media, there are well meaning people that sometimes conflate their own experiences and apply it to everyone. And by that, I mean, obviously, women that have a family history of breast cancer or genetic susceptibility to breast cancer, maybe they had a concurrent other type of cancer that's going to make them at greater risk. There's a lot of people that are concerned that mammography itself has the potential to cause problems. And yet I think the very reassuring thing that you just stated was that the gold standards mammography plus or minus supplemental imaging, based on your specific risks, so you need to be working with someone that's knowledgeable about all these modalities. And actually, I pulled for purposes of our conversation, the current screening guidelines, and it went all the way from as you just duly stated, ACR, so the radiology lens, ACR, NCCN, ACOG, US preventative task force to kind of see there's a lot of different information that's out there. When you know that a woman has greater than a 20% likelihood of developing breast cancer, especially a younger woman, what are the kinds of conversations you're having with her at an earlier stage, obviously, than a middle-aged or older female? Sure. So it's recommended currently by the American Society of Breast Surgeons that we start screening for risk at age 30. We can actually start asking about family history at age 25. In special populations such as Ashkenazi Jewish, African-American women, we actually screen them for their personal risk for breast cancer starting at 25. General population, other than that, we can start at age 30. So whether I order imaging on a woman coming to see me for whatever reason, I capture that moment and we do a risk assessment. Now, we have a couple of tools that we use. The one that I use most frequently is the tire-cruzic tool, and the reason why I use that tool, it is what's been recommended and I see the literature leaning towards using this tool to determine when a woman should start screening, first of all, and second of all, when we should recommend MRI as a supplemental imaging for somebody at elevated risk. We do have other tools available. The Gale Risk Model in particular is a more abbreviated model. I reserve that model really to help folks understand risk reduction medication, which we can talk about a little bit more when we're moving into talking about what makes you at elevated risk. But if I see a woman who's 32 years old, maybe because she had a lump and we discover a fibrinanoma or something with an ultrasound, then I have that opportunity to actually do a risk assessment. And that tool is the one I use most frequently. I ask questions and the tool looks at how old you are when you start your period. Generally, 11 and under is considered a risk. It looks at whether or not you've had a breast biopsy, even if you've had a benign biopsy, what that's really reflecting is if you've had a finding on imaging that warranted biopsy, it speaks a little bit more to that busyness of breast tissue you had a finding. Also looks at first and second degree relatives, not just first degree relative, which the Gale Model only looks at first degree relatives, looks at how old a woman is when they enter menopause, also looks at age of first birth. So if a woman has a baby over the age of 30, we know that the breast tissue changes after childbirth, becomes much more sensitive to estrogen, and then remodels, so to speak, and becomes less sensitive. So if that happens earlier in your life, say in your 20s, there's some protective benefit to that. So we go through the risk assessment for two reasons. One, it helps a woman understand what either modifiable or non modifiable risk factors we look at and pay attention to, and also gives us that average lifetime risk of breast cancer. Now for a woman in their 30s and 40s, average is going to be around 11%. So if I do this for a woman who is 32 years old, and their risk turns out to be 17%, they are now what's considered intermediate risk, they're above average, they're not high. So that woman I would counsel, start mammograms at 35. We start at 40 for average risk. So if I do a risk assessment, somebody's around 11%, I recommend we start mammograms at age 40. If they come in higher than that, but not quite high risk, I'll counsel between 35 and 40, it's reasonable to start sooner. And I really believe that as we move into doing more risk based screening, we hopefully are capturing women, unfortunately, in their 30s, who are developing changes that frequently I see only because they felt a lump. And we know that that lump has probably been there, or that breast cancer, if that's what we discover, has possibly been there 18 to 22 months by the time we're feeling it. So by capturing folks at elevated risk, hopefully doing some screening sooner than 40, as we see more and more younger women developing breast cancer, that's where I really see the risk based screening, trying to help diagnose earlier breast cancer, which is going to lead to much better morbidity and mortality. So really, I'm very committed to these risk assessments. And even if a woman is 28, 29, I may still run the model because you can still run the model and just kind of guide them, help them teach them, even without any imaging. These are our risk factors. This is what we're paying attention to, and something that I think should be updated every year, family history can change, personal history can change. So and then also it helps educate women as to what are the risk factors that we're paying attention to. If you're in your 40s and 50s and feel like your body suddenly stop responding the way that it used to, you're not imagining it. Bloating, waking, sleep disruptions, food sensitivities and unpredictable energy are incredibly common in perimenopause and menopause. But here's what most people aren't told. Your gut microbiome is changing right alongside your hormones. And those changes can influence everything from how you store fat, to how well you sleep, to how your body processes estrogen. 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You want to go to timelinenutrition.com slash Cynthia and use code CynthiaTHERLO for 20% off your order. Again, that's timeline.com slash Cynthia and use code CynthiaTHERLO for 20% off your Mytopure gummies. This is really helpful. I don't think I've ever actually heard it explained that way, so nuanced. And if someone's listening and maybe they're at moderate or higher risk, what are the things that you're lifestyle-wise that you're talking to your patients about that you think are critically important for them to be conscientious about as they are working with a practitioner that is knowledgeable about breast health and breast risk? Well, we continue to see more and more evidence of the impact of alcohol on breast cancer risk. And I think of it personally more and more evidence that I liken it to drinking alcohol if you're pregnant. We don't know how much, right, is so we say nothing because we know that even a small amount could potentially be a concern. And I believe we are starting to move that way counseling folks with regard to risk for breast cancer. Now, certainly women can be moderate drinkers or social. And I think it's important that we're educating not necessarily shaming or placing any kind of blame certainly when we're diagnosing breast cancer, but at least helping women be aware of how much of the association we are starting to see and help quantify that that if you choose, then choose wisely as far as how frequently, how much I think most recently I read that binge drinking words, at least, you know, four in one setting is harmful. Whereas one occasional, perhaps that's a different conversation. I don't know that we really know for sure, which is why I think of it like when we counsel women who are expecting not to drink alcohol, and it's pretty well accepted that we understand that I think we're moving in that direction with breast cancer risk. And certainly I can't expect every patient I talk to to completely abstain, I don't know how realistic for somebody who especially who's even a social, somebody who enjoys alcohol socially. I think it's just part of the education and the awareness that we are learning more and more about that. Certainly lifestyle matters. We see an increased risk for breast cancer reoccurrence for women who are postmenopausal with higher BMI. Not that I'm necessarily a fan of BMI, but it is one of our markers that is still reflected in the literature as who's at elevated risk. Whereas we see sometimes waist circumference being a risk factor for pre menopausal women and incidents of breast cancer. So it's a little bit different pre and postmenopausal when we're talking about weight in particular or lifestyle diet in particular. I still continue to see evidence on plant based diet with a cancer risk reduction in general and certainly exercise and the amount of steps that we can get in. So generally counseling women regarding lifestyle for all cancer risk reduction and in particular breast cancer risk reduction. That's really helpful and I do feel like the alcohol conversation has really evolved especially perhaps over the last three to five years. I know that when I was neatly tucked into cardiology what did we recommend to our patients? You know have a glass of red wine every night that you know we were suggesting that they got adequate amounts of resveratrol and that glass of red wine that was going to be cardio protective and we're starting to realize now that's actually not the case. And so to your point about not coming from a place of judgment coming from a place of just awareness and education is so critically important. Let's talk a little bit about the kind of persistent fears of the connection between HRT in the context of breast risk. Obviously the WHI you know thankfully now we have no longer have this black box warning. Thankfully the FDA has been on board with this. I think as better information is coming out about the risks or the lack there of taking hormone replacement therapy I think there's still a great deal of fear about this and I say this because we get a lot of questions for the podcast. We get a lot of questions on social media. I think there's still a lot of feel about hormone replacements and breast cancer and so when someone is at elevated risk but hasn't had cancer how do you personally walk them through the pros and cons and the nuance and the other side of that is in our current kind of allopathic model a lot of practitioners don't have more than 10 or 15 minutes with their patients. So how do we navigate those conversations which of course are incredibly important and we want to be sensitive to patients concerns but also ensure that we can do so in a thoughtful and timely manner. So it is a very long conversation if you're going to do a good job. I fortunately get to spend about 30 minutes ish with patients and I have to tell you one of my passions is counseling a woman with a history of breast cancer or at risk for breast cancer and menopause health. I will never forget Dr. Mary Claire Haver speaking up and saying she was not a good menopause practitioner and I jumped on that and did a little reel about that as well because I wholeheartedly feel that way about myself meaning that back in 2011 I was at a cancer institute and I developed an interest in taking care of menopause women who had a history of breast cancer who were at risk and really did not prescribe hardly any hormone therapy. Transitioned and really actually thought I was doing a pretty good job with the non-hormonal and thought that that was a good thing right and transitioned to a large OBGYN private practice still taking care of breast health patients and menopause and for the first time four years ago faced with prescribing hormone therapy and having all of the same fears that patients have myself because I was not a good menopause practitioner. I was not as educated as I should have been or could have been in menop in in hormone therapy and menopause health so now remains still one of my favorite most passionate things I feel about is taking care of women at risk and it is a very long conversation. I start the conversation with what are your symptoms? When women tell me they have some of the general things that we understand like hot flashes, night sweats, muscle aches and pains, mood swings, irritability, trouble sleeping, skin changes, hair changes, oh and by the way vaginal concerns that intercourse is painful, I'm itchy, irritated, decreased arousal, diminished orgasm. I split those up into two and talk about the what I call systemic symptoms first and I tell them I will explain what's happening to your vagina and we will talk about that separate and then I ask them are you looking for hormonal therapy or are you looking for non-hormonal if you don't know then the conversation is even more robust because we're talking about both. I think everyone should hear everything we have available and even if I feel like somebody is a perfectly good candidate for menopause hormone therapy at the end of the day it's still their choice so they should also know about non-hormonal and what our options are which continues to grow thank goodness it's amazing the landscape of options we have. So having this conversation with somebody say I just had this conversation with somebody who has atypical ductal hyperplasia which is abnormal cells in the breast comes back on biopsy it is not pre-cancer it actually is removed because we know we have about a 10 to 14 percent chance that there are cancer cells sitting in that area so first we're clearing that up sometimes for folks understanding that and this particular patient was put an aromatics inhibitor for risk reduction which is not my first choice and she was having profound menopause symptoms so the conversation with her included helping her understand what ADH is what that means what her options are for risk reduction and then let's talk about your symptoms in hormone therapy because oh by the way you've had a hysterectomy if you chose to go on hormone therapy we could try estrogen and this as we're understanding could reduce your risk of developing breast cancer by 20 to 30 percent and I believe we're recently now seeing literature even with transdermal we know I know we saw this in the WHO with conjugated equine estrogen now I'm starting to see it in the literature translated into estradiol so reassuring so I also I make sure folks understand what we really understand about estrogen alone and if they have a uterus and we're moving into a progestin or progesterone with what does that mean and just because you have a history or a risk for breast cancer doesn't mean hormone therapies off the table just because you have a family history of anything doesn't mean hormone therapies off the table so we're having these very long conversations with folks very detailed it can be overwhelming that's why I use my whiteboard and kind of split it up in hormonal non-hormonal duovie wonderful product talking to folks at higher risk for breast cancer about duovie conjugated equine estrogen benzodiaxaphen definitely something that I think is a wonderful option for a patient who has at elevated risk and I think we are now seeing even more data coming through showing BRCA positive patients not having an increased risk for breast cancer and doing very well with duovie as well so it is a very long conversation very risk benefit very nuanced if somebody tells me you know what I just can't do and I'm not comfortable and we talk about okay well then let's think about what are your symptoms and I help folks also understand that when we're talking about hormone therapy we may be able to help you with multiple symptoms when we move into non-hormonal we may need a couple tools in our toolbox to be able to help you with vasomotor symptoms or hot flashes and night sweats and also oh by the way you have anxiety or you have trouble sleeping we may have to talk about what we can put together for you in a regimen that's going to help multiple symptoms whereas for a lot of women menopause hormone therapy can address a myriad of symptoms and then we talk to the about the vagina which I do talk about separately I draw my picture of um you know the perineal area vaginal tissues and help explain the changes in the cellular response to lower levels of estrogen all of the symptoms that can happen breast cancer patients at risk for breast cancer patients really try and help them understand and feel good about local estrogen or vaginal estrogen therapy to address that even if we don't use systemic or even if we do use systemic using something vaginally and also thinking about that almost separately. I love your systematic approach and I know that obviously your patients are incredibly fortunate to have you I'm quite confident that most patients are probably not having these detailed you know whiteboarded conversations which I think you know for visual learners is incredibly helpful to be able to see what it is that you're speaking to so talk to me about you know after someone has had a breast cancer diagnosis so we go from at risk to I've had breast cancer what are the major differences in how you approach those menopausal symptoms I know there's this shared consent piece but I think that there are still a lot of women that are continued to be told they're you know five, ten, fifteen years out from diagnosis being told hormones are not an option for you and yet the tide is shifting I think about Dr. Kryn Mann who's done such a good job you know amplifying the research talking about it you know what is the message that you're sharing with them because I think the the primary fear and I'm not speaking for the girlfriends of mine who have had breast cancer but they've shared this with me that there's so much fear of a reoccurrence that they want to be as conservative as possible but they also want to have a high quality of life. Well two things I want to mention first I I find it a privilege that I am frequently someone who is giving a breast cancer diagnosis and I'm very committed to how I deliver that information where I am not just giving them the diagnosis but I'm outlining what treatment may look like based on receptors, stage, grade, any kind of information that I had at that appointment and one of the last things that I will say to my patients is this may if it's a younger patient that may be facing chemotherapy you may experience menopause you may experience a transitional menopause you may experience a permanent menopause part of your treatment may include removal of the ovaries you may have sequelae that happened because of treatment and you have lots of symptoms I want you to keep my card and come back and see me so I I want to put it out there in the very beginning you do not have to suffer in silence your oncologists are there to save your life but I am here for your quality of life come back and I'm happy to say they do sometimes circle back with me and they remember that so planning that seed that there are some things that can help you when it comes to vaginal I love that the boxed warning is coming off I love that we're having these conversations and yes Dr. Corrie Menend has done an amazing job disseminating as have others about the safety and the awareness of vaginal estrogen even with a history of breast cancer I have personally felt this way for over a decade just really understanding what is systemic absorption really mean what is vaginal absorption really mean so telling them in that appointment by the way if you develop vaginal and sexual health concerns please come back and see me please know there are things we can do the second point I want to make is when a woman comes to see me for symptoms of menopause and they are a breast cancer survivor I like to ask them one what are your biggest symptoms what is it that you want help with because if it is vaginal we have a very good conversation I usually am able to help them understand that this is something we do have a lot of comfort with many of us who've done this work for a long time if they are seeking hormone therapy and their breast cancer survivor something you mentioned reoccurrence that I like to say to folks is if you have a reoccurrence are you going to feel it at your fault because you did this because I'm here to tell you reoccurrence has happened and they may happen with you not doing any of this so I like to address reoccurrence fears even with my survivors reoccurrence fears can happen when you get a new when you come in for a mammogram that fear you already had bad news or news that scared you to your core once you may have it again reoccurrence fears can happen when the family member is diagnosed a celebrity is diagnosed when you have a new symptom reoccurrence fears are going to be there if you feel that if you go on vaginal estrogen if you go on systemic estrogen and you feel that that reoccurrence fear is going to be so overwhelming let's talk about that because I want you to know that if you do have a reoccurrence I don't want you to feel that it's your fault because reoccurrence has happened unfortunately no matter what we do and then moving backwards and saying well let's talk about your quality of life like we've talked about reoccurrence fear how do you feel about your quality of life given the fact that reoccurrences can happen and it isn't your fault it isn't something you did so to speak and really gauging where they feel I think you mentioned that it isn't a one size fits all in that somebody could be five years out ten years out somebody could be one year out and it's going to be a different conversation a woman can have triple negative or estrogen progesterone in her two new negative breast cancer meaning that estrogen has absolutely nothing to do with that particular breast cancer and we may have a different conversation about hormone therapy even sooner fortunately I saw a patient back for survivorship care who saw a breast surgeon she had ductal carcinoma in situ which is 97% of the time estrogen receptor positive breast cancer stage zero low reoccurrence risk 95% cure hers actually happened to be triple our estrogen receptor negative which is rare but happens her surgeon put her back on her estradiol patch wow I loved that that's amazing that's progressive I was very impressed by that so it's I like to tell folks you deserve the conversation no matter where you're at in this journey of breast cancer history you deserve the conversation and at the end of the day it is your body and I'm here to help educate you and I believe in shared decision making I certainly don't want to endorse something that I would knowingly know could harm you but I also know that this whole landscape we've been basing decisions and judgments and making calls for patients and advising patients on data that's from the 80s and 90s so it's a conversation that every breast cancer survivor deserves I agree with you and maybe for listeners I do talk about this on the podcast that sometimes it can take 20 years for current research to trickle down into clinical practice and to your point that a lot of the treatment modalities and mindset is really being driven by you know research from the 80s and 90s I think it's even more critically important and that's why I think your perspective and your expertise is so needed that's one of many reasons why I wanted to have you as a guest on the podcast Lisa let's pivot and talk a little bit about a topic we talk about a lot on the podcast genital urinary syndrome of menopause because it is not talked about enough I still think there's a degree of discomfort patients reporting symptoms to their clinicians I mean even as a menopausal female I have a lovely GYN who I like a lot but I remember one of the reasons why I chose her is I ended up I was having symptoms I was having a lot of itchiness and was doing all the right things on paper and it just so happened I got triaged into her appointment book one day and she was so kind and compassionate that I said to her I will forever be your patient because you were so kind and compassionate and what I perceived to be an incredibly embarrassing series of symptoms and I remember her saying to me I think it's time for women to no longer feel stigma about talking about you know she said bikini medicine whether it's talking about a genital urinary symptom or something related to their breasts but she's young she's in her 30s but she said when I talk to patients that are middle aged or older there's still this stigma or discomfort talking about their bodies and even as a clinician myself so when we talk about these symptoms how do you explain kind of an anticipatory way if someone has not yet experienced this syndrome how do you make them aware of things that may come and we know statistically it's not a question of if but when eventually we will get to a point we will lose enough estradiol that we will experience a myriad of symptoms but how do we talk about it in a way that allows patients to feel educated but not terrified I like to screen folks who are coming to me by saying a lot of women will experience this a lot of women may start to feel pain within her course a lot of women may start to just have itching and irritation women sometimes think they have a yeast infection but they don't are you having any of these symptoms the other thing I want to mention to your point about women feeling stigmatized or embarrassed or timid I have found over the years and I think this comes from my sexual health training that the more I say things very matter of fact to women the more I watch their body language relax and they start to be able to have these conversations with me I teach in a sexual health program and I tell clinicians and therapists that I'm teaching about this the more you are able to say these things back to either your clients or your patients the more comfortable they're going to feel you will sometimes see that initial little bit of a they may even physically sit back a little you can sometimes pick up but if you act like you are talking about their blood pressure or their blood sugar or their mammogram results in the exact same tone in the exact same cadence in the exact same matter of fact it starts to become part of the dialogue so much faster for me a lot of women are seeking my help for low desire for difficulty with intimacy from either a low arousal and orgasmia or pain so they're coming in the door knowing we're going to have this conversation and one of the first things I start talking about even if it's just low desire could be even a woman a woman who's not quite menopausal maybe perimenopausal I immediately go to my whiteboard I draw my drawing of the perineal area with the vagina and the clitoris and I say this is the clitoris this is the urethra this is the vaginal opening all of these tissues are made up of layers of cells and I'm drawing and I help them understand vasodilation is part of what these superficial cells help with and if we don't vasodilate we can't have an erection of the clitoris and the more you just say these things their face just lights up because oh my gosh it's not just me it's not my imagination that I can't become aroused like I used to or orgasm takes so much longer or it's blunted or absent and the more you say this it's this realization of the connection between what's happening to them even in even late 30s there are other conditions too and medications like oral contraceptives low estrogen in the vagina so even my 30 year old patient that is coming to me because arousal is difficult desires low we talk about this you are right I think there's a gap I also have time with patients I think there is a way though to get an elevator pitch about genital urinary syndrome of menopause or hypostrogen in the vagina help women understand quickly that this is related when I talk to women about low desire I'm a real stickler that we're going to talk about your vagina first and sometimes I think they have expectations that we're going to move into talking about something folks want to fix and they want to sometimes quick fix and I think there's an expectation that we're going to accomplish everything in one visit and it's going to be a quick fix but when I say I want to back up and talk about your vagina because the relationship we know this from basins model and rosemary basins sexual response model that if you have low arousal you are never going to get to desire so always backing up and talking about vaginal health even in younger women and talking about arousal pleasure why would I want to help you want to have intimacy or sex more if it doesn't feel good so I think this continued awareness of the importance of vaginal health it comes out in so many conversations sometimes I just look at my patient's medication list they may be there for mammogram breast density discussion are you using your local estradiol well it really didn't work well how were you using it let's talk about that are you you know why don't you want to use it there's a way to bring it into the conversation do you ever feel off after meals perhaps bloated sluggish or just uncomfortable you're not imagining it many women in the perimenopause to menopause transition notice changes in digestion that could affect not only energy mood but also even focus I used to finish meals years ago and immediately felt bloated just like my body wasn't getting everything it needed it wasn't about having a gut issue per se it was about my body navigating natural hormonal shifts and digestion is part of that story that's when I added mass zimes to my daily routine it's a comprehensive digestive enzyme formula designed to support your body in breaking down proteins fats carbs and fibers so you can feel lighter and more comfortable after your meals what I appreciate is that it's not a quick fix or even a stimulant it's 18 different enzymes working together to support digestion and nutrient breakdown including enzymes that help break down protein more efficiently and even help unlock key minerals from food and it works across different stomach acid levels which can matter as we age it's vegan clean and thoroughly formulated no hype just smart support for your body as it evolves if you want to support digestion and feel more nourished from the food you're already eating go to buy optimizers and use code synthia 15 to get 15 off today again that's buy optimizers b i o p t i m i z e r s dot com slash synthia and use code synthia 15 today and if you subscribe you'll lock in your supply and enjoy special gifts with purchase this product i've used exclusively for the last five years is the only digestive enzyme that i recommend it is incredibly effective well i love again i love this thoughtfulness about your approach to patients and really making sure it starts with the basics and evolves from there perhaps are the benefit of listeners when you're going through a list of patients medications when they're coming in other than oral contraceptives what are some of the other commonly prescribed medications that you see creating or exacerbating symptoms if you're talking about somebody with you're familiar with cardiac history beta blockers diuretics we can see with some of the cardiovascular medications diabetics sometimes there's an underlying neuropathy or vascular issue antidepressants unfortunately can diminish orgasm or cause anorgasmia and can diminish desire yeah oral contraceptives i think coming those are the main thing main medications coming to mind screening for alcohol use screening for other drug use yeah i think it's important it's interesting this is going to date me but in 2001 when i was a brand new nurse practitioner i went to grand rounds every single week because i was so hungry to learn more maybe listeners don't know nurse practitioners learn a lot on the job we don't have long residencies like like medical doctors do so we learn really on the ground and i had this very wise general surgeon and he said in this grand round this is 2001 he said if you have a patient with sexual health issues erectile dysfunction difficulty maintaining an orgasm etc you need to be thinking primarily at that time he was talking that you really need to be thinking about diabetes until proven otherwise and i would also add in there like i think it's also important for women to understand like with this hypoestrogen state you have reduced nitric oxide production and how important nitric oxide is for vasodilitation so it's not just about men it's also about women and i reflect back on art serpic who is probably now predeceased us but how valuable that information was at such a young age and i remember in cardiology talking to my patients if they were comfortable enough having those conversations saying like if you're having erectile dysfunction and you're in your 30s that's something we need to be dealing with now because it's oftentimes a prelude to eventually going on to develop heart disease yeah absolutely i teach um in a sexual health course at university of michigan for asaqt preparation and i teach the chronic illness weekend and have a whole section talking about cardiovascular health diabetes because if you have any neurologic or vascular issue you're going to possibly have sexual health concerns everything from low desire to lack of being able to become aroused lubrication orgasm i think helping women understand that women experience erection too yeah when you're having conversations with patients and and i know that you are very proactive about patients that have experienced trauma and and how you go about having conversations around that when you're talking to patients maybe they've been through breast cancer treatment maybe they have not how do the conversations change and shift when someone informs you that they have experienced sexual assault or rape or even something as seemingly benign but maybe they had a pelvic exam where there was really poor communication i think practitioners now do a really good job it's been my experience a really good job with communication making sure that they're looking at you in the eye but you and i are old enough that we probably have had a few pelvic exams over the years that didn't go as smoothly as as we would hope or ideally want for a patient to go through i think anticipatory guidance is so important you mentioned you're right i think that there's much more awareness around this for me when i'm doing an exam that's going to include a vaginal exam i generally don't in speculum i'm i don't do annual exams my exams are really going to be focused around taking a look at the outside external genitalia making sure there's no underlying other reason why there's pain or discomfort and letting a woman know that that's what we're looking at before we even have somebody get undressed from the waist down that i'm only looking at the outside this is why i'm looking so a lot of anticipatory guidance around the purpose of it it isn't just because i feel i have to i feel that i want to make sure there's nothing else that we're missing also using that time to help them understand their anatomy i know a lot of practitioners like you mentioned are very proactive about utilizing a mirror and helping folks understand this is the clitoris this is urethra if you've got atrophic changes that have started to happen this is what we're watching for this is reversible this may not be reversible you mentioned trauma and sexual trauma i have a couple rules of thumb when i will pull in my sex therapy colleagues if a woman tells me that they have felt like they feel their whole life some women have experienced low desire since their 20s or some women have experienced whatever their concern is for a very long time i will refer them to a therapist as well i'll explain to them that i'm the clinician and i'm here to give you help you with psycho education around what we understand about sexual response for women i am here to prescribe anything that we think pharmacologically may help you but i really want to pull in sexual health therapy colleagues for the more longer term the other time when i definitely pull in my therapy colleagues is if somebody has any history of trauma so if there has been any sexual trauma it causes me to really stop where i'm at and take a minute and touch base with my patient how are you feeling about this how do you want to proceed and how do you feel about seeing a therapist about this because even if i'm going to continue to work with you for any kind of pharmacotherapies or continued education whether it's dilator therapy whether it's teaching you about moisturizers and lubricants whether it's prescribing vaginal estrogen or prescribing something for low desire i still think that you deserve something more longer term that can help you move through what may be impacting you now and you may not even realize it and then finally if it's a relationship issue rosemary basan's model teaches us that relationship satisfaction is where desire starts and so many things go into relationship satisfaction if somebody has any kind of relationship issues that's where i'm going to say i'm still here for you to help you with any physiologic changes we still want your vagina to be healthy but i really think we need to think about a sex therapist and also helping patients understand sex therapy isn't what they may think it is that a sex therapist is there to help you with your relationship even if that's just your relationship to yourself i've had patients that have had sexual trauma that has impacted them so much they don't feel they can self-stimulate so you may not be in a relationship with another person it may be the relationship with yourself and for whatever reason whether it's stigma whether it's shame whether it's something that you associate that with you are worth having a more robust conversation about this and having some therapy around this it is very multifactorial so many sexual health concerns for women are very multifactorial absolutely and i think about conversations i've had with girlfriends where they've kind of associated when they've had they're a traumatic event or even sometimes in some instances girlfriends who had traumatic vaginal deliveries that then go on to they are so disconnected from their genital urinary symptom system being a place of pleasure to think even as a place of pain that getting around that and working through that is critically important to being able to see themselves as a sexual being again and that is you know in some instances i've had some girlfriends who just had really big babies or traumatic fast deliveries where they have third and fourth degree tears and for listeners these are significant tears you know into the fourth degree tears into the rectum so you can imagine sometimes these things do not fix by themselves and it requires a qualified practitioner and an often times pelvic floor specialist and in some instances surgical intervention to get them back to baseline i would love to just touch back on the genital urinary syndrome piece talk to me about what you see visually some of the permanent versus non-permanent changes that are occurring in menopause or in this hypoestrogen state so first the types of things that we'll see that i feel are reversible and we can see reversible are pale tissues dry tissues and despite the fact that the tissue in the vulva and the labia may be pale in the vaginal entroitus or the area around the opening of the vagina we may see more inflammation and reddened area that's something we can definitely improve upon we can improve upon those objective findings as well as subjective symptoms like pain dryness decreased arousal diminished orgasm now objective findings that i counsel women we may see that may not be reversible is some women will lose their labia mynaura or the inner lips of the vagina may actually thin and disappear unfortunately there isn't anything to treat that sometimes the clitoral hood will reduce and that's again something that is more anatomic the urethrobroprolapse out and actually be protruding out which will increase risk for UTI and cause some irritation almost a urethritis that can be treated surgically if a woman chooses to do that but these anatomic changes we see sometimes as the progression of atrophy moves on and for some women it can happen very quickly for some women it may be they've had genital urinary syndrome of menopause for 10 years and then you see these changes for some women it's only a couple of years unfortunately um where we can see this i think the thing that is also surprising to women is that this is the symptom that doesn't go away being you know i'm gonna be 58 and in my generation i think there's more awareness but thinking of folks even older than me or the baby boomer generation where they were told to stick it out and they got through the hot flashes and they got through some of those transitional and now they're in their later 60s early 70s what they don't realize is this is menopause related and it doesn't go away and unfortunately those sometimes are patients that i'm seeing that have some of the anatomic changes where we can help them subjectively with the symptoms but objectively some of these findings are not going to resolve i think it's such an important conversation i think it was dr rachel rubens real that went viral talking about you were women were losing you know part of the vaginal vestibule and and how that is a permanent and it was going viral with young people because all of a sudden they're like wait a minute what do you mean i'm going to lose my labia minor like time out no one's talking about this and i don't think enough people talk about it in fact i think when i read that i think i sent a message over to my gyn and said wow we're not even having this conversation this is certainly really really important well in order to kind of wrap up the conversation we're going to do some rapid fire closing questions things that are you know you can answer quickly but are relevant to this conversation that we're having one myth about menopause you want to bust that you can't take menopause hormone therapy over the age of 60 super important your favorite non-hormonal tool for hot flashes that isn't being talked about enough the neurokine and receptor antagonists a simple breast health habit women can start this week self-exam use the pads of your fingers check your breasts whenever you think about and last but not least one book besides your own you wish every clinician in menopause and breast health would read estrogen matters such a oh i love the conversation i had with avrum and carol one of those you know life-changing conversations and i know what a privilege that would be yes yeah this is what we do is podcast host i listened to the podcast that he did with peter atia and it was like Thanksgiving day and i told my husband i was like i know it's Thanksgiving but i have to finish this podcast and i immediately reached out to avrum and said i'm an np i listened to your podcast with peter i think it's so valuable i would love to share you with my community and he actually responded it's so it was incredible but you know inspired action for any of us that you know as we're learning things you know reaching out to these people who are really helping to change the narrative lisa i so love this conversation please let listeners know how to connect with the outside of this podcast how to work with you if you are a patient in michigan or learn more about your work you have two beautiful books one is a textbook one is a kind of autobiography that i had the privilege of reading over the course of the weekend while i was traveling got to know you better before we even ever spoke well you can connect with me on instagram i'm at dr mommy pappens and my other instagram is the adopted nurse and i practice in rechester hills at oakland macomb ob gyn center for breast health i'm the clinical director here oh thank you again for your time thank you thank you so much for having me if you love this podcast episode please leave a rating and review subscribe and tell a friend