Not your mother's menopause, with Dr. Gillian Goddard

[00:00:00] I want to ask you a lightning round of questions if you're open to playing along. Sure. Okay, so here we go. If you are in your 40s, what is the one thing you should know about menopause? There is no reason to suffer from symptoms.

[00:00:20] If you are in your 30s, what is the one thing you should know about menopause? You are too young for menopause and if you're seeing changes in your periods, you need to see your doctor. Okay, last one. Maybe the most challenging.

[00:00:34] If you are in your 20s, what is the one thing you should know about menopause? To be really forgiving to your mother and give her some grace because she's going through it at the moment or she might be. Hi, this is Overlooked and I'm Golda Arthur.

[00:00:54] You just heard me throw those questions out to Dr. Gillian Goddard. He's an endocrinologist and writes about women's health and menopause in a newsletter called Hot Flash. There's a lot out there on menopause and I wanted to be able to talk to someone knowledgeable

[00:01:10] about how we navigate it all. Gillian Goddard was game for that conversation. But before we go back to Gillian, I want to tell you that this is the last episode in season two of Overlooked. We're taking a break over the summer and hopefully coming back with season three

[00:01:26] in the fall once we get some funding for the show. But if you want to talk to me or send me ideas for stories or anything else, you can do so by subscribing to my newsletter. Head to OverlookedPod.com and get on the email list.

[00:01:41] Okay, here's the episode with Dr. Gillian Goddard. Hi Gillian, welcome to Overlooked. Hi, thank you so much for having me. Well I am so happy to have you on the show because I follow your newsletter Hot Flash. Firstly, what a perfect title. Thank you. I love it.

[00:02:05] And the thing I really like about your newsletter is it is so detailed and you know, you're always quoting a study or it just seems so solid and so credible to me that I trust it immediately and I think that's so important for health information.

[00:02:23] Oh, thank you so much. Yes, one of our biggest goals with Hot Flash is really to make it absolutely evidence-based and to point out at times when we're talking about things where maybe their evidence just doesn't exist. The study hasn't been done yet.

[00:02:39] So hopefully call attention to some of those things too. Yeah, and I'd love to talk to you about that, about the studies that don't exist. But before we go there, I want to just clarify one term. The term I want to clarify is menopause.

[00:02:54] I wonder sometimes that when people talk about menopause, are they using the term menopause and perimenopause interchangeably? And I guess I'm asking because I'm one of those people who has had surgical menopause,

[00:03:09] which is you know, it's pretty rare to be able to like flick a switch and you're in menopause. Usually, it's much more gradual, much more confusing than that. So I really differentiate sort of before and after that surgery.

[00:03:23] But to what extent do you think that's true that when people say menopause, sometimes they're really talking about perimenopause? Oh, I think it's 100% true. So menopause is a diagnosis that you can only have after you've already been in it for

[00:03:37] a year unless of course you've had surgical menopause. So if you have had natural menopause, you know that you are in menopause when you haven't had a period for a full 12 months, then you can say that you're in menopause.

[00:03:53] But you're right, that term menopause gets used to refer to this entire complex of things that women experience throughout their middle 40s and on through into their 50s. It's also a little bit funny now because a lot of women have IUDs or are taking birth control pills

[00:04:18] into their 40s and 50s. So they may not know exactly when they went through menopause because, you know, they were taking hormones that were changing their menstrual cycles. And I think people talk a lot about changes in the early 40s and even in the late 30s

[00:04:37] that are on the spectrum of perimenopause and menopause but are not truly part of perimenopause called the late reproductive phase or stage. I think it's important to make that distinction as well because a young woman in her late 30s

[00:04:57] who starts to have a regular period should not chalk that change up to perimenopause. And so I think when we start referring to the symptoms women have in their late 30s that may be related to their reproductive aging, we want to be careful about using the term

[00:05:14] perimenopause because we don't want those women to not have those issues addressed. Okay. So menopause is having a moment. The New York Times said it so it must be true. That's right. And, you know, my Instagram feed, for example, is just full of people trying to sell me

[00:05:32] menopause products and services. But what I've noticed is that, you know, while I applaud the innovation and the attention, what I've noticed is that sometimes something pops up on my feed and I'm like, wait a second, that doesn't strike me as being entirely true.

[00:05:49] Is there such a thing as menopause misinformation? Absolutely. Absolutely there is. And I think it stems from the way we consume our media because people are trying to get eyeballs on their feed, on their TikTok and what you can convey in an Instagram post or a real or

[00:06:13] TikTok is you can't convey any nuance or it's really difficult to convey nuance in 90 seconds. And so what I find is what you see on social media a lot is very reductive.

[00:06:27] It is very one note and it's either in my experience, estrogen is terrible and you should use a natural supplement instead. Oftentimes that's coming from the people selling the supplements, which I always try to be very careful about.

[00:06:46] There may be data behind what they're selling, but you still have to remember it's essentially an advertisement or conversely, every woman should be on estrogen. Everybody needs estrogen. Estrogen is the fountain of youth. And I would say the reality lies somewhere in the middle.

[00:07:04] Estrogen is an incredibly useful tool for many women. It is quite safe, but it is not the fountain of youth. Yeah, it seems like such a provocative thing, estrogen, just conversations about it. What is the best thing to do then, Jillian?

[00:07:22] Is it really just to talk to your doctor? I mean, I think you do need to talk to your doctor, but you can go into that conversation with your doctor having educated yourself about what the options are and thinking about what your goals are.

[00:07:40] And I think that this is a part of a doctor patient conversation that is really unrecognized and would make every one of our doctor-patient interactions better, which is your goal and your health care provider's goal may not be aligned.

[00:07:59] And so being very explicit about what your goals are is important. So for example, say I'm having hot flushes and night sweats, my sleep is disrupted and I'm miserable. And what I really want is to have my symptoms treated.

[00:08:17] It helps to go into the conversation saying, I really want my symptoms treated. These are my symptoms and I really want them treated. I've done a little reading and I know that there's hormone replacement therapy and then there's also non-hormonal options.

[00:08:35] Can we have a conversation today about the risks and benefits of those options for me so that we can decide which one might be best for me? I hope that helps listeners because that is such a important and complex relationship, I think between us and our doctors.

[00:08:53] So that's a great way to do it, I think. I want to roll you back a little bit and talk about it's great. Like look at us talking about menopause on a microphone. I know, isn't it wonderful? Say it out loud.

[00:09:06] And I think I'm convinced and this might be because I am a Gen Xer, but I'm convinced that it's because our generation has not just put it on the table but slammed it on the table and said, unlike our mothers and the

[00:09:22] generation that came before us, like we are going to talk about this. We're not going to suffer in silence. I love that it's like so characteristic of our generation. But it does kind of make me wonder, wait, why has it taken this?

[00:09:39] Like why don't we know more about menopause than we do? And I guess when I say we, I'm talking about, you know, us as women, people experiencing menopause, but also medicine. Why doesn't medicine know more about menopause?

[00:09:54] So I would say the answer to this question is a little bit historical. For a long time, people did not do research on women at all. The assumption was that we were like slightly smaller men. And so we can just generalize all the research about men to women.

[00:10:17] Part of that is because there are historically was some issues with medications that women took when they were pregnant that impacted their babies significantly and it rightfully made people want to be cautious about studying women who could be pregnant.

[00:10:34] And until the 1960s, the options for women to control their fertility were quite limited. And we also weren't very good at knowing when women were pregnant. I mean, when my mom got pregnant with me, she had to miss two periods

[00:10:48] before the doctor would even see her to do a confirmatory test. And these days we don't even miss a period and we can take a test in the privacy of our own bathroom. So a lot of that had a big impact on it.

[00:11:03] Then we come into the 90s and people are starting to think about women separately, which was a great thing. And they designed a large study called the Women's Health Initiative. And the goal of the Women's Health Initiative was to look at how estrogen

[00:11:28] impacted women's cardiovascular health and their bone health. So let's be totally clear about that. The Women's Health Initiative was not about what symptoms women were having. It was about how does estrogen impact our cardiovascular health and our bone health and also a little bit dementia?

[00:11:52] The challenge was women in their late 40s and 50s don't have a lot of heart attacks and strokes, which is great. We are relatively protected by estrogen through our reproductive lives. So to give women hormone replacement therapy at the time of menopause

[00:12:10] and then watch them, you would have to wait many, many years, decades to start to see whether the women taking estrogen were different from the women that weren't. And that study would be really difficult to conduct and it would be really, really expensive.

[00:12:29] And so they thought what they would do was get around those roadblocks by giving women estrogen later in life and seeing if it was beneficial or protective there. So the average age of a woman in the Women's Health Initiative

[00:12:44] was in her 60s, so more than 10 years out of menopause. They were starting on estrogen at the time they started the study and you could be up to 79 years old and enroll in the Women's Health Initiative. And what they found was when you gave women a very specific

[00:13:07] hormone replacement therapy, Prem Pro, so Prem Pro is a combination of estrogen and progesterone. It's a conjugated equine estrogen and a micronized progesterone. That's important or just conjugated equine estrogens. And so conjugated equine estrogens are actually isolated from the urine of pregnant horses.

[00:13:29] So that is the formulation that they used when you give women who are average age 65 estrogen back after a period of time, when they have not been on estrogen, you actually increased the risk of cardiovascular events. The study was stopped early because of concerns around safety.

[00:13:50] It was every newspaper. The other thing they found is there was a very tiny increase in breast cancer, but they didn't talk about how tiny the increase was. They just talked about that there was an increase in breast cancer. And women en masse through their hormone replacement

[00:14:07] therapy in the garbage and then just suffered in silence. The other thing that that study did is it really limited who wanted to do research on menopause and women's health? There was concern about it had a real chilling effect on research, research dollars.

[00:14:35] So you couldn't even get the money to do some of the studies that you wanted to do. And even now, a lot of the data that we have about menopause is post hoc analysis of women's health initiative data. That is finally starting to change.

[00:14:53] We have finally started to get enough data to feel really comfortable that in many cases and for many women, hormone replacement therapy is safe. And I think the other thing that's going on is we Gen Xers, I'm a Gen Xer too.

[00:15:09] We watched our mothers suffer in silence and we don't want to have that experience. We are at the peak of our careers. Our kids are older. We're at a point in our life where we don't want to be set back by

[00:15:28] not having gotten a good night of sleep because we're having hot flashes all night. Like we're just unwilling to put up with that. Thank you for that explanation. I think, again, you bring such context and such detail to the simplest of questions. And I think that's really important.

[00:15:43] If I could take us to today, like right now, knowing the historical context, is menopause being taught in medical schools right now? And if not, what is it going to take for us to get there? I think that we are going to begin to see those changes.

[00:16:01] I was actually in medical school when the second study on the Women's Health Initiative came out. That was the study on women who are on estrogen only. And so that was a really interesting time to be learning. I think things are starting to change.

[00:16:18] I think the big place where things are starting to change is especially in postgraduate education. So if you look at the data, so I'm an endocrinologist, which means I was trained as an internist and then I did a fellowship in endocrinology, which is all things hormones.

[00:16:34] But when you look at the data around who is prescribing hormone replacement therapy, most women are getting their hormone replacement therapy, not from someone like me, although I prescribe hormone replacement therapy all the time. They are either getting it from their gynecologist or from their primary care doctor.

[00:16:52] And so what that means is the first line of change is really changing residency training for the future gynecologists and obstetricians of the world and the future primary care doctors as well. And I think those changes are starting to happen.

[00:17:10] We're just seeing some pro hormone replacement therapy guidelines coming out from some of the big issuing organizations like the American College of Obstetrics and Gynecology or ACOG. And so as those guidelines start to change, that definitely filters down into medical education, but it's a slow process.

[00:17:35] Well, at least it's happening, I guess. At least the needle is moving, right? It is. It is. Well, listen, so I want to start to draw us to a close. And I ask all the guests on this show to share a story that, you know,

[00:17:50] we all know that the women's health gap exists. But I think sometimes people talk about it in a very academic way, whereas everybody knows that is incredibly real and that it is visceral and that the stakes are high. You know, things are being lost.

[00:18:08] Things have been lost because the women's health gap exists. Can you think of a moment in time or a thing that happened? A story to tell me where that was really brought to life for you.

[00:18:23] So I saw a patient a couple of years ago, I think, for the first time. And she was coming to me because she thought she might have a thyroid problem. And as we started talking, she listed several symptoms

[00:18:42] that I thought were more likely to be due to menopause. And she talked about how she was having sometimes a 20 hot flushes a day. She was waking up sometimes four, five, six times a night drenched in sweat. This woman happened to be African-American.

[00:19:06] And when I asked her, well, do you think your symptoms could be related to menopause? She said, I thought about that and I talked to my gynecologist about it. And he said that he thought it was menopause, but there was nothing to do

[00:19:20] because hormone replacement therapy would give me cancer. And so I just had to suffer because hormone replacement therapy will give me cancer. And I said, I think I have a little bit of a different take on that. And I ran her through the data on hormone replacement therapy

[00:19:47] and the risk of breast cancer specifically, which is the one we know the most about. And the actual increased risk of breast cancer with hormone replacement therapy in women at usual risk for breast cancer. And in those women at usual risk for breast cancer, there's a

[00:20:06] minuscule increase in the risk of breast cancer. And based on that and based on how she was feeling, which was miserable, we decided to start her on a little bit of hormone replacement therapy. And she came back and her symptoms were better.

[00:20:23] And we said, well, your symptoms are better, but they could be even better. Let's increase the dose of your hormone replacement therapy a little bit and see if you get even better control of your symptoms.

[00:20:34] And the time that she came back the third time, she was feeling so great. She was so happy. She like cried and hugged me and she said it had changed her life. I was a little taken aback by how thrilled she was.

[00:20:53] I think I didn't even appreciate at the beginning how much she was suffering and something like that was so, so easy to do and had such an impact on her life. And the fact that she had really been blown off by a doctor with whom it turns out

[00:21:10] she had been seeing for a long time, she was really disappointed in that relationship. And I wonder sometimes if, I mean, I think I don't think all gynecologists need to be women. I think men can be just as empathic about these things.

[00:21:25] But I think that, you know, if her doctor had taken her seriously and she had double disadvantage because she was not only a woman, but African-American, so a woman of color as well.

[00:21:36] And I think that for me, that just highlighted how ready the medical community is in many cases to just dismiss how people are feeling. Women especially. Such a powerful story and very powerfully told to me. And thank you for sharing that. My pleasure.

[00:21:56] Last question from where you sit. What has been the most overlooked thing in a sea of overlooked things? And where is that inequality felt most deeply? I think the thing that is most overlooked is how women feel. We got very focused on things like preventing cardiovascular disease,

[00:22:20] preventing bone loss, preventing breast cancer. We got very focused on all of those things. And those things are important. But what we lost in all of those conversations is what women are experiencing right now, which is they are in many cases having lots of symptoms.

[00:22:43] They're trying to push through them and ignore them. And I think that while all women run the risk of being dismissed for their symptoms or being told that their symptoms are not important or not important enough to address,

[00:23:00] I think women of color in particular have their symptoms minimized and overlooked. Thank you for sharing that, Julien. Thank you for your time today. It was just a great conversation talking about menopause with you. Oh, it's my pleasure. I really enjoyed it.

[00:23:15] Thank you so much for having me. That's it for Overlook this season. Thank you so much for listening. We're building a community around women's health so that no one is overlooked. If you'd like to be part of it, hit the follow button on this podcast

[00:23:32] wherever you're listening to this. Overlooked is written and produced by me, Golda Arthur, and Jessica Martinez, the host, is our associate producer. You can get in touch with the show by emailing hello at overlookedpod.com. We read all our reviews, so please support the show

[00:23:50] by leaving us a review on Apple Podcasts. Thanks for listening.