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

22:57So I did as much clinic time and daytime work as I could. And my fellow residents picked up the call, which I'm forever grateful because it was a huge burden on them. But it really became after months and months of chemo. So as I was making that six-month mark, it was just, it was getting so brutal, the side effects of chemo. And at the time, I thought it was the chemo. What I know now is it was the induced menopause from the toxicity of chemo on my ovaries. I didn't realize that me calling my husband at one o 'clock in the afternoon saying, I feel like I'm crawling out of my skin and I want to jump out a window and I'm having a panic attack.

23:35or the very low mood and depression, because I'm a pretty resilient, upbeat person for people who know me. I could roll with a lot. But this was the first time in my life where I felt so, and of course I was depressed about cancer, of course, but it was more than that. It was this darkness and gloom paired with a lot of insomnia, horrific hot flashes and night sweats. Did anyone whisper the word menopause to you? No.

23:59Dr. Mary Claire Haver:They're just, no. I mean, they said, oh, it might show your ovaries might, you may not get your period and they'll probably recover your ovaries because you are so young. And then at some point, I can't even remember, some point in the middle of my chemo, they're like, you know what, there's some studies showing that if we give you Lupron to really shut down your ovaries, that it might protect them from the chemotherapy. So on top of like the chemo kind of slowly shutting them down temporarily, then they gave me Lupron injections, which then I think just put me over the edge. Yeah. So Lupron is the medication that we give in a lot of fertility treatments and they give in certain cancers where it basically complete, it's a chemical menopause and it's immediate.

24:41Dr. Mary Claire Haver:Immediate, yeah. So. And I just, honestly, I just really didn't know. I mean, I know it sounds silly that I'm an OBGYN, but remember I was a second year resident, so I was still young and training. And that's when the WHI came out. It was 2002. There was no talk about premature menopause, menopause and all the other side effects. And if anything, I was like, it was the hot flashes. I didn't realize it was everything else. So when did chemo end? It ended sometime that late summer. I actually refused my last chemo. I could not take it anymore. And like a crazy person, I called up the preeminent person in the world at the time who was like an expert in young women and breast cancer.

25:21And I cold called him. I'll never forget it. I think he was at the University of Michigan. And he took my call. And I was just like, I know this is really weird, but I just want to tell you this. and I'm so scared that, you know, I'll never be a mom and I want my ovaries to come back. And do you think I need that last dose of taxotere? And he's like, no, it's okay. You don't need that one. It's okay. And I was like, oh, okay. So I went to my oncologist. I'm like, I'm not doing the last one. She was just like, you are the biggest pain in the ass patient. But she supported me on that. And then they're like, okay, let's kick you while you're down.

25:52And now let's put you on tamoxifen and ovarian suppression. So my new line is that, listen, we have got to think about someone who has had breast cancer or some other complicated medical thing but in breast cancer they've been through surgery they've been the emotional stress of being diagnosed with cancer they've had all these treatments chemotherapy and then when they're done they're like okay now when you're really low now we're going to put you on prolonged estrogen deprivation for five to ten years but we're not going to prepare you for any of it to me it's like kicking a dog when they're down.

26:27That's how I felt. And in retrospect, I'm like, whoa, whoa, whoa. When we are embarking on that, we really need to empower women so that we can optimize things, be like, come on, come on, girl, we got to get you ready for the marathon. Because it's a marathon. It is not a sprint. And that conversation isn't always happening.

26:46Dr. Mary Claire Haver:And there's so much rush. Rush to get the chemo, rush to get the surgery, rush. I understand that. And that's important. But there are times where I say it's OK to just like take a pause and be like, we've got to regroup, reboot for this next phase. And I never really had that chance along the way. So you talk about all the stuff they gave you before chemo prophylactically, stuff for nausea. Yeah. Talk about that. Yeah. So when you go in. The listeners are taking notes right now. Yeah. So when you go in for chemotherapy, they give you a steroid, like a dose of prednisone. They give you anti-nausea medication, multiple different choices.

27:22They gave me injections, Neupogen, to keep my white blood cell counts up. They give you Ativan while you're getting the red devil, Idromycin, to help keep you from having a panic attack. Spinning out. During that. Crashing out, as the kids say. Yeah, crashing out during that chemo infusion. But they didn't give me anything or offer anything to help me cope with the induced menopause that was about to happen and was happening. So for instance, I didn't know it at the time at all, anything about genitourinary syndrome menopause. That was like a foreign thing. No one ever said that to me. So for our listeners, what is genitourinary syndrome menopause?

28:02It's when loss of estrogen, the vagina, vaginal dryness, vulvar, atrophy, clitoral atrophy. Like, yes, it's more than vaginal dryness. Everything is drier, shrinking, thinner, poor quality tissue, decreased lubrication, pain with sex, decreased sensation, urinary, but it's urinary syndrome too. So urinary tract infections, urinary urgency and frequency. So of course that was happening to me. So that's just one example of, I didn't even get like use a moisturizer or lubricant, or these are the things you can do.

28:33Dr. Mary Claire Haver:No one gave you a tub of coconut oil. No, because this was 2001 into 2002, like no one was talking about sexual health with cancer treatments. I mean, we've come a long way and we're doing better, but you've got to remember At the time, it was not at all addressed, right? And so now I say like, okay, if I could have looked back, I would have said, oh, let's pre-medicate her, give her like the lowest dose of vaginal estrogen, like twice a week to prevent the downward decline. Yeah. Because we know, we know the hot flashes are coming. Let's offer this woman something. We know she's likely at very high risk for mood issues and anxiety and depression.

29:14but I was never offered an antidepressant or even the talk of it until years later, like literally years later when I don't even know, it was like probably five years into treatment on tamoxifen. And finally the nurse practitioner, the new medical oncologist that I went to, she was so lovely. She's like, Corinne, you don't need to suffer. She wrote me a prescription for an SSRI and I was like, oh, okay, maybe that will help my hot flashes. I mean, it was crazy. five years of it and I actually have I I pulled my medical records I have the note from the middle of chemo when I was almost about to just like lose my mind and like stop taking the chemo and in the note it says the doctor wrote like horrible hot flashes hasn't slept in months she's terrified of premature menopause that was the line and then I looked at the plan and the plan was prescription for Ambien.

30:06That was it. That basically sums it up.

30:10Dr. Mary Claire Haver:So you did have a baby. I did. So walk me through that. You were allowed. Yeah. So I finished up chemo. And then at the time they just that I started tamoxifen and tamoxifen does not cause you to go into menopause. It just blocks estrogen receptors. So you feel like you're menopausal. Yeah, you can have menopausal symptoms. But because I was very young and at that point, they stopped the loop run. They stopped the forced menopause. Really, let's just see what happens with your ovaries. And so I started tamoxifen and I actually tolerated it. OK, because slowly over the months, my ovarian function came back.

30:47Right. And so I was doing OK on it. Right. And at about the 18 month mark, I decided sort of on my own. I was a little bit of a cowgirl about it. I was like, yeah, I'm going to just stop this. I'm going to get pregnant and then I'll go back on it. And that is what we tell patients they can do now. So there was recently something called the positive trial that looked at young women like me where they would pause their adjuvant endocrine therapy, so tamoxifen aromatase inhibitors for up to two years to get pregnant either naturally or use IVF, have the baby, even breastfeed if they could. So this to your pause, and then you go back on to complete your treatment.

31:28So I basically did the positive trial on myself back then. And my doctors were sort of supportive of it because at the time there was observational data that pregnancy after breast cancer didn't seem to increase the recurrence risk or change the prognosis. And so I was like, I'm going to do this. And we didn't need to use our frozen embryos. We were really lucky. Like literally we had sex 11 days later. I was a crazy person and I drew my own blood in the call room and I ran it down to the lab. And an hour later, I go onto the computer and like my HCG was like, I don't know. It was like 47. No, not even that high.

32:08No, it was like 16.

32:09Dr. Mary Claire Haver:It was so low. I think I had just like, you wouldn't even have a positive pregnancy test. Oh yeah. No, it was like, yeah, it wasn't even urine. I hadn't even missed a period yet. I didn't even miss a period yet. And I was crazy. And then And like 36 hours later, I drew my blood again and I did it again. It's doubling. Yeah. And that's Ava. And that's Ava. Yeah. And she's 21 now.

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36:11Dr. Mary Claire Haver:Not intended for medical purposes. Works independently of Gemini apps. Check responses for accuracy. You've had multiple surgeries since then. Too many. Lots of reconstruction. You have become a leader in this space in medical communication, especially around survivorship and previvorship. What is the, and I hope I've pronounced it correctly, what is the Young Survival Coalition? So the Young Survival Coalition is the premier nonprofit organization worldwide that addresses breast cancer in women 40 and younger because our needs are different, they're unique and more impactful in ways that aren't in someone who is menopausal, say, when they have breast cancer, right?

36:54Dr. Mary Claire Haver:I mean, my DMs constantly, constantly, every time I post about menopause or estrogen, there's at least 10 or 15 people. What about me? What about me? Yeah, my breast cancer survivor. And it's the survivors, the pre-virus. Or people have just been told, you're too high risk. You can't take estrogen. Yeah. And they just feel like they're left in the dust. Absolutely. And so that feeling of left in the dust, I felt it, not in terms of the menopausal conversation, HRT at the time, but even when I was diagnosed, I felt left in the dust because I was the youngest person in the chemo room. And I didn't relate to like the support group women who were much older than me.

37:29So the YSC became a real lifeline. And I feel like it's a similar reflection of the community that I have now in the menopause space. And they were really like my sisters in arms at the time advocating for what we needed. But now full circle now me being a menopause specialists. Now I'm trying to speak to the needs of those young survivors who, like me, are dealing with premature menopause. They're dealing with GSM, genitourinary syndrome, sexual health stuff, and they're not getting answers from their doctors. What they're allowed to do is get pregnant, but no one is talking to them about, oh, well, does it hurt when you try to get pregnant because the sex is so painful?

38:09Dr. Mary Claire Haver:Yeah. You have a choice as an adult woman to make a risk-benefit decision for yourself to pause adjuvant endocrine therapy to attempt pregnancy? So most women don't understand this. It's really a radical concept, especially in the oncology space, that a patient would have as much input into the decision-making around her care. It's almost like it's like medical school. Here you go. Here's your plan. Here's your chemo. And you're lucky to be alive. Like you've described stories of people coming to you after they find you on the internet and talking about their experiences. Like, give me, you know, these, again, they're taking notes, you know, what should they not hear?

38:48Well, listen, I think most medical oncologists out there, I am so grateful for them. And they do want shared decision-making. They're so smart, and they know all the ins and outs of these things. But the reality is they are working in the same medical system that you and I worked in, and they are pressured for time. They're pressured from a hierarchy of an institutionalized like protocol. They're afraid of all sorts of medical legal, the medical legal stuff, the insurance things. So I think even with the best intentions, it's very, very, very hard for women to get individualized care. And then when this elephant in the room of like the fear of, of death, I mean, I feared it for years.

39:32I mean, it's still sitting in the back of my recurrence and mortality. When that enters the room, it really gets in the way. It's like, you know, and if a medical oncologist or increasingly there's a lot of, you know, there's nurse practitioners and PAs who are also seeing these patients, if they don't have that kind of clinical expertise or interest in helping with sexual health or the menopausal symptoms or premature, the mental health and stuff that's going on, all these other things, it's just easier to be like, well, you know, you don't want to risk a recurrence. You have to stay the course and do the most.

40:04And sometimes doing the most leads to people stopping treatment, not completing treatment or just really suffering. So my whole thing is I want to try to find a way for women to have their cake and eat it too. I want you to be treated for your breast cancer. I want you to stay on your medications. And if you need to be menopausal for them either forever or for some period of time, well, we need to support you in every other way because it's very hard for women to hear all the benefits of HRT and all the problems when you lose estrogen, especially early, it's scary. Dementia, osteoporosis risk, cardiovascular risk goes up.

40:40And so when you hear that, you're like, you're like, well, this is depressing. This sucks. Well, maybe I shouldn't be doing these breast cancer treatments. And I'm like, no, you need to do your treatments, but we need to find a way to make them tolerable, to improve your quality of life. And there's lots of ways we can support your long-term health, even if we can't do systemic hormones. And this is why it is maddening and it's sickening to me that we would ever deny women safe things like local, low-dose vaginal hormones, vaginal estrogen, because I like to picture there's all these bricks on your back.

41:17As a cancer survivor, you're dealing with all of these struggles. And if you just take one or two of the bricks off that woman's back, she could stand a little straighter and she could feel a little bit more like herself. So I might not be able to give her systemic estrogen in many cases. Yeah. Although maybe down the road, we can talk about that. But I can give her local vaginal estrogen and maybe she can have sex with her partner and keep with the intimacy. Maybe she doesn't have to go to the bathroom five times a night. Maybe riding a bike or hiking doesn't hurt because it's so painful and dry down there.

41:50Maybe she could have a pap smear. I had two patients in the past couple of weeks who can't have pap smears anymore because the aromatase inhibitors have made their vulvas, the vaginas, so atrophic and stenotic that they can't tolerate a speculum so they can't have cervical cancer screening. That's not okay.

42:09Dr. Mary Claire Haver:Yeah. It's insane. And these are women who are already past treatment, stage one. Like the lack of knowledge in the oncology community about the importance of just this one little thing. I hate to harp on this. No, but it's everything. Like this one thing affects intimacy, relationships, your urinary health. It affects like your ability to have a damn pap smear to get cervical cancer screening. Like come on people. These are now, as I've come to learn, I did not learn this in residency or training, but the mental health, the cognitive changes, the genital, I did know about some of the genital urinary changes, but not all, are expected and predictable.

42:45Dr. Mary Claire Haver:We know they're coming. It's not like it's not going to happen. It's going to happen to every woman in menopause. And every doctor involved in this care, like we're failing. The medical system is failing women because we are not training these clinicians. They're good people. They want to do the right thing. Yes. And the bias that is just built into this of you're worried about your vagina. Yeah. How dare you? Actually, my medical oncologist who is still practicing saw one of my patients. and she didn't know that it was one of my patients. The patient found me afterwards. And when the patient asked to have vaginal estrogen, and the patient is a complicated, she had recurrent breast cancer.

43:25She's at high risk for not a good outcome, but her GSM was incredibly severe. Her 20-year marriage collapsed and her husband left her. And she was really just like, please, can I consider some vaginal estrogen? And I'm really worried about my heart health. And my oncologist slammed, well, my old oncologist slammed her hand on the desk and said, is this about your goddamn vagina? Use some coconut oil. And if you're worried about your heart health, go see a cardiologist. I'm here to save your life. And so that's an extreme example. Some things have changed. Some things have not. There's much more awareness.

44:03There's a lot of medical oncologists. All the AUA guidelines.

44:06Dr. Mary Claire Haver:AUA guidelines. American Neurological Association. Yes. And ASCO is having more of this content. What is ASCO? American Society of Clinical Oncology. There's leaders. My friend, Dr. Eleonora Teplinsky, shout out to her. She's a leading voice out there trying to bridge this gap and help communicate with the menopause specialists need to communicate with the oncologist. As all of the psychiatrists need to communicate with the menopause specialists. The orthopods need to communicate because we're all seeing the impacts of menopause. And I use the breast cancer patient as the most extreme example.

44:39But everything we talked about also applies to the woman with endometriosis, the woman with premature ovarian insufficiency for a reason that we don't even know why it happened. For the woman who just had a complicated menopausal situation because maybe she has some other comorbidity. I don't know, she's got hypertension or something. And someone told her she couldn't have this or a family history of breast cancer. So they tell her she can't have that or that. Right. So this is the most extreme example, but it applies to really all women, I find.

45:07Dr. Mary Claire Haver:Yeah. So you finish residency, you make it through. And then you work, you go to work. Yeah. And a traditional OB-GYN practice. Yeah. So my first job was actually in a community health center because it was really close to my house. So I can like come home for lunch to see my daughter, Ava. And so I did that for a little bit. And then my friend from the Young Survival Coalition, who became like a sister to me, she had a recurrence of her breast cancer. Our breast cancers were very, very different. She had a recurrence when she was pregnant. and she delivered her baby and she died two weeks later.

45:41And while we were in the hospital there, my husband said to me, he's like, you're not getting pregnant again. You're going to stay in your tamoxifen. It scared him so bad. Yeah, and you know what? He was right because Nicole's situation was very different. And I can't compare our medical diagnoses in terms of our breast cancers were very, very different. But at the time I just said, I have a daughter. She's healthy, wonderful husband. I'm going to stick on my medication. I'm going to do what I need to do. I can't pause again. And then that's when, because I make decisions, like literally two weeks later, we have an agency.

46:14We're going, we're going to do an international adoption. And we adopted Lucia from Guatemala. She was born in 2006 and she came home at the very end of 2006. And she's a sophomore in college?

46:25Dr. Mary Claire Haver:She's a sophomore. She's 19. Yeah. And so, yeah. So I say Ava saved me emotionally because I was in a very dark place thinking I'd never be a mom. And then Lucia, I say, saved me physically because of her, I was allowed to stay on my tamoxifen. When did you decide to make the switch to menopause care? So after I got back from taking care of Lucia's adoption, I chose to have my ovaries removed at that time. Because I was like, I'm not going to have another baby. Well, I'm not going to have another baby. I was BRCA negative. And so the doctor was like, you don't have to do this, Corinne. Well, I was like, I'm going in for a new reconstruction.

47:04They were fixing my breast implants. And I says, well, I'm under. Just take the damn things out. I don't want them anymore. My mom died at 54. I know you all tell me I'm BRCA negative, but there's something not right with my genes. I said, they're like, you don't have to. I'm like, no, it's OK. I'll do it. I don't even. I'm glad I did it. We'll tell the audience why in a little bit. But again, clueless. I didn't really realize what surgical menopause was going to mean for me. And bam.

47:29Dr. Mary Claire Haver:Talk to our listeners about the differences between abrupt menopause, surgical, you know, induced menopause and natural menopause. Surgical menopause is abrupt because you walk in to the OR with ovarian hormones being produced and then you walk out, those ovaries are removed. There's no more production of estrogen, progesterone, and you're losing a big source of your testosterone. Testosterone is made in other places. And so from a symptom standpoint, it's more abrupt and more severe and it's permanent. And I think I didn't realize it because my other menopause times were temporarily and chemo kind of gradually put me in.

48:10And then, you know, and then again, the loop run. So I don't think and I was like, oh, I weathered that. And you were older. And I weathered that. And I was just like, I was in a better place. I had my two kids. I'm like, I can handle this. Right. But it was really hard. So when I realized like, wow, over two months, I got like, I gained weight. I gained like at least 10 pounds really quickly. The sleep, all the things, right? All the stuff. And then I was in a private practice. I was starting to see more women coming in with perimenopause and menopause complaints. I'm like, I need to figure this stuff out.

48:41I'm like, because I am not capable of taking care of my own patients with these complaints, much less someone like me who is very complicated. And so then I got involved in the Menopause Society and I got certified and just started to like slowly tailor my practice in that kind of way.

48:56Dr. Mary Claire Haver:And when did you make the switch to, you're working with Alloy Health now with a telemedicine platform. Yeah, I stopped doing OB around that time of switching towards menopausal stuff. So that's delivering babies, which a lot of us do eventually because babies come when they want to come and we have to sleep. Exactly. So it was, I don't know, it was probably sometime around 2010, 2011. I stopped OB, switched to GYN, office-based practice only, and then COVID hit. And I just started to do a little bit of telehealth just for my established patients during COVID because in New York, you know, no one was coming into the doctor.

49:29And by that point, my daughters were in high school and I was trying to be there for them and supportive of them with their high school years. And I was like, you know, this telehealth thing kind of works for a lot of education. Menopause is a lot of talking. Breast cancer survivorship is a lot of talking. It's a lot of like education. Right.

49:45Dr. Mary Claire Haver:Taking menopause is not going to cut it. Yeah. And also I didn't need to examine these patients in the same way. Like, they can still have their GYN. I'm not replacing their gynecologist to do their in-person exams, but I says, this works. And then I was at a menopause society conference in Washington, DC, and Monica Molinar and Ann Fullenweiter, the co-founders and co-CEOs were there. They had a little booth and I met them. I'm like, I do telehealth and I do menopause. They're like, oh, we're going to start a menopause telehealth company. I was like, oh, we should talk. And so we stayed in contact.

50:13And then I joined them and got a lot of medical licenses and started to see patients in a lot of states through Alloy, but also still maintained my own small telehealth practice. So, you know, over, so fast forward over the last, like, I'd say, you know, three, four years, I've really, I've learned a lot because the more you see, the more you learn. Yeah. So I've learned a lot by really only focusing on this, you know, it makes you a better menopause doctor. And so now I'm like really on my mission to, because I have all this experience now to really help the most dismissed, the most complicated.

50:48And so I'm coming back to what I always wanted to be, which was a teacher.

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52:02Dr. Mary Claire Haver:Or a sweet vanilla? Smooth caramel, maybe. Or a white chocolate mocha. Whichever you choose, delicious coffee awaits. Find Starbucks frappuccino drinks wherever you buy your groceries. There's a lot of, I can't take estrogen. I've been told X, Y, and Z. What are some legitimate reasons? Because there's so much misunderstanding, even amongst clinicians, as to who can and cannot take. So in medicine, we call it an absolute contraindication. What are the absolute contraindications to someone taking estrogen? So I'll be bold and say, I don't believe in medicine there are any absolute. Yeah, as Dr.

52:38Blooming says, it's not cyanide. Yes. And I think so what I like to say is like, listen, yes, we have some general contraindications that we're always going to talk about. You've unexplained bleeding, postmenopausal bleeding. We've got to work that up and figure out what's going on. Meaning you're having vaginal bleeding, not your normal, right?

52:55Dr. Mary Claire Haver:We don't want to start hormone therapy in that case because there might be something there that estrogen would feed and we have to figure that out. Absolutely. Especially postmenopausal bleeding or really new onset of very heavy, very abnormal bleeding in the perimenopause. you have some real active liver disease, complicated active liver disease. You've had a recent thrombosis, so a blood clot or a blood clot that goes to your lung called the pulmonary embolus, right? We're going to be very careful there. You've complex cardiovascular disease, like a massive heart attack, a bypass, something significant.

53:26Hypertension, high cholesterol is not serious. Right.

53:29Dr. Mary Claire Haver:Women are being told if they have any risk factors for heart disease, they can't take it. If they have any family history of breast cancer, they can't take it, even with negative gene testing. Exactly. And then the last one, as you alluded to, you personally have an estrogen-dependent breast cancer, new diagnosis in the middle of breast cancer treatment, right? Those are the big ones. But like we can find things in really most of those scenarios where there might be situations where we could consider it in the right context, right? So those are the big things. But notice none of those were a family history of anything, right?

53:58So the biggest one, the biggest barrier that we get is family history of breast cancer. That is not a contraindication to hormone therapy. I tell patients, I want to know your family history and I want to know your other, because it's not just family history. We need to look at all of your risks for breast cancer so that we can personalize your screening, talk to you about preventative measures, both lifestyle, sometimes medication, even surgery, depending on you're the most high risk, like you carry a BRCA mutation, for instance. But it's to do those things. It's not to deny you a conversation about your choices on hormone therapy.

54:35And the Menopause Society makes this very clear. So don't take my word for it. Look at the experts and the guidelines that are generally on the more conservative side. And it says that the preponderance of evidence does not show that menopausal hormone therapy further adds to your risk of breast cancer. Your risk is elevated. It's elevated. We're going to address that with your screening, surveillance, et cetera. but adding menopausal hormone therapy isn't going to significantly increase that risk more that's how you have to think about it and so that family history is often used as like a guillotine yeah

55:10Dr. Mary Claire Haver:to say absolutely no you talk a lot about weird barbie this is weird barbie so the weird barbie is this is ideas that the doctors now are coming to the place where they're like okay we get it this menopause train is happening we've got to get along the ride okay i'll learn how to prescribe hormone therapy for the ideal perfect candidate, like this ideal stereotypical. Thin, Caucasian, healthy, you know, no risk factors. Like, yes, you can have it. Exactly. Like your breast density is zero. There's no family history, etc. But we're all weird Barbies. We're all unique and different. We all bring different things to the table, whether it's like 80 % of us by the time we're 50 will have some other medical condition, migraines with aura, hypertension, endometriosis, fibroids.

55:58Dr. Mary Claire Haver:Women right now, I get blowing up. Oh, I have fibroids. I've been told I can't take it. Oh, I have endometriosis. I've been told I can't take it. Yeah. Oh, I have autoimmune disease. I've been told I can't take it. Migraines with aura. Yeah. Factor V Leiden. It's like the bane of my existence. Factor V Leiden. MTHFR. So these inherited clotting situations, prothrombin, factor V Leiden, great example of individualization matters. We can give you transdermal estrogen. We would just avoid oral. Right. It doesn't mean you can't have it. Yeah. So we do not increase the risk of a blood clot with a non-oral estrogen formulation.

56:39Dr. Mary Claire Haver:Exactly. Let's talk about some statistics that you love to throw out there. One in eight women lose ovarian function before natural menopause. Yeah. That's an inconvenient one in eight. And so I say the one in eight, everyone thinks, oh, one in eight women will get breast cancer in their lifetime. And that is true if you live to 80. It's not one in eight women at age 40. Right, each decade. Yeah. No one talks about that one in eight women are going to lose their ovarian function prior to the age of natural menopause. Average age is about 51, right? Ranges from 45 to 46. So that's a lot of women.

57:10So premature menopause is under 40. Early menopause is under 45. Okay.

57:15Dr. Mary Claire Haver:And there's some specific risks associated with early and premature menopause that a lot of women don't know. I mean, I can't tell you people coming into my office who had ovaries out with surgery electively at 45 and no one counseled them as to the earlier loss of hormones and what that would do to her long-term risk of chronic disease. I mean, it is, it's shocking. And in my mind, it is medical malpractice to remove somebody's ovaries prematurely and not have pre-op counseling, pre-op plan. There are many good reasons why we move over as early. I removed mine and I am so glad I did because fast forward years later, I found out on update testing that I do carry a BRCA2 mutation.

58:02My gut was right. I'm glad I did it. What is update testing? This is important because a lot of women don't understand this. Yeah, a little sidebar here. So family history of breast cancer, you get tested for a gene or you say, oh, my mom is tested for that because she had breast cancer and it was negative. Anybody listening, if you had testing really prior to 2014, 2013, 2014, you should speak to a certified genetic counselor or your physician or ask for a referral to a genetic counselor because prior to that time, we didn't do panel testing. So we didn't include other genes because it's not just BRCA.

58:36There's other genes that can raise the risk of ovarian and breast cancer. But they didn't even do the full sequence of the BRCA gene. They just did like the most common mutations. And my mutation is in something called the BART sequence, which is the large rearrangement of the gene. It's less common, but it exists. So if you had a negative rocket test in your family prior to that time, you need update testing. And when I called my oncologist, I think I need update testing because I was doing all this like continuing medical education and I read about it. He's like, oh, you don't probably need it.

59:09It's really rare. I was like, just do it. And then three weeks later, he's like, oh, I've got bad news. I was like, no, it's good news because now I know why, because now I could have my family members tested and, you know, they can take proactive steps, right? So that gets back to why would someone remove their ovaries early? And with enhanced, there's more women having genetic testing out there, which is good. So we know. And then they're done with their babies, having babies. Okay, you don't need your ovaries anymore in terms of the fertility perspective. So we can remove them surgically. You could have your kick and eat it too.

59:40You can lower your risk of ovarian cancer. You will wake up in the recovery room with that estrogen patch on you. We can give you progesterone. We can give you testosterone. We can manage it. So you've lowered your risk and you get your hormones back.

59:52Dr. Mary Claire Haver:And that confuses a lot of women. Why would you remove my ovaries and then give me hormones back? Isn't that going to increase my risk? So first of all, with BRCA carriers in particular, they're at risk of breast cancer and ovarian cancer. So you remove the ovaries physically in the tubes, you're dramatically lowering your risk of ovarian cancer. It doesn't matter whether we give you the hormones back there. And what's so fascinating, and we can't explain this necessarily, but you remove the ovaries, you actually also lower her breast cancer risk, even if she still has intact breasts. Many of these women will have a prophylactic mastectomy.

1:00:26But what the studies have shown is giving back hormones doesn't negate the risk reduction in breast cancer. Ha, we don't know why. That's another question. But it's really interesting. So basically, the guidelines are actually quite clear. This is NCCN guidelines, as well as ACOG Menopause Society, is that if you are a BFC previvor, meaning you've not had cancer, you've removed those ovaries, whether you've had your prophylactic mastectomy or not, you can and really should have those hormones given back to you up till at least the age of natural menopause, when you can have that same discussion that every average age menopausal woman has about what do you want to do now going forward, And what's really shocking is many of these women have already had her bilateral mastectomies.

1:01:14There is literally no reason to be withholding hormones from them because of all the risks that you were alluding to.

1:01:20Dr. Mary Claire Haver:So you did a study, you co-authored a study, and you found that 94 % of breast cancer survivors report moderate to severe menopause symptoms and 89 % felt that the care was inadequate. How groundbreaking was that? with my co-authors, Dr. Layla Agrawal and Dr. Eleanor Tepulinski. And this is the positive power of social media, right? So we did a study looking at, we called it WISH, Women's Insights in Sexual Health Breast Cancer. So what kind of information were they getting and access to care for their sexual health concerns after breast cancer? We focused a lot on sexual dysfunction, GSM. We asked a few questions about like their menopausal symptoms as well, other menopausal symptoms.

1:02:02And within three weeks, we got over 1 ,800 people who completed the survey. Normally, it takes months and months and months to recruit that many people. But we had this outpouring of participation and the results were profound. You know, 85 % said that they had significant, moderate to severe impact on their sexual health. And almost 90 % said it caused them moderate to severe amounts of distress, which is important. So the dysfunction was there and it caused them a lot of distress. And close to 80 % says it greatly impacted their relationships with their partner. And we allowed patients to make a comment to all the questions.

1:02:48So we have literally thousands of comments on their experiences. And it is, I like to call it shock and awe. So we were really proud to present it at ASCO and it got published because we really want like this to be a wake-up call, right? It wasn't actually surprising that women had these things, but I think it was jarring to see how explicit they wrote about how much it hurt them and how little information they got. Like basically nobody got referrals, nobody was offered all the things because it's vaginal estrogen, yes, but there's a lot of things we can do for sexual health, basically, they weren't getting much.

1:03:27Yeah.

1:03:28Dr. Mary Claire Haver:I'm going to call myself out here because you fixed my semi-broken vagina. You know, we're friends. We talk quite a bit. And I was on HRT early in the game within nine months of when we figured out it was menopausal because I was on birth control pills. I came off. I was immediately off hormones and figured out, oh God, my ovaries quit somewhere back there. And here we are. But I never started vaginal estrogen. I wasn't having any symptoms. So I thought I wasn't having much dryness or anything. And I was like, well, when I get there, I'll get there because I often prescribe them together. But I never thought about prophylaxis.

1:04:03Dr. Mary Claire Haver:Like, why would I wait till something breaks? But I was we were chatting and I was symptomatic because I was struggling with orgasm. I was literally like, why is this taking so long? Like this used to not take so long. Like I am like frustrated here and, you know, trying all the different techniques and different vibrators. And, you know, we go to these conferences and they're throwing vibrators at us. So I feel like I have to try them all so that I can talk to patients about the different methods. And I'm like, this is taking forever. And Corinne just casually goes, I think we were texting. No, we were on.

1:04:35Dr. Mary Claire Haver:You guys, you're like, girl, I don't know what's going on with it. I said, Mary Claire. How much vaginal estrogen are you on? And I was like, oh. I was like, I'm going to out you on social media that the menopause queen isn't using vaginal estrogen. Me, me, the woman who talks about this stuff all the time. Well, doctors make the worst patients. And then really within a month or two, everything was kind of back to normal. So thank you. You're welcome. My distress is much lower. Yeah. And now I, you know, if I lay off, I immediately have urgency and frequency and stuff. So like that keeps me on track.

1:05:06But it's interesting that you mentioned like the decreased or, you know, diminished orgasm or like it's harder to orgasm. It's because this is the one area that we don't say it that much with GSM. It is clitoral atrophy, people. You don't atrophy the vagina and the vulva and the clitoris stays robust. Just magically. Yeah. And also like our friend, Dr. Rachel Rubin, is always like saying that like, guys, like vaginal estrogen is like Viagra for women in terms of it's not exactly the same, but the idea is Viagra brings blood flow to the genitals. And that's what vaginal estrogen does. And blood flow is a clitoris's best friend.

1:05:42Dr. Mary Claire Haver:So did you ever imagine that in all of this, you'd be a medical communicator or influencer, as some people like to refer to us? No, we're thought leaders. We're medical experts. We're medical educators. And we are medical communicators because I'm not in the clinic doing like seeing 30 patients a day anymore. No, me neither. And God bless. And I'm so grateful for my colleagues who are on the ground providing that excellent care in this very, very broken medical system that does not value patients. and it doesn't value doctors either. When we complain about what's happening out there with women getting information or getting menopause care, I don't want the doctors to feel attacked.

1:06:21We get it. We understand. We did that job. We did that job and we need you to do that job. And so we're trying to educate patients so that they're more empowered so that when they get to you, you don't have to spend an hour explaining the difference between transdermal estrogen and that vaginal estrogen is safe, right?

1:06:38Dr. Mary Claire Haver:The day that we're recording this, you posted a video that I shared and it was a very, very popular medical influencer, medical communicator, Dr. Mike. And he was speaking on a panel at a large conference. So tell me, and you reposted it and duetted it and you put in your thoughts about it. Let's go through that right now. You just got back from a big conference where something similar had happened. Yeah. So yeah, Dr. Mike was on this panel and they were talking about the role of how do we communicate health messages to the public? They were talking about it in the framework of what happened with COVID and public health officials and doctors and communicating to the public.

1:07:19So that was the theme. But then it kind of got a little bit deeper and kind of talking about what does the role of social media play and what does the responsibility of people whose job it is to tell people information from a public health standpoint or anything, how do you communicate? And there is a tension in this world now between the people who are publishing and in the research and the people who are on the ground doing the really hard work in the clinics and the people who are out there publicly facing and talking to people on social media. Right. This is the new newspaper. You know, it's the new radio.

1:07:53It's the new this. And it's not going away. But people are a little uncomfortable with it. Right. And I get it. It's very, very frustrating as a doctor. And we see it, too. There's a ton of misinformation out there. A huge amount. And I can't imagine being in that clinic every day and having patients say, look, I heard this. I heard that. I heard that. And I get it. And sometimes it can make you roll your eyes when you hear, oh, you heard this on social media. Okay, great. Right. But that can be a bit dismissive to the patient. And it can be a bit dismissive to the colleagues who are out there.

1:08:22Like, it's hard doing this. It's a lot of work. I do it because I love talking to people on social media about being empowered because I lived all these things. If you listen to my reels, I'm very emotional about it. I really believe what I'm telling patients. And it's work. It's my role that I'm giving back to the medical world. But what I see sometimes at medical conferences or, you know, within these professional societies is a little bit of a roll of the eyes. Ugh, the doctor influencer, which I don't, yes, we have influence, but I'm not an influencer like someone who does not have any medical training.

1:08:58I'm actually a medical expert who's communicating. That's why I like to call ourselves medical communicators, right? And so Dr. Mike was talking particularly about something with the AMA and some kind of messaging that they sent out in rebuttal to some public health information that wasn't, right? So he said the AMA sent out a strongly worded tweet that got 5 ,000 views. And he's like, and then they put their president on camera with, you know, a webcam that was like, didn't work well. And the microphone was not great. I'm like, no, no, we have to be better at communicating because this is the world.

1:09:37Right. And so when people roll their eyes and be like, oh, you probably heard that on social media or, you know, some doctors on social media are talking about progesterone or talking about that women should consider, you know, menopausal hormone therapy for X, Y, Z. we can't be dismissive of our colleagues who are out there. We should build bridges because I love to bring the research to the public. Like I'm not doing all those research studies. So I love to read them and then communicate them to the public. So I'm grateful for them for doing the research. Yeah. I want them to be grateful for us.

1:10:10Dr. Mary Claire Haver:It's almost like a translation service. We do backdrops of the studies behind us to like share the new information that comes out, the new guideline updates, anything we think would enable a patient to make a better informed decision for herself. And I think some physicians, and I hear this, are just like, oh my God, I feel so like stressed that I have to get up there and do that on social media. I'm like, no, girl, you don't got to do that. You could reshare stuff. You can give a little list of the doctors that you really like in your specialty that speaks to your patient's concerns and say to your patient, yeah, I don't go on social media, but here are the accounts that I think are providing high quality information.

1:10:48Tell your patients that. Or if you are on social media, you don't have a big account, it's okay. Just reshare other good content. Direct your patients to credible sources. And be careful about battling in the comments misinformation from people who are not experts. So much of it is bots. No, because you feed and you give that person more power when you pay attention. Better is to shine light in the darkness. So lead with good information or direct your patients to the people who are giving good information. And together, us physicians can drown out all the crap that's going on out there.

1:11:24Dr. Mary Claire Haver:We've got some previvors. We've got survivors. You know, a lot are going to be listening to this. What are some top resources for them? What would you recommend? So if you are a breast cancer survivor listening to this, my favorite source is menopauseandcancer.org because she has information on managing all aspects of menopause and cancer because it's not just breast cancer. It's colon cancer. It's cervical cancer. It's ovarian, GYN cancer. It's lung cancer. There's lots of women out there dealing with that. She's an amazing source. She has physicians. She's got a podcast. She's got a book. Tons of free resources.

1:11:58Nonprofit. That's one of my favorite. If you're young and just diagnosed with breast cancer, the Young Survival Coalition, of course. Any books? I do like this one book called The New Menopause.

1:12:10Dr. Mary Claire Haver:I don't do a lot of, I don't cover a lot. I always refer out, you know, for survivors. No, no, no, but I think it's really important. Because that's a whole nother book. Yes. You know, it's so nuanced. Yes, but no, no, I think it's really, really important for women. I'm manifesting your book for you right now. Oh, well, thank you. But I think it's really important that women actually understand the basics of what's happening from a hormonal standpoint. Put the HRT question aside for a second. Like, you have to name the problem and understand the problem, understand the physiology, so that then you can say to your healthcare team, okay, doctor, I understand why I need to do a hormone blocker or have my ovary removed or whatever the case is.

1:12:48So how are you going to then address the estrogen deficiency? The British Menopause Society has a very lovely guideline called the Management of Estrogen Deficiency in Breast Cancer Survivors. and it's a really simple checklist of all of the things. One of the leading things they say is that women should be referred to a menopause specialist preemptively. Get them involved early. That's not happening. Let's face it. So you need to take charge and really say like, okay, I'm going to do these things, but you need to support me with all of my body systems on how that's going to be impacted by this menopause.

1:13:31Dr. Mary Claire Haver:So hormones are off the table for her. What are some of those resources? We talked about vaginal estrogen, so we've covered that. Yeah, vaginal estrogen, of course. If you have vasomotor symptoms, hot flashes, night sweats, and insomnia, you must address it. I know many people don't want to take another medication. And there are some, you know, yes, you could sleep in a cool room in layers. I get it. But you know what? If a medication, and there are non-hormonal medications, both off-label medications as well as specific FDA-approved medications, The guidelines are clear on that. The Menopause Society has a whole list of the non-hormonal evidence-based approaches.

1:14:08You must do that. Don't try to ride it out, stick it out, because if you are not sleeping at night and your quality of life is poor, it is very, very hard for you to do the lifestyle pillars of nutrition and exercise and sleep and community and your mental health and all of those things. So my friend, a new friend, Dr. Shannon Klingman, who created Lumi, She's an amazing entrepreneur, physician. She's incredible. And she is now fighting breast cancer. And so she's gone public with it and I've helped her with things. And she was on HRT living her best life and she loved it. And listen, I love HRT too.

1:14:47Like we want to prescribe it to the people who we can prescribe it to. But right now she's having to use an aromatase inhibitor. And so she says, you know what? I am feeling better than I ever have in my life. because when I was taking my patch, which I did love, it gave me in some ways a little false sense of like health where she's like, I wasn't leaning into the lifestyle pillars, which you and I always preach about. It has to be non-negotiable. Non-negotiable. The HRT is like a nice ingredient, but you've got to do these other things. And so she goes, now she's exercising and doing all these things like her life depends on it because she says it is.

1:15:23And she says, I feel better. I'm stronger. I have more muscle. My bone is going to be healthy. I'm sleeping better. I'm eating a cleaner diet. I've gotten rid of alcohol. She feels great. So I tell patients, I know that it's a lot of pressure when you've just been hit with all these treatments to be like, oh, I've got to become like this superwoman now. No, I say, but you can take like one brick off your back, like I was alluding to. So you can say, okay, well, you know what? For the next three months, I'm just going to eat clean. Or the next three months, I'm going to like invest in that group exercise class or that personal trainer.

1:15:54Or I'm going to speak to my nurse practitioner or my medical oncologist about getting something for those hot flashes. Because then we slowly piece everything together and we can really improve your quality of life. And then there's some women, and the conversation's moving forward. There are some women within this breast cancer survivor world who may consider menopausal hormone therapy in the future. Sometimes it's not right for them at that time. Sometimes it's never right for them. But there's subsets of them who might consider it because breast cancer is not one disease. It's heterogeneous.

1:16:27Each cancer, you can't lump a DCIS, someone who had DCIS and a mastectomy. Or what they call stage zero. Yeah, with someone who has more advanced breast cancer or someone who is triple negative. And we never shut down our ovaries before. So like, why can't we talk about hermence? Well, we can. So it's opening up. There's a paper being published in January that's talking about a trial that we're going to hope support worldwide called the MENO ABC trial, where they're going to enroll women who are breast cancer survivors and collect observational data about their outcomes. Dr. Larkin and a team had a wonderful editorial in the Menopause Society Guidelines journal.

1:17:06And there was just recently a practice pearl by Dr. Holly Peterson about how we need to approach this difficult conversation because there's more than 4 million women in the U.S. alone. These women want some answers.

1:17:18Dr. Mary Claire Haver:So how would you advise a partner if they're listening to be supportive and lean in. Because women take on all these roles, right? Mother, cook, organizer, head, child, you know, whatever. And then all of a sudden, they get these diagnoses and they have to pull back from all those other roles. And someone has to step up to fill the gap. It's a huge burden on the partner in your life, your husband, your wife, partner, because they do often have to take on other responsibilities. But if they really want to be supportive of some of the collateral damage that's happening, I'm going to really beg them to like get educated.

1:17:59Like you got to know what's happening to the woman in your life. You have to understand like she may not want to have sex with you, not because she doesn't love you, but because it hurts or because it's just less, it doesn't feel as good. And so her brain doesn't want it as much. Or maybe she's so exhausted because her hot flashes are keeping up at night that by the time she hits the bed, she's not thinking about sex. She just wants to try to desperately go to sleep. or if her muscles are hurting or joint pain or all of the menopausal symptoms. So get educated, read a book like yours, get information, read our friend's book, You Are Not Broken is another great one because I think it really helps with intimacy and talking about how to communicate when it comes to like maintaining that relationship and that connection.

1:18:40That goes a long, long way. And tell her she doesn't always have to put up such a happy face. I always wore a mask in terms of, I had the perfect wig. my makeup was always on. No one knew I had cancer. We kind of didn't tell a lot of people about it. I put up a good, good front and I didn't have to. So tell her it's okay for her to be a little vulnerable and break down sometimes. And guess what? When chemo ends, that's when the sadness and the grief sometimes kicks in because everyone's like, you're done. Yay. Pink ribbon. Let's go on like a 5k walk. I'm like, no, I can't be around this. This is depressing.

1:19:16I have so much fear of recurrence and all the collateral side effects. And people don't realize women are in breast cancer treatment for years. It doesn't end when the hair grows back. How old was your mom? My mom was 54 when she died. And we were born on the same birthday. So next December, I'll be 54. Yeah. Which will be 25 years.

1:19:37Dr. Mary Claire Haver:And that's a big day for you. This is 57 and the year I outlive all three of my brothers who died. So I get it. But you do say that the last 30 year life should be the best third. Yeah, it only gets better. And your great relationship, healthy kids thriving. You've got this incredible career that you pivot and you're teaching. You've got this incredible following community. And it's just such an inspiration, I think, to our our listeners. So, so much in menopause is is expecting women to be quiet and to fade away and to become invisible. but unpaused is about really taking the reins back on this part of our life.

1:20:18Dr. Mary Claire Haver:What are you unpausing in your life? Ooh, what am I unpausing? I think this part of my life has given me now this freedom to kind of finally really focus on myself, my development, and let my wings fly. Like I let my birdies fly. They've flown the coop. They're always welcome back to the nest, of course. But I'm unpausing, you know, worrying about everybody else and focusing here and leading, right? So that my daughters won't have to face the same struggles in accessing quality health care and making hard decisions in the women's health space. Because no one has it easy. Sometimes I look back and think like, why me?

1:21:07Why did this happen to me? I went through so much. But now when I talk to all these women out there, every woman is dealing with their own challenge. You don't know until you walk in her shoes. We're all at some point in our life as a woman going to have to deal with something difficult within our health, right? And so I'm excited to empower women to not have to face the barriers that we all had to face.

1:21:29Dr. Mary Claire Haver:Well, thank you for coming on Unpause. We loved having you. Thank you for having me. Menopause made me do it. Oh, she gave me this button. Yeah, menopause made me do it. Menopause made me do it. It's my new mantra. Thanks, Mary Claire. As a reminder to our audience, you can find out more information from Dr. Min at her website, drmin.com, or you can follow her on Instagram, TikTok, and Substack at drminobgyn. For more information, check out her CME course, Managing Menopause and Breast Cancer at heatherhershacademy.com. I'd love to hear from you about this topic and anything else that's on your mind.

1:22:06Dr. Mary Claire Haver:You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness, and navigating midlife at thepawselife.com. Also, my new book, The New Perimenopause, is currently available for pre-order on Amazon. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Mary Claire. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr.

1:22:44Dr. Mary Claire Haver:Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Ryan Reynolds here for Mint Mobile. I don't know if you knew this, but anyone can get the same premium wireless for$15 a month plan that I've been enjoying. It's not just for celebrities. So do like I did and have one of your assistant's assistants switch you to Mint Mobile today. I'm told it's super easy to do at mintmobile.com slash switch.

1:23:22Dr. Mary Claire Haver:Upfront payment of$45 for three-month plan, equivalent to$15 per month required. Intro rate first three months only, then full price plan options available. Taxes and fees extra. Default terms at MintMobile.com.