Episode 14 transcript
00:05
Hi, good peeps. Welcome to the flexible neurotic podcast. You know that friend that you can call to ask anything? That's me. Dr. Sarah Milken. I'm known to my friends as the flexible, neurotic. What does flexible neurotic even mean? Let me be neurotic while I take out my golden shovel to dig deep for all the golden nuggets in the hottest topics, from parenting, to education to neuroscience, and maybe even some beauty secrets. So we can all start living more flexibly. Come join us for edgy conversations with rad moms. Innovative thought leaders and well being practitioners helping you find that sweet spot between chaotic and chill. If you're craving that sweet spot, grab your golden shovel with me. You will walk away with nuggets you can start using today. Hi, good peeps. This is the next episode of the flexible neurotic podcast. I'm Dr. Sarah Milken, the flexible neurotic. Today I have an awesome guest. She's an Instagram phenomenon with her gynecological chat. She's smart with it. So Matter of fact, I love her. This crazy busy Connecticut obstetrician gynecologist has warmed the minds and hearts of so many women from pregnancy through menopause. Every day this guest is teaching us what we need to know as a woman maybe didn't know we should ask or too embarrassed ask. Her name is Dr. Shiva ghofrani. Check out her Instagram you will be hooked. She gives these 10 minute daily chats on Instagram on the ins and outs of the vagina, perimenopause and menopause and pregnancy. We aren't doing that much pregnancy today as we are in the second half of life zone. I got addicted to the style of her teaching. She simplifies the information and breaks it into categories and repeats it back. It's like vagina for Dummies. It's all stuff you thought maybe you knew but maybe you didn't. Get ready for this perimenopause and menopause in a hot flash of an episode. The fourth episode of this podcast with Dr. Sherry Ross. revamping the vagina after 40 helped to understand what exercises and tools we could use to keep the vagina in shape and looking good. This episode will touch on that a bit but it's more geared towards menopause and perimenopause things we should know things we shouldn't worry about things we need to ask about things we need extra guidance on from a specialist. So get ready. I am clearly going to dig deep with my golden shovel to get through all the components of the perimenopause and menopause rollercoaster of 10 to 15 years of life. So here we go. Before we start, I want to know that this episode does not make you exempt from seeking medical advice that is personal to you and your body. This does not make you exempt from getting the amazing dig deep pap smear that we all love. And the tush finger there freaks me out every single time for the rectal exam. Oh my god. This episode is intended to get you thinking about the questions we should be asking ourselves and taking our red flags to our own doctors. This episode has golden nuggets for you to take to your doctor after all of that. Hi, Dr. Shiva. Hi. I'm so excited to have you here. I see you on Instagram and you're a real person. Well, and
03:44
I listened to your podcast, but I listened in 1.5 speeds. So hearing you speak in a normal cadence is so funny to know. Weird.
03:51
I know. You're like I'm in my car. I'm listening to your podcast. It's really early in the morning. I'm on my way to work. Yep.
03:58
I love it. A real person. Yeah, I know. I feel like I've known you forever.
04:02
I know literally. Yeah, totally. Well, it's for john of China, for sure. Yeah, I have to tell all the listeners because I just told you before. I literally just left Dr. Sherry Ross's office. I went for a full gynecological exam. And she was delivering a baby. So she was running late and I was texting you saying, Oh my god, I need 15 more minutes. So I've had everything that we're going to talk about. I just got home 15 minutes ago, I had a pap smear, a urine test, a rectal exam, a breast exam, and an ultrasound. Bravo. I'm so glad I'm here today. Did I nail it?
04:42
I knew like 110% of it.
04:44
And then before I left, she was like, okay, so your mammogram scheduled for next week? Right?
04:49
I'm like, how many like appointments? Not Forget your colonoscopy. You know, we
04:55
talked about that too. They say that those dates change from 5245 Yes, they did.
05:03
Yeah, screening test change from 50 to
05:05
4546 in February, and I was gonna do it. But then COVID came and he gave me such a good excuse, but now I'm back at it.
05:14
The COVID. I know, I know better do it.
05:16
Yeah. But I will say and I did do a story about this today, but I haven't posted it yet, is I think a lot of us are scared to go to doctors right now because of COVID. And I just did this quick little story saying, Hey, you guys, if you're having symptoms, and you also need your regular exams, I know it's scary because of COVID. But don't skip them.
05:37
Yeah, they've actually already started to compile data of the number of cancers that will probably increase because of things like missed screening tests, missed mammograms, missed pap smears, things like that. And so you have to balance you can't be so scared of COVID that you end up missing. It's like the classic cutting off your nose to spite your face. Hey, we can't do that. And that's what
05:57
I was trying to say today. I'm like, Look, you guys, I'm wearing two masks. I'm in Dr. Sherry's office. I'm getting all my tests done. Yeah. And then the mammogram next week, the colonoscopy. I'm like, okay, My birthday is in February, do I wait till after the birthday? Do I do it before the birthday? Well, and here's what I have to remind my patients, it's not like you call today and you get your appointment, I know right away, like you have to meet with a GI doctor. Or maybe it's going to be on zoom, maybe not, then you make your appointment. So like I always tell patients just get the ball rolling, just call and make the appointment. And then today, I feel like this month, the next like two to three weeks, I'm getting all my appointments done and just checking them off. And I'm also doing my kids appointments, because that's another thing is, like I'm behind on some of the HPV vaccines, like we talked about on the phone. And it's because I'm like, Oh, I don't want to take over them to go to the office because of COVID. But then you get behind in everything. And you got to remember in the offices, everybody's masking, I
06:53
mean, we've been working literally since the day COVID hit and we have been masking and my partners and I have all been safe one partner got it. And he got it early in March prior to everyone knowing we were masking, right since then I'm in and out with like, you know, 32 vaginas a day, and hospital delivering and knock wood. Again, just masking is not 100%. But it's really impactful. I
07:15
mean, that's one reason to not go in and out not a reason to knock on them. Well, I want to talk about what my intentions are for this episode, because I feel like you and me we could go crazy wild and this could be 17 hours. So we're gonna outline what we're talking about today. My intentions for this episode as it is for all of my episodes of the flexible neurotic is for us to dig deep with our golden shit shovels in an edgy conversation about how we can and we'll find our sweet spots between neurotic and chill. In this case, we are going to finally learn the true definitions and differences between perimenopause and menopause and what the fuck we can do about it. Today to date, I think a lot of us think we know but we don't really know. And that is the case for me as well. We're going to talk with Dr. Shiva about how she has taken on her golden shovel and helped herself and other women understand the aging of our vaginas and women's health in the second half of life. Dr. Shiva is going to tell us who what and how to assess, fix and process well we all face in the second half of life. Dr. Shiva will give us the golden nuggets for actionable items to slow down the sweating hot flashes. I'm actually sweating right now. sleep better, be less crabby and re elasticizer vaginas. I got that word from you on your damn good love that we're gonna talk about that. We are covering all things perimenopause, and menopause. Are you ready?
08:49
I'm ready. And can I just say one thing that I love when you talk about this flexible, neurotic and what was your tag about? Well, this is what I was gonna say. It reminded me that one of my many isms is about I want patients to be proactive without being paranoid,
09:04
right? Yes, I
09:05
people come in all the time. I'm so scared. I'm so scared. And I keep saying no, no, don't be scared. You shouldn't be fearful. It's normal to be anxious. It's normal to be a little bit like apprehensive. But let's be proactive without being paranoid because if we do that, then we will pick up on any issue and we'll find it early. And then we don't need to be freaked out we need to acknowledge things happen.
09:23
That's what I like about your approach is because and I'm going to talk about that too is because you kind of just take it matter of fact, right to the middle. It's not about extremes. It's about arming yourself with the information so that you can make the next best decisions for you and what decisions are good for you may not be good for the next person. Right? But it's all about finding the middle but before we dig into vagina land before we dig into vagina Lan, I want to tell listeners why I picked you and this is going back to the middle. I do a lot of reading as you know is being nerdy as I am in various topics related to to women and second half of life, and in this case menopause and perimenopause, there are 1000s of experts. And there are experts who are totally Eastern medicine experts who are solely Western medicine. And then there are experts on like, why you shouldn't take the pill or how certain supplements can change your whole life. I felt as part of my initial episodes on women's health, starting with Dr. Sherry Ross. And now you know, that I wanted to be more of the middle ground. I wanted expert voices that say yes, there is this way. Yes, there is another way there is no right way. And here's some things for you to think about and making your own decisions and consulting with your own medical provider. How do you feel about that?
10:44
I love it. Listen, that's another ism. So I love when I read what you talk about it. It really is synergistic. I made up my own little quote that I like thought about. And it hit me one day and I it is nothing is ever only. Everything is always and and I think it's exactly what you're talking about. Right? Like Western medicine is amazing. But it's not only good. And it's not only bad, right? There's both within it seeing it.
11:09
That is
11:10
right. Nothing is ever only everything is always at hand. And I think the more we realize that and embrace that, the better we would be unfortunately, both sides tend to be very antagonistic, right, the people who are like Western doctors who are very pro birth control pill, for example, while they'll talk about side effects, they leave no room for the notion that maybe not everyone should be on it, or as Eastern doctors who are very anti birth control pills really maligned the pill. And that's really harmful to women. Because that is discounting legions of women who really needed the birth control pill, despite the fact that we acknowledge there are side effects. So both sides are actually really should say, there is validity to both nothing is ever only everything is always and there's
11:50
sort of like our political landscape right now to
11:53
very versus everything is versus right, I would say it's like Western versus Eastern, vaginal versus C section. It's very antagonistic and very other. And instead we have to realize is there's just not black and white. We know that like it's so obvious. And yet we still continue to act as if there is an answer, or one right way.
12:11
And I love I love your Instagram because you kind of come in with these like 10 minute daily chats. And you talk about that there are so many different ways to skin something and to see something and to perceive it. And I feel like I want you to spend a few minutes talking to us about your new business venture. I think it hits on a lot of these topics about how we think we know information. We're not sure we have bits and pieces. We might be embarrassed asked certain questions. I mean, you go to the ecologist you think you know them, well, then they start talking to you about your sex life and lubrication, all this stuff, and you're like, silent, right? So I want you to tell us about what you're doing.
12:57
Okay, so Well first, I'll just tell you that the two things that I want to debunk in our new platform is getting rid of fear. I always joke that like fear should be used when you are being chased by a lion go back and talk about what your new platform is called. Okay, so tribe called v platform. So it's tribe called New tribe called V for vagina, right for vagina, my business partner and I have started specifically to increase women's knowledge so that we can decrease their anxiety because what we keep hearing and finding and I see this in my office after 22 almost years of practice, every day, I hear things like, I am just so scared that I'm going to find out I have I'm not abnormal pap smear and abnormal mammogram, that I'm going to have a miscarriage that I'm going to have bleeding during my pregnancy. I mean, things that are so common, they happen every day. And the reason women are scared is because they don't know enough of the information. So their assumption is that abnormal mammogram equals cancer equals death, right? Which is true, I mean, almost never true. So unfortunately, because they don't have enough information, they tend to get anxious. So through tribe called V, we're having two aspects of the platform, the pregnancy aspect, and then the gynecological and women's health aspect. So in the pregnancy platform, which is already open, we have our pregnancy program, and people have already started joining the community where they I joined even though I'm not even close to being brah you joined the tribe called v part and we're about gynecological things. But our pregnancy program we have private membership where people get an immediate 220 page ebook where I have all kinds of nuggets like again, all of these pre emptive what ifs, what if you find out you're pregnant and you have spotting or bleeding? What if you find out you're pregnant and you have a placenta previa or on your ultrasound, the doctor says their system the baby's brain like these are all things that are incredibly common that when you've never heard of it, it sounds so scary or if you've only heard of it through Dr. Google
14:46
it's scary Dr.
14:49
Dr. Google I always say like he went to a crappy medical school
14:52
right so she doctor Google's like my mother to my mother's best friend is Dr. Google
14:57
right. But by the way, he's not your mother's best friend because he is good. airing your mother.
15:00
So I want to explain
15:02
to your mother if she were pregnant in our program, what I would explain is, here's what these things mean. And ideally, if you've preemptively read about this or heard about this, and we have a private community where we do two to four lives every month, where I talk about all kinds of pregnancy stuff, and people literally are members, right now we're from California, Connecticut, New York all over. We talk about things two to four times a month, we invite specialists, so that once something happens, because as we know, something always happens 99 it ends up being okay. But when you haven't heard of it before, it sounds scary. And I constantly railed against hearing the word scary. So the pregnancy program is up and running, and people can always go on triple d.com and join us and then separately, we're going to have our gynecology platform where we're again, going to talk about all the classic things HPV herpes, perimenopause, menopause, vaginal dryness, libido, abnormal mammograms, irregular bleeding, I mean, everything that in your guy's world as a woman, Yeah, sounds dreadful and scary and worrisome. Because you think that it is unique. I mean, I always joke like, when in your regular world, you want to be unique, but gynecology office or with any kind of medical issue, you want to be common.
16:12
We have to normalize our shit. We're all having those weirdo feelings, all of you. I
16:18
mean, when you guys come to me and say I have something really embarrassing. I always joke that, like, bring it on. I'm waiting to hear it. 99% of the time. It's like, I've got hemorrhoids. And I feel like I have a fishy odor like all these things that I get every day. And I'm glad that I can say to you guys, if I take it seriously, I'm going to help you. But this is Don't worry, this is nothing. We see this all the time. And I don't want to diminish it and say it's nothing meaning it's not worrisome, or anything. I want to diminish it and say, here's what it means. Here's what we can do to fix it. Here's what you need to look into. It's very common. And I do think when women really hear how common things are, then they feel more and less normal.
16:55
Yeah. And that's sort of the idea of the podcast, too. In the name, the flexible, neurotic, it's like, let me be neurotic. Let me gather all this information from all these different experts. Let's lay it out in an organized way. Let's have an edgy conversation. Pick and choose what you want to take from it. and
17:13
grow you are increasing knowledge to decrease anxiety, right love
17:17
that. That's another ism you have like another ism ism.
17:20
That is actually our tribe called these like that's our, our platform. I mean, that's really what we're what we're doing. And it's really it's already been fun. And we've just started like we're just growing. But the reception so far has been quite
17:31
your Instagram for yourself. Yeah. You want to tell everyone what it's called?
17:37
Big Love fierce Juju, big love fierce Juju. JUJ you you just kind of like you know, it's like luck. It's like that essence of just having good karma good feelings.
17:50
You know, fast. It goes on and on. Like, you know, I always pick guests for this podcast that I feel like I could just give a hug to food energy, because I feel like when you have good energy, you get good information. Yeah, I want to talk about for a second before we dive into all of the menopause and perimenopause. I want to dive for a second into your personal health journey. And into like a quick snapshot of your childhood. I know Yeah, your childhood has interesting parts to it with your parents. And then your health journey is super layered and complicated. We could probably do three episodes on
18:27
it. I mean, really,
18:29
if you could, Dr. Shiva down for us,
18:33
right. Okay, the nugget version. So my parents are from Iran. They came over as immigrants in the 60s because they went to medical school in Iran and came and did residency here. Wow, my sister and I and they raised us to be really independent. I mean, I always say like if I had to pick two adjectives with which I want to raise my children, it is independence and resilience because I deeply believe that if you aim towards that everything else trickles down. Happiness, abundance, you know, everything will trickle down from independence and resilience, and
19:01
they be examples of independence and resilience. Oh my gosh, so like so?
19:07
Oh, my gosh, well, and I tried to really mimic a lot that my parents did in other words they did they were incredibly deeply loving Persians are very you probably know from being Yeah, mon ship and loving. But they were really strict. There was no BS. I remember, for example, my favorite little like, memories is I was, you know, 910 years old. All the other girls are having sleepovers. Persians don't do sleepovers. We don't know everyone. It's not part of our culture. I remember saying mom, they're gonna think I'm a loser. And my mom's mature response was not Oh, baby, I'm so sorry. It was, well, that's the way it is. I don't really care. Let them think you're a loser. And it sounds cold and harsh. But honestly, in that moment, I realized all at once like she's not gonna let me manipulate her. And by the way, she's not worried they're gonna think I'm a loser. Because if she was she'd be like, I'm so sorry. And had she been sorry and emotional. I think I would have felt like that. Oh my god, they really are gonna think I'm a loser. And now my mother is trying to like cuddle me. And that would have filled me with anxiety and insecurity. And instead, I still tried to manipulate her, but I was like, She's right. They're not gonna think I'm a loser, it'll be fine. And so even in those times, where she was saying, know what she did a lot, I mean, I joke like, a big platform that I maintain that she did was withholding, like, I would hold a lot for my kids, you want the new iPod? Because everyone else has any. Any you tell me Everyone has it, that's gonna make me keep it away for even longer, because I know that in the end, you don't necessarily need these things. And so there was that there's a lot of like, even if we had someone living in the house to help my mom, because she was a doctor, we had to cook and clean, we had to learn how to take care of ourselves. If we got in trouble, she did not dig us out of it. She was there if we really needed her. She was there. But she wasn't there to be our best friend, despite being so warm and caring. And that was so
20:50
funny. You say that because that's exactly how I was raised. Both of my parents are like warm and fuzzy. Yeah, but there was like a certain middle ground on permissiveness. structure. Yeah, my brother and I just knew that, like a nod of disappointment from my mom. Ah, was the worst talk.
21:13
It was worse than being grounded or anything, right? It was just a thought. Yeah, yeah, that's so similar, right. And so it's really hard as a parent, right? It
21:21
was much harder, it's but
21:23
it's so impactful, because it really meant like we had to advocate for ourselves. And there was never a sense that they did not think we could handle it. And they kind of swooped in and helped us, you know, as a psychologist better than anyone, right? That's how we undermine our children's security. And
21:38
I 100% agree, even with this whole COVID situation. Yeah, of course, I have shitty days. And things are frustrating. And I'm sad. And I don't see my parents as much and all these things. And my kids do see that. But my kids don't need to see every single emotion I'm feeling, you know, they need to feel like their parents are strong. But their parents also have feelings. It's kind of just swooshing around to get to that middle. And in terms of like independence, and I was just talking about this the other day, actually, because somebody was like, Oh, are you supplementing your kids learning at all. And I was like, Oh, my husband's a little crazy. Like sometimes he wants like a math tutor to like, pop in and make sure that the kids are like a certain level of math or whatever. And I'm like, That just sounds annoying to me. So I give my kids the math tutors phone number. And I'm like, you call you call you arrange the time is based on your school, schedule your workouts or whatever you're doing. And I have no part of it. And they were like you do? And I'm like, they're 14 and 16. Why should I be scheduling a zoom call for them when I don't even know what their schedule is. And they were just so blown away by that?
22:49
Well, and I think we know this, right, the more and more we do for them now. And the less less they'll be able to do for themselves later, when the big shit happens, right? Like I always say, My mom's and my dad, but my mom's kind of creating the sense of us where we can handle things. Thank God. I mean, then when shit hit the fan, and I had ovarian cancer, among other things, and my sister got a divorce. Like, we handled those things really well. Because we had just been groomed to know that you know, something's gonna happen. It's okay, you're gonna take care of yourself, you have to take care of yourself. So it doesn't make a difference. Yeah,
23:19
yeah. I love the way you talk about your parents even like on your Instagram, because I feel like that's how I grew up too. And I hope that I'm creating that same environment for my children. In terms of your own personal health journey, I know it's been checkered. So why don't we kind of do the outline of that, because I also think it helps inform us that you have been through so much. So when you're talking about a lot of these female topics. It's firsthand.
23:48
Right? Well, and I think that's really important, right? I think doctors learned so much in medical school and residency, and I did I did learn a ton. I don't think I had to have gone through all these things. But I do think it helps not only clinically, I've learned a lot of nuggets clinically through what I've been through. But I think it gives me street cred. I always joke right? Like I can talk to these patients and like I can talk about weight and miscarriage and C sections, vaginal deliveries, ovarian cancer, vaginal dryness, like, and then some. So basically, the nugget version again, is that I met my husband in Tel Aviv when I was in medical school there. We got married when I was 29. And I immediately had had endometriosis. I had a huge 17 centimeter ovarian cyst called an endometrioma. How big is 17 centimeters? It's like I joke. It's like a big grapefruit. It's like the pomplamoose spray fruit. The big one got removed and then I became a resident and so four years ago ob gyn residency and I started having miscarriages in that third year and I had already gotten up to about 200 pounds. I was working like 120 hours a week I got pregnant quickly miscarry got pregnant again quickly miscarry. So that was my third and fourth year residency and then finally got pregnant with my now almost 17 year old that was a challenging pregnancy I became an attending meaning I finished residency become a private doctor.
25:00
I know little about it because my daughter watches Grey's Anatomy. Oh, of course.
25:03
I mean, not so realistic. So Jamie delivered me. Yes,
25:07
yes. Oh, I
25:08
deliver, I got him to 250 pounds. It was a really dreadful delivery and that little boy who's now almost 17 and largely fine had had an intra uterine stroke. It turns out, that was my like, like, every time something happened, I was like, Okay, I joke like, you're helping me relate to my patients like, like perspective,
25:24
I've related I don't need to go through everything. And then flash forward for more miscarriages. And then I have my now 13 year old almost, who was born with a clubfoot, and I was like, Okay, good. Two babies. I'm done. Peace out. I'm 40 I'm fat as all get out I was 250 pounds. I did gastric bypass because I had yo yoed my whole life and tried everything food wise, I lost like 80 pounds and four months after my 40th birthday got pregnant by surprise with my delightful little 10 year old girl now. And that was like another boom, like, I just got the
25:55
chills.
25:58
And let me tell you, I don't know if you know this part. So I always joke very openly about this, that when I had my teenage patients who were like, you know, I'm being really careful with birth control. And they kind of give me the coil. Like I'm being careful. And I always joke like, Oh, do you mean the Shiva ghofrani method of being careful where you think your boyfriend's pulling out? I mean, you get knocked up when you're 40 years old. And I always say to them, like you're an 18 year old, for example, you are fertile, do not pull out. It really happens. Like I really got
26:22
dribble, dribble, and 40 just didn't
26:26
make it all the way out. I was 40. I was not like a young fertile Anyway, she was healthy. And so and then obviously 40 to 46 were like amazing, fun years, I was working my butt off. I was off birth control. At this point. I had my tubes tied. I didn't have any pain with my periods. My practices, like we have so much fun. I was really lucky. And then I didn't integrative masters. I don't know if you knew that. I don't know that. So I started doing integrative masters starting at age 44. It was a once a week, you had mentioned in one of your podcasts with Lisa Goodman, about the vending machine, the vending machine of things. Yes, it was like that. So I called it a survey course of all things integrative. So what we didn't, I didn't learn how to practice these things. But once a month, it would meet in fact, at our hospital, and it was a program that was eight women in a cohort. It was so amazing. I would come home and I would make them do like humming circles I'd make my kids do all kinds of crazy things. And so we did that for two years. I finished. I was supposed to finish in July, June of 2016. I get diagnosed with ovarian cancer and I swear to God, I thought all roads for my integrative masters led to that. Because through like I learned about naturopathic medicine, traditional Chinese medicine in hypnosis, and homeopathic remedies in this city. It was amazing. And I honestly think it was like the therapy I needed. I didn't go through talk therapy, I went through that. And then through that all of a sudden I realized, okay, this is the true like melding of Western east. As I joke, I took my toxic chemotherapy, there was no question that I was not going to take that. But I also made sure that I was eating like bizarrely healthy like my healthiest in my life. I was like the leanest I had been I was doing acupuncture. I was really like I learned meditation. I mean, I was doing all those modalities. I had your own vending machine, I had my own vending machine, and it was not filled with all the candy. And should I did like, what it really helped. And so that was such a good learning experience, not only about western and eastern. But that's where I learned about the menopause really big, like on my own personal world because it happened overnight. And so that was that was profound. And it was really, it's like, I would never take any of that away. I don't regret having gone through it, I would not take it away. It was so much experience for me. And I can say that because now I'm four and a half years away from being done. I'm done. I finished four and a half years ago, as I say, wow. But it's also an amazing story, because you're showing people that they're in addition to the chemotherapy and the western medicine that you did use other Oh, absolutely. ologies. And they helped for sure, even the ones that I didn't actually think acupuncture would help I just for various reasons. Even though I my one of my close friends did my acupuncture, I went into it, I was like, I'll just sit here for half an hour and relax. And the one session I didn't do the acupuncture, I felt like crap. So it really, there were so many things I learned. And listen, my other view of it is if nothing else, it helps you take control of things. And then you feel like this is the part I can control. And that's going to help me feel calmer. So it's really it really is a holistic approach like trying different modalities and recognizing that you get to pick and choose certain things.
29:28
Totally. I love that. Would you say that you had one major Shiva ism that came out of all of that?
29:36
Yeah, yes. One other funny story. I was with my son, I was driving him to school one day, I was Stone Cold bald for six months cuz I didn't want to wear a wig. And I was like, fucking I'm gonna make this look cool. And I like put on tons of my makeup. And so I'm driving him school. He's lovely. But at the time he was you know, those four years ago, he was 1213 years old.
29:53
That's always a fun time.
29:55
He's kind of being selkie about something completely dumb. And I was like, Listen, you have two choices. You either get to like be like ballsy and move on or you're going to sell. And I said, you remember that quote that I love and my sister and I had just watched whiskey Tango, Foxtrot.
30:11
That movie never saw it
30:12
with Tina Fey. And there's a scene or this Army Sergeant gets his has his legs blown off. And she says to him, when she's interviewing him as a reporter, how do you get through it? And he said, sometimes you got to embrace the suck, and move the fuck forward. And I was like,
30:28
Oh my god, I
30:29
love it. So I'm saying this now to my 12 year old son, I'm like, you want to embrace the suck and move the buck forward. And I ended up getting these rubber bracelets made. So I literally have I wear one of these every single day.
30:40
You have such a vibe going, I can't wait till people on Instagram, like a shaven head. dyed blonde. Crazy amazing. You must have like, what 12 necklaces on,
30:53
I don't even know and I don't take them off. I wear them all the time. I took them off initially during the COVID. But now I just wear them now you shower, you sleep in them.
31:00
They love it. But I also think that people like you tell a story about how there is life after trauma. Oh, yeah, I
31:07
mean, I hate to say this, like not only after, like life during trauma, I mean, my those six months from June 17, until I finished chemo in November. And then let's say through December when my hair started growing back, and there were so many amazing things that happened, there were people I met, that I would not have met otherwise, that are still part of my life there was like, Oh my god, I experienced love and engagement from patients and people I didn't even know and prayer chains and all kinds of things that I wouldn't have experienced. I'm not silly enough to say if you are diagnosed with stage four cancer where your odds are really low that that is as easy. I was very lucky that I was diagnosed with stage two, which is actually why we should talk about ovarian cancer and everything but but I do think like, you know, it's like anything else, we get to choose our response to the circumstances, right? We know that from psychology, I could not change the shit that happened. Right?
31:56
That should have only control your inner self. And that's a hardest part about this whole journey of life. Yeah, it really is. Oh, it really is. But
32:03
the sooner you accept that, then the easier it is, right? Because
32:07
I mean, even just with this whole COVID situation. Yeah, it's shining really bright lights on our lives and saying hey, you guys, like a lot of this shit was here before COVID. Right? And you didn't deal with it then and now you have the time. So good luck to you right to figure it out. Yeah. And people are having to including myself like recenter regroup, find some kind of inner energy that just feels more stable. I hope that we continue that because we all need we all need a sense of control for sure. Okay, so as we dive into menopause and perimenopause, I want to talk about what the definitions are and what is the differentiating factor between perimenopause and menopause because I feel like for us laymen are we're like, oh, yeah, sweaty, gross, nasty. Like it's not super specific. It's sort of like names for very nebulous. Yes, shitload of really, yeah.
33:07
Definitely listen to a woman I always joke. So I think I've done this post like three times where I call it the other p word, preparing menopause, because, and that was born of the fact that my sister who's two years older, so she's 52. And I'm 50, almost 51 and every time she has a complaint about anything for the last decade, I'll be like, well, and she goes, are you going to say it's perimenopause again, I don't want to hear that.
33:27
Because in her mind catch all
33:28
well and many women think that perimenopause is the imminent like minute before menopause, which is not so I'm going to start I always start with the definition menopause and then work backwards.
33:39
So the definition
33:39
of menopause is one year with no period, again, at an age where it's appropriate if you're 29 and you have no period for a year, there might be other causes but let's say you're around 5051 because most of us will go through to 51 so a year with no period is menopause. So when you're done with that year, you're considered postmenopausal or in menopause we say write anything about 10 years before can be
34:05
very minor pause
34:06
right I was like you know started jacking. And now that means if you go through it at 51 Okay, that means starting at 41, you can be perimenopausal but some women go through menopause at 50 or 49. That means that 39 or 40, they can start having Peri menopausal symptoms. And the Hallmark I mean, I describe it as if you think of our normal cycle. It's like a nice sine wave, right? It's very symmetric, very predictable sine wave your hormones going up and then coming down and then shedding your lining if that's your period. perimenopause is like I always joke it's predictably unpredictable. You don't know what's gonna happen. And instead of your hormones going up and down like a nice sine wave, it'll be like, up up, down, up, down, down, down, down, up, down, down, down, down, and then it may be normal for three months and then irregular again and then you miss and you think you're in menopause, then it comes back. So when patients say to me, I could XYZ happened in menopause and perimenopause. My response is, anything could happen in perimenopause, When it comes to some symptoms, and you're bleeding, because the Hallmark is predictably unpredictable, right irregularity of your hormones
35:08
can and so about the bleeding for a second. Yes, I know we're gonna get to this, but what is on and off bleeding? And like, what is considered not bleeding at all? Like, I mean, sometimes I just have like, junky brown stuff is that Yeah.
35:24
Well, first of all, it depends if someone's on the pill or the IUD, it's a little bit different. pill,
35:29
we'll get to that. Okay, we'll get to that.
35:31
So let's assume off the pill, I divided into two parts, right? I tell people, okay, if you're off the pill, I kind of try to talk about this again, preemptively. When they're in their early 40s. I never want to say like, Oh my god, it might be perimenopause. So as in a way, like, you're getting old, you should freak out. But I say listen, you're in your 40s. Here's some things that might come up. Anything that is less, I say, I'm not worried about meaning, less bleeding, less heavy, less frequent periods of, you know, fewer days bleeding anything less. I'm not worried as long as you've had your thyroid checked, which you usually check every year. If you see your internist, anything more heavier bleeding, longer, bleeding, bleeding in between periods, soaking through pads and bleeding, you know, more days than usual, is probably still nothing like another ism, I always say is, it's likely nothing. It's likely nothing. But let's check it out, meaning you have more bleeding. Patients will say this to me. I got really heavy bleeding for two or three weeks. But don't you think it's just perimenopause? And my response is always Yeah, I think it is probably perimenopause. But we need to make sure there's nothing else going on because we can't prove perimenopause. And we're gonna talk about that. I know. But there's no your own chest
36:40
hurting. You're like the comforting but honest friend. I sort of feel like that's how I am in my real life. My friends will call me to go we're calling you because we know you're gonna be honest with us. But you're gonna be nice at the same time. But I really just need to know. Yeah, right. Like, we have to have that we need
36:57
that. Because like, Listen, I always say about women, like, we're sophisticated. We don't want that old paternalistic, like, No, honey, you're gonna be fine, period, full stop, we want to be told you're going to be fine. But we need to do XYZ to make sure because then if we find a VC, we're going to take care of it because we're finding it early. What I keep reminding women of Bill listen is I am never going to promise that things are not going to happen. But I will promise that I will be like a dog with a bone. And if we work together and we find things early, then you'll be okay.
37:28
I sort of feel like it's a little bit like that quote or phrase that anything is possible, but not probable. Oh, yeah. I
37:36
say well, it's funny, I, I say to patients a lot. Don't ever ask doctors. What is possible. Ask us what is probable because if you ask us what's possible, we're gonna be like, Huh, we like that commercial real life planning, bla bla bla bla bla, right? It could be any terrible thing. Being
37:49
a neurotic person, I have to remind myself of that. It's like, okay, it's possible, but not probable. It's possible. Right. And that sounds like your approach, which I have. Now, I want to just quickly re summarize the lesson more thing, because I think that delineation is super simple and super helpful. Yes. So tell us again, what that nugget is. What's the lotto one
38:10
when bleeding, anything less meaning lighter period, less frequent period, fewer days, less heavy, anything less, assuming again, that you're otherwise in good health and that you're had your thyroid checked? That's great. Like I patients will say, I'm 45. All of a sudden, my period got lighter. Great. I'm not worried. If it's more heavier than usual, longer than usual, bleeding in between periods. Bleeding long meant more days than usual, then it's probably just perimenopause. But we can't prove that. So we have to systematically disprove other things like we disprove. It's your thyroid dysfunction. We disprove that it's something in the uterine lining that could be causing it rarely it is endometrial cancer, which is unlikely but possible. Often it's things like a little polyp growing in the uterus or fibroid growing in the uterus. So we systematically disprove those things because we can soldier a different
39:03
class hast for perimenopause. That's the bottom line. That's the bottom line there
39:07
because remember, the hallmark of perimenopause is predictably unpredictable because your hormones and your thyroid will fluctuate but not every day or every week. It'll be like over a couple months, right? Your female hormones your FSH and LH will really fluctuate potentially day to day, week to week, month to month. And so you might look like you're in perimenopause or menopause, you might go through three months with no bleeding, hot flashes. If I check your bloodwork, it'll say menopause. Three months later, you start bleeding, and you're oscillating again. So again, you need a year with no period to save menopause.
39:39
Otherwise, I go to the doctor, and I'm 47 years old, and I'm not on birth control pills, and I have all these other symptoms. What can I do my FSH mm hmm, I've read that that number of like 25 or more is menopause. No, no,
39:58
what is distinctly the last The lab result might say menopause. But the truth is, that's not true meaning. So if you come in, let's say you're 47. And you describe to me like, I missed my period for a couple months, I'm kind of ditzy and like all the other symptoms that we'll talk about, I would say to you again, here are the things we need to make sure let's make sure your thyroid is okay. Is there any other symptoms if you're having heavy bleeding, I'm going to send you for an ultrasound. And once we've disproven those things, then we default back to Hey, you're in perimenopause. If you want, I'll do your bloodwork. But depending on the week, and the month, your FSH might be normal, or it might be high, and your estrogen might be normal or might be low. So it can help rule out actual menopause, I would say right, like, let's say you're a 28 year old, and we're worried about menopause, because you missed your period for a couple months, then FSH and estradiol are really valuable. But in that Peri menopausal time, and again, we're going to talk about other ways other practitioners check it, you know, it's only confirming to us what we already know, based on your age and your symptoms. So I often will just add it if patients want it, but I'm very specific. And I say to them, I'm adding it if you want it, but I am telling you right now that there's nothing it's going to say to me that's going to help change what I tell you, which is if you have symptoms, I will help you fix those symptoms. If you want you
41:15
to have the the high FSH and have all these symptoms and have no bleeding for a whole year to me menopausal. Exactly.
41:27
So let's say I'll give you a let's go give you a concrete example. That happens not infrequently. If you're 50 years old, you're much more likely to be close to menopause, right? You're 50 years old, you come to me for your annual next week. And you say Shiva, I have not had my period for eight months, I'm in menopause, right? And my response is four more months. And then I'll say you're in menopause. Until then it's to be determined, right? So you're eight months from your last period. You're 50 years old. Yes, you might be in menopause. But I will only call you perimenopausal so far, four months from now, once we get to a year with no period, then I'll confirm that you're in menopause, right? If I check your hormones that day, there's that chance that they're going to look menopausal. And then a month or two later, you get your period because you've articulated one more time.
42:10
Why? Okay,
42:12
oh, and that happens all the time. And I say I even hear other physicians and gynecologist misconstruing it I have physicians and gynecologist who will say to patients, oh, you're 50 years old, you haven't had your period, eight months? Yeah, you're not going to get pregnant. And that's not true. It's really unlikely you'd get pregnant. It's unlikely if you get pregnant that it will be a viable pregnancy, but it's not impossible. And so you really have to be clear with women that they need, again, a year with no period and sometimes when they're on the pill or with the eye, you just know,
42:36
period thing. Like I said, What if it's like, a drop of brown schmutz, like, literally nothing? Is
42:44
it like a rant? Yeah, it depends. I mean, listen, if you said I would not be literal,
42:49
but I sort of had a
42:51
very important, okay, because I see these things every day in my office, these examples. Let's say, more importantly, let's say I've had a postmenopausal woman, she's legitimately 51 with one year, no period, okay, no bleeding, right? And she says, then after a year, I had like two days of brown schmuck.
43:07
Yeah. Because I have friends who tell me that like, I don't know,
43:11
well, and this is what I would say to them. The likelihood is that brown schmutz, which represents the smallest amount of bleeding that came out of your uterine lining, probably it wasn't enough volume to come out as bright red. And so it sat in the uterine lining where it sat in the vagina, and it got digested, and then it gets that nasty like brown sticky, tacky discharge, right? Yes, probably that was because of menopause, your estrogen levels were low, the uterine lining got so thin, that it was a trophic. We call it atrophy of the uterine lining. And probably that's why you bled. So again, I would say to them, the likelihood is your brown schmutz that was postmenopausal was likely just because of uterine atrophy, the lining was a trophic.
43:51
By bird shit,
43:52
just like just like that schmutz, right? But I can't prove it until I've disproved other things. So you get a pelvic ultrasound to make sure the lining is in fact thin. Because what if that Brown is the lining is actually thick? Then you need a quick endometrial biopsy. What if you haven't had a pap smear in a long time and you're just assuming that you know something else? So you still have to rule those things out? But so the Schmitz let's say the Schmitz was six months into not getting a period
44:18
a very technical term, isn't it?
44:20
What's there is no good word for sure. Once
44:22
I know literally a great word. I need a medical I use it for every English word. Yeah. I'm like Marin, you have schmutz on your eye. Yeah, right.
44:33
Shiva schmutz Can you?
44:35
Okay, so wait, what about this whole idea of you know, you see on social media, test your hormones, your female hormones with saliva tests every day? What's the deal with it? No, I
44:48
mean, and I that's a big side because I don't want to disparage anyone that really like I have close friends for integrative doctors naturopaths a bunch of functional doctors. So I really do respect with Because I think that they managed to have a lot more time to spend with their patients. And I think they're validating patients concerns and patients don't feel good. And the general Western medical doctors, like not your blood works fine, you're fine. And that doctor might be correct, in fact, but they're not validating the patient's concerns, and they're not trying to get to the bigger issue on the flip. So again, that's the western problem. Problem, I would say is the opposite, which is, oh, well, we can check your salivary hormones, your urine hormones, your blood testing over a period of time. Now, here's the truth, patients will come to me. And they'll have spent a lot of money, naturopath, integrative doctor, functional doctor, and they'll say, I went to a doctor, so and so. And she said that my progesterone was low on this day and edited it out all these things about their hormones. And none of it's surprising to me. I'm sure they're right. But it only gives us a snapshot of like that week or that month. And it doesn't change our management, because we already knew that that patient was perimenopausal based on her symptoms, and based on ruling out the things we needed to rule out, right. So I think if people want validation, which I don't blame them, I mean, I send a lot of patients for tests, when I'm very clear to them that you don't really need this test. But if it will give you psychological calm, and some validation, I'll do it. So if that's what it's providing for women, I'm all for it. This whole notion that like, look what we've just discovered through testing, even actually, your example, when you were talking to Elisa Goodman, about the doctor, who would you get not to disparage that doctor, I'm sure. But patients will come to me. In fact, one of my good friends who I adore, if she listens to this, she'll know we talked about it. She's an integrative doctor. And she said, we should really check your salivary cortisol and see how it is. And I was like, Hell no, my cortisol is
46:38
high, like high off the record,
46:40
right? Like, there was no doubt to me. So it wasn't going to help me, I know that I have a very fulfilled very happy life, but it is also a life that is filled with good and bad stress. So I need to work on my stress management, and I'm changing my my methods. And if I needed validation, great, then I should do it. But
46:59
I don't know she's at three o'clock in the morning, three times a week. So there was really not a huge reason for my numbers to be that high.
47:06
Well, but still, like you said, I mean, truly, when you think about it, I think modern mothering and just yeah, I always say a woman in this day and age is a minute. My point to like that naturopath, your naturopath, or my integrative doctor friend is, I pretty much guessed that every woman in America right now, whether it's because she has poor socioeconomic status, racial issues, or because she's wealthy and she has a deep amount of anxiety because of what's going on or because she's a mother or because she's had cancer or because she's working. All these reasons lead to high cortisol levels. So again, it's to me, proving it, unfortunately, only adds to the cost of the system and actually increases the divide between people who get to have access to this and who don't, right would actually do much better, right? Well, we would do better. If we said to everyone, we all need to be a little bit better about eating less processed food, fewer processed carbohydrates like that, I think would be more valid. So I don't want to malign them, because again, many of them are my friends, and I appreciate it. That's like
48:05
the vending machine, you have to find, like, for me seeing that number and understanding that it perhaps should not be that high. I was like, Okay, I could meditate 10 minutes a day on a night. So it's served that function. Exactly.
48:20
So I think if you need it as a and I don't blame anyone for anything, and I need a lot of things like that. It's almost like signing up for a class or something. For You know, when you help when you get it gives you structure and then it gives you something to compare. But this notion that like we've just discovered something that like none of the Western doctors looked at is a little unfair. And I think that's what pits east and west against each other. Yeah, and that's too bad. Because it can we really could use them together
48:46
to help it. It's it's an amazing thing like you talk about Alyssa Goodman or you when you mix things together, and you're flexible and you're neurotic. That's really magic happen. magic happens fees, you build something new, right.
49:02
But we're gonna check it out. Right flexible, neurotic.
49:05
Yeah. I love it. Now in terms of we've been dancing around the symptoms. Yeah. Let's talk about what the symptoms are. They're not pretty. I mean, there's a lot like what are like the top 10
49:18
Let's talk perimenopause versus menopause. Because perimenopause, it's so common again, early 40s patients come to me Hey, how's your period? Oh, my periods regular, everything's great. They feel great. They say and then I start to kind of dance around like, you know, it's not uncommon. breast tenderness. Feeling you're a lot more than you used to acne on your chin.
49:39
I've had a couple of hairs on your chin. I have a little bit less had good.
49:44
Maybe less hair, more hair on your chin, less hair on your head.
49:47
That's that's gonna be something I want to talk to you about is less hair and a little more
49:51
weight around your middle. Oh, my God, I'm not doing anything differently. And I feel like I'm not losing weight. Maybe I'm even gaining weight. I feel like I want to bludgeon myself. Fairly two or three days before my period. Those are actually like if you say those things to me or any variety of those things, not all of them any variety of those things, and you're in your 40s. In my mind, I'm already thinking, thinking thinking being the P word. Like, I think you're in perimenopause. And again, I systematically in kind of like filing things away to make sure that I don't think there's anything else going on. I don't think it's thyroid dysfunction. I don't think there's anything else going on. And then we kind of default to Okay, it's perimenopause, my job and my role is to make sure you're safe. And then my second role is okay, we've made sure you're safe. Do you want to help fix those symptoms? Some women say, you know, it's not that bad. I'll deal with it. And other women want to do something about so
50:38
some women, I would say speaking as one, I think, just want to know, yes, they're okay with it. It's like, Oh, I have IBS. Okay, I know I don't have colon cancer, and that's why I have diarrhea or whatever. And I'm not minimizing it. I'm just saying, sometimes knowing is half I think,
50:57
I would say at least in my population, yes, 90 plus percent of the women feel better when I've like, named it and made it clear that like, I'm not Pooh poohing it, but I'm naming and I'm also telling you, it's common and predictable that you're going to go through it. Then they're like, Okay, well, now I know, as long as I know, it's okay. Some women want to treat it which is also okay. Right. And someone want to treat it Western, someone want to treat it Eastern. But I do think I mean to go back to my sister where she kept saying like, don't use that perimenopause word, why do you have to keep saying it? And I keep saying to her like I say it because I think if you don't say it, then women start to think there's something really wrong. Yeah. Then when we start to think that's a golden nugget right there. Yeah, they don't want it. We don't want to feel alone. We're so great. How happy are we? When whatever crazy shit we have going on? We realize like, Oh my god, you're telling me everyone else has that too. That feels so much better. If you're less neurotic. It's less nerve racking and everything.
51:49
So all those beautiful symptoms sound great because many of them now and because you're
51:56
perimenopause. What are the menopause? And again, remember, there's a crossover. So that's like those are really classic perimenopause and then starting to get into like, you know, maybe a couple years into perimenopause, then you also start to have and this might have happened even before perimenopause for other reasons. I love my husband, but I don't really feel like having sex with
52:14
him. That's a high topic. We're huge. I
52:17
mean, that is like, you know, another whole podcast, right? Yeah. And that's actually nothing to do. Even with hormones. Believe it or not, that's like neurotransmitters that's been married for more than three to five years. That's all those things. But then adding to it, which is a huge topic I love talking about is vaginal atrophy, which I hate the word atrophy because it sounds so decrepid. And you've heard me say this, that instead of saying dry, which is not accurate, it's really that our tissue is inelastic. And that can happen again, even in your 40s. Even when you're still getting your period sometimes because of birth control, sometimes just because of perimenopause, right, and then you start to get a little schutze like God, you know what, I'm just not sleeping as well. And I wake up and I'm kind of sweaty, or every now and then like, I get this big wave of heat. And so that's when maybe the night sweats and the hot flashes are starting. And then if you go through menopause either surgically like I did, or you drift through it, then things all those things we talked about can be there. But then you've started to lose the breast tenderness and the population pain because you're no longer ovulating. And then the predominance are again hot flashes, night sweats, feeling maybe a little bit irritable, vaginal atrophy, and sometimes things like brain fog, and headaches and stuff like that. So all those symptoms are important to address.
53:27
Wow, it's like there's so many symptoms, but it's like, I guess like you said it, you you reduce your anxiety by going to your doctor saying, hey, these are my symptoms, you said you rule out the thyroid, because that's major. You do the ultrasound because you haven't believed it yet. Mm hmm. And so there are things that we can do to start sort of checking things off the list, which is amazing. And I do want to talk about that ultrasound thing for a minute, because I won't say every gynecologist really requires that. And I know it's expensive and insurance doesn't always cover it. But like today, when I went to the gynecologist, I was like, Yeah, and I want an ultrasound. And she's like, yeah, of course you're getting it because I've gotten it in the past and she knew I was wanting it. Right, but I just want to know that I've checked everything off. Is that crazy?
54:17
I don't think you're crazy. But and I say this despite having an ovarian cancer and I am like I mean, I will do I joke like I'll do an ultrasound at the drop of a hat. You tell me you have like a little bit of cramping I'm doing it. That said the right answer is that we shouldn't just do it every year for a couple of reasons. One is I just getting back to you. You had symptoms that legitimize truly like yours was not just like let's just do it every year. Yours was you were having pelvic discomfort and lower back discomfort.
54:43
We did a phone yesterday, so she knew
54:46
that night so you needed to have it. So the reason why ultrasounds are not considered a screening test is because the screening test is very specific. It has to hit certain parameters. A screening test has to make sure that there's an ability to pick it up really quickly with like without a lot of things false positives without a lot of false negatives, it has to be available to a lot of people not that expensive and it has to be able to pick up the disease that we're looking for. In a kind of preclinical, a really early phase right like a mammogram. Ideally, you pick up breast cancer, super early pap smear, you're picking it up, ideally, before you've even had cervical cancer, right? When you do an ultrasound and you'd let's say, you just did it once a year, your ovaries remember change every month. So unfortunately, you could do an ultrasound today, six to eight weeks from now, if you have new onset symptoms, the normal ultrasound today does not mean six to eight weeks from now things aren't going to change. So there's no interval that they found we're doing an ultrasound is going to kind of rule things out. It's not like you need a year for a mammogram. So that's one, two is like you said, it's not covered by insurance. And now people have high deductibles. So they might pay 200 to $800. Because it's not a screening test. It's a diagnostic test. And three is that there's tons of false positives, right? So again, I have a very low threshold to send my patients, but I very carefully remind them and say to them, Listen, I'm doing the ultrasound because you said you had pain or pressure or bloating in your pelvis and that to me, Why will the ultrasound tell us?
56:06
Okay so far,
56:07
so the reasons I would do it, by the way is any kind of irregular bleeding or and I joke like pain pressure or bloating anywhere from like below your rib cage to your pubic bones,
56:16
not a muffin top,
56:18
that's not a row. And if it's pain, pressure bloating that lasts more than like a week or two. In other words, if I ate pizza last night, I'm gonna be bloated today because my eat carbs, I feel like crap. So the first thing I would do is like, mark it in my mind not eat the pizza. If it goes away, it was nothing. But if two weeks from now, I'm still bloated. It's not the pizza from Sunday night or Monday night. And the problem is for most women, they found that we tend to blow off our symptoms. And that's why we don't find ovarian cancer until stage three or four in two thirds of the cases, because we've had six to eight months of symptoms is what every study shows. When it comes to
56:51
symptoms. What do people need to know and remember, though, again,
56:55
if you're having persistent pain in your lower pelvis, persistent feeling like you have to pee that's nuanced that that wasn't found to be a urinary tract infection, a lot of new onset pressure in your lower back significant pain again, on one side or the other that persists. So I wouldn't go six months, but I wouldn't go one day. In other words, if it's two weeks, and it's persistent, even if it's mild, yes, you have to acknowledge that you might end up paying for that ultrasound. And yes, you have to acknowledge that sometimes you have to advocate because not every doctor is going to be like, hey, let's do an ultrasound, they might try to be more conservative. And it's not their fault. They're trying to manage insurance companies and not overcharging you and things like that. If that persists, I would ask for an ultrasound because it's the only way to look. So what are they looking for is they're looking at your uterus, they're looking at the uterine lining, and they're looking at your ovaries. And if your ovaries have a cyst, the likelihood is those cysts are going to go away. But unfortunately, that means Oh, you have to come back in 16 weeks, we saw a cyst. The majority of the time there are features on that ultrasound that can show us that this is a benign cyst, but we don't know that for sure. So when you look
57:55
at weeks, what would you expect to see you expect to see resolution of the cyst. So
57:59
let's say a classic time would be patient comes in a little bit of bloating, a little bit of cramping and maybe even a little bit of bleeding. I send it for an ultrasound because I really want to see her uterine lining because she's having heavy bleeding during perimenopause. But we look at her ovaries and she has a 2.9 or 3.5 centimeter cyst, you know, like a big walnut. And it's simple and clear, which are very clear radiological terms for this is likely benign, but it's there. And it's new. And we don't know if it was there before. So we have to follow up again and 16 weeks, make sure it's resolved. Now what happens when now she has to pay again for an ultrasound for insurance doesn't cover it. And she has to be anxious for six to eight weeks, even though Shiva has said in every way she can. It's likely enough and how did you have these symptoms? I had really significant pain because I had had endometriosis and it was starting to come back. And I thought to myself, okay, this is probably endometriosis. That's what I had had. But to be a good patient. Honestly, I did this just to prove to my patients that I would put my money where my mouth is. I did an ultrasound in my office with my ultrasound tech. And she said, you know, you have a four centimeter cyst, it looks like endometriosis. But I know you and if you had a patient with that you would make her do an MRI. And I was like, I don't need an MRI. I know this is endometriosis. And she actually persisted and was like, I know you'd make them do it. Can you just do it? And the MRI actually picked up on the fact that it was an abnormal looking endometrioma, which is a growth of endometriosis. And so again, I always say like, I'm glad that I did what I would have made my patients do. And I'm glad that my ultrasound,
59:25
why do you want to go from the ultrasound to the MRI? What's that brain event. So
59:29
if you have something in your ovary that looks more solid, or concerning with regard to sometimes the blood supply or if your tube looks like it's dilated, so anything that we have a little bit more of a suspicion than it is not completely benign, then we might send you for an MRI because that can help differentiate sometimes what type of growth we're seeing. But if it's just a simple clear cyst, the need for an MRI is very small. Really, right.
59:54
Okay, well, that's good information to know. I know we're getting into the weeds here, but I feel like there's so few resources that are all consolidated together where it's like, let me spend an hour and a half listening to this
1:00:06
unless people go to tribe called me, scribe to the gynecology members.
1:00:12
Gosh, it's perfect. Yeah. Okay. So in terms of solutions, I know we talked about some people are like, no solutions for me, I'm a solutions person. Hey, don't suffer, sign me up. I don't want to suffer. So I'm going to read this quick list to you that I collected from all of your stuff. Tell me if I've missed something. And then we're going to try to go through as much as many of them as we can. Okay, a combined pill of estrogen and progesterone. Yep. That's birth control pill birth control pills. A separate pill. What's the separate pill?
1:00:45
That's just I think that if you pick this from all my stuff, I think that when we're talking about hormone replacement, okay, so there's two forms when we talk about hormones in general, the birth control pill doses, which is your perimenopausal we want to try to control your symptoms. You want kind of a quick one shot easy thing you can take the combined birth control pill, even if you're 49 years old, as long as you're not smoking, no strollers know
1:01:07
how to tap birth control pills in one set.
1:01:11
So the separate pill means and you're I think you must have pulled it out of when we were talking about estrogen okay. postmenopausal hormone replacement and there are combined formulations there are a single estrogen single progesterone pill formulations that are separate. Got it. There are estrogen patch with progesterone patch ring, gel,
1:01:31
mist, yep, estrogen cream, estrogen pill vaginally suppository, vaginally lubricants procedure stimulate collagen laser.
1:01:43
Yes, but you just mentioned things for two step. Yeah,
1:01:46
exactly. Yeah. So let's talk about birth control pills first, and let's talk about who they're good for who they're not. I mean, look, I know that birth control pills are sort of like the dirty word of women's health sometimes. And I feel like when I look well
1:02:02
in the naturopath world, I know and it makes me sad and upset. And
1:02:07
I'm just gonna, I'm a birth control pill lover. I'm a birth control pill addict. I don't care what you have to call it. But I've been on it since I was 14. I had heavy gross periods, and they were uncomfortable. And at the time, that's what the doctor prescribed. And I've been on it every single year sense, except when I was pregnant or nursing my kids, right. I am 45 and a half years old. I'm still on it. Yeah. Well, and by the way, yeah, people think up some people think I'm crazy.
1:02:37
Well, I'm gonna respectfully say this, I'm assuming you're not smoking. And now know you don't have breast cancer right now what you have done, besides providing yourself with birth control, and decreasing clear data, decreasing ovarian cancer, colon cancer and uterine cancer, right. And you even know your hormones in a way that has potentially helped your mood, and major bleeding less or non existent so that you don't become anemic, that we're one bit of data that is starting to kind of come to light even more that maybe maybe maybe just taking a multivitamin will be helpful, because you might have some vitamin deficiencies from the pill. The problem is that the opponents of the pill in the again, functional medicine world have so maligned to the pill and what I consider like a deeply anti feminist way, because they've left no room for those women who need it because they've forgotten even like your case, where you just want it which is valid. What if you have terrible endometriosis? What if you have a history of ovarian cancer in your family, then the birth control pill absolutely decreases your risk? Could you treat those things holistically? Maybe you can. But maybe you can't either because you don't have the time or the money or the ability. So again, we shouldn't say everyone should be on the pill. And we shouldn't say nobody should be on a pill we should say it could be good depending on your situation. So
1:03:54
birth control pills from what you're saying is sort of like the easiest, yes, way of managing a lot of Peri menopausal symptoms. If you're not a smoker, you don't get breast cancer in your family. No stroke, no
1:04:07
heart attack. Yeah.
1:04:08
And again, I mean, being very overweight increases your risk of those things with the pill. But it's the easiest because it will even out your hormones so that your breast tenderness. Your ovulation, pain is gone. Because you're not ovulating, your mood is better because it's evening things Oh, my
1:04:22
kids and my husband still think I'm a crazy bitch. Sometimes it doesn't have everything.
1:04:27
That might be perimenopause. That might be you know, personality.
1:04:30
So yeah, it's
1:04:31
the easiest and that that doesn't mean it's right for everyone. I don't tell everyone they should go on and I tell everyone, they could go on it and it's easiest, but if they don't want to because yes, there are side effects to it as well. But some people don't like you actually can get vaginal dryness because it evens things out so much. your libido sometimes can go down on the pill, because again, it evens things out so much, but
1:04:49
I feel I'm not really a porn star. So like, what is it anyway? No, I just I just have to like do it enough to get through. You know what I mean? Like, yeah, you gotta use it or lose it. As you Dr. Jerry would say, right, yeah, I mean, and what do you think about looking into sort of hereditary lines, like for me, for example, my mom has been on birth control pills, her whole life loves them. She's an addict also, not anymore, you mean, then I was gonna say, then she started getting hot flashes and such in her young 40s. And then she sort of had that decision to make about whether to go on hormone replacement therapy. And that's going to be my next thing for you is there was a whole controversy and study that I'll let you tell everyone about and talking about the potential negative side effects from hormone replacement, but she decided in her mind with her gynecologist that she at the time she was willing to take those risks on and go to hormone replacement, because she did not want to live without the estrogen. And oh, yeah, I was just gonna say I feel like potentially, like, maybe my body is doing a lot of similar things that her body does. And is it good to look at sort of your family history of what your mother has been through in terms of what you can predict about yourself? Like my mom went through menopause fairly early, or thought she was? And so she went straight from the birth control pill to hormone replacement and didn't experience any of it and was done.
1:06:20
Right. Okay, so
1:06:20
a couple things. One, yes, it does seem that if your mother or your sister, for example, went through menopause early, that can be predictive. And similarly, if your mother, your sister went through it really late, maybe that can be predicted how they went through, it is harder to say, right? Because a lot of women of that generation just didn't talk about it, or they got put on hormones. So we don't really know because back in the day, I mean, even 22 years ago, when I started in training, pre whi study, we were still like, oh, everyone should go on hormones. So we don't really know how every one I
1:06:48
want to talk about that study for a second. Yeah.
1:06:50
Okay. But before we do that, I do want to just talk about so we talked about the pill for perimenopause. Yeah, and that's if you're having systemic symptoms, right. You know, flashes, sweats, mood, breast tenderness, everything. If you're only having heavy bleeding, but you otherwise feel fine, then you can do a lot of the same things we'll talk about for menopause, you can do Eastern technologies, like you can do acupuncture and herbs, those can help, you can actually do the progesterone IUD, because that will decrease your bleeding. And it won't affect anything in your system, you can do something called a uterine ablation where we burn the lining of the uterus so that you don't have any more bleeding. So if you're perimenopausal depending on your symptoms, you actually have a fair number of choices of what to do. So who actually, I really legitimately don't and I'm not just hedging, I say that because it really depends on the patient and what they're feeling. I have some patients who feel so many symptoms, and that in order to piecemeal fix them, I'd have to give them so many different things. Or I'd have to say, Listen, if you want to go to a naturopath and do acupuncture and meditation, although I think it's so great. But the fact is, you might not have time in your life to do it like time and money, you have to go weekly, you have to spend a lot of money. So right now in your life, maybe you want to go on the pill, and then in two or three years, we'll revisit it. Or maybe you want the IUD to stop the bleeding. And maybe you want a little bit of one of the SSRIs to help with your moodiness and your flashes. Right. So it really depends. And that's again, what I think is so important despite being Western, we should tailor it to each patient and what their issues are. Right? Well, you
1:08:16
have time as a doctor to listen to it. All I know is how fast Yeah, having women come in like me who are like, and then this and then that. And then this and then that. I mean, it's a lot to get through.
1:08:27
Well, and here's the truth. And I mean this, I've always wanted to be on the side of the patients and the doctors since I am a doctor and I feel really defensive for us as doctors when people are like you definitely spent 15 minutes with me, but the natural fastpatch spent an hour and I always say like okay, but the doctors taking insurance and getting like $75 for your visit, where's the naturopath got like 250 or $400. So it's not really fair to the doctors to malign us that said, I am really hopeful that in things like tribe called v if I can help women understand more from me as a practicing doctor, then they can go to their doctor and have a better conversation a better relationship, because they might go to them and say, hey, I've already heard I could do XYZ. Here's the things I'm thinking of what do you think that's
1:09:07
why I wanted to do this podcast because I feel like people can take the bits of information that they want to understand more of to their doctor and see. But what about this for me? What could be the Dr. Google?
1:09:19
We could totally we would be up there. So Google Yeah,
1:09:22
yes. We don't want you to talk to hJ Yes,
1:09:26
yes. Okay, so that was the Women's Health Initiative. And it was like a real bummer because women were unfortunately, kind of systematically put on hormones like you're postmenopausal. You're going to be put on hormones, because it's going to help not only with your symptoms, but we're going to help with it's going to improve like the risk of things like cardiovascular disease and dementia and everything. And all of a sudden, this whi study came out in 2000 or 2001. And it like put the brakes because they were studying a lot of things but they found one endpoint, that there was an increased risk of breast cancer. And because it was statistically significant, even though it was not Very high. They literally overnight, women were like ripped off their hormones, which again, the pendulum went from everyone on it to oh my god is for both no one can be on it, which is tragic like right like your mom, if she would have felt like crap, my mom who had had surgical menopause like me, to this moment at 8281 will have flashes she's off for hormones. So that was too bad. And now Luckily, two decades later, we're totally where our pendulum has become like in the middle where most of us will agree. If you need the hormones, and we've talked about the risks, and you don't have clear risk factors, again, like smoking and breast cancer and a stroke or blood clots, then yes, I would let you have hormones. Okay for them,
1:10:39
if you do have breast cancer in yourself or your family, which it seems like, you know, more people than not like there are more people in your life, knowing that have that issue. What is the recommendation for that?
1:10:53
Since you've had breast cancer, you would not be put on hormones. But if your family member had breast cancer, that's not a hard? No, it really depends. It depends on how many people in your family, have you been tested? Have you done gene testing? There's a lot of different factors. So I would not summarily stop a woman from using hormones if her mother had breast cancer, but it depends on the circumstances. And like you said about your mom, it depends on the quality of life. When I had my worst hot flashes, right after my surgery, if you told me, you're going to live like that forever, or you're going to take hormones and you're going to surveil your breasts really aggressively every single year and everything else I would have taken the hormones, because I mean, I couldn't live that way. It was really bad. It was like
1:11:33
I remember my mom talking to her doctor about it. And he she said to him, Look, I would rather live five fewer years with a quality of life and feeling like a basket case. Yes. But I'm not sure everyone would choose that. I know that right?
1:11:48
And I think here's the truth. You don't necessarily know until you feel it. Yeah. And you and I do think it's appropriate, like some of my patients come in, and they're like Shiva. I don't wanna hear about anything else. I just want the hormones. Great. We'll do it. We'll talk about it. We'll talk about what are the safer formulations and things like that. Other patients need to go stepwise, they do want to hear about other things, they want to try acupuncture, they want to try some of the herbal remedies. They want to try some of the other, just simple over the counter things they can get they want to do I tell everyone about vitamin d3. And yes, we're going to talk about
1:12:15
that I can't wait.
1:12:16
And they want to try those things before they jumped to hormones. And so I think that's great, too. I mean, I'm so glad that we have more choices. Yeah, right.
1:12:23
How much of this is placebo?
1:12:25
Oh, no. I mean, I would say Okay, wait with estrogen or with the other
1:12:30
things. It's like if you know that meditating is supposed to be really good. Yeah. And you know, that acupuncture, and you do everything all at once, right, sort of just buying into you might be and here's
1:12:41
the good news. Great. Right now, the placebo effect can be up to 40%. Not all of these have been specifically studied, like acupuncture was studied, and it was found to be above placebo effect. So that's great, right? Well, let's see if we'll see the effect. Like I do my own kind of quirky meditation. I call it Transcendental Meditation my way like I bastardized it. Yeah. And I'm not doing it the right way. It doesn't matter. It works for me, right? As long as it works, and it's harmless. Why not? So we can talk about all those hormone things.
1:13:09
I just don't want everything to take forever. That's a thing. Yeah, yeah, having hot flashes and you're feeling like a crappy mental case. I don't want to like spend six months trying different things out, I just want to get to a solution as fast as I can. Right. And I that's how birth control pills worked
1:13:26
for me and I and I think for you, that's great. And so other women may feel that way. And they may never lay and I think both
1:13:31
and that's why I want to do this because I feel like it gives people options. Now in terms of perimenopause, and all of those fun symptoms. We talked for a second about the SSRIs, which are the anti depression, anti anxiety medications. What is your experience with that?
1:13:48
I think it can really help because and I think it's twofold, right? Like many women will take it because their mood and perimenopause is much worse and it's they try other things, but they're at the stretch of their life where we talked to like you have kids, you're running, running around with your kids, your life feels very frenetic. Your cortisol levels are through the roof. You don't have time to go for acupuncture all the time where you do it and it helps a little bit but not enough so they'll take SSRIs like fluoxetine, they'll take all kinds of ones that will really help there's about three to five that I would say most of us as gynecologist feel comfortable using and it can help not only with so I tend to so Lexapro, Zoloft, Prozac, Wellbutrin and Pristiq are the ones that I feel comfortable using. There's a couple extra but those are the ones I use
1:14:29
some of those who have like a libido low libido so they
1:14:33
might lower your libido. They might also make you feel foggy, so it's like anything else. Some women will say, Okay, I'll take a lower libido because I want to not bludgeoned my family. Other women would say no, I don't want to do this. So again, it's about choices, and trying. The other thing is that they've definitely found in great studies that SSRIs can improve hot flashes. So women who can't take estrogen or don't want to take estrogen or feel like oh, I'm flashing and I'm moody. Let me do a twofer and they do SSRIs so unless they have I've had breast cancer and they're on tamoxifen. If you've had breast cancer not on tamoxifen, you can take SSRIs. You wouldn't take it with tamoxifen because it can sometimes interact with the
1:15:09
SI locks event. Okay, that
1:15:10
was a great discovery that
1:15:12
that would have, right? Do you find that estrogen replacement or birth control pills or SSRIs? Like which one has like the most stigma of your patients like which ones are like, Oh my god, I'm never gonna take an SSRI or an antidepressant? Yeah, never gonna take hormones. I gotta say, I
1:15:28
mean, in my practice, I feel like none of them because my patients that like I have so many patients on SSRIs, I always joke but I would say between the two, I think SSRIs still have more of a stigma. Like even when I talk about it for hot flashes. I'm very careful to say, Listen, I'm going to talk about this not because you're Moody, and maybe you are Moody, but that's not why but it has been shown and even non antidepressant doses to really help so there is still a stigma, which
1:15:53
for listeners to know, too, because if you're embarrassed to tell your spouse that you're taking SSRIs, because you're depressed or this or that, and you need it for hot flashes, that's kind of a twofer. Like you said,
1:16:04
it is a twofer. Although I'd also like to advocate for all of us to not be embarrassed, right? Like I wish we'd all talk about one again, I maintain the more we all talk about our site, we put it out there. And then we hear 10 million women be like oh my god, Me too. Me too. Me too, then we feel better than there's no need to be. The only reason to be embarrassed is when you think you have something that is unique to you in a in a negative way. When it's like everybody else has it. What's embarrassing about it?
1:16:28
Everybody like TMI, please stop. I don't need to hear about your whole gynecological visit. Right? I'm good. I'm just like, done. Yeah. But I know that there are a lot of people like Ali Wentworth, who has a podcast and she talks about that she takes Zoloft and I do think that when people talk about these things, yeah, everyday lives And meanwhile, move towards that normalization. Yeah, like we're all going through this right.
1:16:55
And I think if we all agree that like you don't need to shame people for taking it and you don't need to shame people for not taking it. I shouldn't be angry if someone says they don't want to take Western medicine, but I shouldn't. As again, the other side does malign people for taking Western medicine because nothing is ever only everything is always and right your
1:17:11
ism. I love it. I love it. I love it. Now, if we were to take meditation, for example. Yeah, I know, it's sort of nebulous, but in your practice, what have you found and in your personal journey, what have you found?
1:17:26
So what I found is that for many women, and I can tell you I like me, we our mind is racing, like, right at any given moment are my limits are racing. And I think that that actually is what what I find leads to the most amount of insomnia, right? We were just talking about, my friends are talking about this weekend, but like, our husbands are like, they lie in bed and they like,
1:17:47
immediately, right? Like don't like your dog, would you like to standing up
1:17:50
and you're sleeping? What's going on? Whereas in our mind, we're like, oh, my God did the dog did I take the dog to the bed? Oh, my God, I'm like, did I talk to my daughter about her period and didn't Oh, my God did I like to get the groceries like everything is in our mind. So what I found for me was I actually did take a transcendental meditation class. And I liked that form of meditation, because without talking about it in too much detail on the other forms of meditation, which were mostly guided meditations, like a lot of the apps, which I think are wonderful if they help. For me, they didn't help because I joke that when it was like a guided meditation about like, picture yourself on a beach, and in my mind, I was like a beach. Oh, my God, I have a fat button. I have like cellulite. And I was like, right, like that was still very concrete. And my mind, like many women, is very concrete. So we find our mind racing. So I do hear a lot of women be like, if someone tells me to meditate, it's really annoying, because I can't meditate. And I don't I don't blame them. I mean, I'm sure that again, if we really spent the time we could do it. But how much time do we have? So yeah,
1:18:43
I sort of see it like flossing. It's like I floss. I know, I have to do it. It's part of my routine. And the meditation I'm not 100% perfect with but like, the unplug meditation app, for example. Like I have my phone, it's 10 minutes, the guided thing comes up every single day. It's a new one. It's already selected. I just have to press play. And that's a really helpful thing for me because again, it takes a thought out of it.
1:19:11
Right. Well, and if that works for you again, I think it's great. I and I will say some women love it and some women would say what I said which is I felt like it was my mind would still race so for me tm really like divorces your mind because you're kind of repeating this mantra and it just was really helpful for me.
1:19:28
So I think everyone else wanted to tm for me, I felt like I was like having some kind of like delirious moment of repeating the same thing over and over again.
1:19:36
Right and so that's that's a perfect example. Yeah, you and I despite both having the type of mind that races responded differently, which is the beauty nowadays we have access to all of
1:19:45
it. I just hope people will take this information that they hear from all different resources and just try things out like the vending machine and figure out like what's working what's not and rights, because it's it's pretty amazing how different your response This could be like, even with fertility. I mean, though, I had so many friends trying different things. And as you know, some things work and some things don't Yeah.
1:20:07
And everyone responds differently.
1:20:09
Now in terms of going from birth control pills to hormone replacement. Let's talk about that for a second. Because I just as a personal example, like I said, I'm 45, I've been taking birth control since I was 14. At what point am I? a pill? Yeah,
1:20:28
what's happened? Well, and I don't know if Dr. Ross will say, but what I say to my patients is if you again, assuming you continue to not smoke, and you don't, God forbid, have a blood clot, I will leave you on the pill. And then you and I'll keep discussing it. And somewhere between 5051 to 54 ish in that range, we'll decide together, do we want you to go off the pill because what will happen hopefully is you will have drifted through menopause and missed it like it will ideally, mask all of those symptoms of irregular bleeding, mood changes, all those things that we talked about perimenopause, ideally, you're not going to feel.
1:21:01
And then I believe me, I have my own little list of symptoms.
1:21:05
Well, and here's the truth, you might get pissed off and moody sometimes, right? Because life still does
1:21:10
that saying like, you know, you have like a little blood here. Like I was like, fitzy all day today. And I'm like, why isn't the air conditioning on high enough? Like what's happening? But that's not normally how I feel. But then I'm like, maybe this is my new,
1:21:24
maybe it was the age, right? It could be and actually, so when we talk about some of the natural things you can do that everyone should do. But so let's say you are 5051. And you and Dr. Ross are talking and she's like, okay, you're in that age range. Let's start to talk about going off the pill. And then I'll have patients who are either like, Oh my god, no, she I can't go off the pill this year. Because like, my kid is graduating going to college. So I don't want to like risk it because the truth is getting back to the blood test thing. But can I just check a blood test while you're on the pill and tell you if you're in menopause? The answer is no. Even if I checked it at the end of your pill pack, if you were taking placebos, there still would be there wouldn't be a normal pattern because your estrogen and progesterone of the pill would be suppressing your hormones anyway. So the only way I would be able to check your hormones is take you off the pill altogether away,
1:22:07
there's no checksum
1:22:07
and then I'd still need a year without a period. So again, my patients I kind of bargain each year and just decide at what point are we okay to just Okay, let's stop. And then we wait and see if a year goes by no period, great. If it's six months go by and they bleed and then we decide together is it bleeding I'm worried about or not. So that's if they've been on the pill. Now, let's say they actually you know what, I feel great, but for my mood changes and a little bit of hot flashes. Okay. Maybe they try herbal formulas, black cohosh, Dawn Kwai, red raspberry leaf, there's a ton of different herbal formulations, literally at any pharmacy. Or they try there's actually a Swedish flower extract called represent that you can buy online again, no hormones that can work those take while How do you get go that are ELZEN? represent? I'll put that? I don't know. Yeah, they can take that it can take six to eight weeks to kick in. But it could work. They could do acupuncture, they can again do things like we talked about like meditation. And then the the two things that I really do talk about with everyone. First is caffeine, alcohol and sugar. I'm never gonna say like, give those up completely. But I do try to encourage patients like, play with it so that you feel like you're in control. I realized early on that if I decrease my sugar and my alcohol, not so much my caffeine because I can't do that. I felt fewer hot flashes, which did not mean that I didn't go out and have myself some Margarita sometimes. But at least I knew Oh, I'm having how much because the Margarita so I felt like I was in control. So it didn't bother me as much. Right? So that's a really important one. So sugar, alcohol and caffeine. And which many women will agree they'll go oh my god, you know what, when I have wine, I realize I'm flashing more Oh my
1:23:41
God, I forget it.
1:23:43
Whereas vodka soda, by the way, you might not flashes more, as much so again, and then the other two things are vitamin d3. There's I'd say like decent data. It's a little bit more anecdotal, but some of the data has refuted that this happens. But we know that we are all vitamin D deficient. And we know that Western medicine that says the level should be 30 or 40 is probably undervaluing the importance of vitamin d3. Now they're even talking about d3 as good for the ability to improve your outcomes with COVID. We know that
1:24:13
magic,
1:24:15
right thing when you think about it, it makes sense we are globally deficient in teachers. I myself know that when I got my d3 level above 50 then you can ask your doctor if they'll check it again. insurance doesn't always cover it but it's an easy thing to take. I feel fewer hot flashes. And when I take magnesium at night which helps the d3 absorb I feel better because it helps with anxiety and sleep and leg cramps and pooping and headaches and all kinds of things that can affect you all through your life. But so those are simple things to take. And if those will work then you use you can use the SSRIs Are you take hormone replacement, because it can be safe and really life saving, right?
1:24:53
So you're saying that there are simple things that we can do at home Easy peasy and we Get these tests done. So like vitamin D, for example, that's something that I make every one of my house take. They all hate me for it. They think it's annoying, whatever. And I'm like, especially in COVID right now, where you're not even outside in the sun, you're taking it. For sure. Well,
1:25:15
let me tell you Do you know this trick? They're annoyed because you tell them to take it every day. Right? Right. So do you know that because it's fat soluble, you don't need to take it every day. In other words, it won't get peed out if you take too much. So when I'm on call for a week, and I don't know if I'm going to be home or not, I will preemptively take seven of my little gel caps that night, because I don't know what's going to happen for the next week or so if your kids are going to do better and be more compliant. If they take a once a week or twice a week,
1:25:42
they would be I didn't think you could take it all at once. Like, yeah, there's
1:25:46
there's actually a 50,000 once a week dose, you know,
1:25:49
it's funny that you say that, that I do know, I wrote some notes on that, too, is that what's interesting about vitamin D, since everybody's talking about it is if you get it checked, and then the doctor is like, well, it should be at 50, or whatever that number is, right? If you're taking 1000 or 2000 a day, you're never going to get 250. And nobody talks about it.
1:26:10
I talk about it all the time, right?
1:26:12
So you have to almost Ask your doctor what's medically Okay, I guess I don't know what that number is. But I remember when my vitamin D was so low, they weren't giving me the 50,000 once a week, maybe it was for a month or six weeks. Otherwise, you never get over that hump,
1:26:29
right. And then the mistake a lot of people make is they take 250 1000, once a week for a couple of weeks or months, their level goes up, and then they stop. And then they're not laying out naked in the sun exposing 40% of their body 20 minutes a day. So their vitamin D level goes down again, opposite thing was I took too much too long. Yeah. And you don't want to do that. Because actually, ironically, it rose. Yes, it's
1:26:51
a very fun thing. If
1:26:52
you get your level too high, like maybe above 70 or 80, then you actually might feel a lot of the same menopausal symptoms. So you kind of want that sweet spot is like 50 to 70. And again, it's so gross. But I would I tell patients like Ask your doctor because most patients will come in and be like, No, no, my internist said, my level is normal. And I know all the internist and I love them. I
1:27:11
mean, some of them
1:27:13
are almost too general.
1:27:14
It's like, well, and I say like, they say that it's normal, you're probably at a 30 is my bed like you really want it to be above 50. And there's oncological data to support that there's certainly integrative data. And actually, a lot of the Western data is now saying, we should quote a level of at least 40. So yeah, I would go above 50. So that helps and like I said, the magnesium helps with nicely magnesium.
1:27:35
So why is your is it 500 milligrams a day?
1:27:39
Well, okay, so magnesium is a little more complicated than D because there's multiple different types. I think there's 12 types. So here's where I just narrowed it down because I also, I like things that are easy. I'm not, I don't do all the complications.
1:27:53
You have an ism about that. What's my isn't pretty What is it is simple, but not easy.
1:28:00
Oh, simple. But it was not mine. I wish I coined that. And oh,
1:28:02
my God, like you used to call everything
1:28:06
amazing. Well, and here's where like vitamin d3. If you said to me, what's one thing we should all take? The reason I really aggressively talked about d3, is because I can predict without even knowing your blood test that you're low, unless you're taking it you're low because you're not laying on naked in the sun. Right? Even if you live in California, you get more sun than I do. You're wearing clothing or sunscreen, right and you're working. So you're going to be low. Second reason I love it is because almost all the data shows mostly positive things. COVID bones, the ability to reduce hot flashes, maybe colon cancer, breast cancer improvement in response, if you get diagnosed with all kinds of cancers, right, like there's so many different parameters. And then last is that it's dummy proof and easy. Like if you forget it today, double up tomorrow, right? So it's not like calcium is finicky. You have to take it twice a day, and not more than once at a time and all that.
1:28:53
Right, this is
1:28:54
easy. So that's why I would always focus on D first, magnesium is a close second in that you're not necessarily that magnesium deficient, but taking it at night is going to actually make you feel if I could just tell you that I'm going to reduce your anxiety, help your sleep and help you poop. That's like
1:29:10
I have
1:29:11
like I have this weird leg cramp thing. Sometimes the magnesium is like magic. So I just tell patients, I don't want to advocate for any one pharmacy, but I tell them to go to the pharmacy that has the three letters, mostly because that particular they have a brand that just says plain magnesium. It's 500 milligrams in one pill. Cuz I'm not gonna take like 503 pills, right? Those are the easy things I want to stick to.
1:29:36
Yeah, I know Alyssa Goodman did talk about a magnesium. I'm trying to remember what it's called. I feel like it's called innate it's in my show notes for the Alyssa episode, but it includes all three types of magnesium the magnesium citrate, magnesium citrate, citric glycinate. Yep, like any other one. And, well, there's,
1:29:56
there's malaise, there's three and eight. There's
1:29:59
one Everyone's like, wait, should I buy that one on Amazon or that one? Yeah, neat one that Alyssa recommends has three of them all together. And it's two tablets once a day that equals 600.
1:30:11
Okay. And then the only issue with that is you have to play with it a little bit. Because if it has citrate in it, then it might really make you poop. Like some people can't tolerate it that much. And then if you and if you need to take one instead of two,
1:30:21
I might you wanna, you want to constipated first. Okay, so so far for the quote over the counter easy things, we have vitamin D, getting it to 50 if you can,
1:30:35
magnesium, magnesium, because it helps the D absorb and it helps you sleep, which will probably reduce hot flash age.
1:30:41
And then we talked about the simple not easy of reducing sugar and carbs. Yes, and alcohol and alcohol
1:30:48
and alcohol in your sugar in your alcohol.
1:30:50
Right, exactly.
1:30:52
The over the counter herbs. I mean, the truth is, there are so many there's like hundreds of different herbs. So you could go to a traditional Chinese medicine doctor or a naturopath, or you just go to the pharmacy and Whole Foods and there's multiple different ones and you just kind of have to try and I will say most women whose hot flashes are mild enough will do well with those things. Sometimes they have to switch they'll try one for a couple months. It works it wears off, they try another one. It's harder to say that works for the really aggressive hot flashes that
1:31:18
you just answered my next question or started to what is a hot flash? Yeah, well,
1:31:24
they don't really know Believe it or Not exactly. We know it's from dropping estrogen, right? will precipitate this vasomotor symptoms we say like where your blood vessels dilate and then all of a sudden you feel the way I described it,
1:31:36
like a night sweat and a hot flash.
1:31:39
So during the day, you might like if you ever see me on Instagram, every now and then you'll see me literally get like ooh, like really red. And it literally feels like like heat is rising inside you. And then sometimes people have varieties. Like I said it was like anxiety running through my veins when I first had them. It was a terrible feeling. Sometimes they get like a little prickly feeling in the back of my neck. Other people just get drenched in sweat. So that's different at night. You just will get super super lightweight like
1:32:07
the same thing, but one day, okay. Yeah,
1:32:09
they're all I mean, it's all due to the drop in estrogen, which is why estrogen can really help it. Yeah,
1:32:14
but it's so weird that I take birth control pills and sometimes I feel like I'm having a hot flash
1:32:19
well, and I thought you were talking about skipping your placebos. Is it during your placebos?
1:32:23
Or have you skipped? I skip my placebos? I take birth control pills seven days a week people are dropping?
1:32:30
No, no, that's very, it's a whole nother thing, which I totally fine and safe to skip your period. So the birth control pill estrogen is different
1:32:38
formulation really, than most of the estrogen we give you in hormone replacement. Birth control. So estrogen is fmls. Dial. Okay, most hormone replacement is going to be like conjugated equine estrogen, which is the primary and the pregnant horse urine. Yeah, or Astra Astra dial, which is actually like is actually bio identical.
1:32:58
Oh, I want to talk about that. I know it's a whole nother topic now. Okay, so hot flashes can be sore. I don't know. There's just sometimes like, obviously, if I drink a cup of coffee, I feel a little shitty after I'm like, is that a hot flash?
1:33:12
I don't know. But well, it probably is because you didn't have it before. And again, even though you're on the pill and you're on like supraphysiological doses of estrogen. It's not hitting the exact estrogen receptors that your body would have had from natural estrogen. So you might still have some hot flashes from it. Oh, that's okay.
1:33:27
Okay. Now in terms of hormone replacement therapy. Mm hmm. There's FDA approved. And non FDA approved. Right?
1:33:36
So yeah, talk about those. Okay, now it's even more blurry because FDA approved would be the traditional like, you know, brands were like Premarin, prempro, things like that. And then there were bio identical
1:33:49
Yes, not sure. Right.
1:33:51
But the reason is blurred. I'll tell you in a sec. So there was the ones I could prescribe for you. And I could tell you what those risks are. And I can tell you like risks, benefits and that insurance would cover it. Okay, versus bioidentical, which again, I don't want to malign it on some of my patients are on bioidentical. When I say bioidentical, meaning the ones that are made in formulating pharmacies or compounding pharmacies is what they're called, right? Those specialty mom and pop pharmacies where they really do amazing work, like I rely on them for other things.
1:34:20
Identical trying to imply What is it trying to find the time versus the FDA approved one? Well, that's
1:34:28
the rub, right? It's not even though it's natural, they'll say natural, which isn't really fair. I mean, it's still being formulated in a pharmacy, it's that it is more closely mimicking the estrogen or progesterone that is in our system, like we have extra dial is kind of the most predominant estrogen, right? But there's also estradiol and estrone. So the bioidenticals will actually use extra diawl as opposed to conjugated equine estrogen, for example, right. And so that type of estrogen they use more clinic more more mimics our actual natural estrogen, but it doesn't mean The bio denticles are actually natural, they're so created by someone. But the downside to me is that they're not necessarily as reproducible because each pharmacy can alter the ingredients ever so slightly. They're not covered by insurance. And they're unfortunately prescribed really frequently by many doctors. And again, I don't want to blind people, but doctors who shouldn't be prescribing them, like people are using pellets and all kinds of things that really like I have seen harmful things come from this where they're throwing estrogen in two different forms so as to dial, estriol, progesterone and testosterone are women wanting to take it because it doesn't seem as man made, right? Listen, everything when things look prettier, right? Like I'm going to someone who has a beautiful office, like they're much better about how they present it, they go, you go to a beautiful office, they spend an hour with you, because you've paid them cash. They're calling this Specialty Pharmacy where the person is formulating themselves, so it seems more natural. And to be fair, you probably feel better for a couple of months. The downside is that sometimes within six to eight months of taking some of these, especially if you're adding a lot of testosterone, you crash and you feel really bad. And they don't talk about the effects on like your cardiovascular health and everything. So the irony is that if I give you hormone replacement, I can prescribe. I know there are risks. And I'll tell you the risks, and I can define the risks. If I give you bioidenticals no one's studied them. So no one really talks about the risks, but there clearly are some risks. So I don't necessarily think they're worse, but I certainly don't think they're better. And I think once again, it's versus right now what blurs it what I was saying blurs it is that now the drug companies are smart. They know that women like the term bioidentical. So now some of the drug companies are making FDA prescribed, you know, covered by insurance, hormone replacement that uses Astra diawl. And a certain progesterone that is as close to bio identical as you can get. So they can say it's bio identical, right? Because that was a term that was never like,
1:36:54
official, but just kind of organic versus natural. I mean, yeah, I
1:36:59
mean, we know that there's no real, there's no real definition, right? The fuzzy definition of bio bio identical, has become natural. But the real definition should mean those hormones that tried to more closely mimic the chemical compound than the ones that are synthetically made, you know, in the regular pharmaceutical
1:37:16
now, and I understand that research has not caught up with the bio denticles. But in terms of your anecdotal evidence in your office, do you have enough people having tried bioidenticals, to have enough of anecdotal information as to what you think works or doesn't?
1:37:33
Yeah, and I mean, this genuinely. And again, if someone comes to me and says, I really want bioidenticals, I'll let them do it, I can genuinely tell you. And I always use my sister and example, if it was my sister, I would not put her on bioidenticals. Because if nothing else, she's gonna spend a lot more money. I can definitely say that anecdotally, among my patients who are on the FDA approvals that I prescribed, that are covered by insurance versus bioidenticals. equal amounts of satisfaction and dissatisfaction, equal numbers of women who are like, Oh, I gotta go up on this down on this, try this switch to this try, you know, all like really, really, really, in fact, I go so far as to say, maybe not even completely equal, those women who end up just going on, for example, an estrogen patch that I prescribe and a progesterone pill that I prescribe. And we stick with that formulation, and then just bump up the estrogen doses we needed, probably are more satisfied in the end, because it's way way
1:38:23
out, because I have that in my notes as sort of your little favorite cocktail.
1:38:27
Well, and it's my favorite mostly because once whi came out and like made it all verboten, then a lot of studies came out trying to study like what was what is the most, what is the safest as far as what we're using, and we're trying to use the ones that don't metabolize through your liver, meaning a lot of the pills of estriol metabolized through your liver, which means increased risk of potentially blood clots and things like that. So they found that the ones that bypass the liver, like the cream, or that spray or the you know, the gel
1:38:52
or the patch, now we're going to talk about those
1:38:54
combined with prometrium, which is the branded name for the bioidentical progesterone that I can give you from the pharmacy, that combination was found to probably be safest. It's not so clear. So in other words, if I start patients on it, and they hate the batch, and they want the pill of estrogen, I would give it to them. But that's what I try to get patients to start on if we can. And there's tons of doses of estrogen that we can use the patch for. And how quickly do you know if that patch cocktails working? If it works really well, you'll know right away when you're happy on it. But if you're not thrilled on it, then I try to encourage patients to save it stay on it for six weeks before we judge it.
1:39:32
And where do you put the patch I've never taken Well, you can do it on the front of your
1:39:36
abdomen or the top of your buttocks and you can put it anywhere, but people usually put in places like they're not going to where everyone else is not going to see it. Right. And there's some that are once a week and some that are twice a week. And the whole reason you take the progesterone is because if you still have your uterus and I give you estrogen, then I'm increasing your risk of endometrial cancer of uterine cancer. So the only reason you need progesterone in the Western world is Because you're taking estrogen and I want to counteract that effect on your uterus,
1:40:03
got it? Okay. Gosh, that's why we needed this podcast. There's so much information for me, okay, estrogen cream, who's a candidate for that? Why do we want it? Who's using it? Who needs it? Like
1:40:19
a favorite topic? Okay, because here's the truth. Here's what we can say. If you go through natural menopause, meaning you've drifted, drifted through it, as opposed to surgical menopause where your ovaries removed. Most women, their hot flashes will abate over time. Like I don't know if your mom's tried to go off of her hormones. No,
1:40:35
she hasn't.
1:40:36
Okay, but if she did, and she drifted through menopause on her own, she actually might be okay. Now she might not because there's anywhere from like five to 20% of women will continue to have symptoms. She lowered her dose
1:40:45
at one point,
1:40:47
and did well with it or had to bump it back on
1:40:49
it. Yeah, she kind of felt.
1:40:52
Yeah, so yeah, who knows, maybe placebo effect we don't know, right. But the majority of women who drift through it will get better. And they say like, within most of the women, I can say, I'm going to manage your expectations, just so you understand. In the next like two to five years, we're going to keep working on this. And then by five years out, you might be done with hot flashes. So you might not need them forever, which is great, because most of the data on risk kind of increased past that five year mark, right? surgical menopause is different, like I will potentially have flash forever, because mine were just removed. So those ovaries that will still produce traces of hormones like yours will still produce a trace of hormones, I got nothing. So I can say to women, your hormone like issues will likely get better over time Isn't that great? Except for your vaginal atrophy, right?
1:41:31
That's very rare that you're in elasticity,
1:41:34
the farther you get. And that's because most of those hot flashes and vasomotor symptoms we call it are the delta of the estrogen, right, the Ester is going up and down and up and down in a really irregular way. And it's that difference that's causing the crash right and causing you to have those symptoms. So that's going to get better because once you're done with estrogen, then it's all just done. Once you're done with estrogen, your vagina, Which like the vagina and your vulva is the end organ that needs the estrogen to plump it up. It no longer has the estrogen. Why does that happen? Like, you know, the obvious reason why we died is because we no longer need it in theory, because in nature, I'm done right? Like I'm in menopause. I'm not supposed to be having sex anymore. Because first of all, I'm supposed to be dead at 51. Right? Not procreating What do I need to use my vagina for so I don't need it. So it's no longer doing its work. That's
1:42:23
what's so interesting about this whole thing of living longer, as you say, is living longer. But a lot of years without hormones, a lot of years
1:42:31
without hormones, right, which is also why we have to be careful in this whole natural world, like the natural past still want to talk about natural things, but they're still repeating hormones that were meant to be done. Right? Like, the whole notion that bioidenticals are better is a little bit posterous when like when you're done with your hormones, you're supposed to be done. Now I have no problem giving them to you because I'm a doctor. I work against nature all the time. But if I'm going to sit here and say I'm a naturopath and then prescribe you estrogen, progesterone and testosterone past the years, you're supposed to have them. That's not natural, again, which is fine with me. But then let's at least just be honest about what we're doing. Oh, yeah,
1:43:04
I owe all of it. I use hairspray. I mean, I you know, it's none of my hair totally. It's life. Now for estrogen cream. Tell me what the dirty is on that.
1:43:16
Alright, so the people who shouldn't use it. I mean, I shouldn't say shouldn't altogether like the people who worry about systemic estrogen again, would be people have had a stroke, heart attack, blood clot breast cancer, right? Those are the obvious people, that systemic estrogen, meaning you're taking it patch pill, it's getting into your system to help your symptoms in your body and your vagina is different. So I can say to patients all the time, if you don't have any symptoms, I'm thrilled. You're going to start getting some atrophy. And here's where we can fix it. Because the vaginal, there's cream, there's like you said cream, vaginal tablet, vaginal, suppository, vaginal ring, right? Those are all the different formulations of either estrogen or actually da ga s. A lot of women will freak out and say no, I had breast cancer, I cannot or I hit a stroke. I can't be on it. stroke, you definitely can be on it because the amount that gets absorbed is so so so minimal. Breast Cancer is a little bit of a controversy in that you can absolutely be on it. And you probably need it more than the rest of us even because if your head had breast cancer and on tamoxifen, you're even more a trophic right? But when you use it, your oncologist would usually ask you to use the tablet form the ring form the suppository form because those
1:44:24
would form It's so confusing your I know because you think you think orals of your tablet and your vagina. Okay, we're getting that. Okay, so so
1:44:34
those are the three that are again, absolutely acceptable. But even with breast cancer, even with estrogen receptor positive breast cancer by your oncologist would be tablet cre I mean, tablet ring and suppository. Ask your doctor, I'm not your doctor. But those are the ones that been studied because they don't get systemic. The cream in low dose will not get systemic. But if you mistakenly instead of using half a gram twice a week, you went up to two grams twice a week. There's a small chance you absorb it into your system. So most patients who have had breast cancer will not use the cream or if they do, they have to be very specifically told to use like a very small amount. But the cream works so well. So, you know, there's the downsides and the upsides. The upside is I always say if you use it regularly, it'll work well. And you will be so amazed at how much more elastic your vagina was
1:45:22
using it regularly mean.
1:45:24
So if it's a cream, it's twice a week, to other formulations. Yeah, like the cream and the vaginal tablet are both twice a week.
1:45:31
Okay, that's not that bad.
1:45:32
It's not that bad. I mean, it's not that bad. It's just honestly, like, it's a pain you have to like, I always say like, my trick is like, leave an extra toilet. So that like last thing you do before you go to sleep twice a week, like Mondays and Thursdays or Tuesdays
1:45:42
Are not you can't use it and then have sex. You have to sort of I mean, you could but you shouldn't because in
1:45:47
theory, he shouldn't get it on. Yeah. So you have to me Listen, I don't know how much sex you're having. But like,
1:45:54
I can pick a few.
1:45:55
Right? Oh, my husband's good. Like now? Yeah. Twice a week. So the upside is if you use it, it will work. The downside is you have to use it regularly. Like I patients were like, I used it for the six weeks, and it really worked. And then it stopped working. And I'm like, Really? You kept using it and it stopped? And they're like, Oh, no, I didn't use it anymore. I'm
1:46:14
like, Yes,
1:46:14
I worked out for two months.
1:46:18
So when they say How long do I have to use it? for it? We say as long as you want to have sex, you should use it. You could be 90 and you might need it.
1:46:23
Okay, so that you put the estrogen cream? Is it on your mama? it?
1:46:30
Depends. So like, let's say you said it's just it's just like, I'm just when I have sex, it just feels inelastic and everything, then I kind of try to figure it out.
1:46:38
Classic Bernie
1:46:40
Sanders, elastic and Bernie, Bernie. Yeah. And imagine this and you're 45 you're lean, and you're on the birth control pill. That means that you probably do have some atrophy, meaning the estrogen is me. I know. That's why I'd rather call it in elasticity. Because it means that even if you said, but I get lubricated, because I still get excited. Or I use a loop. I would say great. I believe you. Those are lubricants. Those will make it slippery. But those won't make it more malleable in Alaskan and elastico.
1:47:07
When I use a little feel Bernie Yeah, it slides, right. Yeah, but you're saying that the actual pulling apart like a rubber band is where it's, that's the burning, right? You want it to be more malleable, right? And instead it's taut. Then you're lubricating it so that something can slide up against it and run with it. I know this sounds really stupid, but I feel like because I had c sections, right? My vagina is probably tighter. Yeah, maybe someone who hasn't had who had vaginal births. Right?
1:47:42
Right. So you're thinking like if they hadn't less tight vagina, they shouldn't have this pain right? Now, all joking aside, let's say you barreled, you've had 10 babies barrel through your vagina, right? You have a gaping vagina, right? Like your vocal is actually really stretched out. Maybe the opening right is stretched out, vagina stretched out.
1:47:59
And there's a lot of heads coming through here.
1:48:01
So you still might be a trophic. Right? So it's not as elastic. But you're right, that you won't have as much discomfort if it's taller, if it's smaller, just because no baby has barrel true, right? And it's any elastic, it's really painful. If it's larger and inelastic, it's a little bit less painful.
1:48:18
Manage your mind lately. Yeah. And I'm not burning every single time I have sex. It's, you know, every few times.
1:48:25
Well, and the other thing I really tried to delve into with patients is like those times where as I jokingly call it the labor of love, All right, I'll just do it. Which means you're not having that whole physiological reaction where your vagina when you get stimulated is not just supposed to lubricate it is supposed to lengthen and soften and become more malleable and more elastic. Right? So those times you're like, Alright, let's just do it. I'm going to use a lubricant, this is great, then you're not going through that whole physiological process. And then it might burn a little bit more than the times where you're like excited to have sex.
1:48:55
Right. Got it. Okay. Yeah, I hope my husband's listening in his car. Thank me. Okay, so we bet the estrogen cream in the tablet is like what would be the difference between the cream and the tablet.
1:49:09
So a lot of women say oh, I want to use a tablet just seems so much less messy than the cream. And I'm going to talk about the actually go back to the cream in a second. But the tablet I have found and I've tried all of them is neater and easier and certainly better for women who have had breast cancer. But the tablet goes in your vagina liquefies. You get a little bit of watery discharge, and then there's no coverage for your ball because you started to ask where do you put it? You could put it on your vulva in your vagina and right around your urethra and any of those places because those are all the places that are now lacking estrogen. So that's why women get more frequent urinary tract infections when they're less elastic. That's why their vulva can they can hurt and burn that's why sometimes you can get a little bit of bleeding. I just had a hot flash can you tell?
1:49:51
No,
1:49:52
he had just got like all pink and hot. That's a hot flash people know
1:49:56
you're just mean maybe you're just getting your brain excited. Thank you.
1:50:03
So the cream, I like the cream because it has better coverage. So what I tell patients is I start them typically on half a gram twice a week and I say use the applicator so you can eyeball how much it is
1:50:13
after the applicator like when you get a yeast infection and gross Yes.
1:50:18
And by the way, the box comes with one applicator. So here are the downsides. The downsides, the downsides to the creamer this, it's not always covered by your insurance because your insurance does not give us about your dry vagina, right? You have to use it regularly or it's not going to work and you have to continue to use it forever. The box has deeply, frustratingly scary language on it because they're quoting the data on oral hormone replacement. They have not gotten it removed from the packaging, but it will not cause heart attack stroke, blood clots and cancer,
1:50:47
right. So we have to ignore the box, ignore the box
1:50:50
and then it comes with one applicator. So you need to literally, I tell patients again, I bought up for a couple of times, so you know how much and then once you get used to how much half a gram is and you might need to use more but ideally use less because again, you're paying for it because you don't want it to get systemic if you're getting if you're using too much. But if you're using half a gram, it ends up being like a glob like a little bit bigger than a chick pee right. So I tell patients the easiest thing for compliance, leave an extra toilet, put that glove on your finger, push it up into your vagina and then rub it all on your labia, the vagina up in your vagina and on your urethra because
1:51:23
I created a little art project.
1:51:24
Yeah, and it's like sticky cream. So it'll stick in there and stay. And you really do notice I mean, we say six weeks for to really kick in, but it works pretty quickly. And the tablet like I said easier, ironically comes with a new applicator for every tablet. It's so bizarre, total landfill waste, but just doesn't have as much coverage.
1:51:42
The vaginal ring is really saying that the Cree if you're going through the project, you might as well use the cream because you get the added benefit of it going all around your vulva up and up around.
1:51:55
I think so. And I've tried them all. Again, as long as you don't have breast cancer right now some people even without breast cancer, they just don't want to try the cream. It's too messy. They don't like it, they try the tablet, they don't mind it, the ring, which can last three months. And there's actually two kinds of ring one is only for vaginal atrophy stays in the for three months, but some people feel it when they have sex. The other one is actually feels it or the man feels that a man feels it because it's kind of a bulky ring. It's not like the birth control ring. It's a little bulkier. The other ring is actually for systemic hormones. So you have to be cautious so your doctor will know. And then there's the d h e a s suppository. It literally looks like if you've ever used a rectal suppository, it's like that. Easy to put in that's actually used every night. Upside being I think you forget it less because every night and even if you forget it like two nights, you know your percentage of times you're using it is more than if you forget like one of the two times of the cream. And the benefit is that it's dHg as that converts locally in your vagina to estrogen and testosterone. So the theory behind that is that it may be even slightly safer and that because of the local effect of the estrogen and testosterone, maybe it really will help a little bit more with
1:53:05
you have surgery that no, no okay, that's crazy. Yeah. Oh god, no
1:53:10
one's gonna imagine go to the fridge. No, honey.
1:53:13
No, you know, but it's like even with bleaching your teeth. They want you to keep it in the refrigerator. I'm like, Oh, I'm downstairs. So I actually bought a mini fridge. Like from a
1:53:25
little plastic piece one.
1:53:26
Yeah, my husband's like, this is a nice addition to the bathroom. I'm like, Yeah, sorry. Wait,
1:53:31
my teeth bleach is not refrigerated? I did. I don't
1:53:34
know. My dentist told me some German refrigerate it. But who knows? You might have higher end athletes than mine. I don't know. I don't think so. Because I got the refills from Amazon. And I was curious as to why they didn't come refrigerated.
1:53:47
Yeah. See
1:53:49
that to mind? Yeah, exactly. But yeah,
1:53:52
I mean, there's so many good formulations. And I really feel strongly. I'm actually still shocked at how many patients like when I post this on Instagram, I think that was like one of my most watched videos was women who are like, wait, really, I know, I could do this. This is amazing. Like, they didn't know that they get it badgal atrophy after menopause. And I didn't know that there's a there's a fix for it. And that's so sad because it's such a good fix.
1:54:11
So what's the difference between a hyaluronic acid suppository and the support the da ga suppository you're talking about.
1:54:18
So the da ga or any of the hormones are meant to again, penetrate into the cells within the tissue and plump them up and make them more elastic. The hyaluronic acid just like if you put it on your skin, it's just going to kind of like seep into the very top layer, and maybe create a little bit more like plumpness in that top layer, but not in the deeper layer. So hyaluronic acid is actually a great alternative for women who say like no matter what you say, I don't want anything hormonal coming into my vagina. They'll use hyaluronic acid, or they'll use a combination. A little bit of cream like Mondays and Thursdays and then hyaluronic acid every like three nights for example. They'll use that.
1:54:52
Okay, and that's it. Yep, taking birth control pills. Am I candidate for an estrogen cream? Yeah. I use ginned up.
1:55:02
No, because here's the truth, your fmls dial in your birth control pill is not hitting your end organ in this case, which is your vagina, it just doesn't have that same effect on it. So I put patients who are nursing when they're breastfeeding, really classic time to get a trophic. And if they're actually committed to sex, and they're going to be nursing for a while, it's a hard sell. But those women I'll put on estrogen cream, I have 27 year olds who've been on the pill for 10 years. And again, if they're super lean, so that they don't have extra fat cells so their fat cells aren't secreting s drone, which is that other form of estrogen hormone and they don't have extra estrogen going to their labia. I will give those really lean young patients sometimes topical testosterone, I mean topical estrogen cream to really help plump it up. In addition to the plump up Is it a libido pick her up? Or to really I mean, indirectly Listen, if you like make it more elastic, so it's more enjoyable, then of course, there's more likely
1:55:55
to lead back backs. Yeah. Yeah.
1:55:56
But it's not directly I mean, there's like, I mean, libido is a whole nother topic we could talk about
1:56:01
Yeah, no, we're gonna talk about it cuz they end up being 18 episodes, I'm gonna have to cut into eight episodes because there's so much information to cover. Okay, so we, we did the suppository the cream, the tablet, the ring, the patch, sort of to do a quick overview of the patch
1:56:16
none the patch is important because again, if you're postmenopausal and you want hormone replacements current data seems to support that your best combination safety wise is a patch of estrogen with a pill of a bioidentical progesterone. Okay, the good news is there's two doses of the progesterone and there's like, I'm gonna say, five or six levels of doses of the estrogen.
1:56:43
Okay,
1:56:44
so the good news is you can play with it, right. But let's say you said I hate the patch, and I'm like, the way it feels it keeps peeling off, then you would try the pill. Some of my patients again, use like that mist or the gel, I just haven't delved into those as much, but many gynecologists like them. That's just really personal preference, because I don't tend to use them as much myself for patients, because I haven't ever tried them.
1:57:04
Okay. And I wonder if you if you work out a lot, or is it just goes into your skin instantly? No, I
1:57:11
mean, it's not instant. Because it has to like if you're using it once or twice a week, you know, it's Depo. So it's like it depot's over time. So it like comes out over time, but it's pretty sticky. I will say now, because a lot of the brands have generics, the generic sticky system is not as good. So depends. Yeah, once again, it's something to try.
1:57:29
It's something to consider libido and injections.
1:57:34
We should talk about why does our libido go down? And you know why? Like a lot of the data has shown that it's not. It's not just what we think like we think we say this all the time as women, right? Like, just tired, just tired, not you. I always used to joke like, it's not you It's me, right? I'm tired, I feel fat, I'm stressed and then allow this exist me, it's me, it's me. As it turns out, data shows that our neurotransmitters somehow change when we've been in a relationship. And this is true for women with men and women with women, our neurotransmitters change. So after three to five years, we look at our partner as this like loving, amiable person who we deeply care for. But they lose that, like, you know,
1:58:17
I rip your clothes off, right? Which
1:58:19
is why I don't know if you think about this. But if you have any friends who are divorced, who are your age, who might have kids, and all those things you have, they're having a lot of sex, and they're excited because they're in a new relationship, right? Which doesn't mean like everyone go out and cheat or find a person. It just means that I think again, knowing that I think knowing that though, is helpful for women to not feel because when women come in every day, and they're like, I'm so embarrassed, I don't feel like having sex. And I'm like, Lay it on me. Let me tell you, I can name millions of us who are having sex for less than you even think. So. I don't want women to be embarrassed. So I want them to know that it's very, very, very common. And even, you know, I was talking about like, what's common versus normal border saying that this is actually normal, right? Because it's less normal for married or monogamous women in long term relationships, to want to continue to have sex regularly a lot. I do think women are divided into two a few camps. Those who might not be like, so excited with, you know what they call I forgot what the podcast I did with Kelly and the woman who the urologist who taught Kelly caspersen who talks about receptive desire versus spontaneous right like most of us don't feel spontaneous. Like we want to have sex anymore. But we have receptive like if someone initiates we can get in the mood and that's okay. Right, which is importantly, so most of us will be like, Oh, if I'm in the mood I you know, if you if you ask I'll do it, I'm not going to spontaneously start but I'll do it right.
1:59:36
And then I'll do my labor of love and labor of love.
1:59:39
But those women who are either in new relationships are super excited, or women who are kind of more dedicated. I always joke that it's like exercise. Like I don't feel like it. I don't feel like it again, in my own mind. Oh, funny, lazy. That'd
1:59:52
be I have a friend who told me I swear it's like a totally normal couple. She told me that she showers every Every night before her husband gets home and after she makes dinner to make sure she's prepared for the night for him, and I looked at her like, wow. Like, I get out of like a sweaty leggings. And I'm like, here I am.
2:00:17
So okay, so what that tells me about her is one of two things, she is either really unique and that she's just so excited to
2:00:25
service thing, right,
2:00:27
or just like exercise, she realizes the benefit, it's good for my brain, it's good for his brain, it's good for our relationship, it's going to bond us more, it's gonna keep my vagina in better shape, because the more blood supply is gonna keep it more elastic. And so she does it because she's dedicated and devoted to it. And I have to tell you like, again, just like exercise. I'm like, deeply jealous of those women. Because I think that they, they realize the value, and it's really important. So because getting to the drugs, there are no great drugs, like just a couple we can try actually one brand. And that one's you Remember, we talked about relatives in Yeah, that one for flashes, the same company that makes
2:01:04
you say that, because when you mentioned that, I was like, wait, I didn't, I thought that
2:01:08
was something. So the same brand that makes relatives and yes, they also make a form of it's not relevant. But another form for actually, if you were a PMS before menopause, and they make one for libido, um, called risk Stella, that, you know, here's the truth. It's super easy. It's very safe. It's like two pills at night. It's completely herbal, so it's safe. Why not try it? Do I think that it's like knocking everyone's socks off? I'd say no, but I think there's they have data to support that it works. And I think there's no harm in trying that there's also a couple of herbs that people will try. And then those like horny goat weed,
2:01:47
no way. Such a funny name
2:01:48
might be the best quote of this whole.
2:01:51
Go we'd write literally a purchase something like that Shiva, Amazon bought Whole Foods, but I'm gonna assume
2:01:58
Whole Foods in Amazon. Patients who have used it. I've had two patients who've used in said that they had marginal improvement
2:02:04
margin while margin.
2:02:07
And then there's those two medications that they that are FDA approved, ad D and Lisi. adji was the one that unfortunately, like, you have to take it every day, and you can't drink when you're taking it. And it might increase the number of sexual episodes by like one per month, something that was like, like, okay, so I can't drink and I'm gonna have sex once a month. The shot is intriguing. And I would like to try the shot myself. And I keep talking about it. And I just haven't done I
2:02:33
heard the podcast that you did with the urologist and she said that she had some crazy reaction.
2:02:37
Yes, I can't we need to try it because the the hormone that it's based on Milena Courtney is a kind of an old hormone. So I think it's really not unsafe. But it's an injection, you can only use it twice a week. And here's the problem. I think most of us want something that's going to make us walk around wanting to have sex. This is like, Okay, if anyone has sex tonight, I'm going to use the injection so that I get more in the mood, it's better than nothing. Yeah, means you still have to have committed that you're going to and I think most of us, once we've committed we're going to can get in the mood. It's like getting us to commit to wanting to
2:03:10
Yeah, or dad knowing that like your kids are gonna walk like be at the door or like once a good time. It's hard, especially with like zoom school and all this stuff. It's like not to say that I'm having daytime sex, but like, you know, it's like my kids have weird hours. They're doing homework at weird times. And it's very hard to sort of find that allotted time spa now.
2:03:32
I do think that's actually a really big issue. I think that that's one of the biggest issues probably for many couples. And certainly like my husband, I talked about it. It's a challenge because I do think it becomes a big part of the relationship. And once you don't have sex for a while, it's so easy. Just like exercise. Yeah, it's so easy to just be like, Oh,
2:03:49
let me I feel like I have like a two week rule. That's good. Once it hits two weeks, I'm like, Okay, he's also a really grouchy like I you know, there's like a mood thing too,
2:04:02
totally. For men. It's really important. By the way, who created this situation where they have testosterone, and we don't that makes no sense.
2:04:08
To me.
2:04:09
I think that if I what I say to women is if you are regularly having sex, let's say two to four times a month, I actually think that's really good. If you're having sex more than that amazing. Go home tell your husband your unique if you're having sex less than that, which is incredibly normal. And I don't think like oh my God, that's terrible. I think it's very normal. But I think we should aim for more. Now. Could you almost Of course not. But do I think that would probably be ideal.
2:04:35
Yes. Now in terms of elasticity and sex, I mean, like if you're using a vibrator and you're not having penetration sex, you're not digging into the elasticity issue.
2:04:48
No, you are because elasticity, remember is your your vulva, which is the outside the labia and inside your vagina. So the elasticity is everywhere.
2:04:57
You can tell I'm not a big vibrator. I know
2:05:00
And the vibe the beauty of a vibrator is that you need? Like, I hope you notice I think, you know, the majority of women will only have an orgasm clitoral sight, you know, cuz you know how many women don't know that. I have women who are still educated and they come to me they're like, I have to tell you something. I haven't had an orgasm, even with clitoral stimulation. And I just kind of say because it's like, and they're like, What do you mean? So many women like listeners, if you're listening, if you haven't had an orgasm, it might be because you haven't had any clitoral stimulation.
2:05:30
Job, right. But
2:05:32
your husband just like all of us has been raised on a steady diet of crappy movies who like women were lying there. And he's been with me for 27 hours. Now your husband knows history, right? But you're clearly really open with your husband. But many women again feel like they're a little bit more like they want to keep a distance. They want to keep things a little bit. They don't feel as comfortable talking about it. And they take it a lot. Yeah. So is the question. If you're using a vibrator isn't going to help?
2:05:57
no meaning like it's not going to, like you're gonna have to go inside not just do clitoral stimulation with the vibrator to get the sort of inside a lasticity. Well,
2:06:08
I mean, if you're if you're talking about No, not necessarily because if you have an orgasm from pure clitoral stimulation, you're still bringing blood. So that's the vagina. Yes, yes. Yes. Yes. Yes,
2:06:18
the blood flow is as important as stretching it out. Well, okay. Put
2:06:23
it this way. If you only have orgasms with blood flow, you still could be completely a trophic.
2:06:29
You know, our
2:06:29
dilator right. Well, yeah, I mean, obviously, for some women, they're opening the intro test is what actually gets so contracted that they literally couldn't have sex right. Now, if you only use the estrogen cream and never have an orgasm, the truth is, you still could be really elastic, but like, then what is it for? Like I, I do think that as women, we also should be more committed to ourselves, and I'm guilty of it as well. And actually say, like, we're gonna actually have an orgasm every time we have sex. But most of us do this, like labor of love. Like, let's just get it done. Right? Because it's easier, when in reality, like I keep joking about exercise. And once you're in it, you're like, this is actually really good. Like I should do this again, does even take that long, like maybe tomorrow. Tomorrow comes you're like, No, I want to do
2:07:10
it. No, I know, it's sort of like, oh, but then I don't want to shower after and like, it's like so many staffs. And it's already 1030 at night, and I just want to watch TV and go to bed and go to bed. And like, you know, my husband always says, like, how many steps do you have, like all the layers of your face? Like I get to bad knees, like wants to have sex and I have like all these smelly weird creams on like, you can't always plan everything. I know. I know. It doesn't work that way. It's a conundrum. Oh my gosh. Okay. Now in terms of vaginal lubricants. What's the story behind that? I
2:07:41
mean, there's coconut oil, right, which I love. So I mean, you have to be careful. If you're using condoms, you cannot use oil because the oils might break the condom, especially the next time. But I tell my patients if they're going to be using oil, I love coconut oil, because many people have it because they cook with it. The problem with just straight out coconut oil, is if you notice it's a little bit chunky, and so it'll liquefy in your hand, but it still stays a little chunky. So there's a brand called v magic, which I get no kickbacks from, though I should because I talked about magic, the magic and it's Coconut oil is mixed with essential oils, you can buy it on Amazon, and it's just a little bit more amoliant than regular coconut oil. But even regular Coconut oil is perfectly fine. Believe it or not, olive oil would be fine. It just doesn't know is good. Right? oils are great if you're not using condoms, and they're better like you think about like serger lube or you know ky that we use in the doctor's office. That's just like coating the like inelastic tissue. Where's the oils penetrate in? And they really do again, without condoms. The oils work much better.
2:08:41
Yeah, I know I've ever since I interviewed Sherry, I've been taking the coconut oil baths. And every time I'm in there, I'm like, Okay, I'm leaving my living here, Jane, like I'm doing this for myself and my husband, right?
2:08:54
Yeah, well, and I say to patients, like, you could just have that little thing of coconut oil. Like next year toilet again, forgetting even sex, you can use just put a little bit on your vulva. It's totally safe. Like people are talking about using it now for like infants with diaper rash and things like that. It's literally the most organic thing you can use, right? Because it's something we can ingest and eat. So and that's the important part. It should not be like cocoa butter that you would slather on your skin you want literally coconut oil that you would eat is the type that we're talking about. I know unless you buy the magic, which is for the vagina. I
2:09:25
have not tried to be magic, but I have tried the coconut oil and I love it.
2:09:30
Yeah, it's great, how much better right? And I should just comment that you could get formulated estrogen cream from the pharmacies that do like the bio identical. So if you don't want to use the creams that are prescribed by the pharmacy, okay, you can go and pay out of pocket and have those creams formulated as well. Just to be complete,
2:09:49
right. But again, it's not 100% natural as they say. Yeah, and we're not exactly sure what we're paying for. Right, right. It's not I mean, There's no way
2:10:00
to make it natural and see like extracted estrogen from a woman and like created a national cream out of it, which like, that would be weird, right?
2:10:08
Love it. Okay. Now we're also gonna have to do a whole episode on like teenagers at HPV and all this, because there's so much information out there. Now in terms of like I did with Dr. Sherry also is, as a gynecologist treating women in the second half of life in addition to all the other years, what are the main things that you would say when you go to your gynecologist, it's on you to know that you need these things.
2:10:37
Okay, well, from a screening perspective, if you're over and again, you and your doctor will decide together but over 35 or 40, your screening mammogram, which I still advocate for doing, I start usually at 35, if not 40, for sure. And I still advocate for doing it every year even though there are certain task forces that would say you could go to every two years you could watch
2:10:57
the ultrasound component because every time I go get a mammogram, he's like, I'd have to have the ultrasound and I'm like, Oh, yes, I do.
2:11:04
So the screening mammogram is meant to be the screening test period. And if you have dense fibrocystic breasts, which means firm, hard, lumpy, bumpy, and then depending on your state, they will approve of an ultrasound as a screening test. Okay, other states, some states do not approve of it, meaning insurance will not cover it, it will be considered diagnostic,
2:11:25
because they can charge 50 I think right?
2:11:28
Now you might not have breasts that are dense enough, I don't know what California says as far as state law, do they cover it as a screening test or not, they either don't cover it, which is why you're paying or your breasts are actually not so dense. And when they're squeezing your boobs between those two plates, they actually can see everything. So you legitimately don't need the ultrasound. But if you feel like doing it, there's no harm other than the potential false positives, right? So your mammogram, if you're over 35, you should always make sure that you're getting your pap smear. And you are going to talk to your doctor about the guidelines because the guidelines are challenging and not easy, but anywhere from I'll just give you the broad ranges one to five years. And I still and many gynecologists still, despite the guidelines changing and saying you go three to five years, I still would encourage my patients to at least consider it yearly, if their insurance is covering it, which many of them still do not. Because you're so likely going to get cervical cancer in the span of a year, cervical cancer takes years to develop. But remembering three to five years is really challenging. And every now and then we do see women who go from a totally normal pap smear to pretty abnormal within that three to five year span. So even though the guidelines are very clear that you could wait three to five years, so you shouldn't be angry at your doctor if she sticks with those guidelines. And I don't think it's wrong for some patients to say they'd rather do it yearly. Again, it's definitely a little bit of over testing, we have to be cautious about that. But it's it's a relatively small amount of over testing. When we're talking about specific numbers. When we're talking public health, it's different. And as a joke, I am not here as a public health proponent other than your psychological public health. And you have to really make sure that when something comes up, like I had some bleeding, I don't want your doctor to ever just be like, Oh, it's no big deal. Don't worry about it. Unless she explains to you why. And I hate to say this for the doctor sake, cuz I don't want to take up more of their time because I get it from the doctors perspective. And we are like squeezed in every direction, right? Like, we're getting less less from insurance, we're getting 15 minutes with a patient. We're getting patients pissed because they're waiting too long. Like everything, it's really hard. But if you have a complaint, and your doctor is merely telling you like No, honey, it's okay, no big deal. And she's not explaining to you why, then not only do you psychologically not feel satisfied, which means you're still gonna have anxiety and nerves and cortisol surging through your system, which isn't good. But it means that you might actually not understand when you do need to be worried about it, right?
2:13:43
Like if you can do a part,
2:13:45
right, like, let's say you came to me at 44 and said, I had two days of a heavy period. And I just said no, it's not a big deal. I'm
2:13:51
not worried about it.
2:13:52
What I really should say is, is that what you're used to because if you're always having to do some heavy period, then I'm not worried. But if your period is typically like one day really light that's it and then you're telling me that the last three had been like hemorrhaging for two days. That is different, right? So again, you have to have a little bit more understanding and explanation which like I keep saying, I'm going to try to keep doing online so that you don't have to necessarily burden your doctor because your doctor doesn't always have the time which is too bad but that's a systems issue.
2:14:18
Yeah right for sure. JOHN pap smear mammogram,
2:14:23
well and then the pelvic exam which is different than the pap smear which has very questionable value, but this pap smears when they put in the speculum, the pelvic exam is where they put in their hand again questionable value because
2:14:35
I went through all of that today,
2:14:37
right today. It sounds like you also had a rectal and I don't know if she did that she some some doctors do routinely still do it, which is not wrong.
2:14:44
The guidelines and I but I asked for that in all honesty for the rectal Yeah, even though I feel like it gives me like a panic attack. Yeah, because I don't know I just hear all these like weird stories about people who didn't do it and should have done it and I thought, you know what? Yeah, he's already like down and dirty. And I mean,
2:15:04
right. Here's the good news. The good news is for those of you who don't have it done, which is the majority, I would say, of patients nowadays don't have it done. Because it's not part of the guideline, you don't need it, because the yield of what you're going to find like the reason behind the rectal exam is twofold. One is what if you have a mask that can only be felt a pelvic mass that can only be felt through the rectum? Very rare? That's just rare, right? Second is that if she's testing it for, like, if she did that, and then smeared it on this little thing to test if there was any microscopic blood sheen in my patient population, and I am a, like, a dog with a bone again, about them getting their colonoscopies?
2:15:38
Oh, no, we had a whole colonoscopy discussion.
2:15:41
She didn't say, This replaces that. Right. So in other words, the only value really isn't those patients who aren't getting their colonoscopy, then this does not replace it. But it's and I'm not saying it's right. or wrong that that she did it.
2:15:53
No, no, I asked for it.
2:15:55
Right. But I want people to know who don't get it done. The majority people don't get it done. And here's the downside. Some doctors will still routinely do it. And there's going to be a group of patients who are so like you anxious, disgusted by it, that they won't go back to the doctor, if they think they're getting a rectal exam, right? And so if it's not going to really improve our yield, yeah. And I don't want to do anything that's going to cause discomfort, right? It's kind of like checking your cervix, when you're pregnant after 36 weeks, it's not helping me tell you anything. Why am I going to I wouldn't say the rectal exam is that unhelpful, but it's not again, the likelihood of picking something up on a rectal exam is not so high. So that tends to be personal preference with the doctor. It's gross, but it's so
2:16:33
quick. Yeah. You know what I mean? That is like, Yeah, whatever. Let's move on. Now, in terms of osteoporosis, and bone scan, what's
2:16:42
I gotta say, that is like one of my least favorite topics, okay? Now, because it doesn't exist, it really exists. People do have osteoporosis, they break their hip, they break their vertebrae, when they fall, it's my least favorite. Because because of those commercials, where like, if you're on that medication, and you're gonna have like necrosis of your jaw, your jaw, everyone's like, I don't want to take that medication because my jaw might fall off. And then they don't care about the back, they might fall and break their back. And so because there's so much like anxiety about those medications, and then it's kind of like, why am I going to send you for a bone density, which is going to be an X ray, which is, you know, giving you some radiation, when you've already like made it clear, you're never going to take these medications. So I don't not send patients I do still send patients for bone density. But I tend to reach for that. I mean, it really depends like the guidelines, they used to say start like two years after menopause. Now, some guidelines say you could wait till 65 unless you have risk factors. Like, if you were like you being on having thyroid medication puts you a little bit more risk you being lean puts you in a little bit more risk. If your mom had osteoporosis or actually like fell and fractured her back or her spine, then it's me, her spine or her hips, and it's different. But I tend to if someone has asked to process I send them to an endocrinologist because the endocrinologist really understand the medication, and really understand alternatives and really understand how to manage those symptoms over the like the one to two year periods. So interesting.
2:17:58
I didn't even know what doctor you would go to. Yeah, for the osteo. Well,
2:18:04
it kind of fell in the lap of the gynecologist years ago without
2:18:08
me That's why I kept relating it back to that because my mom would always come back and tell me about her conversations about that. But until you just said endocrinologist,
2:18:17
it really is a hormone issue because it tends to be you know, like problems with your calcium and vitamin D and things like that. And so, endocrinologist tend to know what the best some of the oncologists deal with it and they're actually pretty good at it too. And occasionally, even rheumatologists autoimmune just because even though it's not autoimmune, but yeah, laughs with some of the things. And certainly Listen, there are some gynecologist who are deeply passionate, like the way I love talking about the actual truth of vaginitis. Like some of them really love talking about osteoporosis, but many of us are just not that well trained in it. And there are people who are really well trained in it. So I'm thrilled that I have people in my community that I can send people
2:18:49
to Okay, what about the ovarian cancer test? Ca 125? I know I we talked about it briefly with Dr. Sherry also. Yeah,
2:18:57
I don't know what she said about it. But the bottom line is, it's a terrible screening test. They have anyone pre menopausal. And anyway, like I It is my screening test. Now that I've had ovarian cancer, it is actually the only test I'm supposed to be doing every three to four months. I'm not supposed to be doing any publications or anything. Because the idea is that before anything would show up on a scan, my serum marker for ca 125 would show up because we know that mine was elevated for my ovarian cancer. If you did it as a pre menopausal woman, if you had fibroids or an ovarian cyst, or like a totally benign lesion in your liver, those things could all elevate it. And then what we're supposed to do a laparoscopy and like look in your pelvis for every woman who has it. And
2:19:35
so unfortunately, it's not the same but so you're saying in your practice, it's only appropriate for someone like in your category. It's
2:19:42
appropriate for a few people. So for me sometimes women who are at very high risk categories like they've had mothers or sisters with ovarian cancer, then it's a little bit more appropriate. It's still not like they should do it. But there are some screening protocol suggestions with transvaginal ultrasound and ca 120 Five pen, listen, if I have a long conversation with someone, and they're like, I really want to do it, I'll do it. I'll do it for them. But I want them to understand what we're looking for and what the benefit and what the possible false positives are. And then the really the best reason to use it is, you've seen someone who is postmenopausal with a mass, and you do a C 125. That doesn't mean that it will rule it out completely, if it's normal, but then you want to know, so that if it is cancer, you can watch that go down once they finish their treatment, and then that's a marker for them to follow in the future.
2:20:31
Wow. Okay. Now, hormone panels, FSH, blah, blah, blah. We talked about that at the beginning of the episode. One, would you say? Yes. Okay. And when would you offer it? Other than nerado? Like me? Oh, I
2:20:48
definitely offer By the way, yeah, let me be clear, I would offer it a lot. In other circumstances, a young woman who is having lack of her period, which is called amenorrhea, or missing it, not completely missing it, but just having less frequently, a young woman who's having sudden onset hot flashes or night sweats, I would definitely do it. Okay, when we're doing a panel for something called polycystic ovary syndrome pcls. It's part of the panel, because we watch the FSH and LH levels, and we see the ratio of them. If someone is 48, hasn't had a period in 11 months is going for her thyroid blood test anyway, and it's just curious, then I'll send her for it. But I also again, qualify it with this is like a snapshot in time, this may help us this may change you want to know about it, I'll send you for it. Okay. Women who are like trying to get pregnant and going through fertility treatments, they need it for sure.
2:21:32
Okay, now, in terms of thyroid. thyroid is another weird one where people determine differently, yeah,
2:21:43
thyroid is complicated. And I will really say that I don't feel like I know thyroid very well. So you are looking at thyroid numbers of a patient? And what point do you send it on to a specialist? If they are square in the middle? Then I wouldn't send it to a specialist. Right. But but by the way, there's TSH, thyroid stimulating hormone, and then there's free t four. And then we don't even write and we don't even routinely check for the thyroid antibodies. So depending on what I check for, if it's squarely in the middle that I wouldn't send them necessarily. But if it's on the border, like normal, but either high normal or low, normal and they're having symptoms, then I would definitely send them. And that is where I say Listen, I do think Western medicine is a little bit strict and stringent about how we approach it. Unfortunately, again, I think Eastern medicine has gone a little bit in the opposite extreme of maybe overdoing it with some of the supplements and things like that, because remember, the supplements can be expensive. And supplements can have side effects, just like they can work. They can have detrimental side effects as well. But yeah, thyroid is very confusing. It's very complicated, like some people are very straightforward, just straight out hypothyroidism, and other patients will have, you know, fluctuations from thyroiditis. And I think that is a conundrum and I think probably where we will hopefully learn more and do better in western medicine.
2:22:55
Yeah, I mean, I've said in another other episodes also that I have a goiter. So I don't have hypo and I don't have hyper. But if I go to a regular internist, like my numbers just look normal. But then if I go to the thyroid specialist, he sends my blood work to a special lab that tests for numbers that the regular interrail can't like, I'm like,
2:23:16
three Yeah,
2:23:18
right. Well, listen, this is where I am glad in a way that we live in a country where despite the fact that our healthcare is broken, we do tend to have a lot of specialists, right. So thank God we have endocrinologist and things like that, though. Even there's controversy among endocrinologist about what they would treat and what they wouldn't. Yeah,
2:23:33
thyroid is like 27 episodes. Yeah. Oh my gosh. Okay. Well, I have loved talking to you. Okay, good. Before we wrap up. Yeah, I want to do a quick, rapid fire session with you called fun shit about Dr. Shiva. Okay, so I'm ready. Yeah, ready? Okay, ready? what's next on the bucket list?
2:23:55
Oh, my gosh, so many? Well, first of all, no joke, I am getting in better shape started last week. But I am going, I'm ultimately never going to work. I'm never not going to work. I'm going to continue to work. I'm going to work differently. And my bucket list is like being braver about my what I do physically. I wrote a horse this weekend. I've never done that before. So I mean, my bucket list I'd say is building tribe called V, but I'm already building it. So that is already done. But with that and with a better lifestyle. I'm ideally going to be getting into better physical, like braver, physical health, right? Like, I don't wanna run a marathon. But I do just want to, like, you know, I'm not good at riding a bike, I want to ride a bike, more things like that.
2:24:32
I think that all of this is about the self recreation journey, even all this women's health stuff, because we have to know what the information is to bring it into our own lives to figure out what we can do better for ourselves. Totally, absolutely. Doesn't matter what your better is. Because everyone's better is defo. Yeah, right. Absolutely. It's random, but it's so relevant. Okay, next thing, anything that you've learned that is now on your bucket list. After quarantine,
2:25:01
oh my God, oh, after quarantine. I mean, they just meant after like life with cancer, it could be after quarantine. Okay, I'm gonna tell you life for cancer, that's a better one for me. When I went through it, everybody said they still do. Did you learn that life is short? And I said, hell fucking No, I learned that life is long, and I'm going to live the shit out of it. So it really drove home to me that this fear mongering notion that our, you know, society wants to build around like, life is short, you have to appreciate us you have to savor every moment, I feel the opposite. Like, I'm going to enjoy as much as I can, but I'm going to do a ton of shit, because I'm gonna live for a long time. And so I got to make sure that all the things I do mean something but not every second and every minute, because that's just gonna make me feel much more anxious. So it's almost like this oppositional dichotomy of like, life is long, I'm going to make an amazing and fun, but I'm going to know that every second won't be fun, and I'm not gonna like, idealize it and be like, I want to go back to that time where everything was so amazing.
2:25:59
sex with your husband every day, right?
2:26:03
20 years ago? Yeah.
2:26:07
Okay, what's your secret pleasure?
2:26:09
doughnuts?
2:26:13
doughnuts filling feeling. That's my problem with donut.
2:26:16
I don't mean feeling. Okay.
2:26:21
It's like very literally slather on.
2:26:26
Any kind of serum. I can. Like I have so many serums I will put on my skin have
2:26:32
anything you just if I were going to work?
2:26:34
Oh, I love there's pie the oil the brand called pi p AI. It's rose hip oil cleanser. And then you use like a soft washcloth and scrub your face and I love that. And just good old retina every single night. But if I was going to a beauty treatment, I would have a scrub. I love getting my backsplash more than a massage. I would have a scrub like a salt scrub all over my body.
2:26:57
I love your dog in the background. That's one of them. That's all and
2:27:02
happy her sister is out of the room. Okay, let's
2:27:06
see. What was the last thing you ordered from Amazon?
2:27:11
Oh my god. They're sitting on the dining room table. I ordered platform rubber clogs for the hospital.
2:27:17
No way.
2:27:19
They're like bow crocs. But they're like hilarious because the nurses always know like, I work on my jewelry. And I like I like to wear like funky stuff. And they were like, We just saw this. Someone had platform crocs you gotta order on. So
2:27:32
they sent me a picture of those so cute. Okay, favorite TV show from the past or what you're watching now? Well, I
2:27:41
watch nothing, literally because I'm constantly either sleeping, reading, working or listening to podcast. But I did watch Ted last though. And it's unbeli I
2:27:50
loved it. Oh my god, I
2:27:51
can't wait for the summer when they're going to come out again. I loved it. That was my favorite. I've
2:27:55
actually seen one
2:27:56
because he was so oh my god, you gotta watch all time. And we literally watch all 10 in two nights with our kids. It was like, emotional and fun and quirky and acerbic and quick and everything. Is
2:28:05
it for kids? I mean, like, Is it like, your
2:28:08
kids are fighting my channel? Probably should have been watching it. But your kids? No,
2:28:11
no,
2:28:12
they talk about things explicitly. But it's Yeah,
2:28:14
I just wonder I always wonder if my kids will ever be interested in anything that I walked. Oh, yeah, it's so cute. What is the smallest thing we can do today to start our shift toward self recreation?
2:28:25
Oh, my God, I did you can increase your knowledge to decrease your anxiety actually. And here's what you can do. Truly, I say this so much to my patients, every single one of us has gone through something really probably is a really big deal, right? So if we go back and remember, like, before we went through that thing, and you told us we were going to go through that thing we would have been accepting so scary, I can never go through it. And then we went through it. And we were actually okay. It might have sucked, but we got through it. In that moment. When we get through those crappy things. We literally commit that to our memory and we create those neural connections. So the next time we can draw upon it again and be like, Oh, yeah, wait, remember when I thought that was such a big deal. And I got through it. This time, I'm going to get through it again. And we build on it. And every single time we build on it, we get a little bit more resilient with our ability to say, this is gonna suck, but I am going to get through it. Right. Like, if you told me that I was gonna go through all the things I went through, and I was from 26 to 46. I was thought it was horrible. But now I've been through all that. So there's gonna be another thing I'm going to go through, right? I'm only 51 I got another 40 years on this.
2:29:27
But I go, Okay, well,
2:29:29
I went through the ovarian cancer with no hormones, I'll dry. But I went through that. So I can kind of draw, keep drawing on that experience and reminding myself that the important part is right, when you go through it, reminding yourself so that it gets embedded into your brain and into your mind and into those neural pathways. So that
2:29:44
again, like an actual tool that you use, like do you journal or do you write it down? Or do you just really try to remember it?
2:29:51
I'm like,
2:29:53
I am a deeply disorganized person, believe it or not, everywhere outside of my brain,
2:29:59
my brain Has your brain wickedly, but I don't
2:30:02
have like, well, there's a lot of information. But again, like we talked about this, I don't I don't have any normal schedule right now like my schedule all over the map. So I never have like 10 minutes a day where I can always journal.
2:30:12
What's your bottom line advice?
2:30:14
So one of my isms. Also, another one is nerves are normal. Don't be scared, because fear is a terrible, terrible, terrible feeling that is inappropriately used, right? Like we invoke fear in ourselves. In the wrong times. What we really mean is I'm kind of nervous. I'm kind of anxious, but we say fear, thinking it doesn't make a difference, but it's really stimulating cortisol right. And I always say fear should be used. When you're being chased by an animal in the wild. It shouldn't be used when you're about to go into your mammogram. And you say, Oh, my God, I'm so scared, I'm going to have an abnormal mammogram. Because then when the radiologist walks in and goes, Oh, your mammograms, normal, you're like, you see, and you've already dramatize it to the point where you think, abnormal mammogram again, cancer
2:30:57
death,
2:30:58
whereas really abnormal mammogram means come back for an ultrasound, come back for another view, likely it's going to be fine. Or if it's not fine, you're catching it really early. But instead, we've created all of this, like, again, and anxiety and drama around cancer, and made it such that like anyone cancer is going to die, which is totally not true, like the majority of us with cancer are not going to die. So I really try to discourage people from routinely using the word fear, and actually just acknowledging that they're nervous and anxious, which I would not take away from them. But fear is not the right concept, right. And so I think the more we kind of live with that notion and remind ourselves because people come in again, I'm so scared, I'm gonna have a C section, I'm so scared, I'm gonna find out an abnormal pap smear, I'm so scared, you're gonna tell me that I have herpes, like all these things, again, that are so common, that I feel like if you're living in fear at that, those things are gonna happen, then like you are out of luck, because
2:31:48
those things are gonna happen. Because I know that I've been reading a lot, and I'm actually doing another podcast on this is this whole idea of energy and manifestation. And I'm gonna say that every single thing that you think is going to happen is going to happen, but you are really creating an energy for yourself and personally, right?
2:32:08
It's that whole notion of like, you know, when people say things, like, I'm waiting for the other shoe to drop. I'm like,
2:32:12
I hate that.
2:32:13
Like, because then anytime something goes wrong, because it does, right, like, fascist things go wrong. But if you keep saying like you were waiting for it, or you knew I knew it was gonna happen, then you've just made it so much worse. But instead, it's not the whole like, like a glass half full or like things happen for a reason bullshit, cuz I don't believe that. Aliens thing, right? Like the circumstances are gonna happen. Have you heard that? One of my favorite quotes that I've read the same boiling water that softens the potato hardens the egg?
2:32:46
No, but I love that. Amazing,
2:32:49
right? It's all about to change the circumstances. But what you're made of can respond differently, right? You're a potato, you're gonna stop in your boiled egg, you're
2:32:58
gonna harden,
2:32:59
same water, same circumstances. And it's so true. Like, I keep saying, like, it's gonna happen, right? Like, I don't sugarcoat it with my kids. Like, I tell them, like stuffs gonna happen in your life. So we got to figure out how you're gonna get through it.
2:33:10
Because I totally agree. I mean, even with this whole COVID thing, and I talked to my kids, I talked to my mom and I say to my mom, I'm like, Yeah, the vaccine is here. But you have to figure out how to live your life right now, because the vaccine is not necessarily going to change your life so dramatically. No,
2:33:30
and even if it is, it's still not gonna be for a while your mom, like so long enjoy her a couple months before the vaccine works.
2:33:37
It just seems so long and so far away that I'm like, if we don't live the right now, we're always going to be waiting for like this notion of like, well, in a year, my life will be better. It's like, No, no, no. And that's the whole idea of this podcast, too. It's like, well, what can we do today? What can we do after we've had this conversation with you go to our gynecologist asks for ask for different treatments, learn about them, see what we can do for ourselves. We don't have to accept things as they are. No, we're actually one of one of the services
2:34:09
that I think like one thing that I constantly reliving ties into almost everything we talked about is because women again, are so filled with fear, because they don't know, they're so filled with with emotional anxiety and embarrassment, because they don't know that everyone else has the same thing. Or they're surrounded by people who are faking that everything is perfect. So another concept I really try to encourage women to do is all at once be really honest about all the crap in your life, while still acknowledging how lucky you are within the framework of what happened, right? Like, I'm very clear about the shit that I'm pissed off about, or when I'm in a fight with my husband or whatever. But I also want to acknowledge like, what I'm so lucky to have the complaints that I have, I don't want to act like I'm so lucky. Life is perfect. Look at my life. It's so wonderful. Because that's fake, right? And I don't want to complain about my shit in such a way that I act like my stuff is Such a big deal when there's literally people like starving, getting shy
2:35:04
when I say about the whole zoom school thing, because here in California, I mean, my kids have been on zoom school for almost a year, right? Which is crazy to even think about, not at school ones ever at all. And people were like, Well, how do you feel about that? And boat? And I'm like, you know what? It's a nuisance. Yes. But my kids are not devastated. They're not starving. They're learning. They already know how to read. Could the academics be better? Yes, of course. Could everything be a little bit better? Yes. But think about those kids who are in those situations where they're not learning how to read. And their parents are, you know, frontline workers, and nobody's home ever. Right? So it's all about perspective. But it doesn't mean you can't have your own problems as long as you have knowledge. Yeah, like you're saying,
2:35:54
right? Like, when it's so good, pitching automatic, like, I hate those images are so fake, or like, everything's perfect. Real like, no, it's not, you're lying, right. But I also hate those women who like, have a really good life, and then act like they're, their imperfections are like death and destruction, right? Like, there's got to be a happy medium of being really honest, and also really balanced and grateful for the things that you have. And,
2:36:17
you know, I mean, I mean, I, my kids realize that, too. I mean, they they have the perspective, too, because I serve on a lot of boards with inner city kids. And we're like trying to get kids computers and Wi Fi and right, you know, they're in their house with their laptops in their room ordering Postmates it's a totally different situation, right. And they get that because we talked about it. So I think it's just finding what works for your family. And I think personally, in terms of the self free creation process, I think that getting all of the information you can is helpful for also just like making your body feel good, because so free creation is about identity, a lot of its identity and finding passion and purpose, like you have with a tribe called V in your practice, and not every woman has that separate passion identity outside of their families. But at the same time while you're doing it, you can't feel shitty. No can feel like a hormonal mass, you can feel like you know your energy. Yeah. And that's why I want women to walk away from this episode and be like, Wow, there are things I can do to make my vagina more elastic, to make me feel like less of a hot mess. And this doesn't have to be and there are options.
2:37:38
Yeah. And the other part, by the way is don't look for it. If I kind of liked it my tone, like how are you feeling? And women will be like, well, how
2:37:45
should I be feeling like,
2:37:46
tell me what symptoms I would have? And I always joke like, I used to tell you, you're probably not having right, right? Because some women, some women do breeze through it, and they're okay. And that's great too. It is not one size fits all. We all have different ways of going about it.
2:37:59
I love it. I love talking to you. Okay, I want everybody think about what shit we can start doing today. One small step. I want to thank Dr. Shiva for highlighting the tools and giving us the foundations and inspiration that help us to manage the sweaty and potentially bitchy jungle a fairy mattifies and menopause in the second half of life and hence this podcast Dr. Shiva ghofrani Thank you.
2:38:28
God you I want to know before you leave where everyone can find you. So you can find me tribe called v.com or on Instagram and Facebook at tribe called V or on my own personal platform, which is at Big Love beer studio.
2:38:44
Okay, and website. website is tribe called v.com. Okay, I've loved talking to you. So fun. Good peeps. Thank you so much for listening. If you enjoyed finding our sweet spot today, and digging through layers of shit with your golden shovel, subscribe, subscribe. Subscribe. DM me on Instagram at the flexible neurotic. Tell me which golden nuggets resonated with you. The ones that you're going to start using today to start getting your shit together to find our sweet spots. screenshot it, send it to a friend. This is Dr. Sarah Milken, the flexible neurotic, inspiring you to gather, curate, incorporate, maybe even meditate