Ep. 436 Fear-Based Choices: WHI’s Legacy & Breast Cancer Myths with Dr. Corinne Menn

Today, I am honored to connect with Dr. Corinne Menn, a board-certified OB-GYN and Menopause Society-certified practitioner. Dr. Menn is a 23-year breast cancer and premature menopause survivor and a BRCA carrier who draws on her personal experiences to assist other women in navigating their health challenges.

In our discussion, we explore the ways the Women’s Health Initiative has impacted Baby Boomers and how fear-based decision-making, particularly around breast cancer risks, has shaped women’s health. We discuss the timing hypothesis for hormone replacement therapy, breast cancer risks, and misleading stats and look into empowerment and the differences and biases that shape the experiences of women in perimenopause and beyond. We examine why osteoporosis is a silent disease and how hormone replacement therapy can reduce fracture risk by 30–50%, and tackle the effects of poor metabolic health, the challenges of receiving a diabetes diagnosis, and how statin therapy can influence the course of menopause and beyond. Dr. Menn also shares her personal story of resilience and empowerment. 

This conversation with Dr. Corinne Menn is invaluable for all women- especially those with a history of breast cancer.

IN THIS EPISODE YOU WILL LEARN:

• How the Women’s Health Initiative has caused fear-based decision-making among menopausal women

• Why SSRI medications are inadequate in managing menopausal symptoms

• How the fear of litigation has impacted clinical decision-making in modern medicine

• The cardio-protective benefits of HRT  

• How HRT can help avoid the risk of breast cancer 

• Why starting HRT early is essential for cardiovascular health

• How racial differences impact women in menopause

• How early bone density screening can help prevent rapid bone loss during menopause

• The  metabolic changes that occur during menopause

• How the lack of menopause education led Dr. Menn to experience premature menopause due to her breast cancer treatments

Bio: Corinne Menn, DO, FACOG, MSCP

Dr. Corinne Menn is a board-certified OBGYN and Menopause Society Certified Practitioner. Dr.Menn is also a 23-year survivor of breast cancer and premature menopause, a BRCA carrier,and uses her experience to help women navigate their health challenges. She has dedicated her medical practice to menopause management, the unique healthcare needs of female cancer survivors, and those at high risk for breast cancer. Now practicing exclusively through telehealth, Dr. Menn provides women’s health consultations and patient education. She is also a medical advisor and a prescribing doctor on Alloy, a menopause telehealth platform. Dr. Menn is an active member of the Menopause Society and a fellow of The American College of Obstetrics & Gynecology. She is a dedicated advocate and volunteer for the Young Survival Coalition, serving on their Council of Advisors, leading the Provider-Survivor support group, and serving on the Breast Cancer Alliance Research Grant Committee. She is a frequent speaker and podcast guest and has an active social media platform where she shares her mission of educating fellow clinicians and women on menopause and women’s health.

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“The higher risk or family history of breast cancer should not be used to deny you access to menopause hormone therapy.”

-Dr. Corinne Menn

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Transcript:

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. 

[00:00:29] Today, I had the honor of connecting with Dr. Corinne Menn. She's a board-certified OB/GYN and Menopause Society certified practitioner. She's also an over 23-year survivor of breast cancer and premature menopause, a BRCA carrier and uses her experience to help women navigate their own health challenges. 

[00:00:49] Today, we spoke about the medical tragedy that is the Women's Health Initiative, the impact on baby boomers, those born between 1946 and 1964 which impacts over 76.4 million adults, the role of fear-based decision making, especially the fear of breast cancer, the impact of breast cancer risks and misleading stats, concepts surrounding the timing hypothesis for when to initiate menopausal hormone replacement therapy, empowerment, racial differences, and biases that impact the spectrum of experience for women in perimenopause and beyond, why osteoporosis is a silent disease and how hormone replacement therapy can reduce the fracture risk by 30% to 50%, the impact of poor metabolic health and a diagnosis of diabetes and how this impacts the trajectory of menopause and beyond including our increased risk for heart disease and the utilization of statin therapy, Dr. Menn’s personal history of breast cancer and treatment. This will be a truly invaluable conversation for all women and especially those that have a personal history with breast cancer. 

[music]

[00:02:07] Dr. Menn, such a pleasure to finally connect with you. I know that we've been emailing and messaging and we are finally able to coordinate calendars. So welcome to the podcast. It's really an honor to have you. Thank you for all the work that you do educating not only clinicians, but also women about their bodies and about awareness around the aging process. Something that's interesting to me when I reflect on my mother's generation and I was finishing up my training right when the WHI was published. I think about how many baby boomers, so these are people born between 1946, 1964, kind of post World War II, how many of them feel overlooked, unappreciated because of the information extracted from the Women's Health Initiative that has directly implicated not just their access to care, but their access to hormone replacement therapy? 

Dr. Corinne Menn: [00:02:59] Yeah, 100%. It's really a medical tragedy and there's a whole generation of women who really lost out. I'd say, not just on the benefits of menopausal hormone therapy or HRT, but also just on the basic knowledge of the physiology of menopause. Because I think along with losing access to hormone therapy, there was also just a real disinterest in menopause in general and in managing it. And when clinicians like myself. So, it was 2002 when the WHI results were released. I was a second year OB/GYN resident, it was also when I was in the middle of breast cancer treatment, and we'll talk more about that. But clinicians weren't educated. 

[00:03:42] And so, looking back, I can remember feeling like when a woman came in with menopausal symptoms, we didn't have MHT to offer her. I mean, we had it, but no one was trained in it and everyone was shy to give it. And so, it really made managing these women really difficult. And so, they basically just didn't get managed at all and nobody wanted to deal with it. And it was kind of like annoying clinical scenario that most doctors just were like, “Ah, just give them antidepressant.” And that's exactly what happened. Because we can even see there's data that shows that as hormone therapy prescriptions plummeted by over 75% over the decade after the WHI, well, for every reaction is a opposite and equal reaction and SSRI prescriptions and other off label medications to deal with the constellation of menopausal symptoms skyrocketed. Do those medications truly serve women well? And I would make an argument that they don't in the vast majority of the time. 

Cynthia Thurlow: [00:04:52] Well, and it's so interesting. So, I was neatly tucked into Cardiology as an NP, both inpatient, outpatient, and I recall how many of my patients were put on, as you appropriately said, antidepressants, anti-anxiety agents, how many of them were prescribed narcotics to address osteoarthritic symptoms or even potentially rheumatoid arthritis symptoms that really worsen being off of estrogen therapy, progesterone therapy. And I recall the conversations because obviously in Cardiology we were very myopic. We were like, “Okay, you're here for these specific symptoms. Primary care, GYN is going to address all these other things.” But how many women sat in the office and cried because they were so upset about how they felt like they were navigating the trajectory of perimenopause and menopause pretty well and then the floor is ripped out from underneath them. 

[00:05:47] I think about my mom, who was born in 1946, and I remember she had such bad arthritic foot pain off of hormone replacement therapy that they had her on COX-2 inhibitors, so Vioxx, which ended up being pulled off the market. But I recall her explaining to me that just walking around campus-- She worked at University of Pennsylvania, that just walking around campus was so debilitating and she was an active person. But, these conversations to me just echo in my mind about how we have not served women in particular of that generation very well at all, as you called it, “A medical tragedy.” And so, do you think it was in many ways that there was this fear-based symptomatology? 

[00:06:32] I think about the work that Dr. Avrum Bluming and Carol Tavris have done about helping to educate so many of us. And there was a quote in an article that you shared with me that Avrum had written that said “Take the shortcut, avoid anything that might give you cancer.” That has been the prevailing kind of methodology with regard to helping women kind of navigate this timeframe is just avoid anything that has any concerns around cancer and then we'll have to figure the rest of it out. 

Dr. Corinne Menn: [00:07:00] Yeah, I mean, absolutely. It's fear-based decision making. And I always say the pink elephant in the room is that women and doctors are making their health care decisions about perimenopause, menopause, sexual health, all based on the fear of breast cancer. And that's not rational. And I say that as a breast cancer survivor. I'm not saying we should kind of put aside any concerns about breast cancer risk and we can certainly get into that, but we are more than just our breasts. And the number one killer of women is heart disease. And we are really bad as consumers of medical information as well as just as physicians, patients alike. We're very, very bad at judging what risk means and interpreting risk, and we often overstate risks. And totally understate quality-of-life issues, long-term benefits of hormone therapy, and it's really out of balance. 

[00:08:08] And frankly, I think most physicians really could not tell you accurately what the risks are. Even if they can quote the risks in terms of like kind of generic, like, “Oh, you know, there could be an increased risk of blood clot, stroke, cardiac event, breast cancer.” But when you ask them to explain what are those risks, does it matter? Formulation, timing, type of hormones, and how much is that risk different than other risks in life? And they're really bad. Most doctors couldn't explain because they were never taught it.

Cynthia Thurlow: [00:08:44] I feel like I can say this that when I started my training in the 1990s into early 2000s, I think clinicians, and I'll say this as a kind of a broad statement, I think we practice differently than we do now. Now it is very defensive. Medicine is being practiced. It is very litigious. I think that there are wonderful, wonderful clinicians who want to do right by their patients, but they are so concerned/preoccupied with being sued. And I think that that influences things like whether it's my colleagues working in ER medicine or my colleagues working in Cardiology, irrespective of what background clinicians are working within, there is a prevailing fear of litigious nature of our society right now.

[00:09:29] And so when you speak to risks, let's help listeners understand when we're talking about risks in terms of drug therapies, using or not using certain protocols, let's kind of better understand what is the average woman's lifetime risk for developing breast cancer as an example, let's start there. Because I think that helping women understand this allows us to understand the ramifications, the larger ramifications of navigating perimenopause and menopause. And then what do we need to be most concerned about as we go along in the aging process? 

Dr. Corinne Menn: [00:10:08] Listen, breast cancer is the most common cancer that could occur in a woman's lifetime. The number one killer, though, of women is not breast cancer, by far, it's heart disease. The one in eight stat is really misleading. That's one in eight in your lifetime. So, if you get to age, I think it's 80 is where the number comes from. That one in eight women by the time they're 80 may be diagnosed with breast cancer. That is not the same number. It is not 1 in 8 in your 30s, it's not 1 in 8 in your 40s or 50s, not even near that. I don't have the different decade numbers pulled off the top of my head, but it's a much lower number. And just your biggest risk factor of getting breast cancer is age and being a female.

[00:10:56] And so of course, we've got screening protocols and we want to know and identify women who are at a particularly higher risk. And so how do we do that? We do that by taking like a really targeted medical history, family history, lifestyle history, and then trying to identify women who are at a higher-than-average risk. Not so that we can deny them access to menopausal hormone therapy? No, in fact, those women can have hormone therapy because the data overwhelmingly shows that your breast cancer risk is your risk and that adding in FDA-approved hormone therapy doesn't further increase that risk. So, kind of that higher risk or that family history of breast cancer should not be used to deny you access to menopause hormone therapy, but that higher risk should direct you to see, do you need genetic screening, do you need MRIs along with your mammogram, supplemental ultrasound, other things that we can do. And so, we can walk and chew gum at the same time. 

[00:12:00] And then the risk of breast cancer from hormone therapy, we say it over and over to patients and this is-- I could say this all day, every day on my Instagram account and I would still, get new followers and people will be interested because I feel like we have to just say it over and over again. But in this large study that scared everybody, women taking estrogen alone, women who did not have a uterus and were not taking the synthetic progestin, had a lower rate of breast cancer and a lower risk of dying of breast cancer of up to 40%. And those results held true at the 20-year mark when they looked back on the data. 

[00:12:39] So, estrogen alone in the WHI study showed no increased risk of breast cancer whatsoever. And then in the arm of the study where women were taking a synthetic oral progestin, medroxyprogesterone acetate, which we know is likely less good on your breast tissue, even in that arm. The risk was not statistically significant. It was less than one additional case for every 1,000 women per year taking the hormone therapy. And we saw that risk go up after four years, but that risk was actually not statistically significant, okay? So, by the own protocol that the WHI kind of spelled out when they started the study, that data should never have been reported as an increased risk because it wasn't statistically significant. 

[00:13:36] We can go on and on about how that was very misinterpreted, but it didn't matter because the cat was out of the bag. The message went out that estrogen causes women to have increased risk of breast cancer. And the numbers seemed very, very high because they reported this relative risk versus an absolute risk. So, the media ran with these headline grabbing stats that were incredibly alarming. And then along with that came women's next fears after breast cancer were things like blood clots, stroke, and heart attacks. And that data was also completely, not only misinterpreted, but totally mis-messaged.

[00:14:23] And in fact, when we look back at younger women starting hormone therapy within the first 10 years of going through menopause, we see that they have lower rates of cardiac disease and it's likely cardioprotective. It's not FDA approved for that. And so, anybody out there talking about it, sometimes you get pushback, “Well, it's not FDA approved for prevention.” “Yes, I know that. And I could have bones to pick for that.” Again, we could walk and chew gum at the same time. We can explain to women that the data suggests that at the very least, it's neutral on cardiac function when you initiate it early on, but especially when you're choosing things like transdermal estrogen and bioidentical estradiol and progesterone rather than synthetic progestins. We have a large body of data showing that there are many beneficial effects on cardiac function and cardiac health, in addition to all the other benefits like prevention of osteoporosis, hip fractures, the list goes on. 

Cynthia Thurlow: [00:15:23] All very, very important. And when we talk about the timing of hormone replacement therapy, because I think there are still individuals, again, well meaning, that will tell patients you don't need any hormones until you're in menopause. And so, this timing hypothesis, I think is an important concept for listeners to understand because it has certainly been my experience clinically that I'm seeing probably more of our colleagues that are in this space and talking about this and utilizing hormone replacement therapy earlier as opposed to later. What is it about the timing hypothesis that we think is so important for women navigating this transitional period in our lives? 

Dr. Corinne Menn: [00:16:04] Well, I think there's two things. Well, the timing hypothesis, it really is referring to this idea that in terms of cardiovascular health and protection that it's really hard to go back and fix something that's already been damaged. So, if you're 65 years old, you've been without estrogens for say 15 years, you went through menopause around 50. We know at the menopause transition, this is very, very clear that there's a significant acceleration in your cardiovascular disease risk when you transition to menopause, and it's due largely from this dramatic loss of estrogen. And estrogen is very cardio protective on small little blood vessels in the endothelial lining, okay, so that inner lining of those little tiny blood vessels. 

[00:16:50] There's anti-inflammatory properties to estrogen, it helps keep the little blood elastic and supple. It helps with lipid management and keeping your lipids in good levels. So, when you lose that estrogen, what happens is you can get atherosclerosis, and things start to build up in addition to other age-related changes. So then, we can't then give estrogen at 65 and expect it to reverse it. So, it's not going to turn back time. So, this timing hypothesis emerged because we saw that women who initiated early, ideally in the first five years, by 10 years, those women had the beneficial impact where women pass that time. 

[00:17:27] Listen, hormone therapy, and we can talk about it if you start it after that window of opportunity, can still be useful in many women as long as they're well selected and you use the right formulation, but we can't say at that point that they're going to have a positive impact necessarily on cardiovascular health. So, we should be using it for other reasons. Maybe they're concerned about bone health or they have persistent symptoms. 

[00:17:50] But then the other thing that you said about timing is also important, that there is this old notion in people who are not trained in menopause that you have to suffer for a year without a period and truly be menopausal before we could ever think of giving you hormone therapy. And that's just silly and not based on the physiology, because we know that the transition of the perimenopause is a time of incredible fluctuations. And it could start out where actually estrogen levels are relatively higher than progesterone because they're not ovulating as frequently, so then you don't get as much progesterone, but there can be a lot of drastic dips and erratic drops in estrogen where women will feel-- A couple weeks, they might feel okay, then they might have signs of a lot of estrogen, like breast tenderness and bloating, a little bit more emotional. And then suddenly they are having a week of hot flashes and night sweats right before their period when the estrogen levels are naturally at a lower point, but now in perimenopause, they're really plummeting. And then it all kind of starts up again and it can be erratic. 

[00:18:54] So, we don't need to make a woman suffer for years. We can do a lot of things hormonally, yes, traditionally birth control pills, which suppress the crazy ups and downs, which is one way, and it can work well for some women, but other women can really do well just giving them back, you know, a steady amount of estrogen or targeting it during parts of the menstrual cycle along with either cycling progesterone or giving back just a little bit. I like to kind of say we're adding back a little bit so that you have a buffer zone for when you have these peaks and trials of your irregular cycle. So, there's a lot of different ways to use hormones then. And so, this idea of-- it's really not too early if you're presenting with the clinical picture of perimenopause and you've ruled out other medical things that might be causing it, like a new diagnosis of a thyroid disorder or anemia or something else. 

Cynthia Thurlow: [00:19:49] Yeah, I think it's so important to have these conversations because I still feel like there's so much well-intended misinformation that's out there. You know, very much this, one size fits all philosophy of, “Oh, you have to have suffered for six months before we even address your vasomotor symptoms.” And I'm like, “My goodness,” if you-- Like, my husband's a good example of this. He's a guy, he's never experienced a hot flash. He's never had his-- He sleeps really well, irrespective of what he eats and what he does. And I tell him all the time when I talk to women who say things like, nurses, as an example, I've had 10 years of terrible sleep. And I'm like, “If I had a week of bad sleep, I would have to MacGyver what was going on, but I think in many instances, women are just expected tough it out. And we're here to help women understand that that does not need to be the case. 

[00:20:42] Now, one thing I find interesting when I start looking at the research in these areas, how there are some racial disparities. There are certain groups that will have more magnified and more prolonged symptoms, like African-American Hispanics versus Caucasians or Asians. And so, in your clinical practice, are you even more proactive with some of these patients? Maybe people who've been conditioned to believe, not that they shouldn't complain, like “Just whatever it is, accept it,” but in terms of empowering them to disclose and share with you what they're really experiencing? 

Dr. Corinne Menn: [00:21:18] Yeah, there's a lot of reasons for that. There's a lot of longstanding bias and problems within the medical system that women of color, particularly black women have a higher pain tolerance, which is not true. And there was no understanding that actually menopause symptoms for them can start earlier, be more pronounced, and last longer. And so, what happens is they might come in a little bit younger with some symptoms, and they're written off because they're told you're too young for menopause, because no one taught the physician that there is a spectrum of experience. And we have to believe women when they tell you they're having hot flashes, night sweats, new onset of heart palpitations and anxiety and joint aches and pains. 

[00:22:03] And, yes, it could be due to other things, but we're taught in medical school, if it looks like a horse and it walks like a horse, it's a horse, not a zebra. So, think about common things. But these women are written off, and then the other thing is their symptoms, we know, can last longer, more than 10 years. And so, these women really are often dismissed. But it's also cultural too. In certain cultures, menopause symptoms in many women's families, it's not talked about, particularly in certain groups it's not talked about, people are embarrassed.

[00:22:43] And then many African-American women, their mothers, okay, had hysterectomies. There was a lot of paternalism through the decades in menopause for all women, but especially for black women in the United States. So, black women have a higher risk of fibroids, uterine bleeding. So, it would be very common for black women to certainly through the decades, have early hysterectomies. So, their mothers really had no way to tell their daughters what menopause, perimenopause even looked like because many of them had hysterectomies, and probably the ovaries were removed at the same time. And so they went into automatic surgical menopause, and certainly no one probably helped them. 

[00:23:28] So, it's a huge. It's a huge problem. And with our loss of OB/GYNs, particularly in large parts of the country where the numbers of OB/GYNs going into residency programs or the numbers are dropping, especially in southern states, it's a real critical-- It's really a medical emergency, I think. We're losing access to care, to women's health care in general, just in a time when we need it more than ever. And there's more of a demand for women kind of seeking out equitable care, it's a huge problem. 

Cynthia Thurlow: [00:24:02] It's interesting. I trained in the Intercity. And so, for me, I just recall that as a suburban kid going to Baltimore and training and seeing things I had never seen before, socioeconomic concerns, lifestyle-mediated things that impacted the quality of care for so many patients. Every woman deserves excellent care and that includes our younger women who need access to contraception so that they can decide when they want to become parents or not. And all the way up to menopause, when women again, in many instances, and I recall my grandmother who was a nurse, saying to me that-- She was obviously 50 years older than me, but I remember her saying, like, “Most women never went into menopause, Cynthia, we just had our--" as you appropriately stated, “We just had a hysterectomy in our 40s because we had heavy bleeding, and we weren't allowed to complain about anything. We just accepted the osteoporosis, the diffuse cardiovascular disease, the poor sleep for the rest of our lives. That was just what was expected of us.” And so, I'm so grateful that our generation, I think, is trying to do as much as we can to amplify women's voices so that they can continue to get good care throughout their lifetime. 

[00:25:17] Now, when we're talking around hormone replacement therapy, let's talk a little bit-- We've kind of touched on heart disease. Let's talk about bone health, because I think for many people, until they have a loved one that has a significant fall and a fracture, they probably don't think about their bones a whole lot. They probably may not even understand that as we're navigating this menopausal transition, most women, unless they are taking HRT and they're doing the strength training and they're doing weightbearing exercise, they may not even be cognizant of the fact that their bone health is slowly eroding. What's happening to our bones as we're navigating this menopausal transition? 

Dr. Corinne Menn: [00:25:56] Yeah, osteoporosis, it's a silent disease and we reach our peak bone mass as women by our very early 30s. And how many women of our generation, looking back, women who were brought up in the 1970s and the 1980s. These were not times where young girls and teenage girls were as active in sports. There was certainly no culture of lifting weights for teenagers or resistance training. And the narrative was skinny and really thin was in, lots of cardio, a lot of fad starvation diets. And it was the era of the snack wars going into the 1990s. Everything was low fat, high carb, very little protein. 

[00:26:50] And many, many women of our generation actually never built even baseline good bone density. And they certainly didn't build baseline good skeletal muscle and a kind of a lifetime of muscle memory and of this real habit of maintaining good skeletal muscle. So that's like a perfect-- So, you pair that with then this lack of access to menopausal hormone therapy or even information and then go a step further. The United States Services for Preventative Task Force, which makes these recommendations-- broadly public health recommendations on screening and other medical interventions. They're not a government associated body, although people think they are independent group and they make some good recommendations, but it's very shortsighted in my opinion.

[00:27:42] And for instance, the baseline recommendation for a bone density through them is age 65. And that's how Medicare decides what they're going to pay for. So, most women never are told that at the menopause transition, it's a time of accelerated bone loss, just like accelerated cardiovascular disease risk. And it's really important to get a baseline bone density then so that you know what you're starting with. Because there's two things that women don't understand. One is that, yes, as soon as you start to lose your estrogen, you have rapid loss of bone. You lose up to 30% of your bone density in the first few years of going through menopause. Then the rate settles down, still slowly you keep on losing and the same thing is happening with skeletal muscle. 

[00:28:27] But what a lot of women don't realize is that their past medical history and lifestyle history probably never even gave them adequate bone density. And I actually think there's a lot of women of our generation who had disordered eating in their 20s and teens, and they may have gone many years without a period or regular periods, and that is a low estrogen state. And so, it's shocking when I find the numbers of women that I do bone density screening on, and they're like 45, and they're already like almost osteoporotic. Some are osteoporotic already. And so, imagine entering menopause already in that setting.

[00:29:07] And most women are totally surprised when I tell them that estrogen has been approved by the FDA for the prevention of osteoporosis for decades. And even if you don't have hot flashes and night sweats, you can take it for that reason alone. And rarely are women offered that at their kind of annual check in when they go at that menopause transition, because unless they bring up their hot flashes and night sweats and are seeing a doctor who is up to date on the basics of menopause, no one's going to talk to them about it. And then they wait until they're 65 and then one in two women will have already been diagnosed with osteoporosis by that time. It's like totally crazy and upside down.

Cynthia Thurlow: [00:29:47] Well, what's also interesting to me is I can't think of one girlfriend that I know of that I was friends with in high school and college that was not on oral contraceptives. Again, low estrogen state appropriately, this is again, women having the ability to choose when they do or do not become parents. And I'm not taking away from that, but I add that into how many people were on the pill from their teenage years into their 20s, into their 30s, not realizing they lost out on bone building potential as well. And I think about, again, women having the right to choose some of these things, but not having this degree of fully informed consent. We didn't know. 

Dr. Corinne Menn: [00:30:24] Oh yes. 

Cynthia Thurlow: [00:30:25] And I think that many people-- Yeah, many, many women, including myself, had I known that, oh my gosh, I would have happily stopped taking oral contraceptives to have the ability to build and lay down bone. Because I recall the hospital I worked at in Baltimore, they were doing like a free screening and I recall one of my colleagues was like, “Oh, we should check your wrist, see what your bone health is like.” And I was like, “Oh, okay.” Well, right then it showed I was osteopenic. And so, I recall my GYN was like, immediately sent me for a DEXA. So, I've been getting DEXA this for a long time and it's been waxing and waning. Like sometimes my bone strength was perfect and then the next time it was a little more osteopenic in between pregnancies and breastfeeding. 

[00:31:06] And I just think this lack of awareness, it's not that women don't want to know, it's that they don't know to ask for these tests to be able to discern, like, where am I now? Because I know for myself part of why at 53, I lift the way I do, I eat the way I do is to ensure I don't lose more bone or muscle mass as I get older. Because what people aren't thinking about now is the little old ladies and little old men who get frail, they become sarcopenic, they become frail, they fall, they either break a hip, which we know has terrible prognostic indicators, they hit their heads, they get head bleeds, these kinds of things. So, I think about the future of, to your point, we’re so preoccupied with being skinny and dieting in 1970s, 1980s and 1990s, and yet now we know it's more important to be strong and to do everything we can to ensure we don't become frail, we don't become sarcopenic, that we ensure that we have healthy bones, as healthy as they can be. And I just think maybe this isn't a sexy-- call it a silent disease, maybe bone health is not a sexy topic, but it is one that is relevant to everyone. 

Dr. Corinne Menn: [00:32:14] Yeah. All of this stuff needs to start with teenagers. Like, so when should women learn about menopause? When they learn about their menstrual cycle, frankly because it's a spectrum. And you know, doctors also-- For years I didn't even realize that this kind of trend towards the lower dose birth control pills, 20 mcg even in 10 mcg, like Lo Loestrin, those are not good options for young women. Younger women should really be on at least 25 to 30, 35 mcg because we need a little bit more estrogen exposure to maintain their bone health. And I think that most doctors, their kind of knee jerk prescription is for the 20 mcg birth control pills, I'm not against birth control pills for women. They are, can be life changing, really important, can help with lots of things. But we have to always think about big picture. And if we've got a young woman on these really low dose ones, we should probably rethink that a little bit. 

[00:33:16] The same thing with the women who go through premature ovarian failure. There's a lot of women who go through menopause very, very early. And really, birth control pills are not really always the best replacement. That's another big group of women, early menopause that are totally mismanaged. But yeah, this has to do with a really more holistic approach to informing women about their bodies. And, if you start it young, it won't make it seem like it's some like, “Oh, you're just getting old, it’s like gross thing to talk about menopause, it's somehow shameful,” kind of talk about it as part of one of the transitions in our lifetime. 

[00:33:53] And what I think is interesting is we as a society, we treat all of the different transitions that women go through hormonally, and we intervene. You're having PMS, we do this, pregnancy, postpartum depression. We recognize that the hormones cause changes. But when it comes to menopause, suddenly everyone's like, “Oh, no, we can't do anything with hormones then,” like you've been handing out prescription hormones to girls as young as 11 years old, and suddenly you're afraid to prescribe a very low dose of estrogen, which in relation to the synthetic estrogens in birth control pills is lower dose, actually. And so, there's a lot of really upside-down kind of thinking about how we approach this. 

Cynthia Thurlow: [00:34:38] Yeah, it's interesting to me because I think that one of the reasons why I talk about my personally is to destigmatize what people's perceptions are of what a woman of a certain age looks like. And I'm like, “Maybe if I talk about it, other people won't feel unencumbered to feel like there's a degree of shame or being transparent about the things that I find frustrating,” which thankfully, I think because my lifestyle is pretty dialed in, I sleep well, I'm able to move around. I don't have joint pain or anything like that. I take hormone replacement therapy. But I just think the more we talk about this transitional period, literally, I think the more people will think about it as something that is very normal, which in fact it is. If we live long enough, we're going to go into menopause, that is actually what will happen. 

[00:35:26] Now, one thing that I always get concerned about when I'm thinking about women navigating the aging process is the significant uptick in poor metabolic health, looking at diabetes and insulin resistance and so, and the net impact on a lot of health issues, but predominantly heart disease. For you as a clinician, what are some of the conversations you're having with your GYN patients? If you've done labs that are suggestive of a loss of insulin sensitivity or some concerns around other signs or symptoms that are suggestive that their metabolic health is not heading in the right direction? 

Dr. Corinne Menn: [00:36:06] Again, this comes back to the point where most doctors, myself included for years really had no understanding of the metabolic changes that happen in the menopause transition. And that if we really care about women's lifespan and their health span, we would care more about their risk of breast cancer. Again, it's one of the important things we're going to ask them about. But I really love educating perimenopausal women that, “Okay, this is what's happening with the loss of estrogen. It does a lot of signaling metabolically.” You get more visceral fat around your organs, which then visceral fat is metabolically active and will produce inflammatory factors that antagonize the way insulin works, so your glucose isn't being metabolized as well, a little bit more insulin resistance and at the same time your estrogen levels are lower, so you're losing your skeletal muscle, which is not good because that lowers your basal metabolic rate so, you're not burning your calories as quickly or as efficiently. More fat gets deposited in your liver. We see a lot more being diagnosed of non-alcoholic fatty liver disease. These things are all accelerating in that perimenopause transition. 

[00:37:23] And so, our solution should not be an SSRI, like antidepressant is not going to fix any of those things. What will fix those things? Letting her know that, “Okay, we do need to change how we're eating, how we're moving.” We need to really understand even if you're not using hormone therapy. Put that aside for a minute because I don't want anybody listening to me or us talking, think that hormone therapy is the end all, be all. It is a very important tool. And if we can add back some hormone therapy to help prevent some of these kind of estrogen driven declines in metabolic health and overall health, great. But if we can't, or you choose not to, well, you can still be empowered because if you know, “Okay, I'm going to start losing muscle and bone and,” maybe, more prone to holding on to like abdominal fat and all these insulin changes. Well, I could be really proactive with dietary choices, lifestyle choices, eliminating alcohol, lifting those weights, those things can really transform your body. And if we can add in hormone therapy, it's going to make it all that much easier. But it's not an all or nothing and I think that's important. 

[00:38:32] So, I think that's how my conversations go with women because they often come in with hot flashes and night sweats or other symptoms and they'll be like, “Oh yeah, my internist told me that my hemoglobin A1c is a little elevated or my LDL used to be fine, and now it's going up, and so it opens up.” I'm like, “Well, do you know why?” Yes, it could just, some of it is genetics. Some of it could just be, you were eating bad over the holidays and whatever. But when you start to explain to women what's physiologically happening, they actually are like, “Oh, so it's not all in my head that I'm just suddenly gaining weight out of nowhere.” I'm like, “No.” 

[00:39:08] Because what happens is doctors tell patients, “Well, you just have to eat less and exercise more. There's no reason why you're like getting heavier because of your hormones.” I'm like, in fact, they're not explaining to you physiologically what's happening. So, I think it all comes down to give women education about what's happening to their bodies and then they can make really good decisions for themselves. But if you don't tell them what's happening, how can they? But the problem is most doctors don't know what's happening because there's a menopause education care vacuum. There's no training in residencies. 

[00:39:41] And it's not just OB/GYN, it’s internal medicine doctors, family practice docs, rheumatologists, orthopedic surgeons. If you think OB/GYNs get no training, they get zero. The oncologists, they get none. And so, it can't fall only on the OB/GYNs. 

Cynthia Thurlow: [00:39:59] Correct. Oh, absolutely. And one thing, there were some articles that you-- For listeners that you sent to me probably last year in prep for our conversation, I want to read some statistics. It talks about how white women over the age of 50 have a lifetime risk. If there are 3,000 cases, about a 30% risk for developing diabetes versus African American and Hispanics are about 40% increase in risk. 70% of those with diabetes die of heart disease. 70% women with diabetes are at a 5.1 greater risk for heart disease than women without. And hormone replacement therapy reduces the diabetes risk by about 20% to 30%. So, you're correct, lifestyle plus strategies plus HRT is really helpful. 

[00:40:48] And one thing that I think is very important because I field a lot of questions, although I don't provide medical advice. There was a study called the Jupiter study and I recall when it came out because a lot of my very well-educated patients would say, “If I'm a female and I'm taking a statin, does this mean I'm going to develop diabetes?” And so, I think that I recall there was a position statement by the practice I work for that we were supposed to address their concerns with a particular, “Oh, you won't develop diabetes.” And really we're making the argument that you need to be on the statin. And I'm not telling anyone that's taking a statin to stop it. But just understanding this very close interrelationship between statin utilization in women puts you at greater risk for developing diabetes. And this is significant. And I still think there are patients who are prescribed these drugs, perhaps completely appropriately. Let me be very clear about this. They have documented myocardial infarction, heart disease, peripheral vascular disease, carotid artery disease, but they are not then told, “Oh, by the way, you are probably a greater likelihood of losing insulin sensitivity and going on to develop diabetes.” And I just talked about all these statistics around heart disease and diabetics. We want to do everything we can to mitigate avoiding a diagnosis of diabetes at all possible. 

Dr. Corinne Menn: [00:42:11] A 100%. And this is where you really need full picture. So, if you could get those women in before they got diagnosed with the myocardial infarction or other more serious cardiac disease, you get them in when you start to see those lipids going up and they're like telling you, “I put on 10 pounds, and my blood pressure went up a little bit.” And you're starting to see these changes. Before you get to the point where you need to start doing all of these cardiac interventions and maybe even statin therapy, maybe you get them early enough, you give them the lifestyle stuff and you talk to them about this cardiac disease risk acceleration with menopause and let's put you on six months of an estradiol patch and progesterone and do these lifestyle things, and then let's follow you. And if you're in a relatively low risk category, we can treat you much more preventatively kind of minded versus waiting until you're not only at risk for high cholesterol and heart disease, but diabetes, because by addressing the metabolic changes from the loss of estrogen, you're going to prevent so much of this chronic disease. 

[00:43:22] And I think new focus with the GLP1s and obesity and diabetes, it's this really important that we include that menopause is accelerating your risks of obesity, cardiac disease, and diabetes. So, these new medications, great, I'm so glad they're out there, but let's like also step back and try to get at women before we even have to get into those things.

Cynthia Thurlow: [00:43:50] I think it's so helpful. 

Dr. Corinne Menn: [00:43:52] And this is risk. Like to your point, you said we're really bad at risks. Like explaining risks to patients. We leave out the risks that we don't want to talk about with them and we don't talk to them about the benefits. And so, the statin therapy is a really good example. 

Cynthia Thurlow: [00:44:10] Yeah, absolutely. I think I would be remiss if we didn't talk about breast cancer because you have such a unique history. You mentioned you were in your training as an OB/GYN when you were diagnosed and now kind of full circle. You've now gotten to a position that you are taking hormone replacement therapy. Could you share with listeners a bit about your story? I think it's incredibly inspiring, but I think it also speaks to the fact that breast cancer does not just impact older women, it can also impact younger women. 

Dr. Corinne Menn: [00:44:40] Yeah. So, I was diagnosed with stage 2A breast cancer in 2001. I was 28 years old. I felt the lump myself. I was dismissed by my GYN and my fellow residents who didn't know any better, but they felt and they're like, “Oh, you're too young for breast cancer. It's probably just a cyst. Follow it with a couple menstrual cycles.” Long story short, four months later I was diagnosed and the treatments for my breast cancer, it was estrogen receptor positive, put me into temporary menopause once from chemo and then again from using some ovarian suppression along with tamoxifen. And then finally a third time when I had my ovaries removed. And the ovaries were removed to prevent ovarian cancer because I subsequently found out I do carry the BRCA2 mutation. 

[00:45:26] And so I experienced premature menopause temporarily and then finally permanently. And the collateral damage of that long-erm estrogen deprivation from my breast cancer treatments and then from the ovaries being removed that collateral damage was completely unaddressed in every way. I had no menopause education and training. This was 2001. I was young. I was afraid of recurrence. I did everything my doctors told me to do and I'm glad I did it. Okay, my breast cancer treatments were important. These estrogen blockers or tamoxifen, newer medications like aromatase inhibitors, they're not new, but they weren't being commonly used in my stage at the time, these things have repercussions. 

[00:46:11] And so, again, we can walk and chew gum at the same time. If we need to do temporary interventions to treat a cancer, which means lowering estrogen levels and treating it that way, we need to then address what we're causing in these women. Young women can and do get breast cancer. It's the most common form of cancer in young women is breast cancer. And the rates are rising, probably due to environmental exposures, alcohol, poor nutrition, other factors. But we can't just treat in a really kind of very narrow idea of what women's health is, their breast cancer, and ignore the damage that we're causing. Not just hot flashes and night sweats, insomnia, much higher risks of bone loss and heart disease. Everything we've talked about today, sexual dysfunction and this applies to all breast cancer survivors.

[00:47:06] But the younger the survivor is, the longer she's going to be living with those side effects. And literally nobody out there is really adequately addressing it. There are no cancer centers that I know of in the United States that have a survivorship program that is addressing the premature menopause aspect in an adequate way, in my opinion. I mean, yes, there's pockets of good doctors out there who are trying their best, but there's no really good standard of approach. It's kind of like the Wild West out there for these cancer survivors trying to navigate menopause and cancer. And it's not just breast cancer survivors. It's really any woman dealing with cancer which may put her into either early menopause or just going through natural menopause.

[00:47:51] The collateral damages are profound. And it wasn't until I struggled for years that I realized, “Wait, I need to learn more about menopause to help myself as well as just my average patients in menopause.” And that's when I kind of shifted my career focus. It took reading Estrogen Matters actually to be quite honest.

Cynthia Thurlow: [00:48:08] Amazing book. 

Dr. Corinne Menn: [00:48:09] For me to then feel comfortable, to then take the data and make decisions for myself. And I want to be clear for anybody listening to this podcast, because I do a lot of podcasts where I talk about my use of hormone therapy after breast cancer. It's not a black and white decision. It's not an absolute yes, but it's not an absolute no. And it has to be nuanced. The fact is, we need much better data on the safety of hormone therapy after being diagnosed with breast cancer. 

[00:48:35] We do have data but it's far from perfect. Dr. Avrum Bluming and Dr. Carol Tavris do an excellent job at summarizing the data. So, for any breast cancer survivor out there who wants to get started, to kind of just even like-- This might be mind blowing for them to even think about, start with Estrogen Matters and the new edition, they publish actually within the book all of the data from his really excellent review article of all of the world's literature on this. And so, because the literature is behind a paywall, it's in a medical journal, not everyone has access to it, so they put in the new book. So that's a great place to start. 

[00:49:10] And so, I tell patients like, “You need to look at your individual breast cancer, whether you're negative, positive. How many years were you from diagnosis? Did you finish your treatment? What are your persistent symptoms? What have you tried? What is your risk of recurrence? A late recurrence?” Because breast cancer can come back many, many years later. And then you have to make an individual decision because you're a big girl. You're a big girl. You can make decisions for your own body. So, for instance, someone, let's say there's a really good example, a stage I ER-positive breast cancer, early stage treated. She's a number of years out from finishing up whatever treatments she needed. And either now she's going through menopause or she's already been in menopause for a while and she has been suffering with a lot of symptoms. She's tried all the things non-hormonal. And she's like, “What about me?” Like, I want to try it. 

[00:50:05] So, someone with a very early stage, her risk of recurrence may be incredibly low, maybe like 4% at 10 years. And so, who gets to decide what risk she takes on? We can review the data and say there's a lot of data that suggests women at low risk of recurrence who use hormone therapy, that it doesn't appear to increase their risk of recurrence. We don't have perfect randomized controlled studies to give us that final word, but you can make that decision for yourself, right? 

[00:50:35] And the Menopause Society. I'm very happy this year they updated some of their language in their effect official slide deck on and in their position statement from 2022, actually, if people actually read it, instead of just taking the first line, it says that “In conjunction with their oncologist, women can weigh the risks and benefits. And there's a number of studies that show that hormone therapy after breast cancer does not further increase the risk of recurrence. And this could be done with shared decision making and individualization.” But that's not what happens. The woman is said, absolutely no. You can never even just talk. This is not a conversation I'm having with you. No, no, no. 

[00:51:11] And then they even extend that to even simple things like local low-dose vaginal estrogen, which we really should talk about. And really, women shouldn't like think that's nothing. 

That can be a really powerful intervention for some aspects of your health, not just sexual health, but urinary symptoms, preventing UTIs, but women don't even get access to that. And that part we do have really good data on.

[00:51:36] And then for estrogen receptor negative patients, there's no available literature that suggests that women who are estrogen receptor negative, particularly once they're out of that first two to five years, which is the most common time when a recurrence in those women will happen, that hormone therapy further increases their risk. And I think for our ER negative patients, it's actually an even easier, I think, conversation.

[00:52:00] The bottom line is if oncologists and OB/GYNs are waiting for perfect data on this, then a generation of women are going to suffer and not be able to be given the choice. And we are big girls. I always say this as a breast cancer survivor the decisions I had to make along the way were really hard and complicated. And they give us choices on lots of things. Lumpectomy, mastectomy, reconstruction, the chemo, the different endocrine therapies, genetic testing, all of these different things. 

[00:52:32] And pregnancy after breast cancer, we're given choices on that. And that's a whole really interesting thing we could talk about. And the data is really supportive that pregnancy after breast cancer does not increase your risk of death or recurrence. But when it comes time to a sexual health or menopause health, somehow those things are not considered valid enough to give women a choice. Even if that choice is, listen, I don't have perfect safety data on this, but if this is something you'd like to try and you're willing to take a risk of an unknown using the available data, then we can give her that. We don't have to be gatekeepers. This is not permission, it should be partnership. But that is just not what's happening out there. And there's just too many breast cancer survivors for us to ignore this anymore. We can't stop avoiding the conversation. And because of medical malpractice, fears from WHI, lack of clinician education and lack of time, no doctors have any time in the office anymore. They're like 10-minute visits.

[00:53:30] The breast cancer survivors are just like shut out of the conversation. We're talking millions and millions of women and that army of women is growing every day. So, I'm sorry, people, we can't ignore this anymore. Like doctors, we have to step up to the plate for these women, it's not okay.

Cynthia Thurlow: [00:53:49] That's why this conversation is so important. When I stumbled upon your work and I knew because I have so many close dear girlfriends, I'm going to get emotional. And every time you would share a resource, I would say, “You need to go follow Dr. Menn, you need to be able to share this information with your providers, you need to be able to advocate for yourself,” because you appropriately stated for the women that as one small syndrome of menopause, this genitourinary piece for the women, like we're not maybe understanding this in our 40s and 50s, but those changes in the genitourinary system are the women that I saw in Cardiology that were septic, that means they had a systemic infection, a blood infection, had a UTI. Maybe they had some degree of neurocognitive dementia. They couldn't tell their caretakers they were having burning on urination or urinary frequency, or they just dealt with chronic UTIs that something as simple as vaginal estrogen should be available for every woman because this is not a continence or incontinence conversation, this is a understanding that the sequelae of that loss of estrogen is catastrophic systemically, but on a very local level. I took care of those patients for years and years and years trying to explain to a family member, grandma's on IV pressers, she's got a breathing tube down her throat because of a urinary tract infection that allowed her to become septic. And in many instances, they die from something that is completely preventable from something as simple as vaginal estrogen, so-- 

Dr. Corinne Menn: [00:55:34] Another medical tragedy for all women. 

Cynthia Thurlow: [00:55:37] Yes. 

Dr. Corinne Menn: [00:55:38] For all women, but especially these breast cancer survives. It's really, it is so despicable and I get emotional and really angry about it sometimes. How many of them are denied access to even vaginal estrogen? We have thousands, literally thousands of studies looking at vaginal estrogen, its safety on the breast, in women with breast cancer without breast cancer, in women on tamoxifen, on aromatase inhibitors with premature menopause, you name it is universally safe, even if you're on medications like an aromatase inhibitor where the goal is to keep estrogen levels below what's normal for menopause. So, like basically zero. We have vaginal estrogen formulations that we can feel safe using in these women. Okay, so if your doctor says no because you're on aromatase inhibitor, they're just wrong, okay, you can use it. 

[00:56:40] The ones that I like for that in particular IMVEXXY. It comes in a 4 mcg and 10 mcg little gel cap, really nice, love Intrarosa, but even vaginal estradiol cream, I just will tend to use it more in the lower one third of the vagina. You use a little bit more sparingly just out of the abundance of caution while they're on the aromatase inhibitor. If you're on tamoxifen, I don't care, you use any form of estrogen because tamoxifen blocks estrogen receptors, so we can safely use it. Not a problem. But you should never suffer. And the other problem is you should never be told you have to use all the other things first, fail them, come back two years later with severe genitourinary syndrome of menopause where you now have pelvic floor dysfunction of the muscles, your relationship is broken down, you have frequency and urgency and you're waking up multiple times and it can pee all when we could have given you something from the get go.

[00:57:33] And the thing is, again, this idea of prevention you were alluding to with your cardiac patients right, in the past, when we've got a breast cancer survivor coming in and we're like, we're going to shut down your ovaries and give you these medications or chemotherapy is going to shut down your ovaries or you're removing the ovaries because you're a BRCA carrier. We know what's going to happen. Why do we wait years for the inevitable to happen for women to suffer many times in silence, create fears about vaginal estrogen so that when you finally give it to them, many of them are like, “Okay, but I'm still afraid because we've created so much fear,” and with this idea that they should be using lubricants only or coconut oil only. And I'm like, “You know, those things are like band aids. They're not wrong. I advise people to use them. They can be very helpful. They are not treating the root cause of the problem.” A vaginal moisturizer will do nothing for your urinary tract infection risk. It's not going to make your clitoral atrophy which get healed, and let's face it, that is what is happening, their clitorises are atrophying. 

[00:58:38] The labia and the clitoral hood get thin and can actually scar down over the clitoris so that they lose sensation. Imagine if men penises shrunk, lost sensation, got dry and they got kind of little thin micro lacerations when they had sex. Do you think we tell them to just use some coconut oil? No. And we don't do that for men, even men with cancer. We do strategies to help them. But this is what women get, I'm telling you at the top cancer hospitals in this country, in New York City, in Boston, in Miami, MD Anderson, I'm going to start naming them MSK. I can't take it anymore. When I see the misinformation, the gatekeeping and the harms that are being done to breast cancer survivors, especially low hanging fruit like vaginal estrogen. I get that the hormone replacement therapy MHT conversation is complicated. It needs to be much more nuanced. I understand that not everyone's well equipped to do it, but we do have to change that as well. 

Cynthia Thurlow: [00:59:44] Well, These are really quality of life things. This could be the differentiator between a woman being able to engage with her family for the rest of her life, to feel like she is capable of having a relationship with her significant other, feeling like she doesn't have to worry about vaginal symptoms. I recall I must have had easily half of my women north of 65 were all on low-dose chronic antibiotic therapy. And when I would ask them, why are you taking this? Because back then I was clueless and they would say, “Oh well, if I don't take it, I get urinary tract infections habitually, chronically.” And now I retrospectively think oh my God, I could have just-- Even though it was outside my wheelhouse in Cardiology, I could have said “You need to talk about vaginal estrogen with your GYN or internist.”

[01:00:37] Dr. Menn, this is an invaluable, truly invaluable conversation. Thank you for the work and the advocacy that you do for women. Please let listeners know how to connect with you. Obviously, go follow Dr. Menn on Instagram that's how I found you. But go follow Dr. Menn and get into her ecosystem so that you can learn more. 

Dr. Corinne Menn: Yeah. So, follow me. It's @drmennobgyn. And for any breast cancer survivors listening, this week, I actually just launched with a company called the MiddleList, a course for breast cancer survivors who are dealing with menopause. So, I'm super-- It's like a master class. So, it goes really in depth to everything we're talking about. So, if you need more information on that, check that out. And I'm always, yeah, doing a lot of basically just free education on Instagram because I'm just passionate about spreading the word, particularly for breast cancer survivors. So, follow me there. 

[01:01:29] And also another resource to shoutout is the nonprofit out of the UK called menopauseandcancer.org, another incredible source. And anybody listening, just educate yourself and advocate for yourself because you're the CEO or your health and your destiny, and you get to choose how you want to age and live.

Cynthia Thurlow: [01:01:49] Thank you so much for all the work that you do. 

Dr. Corinne Menn: [01:01:52] Well, thank you for having me. 

Cynthia Thurlow: [01:01:55] If you love this podcast episode, please leave a rating in review, subscribe and tell a friend. 

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