The MiDOViA Menopause Podcast: Real Talk on Hormones, Work, and Wellness for Midlife

Episode 50: The Truth About Menopause: A Menopause Awareness Month Series with Alloy Health

• April Haberman and Kim Hart • Season 1 • Episode 50

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Menopause shouldn’t feel like a mystery you have to solve alone. We sit down with Dr. Corinne Menn—board‑certified OB‑GYN, certified menopause practitioner, and cancer survivor—to clear the fog around estrogen, perimenopause, and modern, evidence‑based care. From the infamous Women’s Health Initiative to today’s safer formulations and smarter timing, we separate risk from rumor and show how context—age, route, dose, and goals—changes the story.

We dig into the “window of opportunity” for menopausal hormone therapy, why transdermal estradiol and micronized progesterone matter, and how treatment decisions shift if you’re 5, 10, or 15 years past your final period. We also spotlight what rarely makes headlines: genitourinary syndrome of menopause, recurrent UTIs, and why low‑dose vaginal estrogen (and vaginal DHEA) can be transformative for comfort, sexual health, and even infection‑related hospitalizations. Perimenopause gets its due as a real, treatable transition with anxiety, insomnia, brain fog, and irregular bleeding—symptoms that too often get fragmented into referrals instead of addressed at the hormonal root.

You’ll leave with practical steps to advocate for yourself: how to prep a focused appointment, what to ask about dosing and delivery, and when to seek a menopause specialist or reputable telehealth. We connect the dots between symptom relief now and longevity later—bone density, cardiovascular health, cognitive function—and make the case for lifestyle medicine you can actually live with: strength training, sleep, nutrition, and thoughtful alcohol habits. If you’ve wondered whether estrogen is “dangerous,” whether you’re “too late” to start, or whether vaginal estrogen is only about sex, this conversation reframes the entire landscape with clarity and compassion.

If this helped you feel more informed, subscribe, share it with a friend, and leave a review—your voice helps more women find evidence‑based menopause care.

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MiDOViA is dedicated to changing the narrative about menopause by educating, raising awareness & supporting women in this stage of life, both at home and in the workplace. Visit midovia.com to learn more.

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SPEAKER_02:

Welcome to the Medovia Menopause Podcast, your trusted source for information about menopause and midlife. Join us each episode as we have great conversations with great people. Tune in and enjoy the show.

SPEAKER_01:

Hello everyone, and welcome to this exciting webinar series that Medovia and Alloy are doing together. This first session is called The Truth About Menopause, The Myths, The Symptoms, and Modern Care. We are proud to bring this important conversation to life through a partnership between Alloy Health, a leader in evidence-based menopause care and telehealth solutions, and Medovia, the U.S. workplace leader in menopause and midlife health. And throughout this series, we'll break down the myths, share the latest science, and highlight the real experiences of women navigating perimenopause, menopause, and beyond. Our goal is simple: to replace silence with knowledge, empower women to advocate for themselves, and give organizations the tools they need to build supportive cultures. Together, Alloy Health and Medobia are working to change the way menopause and frankly this stage of life is understood in healthcare, in the workplace, and in society. Thank you for joining us as we open the door to honest, informed, and hopeful conversations. As I mentioned today, we're addressing the truth around menopause, and we are joined by Dr. Corinne Men. She's the director of Clinical Innovation and Education at Alloy. Dr. Men is a board-certified OBGYN with over 20 years of experience and a certified menopause practitioner with the Menopause Society. She has dedicated her medical practice to focusing on menopause management and the unique healthcare needs of female cancer survivors and those at risk for breast cancer, as she is a survivor herself. Welcome, Dr. Men. It's so great to have you.

SPEAKER_00:

Thank you for having me. It's a really important issue, and I applaud your work.

SPEAKER_01:

Thanks. Ditto. Right back at you. So, you know, menopause is surrounded by a lot of misinformation. There are a ton of myths that persist with menopause. We're going to go through a few today. Why do you think the myths persist and what's at stake if we don't challenge them?

SPEAKER_00:

Well, the myths persist just simply from a lack of clinical education and also patient education, right? So from the clinician side, you know, most physicians have very little training, if any, in their graduate medical experience as residents. Certainly there's very little in medical school in general. And even in the field where we think they would have experience, like OBGYN or internal medicine or family practice, recent surveys show only about 7% surveyed feel comfortable providing evidence-based menopause care and prescribing hormone therapy. And it they even go as far in the studies to say that even those who say they feel competent, most of those prescribers will only prescribe to a very narrow segment of women. So if you're a little bit more complex or early menopause or dealing, you know, with other, you know, things, they don't really know how to handle things, right? So clinical education. And then the other part is patient education. Like women really have never been taught about their bodies at this stage of life. And I like, I compare it to, you know, young girls, women, uh not women, young girls and young boys have lessons in puberty, right? In their public schools, right? There's books for them about what's happening with their changing body. When women, if they get pregnant, there's all sorts of prenatal classes and birthing classes to help prepare. No one's been prepared for this stage of life, but it's happening to every single, you know, woman who is lucky enough to make it to this age, right? Um, and so that that's a really kind of dangerous pairing because the repercussions are that there's suffering, there's, you know, a loss of, you know, um, and there's an opportunity loss because when we know what is about to happen, whether it's sleep disturbances or hot flashes or accelerated bone loss or genitourinary symptoms that impact so many mood changes, all of these things, when you don't know what you can do about it, then you can't improve things, right? And so knowledge is power. And that's why, you know, so happy to work with you to kind of spread the word.

SPEAKER_02:

Yeah, that's why we're here. And you know, when you said um menstruation and education for that puberty stage, you know, my background is in sexual reproductive health and menstrual health, but even that is lacking. So I mean, if we really look at that, you're like, okay, it starts all the way back with menstruation and nothing changes um all the way through to really end of life, right? Because postmenopause gives for the rest of our lives. So I'm glad you brought that up. You also mentioned um something else um, that the window for prescribing hormone therapy is very narrow. And I think that that's a great lead into the first myth that I'd love to debunk. And that is that estrogen is dangerous and that we should avoid it at all costs. What's your thought on that?

SPEAKER_00:

Yeah, well, and just that window. So it's really important for, you know, because this window of opportunity, I'm just gonna like target that for a second before we get into estrogen. So there's, you know, the the um prevailing idea, which is grounded in all of the evidence that we have, is that there's an ideal window of initiating menopausal hormone therapy to not only treat your symptoms, to minimize risks, and to get the most benefit. So when we start it within the first 10 years of entering menopause, earlier, really better in terms of bone protection and what we think is a lower risk of cardiovascular disease, perhaps positive impacts on lowering risks of cognitive changes and dementia risks, right? So there's that ideal window of opportunity. But it's really important to anybody listening to know that if you've miss that window of opportunity, it doesn't mean that it's an absolute no, it means we individualize it with share decision making. And as someone who experienced premature menopause yourself, I just want to shout out that not all women look menopausal and not all women go through menopause at midlife. There's millions of women who have early menopause or premature menopause before the age of 40, um, which then ties into this idea that estrogen is not dangerous, right? Estrogen is a vital hormone that our ovaries produce from the time that we, you know, go through puberty. And there are estrogen receptors in every cell of our body. Yes, our breast cells, our brain cells, our skin cells, our cardiovascular system, et cetera. So estrogen is a vital hormone and it fluctuates a lot in perimenopause, and that's where we can sometimes get a lot of symptoms. And then it goes down to almost zero, you know, in your postmenopausal time. So it's a hormone, and just like everything else, right? Too much or too too little of any one thing, you know, could potentially have effects. But estrogen itself is not dangerous. It's literally the hormone of life, right? Without estrogen, we wouldn't grow a breast and be able to breastfeed babies, we wouldn't be able to get pregnant, right? Um, and what we know, and this is, you know, based on really clear science and really great recommendations from the menopause society, is for the vast majority of women who are entering the menopause transition or nearly menopausal, but the benefits of FDA-approved hormone therapy far outweigh the risks, right? Um, and that conversation should be, you know, individualized for patients. And there's a lot of benefits to hormone therapy. But and I know you're gonna ask me about it, we'll get into the biggest risk or the biggest fear that most women and doctors are confronted with is the fear of breast cancer, right? The fear of breast cancer, I always say is the driving force or the driving barrier to women not getting access to even a consideration or, you know, a talk about um getting hormone therapy.

SPEAKER_01:

Well, the fear of breast cancer was around for several decades, right? And one of the myths was that it would give breast cancer as a result of the women's health initiative study in the early 2000s. You know, can you walk us through what the WHI found, how it was misinterpreted, what have we learned since then? Because I think that, you know, one of the reasons we have a lack of doctors trained on this was because of that study. And the my friends, until you know, I started talking to them about estrogen, was like, no, I don't want to do it because it gets it's breast cancer, it will give me breast cancer. And it's been a really long time, you know, you know, since since this study. But can you help people understand? Because I think if they still go to the internet and do some searching, they're gonna find that as a misnomer. Yeah. Yeah.

SPEAKER_00:

Well, I guess you're going to the internet is gonna pull information from years and years ago and from all sorts of websites that aren't necessarily updated, or if they're not, you know, or they don't explain what the WHI meant. So just like keeping it really simple, back in the early 2000s and late 90s, there was a big study called the Women's Health Initiative. It was the largest study ever done. Um, I think it to today's numbers, over$2 billion, you know, study that um was looking at hormone replacement therapy. Um, and would it prevent cardiovascular disease or would it prevent other chronic diseases? We already knew that it worked beautifully for hot flashes, for night sweats, for preventing osteoporosis and for treating um genital urinary syndrome symptoms. So we knew it worked. Um, but they wanted to know, well, but would it work for a protective benefit? You know? And, you know, they had two arms of the study, an arm of the study where women took estrogen alone. These are women who did not have a uterus anymore, right? They had a hysterectomy. Um, and if you have a uterus, you have to take estrogen with a progestin. So back then, the prevailing medication that was used was conjugative equinestrogen or premerin for the women who were taking estrogen alone, and then um prempro or uh conjugate equinestrogen, along with the synthetic progestin in women who had a uterus. And the study was halted after a few years because they saw that there was an increased risk in the women taking hormones of um blood clot, stroke, and breast cancer. A press conference was held, the message went out, everybody got scared, and overnight they, you know, stopped their hormones. Like the devil's in the details. And in fact, I suspect that most people have never actually read the study, you know, quoting all these scary things. So, what did the data actually show? Women who were taking estrogen alone, okay, and this was confirmed at the 20-year plus mark of following these women, even after the study stopped. Women who took estrogen alone had a 40% decreased risk of dying of breast cancer and a 23% decreased risk of getting breast cancer. So the estrogen alone wasn't raising the risk of breast cancer, right? So that was conjugated equine estrogen or premarin, but that never made it to the news media. Um women who are taking estrogen with a progestin, and I say progestin clearly because it was madroxy progesterone acetate. It's a synthetic progestin. We still use it today. It's not an unsafe medication, um, but it's not the progestin that we typically prescribe these days. Now we use generally an FDA-approved bioidentical progesterone. Okay, so it looks just like what your ovaries would be making. And what they found is the women who were taking that had a statistically non-significant increase in being diagnosed with breast cancer. It was less than one additional case for every thousand women taking it, but no increased risk of dying of breast cancer. Many people critique even that number. But if we take that at face value, that risk is less than the risk of having a few extra glasses of alcohol a week, living a sedentary life, or eating an unhealthy diet, right? So, you know, we have to put one risk into perspective, and that the risk of that particular hormone therapy is not necessarily the risk with what we prescribe today. And then the other big thing that scared women was that estrogen caused heart disease or estrogen provoked strokes or blood clots. And again, devil in the details. In this very large study, the average age of the woman was approximately 63. Most of the women were many years from their last period. Part of the study was that you couldn't have hot flashes because otherwise you wouldn't know if you were taking the hormones or not. So many women who would really be the ideal candidate by today's standards, right? Within the first 10 years, they've got symptoms, et cetera, were excluded from the study, right? So these were older women who already had probably established microvascular disease, heart disease, other risk factors, obesity, chronic hypertension, et cetera, et cetera. And so giving those women an oral synthetic estrogen and progestin is very, very different than giving a younger woman. You can't prevent something that's already happened. And even in worst case scenario, this is how I like to tell patients, worst case scenario, if we just take the face value data from the WHI, even those risks of increased risk of blood clot, stroke were extremely rare. And so we now know we have a contemporary evidence-based approach where we're giving women, we want to offer women earlier when they're healthy, so we can prevent some of these changes. And we've got really what we know now is probably safer, better formulations that we can prescribe women. So really it wasn't the estrogen that caused this big problem, right, in the WHI study. But that's the message that went on. And you know, it takes a long time to remove that fear. And to people for people to understand, over 40% of American women were using hormone therapy at the time. And it dropped to, I think today's quote, you know, anywhere between you here, four to six percent of American women who are eligible for hormone therapy are actually getting the prescription, right? And breast cancer rates did not go down after the WHI. In fact, they only went up. And people ask me, why are they going up? We have an epidemic of terrible lifestyle, obesity, alcohol abuse, environmental exposures, right? So when women are worried about breast cancer and hormone therapy, what I want them to know is that for the vast majority of women, it's safe to take hormone therapy. We've got better options now. And if you're really concerned about your breast cancer risk, you should really be concerned about the other factors that I mentioned, right? And knowing what your baseline risk is. Um because some women have a higher risk to begin with because of family history, death and rest, they carry mutation. But even in those women who are at higher risk for breast cancer, they can still consider using hormone therapy. And the um, you know, the um the data suggests that adding menopausal hormone therapy doesn't further increase your risk. Your your risk is your risk. Um, and whether you choose to use hormone therapy to treat your symptoms and you know, manage things doesn't necessarily further increase your risk. So those are, I know those are a lot of talking points, but I hope that helps you.

SPEAKER_01:

No, it's a great, a great summary of that, of that confusing time and why the you know, now we're only talking about four to six percent of women on hormones. That's you know, that's crazy. And there was a whole generation of women who didn't even get to have that as a way to help them through menopause. So your your example is is spot on.

SPEAKER_00:

And it's important for people to remember that it's your your body is more than just your breast. And I'm a breast cancer survivor, and we could talk about how that's you know an extra challenging clinical scenario. But you know, one in two women will have an osteoporotic fracture in their lifetime. Hormone therapy has been shown to reduce that risk by half, right? Dementia is one of the leading causes of death and suffering in women. Hormone therapy is not FDA approved to prevent dementia. It is not FDA approved to prevent cardiovascular disease. But we cannot ignore the elephant in the room that there's a large body of evidence that suggests that it may be helpful in lowering that risk. And you deserve to have that information. And know that the FDA-approved reasons are hot flashes and night sweats, right? Which then result in insomnia and sleep issues, and we know mood issues, et cetera. That's a lot of women. It's also FDA approved for the bronchitolasty process. So even if you don't have a lot of the other symptoms, if you're concerned about your bone health, that's a reason. It's also approved for the prevention of the genital urinary syndrome of menopause, and it's approved for women who are dealing with premature ovarian failure or early menopause, you know, under the age of 45. Um, and really important for listeners to know any of the data or the controversy on hormone therapy and menopause just simply does not apply to early or premature menopause. Those women should be getting full hormone replacement therapy up to at least the age of natural menopause, unless they have a true contraindication. And if they do have a true contraindication, then we must do everything in our power to support these women because that early loss of estrogen is a devastating thing and really raises their risks of all chronic diseases.

SPEAKER_02:

Yeah, yeah. Such good information. And I'm so glad that you brought up um osteoporosis, cardiovascular health, brain health, because the theme for World Menopause Month is lifestyle medicine. And I'm just so because it's such an important topic. And um, I guess one question I would ask here, Dr. Mann, on this topic is what when should women outside of early menopause POI, when should they start taking hormone therapy? Is there is there a a special, I guess, um age range that is most beneficial?

SPEAKER_00:

Sure. So, you know, certainly when you have symptoms, if you've got bothersome symptoms, you do not have to wait until they're severe, because that's often been the message. Well, tough it out. If they're really severe, then you can start. So I say no, you you don't need to suffer. Um, so if you have symptoms, you can start. You do not have to wait until your periods end. Okay. So a lot of women suffer in the perimenopause time. So anybody listening, perimenopause is the time period before your periods end. And it can range from five to 10 years, right? So there could be women in their late, you know, 30s or early 40s who are starting to have either regular periods or some, you know, um menopausal symptoms. And we can use hormone therapy. And just remember that for those women who might need contraception or managing heavy periods or regular periods, low-dose birth control pills are a form of hormone therapy that is safe. It's effective. So there's a lot of negative ideas out there on the internet and social media that birth control pills are bad. They're not bad, they're very useful, but they're not your only option in perimenopause. Women in perimenopause can use hormone therapy like patches and progesterone. It's just not going to give you contraception and it doesn't always control the regular bleeding as much. So I always tell women, perimenopause, you're having symptoms. We can start on some form of hormone therapy. And then if you're newly menopausal or ideally, really in the first five years to initiate it, our window of opportunity by the guidelines is up to the first 10 years. That's where we see the most bang for your buck. When we go past 10 years, women have to understand we don't have the same evidence that it's going to be as beneficial for heart or brain health, but we it will still protect your bones. It will still improve quality of life if you're having symptoms. Um, and really important, the um WHI original investigators just published an important article in um JAMA, the Journal of the American Medical Association, talking about that we must have nuanced conversations and that the data from the WHI should not apply to women within the first 10 years. And they even go as far as saying for those women ages 60 to 70, it's not an absolute no for them either. These are the primary WHI investigators. They actually said, like, while like there is a slightly higher risk of maybe a blood clot or cardiovascular event, particularly with an oral estrogen, we should really do a risk-benefit analysis and we don't have to deny it. And that the real serious risks we don't really see until you're over age 70. In that point, we really rarely would start it. But it's still even then, not there's never an absolute no or an absolute yes.

unknown:

Okay.

SPEAKER_02:

We get questioned um questions all the time after our sessions, women that are 60 plus, you know, is it too late? Can I still take it?

SPEAKER_00:

So thank you for it depend it depends. And so I always ask women if you're more than 10 years out, what is your goal of treatment? Why do you want it? If you think you have to have it because you've heard all this talk about heart and brain health, I'm gonna tell you your best bet is the pillars of lifestyle medicine. You cannot outpatch a crappy lifestyle, right? Meaning, like if you put that estrogen patch on and you still drink a lot of alcohol and you don't ever move your body and you're eating lots of processed foods, um, not managing your stress, et cetera, sleep, that patch is only going to do so much. It's like leaving the chocolate chips inside of a good cookie recipe, right? You've got to do all the things. So when you're you're more than 10 years out, you have to, you know, rely on lifestyle medicine to read that's really your best thing for your cardiovascular health, et cetera. But if you are still having symptoms, if you are at risk for osteoporosis, um, it's very reasonable to consider. And in those cases, so we start lower dose and transdermal. That's very, very reasonable. And the other thing you probably get questions on is is duration the same as initiation? Meaning, I have a lot of women who have been on hormotherapy for say five years or they're getting close to being on it for 10 years. And the doctor's like, you're getting close to 60. At 60, you turn into a pumpkin and you have to take it away. That is not true, right? So, this idea of age 60 or more than 10 years, that has to do with when we start it. If you're already on it and you're doing well, you don't have a new contraindication, like some new medical problem, um, and you don't have side effects, you feel great, then there is no limit to how long. And the menopause society has very specific language on this and that it should be an individualized decision and that you don't have to stop it. Um, but there's a real problem out there where women are told by their primary care providers or other doctors, like, oh, you've been on this long enough, lady. Time to pull the cord.

SPEAKER_02:

Right, right. You're not on hot flashes, so you don't need it anymore. I've heard that.

SPEAKER_00:

Uh, my course they don't have hot flesh is because they don't have hormone therapy. And then the other interesting thing is the osteoporosis protection is while you're taking it. Now, if you stop hormone therapy after, say, eight years, you've given yourself like a lead time of eight years, right? You've prevented bone loss and you've, you know, maintained bone health. But once you go off to hormone therapy, no, that low estrogen state is going to kick in again and you're gonna have some bone loss, right? So if you are a person who is at particular risk for that, that's another reason to consider staying on it. And what's great is we've got data that even the very, very lowest doses of patches, you know, uh gels, et cetera, are enough to prevent that bone loss. So sometimes as we're older, we might lower, you know, the dose, which is great. I'm so glad you mentioned that.

SPEAKER_01:

Go ahead, Kim. Looks like you have a question. Well, I I mean that was myth number two. Like when do you start it and when do you stop it? And I always joke, you're like, you're gonna have to take it out of my dead cold hand. Yeah, so it's just one of the things that you know, lifestyle medicine is harder than the patch, right? Putting those things into place is really hard to change, um, to change habits. But I I think that knowing that you can take it to feel good for a long time is a good thing. So that's myth. That's myth number two that you just busted on the on the so good.

SPEAKER_00:

Um lots of myths.

SPEAKER_02:

Well, and you know, the other question that we get while we're talking about bone health, and and I think you you touched on this slightly, um, you don't it in order to prevent bone loss, it doesn't mean that you have to increase your estrogen. So you don't have to, you know, mega dose, if you want to call it that, on estrogen to have that benefit.

SPEAKER_00:

Um, it's important. And so we have we know that for women with very early or premature menopause, a 30-year-old, a 32-year-old, they do need higher doses, right? Because it's a different, you know, physiologically speaking, their bodies were meant to have a higher dose of them. But when we're talking about most menopausal women, particularly older women, we just don't need large amounts of hormones. And this, I and this is why we generally use the term menopausal hormone therapy, although I'll I'll use HRT as well because that's what women are familiar with. We've trended towards saying MHT, menopausal hormone therapy, because it sends a message that this is very, very low dose. We are not replacing high levels of hormones. And so I surprise women when I tell them this. When you are cycling and having normal menstrual periods when you're younger, your estrogen every month goes from about 30 picograms per ml up to four, five hundred, six hundred, right? So up and down with an average of below one hundredths, right? That's kind of where you're living at, kind of from an estrogen level in your blood. What we give you in menopausal hormone therapy, um, depending on the formulation and the dose, would raise a level of estrogen up to say anywhere between 20, 50, 60, 70, the higher doses you can get closer to 100, you know, and that would be used for the younger women. But for most menopausal women, the the doses we're giving them are more down in the range of 20 to 50. They're they're they're low, right? So um we're not giving you back high levels of hormones. And that's why in the perimenopause, it's okay to use menopausal hormone therapy. We're not giving you high amounts back. Your ovaries are still doing all of this, right? Up and down with the estrogen. And we give you a little bit of a low dose of a patch so that you never bottom out because that's what happens in perimenopause. Sometimes you have really high, sometimes it crashes and you have a low, and you're not always ovulating, so you don't have progesterone. So we're just giving you like I tell patients, like a buffer to increase your suffering and help transition you to menopause, right? Yeah.

SPEAKER_02:

It's that roller coaster with the hormones that brings havoc, right? Yeah. Yes. You feel like you're going crazy. Um, let's move on to myth number three. We hear a lot. Um, oh, honey, I don't, honey, I don't need to worry about that. I'm already beyond that. I'm already beyond menopause. So I think there is a misconception that menopause only lasts a year or two. And then once my periods stop, I'm done. So what are your thoughts on that?

SPEAKER_00:

Yeah. So the day that you're so one year from your last period is menopause. So that's the definition. And then so after that, women are living postmenopausal. So day one after that, and for the rest of your life is postmenopausal. Um, so symptoms vary for women, but the average length of time that women have hot flashes, night sweats, and often resulting insomnia is seven and a half years. And almost 10% of women will have, you know, these symptoms, these vasomotor symptoms, we call them beyond 10 years, right? Um, so symptoms can persist, and hot flashes and night sweats aren't your only symptoms. As we talked about the bone health, osteoporosis is silent. You don't see that bone loss happening, right? The genital urinary syndrome of menopause for some women presents itself earlier, even in the perimenopause. But for many women, it might be many years after going through menopause that that loss of estrogen really starts to impact the genital structures, the vulva, the vagina, the clitoris, the labia, but also the bladder and the urethra. And women aren't educated that, you know, that called we call it GSM, is progressive. You know, it's chronic and it tends to get worse and it's nearly universal. I don't think I've ever had a patient, seen a patient in all my years of taking care of women in gynecology that I have not seen some changes in the genital urinary syndrome of the menopause. So that's gonna last you, right? Um, your whole life. Um, and I also remind women that the number one reason why an older woman gets admitted to the hospital is for a urinary tract infection, urinary sepsis. Um there's a lot of needless suffering for from that particular part of menopause, and we could certainly talk more about that.

SPEAKER_02:

Yeah. Think um, you know, UTIs that that is definitely something that's not talked about enough. Um, I I've been given permission to mention this, but my mom was suffering from UTIs for years and years and years, um, antibiotic resistant. It got really scary for her. And there was, I asked her the question one day, are you on vaginal estrogen? And she looked at me like I was crazy. You know, she's not married, she's like, I don't know, I don't need it anymore. Um, no. And um, you know, fast forward, her doctor put her on vaginal estrogen. She hasn't had a UTI since.

SPEAKER_00:

So really this is this is what I call low-hanging fruit. And I feel like every doctor who sees women, internal medicine, failing practice, OBGYN, urologists, doctors in the year, they need to know about this because when we're talking about hormone therapy, it's really important for us to differentiate systemic hormones versus local low-dose hormones. So that is hormones that we apply only vaginally to prevent GSM, genital urinary syndrome and menopause. Systemic hormones will help with that, but you don't need systemic hormones if that's your main or only concern, right? And there's an epidemic of suffering in our mothers and in women in nursing homes and just, you know, women as they age, that it's not just urinary tract infections. A UTI can cause you to get fever, to um, you know, have have sepsis, have pylonephritis. What happens to an older woman when they get an infection? They may get cognitive changes, they may feel unwell and lose their balance, they can fall, wake up in the middle of the night and break their hip. This is a very common scenario. Very common. They're getting up multiple times an eight to pee, or they have that urinary urgency and frequency. And infections often um present as cognitive changes or even sign, it looks like almost like dementia in women who are having these chronic infections as they're older. It's a huge epidemic of nursing clones. And just recently, um, at the American Neurologic Association, um, they reported that women who used vaginal estrogen who were older had like an 85% decreased risk of dying of sepsis, of being admitted to an ICU. Um, and so when I say vaginal estrogen is life-saving, I am dead serious, dead serious, right? Um, and it's so simple and and and really should be very accessible to all women. So um I don't care whether you're having sexual intercourse or not, although listen, vaginal estrogen is going to do a great job at protecting and maintaining your the health of all your parts so that you kind of a satisfying sex life. But if that's not something that is a priority for you, I think we all as women care about our bladder health and lowering our risk of infection, right? And so if you're listening to this and you're like, well, my mom's 70 or she's 80, can she start it now? Absolutely. Yes. We can start it at any time and you could stay on it as long as you want. Dr. Rachel Rubin says, till death, do you part with your estrogen?

SPEAKER_02:

Yeah. I really feel like this, the last you know, four minutes of of this webinar, we need to rinse and repeat, rinse and repeat, rinse and repeat. You just need to have that on replay, replay, replay. It's that important. And I think that that's the biggest myth is just because I'm I'm not having sex, I don't need vaginal estrogen, right?

SPEAKER_00:

Um, and there's really nobody that I would not prescribe vaginal estrogen to. So millions of women, this is menopause awareness month and breast cancer awareness month. There are millions of breast cancer patients in the middle of treatment. They're long-term survivors. They may be living with metastatic disease and in chronic treatment. All of these breast cancer patients, I don't care whether they're estrogen receptor positive or negative, it doesn't matter. They can safely use some form of a vaginal hormone, a vaginal estrogen, or there's also um FDA-approved vaginal DHEA, a brand name is called Ninthosa. These are safe options for these women because we have an army, a growing army of breast cancer survivors, over 4 million alone in the in the US, um, who are denied access to vaginal hormones. Um, and if we think about menopause and the suffering with hot flashes and night sweats and join mix and pains and all this stuff, these breast cancer patients are dealing with all of those things. And in general, they're not getting access to systemic hormonotherapy. So if you can alleviate one of the burdens that they're carrying, helping them with painful sex and um maintaining their urinary health, you can really alleviate a lot of suffering in that population as well. So if you know someone in your life who's afraid of vaginal estrogen because of breast cancer, please educate them.

SPEAKER_02:

Yeah, that's an important conversation. Really great advice. And when would you when would you start vaginal estrogen? I think that's a misunderstanding. Yeah, exactly. This which is why I'm asking, right? So it's easy to do. You know, we are beginning to see that vaginal dryness and painful sex. And it's necessarily the case, right?

unknown:

Yeah.

SPEAKER_00:

And in fact, I'm I'm all about prevention. Listen, if you're having hot flashes and some night sweats, you don't have a lot of genital urinary symptoms yet, but you want to start using it twice a week for prevention, that's amazing. It's safe, it's effective. You can also use it if you're using a birth control pill. And in fact, people are told that birth control pills, um, they're wonderful in many ways, but they do lower circulating levels of testosterone. It's one of the reasons why it helps with like hormonal acne. And when it does that, it also is kind of lowering testosterone levels. Um, and testosterone does impact the vulva and the vagina. And birth control pills can cause some vaginal dryness. So vaginal estrogen is really safe if you're on a birth control pill. So if that's happening to you. Um, you know, that would include a lot of perimetopausal women. So yeah, it's not too early to start vaginal hormones and it's not too late to start them. And you can take them if you're also on systemic hormones. You're on a patch or an estrogen pill, you can pair it with vaginal estrogen. You're not double dosing because one is local, not getting systemically absorbed, the other one is systemic. But I've had a lot of patients tell me that their doctors say, well, you don't need the vaginal estrogen if you're also on systemic. But what we know from our clinical experience is roughly at at least half of the patients who are on systemic, they also need a little boost with the local vaginal hormone.

SPEAKER_01:

Yeah. Perfect, perfect conversation for people to understand. Yeah. And because I think we say, yeah, you should do it, but why? And you really described the why, as April said. Okay. In interest of time, we're going to move on to myth number four, which is perimenopause isn't really a thing. We can't treat you until you're in full-blown menopause.

SPEAKER_00:

Of course, it's really a thing. It's the transition zone. We have decades of data on this that we know exactly what's happening. We're having irregular signals from the brain to the ovary. And so sometimes you don't ovulate. Sometimes you ovulate early, sometimes you ovulate once, and then a second follicle is recruited. So you have these, you know, very high surges of estrogen. Then all of a sudden, it drops really low. Um, so it's a universal experience of all women. You don't go from normal regular clockwork periods to no periods overnight. And everybody's perimenopause is different. For some women, their perimenopause um is longer and it's more symptomatic. And for others, it's shorter and it's easier. And it does, and certainly being um healthy and living uh, you know, an ideal lifestyle can help. But I've seen the healthiest marathon runners who are doing all the things and they can suffer um just as much, right? So it's a real thing. And as I alluded to before, we have ways that we can intervene hormonally, either with contraceptive pills, both estrogen alone or estrogen and progestin pills, or a progestin-only form like a progestin IUD or progestin pill, um, or we can use menopausal hormone therapy. We have a lot of options. The biggest problem is that that women face is that if a doctor understands how to manage menopause, fine. But a lot of them only know how to manage a menopause. The perimenopause is very, it's a little tricky. It's it's the it's the hardest thing for us as doctors to manage because we're kind of fighting with your ovaries. Your ovaries are all over the place doing things. Where in menopause, your ovaries aren't fighting us. The hormone levels are low. We just give you back some hormones. Perimenopause, we've got to deal with bleeding and contraception and you know, irregular cycles. And so the vacuum of care really is extended into the perimenopause because of the lack of clinical training and knowledge. So I think that's why women go to doctors and are told, well, it's not really a thing, or you're just anxious. You're you should go to the psychiatrist, you should have an antidepressant, or oh, you're having brain fog and new headaches, you need to go see the neurologist, or you've got back pain, go see the orthopedic surgeon. There might be appropriate referrals in some of those cases, but if it looks like a horse and it runs like a horse and it acts like a horse, it's a horse, it's not a zebra. Yeah. So if you are presenting with clinical symptoms of menopause, perimenopausal symptoms, and particularly period irregularity, and you're of the age, late 30s into your 40s, we have to think of perimenopause first, not last. Yeah. We'd save a lot of healthcare dollars by not sending you to a gazillion specialist.

SPEAKER_02:

You just you just mentioned age with perimenopause. Um I think it's really important to just kind of pause there for a moment, recognize that that um, you know, perimenopause can begin in your mid-30s. You know, if you're looking at the average age of reaching menopause 51 in the US, and then you back into that right time period of um, you know, how long we're in that perimenopause stage before we reach menopause, we're talking about mid-30s or you know, early 40s. Absolutely beginning to experience this. So that myth of being old, right? If we if we Google menopause or uh perimenopause, it's it's a white woman fanning herself with the hot flashes. And that's just simply not the case.

SPEAKER_00:

Um, not the case. And in fact, I find that women can be more symptomatic, it's more troublesome um on their quality of life in the perimenopause than even the menopause. And one of the number one symptoms that women have is new onset of anxiety, depressed mood, um, and insomnia, right? And those things really are really hard because they might be at the height of their career or they're really in the middle of juggling, like their kids starting to get a little bit older and all the stresses that come with that. And now all of a sudden they have this new onset of these mood or sleep issues. So those are the two big things I see. And what happens is instead of women being educated and addressing what is happening from a hormonal standpoint, they're often given band-aids like antidepressants, um, anti-anxiety medications, and sleep meds, which there is a role for those medications. Women who have clinical depression, you know, should be evaluated if they would, you know, I'm not writing that off. But what we actually know, the data suggests perimetapausal mood changes, perimenopausal anxiety, perimenopausal um sleep issues are actually better treated with hormones, right? Um, and women don't actually get that information, right? So I think that's really, really important. And the other thing is you mentioned, you know, the older, you know, picture of an older white woman with gray hair. You know, it doesn't, you know, a 37-year-old or 42-year-old wouldn't relate to that. Um, black women have a higher risk of going through earlier menopause. Black women um have worse symptoms, can last longer, um, and they're way less likely to be counseled or given options. Um, they there's already a lot of distrust in the medical system. And then once they get to this part of their life, there's even more distrust because they're not believed, right? Because they're like, oh, it's it's too early, or no, it can't happen, you know. And so, you know, I think that's really important for us to point out. Yeah, they're suffering. They're suffering. They really are. You don't have to suffer. That's the bottom line. You don't have to suffer. You don't have to suffer. And and really, and I I think it's very important when we're talking about hormone therapy. It's not that we're saying this is the only thing for you, you know. Um, and sometimes that's criticism that it is placed on on people, physicians, you know, advocates that say, Oh, you just want to give everyone HRT. No, no, I want everyone to know here are modern medicine tools that you have a right to access and know the facts on. Um and it's part of, you know, a healthy lifestyle options, right? And so if you, you know, um, and so, and this is also an important message that if for some reason you absolutely cannot take hormone therapy, I don't want you to feel all doomed and right. Um, there are so many things we can do. There are non-hormonal FD-approved medications for hot flashes and nights, but they're not going to protect your bones or do other things, but they can be really helpful for women who absolutely cannot take systemic hormone therapy, which is very few people. So I never want when I advocate for hormones for women to feel left out of the conversation because maybe they're fighting an ER-positive breast cancer or they have some other reason, which there's not many reasons, but where they couldn't take hormone therapy. Um, you know, we're not forgetting about you.

SPEAKER_02:

Yeah. And and not, and I don't want to underestimate lifestyle either. I mean, it's it's actually the first thing.

SPEAKER_00:

Yeah. Right, right. Yeah. And and some people feel overwhelmed by it. Um, but I say, listen, your periods or your symptoms are a little wake-up call. It's a canary in the call mine. It's telling you, all right, girl, this is time to pause and take care of yourself. And so it doesn't mean you've got to become a world-class athlete, but it means you've got to fit in moving your body at least five days a week, right? Like start with a daily walk. You know, you're gonna either get an app or a trainer or join a gym and learn how to lift some weights a couple of times a week, right? You're gonna try to eliminate or cut out your alcohol, you're gonna try to do really, you know, better sleep hygiene, like small changes over time add up because I promise you that patch is not gonna solve all your problems if you're not working with me as your you know, physician and doing these other things that are good for you, right? And I think that's so I think there's like a window of opportunity to initiate a lot of things, right?

SPEAKER_02:

Yeah, that's great. And we feel good, right? We make those we feel great when we feel lifting weights, we're moving our bodies, we feel better.

SPEAKER_00:

It's that positive snowball effect. And you know, um, some of my colleagues, um, Dr. Vander in particular, shall she say, like, you should be doing this so that when you are 70 and 80 plus, you can lift up your grandchild, you can go on a hike with your friends, you know, you can bring a bag of groceries back into the house yourself. And so that's why the lifestyle stuff is so important. Is estrogen hormonaphy gonna give you an edge? Yeah, it's gonna give you an edge. But if you're not doing all these other things, you're not gonna be, you know, living um in a healthy, optimal way as you age. And that's really like to care about, right?

SPEAKER_02:

Right, absolutely. Every time I put my suitcase in the overhead bin, like I can do that. I can do it, right? And I don't want to says, can I help you?

SPEAKER_00:

I'm like, nope, I have it. I I it's so funny. I I think of that every time I lift my suitcase up. I think like, because I I know like some of the older women in my life, they certainly can't do that. And it's debilitated them and then limited um their ability to kind of enjoy life, right? Yeah, all right. So again, that hormone therapy patch isn't going to allow you to lift that suitcase over your head, you know, but it might help you with your uh half flashes and night sweats so that you're not so tired to go to the gym the next day, right? So, like it's all part of a big picture. Yeah.

SPEAKER_01:

That's great. Well, we have a lot of other myths we could break, but I think we've had a great conversation. But let's talk, let's give some action for folks. Lots of doctors as you talk about dismiss symptoms. And what are some of the practical steps that women can take to advocate for themselves in the medical appointments? I always say, like, if you go to your doctor and you don't hear what is the thing that you want to hear based on all the knowledge and information you have, it's okay to divorce your doctor and find a new one. But what do you do to be able to have those conversations with a doctor when they dismiss your symptoms?

SPEAKER_00:

Well, the most important thing is to come prepared. You know, doctors are really, you know, burdened in our current healthcare system. They are expected to see patients in 10 minutes. Um, and an annual visit when you're getting like your pop smear or your routine physical may not be the time to say, like, I want to have a whole discussion on hormone therapy options. So I tell patients, make a dedicated separate appointment if you're seeing your in-person doctor. Go, you can even call a head of time and be like, hey, I'm making an appointment to talk about hormone therapy, options for me, and menopause symptoms. The doctor has a heads up then. And they're not trying to do your PAP and your breast exam at the same time. Number one, come in with your symptoms clearly written out. We don't want like a three-page, you know, diet drug. We want it nice and short and sweet. And there's lots of little like symptom trackers, free ones that you couldn't find online, right? So that's helpful. You can call in advance and be like, does this doctor is a doctor certified by the Menopause Society, or does this doctor have clinical experience doing, you know, hormone therapy? And does this doctor prescribe FDA-approved hormone therapy, or is this doctor doing like compounded things and pellets? So I would steer you over for that to make sure you're trying to find someone who's doing like things that we know are really safe and evidence-based. Um, and then and and it's okay to ask for a referral. Your G B N who's served you well for all those years, you don't necessarily have to give him or her up. They can do your pap smears and stuff, and you can say, like, hey, I got it, it's not your thing. Just like they might send you to a neurologist if you have migraines or et cetera. You can be like, Can you do you have a referral that you recommend for me? And if that is not working for you or it's difficult to get access because you have to wait months and months, that's why, like, you know, companies like Alloy came into existence to expand access to evidence-based medicine to physicians who know who are certified and actually know how to do this. And so, you know, we have to embrace technology and it works really great for menopause care because a lot of it is sharing information, talking through things, and um, you know, being there to make adjustments. Because as I alluded to, from perimenopause into menopause, sometimes what we start with isn't what we stay with. So, you know, consider digital health as an option. We're not replacing your doctor, we're complementing them.

SPEAKER_02:

Yeah. Yeah. Digital health is really wonderful. Um, organizations like yours who focus on perimenopause, menopause, you marinate in it every day, right? This is all the different types of this is what you do. Um, I think is fabulous. And as you look ahead, I guess the the last question that I'd love to ask you, if you were looking in a crystal ball, um, looking ahead, what do you where do you see digital personalized medicine headed? What's in it for the next five years?

SPEAKER_00:

I think the sky is the limit. I think we are going to see a lot of options in digital health in being able to access specialty care um in ways that you know many people would never have access to, whether they live in a rural area or they're they live in a busy urban area where there's they have to wait months and months to get in. And it's going to kind of leverage this expertise of people who are specialists in things like menopause, but it also longevity, this idea of so to me, basic menopause management, it's actually longevity medicine. And longevity medicine doesn't have to be all kinds of special fancy bells and whistles. It's more about focusing on prevention and proactive approaches. So I think there's a lot of opportunity. Um, and you're gonna see more companies. And we know at Allo, we're gonna be expanding more options for women to really think holistically about how they engage. So I'm very optimistic about that. Um, and I'm also optimistic that this army of women, people like you guys and all my patients out there, they're standing up and they're saying, we want more. We want the FT to remove the black box label on vaginal hormones. We want them to change the label on systemic hormones to reflect accurate information. We want drug companies to start to give us better and more varied options for hormone therapy. Um, as well as non-hormonals, as well as we didn't even get to talk about testosterone. Hopefully, one of these will get a female dose testosterone. So I'm very optimistic that though all of those things are going to happen, but they're not gonna happen if we stay quiet as women. We have to keep on you know speaking up and advocating and educating each other. Yeah, because we're 54% of the population. We make healthcare decisions. We can do this. We can do this.

SPEAKER_01:

Oh, so good. Well, Dr. Men, thanks for joining us today on the first of the four um collaborative efforts that we're gonna do this month. And um, if people want to learn more about you or alloy, where do they where do they go?

SPEAKER_00:

So myalloy.com. Um, I see patients in many states, and we have, you know, close to 30 um board certified physicians in all 50 states. So if it's not me, it's one of my amazing physician colleagues who are true menopause experts. Um, and also follow us on um myalloy on Instagram. And I have a very active social media page, uh Dr. Men O B G Y N, um, where I do a lot of patient and clinical education on not only menopause, but also things like premature menopause and breast cancer survivorship. So check all of that there.

SPEAKER_02:

You're busy, you're busy. I think of you every day while I put my face cream on, by the way.

SPEAKER_00:

We didn't talk about that. That you I know we didn't talk about that, but I'm like, oh, yeah. The quick little buzz on that is that whatever's happening to the skin down there is happening to the skin up here, and we can use topical, very low dose estrogens on your um your face too. And we offer that skincare at alloy too, which is really fun.

SPEAKER_01:

Yeah, it's super great.

SPEAKER_02:

Well, for all that you do.

SPEAKER_01:

Yeah, I really appreciate it. And so, audience, we hope you'll join us next week where we'll discuss menopause at work with Rachel Hughes, my Alloy's community manager. And uh, we'll follow up with a couple other after that. And thank you again, Dr. Men. Have a fantastic world menopause month.

SPEAKER_00:

Thanks, you guys. Have a big great day. Take care. Bye-bye. Bye-bye.

SPEAKER_02:

Thank you for listening to the Medovia Menopause Podcast. If you enjoyed today's show, please give it a thumbs up, subscribe for future episodes, leave a review, and share this episode with a friend. Modobia is out to change the narrative. Learn more at Medovia.com. That's M I D O V I A.com.

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April Haberman

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Kim Hart

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