What to Know Down Below™
Welcome to What to Know Down Below™ by Tina’s Wish! We’re here to empower you with the knowledge and tools you need to advocate for your own gynecologic health.
Knowledge is power, and we encourage everyone to join us in learning more about what you need to know, down below!
What to Know Down Below™
Navigating Menopause, Featuring Dr. Shieva Ghofrany
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Featuring Dr. Shieva Ghofrany, OBGYN & Co-founder of Tribe Called V, and moderated by Meaghan Repko DeShong, Tina's Wish Board Member & Partner at Joele Frank, Wilkinson Brimmer Katcher.
Learn more about Dr. Ghofrany at:
https://www.instagram.com/drshievag/
https://telleveryamazinglady.org/
https://www.tribecalledv.com/
Welcome to what to Know Down Below. By Tina's Wish, we're here to empower you with the knowledge and tools you need to advocate for your own gynecologic health. Knowledge is power, and we encourage everyone to join us in learning more about what you need to know down below.
Speaker 2Hi everyone, my name is Megan Repko-Dushong and I'm so excited to be back again with you with my favorite doctor of all time, dr Shiva Gofrani, for another episode of what to Know down below. If you listened to our prior episode, we spoke about perimenopause something that is somewhat new to me as I had to learn about it but in this episode we're going to talk about menopause. Now some may think Tina's Wish. Why are we talking about menopause or perimenopause? Because at Tina's Wish we are. Our goal is to find early detection of ovarian cancer, but we also recognize gynecological health is so important and so not talked about, and so we're here to do that good deed and job that we all need to know more about our gynecological health and job that we all need to know more about our gynecological health. So, like I said, I'm here with my favorite doctor, shiva Gofrani. So please, dr Gofrani, tell us a little bit about yourself before we get into, I guess, kind of one of both of our favorite topics at the moment.
Speaker 3All right, thanks, megan. First of all, thank you for having me. I love being here and I love collaborating with you guys. I am Shiva Gofrani. Like you said, I've been an OBGYN since 1999 in private practice in Connecticut. I actually still deliver babies. I'll be on call next week.
Speaker 3It'll be exhausting and wonderful and miserable and magical, like everything, and I separately have a private telehealth practice for perimenopause and menopause because we recognize how valuable and important it is to help women get educated. I'm thrilled I get to be the board president of Tell Every Amazing Lady, which partners a lot with Tina's Witch to help educate about ovarian cancer. We're a smaller ovarian cancer nonprofit because I myself had ovarian cancer when I was 46 years old, which was now nine years ago. I'm happy to say it really helped me educate myself from the patient perspective, separately from the doctor perspective, so that I could instruct people and just, I think, kind of convince them to take care of their own health a little bit more. The reason I think it's so good and valuable that you and I are going to talk about this and that Tina's Wish addresses it, is women don't only have ovarian cancer or only have breast cancer or only have any of these things right.
Speaker 3We all have overlapping buckets and, like I keep saying, overlapping Venn diagrams and, in particular, the ovarian cancer community. Either because they have a family history with a genetic predisposition or they've gone through ovarian cancer themselves. They often go through surgical menopause and they are very scared about how they're going to feel and unfortunately, their oncologists, who are so well-meaning and really poised to help them survive, don't address menopause symptoms. We know that from tons of data. I mean, I've seen it anecdotally with my own patients, I've experienced it myself as a patient and now we see more and more data showing that none of the side effects of menopause, especially surgical menopause, are addressed as well as they should be, and so it really does affect your population for sure. So I think it's very relevant in addition to just general women understanding their body. So thank you, can't wait to talk about it.
Speaker 2Okay, well, perimenopause, what we previously talked about. If you didn't listen to that, you should, because I learned a lot and I think our listeners will, and that's the transitional phase before menopause. But I think you know, I'm used to hearing about menopause in a different way and I think it's fascinating when you talk about it in really simple terms, like what it actually means, because I think we just think of it as a stage of life, but there's actually like science behind it and how the body works, and I don't know if everybody knows what that actually means. So I'm going to start super basic, which is tell me what menopause is.
Speaker 3Yeah, Okay, I love starting with the basic definition. So menopause is literally the day you've had a year with no period. That is menopause. That's like that moment in time where you've had the year with no period is menopause. Everything after that is postmenopausal. And the average woman will go through menopause at 51. So that means at 51-ish you've had a year with no period. Forever after you can live till you're 100, you're considered postmenopausal.
Understanding Menopause Basics
Speaker 3Everything before that, while your hormones are fluctuating, is perimenopause. And that can be up to a decade before menopause, where your hormones fluctuate and don't do the natural rhythm of that sine wave. That is more predictable, where you ovulate and get a period but instead do this unpredictable situation where your hormones are up and down, up and down and they can fluctuate day to day, week to week, month to month. And again, that's the definition of perimenopause and that, like I keep saying, can last up to 10 plus years. So menopause around age 51, perimenopause can precede it by about 10 years.
Speaker 3But because the normal range of menopause is between age 45 and 55, even though most women will go through it, the average is 51, but you could be normal 46, be post-menopausal and if you do the math, that means that 10 years prior to that so starting at 36, you could have become perimenopausal, and it might've been subtle. We're like I just feel a little lousy, I'm not sleeping well, my libido sucks, I'm emotional, I'm moody, I'm hot, flashy. It could be very subtle and it could be also during a period of time where you're trying to get pregnant or are pregnant. So, as you can see, just hearing all of that, it becomes very confusing for people because it's not a definable. One test tells me what it is. It's a more, it's a process to understand.
Speaker 2Right. But if and I'm trying to break it down to like simple terms like perimenopause lasts longer or it's a longer defined stage, right? Menopause is correct me if I'm wrong is essentially the time where it's like you get your period and then you don't get it for a year, that's considered menopause, right? That?
Speaker 3moment where you realize like, oh, it's been a year since my last period. That's literally the moment of menopause I knowusing. And again, it's confusing because we don't tend to say perimenopause, post-menopause, when we define the two like the before and after, right, okay. And we should, like I, try to constantly say you're either perimenopausal or post-menopausal. But inevitably because language is challenging and it's cumbersome to use the words, people including me, will say, oh, you're menopausal. But when you say I'm menopausal, now that you're hearing the definitions you realize it can be confusing. When someone says I'm menopausal, do they mean I'm postmenopausal, I'm done with my period, or do they mean I'm perimenopausal, I'm going through the transition? And the truth is they mean both, depending on the person and the context. So we should be very specific and say you're either perimenopausal once you've reached that stage where your hormones are starting to fluctuate and that can be anywhere from your mid to late thirties to early forties or you are postmenopausal, meaning you have had a year with no period and ever after your postmenopausal.
Speaker 2Okay. So I'm a big believer in personal relating this to person, one's life personally, because I think, again, not enough people talk about this and they're not comfortable doing it and honestly, I have to give you a great big shout out because you make me feel so comfortable. So I'm having I mean, I'm the girl that said that I went to a doctor and they told me I had a bulky uterus on a podcast. So here you go. Right, I'm an open book, but I am someone who, um, went through extreme IVF, tried everything you could possibly try, multiple miscarriages, all of that and I welcome to sun via surrogacyacy Not a lot of people know that because I don't talk about it yet that much, but you know, had to figure out right Like we wanted our family so badly that we did everything we possibly could. And that's what I will tell him for his entire life, especially when he starts to say no to me.
Speaker 3He's like.
Speaker 2Do you know what I did today?
Speaker 3I can't wait.
Speaker 1I can't wait.
Speaker 2But because I was going through so many rounds of IVF I believe I was. My body went into perimenopause or I was already going through perimenopause based on your data or facts right of like the age range, and now I think, not think know because of our discussion that I am postmenopausal.
Speaker 3Yeah Well, and here's what's interesting. There's no way to prove this, but what led your body to not necessarily be able to get pregnant spontaneously on your own, or even get pregnant and keep the pregnancies, despite multiple rounds of IVF and everything might be the egg quality that wasn't necessarily optimal that now led you to have what I think is a little bit of early menopause.
Speaker 2Right, and to turn it back to Tina's wish just for a second, which is how I got involved, is because I, of my bulky uterus, you know, got my sonograms, all that stuff, and found out that there was a growth on my ovary and fallopian tube and all that, and had to, you know, get moved to oncology and had one of my fallopian tubes and one of my ovaries removed. So then that also will change the hormones in your body, right, when you, you know your body's made to have two and now it has one and it has to adjust to that. Yeah, like I really put my body through it from a hormone standpoint Right.
Speaker 2So, like them wanting to be like I'm done, I'm out.
Speaker 3I don't blame them Right. Well, I think the common conception no pun intended and I would say maybe misconception is. I went through all of these rounds of IVF and it must have like burned out my ovaries and caused earlier menopause or early perimenopause. And is there a chance? Maybe, but scientifically it seems more plausible that people who have gone through it a little bit earlier had had issues that led them to IVF that then are now we're now seeing it. Do you see what I'm saying?
Speaker 2Yeah.
Speaker 3And I think that's valuable to know, just because I do think many of us tend to be like, oh my God, it must've been da, da, da, and. And we don't want to take on the burden of that blame. And I don't want you to take on the burden of that blame because I don't think that anything that you did caused it, and I don't think anything that the that the hormones that you had to take caused it. I think it was your ovaries that weren't doing what they needed to do to begin with, needed to do to begin with, led you to need those hormones and now led you to go into menopause early. If, in fact, that's what you've gone through, that's what we're going to talk about.
Speaker 2Yeah, and, by the way, I think for the listener it's really important that, like I believe my journey was for me, I learned so many things about IVF and surrogacy and ovarian cancer and all of these different things that have led me to be at this point where I can have these open conversations, and I hope that there's one, at least one person, that I can help. So I it's not like a what was me story, this is a life inform me, I like to be knowledge right, and these these times, so okay. So menopause, let's talk about time. So okay. So menopause, let's talk about when we talk about menopause. Can you run me through like symptoms that people have, because I think it can also be confusing. I think we've hopefully changed the confusion between perimenopause and menopause, but like some of those same feelings in talking to you, can stick around Absolutely.
Symptoms and Health Implications
Speaker 3So let's talk about a classical. A classic patient in my practice would be like mid forties. She'll come in, she's otherwise mostly healthy, let's say mostly um, resourced enough to be able to come see the gynecologist, whether she has private insurance or Medicaid, and she might say things like and it doesn't, and she doesn't need to have all these symptoms. She needs to have any one of these symptoms, but she may have all of them, some of them. She may have some of them this month and then none of them, and then all of them next month, and then it might fluctuate. But from the head to toe she might have hot flashes, night sweats, mood changes, brain fog, sleep disturbances, a little less hair on her head, a little more hair on her chin, some acne, some breast tenderness, some ovulation pain, irregular periods that might be more or less heavier or lighter. She might notice that her libido has tanked and she might notice that it hurts when she has sex because her labia and her vagina and her vulva are painful because they're less elastic. So those are, that's like I always joke. That's like the laundry list of really basic symptoms. And then there's a lot of, a lot more kind of esoteric symptoms that we're learning more and more about, like joint pain and muscle pain and things like that. So not only can you obviously believe because you've been through it, but if you didn't have haven't been through it, you'd know those things can make you feel lousy, but in addition there are health implications as our estrogen starts to go down, especially when we become post-menopausal, where we no longer have our period. That lack of estrogen can be what leads to the higher risk of dementia for women, the far higher risk of osteoporosis, because our bones are at risk cardiovascular risk goes up. So all of these things, these health risks, actually go up because, if we remember from nature's perspective, we were not meant to live much past our mid fifties, maybe right. So now, because of modern medicine, because of nutrition, because of things like that, we've prolonged our lives, which is wonderful, but we tend to prolong our life with chronic illnesses that finally we're starting to address and learn that yes, repleting your hormones post-menopausally is not natural, because you were not made to have your hormones post age 51-ish, when you've become postmenopausal, but by repleting them we are improving your longevity because we know that people are living longer. So we're decreasing the risk of osteoporosis, fractures of things like colon cancer. Estrogen can decrease the risk of colon cancer, of heart attack, stroke, dementia. So there's a lot of health benefits to taking hormones, but it needs to be done judiciously, in the right population and with a conversation of risks versus benefits for the doctor.
Speaker 3But again, the typical patient is going to have any of those symptoms and they're going to come in and they're going to think they're broken. They're going to think there's something unique and I'm always happy to be like guess what? You are so normal and not unique in this situation. You don't want to be unique when it comes to your medical health.
Speaker 3I actually am happiest when I can say to a patient let me guess what you're going to tell me. Let me guess that you're going to give me a variety of any of these symptoms. And when I see them with their eyes open wide, like oh my God, it's like she knows what I'm about to say. That makes me feel so happy Cause then that implies to them like the good news is, this is not different or unique. This is not a like oh my God, no big deal, you're like everyone else. Let's blow you off. This is a hey, you're like everyone else and I can define what this is and I can help you through it. So that's what I want us to be able to really encourage women to know.
Speaker 2Right, so let's say so. I'm actually going to my doctor in two weeks and I want to have this discussion with my doctor and you and I have talked about like there's like doctors have a limited amount of time, Right. So I want to. And that's not their fault, it's a system, it's like they, they want to spend an hour with you.
Speaker 3If they actually got reimbursed where they could then open their doors, they would, but they can't Totally.
Speaker 2So if I want to go in and be as informed as possible, to talk about this and not just talk about my symptoms like, okay, so I've probably checked a couple of those off of yours, right? So I come into your office I say my sleep's weird, I kind of have these like mood swings, I get night sweats. Okay, so I've checked off a couple. Then what tests do I want to sort of make sure on the list that the doctor's going to do, because you can't just say here, throw on this estrogen patch and you're fine, right, we need the proper testing because our hormones are all different.
Speaker 3Yes, I'm making that face, ish. Okay. So let's separate into two different categories. Let's talk about your situation second, because it's a specific and a little bit different conversation. Let's say it's a more typical 46, 47 year old who is out of the range of this being considered early menopause. Right, so she's 46 or 47. She's getting her period. It might be irregular, but she's still getting it occasionally. So she's not postmenopausal, she has these symptoms.
Speaker 3I would say to me what I think would be great is a patient to come to me and say hey, I've already educated myself. I've listened to your podcast, I understand what's happening. I think I'm in perimenopause. I know that we need to check certain things to rule other medical issues out. Like we need to check my thyroid, my vitamin D, we need to make sure that I'm not iron deficient. If I'm having any other weird symptoms, like pelvic pain or heavy or irregular bleeding, then we need to do a pelvic ultrasound. Once we've done all those, then we will default to oh, it's likely perimenopause.
Speaker 3And I recognize that you won't be able to check my female hormones, meaning my estrogen, my progesterone, my FSH, because if you check them, they won't necessarily give you the answer, because I recognize that my hormones fluctuate every day to day, week to week, month to month, like I would love for a patient to come in and give me that two minute spiel, because then I'd be like great, we're starting out ahead of the game. You get it, you understand it. Let's rule these things out. Rule out thyroid dysfunction, anemia, vitamin D3 deficiency, among other things. Let's make sure you've had your routine physical with your doctor where we know that you don't have diabetes and insulin resistance, stuff like that, and then we can get to talking about treatment. So that's what I would love the average person average in a good way this time, right, yeah, your case is different because tell us how old you are.
Speaker 2I am 44, almost 45, and I have not had a period in over a year.
Testing and Medical Approach
Speaker 3Right. So by definition, because let's just review again the average age for menopause is 51, which means the average age for the time where you've had a year with no period, but the normal range is anywhere from 45 to 55. You were 44 when you discovered that you had a year with no period, right? So you're technically in early, quote unquote early menopause, not premature menopause, which would be below age 40, but early menopause. And why do we care about that? Is that has different implications. Because assuming you really have stopped your period altogether and assuming that again your doctor will check your thyroid will check in your case something called prolactin, which is the hormone that can make you lactate, but also that hormone can suppress ovulation, and that's not menopause, that's a different entity. They should obviously again check things like iron deficiency and check your vitamin D3. Also, in your case, I would check for insulin resistance, which is also known as polycystic ovary syndrome, because there are some women who have that. They were never diagnosed with it officially, but it kind of gets unmasked during this time and again, that's a different reason to not get your period than menopause. So there are things that your doctor I'm sure is going to rule out. Once she's ruled those things out. If she determines, no, all these things are fine and in your case she checks your estrogen and your FSH, then she will hopefully say, okay, megan, you're in early menopause and in your case, unless there is a glaring risk factor against it, you actually should be on hormones.
Speaker 3My other patient where we described a like 47 year old typical one she could be on hormones but we're not yet at the point where we would say she should be on them medically because she's technically in the normal range of menopause. Okay, if you go through early menopause, then we know that your brain health, your bone health, all the other parts of your body, like your cardiovascular health, actually need the estrogen because you're missing out on estrogen five to seven years more than another woman who went through it at a normal time. So again, all the data really shows that in women who have gone through early menopause and this is particularly true for our audience, because many of our patients here on this podcast will have gone through surgical menopause, either because of ovarian cancer or because they wanted to go through prophylactic removal of their ovaries to decrease the risk of ovarian cancer because of family history those women absolutely need to be addressed and treated for their long-term other health risks Again brain health, cardiovascular risk, bone health, among other things.
Speaker 2Okay, I'm prepared now for that. Also, you mentioned dementia and like that's impossible for me to get, because I'm always right, anyway. But I guess you know, I think about this like cause, I think about mental health, right, and that's always it's. It's a really important topic that I also think we're talking more and more about. But I think this could have a really big impact because I mean again, someone like me who went through, you know, kind of okay, I have to have an ovary removed. They were hoping that they could save my uterus and other like to try to have children down the road. And then you know to go through IVF and not like to try to have children down the road, um. And then you know to go through IVF and not not be able to happen, and then go through surrogacy and welcome my beautiful son, um, that I'm so lucky that me and my husband have Um.
Speaker 2So again, don't get me wrong, I think this is the journey I was meant to go down, um, for so many reasons. But mentally, I think there's a point where women can go crap, like my body is not working Right, and so then you go through these things and like, okay, for me it's like I have a son like okay, I don't really care, like things didn't work but I figured out a way, like a solution. But I feel like I'm facing it again, where I'm like there's mental kind of cloudiness and overview and like you're overthinking and like, oh my God, can I be going through this at this age? Is this actually possible? Like why me, right, like you, go through these kind of natural stages of thought?
Speaker 3Well, and I think it's threefold. I think One is the general like. As women, we are consistently societally being told that like our value and our worth has to do with like youth and beauty and fertility and all these things that like. Then we reach our 40s and we're like, oh my God, fertility is gone and our youth, we believe, is waning, even though you and I have agreed that like we feel better than ever and all those things. So I think there's that. Then there's the very personal that you've gone through Like. There's the mourning and the loss of like. Thank God you have your son, but you also went through a lot and it's still. It's a lot to physically and emotionally have gone through and now your ovaries aren't working, all those things. And then there's the very real just wow.
Speaker 3When your hormones either fluctuate or are down, it absolutely can create, it can either unmask underlying depression and anxiety, which we know. We know that women who have had depression and anxiety in the past. It will be exacerbated during perimenopause, for sure, and the good news is hormones can really help, maybe more than antidepressants for some women depending and it can be a time that gets unmasked, like women who have never had a history of depression or anxiety and all of a sudden have Anxiety, might be their most pervasive symptom. Things like even palpitations, which might cause anxiety or be caused by anxiety, which are often blown off for women. Oh, it's just your anxiety, as if that's like some made up thing, when in reality it's your hormones creating the sense of anxiety that can also create the symptoms of having heart palpitations, and so there's so much involved with it.
Speaker 3And yeah, I think a lot of it is. It's. It's there's so many parts of our body that are affected by our hormones and it's so complicated. I mean, patients will say to me often they keep telling me my hormones are normal, but I know there's something off and they're both right, meaning they who are telling your hormones are normal, meaning the doctors or clinicians are technically right, meaning on paper your hormone values might be normal, but you are also right and they should tell you that. Yes, even though your hormones are normal on paper, that doesn't mean that they're always appropriately working in your body, because of receptors, because of how hormones interact and your feelings are real. So it's complicated.
Speaker 2Yeah, because I mean that to me also. Like I think I think of like professional lives, right, like we're all women who you know are. To me it's like prime, right Like we are, we will. For me personally, I want to be the best that I could possibly be at everything in my life, whether it's professional a mom, a wife, a daughter, a sister, a friend, right Like. The list goes on and on and on.
Speaker 2But I think of professional life and for me, what's been interesting is there's times where I have to it like where I used to be super quick to just kind of react and like know my reaction, like I almost feel like I have to take a step back and like slow it down and I'm wondering if that's like part of the hormones that like cause it's. I'm like wait, give me a second. Like I need to just think this through, right, like I want to write it down, I want to like think about things and, by the way, that's not a bad thing, like people should just read and whatever. We don't need to always react immediately. But I'm just saying it's very different for me to experience where I'm like okay, I need to take like a little bit of a step back.
Speaker 3Yeah, I think that's, but I think that might have to do with what you said, I think, in one of our past episodes that like now you're at the age where there's like an inner knowing that like it's okay to not know everything, it's okay to not be perfect, it's okay to not be the best, best, best, like we're striving to do well, but we want to do it in a more intentional way. That might be, might be slower.
Speaker 2But I think the hormonal changes that women are going through, whether it's the normal timeline, early later, whatever it might be, I think it's fair to say like it it will impact every component of your life personal, professional, alone time.
Debunking Common Menopause Misconceptions
Speaker 3And that's not to say doom and gloom. I mean I definitely have people who are like I think I feel fine and I'm like good, listen, I'm not here to demean anyone who says they feel fine or be like really, you think you feel fine, you actually feel like crap. I don't want to say that to them, but but the truth is I think many of them don't realize some of the symptoms that are perimenopause or postmenopause and so they don't attribute Like. This is a classic one Women will say to me you know what? I totally feel fine. I mean, I really don't have hot flashes or night sweats, I feel fine. Ok, tell me about your sleep, oh, and then they'll say well of awake for the rest of the night. But they just chalk that up to like isn't that normal? And the answer is well, yes, it is a very common symptom of being perimenopausal or postmenopausal. But, and it's not good for us Lack of sleep can lead to brain fog, dementia, cardiovascular risk, heart attack, diabetes.
Speaker 3The list is long. So we shouldn't just accept it because we can tolerate it. Quote, unquote. Because again, what have we been taught as women? It's just your period, honey, pat on the back, suck it up, buttercup, it's just pregnancy. Oh, yeah, you're peeing on yourself after you delivered vaginally, that's all normal. Oh, you're not sleeping after three in the morning? Yeah, that's typical. Like we're taught that all these things are normal and that we have to deal with it, whereas men 30 to 40% have erectile dysfunction. They're not taught like honey, it's normal. You're not going to be able to get it up. 30 to 40% of you they're actually told it's pathological and it's labeled as dysfunction so that it can get treated. But it's actually a very common thing. So, again, we can recognize these things are natural. We can recognize these things happen. We can recognize that oh my God, it's not tragic, but also recognize that it can and sometimes should be treated, because we're supposed to be living longer than we ever were before. So we want to live longer and live well 100.
Speaker 2Yeah, so do you look, this is something that you you've pointed out, that this is not something that doctors are taught kind of in residency and all that stuff, right it's. It's something that doctors need to put their own time, effort, dime into when they're also like treating patients right, like this is people's life and death stuff, right. So and then we're being like, oh hey, on the weekends, why don't you just uh?
Speaker 3go study, take an exam and study and go to a conference.
Speaker 2Do some more work after med school, right, um, but you know it is something that's important because it is something that women are becoming more educated about and so they're asking about, right, we want, you know, doctors who will understand that. But are there, are there, misconceptions about menopause that you think are important to debunk? And I'm going to take stigmatism of that out of it and like people should talk about this, right, like, let's take that one off the table.
Speaker 3Okay, I mean, yeah, there are a million. I'll give you a couple. For interest of time, I'll give you a couple. Well, two prevalent ones that are kind of more concrete and easy. A very common one is but I thought hormones caused cancer and I thought hormones were bad to take.
Speaker 3Okay, untrue period, and I can say that as a blanket statement, not to say that there are not some cancers that have slight increased risk from using hormone replacement, but to say hormones are bad and they cause cancer period is wrong. It's an overstatement. There's a very clear reason why it is overly stated frequently and it has to do with that study that we talked about in one of our episodes, the WHI study that came out in 2002 that erroneously scared millions of women and doctors into thinking that hormones cause breast cancer. The definitive data from that study has now been reinterpreted and we know that there are some patients who are older who might have a slight increased risk, but it's very slight. But there are actually millions of women who will have less risk of breast cancer when they're on estrogen alone in particular, for example. So, again, wrong to say it causes breast cancer and that it's scary. So I'm glad that we're starting to talk about that more and getting more educated.
Speaker 3The second, and even more like frustrating is, I thought, vaginal estrogen. So you know we can use estrogen systemically, which is hormone replacement, or we can use estrogen just vaginally and vulvar, in the form of cream or tablet or ring, and it's meant to help make the tissue more elastic, make it more plump, make it less what people will say is dry, but I like to say inelastic, and so then they have less pain when they have sex and less likelihood of a urinary tract infection. Right, and a huge misconception is that vaginal estrogen is bad or dangerous, or if I've had breast cancer, for example, I can't use it, and that is definitively wrong. I would say 99.9999999% of people on earth with a vulva and a vagina can use vaginal estrogen very safely, including women with estrogen receptor positive breast cancer, because we have thousands of studies showing that vaginal estrogen does not get into the system. So if we could just get that message out to millions of women.
Speaker 3We would decrease pain during sex and we would decrease. If we want something really concrete again tons of data to support. We would decrease pain during sex and we would decrease. If we want something really concrete again tons of data to support. We would decrease urinary tract infections, which cost billions of dollars to the American medical system, not to mention women's discomfort, but billions of dollars just in antibiotic treatment and hospitalization. So if we could get all the women to understand that vaginal estrogen is incredibly vital, important and safe, that alone would actually save billions of dollars and vaginal estrogen, to be clear, is prescribed by your doctor.
Speaker 3Prescribed by yeah, your doctor, nurse practitioner, midwife.
Speaker 2I don't want people like Googling this and like whatever, but I think yeah, yeah, yeah, no it is prescription.
Speaker 3It should be. By the way, many of us believe it should be over the counter because the risk is so incredibly low, like beyond low, it should be over the counter, um, but it is currently prescription. But if your doctor can't or won't prescribe it and again, I hate to ever malign doctors, but if your doctor can't or won't prescribe it then that is something where I'd say that doctor really, really, really, really, really is very undereducated. So if they can't or won't, there are online programs where they'll prescribe it and I would have no qualms with people getting it online because it's incredibly safe. I would say I'm going to make a bold statement and say I think it's actually safer than them using over-the-counter yeast infection cream all the time. Only in that, using over-the-counter yeast infection cream, you might be misdiagnosing yourself with a yeast infection when in fact, you have a sexually transmitted infection or something else, whereas if you are peri or postmenopausal and you're having pain during sex in your vagina or vulva, using vaginal estrogen will absolutely be impactful and is incredibly safe.
Speaker 2Okay, I think that's super important for people to understand. I loved those debunks, by the way, so I guess you know this can be a very overwhelming time for women. Right, it's? It's. I hate to say this, but it is emotional because, people think women who are emotional right, Like there's, like whatever, give me a break, right.
Speaker 3There's emotions about everything. Emotions are wonderful. They're exhausting, but they make us impactful and empathetic and collaborative.
Speaker 2Thank you, I totally agree with that, but it can be overwhelming and it can be emotional and it can be defeating at times and it can be questionable, like am I doing this right? Like right, you have all this stuff going on. Are there support systems that people can use or kind of? And I'm thinking are there good online resources for people because, like, obviously they're doctors, right, we could do that. And everybody should talk to their girlfriends about this stuff.
Speaker 2Like, seriously, have conversations with each other, because you're going to learn from each other um but are there other ways that women can kind of, you know, find support, find recommendations, all that type of stuff that you'd recommend because you're heavily involved in this area and so I want to get your opinion.
Speaker 3Yeah, I think. I mean I always say beware of the people who are trying to sell you a product that claims to fix everything. That's the big, that's the warning Menopause Society. So menopause societyorg is a great organization. It's kind of our governing body, if you will, for menopause. It's how many of us learn more about it.
Speaker 3I think many of us have frustrations with it because they tend to be a little on the conservative side, but they have very good evidence-based medicine. It's where a lot of us have done extra training and that website has great information for patients but also has a directory for doctors who have gotten extra training, which doesn't mean the doctors who haven't gotten extra training. If your doctor is not on that list, it doesn't mean she doesn't know about menopause. She might very well know and never did the training because she didn't need to. And similarly, some people on that list aren't necessarily as up to date as they should be, but it's a great start.
Speaker 3And then, honestly, going to Tina's Wish or telleveryamazingladyorg, we have a lot of information now about menopause because we recognize that menopause is affecting the population of women who have cancer especially. They're dealing with so much because they're dealing with cancer and menopause. And then listen. I think that I have a whole list of resources that I can always give you to attach of different podcasts and books and things like that. I think it's too bad that we have to like direct people to do all of this research on their own when in reality it should just be a conversation with you and your clinician where you get like an hour every couple of months to really talk about things. But it's just not how the Western medical system works right now. But yeah, there are luckily a lot of resources out there now and again we can add lists.
Finding Support and Key Takeaways
Speaker 2We can add to the list under the podcast. So for those of you listening, that's going to be a really important takeaway. But I know we're running low on time, so I'm going to ask you my favorite question, which is rapid fire what are the top three takeaways you hope listeners remember about menopause?
Speaker 3Okay, oh, I like this. All right, menopause it's natural, it's normal. But that doesn't mean you have to take it sitting down. I always joke that we get to be like, oh, it's natural and normal, so that we can like, not fear it. But we can say I usually swear, but I won't swear today. We can say sorry, nature, not today. Right, it's natural and normal that at age 51, I'm going to stop my period and have hot flashes and night sweats. But that doesn't mean I have to suck it up and deal with it. We don't want suck it up buttercup anymore. We should stand against that. That's one.
Speaker 3Two hormones are not bad. They're not scary, they're not dangerous. They can be life-giving, they can be very safe. Yes, there are some risks, but the risks have been overblown. So please have a conversation with your doctor and if your doctor or clinician is summarily saying, oh, you don't need them, then I never want to like, encourage, you know, leave your doctor in doctor shop. But if your doctor is summarily writing them off and saying you don't need them, then you should find another clinician, which doesn't mean just find someone who's going to say yes to you, but find someone who's going to collaborate and discuss it with you and explain to you maybe why they think you do or don't need them right Risks, benefits, alternatives and you should be able to make that decision. And third, vaginal estrogen is safe and so impactful for the majority of people with vaginas and vulvas. You might not need hormones forever, but you will likely need vaginal estrogen no matter what.
Speaker 2Okay, and then I'm going to add a fourth, which is we have to advocate for ourselves as patients, and doing some work before you go to a doctor's appointment, or being able to really describe how you're feeling and being in touch with that is so important, because a doctor can't guess just taking a look at you. And we have to tell them and fight for ourselves and sort of stand up for ourselves to say like no, I don't accept this. I want you know X, y, z or whatever it may be, just like you told me what to go in for tests and all that stuff to make sure Right.
Speaker 3Because that stuff to make sure right, because we want to make sure yes, Right, well, and actually this is something that we didn't talk about, that I meant to talk about. When you go to see your gynecologist in two weeks, is that your annual exam, like your yearly?
Speaker 2exam.
Speaker 3Yes, okay. So this is a really important point and again, this is the fact of the American medical system. So please don't blame the doctors when you go for your annual exam, which can sometimes be called like the well woman visit or a screening visit or a. You know, theoretically you are only supposed to go in there with no complaints and she is supposed to do all of the screening tests a breast exam, maybe a pap smear, if you're due for it, certainly looking at your vulva, doing a pelvic exam, talking to you about are there any new changes in your family history and any of your symptoms, so that she can decide what other screening or diagnostic tests she needs to do.
Speaker 3Okay, now, of course, I don't blame you. You think, like most people, I should go into my annual exam and wait to see her, because that's going to be better for both of our time. She's going to do all the things she needs to do. I'm going to tell her my complaints and then we're going to strategize. But in fact, that's not what the annual exam is meant to be and this is not what the way doctors would strategize it. This is the insurance company. They pay one fee for a screen exam or annual exam. They give you 15 minutes. She has to. I mean, it's not that they give you 15 minutes, it's that you could. You have a problem like what you want to discuss, which is a big deal, then in theory, the best thing to do is to make a separate visit, or she might have the latitude of saying oh, I actually have more time, let's talk about it.
Speaker 3And then she could bill it as an annual exam with a problem visit. But that means that you will get a copay. Even if you're not supposed to get a copay for an annual screening exam, or if you have a high deductible, you will get charged separately for that. So again, these are annoying logistics, right, like she does not want to have to worry about those logistics or tell you about them. You don't want to have to worry about them. But the reality is, this is what work, this is what happens.
Speaker 3Now I'll tell you when was seeing patients full, full time in the office up until three years ago, all day, every day. I wouldn't even have that conversation with patients. I would say like, okay, this is your annual, let's talk about everything. We would talk about everything. I would talk fast, I would try to address everything I could. I would run over time. I would probably give them 20 to 30 minutes each, to the detriment of the other patients who were then left waiting. But then the other patients would get time with me. I wouldn't leave the office until eight o'clock at night.
Speaker 3I wouldn't necessarily bill differently for it, which was not good for me or my practice, but what that led to is me being exhausted and not being able to continue doing it in that way or I shouldn't say not being able to, choosing not to do it in that way where I saw 30 to 35 patients a day. So I say all that because I really want patients to understand why it is the way it is and why it's a system that is broken for the doctors and patients. But the way around it, at least right now, is to have patients, no pun intended, and go back and make a couple of visits, which is understandably hard. Like people don't have the privilege of time, no matter how much privilege financially they might have, they don't have the privilege. Like you work, you don't have time to go back 10 times, but unfortunately you might have to.
Speaker 2Well, I'm going to call actually and say I have questions about this. Can it be added Like can can I address them during my appointment? In two weeks or should we make a follow-up appointment?
Speaker 3I'm going to do that right now Amazing. I love that Good Good.
Speaker 2Well, dr Grafrani, you know I love you. Thank you so much for joining us again today and for sharing your expertise with our listeners, and a huge thank you to everybody who's listening. We hope this episode gave you information and, like I said, empowerment, because you need to as you're navigating potentially menopause or perimenopause or any of these other topics that have been discussed on what to know down below. We want you to do so with confidence and with knowledge. If today's episode taught you something new or inspired you to take action to prioritize your gynecological health, we'd love to hear from you. Leave us a comment below or send us a message on Instagram at Tina's Wish or Dr Gofrani.
Speaker 3Dr Shiva G on Instagram or drshivagcom.
Speaker 2And don't forget to like, follow or subscribe wherever you listen to podcasts, so you don't miss an episode. Thank you so much. Thank you.
Speaker 1For more information about gynecologic health, visit tinaswishorg slash whattoknow. That's tinaswishorg slash w-h-a-t-t-o-k-n-o-w. And like, follow or subscribe, wherever you listen to your favorite podcasts.