Ep. 555 “It’s Not Just Hot Flashes” – The Most Overlooked Heart Disease Risks in Menopause with Dr. Jayne Morgan | Menopause & Heart Disease

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 had the honor of connecting with Dr. Jane Morgan. She's a cardiologist and vice president of Medical Affairs at Hello Heart specializing in Women's Health and Cardiovascular research. Today, we spoke about lapses of information on parimenopause and menopause for most clinicians training, gender neutral training, as well as considerations to how men and women are treated differently in the medical system. The things that Dr. Morgan likes to focus on in terms of educating women in middle age, both in terms of hormone replacement therapy and what she refers to as clusters of diagnoses, things like diabetes, dyslipidemia, high blood pressure, and weight loss resistance. We spoke about how women present differently with myocardial infarctions, those are heart attacks, how they have atypical chest pain, they tend to have very vague symptoms, and they can have microvascular disease. Next, we spent time talking about specific screening recommendations, including things like EKGs, LP Little A, and looking specifically at mammography to see if there's any microcalcifications and maybe suggestive of being a greater risk for cardiovascular disease. This is a delightful, lively, and fun conversation with Dr. Morgan. She's a joy to interview, and I look forward to further interactions and podcasts with her on everyday wellness. I love your Morgan, such a pleasure to connect with you, welcome to everyday wellness. Thank you. I love being here. When you think about when you were a new cardiologist, compared to now, what are the opportunities with middle-aged women that you reflect on that you could have done differently? Knowing as much as we know now about the role of estrogen and progesterone and the influence on the heart, you know, I didn't even know anything about middle-aged women. I never, you know, you hear the term, it doesn't have anything to do with science or medicine, it's sort of, you know, your grandma or someone like middle-aged, it was not a term that came into medicine or science at all, and it certainly didn't have any bearing on how therapy would be administered, or driving levels of consciousness or awareness or even approaches to a patient. So it just simply didn't exist, it didn't exist for me. I was a cardiologist. Middle-aged women were the same as a 20-year-old woman, was the same as a 70-year-old woman. At least, though, as we got into our 70s, we at least started saying, well, for geriatrics, we should consider, you know, so maybe something to that degree, but other than that, there was really no emphasis, no de-emphasis, no discussion, no talk about it, nothing. Yeah, it's interesting that we have a very, very much a shared experience. Like, I was coming of age as a new nurse practitioner, right, at the time the WHOI came out, and so listeners are very familiarized with the study, and I had patients that would tell me and clinic or tell me in the hospital how terrible they felt, not being on hormone replacement therapy, but I had no sense or idea of how influential that was at that time. And now, when I think about all the patients I would tell them, well, it's normal to get hypertension or high blood pressure with age, because your arteries get stiffer, and you it's normal to have arrhythmias as you get older, because it's just what happens. And so I acknowledge now very humbly that what I understand now, I think, was very different than the way that we were trained, or certainly even the little bits of information we had about menopause. It was like, menopause happens, you drop off a cliff, and then, you know, we go on with the day. And I think that I'm grateful for work like yourself, where you're helping to educate women, help them understand the physiology and what's happening in their bodies. So let's talk about why menopause is this very important turning point for cardiovascular health and women. I think not enough women understand that one in three women will develop atlascotic cardiovascular disease or heart disease to make it a little more easy to wrap our heads around. What's changing in our bodies is we're navigating that menopausal transition specific to the heart. So I was going to say if we just go back for a second, when I was in my cardiology fellowship, I remembered my program director talking about the women's health initiative and asking me, I was the only woman in my program. Would you consider hormone replacement therapy if you had an increased risk of breast cancer? And I remember saying absolutely not, I wouldn't do it. And that was, as I look back on it retrospectively, my entire training in hormones, sort of that question that he asked me in front of all of the other fellows. My response of never would I do that if my risk of cancer was increasing. I never read the study, didn't know about it. He was sort of telling us about it. I decided, wow, no, that's not something I would do. And that was the end of the conversation. It was never ever brought up again. It was just sort of null and void. And for the next 25 years, nobody talked about it. And it certainly was never ever ever a part of any training in cardiology. And so when I look back on that, it's interesting that my cardiology director actually asked that of the cardiology fellows. So you may have been a little bit more forward thinking that I gave him credit for at the time, because you know, cardiologists, I'm not an OBGYN. And you know, when you think about menopause and think about women's health for the entirety of the health system existing, women's health has just been reduced to reproduction. We're just kind of breast vaginas, pelvis, that's it. And that's what we get. And that's where we focus. And that is very important. I mean, we should focus there. And we've been very successful in driving down cervical cancer, and breast cancer, but that really hasn't been a focus on the heart at all. And then the last thing that I would say is during my fellowship, there was never any discernment between women and men. So no gender approach. Not only was there never a gender approach, it was sort of a one-size-fits-all I certainly learned cardiology that way. One-size-fits-all. And even for me, it never occurred to me. Maybe I should be thinking about this differently in this woman. A couple times I would say, and many doctors would say that she's kind of small. Should we cut the dose in half? This is very non-scientific and it's getting bad. And then we would, you know what, that's probably a good idea. Let's give her half and see what happens. And we'll tight trade it up. Let's not give her the full dose. So it was just kind of those kinds of discussions, very unscientific. Never going back to say, why are we having these unscientific discussions about cutting the dose in half? We don't have any data on 50% of the dose. But we are recognizing that the body habitus and size is different. And yet we're not going back to the source to say, hey, drug companies, why haven't you had women in these trials? Why aren't we including them? It was just not a conversation. These were just things that you manage as a physician. You just managed the environment and you managed women by prescribing scored tablets. And so for your audience, that means those tablets that have like a nice little line in the middle. Doctors love those. Cardiologists. If you're having side effects or maybe your blood pressure has dropped too low, we've prescribed an anti-hypertensive. We love to say, cut the peel in half. And if those pills are scored, it's so easy. And who are we saying that the most to? We're saying that to the women. Cut the pills in half. Or you know what, I think that dose may be a little bit strong for you. You're a little small. I'm going to prescribe them, but there will be a line on the pills. I want you to cut the pills in half and take half a dose. And let's follow up in two weeks. And then we'll see if you can take the full dose. So all this hoca spoke us. I call that hoca spoke us science now. But that's literally how we practice, right? That's how we protected women. We were prescribed scored tablets. And all you know, it was just crazy. It was crazy. Yeah. There's a drug that you're very familiarized with. The calcium channel blocker call Amelodopene. And I used to say the 2.5 milligram dose was for my little old ladies. Because that was like the pur- I did they just needed a little bit. A little bit of an anti-hypertensive. And I used to say all the time that was like my perfect dose for my little ladies. But to your point about scored tablets makes it much easier to divide the pills into right. Did that crazy? Yes. I mean, those are the kind of practicalities of practice thing that you're thinking that way. Is it going to be easier for this patient if it's scored? It makes it easier for them to divide the pill in half. When you're thinking about it, why don't you feel that the right dose in the first place for women? That's the question we didn't ask. Yes. We're only just managing the situation as it comes to us. We're not thinking more deeply into why am I doing this exactly? Well, even you're talking about gender neutrality that, you know, we treat men and women the same. I mean, I think about that I admit that I probably thought very similarly at that time that, you know, whether it's blood pressure or heart disease or lipid management or arrhythmia management, any of those things thinking very thoughtfully because we may adjust doses based on renal function, kidney function. We might base it on hepatic clearance. We might base it on can the patient care remember to take one more pill. But we're not thinking at all about the gender piece and how, where they are in a menstrual cycle, are they menopausal? Or, you know, are they never a conversation about menopause or pariamidopause? In my entire cardiology fellowship and also the entire time I was practicing, sorry to say. So I, even as a physician, was not giving top line care to my female patients. Wasn't trained in it. It wasn't occurring to me. I wasn't thinking about it. If you have symptoms, what are we thinking? Hot flashes and night sweeps, you know, just kind of deal with it. That's what everybody does. You deal with it or if for whatever reason is really bothering you, talk to the OBGYNs. They're on the other side of the hospital. Go over, you know, it's just kind of like, why did you get lost? Why are you in cardiology? How did you end up in cardiology? You know, and it's not even a conversation that you would have. I don't, you know, recall anyone bringing it up. But I imagine the old Dr. Jane would have been baffled if someone had made an appointment to see me to talk about their menopausal symptoms. Just would have blown me away. Like, oh my god, you're a law. Did you get lost? I'm a cardiologist. And so my what a long way we have come, how much further we need to go, the beauty of living in science, the beauty of loving and understanding that to truly be in science, you are perpetually a student that you are never a master. And I think that is a hard concept to get across. I think it's why it's difficult for us to talk and train and teach about menopause because many people are masters of their domain. I know everything that I need to know. Or it's not in the guidelines. If I have to, you know, everything comes from the guidelines. In other words, so I don't really have to think. I just need to follow have enough things to think about. And menopause requires you to think because it's only just inching its way into the guidelines. So we've got to actually understand the science, understand the physiology, understand the pathophesiology, the practicality, the history of medicine, unravel the women's health initiative. That's like there's too much work for everybody. The matter is you've got to always humble yourself and always be a student. You are never ever a master. If you are in science, if you are in medicine, you will never ever ever master it. And if you think you will, you need to leave. It is always an opportunity to learn any fall. Everything I've learned on menopause, I learned all my own. I learned after my fellowship, I learned after my practice, I learned from home and aha moments throughout my career as I'm thinking terminology. I've talked about that a lot. Terminology that was used mostly for women and how it always kind of bothered me, but I wasn't quite sure why. Didn't like it. Notice that the women had these symptoms. It wasn't thinking and they're probably receiving worst care too. Wasn't taking that next step. And so, you know, for anyone out there, no matter what your profession, I can't even think of a profession as very finite. Maybe math. I don't know. Math maybe even is not. But most things continue to evolve and you've got to be able to grow and be able to think. And I think when you're in this menopause world, all of us are students. And we love being students and we're comfortable being students because what I say today actually may change tomorrow, may change next week. We may have more and more information. It's women's health that is going to push this envelope on how quickly science can evolve. We will be integrating digital health. We'll be integrating AI. We'll be doing everything because by golly, we're not going to wait another generation for evidence-based clinical trials to run through their 10 or 15-year cycle. So, we can figure out whether we can prescribe extra-gener progesterone. We've got enough information and guess what? We can also think for ourselves. And so, that's kind of where we are. That's where we are. And that's how we got here. It's a sad story. And the majority of medicine is still not on board. It still needs to learn about it, needs to hear about it. So, we'll just continue to beat the strome. If you're in perimenopause or menopause and are feeling more fatigued, dizzy, light-headed, struggling with headaches or noticing your workouts feel harder than they used to, electrolytes may be part of the missing piece. As estrogen declines, we lose some of the fluid regulating and vascular protective effects that hormones once provided. That means blood pressure regulation can shift, cortisol can run higher, and many women become more sensitive to dehydration. Especially if you're strength training, walking more, intermittent fasting, or reducing process foods. That's why I love element. It is my favorite electrolyte formulation, and I've exclusively used their products for the past six years. Element contains a science-backed ratio of sodium, potassium, and magnesium without sugar, artificial ingredients, or unnecessary fillers. It supports hydration at a cellular level, helps reduce muscle cramps, improves energy, as well as recovery, and can even support better stress resilience. This is particularly helpful in midlife when we're prioritizing metabolic health and muscle preservation. I personally use element throughout the day, and it's become a staple in my routine as well as my household. If you'd like to try it, go to drinkelement.com. Splash Cynthia. To receive a free sample pack with any purchase, stay hydrated, stay strong, especially in midlife. 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 microbeom 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. That's exactly why I wrote my new book, The Menopause Gut. In this book, I walk you through the science of how the microbiome, metabolism, immune system, and hormones are all connected during midlife. But most importantly, I give you practical, realistic strategies you can start using right away without extreme diets or complicated protocols. You'll learn why the same diet that worked in your 30s may not work now, how your gut influences hot flashes mood and weight, the truth about fiber, protein and blood sugar in midlife, and the daily habits that help your body feel safe, stable, and resilient again. If you're tired of blaming yourself for changes that are actually biological, this book will help you understand what's really happening and what to do about it. You can pre-order the menopause gut wherever books are sold, and when you do, be sure to check out the special pre-order bonuses I put together for you. Again, you can go to www.synthethorlo.com. You'll click on the banner, it'll take you to multiple options for where you can order the menopause gut in pre-sale. Yeah, no, I love everything you just said, and I believe in being a lifelong learner, and I encourage listeners to always be learning and evolving and shifting and changing, and I always say, gosh, I don't practice the way I did 10 years ago, right? So it's like we should be learning and questioning things and not be rigidly dogmatic because that's what you want to go to a doctor who 10 years later is still practicing the way they were 10 years before. Think about that. Things change, they need to have gotten CMEs, they need to have gone to conferences, they need to have learned what are the newer techniques that need to be used in different equipment. I mean, do you want someone who 10, 15 years later is still practicing exactly the same? No, you don't, you really don't. No, so if you were going to give women that are listening some kind of broad strokes about heart health and what you want them to understand about, they're changing physiology, because it's important to distinguish that. What we worry about in a 20-year-old female is different than what we worry about in a 55-year-old female. Where would be your starting point from cardiovascular health? Yeah, from first, you know, I would like to start with saying your best years are yet to come. It's going to be a more fun. I want you guys to know that, right? It's going to be 40 of you good, 50 is going to be even better and you're here to help you make it better. You will, there's nothing like lived, learned experiences and the confidence and bravado and a little bit of swagger that goes along with that where, you know, your previous attendings, those are the senior physicians who teach you and and people who are very senior to you and empower often men. That's really I'm using the code for men. Then giving you information, that's false information, you're good, it's kind of telling you, it doesn't sound right. You will feel more empowered to say it instead of just thinking it. You will say, that doesn't sound right, that doesn't feel right and be comfortable with saying fee-ylings, you know, in corporate America, women have been taught, don't ever say feel, say think, don't feel. Well, you know what, I think that's our superpower. We actually do feel and we have, and I think we should reclaim who we are in the corporate environment. And if we want to feel something, that's what gives us the advantage and let's stop saying, I think in doing all the corporate speak so we can be like, man, we're not men, we are maybe superior. We actually can feel some things too. I'm feeling comfortable saying that we feel them and we acknowledge it and we have a broader perspective of the human experience and not from such a narrow, egalitarian perspective. So get ready for 40, really love 50, 60 is going to be awesome too. So I just want to say that. And now, when we talk about cardiology, what are the things we want to talk about? I want you to always have the conversation about hormone replacement therapy. I want to be clear. I'm not saying take hormone replacement therapy. I am saying have the conversation. You are entitled to that information. It is owed to you such that you can make the most informed decision about what is best for you. Now, what has happened with the black box being removed from hormone replacement therapy is that allows us to do that previously. Other people, by other people, I mean men. The government was making those decisions by government. I mean men and the FDA were all making those decisions for you. They took that decision making from you. We've already decided that this is not good for you. So now you get to make that decision about what's good for you. And I think that's the best thing about removing the black box. Not to encourage women to just take hormone replacement therapy. We're not selling it on the corner. We don't have an open kiosks. The point is for you to be able to have an informed conversation and make that decision for yourself and maybe encourage your physician to inform themselves so that they can have that informed decision that informed conversation with you. So that would be number one. I want you to have that informed conversation. Number two, I want you to understand the cluster. And what is the cluster? The cluster is all of the risk factors for heart disease that happen during very menopause. And they all come at the same time. You know what? When I think about this, I can't even believe we haven't figured this out before. But the fact of the matter is high blood pressure, high cholesterol, weight gain, insulin resistance, diabetes are all independent risk factors for heart disease, including sleeplessness, independent risk factors. We treat them independently. It's a risk factor for heart disease, Mr. Jones. But when Dr. Jane comes in with all the risk factors happening at the same time, nobody talks about it. Oh, I don't really know what that is. You know, just a minute. Nothing you're going to do about it. So that cluster is actually quite dangerous with a lot of things are happening at the same time. That's why it's important to have the conversation about hormone replacement therapy and what that means. But it's also important if you're prescribed medications. And I say this on my pages on Instagram, LinkedIn, I'm not saying something new. You can follow me at Dr. Jane Morgan, DR, J-A-Y-N-E-M-O-R-G-N. If you are prescribed medications, especially for blood pressure, for cholesterol, you need to take them. And I want to say that again, especially if you are at midlife, don't kid yourself. I've had low blood pressure my whole life. This can't be real. I must have been rushing into the office. Or I had extra coffee that morning, maybe those things are true. And actually, if you watch my page today, actually talk about the right way to take blood pressure. But those things can be true. But if you have repeat measurements, and they are elevated, and by repeat, I don't mean once a year for five years, it takes you five years to figure it out. I mean, in the same day, take blood pressure during the day. If it's elevated, then you see your physician and they prescribe medications, take those medications. Because what I find is people like to brag that we take no medications. Because that makes us feel healthy. And you know what? Because all of the years of our youth, we didn't take medications. And we were healthy. Medicines are associated with your sick. And so it's easier for our mind to reject taking medications. I'll be fine. I'll just exercise a little more. I'm going to eat a little less meat. I'm going to lose a little weight. And I'll be fine. The fact of the matter is if you're a midlife woman, you may not be fine. Those things may not be enough. And here's the rub that's really going to get you. You might not even be able to lose weight. So think you're going to lose weight. And you don't. And then you keep trying and you don't. And you keep going. And you don't lose that weight that's holding on because our hormones, leptin and garolin are still in there now. And they're all upside down. And so don't get into a cycle where you're kidding yourself. Medications actually keep you at that healthy state that you were in when you were younger. It's not not taking them. That's making you healthy. And you feel good about yourself is the opposite. Taking the medication is keeping all of your numbers back down to where they were when you were 20 and 30. Those are the risk factors that you want to decrease because during paramedics, they occur in a cluster. So more than one can happen at once or they can happen successfully. And the next thing you know, you're overwhelmed. There's like a million things going on. Unfortunately, they're all risk factors for heart disease. People haven't heart attacks women in their 30s and 40s is known. It does happen and be clear it does happen. That's why paramedics is a risk factor for heart disease. Yeah, I think it's such an important message that there should be no shame. If you need to take a medication to lower your APOB, your LP little A, if you need it for your blood pressure, there's no shame in that. I think that I love that there are people out there who say very proudly, I don't need to take any medications. That's great. But if you do need to take a medication, that's okay too. I take Zedia because I inherited some crappy genetics. And that has, you know, dropped my APOB precipitously, thankfully. And I see no shame in that. And I try to share that to the people understand, even I, it's a pretty healthy lifestyle. I need to take a little bit of Zedia and that works beautifully. Absolutely. Just because you don't take medications doesn't mean that you shouldn't be taking them. There's a difference. And so don't catch yourself. The mind is so interesting. We, the mind takes us oftentimes where we want to be, where we feel comfortable. And you get stuck in that comfort of, I'm healthy because I don't take medications. I don't need medications. And in fact, you're kidding yourself. Your mind is kidding yourself. So I want you to kind of unwind that. And if you're prescribed something, take medications, let me tell you something. I'm a part of the profession. I don't know of a single physician who will insist that you take a medication long after you no longer need it. So if you're prescribed blood pressure medicine and you lose 30 pounds and you're now exercising an hour day and you know, you've done all of your cutouts salt and you followed the dash diet and you've done all these things. And now every time you come in, you have low blood pressure on your blood pressure medication. Nobody's going to keep you on your medicines. We're happy to wean you down. We're happy to take you off of your medications. So I always say start them. If you reach your goals, we'll take you off of them. But don't start by saying, I don't need them. I'm going to do X, Y and Z. And then if that doesn't work a year or two or three down the road, I might take medications. That's a long time for pressure to be beating on the inside of your arteries. And that takes a toll that builds up atherosclerosis that builds up plaque that makes those arteries stiffer, meaning it increases your blood pressure. So that's a long time for you to be kidding yourself. And like anything with age, we really kind of don't get away with it. We sort of think we do. That's why blood pressure is a silent killer because we're not feeling anything. We're really not getting away with it. Except mentally, we feel good. We feel good mentally. But your body inside is aging. Yeah. Well, I mean, how many times did you see and I saw patients who didn't take the blood pressure piece seriously and they didn't fully acknowledge they needed medication until they had kidney failure, until they had a stroke. I think we don't want any listener to ever experience. And so I think from experience, one thing about women that I think is important to kind of reemphasize is women's heart attack symptoms are typically different than men. Let's talk about this because we know the women 10 to percent later, they tend to present with small vessel disease. They tend to not have as great outcomes overall because they take care of everyone else in their lives, but themselves. Yeah, this is a good point. And this is one of those things where you know, when I talked earlier about, you know, you sort of have these mm, questioning moments, mm, in your cardiology fellowship. But you know, you go lowest person on the totem pole, you ask your senior attending and they poo poo it. No, that that that that. And then okay, I mean, they write they hold all the information. They certainly hold all the power. You're just they're learning. In my cardiology fellowship, I noticed that women often had a typical chest pain. I didn't really know what it meant. I wasn't thinking, oh my god, we're killing women. I just noted that a lot of times they had a typical chest pain and we actually would write a typical chest pain rule out panic disorder. Even I can't believe, but yes, I did that. You can probably go back into my charts and see that I literally wrote that on women. That's what we were trained to do. Oh, this might be a panic attack. Women often have panic attacks. That I knew. I didn't know why, but I knew and I'm being tongue in cheek like, oh, yeah, the trend women have panic attacks. So we always need to make sure they have an hardest attack. They have panic attack. I don't ever remember trying to figure out what our man was having a panic attack or not. But we always were trying to decipher that for women. And it got to a point where I started having an aha moment again, not really connecting the dots, not saying, oh my gosh, we're doing a disservice to women, but just starting to notice, most of the people that we describe with a typical symptoms are women. That's weird. And when I brought it up to my attending, it was like, oh, that's because they're really having, you know, wink, wink, the panic attack. So in other words, we're sort of, we're being nice and sane, just pain, but it's not really just pain. So it was kind of that wink and a nod. And yet I then started to notice because we would sometimes keep people for a few hours and what we call rule out am I? We would draw blood. And their enzymes was start to increase, which is an indicator that they were having a heart attack. And yet we sat on them for a day while we watched their enzymes. And even if they bumped a little bit, we would say, oh, let's just see that might be whatever or something they've done. Let's see if they go back down and we wait another six hours and enzymes go back up. And it was just like crazy. Like literally women had to prove first that they weren't having a panic attack before we would say, okay, okay, okay, it's a heart attack. Okay, you got me. Okay, you know, unless their enzymes were really, you know, just off off the chart. So if they came in with these vague symptoms, when I say vague symptoms, what do I mean? I don't mean the crushing chest pain and chest pressure and shortness of breath and diurefereesis means sweatiness. And you feel like dizzy, you're about to pass out, you know, it's very dramatic. No, maybe you just like, I'm just, you just feel run down. You just feel run down. You wake up in the morning, run down. You haven't even gotten up you're tired. And you know, for women, because we do so much for other people, we can always find a million reasons why we can be tired and quite frankly, probably most of them are justified. But if you are tired all the time, if you wake up tired, if very little exertion makes you tired, if this doesn't go away after a few days, that is not normal. And you should see someone. So fatigue, so chronic fatigue is one. Also like abdominal nausea, abdominal bloating, you know, again, it could be attributed to any number of things, right? abdominal bloating, lower back pain, jaw pain is another one that might send you to the dentist or even pain in your right shoulder and arm, not the left one. So back to that microvascular disease that women can have. And so it's no wonder that women have had a hard time figuring it out because even doctors haven't figured it out. And when we did a survey of physicians, primary care physicians and cardiologists, 80 percent, I think it was 80 percent of primary care physicians admitted that they did not feel comfortable treating a woman with heart disease. And so when we look at cardiologists, I think it was 40 percent. Said that they didn't feel comfortable treating a woman with heart disease. And at first, it's like, oh, it's much better than the primary care, it's half the primary care physician. But if you think 40 percent of cardiologists don't feel comfortable treating women with heart disease, when literally that's what we do, like we're the cardiologist, but 40 percent of us. And I had to think about that for a moment. And I was like, aha, the reason for that is most cardiologists are men. So let's think about that. It's unwinded a little bit more. If 40 percent admitted that they didn't feel comfortable treating women, there's probably another 40 percent that are completely incompetent in treating women. But of course, never admitted because men are more likely to overstate their abilities. And so women are more likely to minimize our accomplishments. Men are more likely to overstate. So when 40 percent would admit, it's probably a much higher number that actually just had no business doing. And so I, you know, I think about that when I go back to my cardiology fellowship because the all men in my cardiology fellowship and there's one other woman and we were the first women ever. And I was, I committed the biggest sin, right? In training, I got pregnant. Oh my god. So as married, I had one son and I was pregnant with my second son. And when I tell you the men in my fellowship program eviscerated me, punished me, angry, just the the the isolation, the marginalization, the contempt for me to dare get pregnant and because we're women, I had designed my entire program once I found out that I became pregnant such that when the baby was born, none of my male colleagues would have to cover me because I was going to do all of my hard rotations while I was pregnant. And then so when I left on my maternity leave, I would only have electives. So no one would have to cover me. Now, would I do that again? I would not because doing all of those hard rotations while I was pregnant on call, 36 hours, all of this, just so the men weren't going to complain about me. When in fact, they complained and complained and complained and complained, although not a single one of them ever had to lift a finger to help me. And when I look back on it, they should have. I was working nonstop as a pregnant woman. So nobody would complain about me when I was out on maternity leave. By the way, maternity leave lasted just six weeks. And I think I was paid like half my salary or something for six weeks. This is crazy. But here's the point that I'm making. In case you think I'm a whiny woman, another another conversation, here's the point that I'm making. My son who was born then, the one that I was pregnant with, is 29 years old now. So that was 30 years ago when I was pregnant with him. Those men in that program to this day still do not speak to me. No. Do not speak to me. Do not acknowledge me. 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That's unbelievable. I on so many different levels. So for listeners, I can attest the fact that when I started in cardiology back in 2001, there were two female cardiologists in a group of 50 providers. So it was nurse practitioners and physicians. Mostly physicians, we are a really small service of this larger practice. There were two women and the stories that these female cardiologists told me about their training are very similar to what you're saying, Dr. Morgan. Well, experience was and that they had to go above and beyond and everything they were never allowed to make a mistake. They were never allowed to ask for time off. And you would never given any help or any support. Everything was made more difficult for you. And the chair and the program director allowed it. It comes from the top. So they allow it. So they also didn't feel or didn't I'll say feel. I'm going to own the word feel. They didn't feel that I was sufficiently grateful to being a cardiology fellow because I dared to get pregnant. Like I just threw it in their face. They let me in here. You let me. Oh my god. So, but this is the training and the point that I'm making is that my training was so isolating and so brutal and so uncomfortable and so unfriendly all because I got pregnant. Prior to the pregnancy, actually it was kind of okay. Once I got pregnant, I was dead to them. And when I tell you, these will be the same men answering the survey saying that they can give good care to men when 30 years later, my son is 29. Wow. They have never spoken to me again. No, that's fair. And understand that. That's people always see themselves in a light that maybe is not true through a different prism because it allows them to live with themselves. Yeah. And it's the same thing when we talk about people bragging about not taking medications, it allows you to feel good about yourself. You don't face an uncomfortable truth. Now, maybe they're not facing the uncomfortable truth. Maybe they really like it and they live in it and they relish it and they love. They probably never thought of me again, which is fine. The point that I'm bringing up about them because I have not reached out to them either. But the reason I bring them up is that they are all cardiologists. Okay. And we talk about giving gender specific, unbiased, empathetic up to date care. Think about the actions of these people and what that what kind of reflection that really shows unconscious bias is carried by physicians. And it is transmitted to patients is one of the reasons that black patients more often prefer to be seen by black physicians because of this unconscious bias. There are biased physicians and then there are those who will say they're not biased and have unconscious bias. They think or they kid themselves that they're providing, you know, the top level of care. So these are all things that, you know, as a black female and as a physician, I'm walking both sides all of the time. And then when we talk about menopause, it's like just a volcano meeting a tornado and it's just a big explosion. And that's where we are now and we are moving this forward and we will continue to move it forward. It would be nice to have men support us and we've had lots of men come forward, but there will be men and women who just will not be able to be moved. And that's okay. We will leave them where they are and continue to move past them. And something for your viewers, if you are seeing a physician, a nurse practitioner, anybody you're seeing and they are no longer serving you. But you've known them for 20 years. They've delivered all your babies. They've been there through every flu episode, every whatever you've had and they've just been great. They called you on Sundays and checked on you and you just think the world and the moon and yet here you are at menopause and you can't have a conversation and they don't know anything about it and they keep sending you out with antidepressants and you feel terrible and it's been two years with the doctor that you love who called you on Sundays, who called you from his or her vacation. Like that super special doctor who went the extra mile. I want you to listen to what I'm saying very carefully. You need to drop them like a hot potato. It's over. It's over. It was a great relationship. It doesn't have to be acrimonious, but they no longer serve you where you are now in your life. So you need to bid them goodbye with a professional handshake or hug. Thank them for all that they have done for you. But now you need something else. Don't be afraid to do that. As for women, we tend to stay too long because we remember all of the nice things someone did for us all the time they went over and beyond. Which is great. This is why I'm saying you doesn't need to be a blow up, but it's time to move on to something else. And I mean right now you dropped them like a hot potato and you got to just keep moving. No, I think that's such important advice. I want to be mindful of time, but I would love to you for you to briefly talk about if someone's listening, maybe they have a family history of heart disease, maybe they just want to do baseline screening. What would be your recommendation as a starting point for assessing cardiovascular health? What would be the most important things that you would make in terms of recommendations for a woman in perimenopause or menopause? It's maybe not yet having symptoms. Let me be clear. Maybe someone who's just the worried, I always call it the worried well, people that are being proactive and listening and want to be conscientious about their heart health. So a couple of things. I would say get your LPLudal HX. So there's some basics. I'm going to go beyond the basics. I would say get your LPLudal HX. I would say S4 and EKG. And I would say go back over your last two mammograms and see if your doctor can have a radiologist read to see if there are any microcalcifications in your mammograms. Because that could be an indicator of calcifications in your heart. So those would be three things that I would ask for that are not standard in any office. If you want to be like super next level, then those may be three things that would ask for. Now, if we want to get down to the basics and the basics is really what preventive medicine is all about. Let me just talk about the basics. I'm going to talk about the cluster. You got to get your blood pressure under control. You got to get your cholesterol, the HDL, the LDL, LDL, especially in triglycerides need to come down. We've got to work on weight which is going to be even harder. So we've got to think about what those strategies are. If that work on good sleep hygiene, sleep will elude you again. Or a moment placement therapy, it's specifically progesterone could be helpful with that, but there are other techniques as well. So, you know, before we, you know, jump off into next level EKG LPA microcalcifications on your mammogram, maybe just start with the basics. Is my, can I get my blood pressure? How do I reduce my risk factors right now? Do I need to open this prescription bottle? I actually take these pills that have been sitting there for a year that I've never taken. So I would just start at the basics where you leap into advanced menopause. I was just starting to get a pause 101. No, I like that because I keep saying this over and over again, majoring in the majors. Like the things that are going to drive a lot of lifestyle mediated symptoms, concerns are the basics. And I think in so many instances it's easier to say, oh, let's do a CAC. Let's do a CT angio. Let's do clearly. Let's do all these other things. It's like, no, no, let's start. Let's be thoughtful. I love that you brought up the mammograms looking for microcalcifications. Dr. Thomas Day's brain brought that up a couple times. And I know who listeners are listening to that. These are tangible things that are accessible for most, if not all. Let's round out the conversation. Just explain what LP little A is. Listeners have heard this before, but I would love your take on it. And we know that it's genetically mediated. We can also see some differences racially as well. Yeah, yeah, yeah. So you can think of LP little A. It's lowercase L, lowercase P, parenthesis, lowercase A, parenthesis. Isn't that fun? Lipoprotein A, LP little A. And it is actually worse than our bad cholesterol. And here's the rub for all your listeners. Doctors have known about it. We know about it. We know about it. Right. We always have known about LP little A and ApoA and ApoB. We know about all of these. But it's not a part of your cholesterol profile. And you may say, if a doctor's know about it, why is it no one's ever tested before? Here's the little funny thing. Unwritten rule psyche about medicine. We don't really like to test for things. For which we don't have a treatment. We don't really have anything to offer you. So no need to test for it and get you upset about it because there we can't do anything about it. So let's just not test for it. And so nobody test for it. It's not a part of your standard cholesterol profile. But all doctors know about it. Unlike menopause, all doctors don't know about it. All doctors do know about it. I mean, they just don't test for it. There's no treatment. Now, is there no treatment? That's a yes and no answer because we now are encouraging people to get their LP little A's drawn because you can work on aggressive lifestyle modifications. So if you have a patient with an elevated LP little A, you may want to be even more aggressive with your level of lowering their LDL, of lowering their triglycerides. You may want to be even more aggressive, but the rate it would you do that. If you're smoking, we probably want you to quit like right now by your sitting in the office. Give me that cigarette. It's over. So we may want to follow you more closely. We may now prescribe a nutritionist and get super aggressive about losing weight. So there are a lot in exercise. There are a lot of things that we can do with regard to lifestyle modifications to address elevated these, this LP little A, elevated LP little A to ensure that we can reduce your risk as much as possible. That wasn't the way we were thinking before, but that is how we're thinking now. And now on the other side, even though there's not a medication available, medications are coming available. So there are medication from Novartis called Pelocarsin. I happen to know about it because I sit on the steering committee for the last four or five years developing Pelocarsin in our horizon and our heritage trial. But other drug companies are also racing to bring these therapies to the market. What do we want to see? Not only do we want to see that the LP little A is decreasing. We really want to see that cardiovascular endpoints are moving. We want to see that this drug not only lowers your LP little A, which makes us feel good psychologically. Remember, I love that. Look at that number. I'm good. We need to have proof that a lowered LP little A also means a lower risk of heart disease and a lower risk of stroke. And it's not just a pretty number that's making us feel good, right? So we're trying to move away from feeling good and actually being good. And so that's where we are and we'll see what the data shows. Well, I can't think of a better way to end the conversation with you. This has been such a pleasure and you're right. You know, for a lot of us as clinicians, we like to see those numbers change. But the real tell is does it lower our risk of heart disease or is it just psychologically sort of an adaboy? Look at me. I'm sick on a page, I say. It's just lipstick on a pig. It just makes it better, right? Anyway, it's been such a pleasure. Please let us know how to connect with you. Yes. This podcast had to learn more about your work. Yes, you know, listen, follow me Instagram at Dr. Jane Morgan dr jay. Why there's a why in my first name? Jay why and E mo R. J. In, but you can also find me on threads on tick tock on YouTube and also on LinkedIn Jane Morgan MD J. A. Y that why is still there? Jay why? So I'm on a quite a few of the social media platforms. I do a lot probably on Instagram and I'm on LinkedIn, but you can see me really in any number of places. So I hope you give me a follow. I talk about medicine. I talk about women's health sometimes to make a few jokes, but I try to keep it light and make certain that when you come to my page, you can, you know, you can learn a little something. Absolutely. Thank you again for your time. Thank you. If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.