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BackTable / OBGYN / Podcast / Transcript #51
Podcast Transcript: Menopause Matters: Clinical Strategies & Patient Support
with Dr. Jessica Ritch
This episode features host Dr. Mark Hoffman and guest Dr. Jessica Ritch as they discuss the lack of menopause education and research during medical training, and the necessity for practitioners to learn more about menopausal symptoms and management strategies. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) EnRitched: Enhancing Patient Education through Podcasts
(2) Common Patient Complaints in Menopause
(3) The Role of Hormone Evaluation in Menopause
(4) Testosterone in Menopause: Benefits, Risks, and Clinical Use
(5) Postmenopausal Hormone Production
(6) Bridging the Gaps in Menopause Care: A Patient-Centered Approach
(7) Addressing Sexual Dysfunction in Menopause
(8) The Future of Menopause Care
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[Dr. Mark Hoffman]
Thank you for joining us on today's episode to talk about your podcast and also about menopause. This is something that I think you've talked about in your podcast, but also, we don't get a lot of menopause education in residency, at least I didn't because a lot of our resident clinics are OB-heavy and a lot of younger patients. That was something that when I got out of residency and into practice, especially as a gynecologist, I was getting a lot more exposure to menopause than I ever thought I would.
Tell us about your practice. Tell us about, where you are and how you got there. Then, and then we'll get into menopause.
[Dr. Jessica Ritch]
Great. As you mentioned, I'm at the Florida Center for Urogynecology. It's a private practice. I am the minimally invasive gynecologist in the practice. We have now two urogynecologists. We don't do any obstetrics, we don't do any cancer stuff, we really focus on benign gynecology. We have some great pelvic floor physical therapists in our practice. We have a really great center for that sort of thing, which means that we do specialize a lot in the things that we see as minimally invasive. Urogynecologists like fibroids and bleeding, pelvic pain, endometriosis, prolapse, incontinence, and all of those things.
We also do a lot of just routine gynecology. Running the gamut from, adolescence all the way up to 102. Just like you, I really didn't get much training on menopause in my residency. I think we had one lecture a year and it was a reproductive endocrinologist at the time who was like, "Well, as my patients got older and I got older, we were all going through menopause," and she picked things up and told us along the way. We really didn't see a lot of patients on it. We really didn't do a lot. Just like you, as I got into practice, I had to learn a lot more about that.
[Dr. Mark Hoffman]
We were so lucky in my practice when I first started. Kathy Dillon was-- Our division of-- what do we call ourselves? Gynecologic specialties, I think, because I was the first MIG surgeon and then we had a urogyn and then we had Kathy Dillon who was doing GYN-only menopause in clinic. We became this little land of misfit toys. She was NAM certified, North American Menopause Society, which I'd never heard of until I met Kathy. She had become like the resource. It was unbelievable how much she knew. Yes, I definitely have had that experience of just understanding, not just what we didn't know, but how much is out there and how much one person can know.
I'm sure your patients are very lucky that you've taken an interest in menopause, that you have decided to make that a big part of your practice. What have you done to become, I assume, like all the menopause patients get referred to you now that you're someone who has an interest and expertise in menopause?
[Dr. Jessica Ritch]
Definitely when I started out in practice, it was really that, as an urogynecology practice, we see so many women who have genitourinary syndrome of menopause. Basically, almost everybody who walks through our doors gets some vaginal estrogen or some kind of thing, therefore, but then they were having all of these other issues too. I was doing a lot of the routine care visits and hearing a lot about menopause. It was really something that my patients brought to me first. It wasn't something that I went and sought out initially.
Just like anything else I do in my practice, I always want to find answers for people. If it's something that I'm not sure about, I'm going to go and do a deep dive and do the research and talk to as many people as I can and listen and read up on what I can do and really try to get solutions for my patients. That's really how it started.
Then as I progressed, and as I'm getting a little older now as well, and in perimenopause myself, I really started to see more and more patients and see more and more symptoms and really just hear about people who were just being ignored or just getting the standard brush off from the routine OBGYNs that they were seeing. Not because there's anything wrong with those OBGYNs, but they're very busy with delivering babies and these other things, and they didn't get this stuff in their training either. I just sort of took it upon myself to learn more about it and to grow with what my patients' needs were.
[Dr. Mark Hoffman]
I will put myself into that group of people. I didn't know a lot and for what I was doing, it wasn't sort of what I trained to do. I'm not going to pretend like I was nearly as dedicated and thoughtful as you in my approach to dealing with menopause, and I was a little spoiled with Kathy Dillon, and now Kate Harris, who is on our team, a nurse practitioner who has learned from Kathy and become like my go-to. Now I have another person who is taking that on. All these questions start and-- I don't know, I feel like it's like someone asking me an obstetrics question these days. I'm like, "You should probably ask an obstetrician."
I've been a little spoiled because I have people in my practice who are like you, interested, dedicated, educated, and understand the complexity of it. How much of your practice now is menopause or management of perimenopause symptoms in that population? Because I imagine you're also a busy surgeon.
[Dr. Jessica Ritch]
Right. I still do a lot of fibroids, bleeding, endometriosis, and pelvic pain, but honestly, a lot of it starts to go hand in hand a little bit. Particularly when people are coming to me with bleeding issues, sometimes it may be partly related to their fibroids, but it may also be perimenopause or hormonal issues. There's a lot of overlap. I would say, definitely the menopause side of things is growing, especially since I've been doing the podcast and I have my patients who refer their friends to the podcast, and then their friends come and see me and their family members. It's growing more and more, but there really honestly is a lot of overlap between the patients that I'm seeing too. I may take somebody to the OR to treat their fibroids and then we still have to deal with their perimenopause issues afterwards. It's quite a bit.
[Dr. Mark Hoffman]
If I'm being honest with myself, we're gynecologists, so we take care of a lot of postmenopausal bleeding or like you said, patients who have perimenopausal bleeding, how we're managing that. We address the bleeding and now it's like, "Oh, well, now you go talk to somebody about your hot flashes because I don't know anything about it." The reality is that's taking care of the whole patient and that's what we should be working on.
(1) EnRitched: Enhancing Patient Education through Podcasts
[Dr. Mark Hoffman]
I'm much better than I used to be and much more educated than I used to be. I thought my lack of appropriate education on menopause was a great reason to have you on the show and tell us all about it. Let's talk about your show a little bit and then we'll get into some more medical stuff too. Where did that come from?
[Dr. Jessica Ritch]
Right. As you mentioned, I think it's great when you're in a big academic institution and you can segment those things out a little bit. I always thought that that's how I would practice. That's just not really how life turned out. When you're in private practice, not that you can't refer things out, but you want to take care of people and their whole issues a little bit more when you don't have quite the same amount of partners to put people through or put to in your same institution.
The show really originated, rewind back to early 2020. I was very pregnant with my third baby and I had her about a week before everything closed down with the pandemic. I was feeling very burned out and overwhelmed with being a busy surgeon, with having my third baby, with everybody suddenly being at home with the pandemic. I was really looking, "What else am I going to do with this stage of my career?" I got into a bit of a physician coaching group.
There was a lot about putting yourself out there that we have things to share with people in general, that it doesn't have to be some perfect message each time, but to get out there on social media and in other pathways. I started to experiment a little bit with Instagram, TikTok, YouTube, and all of these other things. While I was doing that, I started to think, "Okay, well, maybe a podcast would be a good way to go." I had a TikTok video that I had done. It was just like a one-minute something on genitourinary syndrome of menopause. Didn't think much of it. I think I did it in some side office one day just after I saw a patient and I wanted to talk to people about it. It went for me, what was viral, not really viral in the like millions of views ways, but within a weekend, it was over 100,000 people that took a look at it.
[Dr. Mark Hoffman]
Oh, wow. That's viral for anybody, I think.
[Dr. Jessica Ritch]
I thought, "There's really something here. There's really a place where people are lacking information." Of course, I knew that we lacked that information in our training. I knew that my patients were coming to me just feeling lost and needing answers. At the time there really wasn't a lot of stuff out there. I just started to jot down some ideas and just off the top of my head, I had 25 episodes on menopause and I knew people that I wanted to bring in and talk about it. I just said, "Well, let me, let me just get started and I'll learn this as I go. I'll bring the information that I have and I'll bring on experts to bring the information that I don't have." It's really been a great experience.
[Dr. Mark Hoffman]
Is it just you? Are you recording, editing, promoting? This is 100% you?
[Dr. Jessica Ritch]
It's not 100% me, but mostly. All of the ideas, all the scheduling come from me. I do have a virtual assistant who posts it and does some social media stuff. I do have a podcast editor because at first, the first, I'd say 10 episodes I edited myself. Then that was just not sustainable because it took a lot of time. I'm a mom of three, a busy surgeon. I was trying to do these episodes weekly, which is what I've been doing. I do have an editor and I do have a social media person, but mostly it's me.
[Dr. Mark Hoffman]
Look, we do this show every couple of weeks. We have a full team behind us that we did not build. We were lucky to get to be a part of it. You met our engineer Aaron before the show started, so you see how much help I've gotten to be able to do this at all. To think about what you've done on your own, it's not a small amount of work. It's very impressive. The show's great by the way. If you haven't listened to it, we'll put that in the show notes too, but EnRitched Menopause wherever you get your podcasts. Good for you. Congrats, it's fantastic. I was so excited to see it. It just popped up, I think, on my social media, I was like, "Oh wow, amazing. We got to get her on." Good for you. It's awesome.
[Dr. Jessica Ritch]
Thank you. I found it to be like really a valuable resource in general. Of course, I send it to friends and family members and things, but with my patients, we only have so much time in the office when we're counseling somebody and menopause is one of those things that it's so broad and it takes a lot of time and people need a lot of counseling. It's a really easy tool for me to say, "Okay, I'm going to start you on this and this is what I think's going on. Listen to this episode, this episode, and this episode, and then we'll come back and refresh." It actually really helps my practice a lot too and saves me some time.
[Dr. Mark Hoffman]
That's how you're getting your listeners. You're making your patients run your numbers up. No, that's brilliant though. It's a great clinical tool. It's a great way to communicate with your patients, like you said, in a way that is outside of the scope of what you have the time for in a 15-minute visit or whatever, the time we're allotted to see a patient. To be able to actually talk to them through your podcast and then they can write the questions down, come back and you can probably save a ton of time and they feel like they're getting a lot more information. That's fantastic.
[Dr. Jessica Ritch]
They are. there's only so much you can cover and even a 30-minute visit, there's only so much you can cover. I've got hours of podcasts out there that they can listen to. It's great. I've also had the opportunity of learning from so many of the experts that I've had come on. Menopause affects people from head to toe. I've had dermatologists, cardiologists, neuroscientists, nutritionists, personal trainers, and the whole gamut of people come on. I learn a lot from them and then I can incorporate that into my practice too. It's been really wonderful.
[Dr. Mark Hoffman]
Your podcast is patient-facing.
[Dr. Jessica Ritch]
Yes.
(2) Common Patient Complaints in Menopause
[Dr. Mark Hoffman]
I guess that's the audience versus our show, which is physician-facing. We know you know how to communicate with patients and you've done a great job with that. For our listeners who are primarily physicians, APPs, and other women's healthcare providers, talk to us about your side of things. What are the most common complaints that you're getting? What are the things that you manage the most frequently in your clinic in terms of menopause/peri-menopause complaints?
[Dr. Jessica Ritch]
Most of the time it's those patients that-- I used to just give a big sigh when I saw the chief complaint coming that it's like hormonal imbalance or they just don't feel right. A lot of people are coming in, they just don't feel like themselves. They know that something's off. They may have the more recognizable symptoms like hot flushes and things, and those people are a little bit easier to pinpoint. They may have more irregular periods and that's a little bit more easier to pinpoint too. Many times it's just, "I don't feel like myself. I'm fatigued. I'm not interested in my partner anymore. I have more mood swings. I maybe have pains in different parts of my body that I wasn't used to having," like in the joints, or, "I'm getting headaches or--" whatever it might be. It's usually like a whole constellation of symptoms.
I would say the most common thing that people are telling me is, "Just don't feel right. I just don't feel like myself. I feel like my body is turning on me," or, "I just don't recognize myself in my own body." Just like when we have to go through and really tease out what's exactly going on with somebody who's got chronic pelvic pain or abnormal bleeding, it's the same sort of thing. We have to tease out, "Okay, well, what do you mean by that?" and, "What is that symptom and how frequently is it happening? Can you track it with your cycles?" It just takes that careful dissection of the history to get to the bottom of things.
[Dr. Mark Hoffman]
We all hear that all the time. We all hear, "I just don't feel like myself," but to then take that and try to tease out actual things. The amount of patience that you have, I think of your kids as being very lucky. My kids have a father who's not nearly as patient.
[Dr. Jessica Ritch]
I'm learning patience.
[Dr. Mark Hoffman]
When patients say, "I don't feel like myself," what's an example of how you might address the things you might find in a patient who says, "I just don't feel like myself," because it's such a fake complaint? It's so hard to know where that can lead.
[Dr. Jessica Ritch]
Right. Just like we're taught in medical school, you start with the broad questions and try to narrow it in. "What do you mean by that?" Then we get into, "Okay, is it the fatigue? Are you feeling that all the time? Are you feeling that at certain parts of your cycle?" When we're talking about low libido or not being interested in your partner. some of that is maybe you just don't like your partner, but some of that is hormonal changes and genitourinary syndrome of menopause and pain with sex. It's really that I'm getting into asking each of those questions.
Honestly, when you start diving into it, you'll realize that it really does affect every part of their body. They may be having headaches, they may be having joint pains. They're having more depression, more anxiety. They're having hot flushes. They're having weight gain. That's one that I hear a lot. Everybody's worried about the weight gain around the abdomen, which is the more central obesity we always hear about. That becomes an issue. A lot of so many women that come to me and they say, "I just turned 40," or, "I just turned 45," or, "I just turned 50," and, "I'm doing all of the same things and I am gaining all of this weight. I just don't feel like getting out of bed anymore." Those are the types of things that we hear a lot.
A lot of it is just reassurance in the first part of things, just telling people, "Okay, you're not going crazy. Your body's not abandoning you, but that this is a change and this is a change that's as big as puberty." Once I can start to have people assess it in that way, they're like, "Oh yes, my body changed pretty drastically and permanently in puberty." Everybody expected that change and they knew that they were going to go through it. For some reason, I think because menopause, and luckily we're talking about menopause a lot more now in these last year or two, but menopause for such a long time has been something that hasn't been talked about, has been completely ignored. So many people are shocked when they get there, no matter what the age of the patient, I always hear them saying, "Oh, but I'm too young for this. I can't be going through this." Really those perimenopausal changes can start as early as the mid-30s, even in normal menopause, let alone premature ovarian insufficiency and things like that.
You really just have to have an ear for it and think about what could be going on. Lab tests can be helpful, but they're not that great. It's really listening to the complaints and trying to work people through that.
(3) The Role of Hormone Evaluation in Menopause
[Dr. Mark Hoffman]
Can we talk about labs for a second? I have so many people coming in of all ages, "I want my hormones checked. I want my hormones checked. I want my hormones checked." There are a lot of different types of practices out there. We have patients who see homeopathic or naturopaths, and there are other names they use. People who are getting their hormones checked on a regular basis and they're getting the pellets and the hormonal implants and those things, can we talk a little bit about the hormones because I think I have a very old-school understanding of vaginal dryness, vaginal estrogen, high flashes, systemic estrogen. Otherwise, I got nothing.
I can stay away from those hormone salesmen, snake oil salesmen who are just trying to get rich off normal things. Am I close? Am I way off in my management? Help me out here, because I feel like I'm doing what I was taught years ago. Has much evolved? Tell me how you approach those types of questions, those types of patients
.
[Dr. Jessica Ritch]
Yes, you're actually not that far off. I do-- [chuckles] Give yourself a little pat on the back. The same thing. Many people come in, "I want to check my hormones." At the same time, I don't just say, "Okay, let's check your hormones." I say, "Okay, well, what is it that's bothering you? Why do you want to check your hormones? Let's talk about whether this is going to be useful or not." Most of the time I'm telling them, "I don't think this is going to be very useful, but we can check." Now, sometimes it is, if they're having irregular periods and symptoms, we want to look for things like PCOS. We want to rule out thyroid disease. We want to look for prolactin issues. All of these other things.
Honestly, I'll check an FSH because if it's elevated, it confirms what I tell patients, "We already know that you're at least in perimenopause. The level is not going to tell me when you're postmenopausal. If you don't have a uterus, that's a little trickier to do." We have to go by the periods at least somewhat. We'll check an FSH and we'll look at things like estradiol and progesterone and testosterone. I don't even require a baseline for that. I do it if somebody wants to know it, but I'm not going to treat somebody based on those numbers. I would use those numbers more when we're treating somebody, if we want to adjust the dosing or if we want to look and see if things are getting a little too high around those areas, then I would look at those hormones. Most of the time, the labs are fairly useless to me other than ruling out the other conditions that can mimic perimenopause and menopause, particularly thyroid disease.
The way that I always counsel my patients is I tell them, "Look, we're not going to treat a number." While there are, especially here in South Florida, so many of these bioidentical hormone clinics that say, "We're going to test your saliva, your blood, or your urine. We're going to look at these levels of hormones and we're going to give you this number of hormones based on what it is." I have so many patients that come to me and they say, "Well, I'm on this because my level was low." I was like, "Okay, but what were you feeling to get on this?" I don't want to treat a number. I don't want to treat a lab. What number you have today is going to be different than the number you have tomorrow versus next week because they're still fluctuating. What number feels good to me is going to be different than what number feels good to my patient and to their sister and to their neighbor. We really want to treat based on symptoms, not based on those lab numbers.
[Dr. Mark Hoffman]
Okay, good. I feel a little bit better because that's what I tell folks, like, "I care about you and how you feel, not the lab." The lab says you're not in menopause, but you're having hot flashes and vaginal dryness. Do we treat? Do we ignore those symptoms? I don't want to ignore the symptoms if patients are saying they're having those symptoms.
[Dr. Jessica Ritch]
You're in line with ACOG and the North American Menopause Society, so don't worry, you're on the right track.
(4) Testosterone in Menopause: Benefits, Risks, and Clinical Use
[Dr. Mark Hoffman]
Good. The other big thing I want to ask, though, about this in terms of hormones is testosterone. A lot of testosterone questions, and I feel like I don't know anything helpful to tell patients about testosterone. I know that ovaries do produce testosterone, and I understand that when you go into menopause, your ovarian hormone production goes down. That includes testosterone. You're nodding, so I'm hoping that I'm somewhat right here. Tell me what you know about testosterone in the menopausal patient and what we can be telling our patients.
[Dr. Jessica Ritch] That is true. Definitely, the ovaries are producing testosterone. The testosterone seems to drop off a little bit later than the estrogen does. We tend to lose estrogen a little bit sooner and progesterone. The testosterone drops off a little bit later. I will tell you that my opinion on testosterone has been evolving, and it's still evolving, but here's what we know.
We do know that women who are getting testosterone supplementation do feel better in terms of less fatigue, more energy. They have improvements in libido and muscle mass, so it can be helpful in those ways. We do know there can be side effects to testosterone, so abnormal hair growth, acne, virilization things like voice deepening, clitoromegaly, things like that, that people don't necessarily want.
We don't know a whole lot about risks. These are not really well studied in women. The studies that we do have typically are followed for six months or less. They're usually using a topical patch that's not available in the United States. It looks like, at least from those small studies, that things are fairly safe in women. When we look at men, of course, the concerns in men are always things like cancers; prostate and testicular cancers, and cardiovascular disease. Some of the newer evidence suggests that it may be safer in men than we had originally thought, but there's really still not a lot of data on women.
It's not something that I start with. The argument I think a lot of people make who do a lot of testosterone therapy is that we would offer this to men. We care more about men's quality of life, it seems, than we care about women's. I agree, there are a lot of things that we do for men that we don't necessarily do for women, but I do think it's more of a conversation. I do think it shouldn't be a, "Well, your testosterone is low and you need testosterone." It should be a conversation about the risks and benefits. Just because somebody's male partner will take anything at any risk to improve their sex life, does not necessarily mean that the woman wants to do the same. It's really a conversation about risks and benefits.
When I'm starting someone on a hormone replacement therapy, I always start with estrogen, and then, of course, progesterone, if they have a uterus, to protect the uterus. Then even if they've come to me for testosterone, I say, "Well, let's just wait on that. Let's see how you feel first with the estrogen," because a lot of the symptoms that they're having in terms of the fatigue and also the libido and energy, those are going to improve with the estrogen alone, which are much better studied. We know the risks and benefits in women of estrogen and progesterone much better than we know testosterone. Then I say, "If you're still having very bothersome symptoms, then we're going to consider adding a topical testosterone," but that can get a little bit trickier.
[Dr. Mark Hoffman]
Is it trial and error, really? Are you measuring testosterone? I know we talked about labs a minute ago, but do you check testosterone levels in women at all? Is there any value in that?
[Dr. Jessica Ritch]
I do check them initially, but again, the initial is really more to rule out the other things, particularly in the perimenopausal person, to see if it's a PCOS issue or something along those lines. If I'm supplementing testosterone, which again, I don't start with, so it's not the majority of my patients who are on testosterone, but if I'm supplementing testosterone, then I will check the levels mostly to make sure that they're not getting crazy high. There are no set therapeutic levels for what a woman's testosterone should be, so it's not like you're titrating a dose to a specific level. It's more like, "Okay, well, what's the normal range of what a woman should have?"
I do have some patients who are on the pellets and other things, not that I've given them the pellets because I do not do that, but who have come in on pellets. Sometimes their levels are three, four times what a normal female should have in terms of a testosterone level. I don't think that's where anybody needs to be.
[Dr. Mark Hoffman]
What are the kinds of things we should be looking for? You mentioned energy and libido. In terms of response and dosing and things like that, we don't need to go through specific doses, but is it similar to estrogen where it's like, "Let's give you a little more, see how you feel. Let's give you a little more, see how you feel." Then you have a point where "Okay, I don't think any more is going to help," and it's more of a trial-and-error type thing?
[Dr. Jessica Ritch]
A little bit. There are some guidelines. There are basically a couple of different ways that you can do testosterone. Some people will do injections in the pellets. Like you said, I don't do that. The pellets I'm not really that comfortable with. I think they're poorly regulated, not well studied, can be inconsistent. There is, of course, FDA-approved testosterone for men. Topical, a gel product that you can use. Generally, for women, we just start at a 10th of the dose of men. Not super scientific. It's like a pea-sized amount that they rub into their skin. That's one way to do it. They probably won't have that covered by their insurance, but because the tube is going to last them so much longer than it would for a man, it's usually one or two tubes in a year.
The other way is to use a compounding pharmacy, which as I said, I'm not a huge fan of compounded bioidentical hormones. I do use compounding pharmacies when I need to, when I can't get something that's commercially available. I have a few in my area that I feel comfortable with, but it's sort of the same thing. We just start at a low dose and then we build up from there. I will talk with the pharmacist specifically about how they make that and how we can dose each patient.
Really then, I'm checking the levels to see, "Okay, are we getting too high?" Then for the effectiveness to see, basically it's always, "How do you feel? How do you feel with that?" Some people feel great with it. I would say the majority feel great. They have more energy. They have their sex lives back, but I do have a lot of people too who are just like, "Whoa, that was too much. I don't want to be on that anymore." It's always trial and error. You have to see how each person is going to respond to it, just like with anything else.
(5) Postmenopausal Hormone Production
[Dr. Mark Hoffman]
Do the ovaries still make a physiologic amount of testosterone that's of value after menopause? I know that there was this whole push, I think, like when we were in training, I'm a little bit older than you, but it was, "If you're going to get a hysterectomy, leave the ovaries out." In the last 10 or 15 years or so, I've been like, "Leave them in no matter what, unless there's something wrong with them." Now the pendulum has swung back, saying, "Probably can take them out at 50," or, "If you take them out earlier, you can probably just give them HRT and they're fine."
What do we know about postmenopausal ovaries, what they do, whether it's estrogen, progesterone, testosterone, and how are you counseling patients on that?
[Dr. Jessica Ritch]
Generally the first thing that drops off is the progesterone. That's typically because not really ovulating regularly anymore. If you're not having that ovulation trigger, you're not getting that same rise in progesterone that you usually get after ovulation. That tends to drop off first. I think that's why I have so many patients who come in to see me who are just on progesterone. They've gotten some labs that show that they're low, I don't see much value in that. Progesterone, there's some evidence that it can help with sleep for people with sleep apnea, but in general, nobody should just be on progesterone.
Then, of course, the estrogen starts to drop off as the ovaries aren't responding more to the FSH. Even though FSH is going up and up, the ovaries are going to stop responding at some point so the estrogen is going to drop off as well. Then testosterone is a little bit of a lag. It's a couple of years behind the estrogen and progesterone in terms of the drop-off because it's not really the same cyclic stimulation that we see in the ovaries for the menstrual cycle. The ovaries are still producing some testosterone even when the estrogen and progesterone are dropping. Then of course we have steroid hormone production in the adrenal glands, although much less so than we were getting from the ovaries. It is a little bit of a slow drop.
Like I said, the majority of symptoms that we're seeing in perimenopause and menopause are due to, first of all, the erratic fluctuations of estrogen that are happening in perimenopause. I will have some of those patients that come to me that are monitoring their labs all the time. I have a nurse who I see, and she's always like, "But the estrogen was so high." Then we go through the pattern. We're like, "Yes, it went high because the FSH was so high. Then it stimulated the estrogen." We're not going to treat the numbers. We're going to treat how people feel, stabilize things along the way, and then see what we need to add back in to get you feeling better.
(6) Bridging the Gaps in Menopause Care: A Patient-Centered Approach
[Dr. Mark Hoffman]
It does feel like we just don't know as much as we should. We've practiced in the field of women's healthcare for our whole careers now. Neither of us is shocked to talk about a problem that is specific to our female patients that is poorly understood or underfunded or those kinds of things. It does take people like you to take that extra step of listening to patients and seeing what works, seeing what's out there. I'm maybe a little more conservative in my practice for things I don't know about, which I don't think is a bad thing. Just, if I don't know about it, I'm not going to mess with it.
We are in many ways depriving our patients of options for treatment for things if we just say, "Oh, well, ACOG or NAMS says don't do it," that's that. Well, no, we just may not know enough. Providing patients with the available information and say, "Look, this is what we know, this is what we don't know. These are the risks." Make sure we allow our patients to make as informed decisions as we can but to say no without at least engaging in that conversation does feel very paternalistic. I applaud you for your work and for giving our patients that. I think a lot of folks out there who have practices and manage patients-- I guess, docs who have a large menopausal volume in their practice who do this stuff. There's clearly a need for it. It's a huge part of the practice. I hear a lot about it, In my practice, I just don't know much about it.
[Dr. Jessica Ritch]
Yes, of course, the funding for women's health is abysmal, we don't know so much about so many things. We're very quick to drop something if we start to see an issue, which I get. I think that the safety part is most important, but we definitely treat women differently than we treat men. We need more information, but in the meantime, we have to work with patients. NAMS has started to come around on the testosterone issue and does say that it's appropriate in certain areas. Like I said, that's taken me coming around too. At first, I was not very convinced about testosterone, but patients kept coming to me and asking for it. I've talked to more people, done more research. Again, it's not like I'm going to give everybody testosterone, but I can say, "Okay, well, these are the risks that we know of. This is what we don't know. These are the benefits." Then we make a decision together.
[Dr. Mark Hoffman]
I've done the same thing with surgery. I think initially I was like, "Well, here's what we can do. I can't do this." Then it's like, "Well--" I'm not saying we should just say, "Well, whatever the patient wants, I'll do." Obviously, we have to be thoughtful in how I counsel, but I also trust patients to make informed decisions about themselves. We have cosmetic surgeons who do all sorts of things for no clinical reason, right? I also think patients have bodily autonomy and they have the right to make decisions about themselves, even if it's not what I think I would do. As a male gynecologist, I have no idea what I would do in that situation because many of the times I've never been in that situation.
Number one, listen to your patients, listen to your patients, listen to your patients. It's like shockingly and not shockingly the most important thing we can do that we also just have to remind people to do again and again and again, and have patients say, just, "Thanks for listening." The further along I've gotten, the better listener I hope I've gotten. A lot of times we don't necessarily intervene or do anything, but just by listening, we can make a big impact on our patients. Huge part there.
I think educating ourselves enough, but allowing our patients to make informed decisions, saying, "Look, this is what we don't know." I think that's something I've done with surgery more and more is, I don't know that I think that's what I would recommend, but also, there's a possibility of improvement and there's some value there. You understand the risks, you understand what we're getting into and we document it and we write it down and we have a plan. Again, multiple visits, we're reviewing, you go home, read about it, but trust your patients, listen to your patients, trust your patients.
[Dr. Jessica Ritch]
Right, with anything else, you would just say, "Okay, well, this is what I would recommend, but if this is something else you want to do, I think that's a reasonable decision and these are the risks and benefits." Yes, we always have to listen to them and know we are not just technicians doing whatever people order up. We still have to listen to their needs and try to address them as well as we can.
[Dr. Mark Hoffman]
Admit that we just don't know enough. We just don't know enough. There's this big black box of information out there that we doctors don't know. My wife's not in medicine. She's always asking me, "How could you guys not know this stuff?" I'm like, "Somebody has to pay for someone's job to go do the research to go figure these things out. There's a lot out there to figure out." We don't know all the answers and it is frustrating, I think, especially for patients, but especially for something like menopause. I understand some super rare thing, but this is basically everybody, right?
[Dr. Jessica Ritch]
Yes, exactly.
[Dr. Mark Hoffman]
Half of everybody, I'd say, but unfortunately the half that gets less funding, that has less support in healthcare. It's not shocking, but it is something that is not rare to go into menopause. It's basically 100% of people eventually–
[Dr. Jessica Ritch]
As long as you live long enough, it's going to happen
(7) Addressing Sexual Dysfunction in Menopause
[Dr. Mark Hoffman]
Live long enough, that's right. That's right. Let's talk about sex. How much of your practice for menopause is around sexual function and changes in sexual function, whether it's hormonal, whether it's anatomic, physiologic, and those kinds of things?
[Dr. Jessica Ritch]
I see a whole lot of people for sexual function and that's partly because of my menopause practice, but also partly because of my pelvic pain practice. Some of the people that I'm seeing are 19 with sexual function issues, but definitely, I'm seeing a lot more people who are coming in that perimenopause, menopause with pain with sex, with lack of interest in sex, with dryness, discomfort, tearing, genitourinary syndrome of menopause, lichen sclerosis, pelvic floor dysfunction, all of the above. We have to capture all of those issues. I never want to do too many things for somebody at once, but generally, it's like multiple different issues that we're working on. We're going to give them something for the lack of estrogen in the vagina. We're going to work on their pelvic floor if they have that issue. We're going to treat the lichen sclerosis if they have that issue.
Generally, I'll start with those things first before I start doing things to treat libido overall because if somebody's having pain with sex, of course, they don't want to have sex. That's a given. We'll work on those issues and then if we're still having an issue, then I start to address the libido side of things a little bit more.
[Dr. Mark Hoffman]
Is testosterone it for libido? What are our options? As you said, I think if it's pain, in general, we have some options, like you said, whether it's just vaginal dryness and atrophy, lichen sclerosis, which you can see and treat, or musculoskeletal causes of pelvic pain and dyspareunia. If they're not having those things and it's truly just libido, what are options? I do feel like I'm just letting people down every day when they say, "My libido's gone down." I'm like, "Sorry." I would love to give them more information.
[Dr. Jessica Ritch]
There are options out there. Again, it is one of those multifaceted approaches. There are a lot of changes that are happening in life at that time too. We have to deal with all of that. Sometimes it's you don't like your partner. Sometimes you're running around between your job and your kids and your elderly parents that you're caring for, your PTA meetings and sex is the last thing on your mind. People are so busy right now. Sometimes it's just that your body's changed and what you like has changed and you haven't really taken the time to explore that. Sometimes it is really just like a hormonal issue. Usually not. Usually, it's like a multiple issue. Yes, testosterone is one of the things, but I have a great sex therapist. It's on my podcast. It's local that I have people work with.
I really like the Rosy app. I don't know if you're familiar with that. This is a great place to refer your patients. It's an app. It was developed by an OBGYN, Dr. Harper, you should have her on. She's out of Texas. She was having trouble with the sexual issues that her patients were coming to. She created this app where they have everything from erotica at different levels of steaminess that people can handle to sex coaches and anonymous group therapy. They have all of these different levels of ways that you can address libido and information. I'd like to refer people to the Rosy app.
There are some supplements out there with some limited evidence. Typically, I don't know if we can talk about different particular brands, but I like the Hello Bonafide brand for a lot of their supplements because they have things like Revaree, which is hyaluronic acid for the vagina. They have some supplements for menopause and they have one called Ristela for libido, which for some people it doesn't work, and for some people, they tell me it's life-changing. It's a little bit of a, see what works for them.
Then there are the newer non-hormonal things that are out there. There's Addyi, which is the oral medication, that people will call the female Viagra. It's not female Viagra, but it is something that can improve interest and can improve the sexual experience in general. Just like anything else, it's not perfect for everybody. I've had some patients who haven't gotten much improvement from it, some that do. The data I find is not super compelling; one increased sex episode a month. I think it's also a little bit of how they have to measure that. It's really hard to measure your interest in sex or your sexual satisfaction. Just one episode a month sure might be like a big deal for somebody who wasn't having sex before or wasn't having enjoyable sex before.
Then there's [unintelligible 00:43:53], which is more the injection. I don't use as much of that because I find not many people want to inject themselves an hour before sex. I don't tend to use a lot of that. The point is that there are options out there. There are things that you can do. You can at least refer people to some podcasts or some literature or to the Rosy app so they can start thinking about, "Okay, what is the issue that I'm really having?" Everybody, of course, wants to just pop a pill and have everything all be better, but that's really not the solution for most people, it's usually communication in their relationship and working on the pain issues and a multifaceted approach.
[Dr. Mark Hoffman]
Yes, I was taught and I tell this to my patients, the brain is the biggest sex organ, right? If you don't like the person you're with, tough to be intimate with them, or dealing with significant financial distress and you're going to lose your house or get fired from your job. Yes, it makes sense that your brain is like busy doing other stuff.
[Dr. Jessica Ritch]
Hard to feel sexy at that time.
[Dr. Mark Hoffman]
It makes it tougher for everybody involved. To be able to elicit that history and understand the stress that people are going through, back to what we were talking about earlier, it's to say, "It sounds like you're dealing with a lot. Sounds like maybe your brain is prioritizing things here. Don't put that much pressure on yourself to be everything." Sometimes just hearing that, listening to your patients, and providing reassurance that they're not broken, they're super busy. Then most of the time, that's where the conversation goes and they just needed to hear it. Sometimes they'll bring their partners back in. They, say, "Listen, things are stressful right now. Things are crazy right now. Let's just make sure we're putting things in order." I think that's a huge part of it, but to know that there are other options. I do get to the point where patients are like, "No, no, everything's great. My libido is not where I want it to be." To know that there are other options, there are things out there that may work is pretty valuable for patients. It's pretty powerful knowing that at least there are things out there they can try, whether it's apps.
This seems to be a topic so ripe for social media blogs or groups and things like that online because people like me don't know enough, and so they're going wherever they can to get help. Having someone like you, who's an authority in this, who's trained, who's done their homework, who can provide that information, I think I'm not surprised at all that you've got a lot of people very interested in your show and in what you're doing.
[Dr. Jessica Ritch]
I think that we really underestimate it. This may sound a little bit woo-woo, but I think that we really underestimate as doctors how much we really are healers and how much sometimes just listening to our patients, validating their concerns, giving them options, letting them know that, "Okay, maybe this isn't the answer, but I'm going to stick with you and we're going to keep working on this until we get you feeling better." That has tremendous healing effects. There's data to show that even just understanding what's going on with your body in menopause and in many other conditions makes a huge difference. Having somebody who's a caregiver, who has some knowledge and information who can share that with you, who cares about what's going on with you, it makes such a difference. I think we really underestimate that.
There is so much out there in social media in terms of misinformation. That's really part of why I wanted to get out there and at least put out some good information. It's not like some magical cure. I'm not going to say, "Oh, you're going to evade menopause with these three easy steps." That's not what I'm trying to do. It's really basic information that people just need to hear and they need to trust it enough that they're going to act on it. That's really the difference.
[Dr. Mark Hoffman]
I think maybe it's our pelvic pain training too. I think a lot of it is we've heard so many people over the years who just say, "No one believed that I was in pain." Just saying, "No, I believe you. I can't promise results. I can't promise an outcome, but I can promise that I'll be here, that I'll keep seeing you, that we'll try to figure out what's going on." It's not all they want, they want to feel better. At the very basic level, "I believe you." What's the line at the beginning of your show? "You're not alone. You're not crazy." Is that what?
[Dr. Jessica Ritch]
The reverse, "You're not crazy and you're not alone."
[Dr. Mark Hoffman]
They could be crazy and alone, but that's not always the reason. I think just like we said, validating and just listening. Whatever we're doing in medicine, maybe in life, just listening to people and not trying to solve necessarily, it's not always about the solution, sometimes it's just about having someone who's willing to walk down that road with them and just say, "I'll be there for you and you can keep coming back to see me and we'll listen." That seems to be a very powerful thing that many of our patients in both chronic pelvic pain and other complex medical conditions where we don't always have the answer-- This is a big one. This is one that is extremely common that affects, like we said, almost-
[Dr. Jessica Ritch]
Everyone.
[Dr. Mark Hoffman]
-everybody if you live long enough. Right.
[Dr. Jessica Ritch]
I agree 100%. I do think that my pelvic pain training really helped me to get into this area more. Just like you said, my pelvic pain visits probably take the longest, but I would say the menopause visits are the second longest there because once you start listening, people really open up and they have all of these things that they just never really shared because nobody really gave them the time of day to do that before. That's where it is helpful to have a resource to get them started and move through.
So many times it's just really, they went to multiple different doctors just like those pelvic pain patients and they were told, "No, you're too young to be in menopause because you're 42 and not 52," or, "You're still having your period," or, "Your FSH is low today, so it can't be that." Again, you've got to put the pieces together, validate them, and walk with them.
(8) The Future of Menopause Care
[Dr. Mark Hoffman]
What's next on the horizon for medicine, or for menopause? What's coming down the-- is it pike or pipe?
[Dr. Jessica Ritch]
Coming down the pipeline.
[Dr. Mark Hoffman]
[chuckles]
[Dr. Jessica Ritch]
There are a few things that are sort of new-ish in the menopause area too. It's not all just estrogen therapy. Earlier, well, I guess it was last year now, there was the release of Veozah, which is the neurokinin 3 receptor antagonist. That's for hot flushes specifically. I do think that that's a nice option that's out there for people who can't or don't want to be on hormones, particularly people who are aging out of when the hormones are really safe. That's something that's new.
There are some newer vaginal suppositories, like a DHEA suppository. It's been around for a little while, but for people who've been out of training, you may not have really looked into that. For people who aren't tolerating estrogens, who have issues, that's an option down there too. There are combinations of estradiol with selective estrogen receptor modulators for hormone replacement therapy for people who aren't tolerating the progesterone side of therapy. We have a lot of new-ish stuff. People who have been out of their training for 5 to 10 years or more, you have to keep up on some of that.
In terms of what the future looks like, hopefully, better research. I do think that menopause is having a moment in society and women's health. The lack of research in women's health is being a little bit more recognized and a little more federal funding starting to go towards that. Hopefully, we'll get a little bit more information along the way. I really think that what I see for the future of menopause care is really a more comprehensive care solution. Not just you come in for 10 minutes, we measure your hormones and give you a pellet, but really what we've been talking about this whole time, having a conversation, using medications when we need to, but also using lifestyle factors.
There's lots of data out there supporting things like diet, exercise, meditation, acupuncture, and all of these other things that can help along with the symptoms. I think really bringing those together in a more comprehensive way is important. Just making sure that both providers like ourselves and then people understand what's coming and understand that menopause is a part of life and that it can start earlier than-- People think about it as grandmas and it can start a lot earlier than that. Just recognizing that and getting people to treatment and to getting to understanding a little bit easier I think is so important.
Also recognizing that this is like a new phase of life, it's not the end of things. People think of it as like sometimes the end of womanhood or the end of my sex life or the end of-- It's not that. So many people that I have spoken to through the podcast and now more and more with my patients, it really can be a new beginning, a time to make pivots in your life, to reevaluate where you want to be. I have so many patients who are post-menopausal who tell me their sex life is better than it's ever been because they've gotten rid of all of their preconceived notions of what sex should be like and are actually doing it for themselves for the first time in their lives. It really can be a great time. We just need to give people that comprehensive care that they need and hopefully get a lot more data on the treatments that we're giving and the safety and how long we can use them, what doses we should use and all of this information.
[Dr. Mark Hoffman]
So much to learn. We can have you back on in a year or so and you can tell us all the things that have come out in that time and review everything. I know you're busy. We appreciate you coming on. This has been extremely helpful for me and hopefully, some of our listeners who, like me, have not been as up-to-date for our patients as they should be, or at least aren't as aware of what's going on out there for managing and caring for folks with menopause.
Thank you so much for coming on. We encourage all of our listeners to listen to EnRitched Menopause, wherever you get your podcasts. Also, I'm going to start using it as a resource for my patients. Let them know so they can go get their questions answered by somebody who actually has an answer, who actually knows something.
Podcast Contributors
Dr. Jessica Ritch
Dr. Jessica Ritch is a minimally invasive gynecologist at Florida Center for Urogynecology in Miami.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2024, April 16). Ep. 51 – Menopause Matters: Clinical Strategies & Patient Support [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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