82. Menopause Doesn’t Have to Be Hard

Dr. Culver: We do. We sure do.

Maryann: We know that there are dozens, if not hundreds, of menopause-related symptoms, and some of them are more obscure than others. We know that hot flashes. Those are the biggies. But what other symptoms are we becoming increasingly more aware of as being menopause related?

Dr. Culver: Very good question. Because we know that menopause hormone therapy is FDA approved for hot flashes and night sweats, and we’ve talked a lot about that. But also the symptoms that women experience with estrogen decline, such as women have, trouble sleeping. And we know even if there’s not hot flashes or night sweats, if your estrogen is declining or you have fluctuations and so forth, then women do happen to have poor sleep. And when you have poor sleep, then there’s a whole cascade effect. So either sleep can influence the promotion, of other symptoms or lack of sleep or deprivation of sleep, but also independently, decline of estrogen can cause things such as joint pain. People are now really talking about, as I’m getting older, I’m having these joint pains, or these pains that I didn’t have before. I’m having now more, you know, vaginal dryness, or I’m having some more urinary, symptoms, like I have to go to the restroom more often, or I have dry skin.

Maryann: Dry eye is a big one.

Dr. Culver: Dry eyes, exactly. And then the big one, which is, you know, near and dear to me, is you. You can have an increase in depressive symptoms, and you can have an increase of. Of anxiety. Now, the thing about that is, is that if you address some of these really the top concerns, such as things that would disrupt your sleep, that is really, really important, and also to go into your past histories and so forth and what could potentially be exacerbated during the midlife. But there’s again, 36 some, plus symptoms and possibly counting. And the important thing is to validate what women are experiencing, because we may not know exactly the murad of effects that declining estrogen can have because we are finally listening to women. Right. We’re finally validating.

Maryann: I love that.

Dr. Culver: So I’m sure down the line, if a woman tells me for certain this is just evolving and it’s occurring, I’m going to listen. And the more we do that, the more we will again have information and feedback to give women. But primarily, I’d say it’s the women are complaining more about the brain fog, the trouble sleeping and the mood and the anxiety.

Maryann: Good times.

So, what I love is that you and your menopause partner at Pandia Health are two of only 1000 ob gyN practitioners in the United States who are menopause society certified practitioners. Tell us why this additional layer of expertise is really great for patients who are traversing menopause.

Dr. Culver: Yeah, well, I think that’s now increasing, so hopefully, I think it’s up to 1,500.

Maryann: Oh, great.

Dr. Culver: Yeah, great. For menopause society for, you know, making sure that there’s two exams a year, if maybe there’s more. But, you know, there’s a real, real push to get people to the level of understanding with the guidelines and the basic research that the guidelines are based on. but it is really important because, we are validating, we are very vocal. And if you undergo the certification, you’re actually saying to your patients and to yourself, I’m committing myself to going through this process and learning this curriculum. OBGyns, General Ob GyNs, of course, can prescribe and see patients in the peri and menopause space. And I know as a very busy clinician, sometimes we can’t go to these meetings all the time and we can study at home and do online courses. But this extra certification is a level of commitment that, you know, this is something that, this is very dear and that you want to present that. Yes, I got the stamp and I went through the certification, and I’m committed to help you.

Maryann: Well, I appreciate that. I thank you on behalf of all women. So, circling back to what you said a little while ago about anxiety and depression as two of the symptoms, I think it’s so unfortunate that sometimes our menopause symptoms can be confused with other conditions and women particularly in perimenopause. And our hormones are just really fluctuating. They’re all over the place. They’re often diagnosed with depression or anxiety. How do you determine whether a woman is experiencing hormone related symptoms or something else?

Dr. Culver: Yes, that’s very, that’s a very important question. And, you know, we worry and we are concerned with women that have major, depressive episodes and suicidal ideation that can increase during this vulnerable period. So the transition perimenopause and menopause. Well, the transition from perimenopause into menopause is this vulnerable, window, and it also can be a window of opportunity, so you can separate that out. But this vulnerability time is really important to look into the past history of a woman’s mental health and how her life experience has been previously. Did she have premenstrual dysphoria disorder? Had she had depressive episodes before? And taking that into that context, there is a minority of women that have first time onset of depression in perimenopause, early menopause, but that’s still the minority. The majority of women that have, perimenopause and depression episode are women that have had experience in some mental health challenges in the past. And maybe they haven’t been properly diagnosed, but if you go back and ask questions, they’ve had histories of that, of feeling sad or depressed mood. So that’s really one of the first things is to ask about. And the second thing to really ask about is how are you sleeping? And because we do know that if we improve our sleep, we can improve our coping and also asking about other stressors in their life.

Maryann: Right, right.

Dr. Culver: And are they connected to people? So really, diving into what is their current situation? And number two, are they safe at that moment? Because if you’re dealing with someone point who has major depression, it’s a whole different pathway. Right. But if you’re, you really have to get them care right away. And that doesn’t mean that hormone replacement wouldn’t be an option, of course, but it’s about a safety issue. But to decide between the two is really helping someone optimize so that they don’t have a recurrence of a depressive episode. So it is asked that we should be screening when a woman gets into the perimenopause period of time and to be proactive. So if a woman has had, episodes before, make sure that they tell, you what has worked before in the past. And is it initiating cognitive behavioral therapy once again? Is it improving your social bonds, is it improving sleep and really keeping an eye on that? And then, of course, hormone replacement therapy is now more and more looked upon as potentially like the treatment. If you’re having these physical complaints that could be compounding or could be placing someone at risk.

Maryann: Yes, and we’ll get into treatments a little bit later. But I feel like a lot of women are first given antidepressants or anti anxiety meds before they’re even talking about hormone therapy with their doctors.

Dr. Culver: Right. And I think it’s because there’s just a lack of time. Right. And then again, there’s that knowledge gap. So, you know, I would love for, I don’t know if a psychiatrist, I mean, if you’re seeing a woman that does not have any restrictions to, has a medical history that is, healthy, otherwise healthy, and because you’re in the psychiatric space. But if you’re seeing a woman, it would be wonderful. If that’s the woman that’s there, maybe she needs hormone replacement therapy or menopause hormone therapy if it’s mild depression or before taking another kind of medication. So we really want that education to go into, again, other spaces like psychiatry, because you’re absolutely right. Or is it a combination? Right.

Maryann: Right.

Dr. Culver: Initiate something. Let’s entertain and let’s think about adding hormone therapy.

Maryann: Gosh, you’re right. I mean, menopause truly does touch on every aspect of a woman’s health. It really is amazing.

Dr. Culver: But it’s really about asking and, taking the time to ask about what were the risk factors. Are there risk factors?

Maryann: I talk about this a lot on the show, but we are sort of in the middle of this menopause renaissance, if you will. Thanks to the Internet and more available information, more women are out there breaking the taboos surrounding menopause. We’re talking about it unlike our grandmothers and our mothers. And we also know more than generations past, how knowledgeable would you say is your average patient about identifying her own symptoms and asking for what she needs?

Dr. Culver: That is a tremendous question, I’m sure. And I’ve seen the evolution of the knowledge that women have, like, from years before coming in and not being able to necessarily articulate with the words that we now use that really are descriptive. Right. so now women come in with the words that, like, we’re talking the same language, we have the same vocabulary. So when they say, you know, hot flash night sweats, they’ve already read the description of it. So it’s not like, a paragraph of what they’re feeling and then sensation they’re actually, they really know the terminology. So we’re talking, we have a better conversation because they’re using terms. And sometimes we have to clarify the terms and make sure. But they know the terms, so therefore there’s better communication. And then they also, have been seeing, so much out there by social media, and there’s so much consumer driven, medical care. Right. And so I am seeing an evolution of women actually coming in and saying even their preference, even, like, I’ve already decided that I’d like this route or that route, which is really great.

And it’s also really important to, again, talk about options. Right. I mean, that’s why we are doctors and we’ve been educated in this. But, it’s very important to talk about options and to, even help women dispel maybe some of the things that they’ve been educated on. Right. So there are all different kinds of education outlet. So some of the time we are actually trying to dispel certain myths or help guide and streamline what are the top concerns.

Maryann: Right. To some degree, I can only imagine this can be a, bane for doctors sometimes. I have a friend who’s an ER doctor, and she keeps saying to me, people come into the ER, they think they know what they have already because they’re googling stuff and they think they know better than me, which is, you know, of course, the flip side of having more information out there. Which brings me to my next question. How much of this information, or actually how much, how much misinformation is actually out there on menopause, hormone therapy and all that stuff?

Dr. Culver: Yeah. it’s hard to say because the way that social media is and who you follow, who you associate with, who your colleagues are, you know, you’re kind of fed your own message. But I do see quite a few women that are getting information from, people that mean well, but there are other specialties or there’s other aspects or branches in healthcare or wellbeing care, that I have to address and say, you know, we are validating your concerns. I understand that there are very different, ways to approach health and wellbeing, but we are seeing that. We are seeing a lot of people coming into the space that mean well. But it is our job to really state what has been shown by medical studies to be effective. And to be very, concrete about that as well. Right. And I believe the North American, or the menopause society. Now, menopause society, not North American Menopause Society, has published guidelines on the non hormonal management and therapies for vasomotor symptoms, which is, you know, the top concern, and top symptom. And that was really helpful for women because then we were able to. To say, look, we did take a look at that and had a group of experts. Now, again, it’s not always everybody has their own personal journey, but our job is to say, in this space, this is what has worked. And there is consumer driven healthcare, and there’s a lot of women seeking help, and we have to just make sure that we know when we counsel them what has worked. And most of these treatments are not, expensive per se.

Maryann: Right.

Dr. Culver: They involve laboratory testing. For the majority of women, having care and addressing major and main concerns, should be relatively easy. And we need to break down those barriers for women to get the concrete and the effective care.

Maryann: Okay, so as you said, every woman’s menopause journey is different. Right. And you provide patients with a personalized treatment plan, which is so great. What kind of review do you conduct to determine this customized regimen? Can you give us an example of what it might look like? Does it expand beyond hormone therapy? If so, how?

Dr. Culver: Yes, that’s a great question. So, in terms of menopause, and midlife therapy or consultation. So women will fill out a form and we ask for all of medical history looking for, are there restrictions or outliers that would make a woman not a candidate for hormone therapy? Because we do know that hormones are the most effective treatment for hot flashes and night sweats and, of course, vaginal dryness and prevention of osteoporosis and so forth. It’s FDA approved, but we look for restrictions, and then we look at symptoms, we look at menstrual history. And I also always like to ask, like, what are your main concerns? If you wanted two or three things that you have to address. Now, let’s start with that and make sure that whatever recommendation is made is addressing, a woman’s top concerns.

Maryann: Prioritize.

Dr. Culver: Yeah, and prioritize. Exactly. Then we know that we can adjust and address other symptoms as well. But if you’re taking care of top concerns, there are a lot of times when you do that, again, there’s that cascading effect and that we can see that there’s resolution and alleviation and, other aspects of symptom management and well being will improve and so forth. When a woman feels like she’s taken care of. So essentially that is the individualized approach is really asking what is important to her. Yeah.

Maryann: And I do think many women are still confused about whether or not they’re even going to consider hormone therapy. We know that the studies conducted more than 20 years ago, they’ve all been disputed and that most practitioners now deem hormone therapy safe, but we’re still confused about whether or not to embrace it or to write out our symptoms.

Dr. Culver: Right.

Maryann: Go hard on the lifestyle changes first. I mean, personally, I’m in that camp because I’ve managed to minimize my symptoms through diet, exercise, drinking tons and tons of water, eliminating alcohol, stuff like that. But what’s the process for determining whether or not hormone therapy is the way to go? How do you know if you are a good candidate for it?

Dr. Culver: Yes. So it really is looking at should we be prescribing menopause hormone therapy for prevention? And so, yeah, it’s pretty evident that when a woman presents and she has symptoms, it’s FDA approved for treatment. Right. It’s a bit more confusing when a woman may not have symptoms. And they’re not presenting, they think, well, I feel fine because there is a minority of women who don’t have any symptoms. And through.

Maryann: Yep. And you’re afraid to tell other people about that.

Dr. Culver: Exactly. But then those are the group. That’s the group of women that question, well, should I be doing this for prevention?

Maryann: Especially if you have Alzheimer’s in your family, stuff like that, that you’re now getting conflicted signals about.

Dr. Culver: Right. So that’s the interesting group of women that come in thinking, “Am I supposed to be on this?”

Maryann: Yes.

Dr. Culver: We can’t FDA approve prescription for prevention. We can for osteoporosis prevention in menopause women. and, but we do know that we have positive impact on other aspects of our life when we take menopause hormone therapy. And that’s where the clinical research needs and is continuing to be done so that we have those answers and that we can say with definitive that should we prescribe for prevention? So right now for dementia, that’s a really hot topic. And it should be because women suffer from Alzheimer’s more, than men. And we do know that the data shows that if women go into premature menopause or early menopause, they have higher rate of dementia at the age of 65 than someone who went in through naturally. So we have this sort of knowledge base and then we have also women that are and women scientists that are examining this, and we do though, that estrogen is a master regulator in the brain, but we’re not there yet with the study to say that we can use hormone therapy as a preventative measure. But we do have good implication, and it is thought that estrogen may play a role, right?

Maryann: This is so frustrating. This is the most frustrating thing about menopause. my sister and I talk about it all the time because our mom has, Alzheimer’s, and we both have had a relatively smooth ride during perimenopause and. But there’s always that thing in the back of your mind, like, will I regret not going on this now when they find out ten years later that, you know, it could prevent these diseases? So I’m so happy someone’s out there doing the research. We need so much more. Right, right.

Dr. Culver: Well, it’s Dr. Lisa Moscone. She’s coming out with a book, and I think it’s coming out in about a month. but we do know that the vulnerable period of time is the transition period, right. If a woman, wants to do this and she has a history of Alzheimer’s in her family and she’s concerned, and there are no, restrictions, there’s no health restrictions from being on, estrogen or menopause hormone therapy. You can have a conversation with your patient and decide and have a shared decision making. Right? So that’s where it comes in. That’s the part of knowing and asking about the concern. Right. And the well being.

Maryann: But here’s what makes this even trickier. If you look at, a box of vaginal estrogen, a lot of people have shown this on social media. It says right on that box. Risks include dementia. And women are like, what the?? Like, how are we supposed to tease that out? That is really confusing. And my doctor personally has told me, oh, don’t listen to that box, because that’s just overly precautious. It’s not, from my experience, anecdotally, it’s not causing that. What’s your take on that? Why is it so confusing?

Dr. Culver: Well, because it’s just immediately extrapolated from the women’s health initiative study, and they haven’t removed it.

Maryann: You mean the one from 20 something years ago?

Dr. Culver: That’s it. It’s just. It’s just extrapolated all the way down from that. You know, one arm of patients that were on, you know, cee MPA, you know, and they didn’t. They looked, and they were women. That were older and so forth.

So there was this one group where possibly there was one increase, one person in 1,000 of nonfatal breast cancer m possibly in that arm from whi. So over the last two or three years, there’s been a re examination. And, estrogen matters is another wonderful resource to talk about reanalysis of the study and what we do know now and so forth. So really, that black box warning, people have been trying to have that removed because it’s just a direct extrapolation. And there are, few studies, but there are studies that show that low dose vaginal estrogen is absorbed in such nominal amounts, and that if it’s absorbed just like transdermal, you would have first pass, you know, effect. You have a lower chance for venous, thrombotic events and stroke and things that go along with increased clotting. So it’s really just, it makes sense scientifically that it’s not absorbed in a statistically significant amount. And even if it is absorbed nominally, it’s in a way of like the same as transdermal. It’s bypassing, hepatic metabolism on, you know, it has the first pass effect. So there you go. But it’s ongoing and, we have to continue, to educate women. And it’s too bad because, you know, it’s hard when it’s all in writing and they see.

Maryann: So is that the FDA that’s in charge of putting those labels on packaging? So they have a long way to go.

Dr. Culver: Yeah, absolutely.

Maryann: And, you know, this is what I find interesting. Many women out there, they think that if they go on hormone therapy, it’s going to restore their youth, that they’re going to have all the estrogen that they lost suddenly back in their bodies. But I was reading this chart on actually estrogen levels throughout a woman’s lifetime and the effects of hormone therapy, and it only brings your hormones, your estrogen back up to like a fraction of what it was before you hit perimenopause. Right?

Dr. Culver: Yeah. yeah. It’s really not meant to go into supraphysiologic levels. It’s really to just bring it back into menopause a little bit above menopause level. But, and then women are a lot of times asking, like, is this the correct dose? You know, is this the correct dose for me? Like, is this really doing what it’s supposed to do? And I said, you know, by guidelines, the correct dose is when your symptoms are mostly alleviated, can’t go 100%, but, you know, if you’re 80% to 90% symptom free or 80% to 90% alleviated, then that’s the correct dosing. So that’s, again, sometimes one of the more prominent questions, that we.

Maryann: Get, can doctors play around with those dosages at all? I mean, how flexible is that?

Dr. Culver: it’s pretty flexible. with, there’s, you know, sometimes there’s, ah, shortages. Right now. Right now, I think we’re, the US is experiencing some micronized, progesterone supply issue. but for the most part, if there are different routes, right, there’s the transdermal patch route, there’s an oral route, there’s now a spray. So you can play around with dosing, but you have to be. And that’s why certification of menopause society, as a practitioner is really important, because I think when you see more and more women and you have a large volume of women that you’re helping, you really get to understand the nuances on how you can adjust and feeling comfortable with that. But you’re absolutely right. You can adjust. You can, you know, increase dosing by, you know, a half. You can change the amount of sprays that someone has if it’s a metered. Right. you can prescribe just a certain number of patches. And we have varying level of patches, you know. Yeah.

Maryann: And I want to get into all those different forms that hormones come in. But first, you know, wow, I did not know there was a shortage. Everyone’s already lining up for ozempic. Now they’re lining up for hormones. Oh, boy. Okay, so hormone therapy comes in many forms. You’ve mentioned a few of them now, but can you just, like, briefly take us down the list of all the different options a woman has and what each of them is used to target primarily? That would be great.

Dr. Culver: Yeah. So, menopause hormone therapy, can range from progesterone alone to estrogen and progesterone to estrogen. And then, of course, there’s non hormonal, but we won’t get into that. so really, it boils down to, again, symptoms. Right? So perimenopause generally has a myriad of symptoms. Menopause also has symptoms because we know that symptoms persist well into transition and beyond. So really, it’s about focusing on the symptoms. So it’s pretty common that we may prescribe progesterone alone, and that is oral route. We know that the oral route of progesterone is what is clinically, superior and better. Right. The absorption of oral progesterone. Sometimes people may have, a slight intolerance and that, infrequently, we may say you can use it intravaginally, but that’s off label. But it’s a possibility. Now, along with that, women can be on, progesterone only pills, too. Again, you have to ask somebody, are you still concerned with prevention, of pregnancy? And so if you are, then the progestin only pill with northidranone or drosperinone. So there’s, there are options, but generally speaking, it’s oral.

Maryann: What about the patch? How is that different?

Dr. Culver: Yeah. So when you move over to menopause, hormone therapy, and let’s say you’re in perimenopause, that does not cover pregnancy. And for some women, that might also be something that they want because they may have been somebody that has wanted children. So menopause hormone therapy does not protect against pregnancy, and it doesn’t suppress ovulation, but it can add back and stabilize and to kind of deliver a baseline level of hormones to alleviate symptoms. So transdermal has been very popular because you wear it and you can change it once a week or twice a week depending on what you’re prescribed. And there’s varying doses of that.

Maryann: Transdermal is the patch, just to clarify.

Dr. Culver: Yes. And there are transdermal sprays too. But the patch comes in different doses. And if you have a uterus, you have to have a progestin or a progesterone, and that is prescribed, again, orally. But there’s also a patch that can have a progestin and also the estradiol. So there is vaginal cream and so you can use that. But that’s dependent on, again, if you have a uterus and then some women who’ve had a hysterectomy and still have their ovaries in place, let’s say they’ve had endometriosis or pelvic pain or a lot of bleeding that led to anemia or fibroids, you can also add back progesterone, because progesterone, we know, has been very helpful for sleep. So that, again, that is why symptoms and asking what are top concerns, again, point to what route a woman should be offered. And what hormone to be offered.

Maryann: Yeah. And just to clarify, the vaginal cream that does not kind of work systemically, does it? Or does it just more localized treatment if you’re having dryness or irritation, right?

Dr. Culver: Yes. So, vaginal cream, estradiol. Vaginal cream, also is used for, the prevention of genital urinary syndrome, of menopause, which we know that when we have declining levels of estrogen or even androgens, we can have vaginal complaints. So we can deliver that vaginally as a cream. There can be a suppository, there can be a ring, and then there’s also a treatment that delivers vaginal estrogen to a systemic level. But again, that’s hormone replacement. But generally, to treat vaginal symptoms, you can use a targeted approach, if that’s the only thing that you’re concerned about. But it also can be used in addition to systemic hormone therapy, which goes all over your body. So you can use the two together. If you’re really targeting. If a woman’s very interested in their sexual health and that is like one of their top concerns, you can use both.

Maryann: OK, great. You, know, a lot of women mention wanting to get tested, get their hormones tested. I always found this interesting because in perimenopause, how do you know, how can you be tested if your hormones are already, like, bouncing all over the place? How do you find that moment in time to test? Right.

Dr. Culver: Well, and, to your point, that is why the menopause society does not recommend testing. Right.

Maryann: Yeah, I know.

Dr. Culver: Yeah. So in gynecology, we’re trained to identify and treat many different conditions. So we’re not saying that testing is an absolute. No, of course not. We sometimes have to test because we’re trying to discern what’s happening. Right. But there’s, a list of things, a list of concerns, but it’s not as common as if someone says, look, my menses is irregular and I’m having symptoms. I don’t need a lab test. I don’t need a lab test. You know, if you don’t respond to my treatment and we’re adjusting and so forth, and you’re not having a response, then, yeah, let’s do a lab test. Because I can assure you you have adequate levels of hormone, by what I’m giving you, and therefore, maybe your symptoms are due to some other medical condition. So, yes, that’s when it can be helpful. It also can be helpful when women are trying to transition from oral contraceptives into menopause hormone therapy. And so what we do is a lot of times people are on continuous birth control and we say, stop your birth control for three or four days and even up to seven days, have your blood drawn and see where you are and decide if you’re not menopausal. M yet, then we can continue with oral contraceptives if medical restrictions do not exist, or we may counsel you still to move over to menopause. Hormone therapy, those are the instances. And we’re seeing a lot of women coming in with a lot of lab work. And frankly, it would require some of these lab work or results. Looks like I’ve got to get some kind of certification to look at some of these. I mean, sometimes it’s like 50 or 60 different things. And I’m just wondering what is driving this? So again, symptoms, top concerns go for the most common and effective form of treatment. And then if that’s not working, yes, dive, in. You know, everyone again, is unique and has their own journey, but we really trying to dissuade the over consumerization. Right. And taking, money away from women and believe and instilling to women that there’s a lot more to it than what it is. So, yeah, we don’t recommend lab testing in the majority of women.

Maryann: Are there any menopause symptoms that hormone therapy will probably not address? You mentioned non hormonal therapy a little while ago. Is there a correlation?

Dr. Culver: Yeah, so there are. Well, first of all, there are autoimmune diseases or conditions that occur more often in midlife. We’re seeing more, rheumatoid arthritis, seeing thyroid conditions. and so, therefore, to really pay attention to symptoms such as fatigue and so forth. That’s why a comprehensive exam is always important to make sure you have your gynecologic visit or your internal medicine visit, and to visit these symptoms in another light as well. but yes, that can mimic perimenopause. Right. Wellness is super important. So if you, the top concerns are, are you exercising, are you sleeping, are you eating well? Mm

Maryann: Yeah, I was going to say, and a womans metabolic health is so affected in midlife. I just did a show with an endocrinologist and we talked about pre diabetic, you know, the prediabetes epidemic among midlife women. And its just amazing how everything is like you mentioned earlier, just all tangled up in each other, you know?

Dr. Culver: Exactly. And so it’s really about when, when they come specifically to you for menopause and my perimenopausal symptoms to look at again, their symptoms. And we do know like some of the common things that it can be confused with, like you said endocrinopathies and even cardiovascular. So we just make sure that if we approach this concern and we deliver a treatment that it does resolve and get better. And if not, that, we have to make sure that the other conditions are being assessed for and addressed. Yeah.

Maryann: And also in terms of non hormone treatments, what kind of lifestyle changes could she try first? What do you recommend? But you mentioned sleep being very important. What else besides sleep?

Dr. Culver: Well, yeah. So what else of course is, you know, exercise. Right. Exercise is top. And eating well. Oh my gosh, the diet. I mean, there could be, you know, the mediterranean diet always comes up for me as one of the top diets to follow or the way of, of eating to follow. But we do know that exercise is just absolutely imperative. And the connections with people and social engagement, all of that has influence on how we are in our well being and our level of mood and our level of energy. So you have to take account lifestyle modifications and really emphasize that. And particularly right now, when women are concerned in talking about cognitive and brain fog and so forth, then their fear about dementia and Alzheimer’s is generally a lot of the concern that I see, coming through with women is that lifestyle and, preventing heart disease through diet and through exercise, it, can’t be emphasized enough. I mean, that’s imperative.

Maryann: Yeah.

Dr. Culver: And in terms of non-hormonal methods to treat vasomotor symptoms, unless you have a restriction, it’s still the most effective treatment. So if you really want a good night’s sleep, it’s hard to beat taking that versus somebody prescribing a sleeping aid. I mean, I frequently, wonder why women would want to take something that is different from something their body has already produced and has already seen for sleep. If we do know that, if we alleviate hot flashes and night sweats, that you’re going to have a better sleep. And sleep is definitely associated, sleep deprivation is definitely associated with diminished, cognition and dementia and risk of Alzheimer’s.

Maryann: I can’t tell you how many women I know are taking CBD oils at night to sleep. I don’t, I don’t like any of that stuff. But, What do you think about that?

Dr. Culver: I don’t know. Jury’s still out, right? Yeah. I mean, they are doing studies, but we do know that more and more women are turning to CBD and also to, thc for menopausal symptoms. We do know that that’s a trend. And of course guidelines, wise, we do know what’s effective.

Maryann: So along those lines, Pandia has its own pharmacy. Right. what sorts of menopause related products is it? All of the ones you talked about?

Dr. Culver: Yeah. Pandia Health offers all the FDA-approved menopause hormone and perimenopause hormone therapy. Offer oral contraceptives, generic as well. goes through insurance as well. If people have insurance, which is a, good thing. It’s a good thing to be able to have, medicines and treatments covered, but, if not, there are generics, and it’s not, the label of, pandia health. We do prescribe the FDA approved treatments.

Maryann: And you guys provide online visits only. Right. How do you compensate for that, not being in the room with the patient? And do you ever work in conjunction with that patient’s doctor in their own city?

Dr. Culver: Yeah, that’s a very good question. and very, important for a distinction. So right away, we are not taking the place of the in person gynecologic, visit, particularly the comprehensive annual exam, because that is so imperative. Every woman has to have a physical exam with a visual inspection of her cervix, vagina, vulva, and the rest of the body. Right. What we do at, pandia health is we remind women and we notify women that they have these screening guidelines that they. That they should be following and to make sure that they have these done with their regular physician, and that they have an annual exam every year. But what Pandia health and other telehealth companies, provide for, for women in this perimenopause menopause space that have concerns is that women frequently are waiting for appointments and they’re suffering a lot. And so we have an extensive questionnaire and extensive messaging, and we can, prescribe effective treatment for women’s symptoms, because women shouldn’t be left suffering for months to get into their doctor.

Maryann: I’m trying to imagine how I would phrase it with my doctor. Like, I just went to Pandia and they gave me a new treatment? Do you advise women on how to talk to their own doctors about [getting their hormone therapy from your company]? Because there could be some conflict there, right?

Dr. Culver: You know, I’m really recognizing that there is very little conflict, really. The only conflict that I think arises is when a woman’s been receiving information from someone outside the medical community. OB/GYNs have so much work, there’s so much to take care of, that if a woman comes in and says, look, I went to Pandia Health that has OB/GYNs, and I was prescribed an effective treatment that’s FDA approved. The doctor’s like, “Great, tell me about it. Is it working? That’s wonderful. Now maybe we can focus on something else that’s really important too.”

Maryann: Good to know.

Dr. Culver: Maybe that allows more time to really focus on something because you’ve been treated, but now there’s something that you can perfect or something can really address, or it opens up time to talk about someone’s marriage or what’s happening at home. Maybe they want to talk about breast health for a long visit. So I think it’s really helping. I have not seen, and we’re very collaborative, so women may, say, oh, I can’t, I’m here because I can’t see my doctor, but she prescribed this. But I think I need an increase in my dose. That’s great. I can help you right now.

Maryann: The thought of all of your doctors and people in your medical, you know, community, being in collaboration is just so nice. It is just a wonderful thought, and I love that.

Dr. Culver: No, I think it just, it comes from, of course, the physicians that are involved in the telehealth and the platforms is that we’ve all been in a, practice too. Right. So I’ve had a private practice. I know, I know, I know the people. I know exactly how this physician, is reacting, or how they feel about, a woman coming in on something that they normally prescribe, but it’s normal. It allows, again, me to focus on something else. And particularly if someone’s well trained, you’re prescribing the adequate and guidelined and FDA approved treatment. Right.

Maryann: And something I’m personally excited that Pandia Health is doing is focusing on educating companies. Can you tell us a little bit about what you’re doing in that arena?

Dr. Culver: Oh, wow. Yes. That is, something about. That’s a new thing, right? Well, relatively new. It should have been ongoing years ago. Right. We do know that women have, been working through transition. Right. And we’ve needed health days, and there are, we still have so much work to do in the pregnancy space. Right. And the new parent space. But menopause is also a continuum, and perimenopause is a continuum of our reproductive history. So working in the perimenopausal space and recognizing that the workforce needs to know that women need maybe time off to go see their doctor, they need maybe. I, think it’s just all in all, just more about gender equity, right? Because we do, we’re recognizing not only is this, yeah, we have some medical symptoms, but we also care for others. We care for our parents, we care for our children. Still. We are caretakers, primarily, and we’re working as well. So it’s not just the condition or the symptoms. It’s really what happens to women in midlife. And are we really setting women up to. To prosper? Right. Are we setting women up that allows them time and recognition and validation for the needs that they may have outside the home so they can be very effective at work? Right.

Maryann: We’ve come such a long way. I mean, our generation didn’t even have, you know, nursing rooms, a place to go to pump breast milk at our places of work. And now I feel like it’s so encouraging that companies are talking about this and talking about how to support women going through a transition that, by the way, 50% of the world’s population goes through. So thank you for doing that. And, finally, I would love to know what advice you would offer to a woman out there who is having a really tough time with perimenopause or menopause and doesn’t feel like herself, or a woman who simply just can’t get the help she needs from her doctor. What first steps would you tell her to take?

Dr. Culver: The first step is to read and go to resources that are from board certified OB/GYNs, first of all. And we all vary. We all have our beliefs, and we all take into the practice of medicine ourselves and our own personal beliefs. To find somebody who is part of your tribe, right? It’s to find, if you’re, an extreme health nut, find that ob gyn that loves all that lifestyle stuff, right? That just really puts it on their website, their front page. You get an idea, right? You really get an idea of like, oh, this person has similar interests as I do, so that the conversation and the recommendations are going to be more aligned with your own belief system. So that’s number one. Number two, resources such as the American College of OB/GYNs, the North American Menopause Society, which is now the Menopause Society.

Maryann: Yeah, you mentioned that. I’m on their website right now, and you’re right, it’s Menopause.org. But they’re still calling themselves the North American Menopause Society. When are they changing that?

Dr. Culver: They changed it more or less to be more inclusive. There’s also the International Menopause Society, which is really important. A lot of members that are part of the Menopause Society are also members of the International Menopause Society. There’s also the International Society of the Study of Sexual Health in Women. That’s a big mouthful. And that’s called Isswsh.

Maryann: I like it.

Dr. Culver: And so sexual health, again, is on the forefront. Women are claiming sexual health and wanting sexual health. And it’s out there now. It’s a conversation. There’s no shame and wanting pleasure. There’s no shame and wanting to have a healthy, intimate relationship with whom they wish to choose to.

Maryann: And I have to credit the generation beneath mine for that. Like, they have created this whole category of wellness, a sexual wellness category, which is so important.

Dr. Culver: Yes, absolutely. So really, you’ve got, I just noted three very important societies, or four very important societies that all have, like, patient, tabs, patient education areas. And that’s where I would get my resources. Menopause society has these amazing videos that are like seven or eight minutes long for a patient. And you can watch that and boom, you have the top people have done the studies, you have the experts. You have the experts that we go see every annual exam, give you the seven or eight consensus statement or their own condensed version that you can understand and take away with. And there you’ve got medicine. Right there you’ve got the updated research driven guidelines, ah, and standard of care. Therefore, you arm yourself with that, and then you start recognizing, oh, wow, this is me. You know, I’m feeling this. I am recognizing this. Then you take that information and you take it to your doctor. I mean, literally, we’ve been advising women to download, download your information, download the statement, and take this to your doctor and say, look, I circled this. It says this. Can you explain this to me? Can I please try this? You know, what do you think about this? And really providing that patient education and validating, saying, this is me. I’m now educated. This is the vocabulary. I’ve taught myself. And to bring that now, if you can’t get an appointment, of course, there are online telehealth, menopause companies, and Pandia health, again, has been in the space for reproductive care for several years now. and people use oral contraceptives a lot in the perimenopause time. And we’re trying, you know, women have to prevent, pregnancy. We treat oral contraceptives. We use oral contraceptives for many treatable gynecologic conditions because we, can, and it’s effective. So it’s a very, normal space for pandia health to, move into menopause and to treat perimenopause and menopause. And so you can access telehealth. And again, if you’re educated with your top concerns and have the vocabulary, you can have a really good and comprehensive review of your medical history, your concerns, and then have treatment and then work with a doctor to adjust dosing and to alleviate your symptoms or alleviate your concerns and to treat the conditions that you’re concerned about. Okay?

Maryann: So do your research, then talk to a doctor who is certified in menopause. And I would add one to that list. I would say, and know that you’re not alone, that there are so, so many women going through similar symptoms that you’re experiencing and they’re having similar issues. So you are not alone in this. doctor Culver, thank you so much. Please tell everybody out there where they can find you and Pandia health online.

Dr. Culver: Absolutely. You can find me and a group of us at Pandia Health, and we offer, again, perimenopause menopause consultation, evaluation, and treatment, and again, with ongoing messaging and contact with your prescribing doctor.

Maryann: So it’s pandiahealth.com. Right?

Dr. Culver: Right.

Maryann: Thank you so much, Dr. Culver, it was a pleasure talking with you today. And thank you for all the valuable information.

Dr. Culver: Yes, thank you for having me, Maryann. I really appreciate it, and I really hope that the women listening take charge, optimize their well being, and address any concerns that they have. Don’t wait any longer.

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