Hormone Therapy for Breast Cancer Survivors with Dr. Mindy Goldman

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My virtual JJ will reply directly, and trust me, this will make your day. So subscribe now at SubscribeToJJ.com and text me your review. Let's keep thriving together. We're gonna go deep into a subject that has come up time and time and time again, and it is, can you go on hormone replacement therapy if if you are a breast cancer survivor. This is a subject we've talked about on some of the other podcasts. I will link to those within the show notes along with some other options for how to do early detection. Today we're going to go a little bit more allopathic. You're gonna— we're gonna hear, um, the doctor here talking a little bit more about some of the different drugs, but she's also going to talk about some of the natural alternatives as well. Here's the thing, I think we need to look at all the tools in the toolbox when we are in a life-threatening situation. I know that when my son Grant was hit by a car and left for dead in the street, I was like, "Bring it all in." And what I got through modern medicine and trauma centers saved his life. And then what we did on the back end through some of the more innovative techniques and natural alternatives brought him back to life. So we used it all, and that's what you're going to hear today as well. You're going to hear some of the things that you can do naturally, some of the things that you can do with drug interventions, and this is really important because you want to be able to look at all of these things and then make the decision that's best for you. And what I love the most about Dr. Mindy Goldman is that's really her message, is get all the information, be critically open-minded, and And then work with your doctor, work with your care team to make the best decision for you, looking at all the tools available. So Dr. Mindy Goldman, I was really fortunate to sit across from her at a dinner table the night before Tamsen Fadal's World's Hottest Menopause Party. Dr. Mindy is part of the M-Factor part of the How to Menopause book. Book and a major resource because she really works within the intersection of breast cancer oncology and gynecology. And I actually don't know anybody else really working within that intersection. She's the Chief Clinical Officer at Mitty Health. You'll hear more about that during the podcast, but basically this is a company now that is in 50 different states and it is providing women medical care in the middle of life, right, insurance-based. And she's done a whole module, a whole training within this for her providers to be able to work in the space of breast cancer survivors and what they can do in terms of can they go on hormones, what are the other alternatives they have for symptom relief, etc. So that's really exciting. She's also a clinical professor emeritus at the Department of Obstetrics and Gynecology and the director of the Gynecology Center for Cancer Survivors and At-Risk Women Program at the University of California, San Francisco. She literally created this department, created this program because she saw the need when her own friend died of cancer. She's MEDI's chief clinical officer And that is where she again has created a program that she teaches their providers— there are 300+ providers now— how to do. She's nationally recognized as an expert in the menopausal symptoms that come with the treatment for breast cancer and how to improve them safely and effectively. Again, we're going to be walking through the natural options you have and the drug options you have. And so you'll be able to take this information and work with the doctor to make the best choices for you. She's created a unique program that bridges gynecology and breast oncology and provides breast cancer survivors with care that's focused on quality of life. And this is such a big thing because you hear so often that— and I've seen this with some of my friends— they've gone through treatment and then they're just suffering. And that's what she wants to stop, is that type of suffering. She's a nationally recognized expert expert in this field, and in 2012 she authored the American College of Gynecology Technical Bulletin that provides the comprehensive clinical guidelines in the management of gynecological issues in women with breast cancer. And she is also on the survivorship panel for the National Comprehensive Cancer Network and is the subcommittee chair for the panels on sexual functioning and menopause and helped author the NCCN management guidelines in these areas. So yes, she knows what she's talking about. And again, she's going to give you the whole range of ways that you can look at this, um, from drug options to natural options. I'm also going to put some other links in the show notes. She talks about mammograms within this. We also have Dr. Jen Simmons, who's been on this podcast, who has a new form of imaging as another option. So I'm I'm going to make sure you have all that information so again you can look at all this and make the best decisions for you as to what you want to do. I'm going to put all of this at jjvirgin.com/drmindy and I'll be right back with Dr. Mindy Goldman. Stay with me. Ready to soundtrack your summer?

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Thanks so much. I'm really happy to be here.

Well, I appreciate your time because this is a subject that obviously is rife with misinformation and fear. And I think we're going to cut through a lot of that today. And we are going to really be talking deep into breast cancer, breast cancer survival, but in relationship to menopause and can you take hormones. And what I see from your bios, you seem to have this perfect intersection between gynecology and breast oncology. And what I'd love to start with is how did you get into this whole thing?

Yeah, thanks for asking me that. I Really got into this based on helping a dear friend who got breast cancer at a very young age and passed away in a year and a half. And I helped take care of her and went on leave from my job at UCSF where I was on the faculty as a general OB/GYN and took care of her, helped her die at home with her family and partner. When I came back to work, realized I wanted to do more for cancer survivors. My department negotiated with the Breast Care Center at UCSF and they put me there. What started happening was I was brought on to do what was called follow-up, to learn how to care for people who had had breast cancer. I worked side by side with oncologists and breast surgeons. And what started happening was because I was a gynecologist, people were asking me, hey, my patient was thrown into menopause from chemotherapy. What do I do? Or my patients having vaginal dryness and sexual function on all these breast medicines. What do I do? Are they having bleeding on tamoxifen? And I look in the literature and this was in the early 2000s. And I was shocked because there was nothing there. And fast forward now 20+ years, I feel very lucky that I have been able to help develop a field that really didn't exist, bridging breast oncology and gynecology and focused on quality of life issues for cancer survivors. And I've been able to work with the American College of OB-GYN helping write guidelines. I currently work with the National Comprehensive Cancer Network. Where I chair their menopause and sexual functioning panels, helping provide guidelines for oncologists nationally. And now that we're having this conversation and the— and more and more people are having these conversations, this is becoming really an established field, or I'd like to hope it's becoming an established field within GYN, really focused on managing quality of life and menopausal symptoms in cancer survivors.

Let's just make it so.

Exactly.

There you have it. I've heard from so many people that they've gone through, you know, breast cancer, and whether they were in menopause at the time or then they were in menopause, now they're in menopause and they don't know what to do to manage the symptoms, and the medications they're on are making the symptoms worse. And And the rule of thumb, what I hear from all of them is, "I cannot take hormones." I'd like to walk right into that big question first. That's probably the biggest one, right?

That is the biggest one. So one thing I'd like to clarify is that breast cancer is not breast cancer is not breast cancer. And really breast cancer is a compilation of a number of different diseases. And the truth is there are some breast cancer survivors that can take hormones. So when someone has a breast cancer, they send the tumor to see if it is sensitive to hormones, estrogen and progesterone. And if it is not sensitive, hormone-negative breast cancer, those people can take hormones once they have been free of disease for a period of time. When they are first being treated, they typically get chemotherapy because we don't have other hormonal or anti-hormonal therapies to give them, but once they are doing well for a period of time, we don't have evidence that says the use of hormones increases the risk of recurrence in people with hormone receptor negative breast cancer.

What percentage of breast cancer, um, breast cancers are hormone receptor negative breast cancers?

Approximately one-third. So it's more common to have hormone receptor positive breast cancer, and those are the ones where the use of hormones is more controversial. And really to look at those patients, I think we need to talk first about do hormones cause or increase the risk of breast cancer in the first place. And, um, that's where I think a lot of the misinformation is still out there. So a lot of what we know about hormones and breast cancer came from this large study that people still quote called the Women's Health Initiative. It was the largest NIH-sponsored trial designed to see whether the use of hormones prevented heart disease, which is the— as you know, is the number one cause of death for women and men, and whether it was associated with any adverse risks. And there was a lot of bad publicity when part of the study was stopped short with the finding it didn't prevent against heart disease and it surpassed the threshold for breast cancer. And we could spend this entire podcast tearing apart that study. We know that The heart disease, the reason why they didn't see the benefits was that the average age of patients were in their 60s, 63, and that hormones, if started early, are preventative for heart disease. But in that study, they used specific types of hormones, the ones that were most commonly prescribed when they were accruing patients for that study. And they were synthetic hormones, and in particular, a synthetic progestin. So when women take hormones, estrogen is the component that tends to make you feel good, but if you have a uterus, you need to balance that with some form of a progestogen to protect against uterine cancer. In the Women's Health Initiative, they used a synthetic form of a progestogen, and studies since then have confirmed that largely the risk of breast cancer is associated with combination estrogen and synthetic forms of progestins. Turns out estrogen alone is actually associated with lower risks of getting and lower risks of dying of breast cancer. So we know it's more the progestogen component and specifically these synthetic progestins. And there are studies since then that suggest bioidentical forms of progesterone. So bioidentical means formulations of hormones that are similar to what our body produces. And there are studies that suggest bioidentical forms of progesterone are not associated with an increased risk of breast cancer. So I want to clarify that hormones do not cause breast cancer. And the increased risk that has been seen is largely associated with formulations that use synthetic progestins. What we are missing is data looking at bioidentical formulations of hormones in people who are at high risk for breast cancer, including prior breast cancer survivors. So that gets back to your original question, which is Can breast cancer survivors use hormone replacement therapy? It really still needs to be an individualized discussion for women with hormone-positive disease when you're talking about giving someone the current formulations of HRT, which are bioidentical formulations.

So you look at this and you wouldn't know if a tumor was hormone receptor negative till you had a tumor. So you would have no way of knowing, right, if someone was likely to develop a hormone receptor negative or positive tumor unless they had the tumor that you could test?

Exactly. But we know that it's more common to develop the hormone positive tumors.

But yet you didn't see an increased risk in breast cancer with using bioidentical hormone replacement.

So the— well, I will clarify.

I'm trying to make sense of these two things. Yeah.

We don't have these large randomized controlled trials like the WHI with bioidentical formulations of hormones. But I will tell you that the best evidence we have really suggests that the higher risk of recurrence is with combination estrogen and a synthetic form of progestin, and that the studies that have looked at estrogen alone, it's associated with lower risk of getting breast cancer. And we are limited and do not have enough good long-term studies looking at breast cancer risks or the risks in people who have had breast cancer with these bioidentical formulations. So yes, what you are correct is you don't know what type of tumor you're gonna get, but there's just, there's still a lack of data out there. Yeah, it's so frustrating. We need these studies, right?

Well, because you look at it and go, okay, well, if your risk, you don't increase your risk being on bioidentical hormones. So that's not causing the risk, but you could have a hormone-positive, receptor-positive cancer, then you have to be concerned about it. But would you, if it was hormone receptor positive, but it was only for, say, progesterone, could you use estrogen if you didn't have a uterus?

Yeah, that's a really good question. So this is—

Protect your heart, like, you know what?

Yeah, the standard of care is when someone has a hormone receptor positive breast cancer, cancer, whether it's estrogen-only, progesterone-only, or estrogen and progesterone positivity, the standard is that they give these hormonal therapies to modify the tumor environment, and those are drugs like tamoxifen and the aromatase inhibitor. Now, where it's even more confusing is those therapies tend to modulate the estrogen receptor. So particularly with aromatase inhibitors, Those are anti-estrogens. And so that doesn't make sense because we've already said estrogen alone prevents breast cancer, yet you have breast cancer and we give you these anti-estrogen therapies. And there is some increasing data that suggests what those anti-estrogen therapies are doing is really modifying the progesterone receptor. So I think there's more and more of a thought that it's the progesterone receptors that are involved in the breast cancer, that estrogen alone is safer than we thought, but we're not at the point where we're saying people with hormone-positive breast cancer can use estrogen or should be using estrogen to treat their symptoms, particularly when they're on these hormonal therapies. So it is a really complex topic. And I wanna be able to simplify things for her.

Yeah, we'll have some action items. But, you know, but I hear this too. And then you think about it as you pointed out, which I feel like it's missed, is our biggest risk factor is heart disease. And then you look at the role of estrogen in your brain, in your heart, in your bones. And then you are on estrogen blockers. And I would look at this and I think of how our bone density falls off the cliff when we go through menopause if we're not replacing estrogen, the risk of dementia. What happens— I used to work in an office where they would come in, I'd come in to review lab work, and I wouldn't be able to see anything. I'd get the lab work before I'd see their history, and I could tell if they were on hormones or not. Like, you could just tell. You could see it in all of their, you know, their inflammation, their insulin, their cholesterol. So I'm just wondering what's happening to these women on these estrogen blockers, on these aromatase inhibitors, with their bone mineral density and their cardiovascular health and their dementia risk?

Yeah, well, first of all, these aromatase inhibitors have only been used since around the early 2000s, so it's not like we have 30 years worth of follow-up to see what happens with their heart. And I would say that's one of the areas that we don't know is long-term cardiovascular risk. I think we do have a very good understanding of bone risks. We know that aromatase inhibitors are associated with both more symptomatic things like more joint pain, as well as negative effects on bone density. We know estrogen is important for maintaining and promoting bone health. You see a higher risk of bone loss and fractures when women are taking aromatase inhibitors. Many breast cancer survivors who are on aromatase inhibitors need to be on additional medications for maintaining bone density. So, you know, I think that when I see a lot of patients who are worried about hormones, everyone thinks about cancer, right? We've all known someone or we may have been close to someone who had cancer, died of cancer. I think we're all worried about cancer. And oftentimes people don't think about we are most likely to die from cardiovascular disease. And when we look at risks with hormone replacement therapy and breast cancer, again, my own view is that current formulations of bioidentical hormones may not increase breast risk at all. We don't have the big randomized controlled trial studies, but even when you look at the WHO and you look at the absolute numbers, it's similar to the risks associated with obesity and having 2 glasses of wine per day. Lifestyle things have a huge impact on cancer risk, and people focus on these things like HRT and not focusing on the things that you can do yourself.

That one study, I feel like, set a whole generation of women just, you know, they're like this lost generation. It's just awful. It's really awful. Someone coming in who is a breast cancer survivor who is hormone receptor positive, what are some of the things that they can do for all the menopause symptoms then if they can't use hormones?

I'm so glad you asked me that because the big—

I hope you have something really good.

The biggest thing is I want people to hear that no one should suffer. I think a lot of cancer survivors get told, be thankful you're alive, we've got all these wonderful treatments. We will keep you alive and just deal with the side effects of treatments, and that just isn't true. So certainly when someone is going through active treatment, that's not a time where we would have these conversations about the use of hormones. What I do like when people are candidates for hormone therapies is I like to think of it as it's sort of a blanket treatment that can treat many different symptoms: the temperature dysregulation, the mood changes, the sleep dysfunction, the vaginal dryness, the sexual dysfunction, the joint pain. When someone has breast cancer and is going through treatment and you can't do a blanket treatment like that, you need to target the individual symptoms. So when it comes to hot flashes, we have many other alternatives. There are prescription drugs, low doses of a number of different medications, antidepressants, neuropathic pain relievers, overactive bladder medicines. A whole slew of anti-seizure medicines, whole slew of medications that in low doses can treat hot flashes. We also have a new category of drugs. First drug that we understand the mechanism of how hot flashes occur and where it targets. It's a drug called fezlinatant. The trade name is Vioza, and it targets what's called the candy neurons in the hypothalamus in the brain. Which is where temperature dysregulation occurs. And so that's just another tool in the toolbox of different drug options that are available to, to target the temperature dysregulation. Then we target sleep, because if you're not sleeping, there's lots of data that says you don't exercise as well, you don't make healthy food choices, you're just not going to feel as well. So there are plenty of supplements that can be used for sleep. Magnesium glycinate, lavender, which can be helpful for sleep-related anxiety, L-theanine, ashwagandha. We try to figure out, do people have trouble falling asleep or staying asleep? We know the incidence of sleep apnea goes up after menopause. We send people for sleep studies. We do a deep dive focusing in on their diet. What they're eating, when they're eating. We talk to people about timed eating, which can help improve sleep and helps decrease hot flashes at night. So there are many, many different things we can target into vaginal dryness and sexual dysfunction. And even when someone is on these anti-hormonal therapies like aromatase inhibitors, they can still use certain types of vaginal estrogen. So we can treat that. Which there are treatment options for sexual dysfunction. So virtually every symptom that women come in with in the perimenopause and menopause that cancer survivors also have, we have treatment options that are available. They may not be as successful sometimes as the overriding HRT, but there are many, many treatments that can be given.

So let's, let's go back to before you, you discover you have breast cancer, and hopefully you never do, because you, you threw out there, and I think that it's important to go a little deeper into this because it does tend to get ignored. You know, when you look at the risk of alcohol consumption and cancer, it's insane. Like, insane. Um, so I would love to go through if someone, someone was looking at this, because all I've seen so far out there is someone finds out they have a family risk, which I, I would love to hear the genetics because I've heard it's what, maybe 20% is genetics. I'm throwing a number out, so, you know, but they'll have a prophylactic mastectomy, and I'm thinking there probably are some better things we could be doing here. So what would be some of the big risk factors? How much of a risk factor are genetics, and what are the things someone could do to never end up having to be a breast cancer survivor because they never got it in the first place?

Yeah, so it's important to realize that familial and genetic risks are different. So many people have a family history of breast cancer. About a third of women may have a family history that, that may be in a mom, a sister, an aunt, a grandmother. Of familial breast cancers, about 15 to 20% of those are actually due to genetic mutations that we can check for. I think people have most commonly heard of the ones called the BRCA genes, but there are many other genes that we now now know of that can also increase breast cancer risk. Now, in people who are high risk, we oftentimes follow them differently. So they get some of the education that everyone should be getting. So there are lifestyle things that people can do that can help prevent cancer. The biggest is exercise and actually specific amounts, 150 minutes a week divided times interval cardio is really important for breast cancer prevention. It's also been shown for colon cancer prevention. We are seeing higher risks of colon cancer. Guidelines now say people should get colonoscopies starting at 45 instead of 50. Minimizing alcohol can help.

Okay, wait, wait, let's go back to exercise.

Hold. I mean, I meant to say— I meant to— sorry about that. Um, exercising regularly Can—

But you mentioned, you mentioned interval. Yes. So were you meaning doing that 150 minutes in like a high-intensity interval type of thing? What were you exactly saying?

Yeah. So it's a, first of all, it's 150 minutes over the course of a week. That's the minimum we want people to get. And during the times that they are exercising. So let's say someone's gonna do 50 minutes 3 times a week. It is important that they are getting interval training during that time. So pushing their heart rate, coming down, pushing their heart rate, coming down. I would tell you that I'm not clear when I've looked at studies that people understand the mechanism as to why that is more important than sustained cardio, but there's evidence that it is that interval training that is more important.

It's the lactate. It's the lactate and it's creating apoptosis. It is like, if you look at people who are very serious, not the long cardio, long slow distance people, but the interval people, I think we're going to like look at lactate as our therapeutic drug of choice here. And so it's that building up of lactate when you go hard, recover, go hard, recover, go hard, recover, that then can then go to tissues and trigger all sorts of stuff. We already know that contracting muscle I call it the multitasking messenger. But there's another thing that happens with lactate. I mean, for the brain as well, for the heart as well. That's incredible.

So interesting. 'Cause that converts to anaerobic metabolism, which likely is really not healthy for cells.

Yes. So cancer cells hate it.

So, you know, our cells need oxygen.

Yeah.

So interesting. Interesting. Thank you. Because I've always had a tough time understanding. What's the mechanism? But so we know that that's one thing we can all do. And it's not just breast cancer, it's colon cancer, liver cancers, lung cancer. There's a number of cancers now where there is evidence that regular exercise can decrease risks. Maintaining normal body weight is important. We have evidence for obesity is associated with higher risk of diabetes, higher risk of cardiovascular disease, all of those things. Together are associated with also seeing higher risk of cancer.

Gosh, I wish we would get into this unpacking weight and having it be body composition.

Yeah.

You know, especially for women who could be totally normal weight and a skinny fat, you know, I just wish we could get into not just looking at body composition rather than weight. I think that is the, such the missing piece in the medical field, but also looking when you do look at body fat, where is it? I don't really care if your thighs are fat, but if you've got visceral adipose tissue, we got a big problem.

Central adipose tissue is the one we know that that has the higher cardiovascular risk. I totally agree with you, and I think we need more studies specifically looking at that.

We just have to use an InBody scale or a, some kind of scale where we can actually see this when you go to the doctor's office. And by the way, high-intensity interval training is like super effective for burning off visceral adipose tissue.

Yeah, I've listened to your other podcast about that.

Oh, we are so in line.

Okay. The other thing is minimizing alcohol. I think people don't realize that alcohol is a risk factor specifically for breast cancer and specifically for the more common hormone-positive breast cancer. And so in the breast world, we will guide people No more than 2 to 3 drinks in a week. And once people are diagnosed, we really try to have them cut back to as minimal alcohol, as little alcohol as possible. And we know, so these are simple lifestyle things. I know they're not simple for everyone, but there are many things that we can do that can be preventative for cancer in the first place.

Any foods that you love or you would say absolutely run from that or make sure you get that in?

I wanna— I think there's a lot of misinformation about foods out there. I think people are worried about soy, for example, and if they do, they're drinking soy milk, they're having excess soy in their diet, that that's going to increase the risk of getting hormone-sensitive cancers like breast, endometrial, and we don't have good evidence for that. So I will tell people It is okay to include soy in your diet. I think there's a lot about, you know, in the whole longevity space of minimizing antioxidants and different types of diets that are probably the most healthy for us, like Mediterranean-type diets. I think what we do at MEDI is we will review what people are eating, when they're eating it, because I think people don't realize the importance of I had mentioned before timed eating, that that can be helpful for both symptoms, particularly symptoms like hot flashes and improving sleep. And all of that is important for our overall health and well-being. So with timed eating, for example, it's important to not have a big meal within 3 hours of going to bed. When you have a big meal and have this big caloric load, Your body gives heat, gives off heat when it processes that, which can worsen nighttime hot flashes and night sweats. You don't process food as well. It's going to contribute to weight gain and all of the detrimental effects associated with that.

And you sleep like crap.

You sleep like crap. So we could have whole conversations about diet, supplements, all of that. But one of the things I do think is important that people look at labels, look at what they're eating. I think people can go overboard with some of the supplements that are out there, but there are basic, basic things we can all do to prevent cancer. Main— getting regular exercise, minimizing alcohol, trying to eat a well-balanced meal with enough fruits, vegetables, certainly enough protein. A lot of menopausal women aren't getting enough protein, minimizing all of the carbohydrates, certainly not eating processed foods, things like that.

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What about, um, things like sauna? Have you looked at that at all, uh, as to whether there's increased risk? Well, could it be— I mean, you know, when you look at— when you look at something like, um, diabetes, and I remember looking at the NHANES study and, and a a study they'd had based on what they were finding in there that the diabetes increase was due to the, the storage of toxins in the fat cells. And I just wonder if some of— if we are exercising well but we're also doing things to help us regularly get rid of toxins, could that also be a help?

I think, uh, we don't have enough studies that have shown does it actually have a impact, but there's certainly a lot of benefits, right? Also look at like the whole theories. I think these extremes of heat, when you look at the extremes of cold and the cold plunges, there's a lot of interesting information coming out about how these extremes in temperatures may impact our body and our body's metabolic function and our body's inflammation and the impact that that could have on cancer development. You know, my personal thoughts are with things like saunas and steams, that not only does it allow you sweat, it releases pheromones, it allows people to relax. We don't have a good handle on stress and its impact on disease. We all say stress is bad for us, but we think stress can increased risk of cardiovascular disease. Stress may really be involved in cancer development. So any of these things, in addition to sweating out the potential toxins that we have, I think the beneficial effects it may have on our body's ability to relax could really be important in the development of— in preventing the development of diseases like cardiovascular disease and cancer.

I know, you can go in there and shut the door. Exactly. Shut them out. Someone, let's give you a hypothetical patient. She's just in perimenopause and not on anything yet, starting to have those symptoms of perimenopause, finds a lump. Walk us through, be like, if she were your patient, what would she be going through? How should we handle it?

Okay, so the first thing to know is that many women have the so-called lumpy bumpy breasts or fibrocystic breasts, and in the second part of someone's menstrual cycle when progesterone is produced, sometimes people will actually feel their lumpiness in a more discrete way. Meaning someone can think they feel a lump. It may actually be due to the hormonal changes of the cycle. So the first thing that I tell someone to do is let's wait and see what happens with your next menstrual cycle. Now, the problem in the perimenopause is sometimes cycles are spacing out. So if they don't get a cycle in a few weeks, I'm going to want them to come in and get that lump evaluated. When someone has an evaluation of a lump, first thing is it usually includes a clinical exam to determine whether something is likely solid or cystic. Cysts are by and large almost 100% of the time benign. A cyst can be aspirated even in the office, and if fluid is obtained, you can see if that goes— that lump goes away. Bring someone back again for a follow-up exam, make sure it goes away. Many people don't do aspirations in their office and they send someone for imaging. Imaging includes getting a diagnostic mammogram to target into that area and a diagnostic ultrasound. Ultrasounds are really helpful, uh, mainly in telling if a lump that's there is solid or cystic. Again, if it's a cyst, it's benign. With benign cysts, like people who have these so-called fibrocystic changes, they get these discrete cysts and we don't aspirate them because they can come back. We aspirate them only if they're really big and really painful. If it's a solid lump, that needs to be evaluated. So people will get some sort of tissue diagnosis. If you can feel it, they get what's called the fine needle aspiration. If you had sent someone for a mammogram and it was only seen on mammogram, they can get mammogram-guided biopsies. And then everything depends on what that biopsy shows. You know, it can be benign tissue, it can be atypical tissue, and it can be cancer. And depending on those results determines sort of what's the next steps and where they're going to go from there.

And if it's cancerous, so now they're going in for cancer treatment while they're having all their perimenopausal symptoms, there are— how do you keep them from going absolutely crazy with the two things going on at once?

Yeah, that's a great question. Again, one of the things I always want to see is what's the treatment going to involve, because there are many, many different types treatments that people get. They get different types of surgery— lumpectomy, mastectomy. Some people get radiation. If they have hormone-positive disease, they are going to be recommended hormonal therapies. There are different side effects with tamoxifen versus aromatase inhibitors. To use an aromatase inhibitor, you have to be menopausal. That means if you are perimenopausal, they are going to throw you into menopause by giving you shots. To shut your ovaries down, or we sometimes surgically remove the ovaries. If you're hormone negative, you may get chemotherapy. So a lot depends. I always work closely with my breast team to understand, okay, what are the steps that are going to happen? And then I can more aptly guide someone. So if I know that their treatment is going to include something like an aromatase inhibitor, We're going to be aggressive at talking at that initial visit of, you're likely going to have a worsening of your temperature dysregulation. Let's go through the different options that we can give you if that starts to become a problem. I know when you're on an aromatase inhibitor that you're probably going to have horrific vaginal dryness because those drugs shut down all estrogen production in the body. Let's talk about what you can do to be proactive at preventing some of that. So there's a number of over-the-counter things that people can try, and the recommendations actually from organizations like the NCCN are to try over-the-counter things first before we talk about, um, the use of vaginal estrogen. I'm going to talk to them about their diet. I'm going to talk to them about their sleep. When you're diagnosed with cancer, people tend to have a lot of anxiety. So we're going to talk of ways of doing stress reduction. We're going to talk if we need supplements when it comes time for sleep to try and keep their mind from going. So there's a lot of things that I think we can talk to people about beforehand that allows them to be a little bit better prepared for all of these treatment-induced side effects.

And you said likely even with a hormone receptor positive, you'd be able to do something like a vaginal estrogen cream.

Exactly. Well, I would tell you, so vaginal estrogen comes in 3 different ways: creams, rings, and suppositories. There are some theoretical concerns when you use a vaginal estrogen cream in the setting of hormone-positive breast cancer that when you push a bunch of cream in the vagina, that the surface area is greater and it could potentially lead to rises in hormone levels and that maybe that, that is not safe. I will tell you there are studies, in fact a wonderful study was published this past January which was a big systematic review and meta-analysis of all the studies that have looked at the use of vaginal estrogen and breast cancer survivors and did not show any impact on dying of breast cancer. So we know that vaginal estrogen is safe for virtually almost all breast cancer survivors. In people who are on, for example, aromatase inhibitors, because those drugs function to suppress all estrogen, we tend to use the suppository and the ring formulations because studies suggest that those are more likely to stay locally without any rises in the bloodstream.

And one more, um, this might be out of left field, but where would testosterone use come in?

Okay, so let's talk about testosterone in general. So the best evidence for testosterone in women is for improving sexual functioning in postmenopausal women. There is emerging evidence for other things. Like bone health, muscle mass. I think we have much better evidence in men than we do women, but it is emerging. Also evidence for metabolic health, overall well-being, that's more emerging. And testar— so most of the women coming in asking about it, what we see at MIDI and what I see in my breast cancer survivors are more people asking about it for vaginal dryness and sexual health. We don't have enough safety data to fully say that testosterone is safe. I sort of put it in the same categories that we talk about with HRT, and particularly it's for women on aromatase inhibitors because what happens in the body is all women, we all have hormones that are produced. Our adrenal glands put out DHEA, DHEA is converted to testosterone. Our ovaries put out testosterone in the body. That testosterone is changed to weak forms of estrogen by an enzyme called aromatase. When you use an aromatase inhibitor, you inhibit that reaction.

Hmm.

And so the concern, if you gave someone lots of testosterone, could it overwhelm an aromatase inhibitor and would that be dangerous? Now, most times we are giving levels that maintain people in certain values where it's less likely to have an impact, but we don't have enough safety data. So what I do with breast cancer survivors is I think everything's shared decision-making. I am more apt to try, for example, vaginal estrogens, 'cause I think we have more data with that for treating vaginal dryness and sexual dysfunction. If I treat the vaginal dryness and then they wanna know, "Can I use a little testosterone for my sexual dysfunction?" I will potentially, in a shared decision-making, be willing to offer that. If they're on an aromatase inhibitor, I may be more likely to suggest one of the FDA-approved drugs for sexual dysfunction, the Flibanserin, the Addyi, or the broliminotide, the Vyleesi. Now, those are not FDA-approved for postmenopausal women, so unfortunately, They have to pay out of pocket. But there's—

wait, wait, wait, wait. Those drugs for sexual dysfunction in women are not approved for women postmenopausally?

Yep. Isn't that crazy?

When do most women have sexual dysfunction?

Postmenopausal.

What is that, some kind of mean, mean—

I know. I don't know. My understanding was they thought they would get it through the FDA easier if they first studied it in premenopausal women. So, but—

It just leads me to the, if women were in charge, things would be different. Okay, so wow, that is the silliest thing ever.

Can I also, one thing I did wanna clarify that I felt like you mentioned, but I didn't fully touch on is you had mentioned family history and genetic mutations.

Oh yes, yes.

I wanna clarify for your listeners that You can use hormones. I think those people are told, "I can't ever use HRT because I have a family history of breast cancer," or, "I have a genetic mutation," and we do not have any evidence that says the risk of hormones, if there is any risk, and as I have said, I'm not convinced that the current formulations do increase risk, but even if they do increase risk, we don't have any evidence that says It adds on to the risk that someone has based on family history or genetic mutation. That doesn't mean that they don't need to be followed closely. So closely means they need regular breast exam, they need regular imaging, which is mammogram plus or minus, some people may need an MRI depending on if their risk is high enough. They may— we will always guide them about lifestyle things about minimizing alcohol and getting regular exercise. So their screening may be different, but they can still use hormones.

Lifesaver. You've mentioned MIDI Health a couple times, and I would love you to share MIDI Health. You're one of the founders, right?

Yes, and I'm the chief clinical officer for MIDI.

Okay. What is Middie Health?

Yeah.

Middie.

So Middie Health is a virtual telehealth clinic or virtual telehealth medical practice that is covered by health insurance and is focused on treating perimenopause and menopause. We also do some aspects of primary care like weight management, bone health, lipid management, We cover many issues because we know that women have limited access to find experts who can help treat their perimenopause and menopause symptoms and really do a deep dive into what the evidence shows. But we also know that people have a tough time getting into their regular primary care providers these days.

Well, who would want to go to their primary care provider for menopause?

Exactly.

Like what?

Well, We also know though that, you know, one of the things that I'm really proud about at MIDI is we have all of these evidence-based protocols and we teach our clinicians about all these different aspects of perimenopause and menopause. But I've been in practice 30 years and I'm a better provider since I joined MIDI because now I realize I need to understand cardiovascular health much more in detail so that I can safely provide hormones. And in the past, I didn't really understand as much how weight and how body distribution of fat and all of that impacted our metabolic health and how that impacts perimenopause and menopause. And so at Middie, we have both primary care providers and women's health providers, and together we have worked in developing these protocols that all interact with each other. You need to know clotting if you want to understand, like, can I use hormones if I'm at risk for a blood clot, or I have a family history of cardiovascular disease. I am really proud of what we have developed, and then I particularly joined to help us launch a national cancer platform. We are in all 50 states, And we, as I said, we are covered by health insurance and we are providing cancer survivors with care in every single state in this country.

That is so fantastic. So you told me before, so I wanna make sure everybody understands this. You've created the only program that I know of here, um, where you've taken menopause and combined it with breast cancer survivors and then trained practitioners so that they are now in virtual a health setting to support breast cancer survivors.

Exactly. So we actually have a curriculum that we have developed that all of our providers have to take and pass. They actually get credit for that, and we have more than 300 providers. And again, we are licensed— our providers many times are licensed in many states, and We're really doing this because I want that conversation where cancer survivors are told, "Just be thankful you're alive and deal with the side effects." I want that to stop, and it should stop. There are so many treatment options. And so it's important for us to be— for me, it was important to develop this curriculum, train our providers, but the other thing that's important is Literature is changing all the time. When I told you that article that came out on the safety of vaginal estrogen, that came out only a few months ago. We are continually looking at the literature, updating our protocols, and teaching our clinicians so that they can use emerging evidence with their patients to help come up— do shared decision-making to help them come up with the best treatment options for them.

Well, that in itself makes you different than everybody else out there, right?

Medicine is changing. It's not static. And people are using data from 20 years ago to scare people about the use of treatments like hormones. That's just not—

it's still the prevailing thing. It is still the prevailing thing.

You know, unfortunately, what happened with the fallout from the WHO is that because the thought was hormones are awful, they cause cancer, that also led to let's not train anyone in this area of medicine. So pretty much anyone who had been trained in medicine, whether you're talking of medical school, nursing school, nurse practitioner, PA, different areas of medicine, people didn't get training in perimenopause and menopause and the true risks and benefits of HRT. Wow. And we are trying to change that.

I think you're, you're changing it.

Well, doing podcasts like this is really changing that conversation. I think media is changing it, and we are really trying to change that at MEDI.

I just want people to know there's options out there. We get so many DMs about the fact that I can't find a doctor to help me. My doctor said I couldn't do this. So I was like, when we, when we met at dinner at Tamsen's Hottest Menopause Party, I'm like, oh boy, you're doing what? Thank you.

You know that people seek, the data is 6 different providers for the symptoms that they're having, thinking, you know, I'm having this joint pain, I need to go see an orthopod. I'm having weight gain, I need to go see an endocrinologist. Their gynecologist is telling them, I'm not sure it's menopause, just deal with the side effects. There. So people seek out so many different healthcare providers. We need to change that.

Yes. You know what was so funny? I'll, I'll wrap after this, but I used to teach this course to healthcare practitioners called Overcoming Weight Loss Resistance. And it was all the things that could get in the way of you losing weight or cause you to gain weight. One of 'em being perimenopause, right? And so I knew all the symptoms that we knew back then, Back then, I didn't know anything about musculoskeletal syndrome. I hadn't met Dr. Vonda yet. And I certainly didn't know about bleeding gums. But like the minute my thyroid dropped, I knew it. And so I went and got help from my doctor. This, I started feeling a little off for a month or two, couldn't recover from the gym. And then my gums were bleeding when I was flossing. So I go into my dentist, a guy, and I go, I don't know what is up, my gums are bleeding. He goes, low estrogen.

Wow.

I know, I know. Dr. Craig Conroe in Palm Desert, man, shout out to you. Because I was saying, oh, and then I went, oh, and I'm getting a little inflamed when I work out. Oh, and because I didn't have the hot flash thing, so I was like, didn't, didn't know. And, you know, just had a little shorter, heavier period, but nothing obvious. So that was the thing. So that is what's what's so cool is if you— we get these symptoms out so people realize, oh no, that's all this thing here. And then you have one place you can go that can treat all of the things because it's all the same, you know, the same.

You know, it's true. I think the perimenopause is even more of— it's more confusing to women compared to menopause because people have heard of menopause. They know their periods stop.

Yeah, it's obvious what happened.

But perimenopause, you're still having cycles, yet you can get all of the same symptoms, and it is a confusing time period. That's when people are going from doctor to doctor to doctor. And so educating people about that is so important. So appreciative of all you're doing and for letting me come on and talk about this, because the more we can get this message out there, the more that women will not have to suffer.

Agreed. And no one should have to suffer. So I'm going to put all of your information at jjvirgin.com/drmindy. So we'll put the links over to joinmidi.com. That's where— I love the fact that your website for Midi Health also has all of this information on breast cancer and what to do with menopause. So lots of information there. We'll make sure all of that is in the show notes. And I super appreciate your time today. Thank you.

Yeah, thanks for having me.

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