45: How to Thrive Through Menopause After Breast Cancer with Dr. Corinne Menn

Hello and welcome to the Kenya breasts podcast with Dr. Jen. The show dedicated to empowering women through knowledge, tools and resources to take control of your breast health journey. I'm your host, Dr. Jen Simmons, and I'm thrilled to have you join me on this insightful and inspiring journey. As a breast cancer surgeon turned functional medicine physician, I'm on a mission to empower women to live their breasts and need best lives. This podcast dives deep into all topics related to breast health, including prevention, diagnosis, treatment, and holistic approaches to support overall well being.

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Hello and welcome to the Keeping abreast podcast with Dr. Jen. I am your host, Dr. Jen Simmons, and today I am delighted to have Dr. Corrine Men with us. Dr. Mann has an amazing background and serves a tremendous purpose in this world in that she is caring for what I refer to as the forgotten population, and that is the population of women who have gone through menopause and are expected to kind of white knuckle their way through the rest of their life. And a lot of this is left over from the Women's Health Initiative study that was completed in 2002. 2003. And we need people like Dr. Men to help us to reframe that data and to reshape the world that many, many women are living in. And so, Dr. Mann, I would like to welcome you to the show. I'm so delighted to have you here.

Thank you for having me. Thank you for giving, you know, me, a platform to discuss the important women who are either at high risk for breast cancer or have, you know, dealt with a breast cancer diagnosis because they are forgotten.

Yeah.

And you know a little bit about that.

I do, actually.

So I would love for you to share your story. But first, I, I, I'm curious why you even went into medicine in the first place, because your story started pretty early. So. Are you from a medical family?

No, in fact. So I went to George washing, sitting in D.C. thinking I was going to be a political science major. Had zero interest in science or medicine at all. But after my first year of college, I realized, like, the poli sci route was not for me. I just didn't have a passion for it. And in retrospect, Looking back, I think I always wanted to be a teacher, actually, but I felt this kind of pressure that like, I needed to make more money and that wasn't good enough, which is just silly notion, right? And honestly, I think one of the attractions to eventually going into medicine was this idea of being able to, like, work with people, the human connection. I was always more of a social science type of kid or person, right. And so when I kind of found myself liking the biology class and I took a genetics class, it's like, wait, I could do this? And I liked that there was a direct path. I knew I was going to have a job at the end, but to be honest, that was my attraction. I did not come from this, like, big medical background, but once I got into it, I says, well, if I'm going to go to medical school, then I'm going to do women's health. I knew that and, you know, early on wanted to do ob GYN and, you know, loved the kind of the, the communication and the relationships that are developed as an OB GYN with your patients. Right. So when it was a second year OBGYN resident, it was 2001, and that's when my mom had been diagnosed with stage four ovarian cancer. That's a long story for another podc, but she died suddenly two months later. And at the same time I had felt a small lump in my right breast and I kind of ignored it. My fellow physician, OB GYNS, NY Female I had my colleagues, they felt that, they're like, ah, you're too young for breast cancer. You know, you're, you know, you don't have any family.

That's still happening.

It still happens. It totally happens, you know, and my attendings, my female attendings also were like, yeah, just follow it for a couple cycles. Now, in retrospect, I was a 28 year old with a palpable mass that was firm, and my mom had just been diagnosed with stage four ovarian cancer. You think someone would have been like, hey, you should probably get that checked out. But they told me to wait a few cycles. And so at my mom's funeral, I came home that night and I was like, I should probably get this checked out. But I wasn't even nervous. And so this was. And then, you know, by the time I got an appointment and got the biopsy done, it was December of 2001. It was right before the holidays, and I got paged by a radiology resident and was like, oh, Corinne, it's invasive breast cancer. They paged me in the middle of prenatal clinic. And so I was newly married, like I said, 28 years old, just kind of grieving the loss of my mom. And it was a pretty devastating diagnosis. Diagnosis, obviously. And then to make a long story short, it was ERPR positive, HER2 negative. It was stage 2A. I had a tiny area and one lymph node that was positive. That showed a little focus of invasive cancer there. And I wound up having bilateral mastectomy, reconstruction, six months of chemotherapy with ovarian suppression with Lupron, and then followed by recommendation to go on tamoxifen. I did that for two years and then was lucky enough to work with my oncologist and a fertility specialist in New York City. And I did save embryos with my husband prior to starting chemotherapy. Wound up not needing those, but those were on reserve and they supported. And this is a very interesting point that we'll circle back to. This was in 2000. By this point, it was 2004, right. Two years into taking Tamoxifen, and they supported me in pausing my adjuvant endocrine therapy. I got pregnant. We didn't need ivf, got pregnant on our own, delivered a healthy baby girl in August of 2004. Once I delivered her, I decided to go back on Tamoxifen, this time without Lupron, because I was really struggled with the ovarian suppression. This was shared decision making, and I was supported. And I bring that point up because it really talks about this idea of giving women with breast cancer a choice. And so I had a choice to pause endocrine therapy, get pregnant with very high levels of estrogen. Right. In the tens of thousands, your estrogen levels are. And then I had a number of months before I got pregnant where I had high estrogen levels and then a postpartum recovery, and then went back on my Tamoxifen. And that decision was, you know, my oncologist supported that because there was data way back in the early 2000s that pregnancy after breast cancer did not seem to increase your risk of recurrence or change your prognosis. And just last year, there was, you know, a really important study that was, you know, released and widely celebrated at the San Antonio Breast Cancer Conference and, you know, around the world, called the Positive Trial. And that was, you know, a randomized controlled study where they looked at pausing adjuvant endocrine therapy in premenopausal, er, positive breast cancer patients. And it kind of confirmed what the data had suggested back when I was diagnosed that pregnancy doesn't increase that risk and that patients should have an option of shared decision making. So I just bring that up as a, as a starting point on. It seems like as a society and as a medical community, we value breast cancer survivorship's access to fertility preservation and access for them to have the option to have a pregnancy because we value women's bodies if they are making babies. But when women enter premature menopause, and we could talk about all the ways that a breast cancer survivor may enter menopause because it's many ways that they may be pushed there, suddenly, suddenly, that is, they meet a brick wall and they have no access to shared decision making on how they're going to manage that menopause. And I think it's because we don't. And this, this feeds over into the average woman in menopause. Clearly our country, our society, our medical system does not value a woman's, you know, sexual health and her hormonal health and how she ages. When it comes to menopause, all of the data, all of the, you know, time spent with your ob GYN is dealing with your years prior to menopause. But once you're menopausal, it's like, you.

Know, you don't matter.

That's you're the population. You're, you know, so you're the forgotten population just as a menopausal woman. But then when you add in other layers, whether it be high risk for breast cancer, breast cancer survivorship, or I often like to say there's a lot of other forgotten women out there, women with endometriosis, women with premature menopause for other reasons. You know, these women are really, are really left to fend on their own with very, very little support. And it's a very large number of women and growing out there.

Well, I think this is mostly in agreement with that whole demonization of estrogen. Right? Estrogen is bad, estrogen causes cancer. And it's studies like this, I mean, it should have been out there. Before we throw logic out the window, the fact that we see the preponderance of breast cancer in the postmenopausal population where estrogen is very scarce, as opposed to the premenopausal population or the, you know, the very young, that the teenagers, or as you said, a pregnant woman has 10 times the amount of estrogen as someone who is not pregnant. So, but this whole demonization of estrogen fits the narrative. And so, you know, if estrogen is no longer there, it's no problem because estrogen is bad.

Yeah. And it's more nuanced. Like, I think some wonderful things have happened in the breast cancer treatment world over the past decades. Right. We're getting more and more nuanced in many ways. And we give women who are diagnosed with breast cancer a lot of options for shared decision making and personal preference. For instance, we offer them mastectomy versus lumpectomy. That can be individualized. We now have oncotype scores, so we can help determine who really needs chemotherapy and who doesn't. That's nuance. And then we look at receptors and we can treat, make treatment recommendations based on estrogen receptors, progesterone receptors, HER2 receptor. So there's a lot of nuances in how we treat a breast cancer patient, but once she's completed her treatment, the nuance on how she's going to deal with her menopause goes out the window. And we treat these breast cancer survivors like they're all the same and they're not. DCIS is not the same as invasive. And then within invasive, we obviously have different stages of disease, different estrogen versus estrogen receptor, positive versus negative. And we need to individualize patients because there are some where the answers on could they have estrogen after estrogen therapy after breast cancer? In some of the cases, it might be a little bit easier to counsel that, and it may be a little bit more complicated. But we still have some data, and I think that women deserve at the very least a discussion on what the data we have is and let them make decisions for their body and how they want to live as a survivor, because we do that. And this is why I brought up the pregnancy thing, because we do it for pregnancy for them, and it's celebrated and there's recommendations and it's considered a standard of care to talk about fertility with a breast cancer survivor. So why can't we do it? When it comes to her menopause and her sexual health, we have data. Right.

It's.

And so it's exactly what you, you said. It's. It's just kind of a continuation of this demonization of estrogen and also this disregard to a woman's quality of life as she ages. Or.

Or quality as she ages.

Yes. Right. Yeah.

Because that's a problem too. And I love that you had shared decision making and were given the opportunity for pregnancy. I still feel as if that is discouraged in many circles that a woman with a hormone positive breast cancer is advised against a pregnancy, even though there's no data to support that.

Well, I mean, Anybody who's doing that is actually really not following the American Society for Clinical Oncology guidelines. I mean, this is coming from the horse's mouth, so to speak. Anybody should, you know, if they're getting pushback, they should speak to their oncologist. The positive trial was, you know, just released last year. It's very, very important. But I agree with you. You know, it really comes down to very. It depends on who your doctor is and what cancer center you're at, and if they're going to you talk to you about those options. But, but at least those conversations are being had. The conversations on menopause care is not. And the point that we have to, you know, I think there's a huge pink elephant in the room. People need to understand this. There are 6 million breast cancer survivors in the world, 4 million in the US and growing. Okay. Each year we add, I think it's about 300,000, 000 new diagnoses of invasive breast cancer. I think it's about 60,000 for DCIS. And we know that these. Yeah, right. And. And these numbers.

Yeah.

So, yeah, you're in the ballpark. I'm in the ballpark. So basically the, the main point is that we have a growing army. These are not small numbers. A growing army of breast cancer survivors and thrivers out there. And then even more women being diagnosed with genetic mutations because more women are being offered genetic testing, which is great, so that they can make informed healthcare decisions. But so then the growing number of BRCA previvers, I call them, they've not had cancer yet. They're kind of growing into this mix. And nobody's talking about what are we going to do for these women? Because in many cases, their menopause does not come naturally. It doesn't come at the natural age of menopause. It either comes early from treatment side effects. Right. Whether they got their ovaries removed or chemotherapy induced premature menopause or other medication induced menopause, or for the pre virus women who have not had cancer, they're having their ovaries removed early to lower their risk of ovarian cancer. So say at age, by age 40, many of them have their ovaries removed and now they're in surgical menopause. They've never had cancer. And nobody informs them that their risks of the premature surgical menopause are very significant. If not treated with estrogen, and they're being denied access to hormone therapy despite us actually having guidelines and statements that these women can have hormone therapy.

And so they're and should. And should. Should.

Right. Should. For their long term. Bone, cardiac, brain health, sexual health, everything. There's, like no data points that say these women, regardless of whether they have intact breasts or not, if their ovaries are removed early to lower the risk of ovarian cancer, they should have hormone therapy at least up to the age of natural menopause. And then at that age, they can continue just like any other menopausal woman, you know, can continue. And many of them wind up also having their breasts removed. So it's really a moot point in my position, my. My view. But many of them are denied access to it.

Yeah.

Okay.

I'm curious because you. You have a tremendous breadth of knowledge in the area of hormonal health and hormone replacement therapy. But as we've spoken about on this show before, that did not come from your ob GYN training, because unfortunately, we think of ob gyns as being the masters of hormonal health. But in truth, they're surgeons who get very little training in the area of hormonal health. So how did you learn all of this? Was this born out of your diagnosis and necessity, or did you. Did you somehow determine that this information was really important?

Yeah, Well, I. You're 100% correct. People don't realize OB GYN is a largely surgical residency. Half of our time we're on the labor and delivery floor where we're doing a lot of surgery. We're doing C sections and delivering babies. That's 50% of our time right there. And taking care of, like, high risk, you know, obese and people, postpartum complications. Then the other half is we're in the or, we're doing hysterectomies, ovarian cancer cases, fibroids, irregular bleeding, and then a little bit of time doing family planning and clinic work. I don't know. We. We didn't have any menopause clinics. We had. I had no lectures on hormone therapy and my residency. I was. It was 2000 and, you know, 2000 to 2004, it was the height of the WHI. So if they were going to talk about hormone therapy, the time I was in residency, that all got pulled away. So I was never taught it at all. In fact, I was a terrible menopause care provider because I just wasn't educated. And I remember when patients would come in with those complaints into the clinic, the residents, we would roll our eyes. We're like this whiny woman, like, suck it up. Like, you know, like, we had no sympathy because we were not educated. I had no idea. None. And we're not really hormone specialists. Right. The reproductive endocrinology fellows who go on for three more years of training, they learn about hormones, but they learn about it in the context of getting a woman pregnant. Right. And the field of endocrinology, which is a subspecial, you know, subspecialty of internal medicine, they're the hormone specialists, but they have very little training in menopause, you know, and because it's just assumed that the ob GYN will take care of it, you know, the endocrinologist is dealing more with thyroid disorders and, you know, diabetes and, you know, other more complicated adrenal health. But, you know, so basically no one's trained in it.

And so I actually don't think that they're trained in any kind of health. They're trained in disease and dysfunction.

Well, that's certainly true.

In any kind of health.

Well, that's true. There's a real, you know, reactionary and not a proactive approach to. To medicine, unfortunately, across the board. And I think nobody gets it worse than women. Right. So it wasn't until it was when I finally decided to have my ovaries removed. So going back to, like, you know, my. My kind of. I kind of finished chemotherapy up when I was around 29. When I was on Tamoxifen for a couple of years, I was having regular periods. I was not on Lupron. I was just taking Tamoxifen. And so I actually tolerated Tamoxifen. Well, I wasn't thinking that much about menopause. I had had a. A temporary early menopause from chemotherapy and then a little bit of Lupron use. But then for a couple of years, I was just.

For the people that don't understand what these drug are and what you're talking about, can you just explain a little bit about Lupron? The reason that we. Lupron is prescribed, and typically it's prescribed along with an aromatase inhibitor. But you took it along with Tamoxifen.

Yeah. So in my case at the time, there was an idea that if you gave women Lupron, which basically put you into a temporary menopause during chemotherapy, that it might help preserve your ovarian function. So I was initially put into temporary menopause to preserve my ovaries, to kind of protect my ovaries from the chemotherapy. So I had an initial, you know, first time experiencing menopause from that. So Lupron plus the chemo kind of shut down my ovaries temporarily. They perked back up once I recovered from chemo and I did not use Lupron and then I used tamoxifen alone. People need to understand women who use tamoxifen who are premenopausal. These are women who are still ovulating, getting their periods. They tend to tolerate tamoxifen better. They can menopausal like side effects or menstrual irregularities for women these days who are higher risk for breast cancer recurrence. Often women will be given Lupron to shut down their ovaries along with an aromatase inhibitor, or sometimes along with tamoxifen, one or the other. And so in my case, I had a period of time on just tamoxifen alone, had a pregnancy, went back on my tamoxifen again without ovarian suppression. But then, because my mom died of ovarian cancer, I made the decision to get my ovaries out. Even though my genetic testing at the time was negative. I was tested and they said, you do not carry the BRCA gene. It never sat well with me.

Was your mom tested or was it not?

No. Well, the story gets more interesting. So my mom had died suddenly. She was not tested, and it was 2001. They were not doing widespread testing when I was first diagnosed. They're like, yeah, you can do that test, but it's not. We don't really know. It was not even encouraged. I did get it done. It was negative. I was like, really? That makes no sense. My mom was 54 with ovarian, and I was 28, depressed. So fast forward, I was at this point around 33, I think. And I just said, you know, I.

What?

I'd already had one baby. I was not going to have another biological pregnancy. We. We adopted a baby girl from Guatemala. She just turned 18 this weekend. So I said, I'm done with my family, thank you. I have two girls. I was like, I just want these ovaries out. And again, Jen, this shows how little I was trained in menopause because I was very flippant about it. I was like, I just want these ovaries out. I mean, honestly, looking back, I, I like, like, I didn't even think about what was going to hit me. And that's when I really woke up to premature, what premature menopause truly is, because nobody. There was no oncologist pushing me to have my ovaries taken out. I did that because I was worried about ovarian cancer risk because of my, you know, and so even though I was Broca negative. So these ovaries come out and overnight I'm plunged into surgical menopause. And then I continue on my tamoxifen. So that's when I had a wake up call where I said, I've got to learn about menopause. I'm like, what the heck? And nobody counseled me.

The listeners, a little glimpse into what surgical menopause feels like because people are not adequately informed from my, from my standpoint and my viewpoint. And I think that goes a little bit with mastectomy as well in that I think it is totally underappreciated. I think a lot of people make a decision about mastectomy out of fear. Just like you were like, just get rid of those ovaries. People are feeling, just get rid of those breasts. And they don't realize how deep those scars actually run. So I think that that happens out of fear very, very commonly. But unlike the breasts, when you remove it, I mean, yes, there are very deep emotional scars for sure, but the removal of the ovaries in a premature woman, in a premenstrual woman, that's a little bit of a living nightmare, as I'm sure you'll share.

Yeah. And so it's actually embarrassing looking back and thinking about how clueless I was and that my gyn, my oncologist, nobody was like, but Corinne, you're BRCA negative. Which just for the listeners to understand, then fast forward about at that point, I don't know. Seven years later, I was opening up my own medical practice where I was doing a lot of focus on GYN only in these patients. And I came across the data that it said prior to 2013, the large rearrangement of the BRCA gene was not part of the testing. So I asked my oncologist. I had to. My oncologist didn't tell me. I said, listen, I need my Broca test, repeat it. And they're like, oh, it's not really necessary. I says, well, actually it is. It is necessary. And sure enough. And also, yes, and of course it's necessary. I had breast cancer at 28. It didn't include the larger derivative of the gene. Yeah. My initial testing was done at a major New York City famous cancer center. They never called me back and said, hey, do you know if you had your testing done before 2013, that it wasn't a complete assessment of the gene? Sure enough, four weeks later, I get my results on BRCA2 positive. So my intuition was right in getting those ovaries removed to lower my Risk of ovarian cancer. But. So there was a reason that I had it removed. But it was kind of in retrospect. Right.

But regardless, would you have made. I know you would have removed your ovaries. I totally get that. Would you have removed them then?

I would have had. Maybe not immediately then, because with the BRCA2 diagnosis, BRCA1 versus 2, the ovarian cancer tends to come later with BRCA2. That being said, I don't know. My mom is still very young, 54 for ovarian cancer. But regardless, getting back to your initial question of was I prepared and what happens with surgical menopause? No, I wasn't prepared. And for the listeners to understand, what does it mean when you take your ovaries out? You're removing all of your estrogen, you know, production capabilities, basically. And it's not a. Virtually all of it. Yeah, virtually all of it. And it's not like a natural menopause where there is, you know, many years of a slow decline or in perimenopause. There's a lot of up and down. Yeah. It was like from no ebb and flow. No ebb and flow. Literally overnight. So I just tell women it's chemical. It's surgical castration. It's. It's. If we cut off the testes or, you know, testicles of a man, it's the same thing that we're doing to women when we remove their ovaries. And there are many times it's. There's a reason to do it. Okay, all right, so let's just. So I had a reason. I carry the BRCA2 gene. I wanted to lower my. All right, I'm not saying there aren't reasons to do it, but when there is a reason to do it, you must counsel the woman that overnight she's going to start to experience all of the signs of menopause. And it tends to be more severe. Hot flashes, night sweats, insomnia, new onset of mood changes, anxiety. Those were the top five things that I experienced immediately. A few months later, lots of joint pains, muscle aches. In two months I gained, I kid you not, 10 pounds. Easily, easily I gained. The insomnia was horrific. The vaginal symptoms, sexual symptoms came a bit later, but not too much later for me. Again, I was still not a very well educated menopause provider for my own patients. So I was not proactive about anything. So I would do things differently in retrospect. But really that's when kind of this shock to my system when I was like, oh, I experienced this a bit with chemo and Ruth Lupron, but it wasn't prolonged. Right now, this was really, like, severe. And it's. When I joined the men, it was called the North American Menopause Society then. But that's when I joined the North American Menopause Society and started to get a bit educated about the general treatment of menopause. But again, none of. None of the education through NAMS at the time really was tailored to a breast cancer survivor. But at least at that point in my career, I started to become more sympathetic and knowledgeable at dealing with the average menopausal woman on the average premature. Premature woman. Menopause women who did not have breast cancer. So I thought I. So I think for many years, I started to be a good menopause practitioner for the average person. Right. But I still wasn't a good practitioner for the breast cancer survivor. Right. Because I had a huge amount of fear at that point. Now I was. Was, you know, obviously surgically in menopause, and I continued on my tamoxifen. I wound up taking tamoxifen for over 10 years because I had had some pauses during the way for pregnancy. And a couple of times I just paused it for, like, six months because I couldn't take it anymore. But in retrospect, looking back, I actually tolerated tamoxifen. Well, it was the suffering of the premature surgical menopause that was really driving a lot of my symptoms. Symptoms, right.

And do you feel as if they were worsened by.

Yes. Yeah, probably. I think my. Probably my hot flashes and my insomnia were worse, but it was really that surgical menopause, which was really tough for me. And, you know, I do see clinically that, you know, some women just have a hard time on tamoxifen, regardless of whether they're menopausal or not, and others don't. And I think it comes down to receptors and how we each, you know, kind of deal with. With it. For me, I was okay in it.

I also think that it has to do with our own ability, our own inherent ability to metabolize tamoxifen. Because tamoxifen is a pro drug, Right. And we have to metabolize it into endoxifen, and then we have to break it down. So the same people that struggle with all of those metabolic processes may also be struggling with tamoxifen metabolism.

Absolutely. It's. This is why, you know, everybody needs to be looked at individually. And there are some people that don't even respond or have any benefits amongst them. And I am not here, just so you know, disclosure. I'm not here to discourage anybody from doing the treatment that their oncologist recommends for them. I always want women to know what the, why they're being prescribed something, what their absolute benefit of having it is versus any risk. Because another thing I think, which is a little off topic here, but that, but I think it's an important thing to say is that I was diagnosed many years ago. The standard of care now has become more aggressive in terms of the level of adjuvant endocrine therapy that premenopausal women are offered. When I was going through treatment, tamoxifen alone for premenopausal women was really, really, really commonplace. Okay. Now it's shifted to now first line is ovarian suppression. So using that medication, we said like Lupron, shutting down your ovaries or having your ovaries surgically removed. And women do this all the time without thinking that once they're removed after five years, they don't come back, you know, so where Lupron, you can give it to temporarily put you into menopause, once those ovaries are out, they're out. Right?

Yeah.

And so now women who are premenopausal are given ovarian suppression, often with an aromatase inhibitor, which is different than tamoxifen. In aromatase inhibitors take menopausal levels of estrogen, which may be about, say 10. Right. And put it down to basically zero. So it's like super duper menopause. It's really remove, like lowering estrogen to almost zero. So it's a very profound deprivation. And what I one alarming thing I find, and while we do have data that in higher risk, women who are at higher risk of recurrence, say, you know, lots of positive lymph nodes or more advanced disease women who needed chemotherapy. There is a small overall survival benefit for an aromatase inhibitor and ovarian suppression versus tamoxifen. But in lower risk women who did not need chemotherapy, who have a low oncotype score, there's actually not a survival benefit. And no one explains that to patients. And even if there's a benefit, in many of these patients, the benefit we're talking like single digit percentages. And women feel very pressured, I find, to do 10 years of ovarian suppression aromatase inhibitor, which again, I'm not saying isn't right for some people, but women are not presented with the data and anybody can google the data, there's is called the soft and text trial. Soft. There was a 12 year update of the soft deck data. And you could have an oncologist on here to talk to you about the nuances between that. Because there are nuances and the, the bottom line is lower risks. Patients who didn't need chemotherapy may not really need the more severe adjuvant integral therapy.

And, and then you have to think about the flip side of that, which is that if we are going to put women in premature menopause, we're going to have to deal with all the things and all the implications of premature menopause, not to mention that it will accelerate heart disease, which is the number one threat to a woman's life anyway.

Exactly this. And so what I'm saying is I'd like women number one to have proper informed consent prior to any of these decisions and really understand your risk of. I'm just putting out sample numbers, but let's just say your risk of recurrence is 8%. Using some type of endocrine therapy is going to roughly put it down in half to say, let's just say about 4%. So when you're talking about the difference between ovarian suppression alone with tamoxifen with aromatase inhibitors, there's nuances, but there's just small differences between those numbers. And you need to understand that. And you need to understand the cardiac risk, the bone loss, risk to dementia, sexual health and just quality of life and how. And people are not given that. They're just like, oh, you're menopausal, we're going to make you menopausal. Here's the prescription. See you in three months. And this is what they're told. You might have some hot flashes and you might have some joint pain and a little vaginal dryness. Use coconut oil and here's some Prozac or another ssri. That is basically what usually the effects are. Yeah, effects her. And that's. And literally that is the counseling. There's no counseling. Meanwhile, we have very important position statements from the menopause society and ACOG on the proper management of premature menopause in non cancer patients. And those guidelines are really clear that there's very high risks of, of accelerated cardiovascular disease, dementia, osteoporosis risks. But all of that counseling literally goes out the door. Nobody talks to the breast cancer survivor about that and weighing that risk versus the risk of breast cancer recurrence. Right. And so again, I'm not saying there's any right or wrong answer on what treatment you get, but you must be informed of the big picture. And that's not happening in the oncology visits. And nobody is. Also, no one's being proactive. Even if patients decide with their oncologist, okay, I'm doing an aromatase inhibitor and ovarian suppression or I'm doing tamoxifen at that meeting when you get that prescription, that is when you must counsel the patients on what to expect. Because women are hit with like a tidal wave and, and no one tells them that, oh, I could have new anxiety, new depression, I can have debilitating joint pain so that I can't do the lifestyle things you want me to do for hot flashes, which is exercise, eat a healthy diet, but I can't do that because I can't move my elbow. Brain fog. I can't move my elbow. So I say, why are we sending these women off without at least a proactive plan? Can being like, listen, we know this is going to happen. Here are some things we can do, even if it is a non hormonal medication. And for God's sakes, why are we not giving these women a prescription at the same time for low dose vaginal estrogen? We tell women.

So now I really want to dig into that because the, even, even talking about low dose vaginal estrogen gets the medical oncologists all in an uproar. So I first want to talk about why do you think there's such a disconnect between the clinical guidelines that are out there for women who are in premature menopause and for women who are in premature menopause because they've been treated for breast cancer? Why are they left out of the equation because it's about fear?

Well, it's because it is fear. And it's also because there's a tunnel vision mentality where it's only about the reduction of recurrence, which is very important, obviously, of course, but that can't be the only discussion. We need to look at her whole body. I say, imagine if every day we were out there removing the testicles of 35 year old, 40 year old men, sometimes younger, and telling them to just get on with it and use a little moisturizer on their shriveled penis. I mean, it would just not, it doesn't happen. We would never do that to men. And I think it all comes down to we just, we don't value and we don't recognize the side effects. And this is because the oncologists are victims here too. They are not trained on what actually Happens to women. They're so busy in their clinics and they're overburdened and they don't have time to do shared decision making. Frankly, they're the victims of these big health systems. Right. So they don't have time to be like, listen, I know this is going to happen. Here's, you know, let's have an hour long discussion about all the options. They just don't have time for it. And so it's just easier to write the prescription. And many of them I see don't even see their oncologist. They see a nurse practitioner or a PA for these routine, you know, aromatics.

Yeah, they're checking the boxes, right.

They're just. And so to me, I like to always talk about like low hanging fruit. As I say, vaginal estrogen, for instance, you've got a woman who you're sending off on an aromatase inhibitor or on tamoxifen ovarian suppression, you know, what's to come. Okay, it's not a maybe, it's just when is it going to happen that the vaginal dryness, painful sex, decreased lubrication, decreased sensitivity, orgasmic dysfunction, the clitoris literally shrinks from the aromatase inhibitors. We have, as you say, even asco, American Society, Clinical Oncology, Menopause Society, acog. There are position statements and a lot of data supporting the use of, of local vaginal estrogen. We are not talking about even systemic hormone therapy here. Yeah, and do you know, I think it's the numbers. They're all over the place. But I see up to like 30% or more of patients stop taking their adjuvant endocrine therapy because nobody is addressing the side effects. And, and when you ask women who have stopped aromatase inhibitors or they've stopped amoxifen, if you ask them why did you stop, 50% of them cite the sexual side effects, which is tragic because we can proactively treat the sexual side effects. And I use the example of when I was having chemotherapy, they gave me premedication, they gave me medications for nausea, right. To, and, and some other medications to help with the anticipated side effects of chemotherapy. I got the prescription for them and I was ready to go. Go, right? Why don't we do that when we are giving someone that we know is going to cause sexual side effects? Because what I hear is from women who are two years, three years, four years or more and they're like, my relationship has collapsed. I have horrific painful sex. It feels like knives are cutting inside of me. And at this point they've had so much estrogen deprivation to the genitourinary tract, frequent urinary tract infections, getting up to two or three times an ATP that.

That'S no joke either. And another part that no one talks.

About and to me when you're talking about, we already know these women are going to have some night sweats and insomnia because of the loss of estrogen. Why are we making them get up to pee twice a night? Because they have urinary urgency. So to me, me, vaginal estrogen could help someone be able to sleep through the night, have protect her urinary health and also protect her sexual health. These are younger women and women of all ages deserve to have pain free intercourse. Okay. And the problem with the, what I push back with the medical societies is this there they, they do have statements that say local vaginal estrogen can be used and you know, it's safe. And we've, every year we've got more papers, you know, looking at the data and showing that it's very, very safe. But all the society guidelines suggest starting with a moisturizer like coconut oil or a non hormonal moisturizer. And listen, there's nothing wrong. You want to start with a moisturizer, go for it. That's great. And I consider it a part of, I call it a trifecta, a moisturizer. Vaginal estrogen is the mainstay and a very high quality sexual lubricant. Those three things together. But if you think you're going to moisturize your of estrogen deprivation to your clitoris, to your bladder, to your urethra, you're fooling yourself. A little moisturizer is just going to maybe make you a bit more comfortable. It's not wrong but it's not going to treat the problem. And so what you do is you have women who have been moisturizing for like two, four, five years and now the skin is so decompromised down there that it's going to take longer and it's a lot harder. And then what happens, Jen, is they get pelvic floor dysfunction, a lot of muscle contraction and muscular dysfunction in the pelvis because of all of the pain that they experience with sexual interaction. And that does a huge, that's a huge problem for these women. It can be treated but it's going to take them a lot longer. And so I am always wondering why are we not offering the lowest dose of vaginal estrogen? We've got some very low dose products like 4 micrograms of Invexi, or you can use vaginal estrogen cream in smaller amounts if you want to be that much more cautious, although you don't really need to be. But we can be very proactive in the beginning so that we don't have women suffering. Why are we playing catch up? It, again, it makes no sense, and it's because we just don't value that aspect of her life. Yeah, yeah.

And also, I mean, it falls outside of the scope of what the, of what the oncologists are thinking about. Right. Because they're, what they're thinking about is how to safely deliver their drug. And they, this doesn't. What they, what they consider safe are life and death things. And they're not thinking about quality of life things. Yes. Even though it's the quality of life things that ultimately weigh the heaviest. Because if you're in pain all the time, if you're suffering all the time, if you lose your relationship, if you lose your mind, if you lose your health, you don't have a life worth living. These are where the recurrences come from. And yes, they're not putting that together.

Yeah, it's, I just think that it, you know, and the thing is, it's not actually, it's really, actually not that difficult. It's literally just asking questions and giving informed consent for the drugs you're prescribing, describing, and then understanding that once a woman finishes her treatment, we need to then be able to have an intelligent conversation with her about menopause. Because some women will enter menopause during treatment. Other young women may complete their treatment, go on to have continued normal menstrual cycles, and then at some later point go through menopause. Other women might have their ovaries removed like me, because they carry mutation. So, you know, so breast cancer survivors will enter menopause for different reasons and at different times, but at some point they're all going to go through it, and we can't just ignore that, God willing. And so the other point is, and I think, you know, this idea of nuance is really, really important. Important. And I, I bring up some. We talked about before we started the podcast about some common sense situations where the fact that they're being denied access to hormone therapy makes no scientific sense. And it's actually embarrassing. It should be embarrassing for a doctor to not understand this. And it's, it happens all the time. So here's a perfect example. And I, I interviewed her on my, on my Instagram page. You can go back and look her name is Jamie. You had estrogen receptor negative disease at 29. So she had chemotherapy, she had a bilateral mastectomy, she went on to her ovaries, recovered from chemotherapy. So she went on to have many years of normal estrogen production. She had a twin pregnancy. So now let's just remember estrogen deprivation was not part of Jamie's treatment plan. Because she's estrogen receptor negative. Yeah. And at this point, she's seven years past her initial diagnosis of stage one, er, negative breast cancer, which we know if estrogen receptor negative patients are going to recur, they tend to recur in the first two or five years. So she's out of this five year window. She's had sky high levels of estrogen for almost now, seven years. But she's a BRCA1 carrier. So she was done with her childbearing. She was 37. We recommend the ovaries are out by age 40 to lower the risk of ovarian cancer, not to deprive her of estrogen, but to lower the risk of ovarian cancer. So she did just that. And suddenly nobody would give her a low dose of estrogen to treat her premature menopause. It makes no logical sense. Estrogen deprivation was never part of her plan. If she did not carry the BRCA1 gene, she would have gone on to have, have estrogen up until age 51. Average age. Right? Yeah. But suddenly she was denied it there. It makes no logical sense. So finally, after, you know, seeing a lot of physicians and finally we spoke, I made her read the book Estrogen Matters. I gave her all the literature and I says, this doesn't even make scientific sense. You should say to your oncologist, how come you never, never suppressed my ovaries before? Like, if that was so important. And then the oncologist was like, you're right, Jamie, you can have estrogen. But she had to, like, fight and, you know, you know, advocate for herself. And along the way, she spent a number of years, it took over two years where she couldn't have sex with her husband anymore. She hadn't slept a full night's sleep for over two years because the hot flash is the night sweats during the day. She had felt panic attacks. No one really addressed her accelerated bone loss. She had a significant drop in her bone density. Nobody explained to her anything about cardiac disease. No one did lipid levels on her or talked to her about. And so it was really, to me, it's a tragedy. We were able to, you know, we got her on hormone therapy and she was doing pretty well, but you know, out at some point in time it wasn't enough. She still had a lot of libido problems. And we said, listen, you've lost the source of 50% of your testosterone as well. And we added in testosterone, which is.

Another thing that, that people don't talk about because when you have a premature menopause, it's not only estrogen you're losing, it's testosterone. It's testosterone.

And it's totally the too.

So you, you actually spend a lot of time thinking about the unique health concerns of breast cancer survivors. So, and we've alluded to a lot of those things, but can we, can we really dial down into that now and talk about the things that you think about? And obviously it's going to be different for the different forms of breast cancer and your, your concerns are going to be different for people with non invasive changes rather than invasive disease. The receptors matter. Although, you know, I, I could make an argument that our biological hormones are not contributing to disease and it's, it's the environment that ends up being the thing that's truly influential. But what are the unique issues that women who are breast cancer survivors? Because as you said, there are 6 million and counting of them in the world. These are, this is a large population of people that, that need our help help that need our attention and that need specific attention to them because this, this broad based care of care for them while they have cancer and, and not not care for their holistic selves. It's not working.

No, it's not working. I think the most important thing is you have to, you, you have to be the CEO of your own health. Because if you think the medical system is going to take care of your needs as a survivor survivor, you're wrong. It's not happening. I have patients from the top cancer centers in the country who supposedly are being seen by their survivorship clinics. And what I find most of the survivorship clinics promote vaginal moisturizers, nutrition and exercise, which are all perfectly good and important things, but none of them are actually giving these women real survivorship care. I think you have to understand that most breast cancer survivors are going to have some sort of premature menopause. And if they don't, if they are diagnosed at a later age when they're already in menopause, they are having impacts of their treatments often on accelerating some other disease processes. So I think they have to kind of, of think about their health and they've got to go through it in A system way like think about, they have increased risks of brain health, brain health changes, cardiovascular changes, bone health changes, genitourinary changes, sexual changes. Right. And so you have to kind of break those down and say, what am I doing for each of these things? Because you're more than just your breasts and more than just your breast cancer recurrence. And so how you address all of those things is going to depend a bit on are you in the middle of treatment or have you completed treatment? If you've completed treatment, what is your risk of recurrence? What is your estrogen receptor status? Not that it's wrong to consider hormone therapy and estrogen receptor positive breast cancer patients, but it'll be a bit more nuanced. And so, you know, I think that some very simple pearls women can remember is of course you have to lean into your holistic toolkit of lifestyle, stress reduction, exercise and nutrition. Those things are incredibly important for you. So you know, you need to be doing, you know, lean into those even harder than the average person. But to say that those are the only things you can do is not true. Then start with the low hanging fruit of sexual health and vaginal estrogen use. Every single breast cancer survivor. I don't care what your disease burden was or what your receptor status is. You can use vaginal hormones, FDA approved vaginal estrogen. There's FDA approved dhea. You can also use off label use of testosterone in all breast cancer survivors because testosterone deprivation is not part of the treatment plan for breast cancer patients. So why would we remove their ovaries? Can we not have a discussion of safe use of testosterone? I don't support palate use, but there's safe use. International Society for the Study of Women's Sexual Health has very clear data on how we can offer, you know, low dose testosterone systemically to women to help with libido and other things. It's not just libido. You have to be proactive about your bone health and talk to your doctor. Well, you're causing bone loss in me with your treatments or my premature menopause. So what are you going to do for me? Right, non hormonal bone, bone treatment options. But also what about the role of estrogen? And then women have to understand there's data, not perfect data, but there is data on the use of hormones after breast cancer diagnosis. So there's two important pa, two papers that I think are recent and important for women to know about because I think those are important starting points for them to talk with their physician. So one is Dr. Avrim Blooming. He was the guest editor for the cancer journal in 2022, the May 2022 issue. And the article is titled Hormone Therapy after Breast Cancer. It is time. And he reviews an exhaustive review of every published article from 1980 to, I think, to present day of the use of hormone therapy after a breast cancer diagnosis, as well as an exhaustive review of all of the meta analysis and secondary, you know, looks at those 25 studies. It's a very important article that you can see it, I can put it for your listeners or there's a link in my bio on my Instagram. So basically the short answer on that is, of the 25 studies, none show an increased risk of mortality and only one shows an increase risk of recurrence. And that's only a local recurrence. And that's the Habits trial. And it's a flawed study. There's some good in it, but there are some flaws in it. They didn't require mammograms on the patients entering that study study.

They also didn't stratify as to severity of disease. And the only people that had a recurrence were on hormone replacement and tamoxifen in that study.

Yeah, it's, it's very, very interesting, that study. And they also, which is very, very interesting for anybody who wants to like, dive into the Habits trial. At the same time the Habits trial was going on, this, the Stockholm trial was going on, which was they were both randomized controlled studies in Scandinavia. And in the Hobbits trial, there was a larger number of women who did not actually receive adjuvant endocrine therapy. This study was a number of years ago. It's not the same standard of care of how we treat patients now versus then. A lot of the women who were given hormone therapy in the Habits trial were. They were all mostly given the synthetic progestin, whereas the Stockholm trial used kind of, I would say, like a little bit more modern approach, modern formulation. And there was not a stratification of, you know, risk of recurrence in the Habits trial. So there's a lot of problems. But even with those problems, the Habits trial only showed an increase in a local recurrence or a new primary in the other breast. And it was all within the first two years of being on the hormones. And they were not required to report any screening mammograms. So we actually don't know if these women even were screened properly prior to entering. It's a huge problem. And at the same time, that was going on. It's very important for listeners to know. There was another better design study called the Stockholm trial, which, which also looked. They both ended early, prematurely because of the increased risk of recurrence that they saw in the Habits trial. But they continue to follow these women. And the Stockholm trial reported at 10 years. I believe they, in the Stockholm trial, they showed no increased risk at all for recurrence at all. And they followed those women who had the local recurrence of the Habits trial. And at the 10 year mark, those women did not have an increased risk of distant recurrence or an increased risk of mortality. Mortality. And then there's 24 other studies that show no increased risk of recurrence. Now to, to the point, some of these studies were very small. Some of these studies did not follow women for very long. Some of them follow them for longer. But there is data is my point. So what I tell patients is there's not perfect data on hormone therapy after breast cancer. And if you are going to sit around and wait for the perfect randomized controlled study, we will all be dead because it's not, not happening. Let's just be honest, it's not happening.

No, you're right.

And so we have some data. So this is what I, I say to patients. I'm like, let's look at your risk of recurrence. Let's look at your cancer. Let's look at the data. Oh, and I should add in the menopause journal, bravo to them for publishing it out of Spain, there was some researchers who, it wasn't new, new data. They looked back at this old data data and they picked a few randomized controlled studies to kind of reinterpret and they basically stratified it by estrogen receptor negative and estrogen receptor positive. This was just published and it was highly supportive of that. There is not a data point published in the world that has shown estrogen receptor negative patients have any risk whatsoever, even in the Habits trial. Right. So when you're looking at receptor status. Right. And so I think that article was very important for these estrogen receptor negative patients because why are they being denied access to hormone therapy? It's like we're treating all breast cancer survivors with a, with a, you know, a blanket statement.

Yeah, it's like, get your sign and then you have to go into this group where.

And that's it.

Like no allowed.

But it makes no sense. It doesn't even make sense. So, so I think. So those two published journal articles are wonderful starting points for you to Read and review. And then even in the, let's say, quote, unquote, more complicated estrogen receptor positive patients. Even in those patients, in the end, to me, I feel like it's your body and your choice. And if a doctor says to you, okay, Corinne, let's use my case as an example. You were a very early stage 2A, technically, they'd make me a 1B. Now you are at this point more than 15 years from your diagnosis. You have no evidence of disease. You've completed all of your treatments. You are now in premature surgical menopause. Your quality of life is really suffering. Your risk of recurrence is not zero because we know once you're diagnosed with breast cancer, there is no such thing as zero recurrence risk. There's a small increased risk of recurrence and it could be local or it could be distant medical. And if it's metastatic, it's not technically curable. And whether we give you hormones or not for your menopause, it appears based on the data that there's not going to be an increased risk. But we don't have the most perfect data. We don't have a definitive answer. But it's your body. And if you're suffering and you're willing to take a small, theoretical unknown risk that giving you hormone therapy could cause your metastatic disease to resurge. Right? Or, you know, have a recurrence, that's a risk that a grown ass woman should be able to make for herself because we must balance it at about the risk of. I was 33 with surgical menopause. I have two grandfathers who dropped out of heart attacks in their 50s. You know, I was having lots of, you know, quality of life issues. I should have the option to try some hormone therapy. So that's exactly what I did. And I worked with my oncologist and I said, hey, let's start with the lowest dose estrogen patch and progesterone. So I started 0.025 patch and 100 milligrams of progesterone. I finally got myself to be consistent with vaginal estrogen along with that out. And guess what? In a few weeks, it was like a light went off in my head and I felt better. And I slept for the first time in many, many, many years. It took some time, but my joint pain started to go away. I felt much better. So then my lifestyle strategies, like my exercise started to pay off. And for me, me, I feel comfortable with that decision. It's an informed consent. I'm A big girl and I can make it because I want my quality of life to be good. And then a few months later, I really started to be more educated about testosterone because again, we're not trained in this either. This is another whole other issue. And I finally was like, wait. Testosterone deprivation was never part of my treatment plan. My testosterone level was like four. And so then I started testosterone and that was really, to me an important part. And same with the case, I brought up my friend Jamie. The testosterone after a few months was really kind of like the icing on the cake. It kind of pulled things together and she feels much better. Right. So I think that's a comment.

You made a comment earlier that you believe in testosterone but you don't believe in pellets. I know a lot of people out there, there with pellets. So can you just quickly comment about why you feel the way you feel about pellets?

Yeah. And listen, I want to say, listen, I think there are doctors and patients who are using pellets and they feel good on it because guess what, they're getting replaced with testosterone. And the reality is, don't feel guilty if you're using pellets. Many women, that's their only access to care, right? Their regular OBGYN helping them. So they basically get pushed to a doctor or pellets. The reason why I'm not a huge fan is because once you put that pellet in, we can't take it out. Right. We have really good guidelines actually on how we can use transdermal testosterone gel. Either an off label use of it of the male, FDA approved version, or we can work with a high quality, you know, you know, respected, reputable compounder, which are very good compounding pharmacies out there. And when we don't have an FDA approved product for, for women, that's when we can lean on our compounding pharmacy colleagues. There are good ones out there that can formulate an appropriate testosterone prescription for a woman and it's transdermal, applied daily. We can control it, we can increase it, we can decrease it. It's safe, we've got better data on that. So. And it's lower cost.

What you can't do with pellets, you can't do pellets being expensive. Once you're dosed, you're dosed and you can get very high doses of testosterone, which for those of you who don't know and don't understand how it works, if you have fast aromatization genes, then you are going to take that testosterone and make a whole heck of a lot of estrogen out of it. And people don't realize that, that.

Yeah.

So people have their testosterone pellets in and they're like, well, yeah, but look how high my estrogen is. I'm like, I know. That's why.

And the thing is, the studies on the testosterone pellets are all produced by the Bio Tea company. Right. Like, and so these people, many pellet doctors, people, doctors who are choosing to use pellets or nurse practitioners using pellets, they go for a weekend course. They're not actually hormone experts, and they actually don't offer patients the option of using a transdermal testosterone. Now, listen, there are some expert sexual medicine urologists out there who really understand how to properly use pellets. And there are people who use it properly in certain situations. I'm not saying they're 100% wrong, but for the vast, vast majority of women, they should not be getting their hormone therapy for pellets. And the other thing is, I find it very curious that the people who are putting in pellets tend to never want to talk about proper estrogen replacement or, or the proper use of progesterone. They only just want to load these perimenopausal ladies up with pellets, charge them every three months. Expensive, unnecessary saliva testing or urine tests. It's, it's just not necessary. But if you are using them, don't feel guilty, but just question, question your doctor. What? Why are you only offering me this? And you can go to Ishwish and see their guidelines. It's actually, you just don't need to do it. Yeah. And we can actually use.

And if you are, make sure you're checking estrogen levels because, yes, it's not just testosterone that you need to follow when you have pellets.

Yeah. And a lot of people don't even know. I'm like, what's your dose? What's the pellet dose? Is there estrogen in it? Because sometimes they actually put estrogen pellets in too. People don't even know know. And what happens is they come up back with very, very high levels. Like, I've seen testosterone levels, 400, 500. It's way too high. We don't need that. And there's no science on it.

I was speaking to a medical colleague yesterday whose, whose levels are so high. And she, you know, her, her doctor said, no, I, I use pellets because I get great results. Results. And I said, those levels seem way too high to Me So you know, everyone is kind of vulnerable to this, to this thinking and decision making. And it comes back to we really do have to be the CEO of our own health and share in that decision making.

We do. And Jen, I just realized the time I've got another meeting I have to go to so I have to wrap it up up. But I did want to just say a couple of things about where to find me and some little final messages.

You, you, you do something very unique. So I would like you to talk a little bit about Alloy because there are so many women who are out there in that, in that space and we, we can talk briefly about the difference between have breast cancer and had breast cancer and in the population of women that had bre cancer that need help, that need quality of life and oftentimes that quality of life is going to come with hormone replacement. How, how, how does your, the company that you work for, how, how do you handle all of these demands? Because there's a lot and they're out there.

Yeah. So just so, yeah. So to back up for one second. So just in terms of what I do is I, I do, I have a private practice but I not taking any new patients but I do do breast cancer survivorship education group visits. It's five women. We review all the literature and all the data and I, I send them on their way with very practical, actionable things that they can do to work with their oncologist or their own local GYN because when and contact me from all around the country and literally now all around the world. So I do these breast cancer survivorship kind of boot camp group education kind of visits. So that's why I do my private practice the rest of my time. I am a prescriber on the Alloy platform which is a wonderful menopause telehealth platform for women, the average woman to get access to menopause trained OB GYN specialists who know how to prescribe and practice evidence based medicine and will provide FDA approved hormone therapy and it works great for the average woman. We do help breast cancer survivors with vaginal estrogen and non hormonal options. But as you can see from this discussion, systemic hormone therapy for breast cancer survivors. Survivors. We need informed consent. We need more decision making. We're working on a path forward via Alloy telehealth so that breast cancer survivors could have their own path. We can still help them right now with vaginal estrogen and some non hormonal options and then giving them some tools to get systemic hormone therapy from their Their, their healthcare team. But right now we can't help women with invasive breast cancer, but we will help. We didn't touch much on dca. I think DCIS patients are someone that we can help with hormone therapy on Alloy and also women who are at high risk for breast cancer. So you've not had breast cancer, but you carry the BRCA gene or some other reason why you're higher risk. Those women are not precluded from hormone therapy. We have very, very, very, very clear guidelines. Right. So I enjoy seeing patients, either me or you see one of my other colleagues on Alloy, and we can really help you. And for patients who maybe can't help with systemic hormone therapy, we try to give you tools and some, some way for you to try to help, to advocate for yourself. But this is a work in progress because as you can see, it's pretty. I shouldn't say. It's not that it's so complicated. It's that there's so much fear and misinformation out there that it takes a lot of time to educate women and then also help educate them and their providers so that they're not in antagonistic relationships with their primary care doctor or their local OB gyn, you know, so we, I think I'm trying to, then on the side on Instagram and doing podcasts with people like you to try to like, start to get this message out that we need to like, use a little bit of common sense and reason. It doesn't need to be all fear based. And we need to look at the big picture. And it's not just about, about breast cancer recurrence reduction. It's about quality of life. And also in the end, Jen, this is women's reproductive rights. And those reproductive rights extend beyond menopause. It's not just about birth control and access to proper family planning and abortion access. This is, this is also access to sexual health care and menopause care because we're, we are, we should be valued more than our breaths and more than, you know, our reproductive years. Right? And so that's why we have to talk about this. And I just, I always come back to my, I always say if we were cutting off the testicles of young men, millions of them every year, and telling them to just go away and use a moisturizer on their penises, it would be a natural national uproar and tragedy. But that is what we are doing to not only breast cancer survivors, but we're doing it to other women as well with, with other reasons.

The whole Menopause population. Yeah, yeah. And I know that Avraham Blooming famously says, you know, if men were told that they're going to get to a certain age and then sex will be extremely painful, not enjoyable, you'll have no desire to do it, but just white knuckle your way through it for the relation, for your relationship for the rest of your life. Like it wouldn't happen.

It wouldn't, it wouldn't happen. It is an abomination. And you know, and, and one thing that you said earlier was that there are guidelines. Okay? We are not talking. This is not my opinion. This is not a void of, of data. There's actually data on everything we discussed today. And I, my, you know, my final word is, you know, be a CEO. Write down your concerns and schedule appointments with your healthcare team specifically for and let them know this is why I'm coming and I want to have a discussion. And it may not fit into your annual exam or your routine checkup. Your three month check in with your oncologist if you may need to make a separate appointment because they're victims of time in the healthcare system and if they're not willing to, and you use these words, shared decision making, informed consent, a review of the available literature. But with that I have to run because I totally get it.

So just to summarize, everyone should be on vaginal estrogen because we need that to protect our long term health. There is no perfect data, but everyone needs to decide for themselves, partner with someone and undergo shared decision making after review of all the data. And you need to be the CEO of your own health. Dr. Corin Men, thank you so much. This was amazing. Where can people find you?

Well, following me on Instagram, Dr. Men, OBGYN. Check out alloy myalloy.com and the link in my bio on that Instagram as well as my website, drmen.com will, will provide you with more information. So thank you so much for having me. I really appreciate it.

Thank you for being here today. I loved it. And we'll have to have you back because there's so much more to talk to you about.

There's a lot to talk about. All right, Jen, you have a great day.

Thank you. You too. It's Dr. Jen. It was so wonderful to spend time with you all today. If you liked this podcast, let us know. Share it with a friend and I will see you next week. It's Dr. Jen. Bye for now.

Thank you for joining me on this episode of the Keeping a breast podcast with Dr. Jen. I hope you found the discussion informative and empowering. Remember, breast health is health, so by staying informed and taking proactive steps, you have the power to optimize your well being. My team and I encourage you to apply the knowledge gained from today's episode to make positive changes in your life and share what you've learned with others. If you enjoyed this episode, please subscribe to our podcast and leave us a review. Your feedback and support mean the world to us and help us to reach more people who can benefit from these conversations. Stay connected with me on social media where I share additional resources, advice, updates and announcements related to breast health. You can find me on Facebook, Instagram and YouTube. Dr. Jennsimmons and remember, MyGen has two N's, so until next time, remember to stay proactive, informed and confident in your breast health journey. The key to your health is you.