Menopause and Hormone Replacement Therapy: A Specialty Physician Weighs In

Welcome to the Living to 100 Club Podcast. Here's our host, Dr. Joseph Casciani. Well, hello to everyone joining us today on our podcast. You're listening to the Living to 100 Club, one of our public episodes this month. And I'm your host, Joe Casciani. Each week, our conversations educate and inspire, helping you get the best out of all the years we are given, regardless of what obstacles come our way. These public episodes air twice a month. With our premium club membership, paying subscribers can listen to all episodes, so subscribers have access to 2 additional episodes per month. All episodes share educational and inspiring stories with practical tips and strategies for aging well. Premium episodes are for subscribers only, so be sure to sign up today at livingto100club.supercast.com. Our guest for this podcast is Dr. Michael Green, Chief Medical Officer at Winona, a site addressing and treating menopause symptoms. In this program, we discuss the symptoms of menopause and the links between menopause and other physical conditions such as urinary health, weight gain, heart disease, and depression. What are the effects of menopause on the health of women? What is hormone replacement therapy, HRT? And who are good candidates for HRT? Join us as our medical expert discusses how to empower women to make the second half of their life better than the first. First, a little background. Dr. Michael Greene, MD, is a board-certified OB-GYN living in Lake Arrowhead, California. He received his MD at St. Louis University in Medicine In 1993, Dr. Greene completed a family medicine residency at the Ventura County Medical Center and became board certified in family medicine in 1996. Due to his interest in women's health and his love of delivering babies, Dr. Greene did a second residency in OB-GYN at the Carolinas Medical Center in Charlotte, North Carolina. Dr. Greene spent the first 17 years of his career doing OB/GYN as chief of OB for the Centers for Family Health in Ventura, California. He's currently the site director for OB/HG at Northridge Medical Center in Northridge, California, where he works as an OB hospitalist. He has a successful YouTube channel, Med Twice, with over 27,000 subscribers and 7 million views. MedTwice is a patient education channel focusing on OB-GYN. Dr. Greene, thanks so much for joining us today.

Thanks for having me, it's my pleasure.

Great, great. Yeah, you're welcome. I always like to open by asking our guests to tell us a little bit about the journey that brought you to where you are today. I covered a lot of the the highlights, but what were some of the maybe turning points for you that brought you to where you are today?

Yeah, so one of the big things, you know, anyone who knows what medical residency is like, things are crazy for doing two residencies. I got about halfway through my family practice residency and really fell in love with delivering babies. I was told that I had good surgical hands and really felt a passion for women's health. And so I figured to do it right, I should do an OB-GYN residency. So dragged my wife across country and, uh, and we did that. We just celebrated our 35th wedding anniversary. So that's been a big part of my success as well. So I did full scope OB-GYN with some administrative duties in Ventura where we raised our kids. And then I took a job running the OB hospice program in Northridge, uh, which gave me a little bit more time, more quality of life, kind of time off and time and allowed us to move to Lake Arrowhead, which had always been a dream for my wife and I.

Sure.

And then my oldest son has a company doing a lot of software development and they also do startups and they decided they wanted to, at the sort of at the very beginning of COVID realized that they want to do a telehealth startup and pulled in as a chief medical officer for Winona to take, do women's health, basically hormone replacement therapy for the menopausal woman. And so that's been really has sort of transitioned to my full-time job, my side gig. I'm actually March 1st stepping down as site director. I'll still be doing some shifts at the hospital, but really focusing my time on this venture with the telehealth for hormone replacement therapy. Sure.

Yeah, yeah, thanks for that. That's a good ride you've been on. So you've reached a point where you're comfortable and you're providing your expertise to those people who need it. That's good. So let's jump right into the topic about menopause. Help us understand what are the symptoms and how does it affect someone's health?

So menopause, um, what happens as women transition through the sort of fertile period to the menopause period is the ovaries become less efficient and they make less hormone. And it's not sort of a gradual decline, but it sort of starts and stops. And that causes a lot of symptoms for women. Eventually the ovaries stop making hormone completely, and some of that start and stop then calms down a bit and things get a little bit easier. But there's this transition period we call the menopause transition that can be very disruptive for women, generally between the ages of 35 and 60, somewhere in there. And, um, it really changes a lot about how they feel. Changes sleep. It can change, you know, the way their outlook towards life. It can cause depression, anxiety, a lot of physical discomforts, and brain fog, where there's sort of less mental acuity, which can be a real problem, particularly at this point in a woman's career when she's really kind of getting into that leadership role in a lot of situations and really needs to be, you know, operating full steam. And so all these changes kind of come crashing down at this time. And for some women, it's really not much or not at all, but for some women, they're really affected and it can become, you know, a really major issue.

Mm-hmm.

On top of that, the decrease in hormones have other changes that are less obvious, but it can increase the risk of cardiovascular disease, heart attack, stroke over the long term, and also decrease the bone mineral density, which can set people up for fractures later in life. So these are all challenges that are going on at this, at this age, uh, and can be a real challenge for people.

Sure. Now, did you say that this happens when the ovaries stop functioning completely, or is this part of the whole process?

Yeah, it's mostly the part of the process. It's the decline. The ovaries really become less efficient, make less hormone, but they sort of make it in like spurts rather than a smooth production of hormone, and that can cause a lot of the symptoms.

I see. Okay. So a lot of the signs, symptoms, clinical signs, that's part of the process. So it doesn't necessarily intensify there when the ovaries stop completely, but it's been an ongoing progression?

Correct.

Yeah.

And actually some of the symptoms actually get better once this transition is over.

Oh.

Um, some get worse, but some actually get better.

Sure. Well.

Although there is, um, something called surgical menopause when women have their ovaries removed surgically. And that can be really hard on women because it's sort of a, you know, everything's fine one day and then the next day, boom, no hormones at all. And that can really be tough.

What would be the need for that surgical removal of ovaries?

It can be different things. There can be cysts or tumors on the ovaries. There can be certain, um, sort of disease processes like endometriosis is a common reason to have that surgery. There's various problems that can happen where the ovaries need to be taken out.

And HRT, hormone replacement therapy, that's largely what you're offering through your website, which we'll talk about more in a few minutes, but when should someone consider HRT?

So HRT, once symptoms start, HRT can help relieve symptoms and improve quality of life. So some people think, well, gee, if I put this off as long as possible, I don't have to have these medicines as long. And so they suffer through these symptoms for quite a while. There was a really landmark article that came out about a year and a half ago that looked at cardiovascular disease and hormone replacement therapy. And really what they found was that the earlier women start hormone replacement therapy, once the process begins, the better off they are long term for heart health. And so our cardiology colleagues are sort of pushing, hey, start— don't wait to start HRT. Once symptoms start, the sort of clock is ticking. And if you start this earlier, you get a lot more benefit as far as preventing heart attack and stroke and these kind of things. And so there's a big benefit long-term health-wise to starting HRT earlier rather than later.

So the hormones offer some kind of preventive effect for cardiac condition, any heart—

Absolutely. It's interesting. If you look at heart attacks, In the age group premenopause, men are much, much more likely to have a heart attack than a woman is. If you look postmenopause, women eventually catch up to men. And we think it's the loss of the hormones, particularly the estrogen, that causes that. And so estrogen seems to be cardioprotective. It protects the heart. And so once the ovaries stop making that, that protection is gone. Hormone replacement therapy helps bring that estrogen to sort of normal youthful levels and protect the heart and keep the the risk of heart attack down. At least that's the mechanism that we currently think is going on.

So is HRT contraindicated for some women?

Yeah, absolutely. So women over 60 that have never been on hormone replacement therapy, it's considered risky to start hormones at that time, mostly because they've sort of lost this cardioprotective effect. And now they've got some probably underlying heart disease, even if it's not recognized yet. And so starting hormones at that time can pose a problem. Women that already have a known history of heart attack or other cardiovascular disease, history of stroke or TIA, that would be a contraindication as well for similar reasons. Women that have had blood clots, so-called DVT, like a blood clot in the leg, or a PE, pulmonary embolism, so the blood clot to the lung, HRT would not be safe for them because it can, in those women, can increase that risk further. Um, so we wouldn't want to start it in them. But, you know, most women in the age group we're talking about don't have these problems. And so for, for most women, it's, it's very safe. But again, you know, you have to screen people appropriately to make sure it's going to, going to be safe.

Sure. So there may be some risk factors present that would suggest, contraindicate the need for HRT.

Yeah, sure.

Okay. So what types of treatments are there? I mean, you mentioned when we spoke earlier, there are different hormonal treatments.

What are some of the So estrogen plays the biggest role, and estrogen can be given in different ways. So there's a pill form, there is also a cream that is put on the skin each day, and then there's a patch that can be placed on the skin and worn all the time. Those are the main ways. There's also an estrogen vaginal cream, but that really, that's really good at treating vaginal symptoms, but it doesn't do all these other benefits that we talked about. So in some women that have really are suffering from a lot of vaginal symptoms, sometimes we end up using both one of these other types of estrogen as well as the vaginal cream. In a woman that still has a uterus, progesterone is necessary with the estrogen because estrogen by itself can increase the risk of uterine cancer. When we add progesterone, you actually decrease the use of, the risk of uterine cancer even below women that aren't on hormones. So we always add progesterone with estrogen in women that still have a uterus. And the progesterone can also be given as a cream or a pill. One of the ways that we use progesterone. And then testosterone also decreases in women through this time period. Testosterone can be a little tricky because if you over-replace it, you can cause side effects, you know, that aren't very pleasant, what we call androgenic side effects or male-like side effects. And so you have to be careful with that. So another way to do estrogen— sorry, testosterone replacement is to use a supplement called DHEA. And that's a little bit safer because it's really hard to overdose that. Unless you get into sort of crazy doses, but in, in reasonable doses, it's a little bit easier. It's a little bit more gentle way of doing it. So that's the way we do it at Winona, just because it's a little safer and easier.

Okay. So if you determine that testosterone level is low on the initial assessments, that's when you would add that as another modality. Correct. Yeah.

Yeah. So those are basically the 3 hormones, but primarily estrogen does the heavy lifting.

Okay. Are there some natural remedies aside from the HRT for treating menopause symptoms?

So with the exception of maybe childbirth, there are probably more sort of home remedies and natural remedies for menopause than almost anything. The amount of myths and home remedies involved in childbirth is just outstanding. I once gave a lecture at the hospital about this, but there's quite a few for menopause as well. Honestly, there aren't many that really work or have proven to work. In good studies. There's all kinds of things that people try and supplements out there, you know, that tout benefit. And some of them may give a little bit of benefit, but they're not going to give both the symptom relief and the, the long-term medical benefits that estrogen is going to give.

So a lot of anecdotal studies, I'm sure, and reports, but nothing that's showing up in the research literature that is shown to be effective.

Yeah, I mean, there's actually been a lot of research on these, and the good, what we call randomized controlled trials, where they check them next to a placebo, have not shown that to be of benefit at all.

Yeah. So tell us about your— the website, Winona. What it offers, who's it for, how does someone qualify for the services?

So Winona, it's bywinona.com, is a telehealth website So it's all done online. And it basically, the way to start is there's a quiz to see, are you having symptoms that sound like menopause? You know, is this really the right thing for you? And so if the quiz says, yeah, this is something that might help you, then we have a, what's called an online adaptive interview that asks you questions and the questions will change based on your answers, sort of an AI to take your history that's relevant. And we're looking most importantly, do you have anything that would make hormone replacement therapy dangerous. So our philosophy is safety, safety, safety. So that's the number one thing. And then we also ask questions to sort of get an idea of, you know, what symptoms you're having and other health issues that may affect the choice of product and dosing. And we ask your preference, you know, do you prefer a pill or cream or a patch? And then I've built an algorithm that takes all this information, and suggests a treatment protocol. And then if that's something that you want, then it goes to the doctor. And so we all have, we have board-certified physicians review everything, ask you follow-up questions if necessary. And if it seems, if it's safe and you're an appropriate candidate, and this is medicine that will help you, we go ahead and provide prescriptions. So we have a compounding pharmacy that will send the prescriptions in the mail. And then we check in with you and make sure things are working and adjust as necessary to make sure that the dose is just right. But that's basically how it works.

Yeah, that's good. How does one qualify? Does anyone qualify for accessing the services?

So anyone can get online, obviously. Really, so those contraindications we talked about, so you have to be between 35 and 60. You have to be in a state that we service, obviously. And then you have to be a good candidate, and not only medically that it's going to be safe, but you have to be someone where this is actually going to help you. So we don't want to put you on medications that aren't going to work. So assuming all those, then you would, would qualify.

Okay. Yeah, so you mentioned there is the physician that interacts with the person through a telehealth session. So theoretically, someone visiting the site and conversing with the physician would get the same services as if they were in their outpatient office of their, their specialty doc?

That's the design. So yeah, it's important that you get the same quality of care online than you would in person. The nice thing about hormone replacement therapy is that it doesn't require a physical exam and it doesn't require lab tests. So it's sort of the perfect thing for telehealth. So interaction can be done online. You don't really You know, there isn't anything to poke and prod, and there isn't lab tests that need to be done. So it makes it very simple. We're using right now a type of telehealth called asynchronous telehealth. Basically means that there isn't real-time interaction between the doctor and the patient, but rather a back and forth that happens separate. So we get a lot of patients in the middle of the night. Somebody wakes up in the middle of the night with terrible night sweats and hot flashes and can't get back to sleep, and they get on their phone and they find us and they're like, this is what I need. And so they fill out the stuff. And then in the morning we look at that and say, oh yeah, you're a great candidate. And there can either we fill the prescription, there's some back and forth through messaging. But the nice part is it's very convenient for the patient. She doesn't have to leave her home. She doesn't have to make an appointment except walking to the mailbox to pick up the medications. So, you know, it works really well that way.

And how long would it take from the time the order is written for the meds to the delivery time?

So depending, um, where in the country you are, a few days, no more than a week.

Wow, okay. And you made an important point also that there is, there is some follow-up after the prescription, after the initial medical contact. There is some follow-up periodically with the, with the patient. How does that work?

So yeah, that's really important. So when I was designing this thing, I really said to myself, this is a patient in my office, what would I do? And so if you came in my office and we had a conversation about hormone replacement therapy and I wrote you a prescription, I would want to see you back in 3 months, touch bases, see how it's going. And if everything's good, write you a year's worth of prescriptions and see you every year. And if there's some changes or adjustments, we could, we could do that at that time. And so that's what we've done online. So at 3-month time period, we reach out, We have another telehealth asynchronous visit, see how things are going, assess do we need to change anything? Is everything great? And then we write for a year's worth of medicine and touch bases that way every year. We're available any time. So if something, you know, a problem pops up or a question, patients can message us and we all, you know, as a rule, we get back within 24 hours, but usually a lot quicker than that. And sometimes, you know, everything is good, and then after 6 months or 9 months, all of a sudden the body readjusts and the medicine needs to be adjusted, and that happens.

And so, yeah, you have to take a closer look.

Sure.

So how about health insurance? Does someone's health insurance cover these services?

So we take HSA and FSA cards. We do not primarily take health insurance, but we do have patients that have been successful in sending bills and getting reimbursed you know, to their insurance themselves. And we have, we have a section on our site they can download, you know, some of the letters and forms that the insurance may ask for. But we don't do primarily take care of insurance or fill out insurance forms, but we have had people successful in getting reimbursed from their insurance. It depends on— there's so many different plans, deductibles and all that.

Yeah. And someone seeing their doctor in person might have the same challenges getting the insurance to cover, right? I mean, it's—

that is true, right? It's sometimes— yeah, insurance is not like— yeah, I know. Yeah. But, you know, we've made a real effort to try to keep this— keep costs down and keep this affordable, which is one of the reasons that we do this with the asynchronous telehealth. It means we have to pay our doctors less because it's more convenient for them. We have our own compounding pharmacy, and so we can control costs that way. And we think, you know, we do this for a fairly affordable price, even if people have to pay completely out of pocket.

Sure, sure. How about people from outside of the US? Can they access Winona?

Unfortunately, not at this time. The, uh, the, uh, healthcare laws are really tricky and cumbersome, uh, and so at this point, um, we're really trying to expand into as many states as we can in the United States. Sure. You know, we of course, you know, have thoughts of going internationally, but that's probably a fair ways off.

Yeah, yeah. Well, with the telehealth restrictions, I mean, you certainly have to have the MD licensed in the state, right, where the patient resides. I remember that from our nursing homework. Sure.

Yeah, yeah, yeah.

So that's a big— I mean, that's a big— important to stay compliant with that, obviously. So you can't just jump into any location where you're patients might come from. Sure.

Yeah, that's been, uh, yeah, that's been one of the big challenges is, um, I've gotten very good at reading legislation and, uh, you know, understanding the hoops that need to be jumped through because we'll make sure we do this right.

Yeah. And getting licensed in several states, getting licensed in a few states, right?

And that's right.

Yeah, those days. Sure. Yeah. How about services for men? Is this, is this something that men can access?

So we don't do hormone replacement therapy for men. Men sometimes do need testosterone replacement therapy, and there are some really quality online companies doing that, but we don't, we don't do that ourselves. There's a couple of challenges. First of all, testosterone is a controlled substance, so it raises the bar and changes how telehealth can be done. It's very difficult to get that done. And generally lab work needs to be done as well. So it really increases the complexity.

I see.

And then lastly, quite honestly, I'm an OB-GYN, you know, by trade. So, you know, we try to do right now, you know, we do one thing and we try and do it really well. And so, you know, there are other resources for men, but unfortunately that's not something that we provide. And actually that was one of the, that was one of the things that really sort of got us into looking at hormone replacement therapy is that at the time there really wasn't anybody doing menopause management. And there were a ton of these companies doing, you know, erectile dysfunction and testosterone replacement. Sure. So it's like, and this is the way unfortunately healthcare has been, is that, you know, the women, the healthcare towards women sort of lag behind. And it's like, gee, there's all these resources for men and there's nothing for women. And so we thought we could come in and be part of the picture that provides that.

Yeah. Yeah. Meet a valuable need. And if people do not need to travel or cannot get an appointment with their doctor for a month or two, that's a valuable service that you're, um, you're providing. You're meeting some important needs. I can see that. Sure. I'm curious, where did the name Winona come from?

Yeah, that's funny. So that actually was chosen before I came on board, and I'll be honest with you, I think it's just— it was sort of a marketing, like, oh, this would look good. Sure. I can tell you a funny story about my YouTube channel, the MedTwice channel.

Yeah.

My son and I, it was actually his first project. He was still pretty, pretty young. And we had bought mypersonaldoctor or myprivatedoctor.com or something. And that's what we were going to call this. I'm in my office and all of a sudden I see that my credit card was charged to buy a domain name MedTwice. And I'm texting him, what are you doing? So he, I called him and he's like, it just didn't look good on a logo. He was like, you can't make this look good. And so he searched for something that was available and came up with MedTwice.

That's right.

So I have a feeling that's how Winona, uh, came about as well. Sure.

Honestly. Is that still active, MedTwice? You're still doing education?

So I have not, it's really interesting actually. We haven't really made MedTwice videos in a long time.

Mm-hmm.

Um, and yet the site keeps growing. I was actually just talking to our vice president of marketing maybe an hour ago as we were talking about video quality, and I'm like, if you go look at my old MedTwice videos, those were made 10, 15 years ago on an old iPhone, you know. Yeah, they're like potato quality, but the content's good, and that's what people are interested in. Right. You know, do it right and The marketing sort of goes for itself.

Yeah, I like that. I like that content takes priority. I was listening to someone talk about creating videos and he said, "Done is still better than perfect." Right. So it kind of says it all. Yeah, we can wait till it's perfect or we can get it up and get the message out there.

Sure.

Yeah. So what's the takeaway for the listeners here, Mike? What would you hope our listeners take away from this conversation?

So first, that if you're suffering from menopause symptoms, there is treatment for that. And whether you do it at Winona or you do it with your personal doctor or somewhere else, don't be afraid of this. There's no point suffering and having a decreased quality of life out of fear of the unknown. And unfortunately, there's a lot of bad information out there about hormone replacement therapy that's really scary for patients. You know, that it does all these causes cancer and does all these terrible things. And it's just not true for, again, for a patient that's appropriately screened, women that start hormone replacement therapy before 60 have a longer life expectancy and a higher quality of life than women that have never been on hormone replacement therapy. So I think that's an important thing that's misunderstood out there. And even among doctors, there are doctors that are afraid of it and just, I don't prescribe it. So there's no point suffering and with these symptoms, number one, 'cause there's treatment for it. And so you might as well feel better. And not only that, but the treatment besides helping these symptoms also works behind the scenes and increases longevity and quality of life. So, you know, try to get past the fear, educate yourself. We have one of the things that we built on Winona is a very large library of educational blogs, um, and articles that are all referenced that kind of debunk some of these myths. 'Cause like I said, there's a lot of myths when it comes to menopause management. So educate yourself, see if you're a candidate, uh, and do something proactive for your health. Get yourself feeling better and living longer, I think is worth doing.

Yeah, that's great information. So you take a lot of the appropriate risk management steps. So the fears that people have more generalized about HRT are not valid, but there are some risks and you need to consult with a quality authority on this to make sure you're not at risk for taking the HRT.

Yeah, absolutely. I mean, every now and then I have a very disappointed patient who I say, I'm sorry, but this is not appropriate for you. You know, I wish it was, but you know, the last thing I want to do is hurt you. But for the vast majority of women that are suffering with symptoms, the treatment is safe and effective.

Well, that's good. That's good message, good information, reassuring for a lot of our audience members, I'm sure. Well, looks like we're out of time for today, Mike. Before we wrap up, I just want to remind our listeners to visit my website livingto100.club, sign up for our email list, and download a free copy of my 9 Tips to Make Living Longer Enjoyable. You'll also see an option to contact me with your questions and comments. I welcome your feedback. And finally, be sure to subscribe to this podcast series as a premium club member so you don't miss any episodes, maybe the episode that could seriously affect your decisions, outlook, or your actions. Sign up at livingto100club.supercast.com. Com. That's livingto100club.supercast.com. Dr. Green, thanks so much for being a guest on our show today. For those who might want to contact you, how can they do that?

So come to the website bywinona.com and you can get a hold of us there. Um, we have a customer service, uh, patient services people that can help you and guide you as well.

Okay, are you saying buy, B-U-Y?

B-Y, B-Y-W-I-N-O-N-A.com.

Okay, so information available and people are encouraged to go to the website to look at this resource. That's great. Well, thanks so much for being a guest today. I appreciate your sharing your expertise.

It's my joy. Thank you for having me. I appreciate it.

And thanks to all of our listeners for tuning in. Hope to see you next time.

Hi, this is Suzanne Newman, host of the Answers for Elders podcast and radio show. We are the North Star that guides you through the complicated journey of senior care with trusted experts in money, law, living solutions, and more. So join us on this station, your favorite podcast channel, or just go to answersforelders.com. Meet the wayshowers who will help your journey go a lot easier.