Ep. 472 What Women Aren’t Told About Menopause & HRT with Jackie Piasta

Today, I am thrilled to reconnect with my friend and colleague, Jackie Piasta. Jackie is a Vanderbilt-trained nurse practitioner. She is board-certified in women's and gender health, and has been practicing since 2010. She serves on medical advisory committees for several foundations and co-hosts the justASK Podcast. 

In our discussion today, we dive into the challenges menopausal women face with hormone replacement therapy due to the lack of provider education on the effects of oral estrogen, the importance of bio-individuality, and how nuanced messaging can make all the difference for women. Jackie unpacks the latest guidelines from the American Urological Society, which address vulvovaginal, urinary, and sexual health symptoms, and explains the importance of addressing those issues proactively. We also explore fertility tracking in perimenopause, especially for women using long-acting reversible contraception (LARCs), and the latest trends in hormone testing.

You will not want to miss this insightful conversation where Jackie sheds light and offers practical guidance on the often-missed details of women’s health.

IN THIS EPISODE, YOU WILL LEARN:

• Why bio-individuality is essential in menopause treatments

• The challenges OB-GYNs and other clinicians face in staying updated on menopause treatments.

• Why healthcare providers must become more educated about hormone therapy

• Jackie explains the historical context surrounding the vilification of oral estrogen.

• How the new American Urological Society guidelines are now addressing symptoms of perimenopause and menopause

• Why vaginal laser therapy might be harmful for some individuals

• Why diagnosing menopause in women using long-acting reversible contraceptives (LARCs) is so challenging

• Why hormone level labs are needed to guide clinical decision-making on menopause treatments

• Jackie highlights the need for more research to understand the hormone levels that protect bone health.

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“Estrogen helps to control the microbiome- the elasticity, the collagen, the general makeup, and secretions.”

-Jackie Piasta

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Connect with Cynthia Thurlow  

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Connect with Jaclyn Piasta

• Monarch Health 

• Jackie on all social media: Jackiep_gynnp

• The justASK Podcast

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 reconnecting with friend and colleague Jackie Piasta. She's a Vanderbilt trained nurse practitioner and board certified in Women's and Gender Health. She's been practicing since 2010 and serves on the advisory medical committee for several foundation and cohosts the Just Ask Podcast.

[00:00:49] Today, we spoke about messaging to women and why bio individuality is so important as well as nuanced conversations, why menopause and menopause hormone replacement therapy can be challenging due to the void of education for providers, the impact of oral estrogen and again, why there's a research void? New guidelines for the American Urological Society specific to vulvovaginal, urinary, and sexual symptoms and why it is so important to address these proactively, discussions around things that are not effective or potentially even harmful, fertility tracking in perimenopause, especially for women on long-acting reversible contraception or LARCs, why lab work can be helpful in many instances? And last but not least, trends and labs in the hormone space and some of the things that require more research before they can become frontline therapies. 

[00:01:46] As always, an invaluable, insightful conversation with Jackie and one I hope we will continue to do so throughout the next several years. 

[00:01:55] Well Jackie, such a pleasure to have you back on the podcast. I've been so looking forward to this conversation. As I promised listeners, we will continue featuring nurse practitioners because I think our voices are so vital and so needed. And before we started recording, we were talking about the recent podcast with Peter Attia and Dr. Rachel Rubin. And there was one prevailing theme that you and I were focused in on, really the silence of the medical community that has perpetuated women's suffering. And so, my hope and my intent is that these conversations will get women talking, having communication with their licensed healthcare provider for advocacy purposes because I think about my mother's generation in many instances are the ones like we're seeing the sequelae of not having the option of being on menopausal hormone replacement therapy and the impact on their bones, their brains, their heart, their genitourinary system, which I know we will be talking about today. And so, I'm curious because you know Dr. Rubin personally, your biggest takeaways from that conversation with Dr. Attia? 

Jackie Piasta: [00:03:03] Yeah, no. I think-- And we talked about this, Cynthia, in the first episode that we recorded together was that women-- The most difficult thing about this space and the menopause space and the hormone space is just the utter mixing of information and where do we go? And actually, Rachel Rubin on the podcast with Dr. Attia was like “There's the textbook answer, there's the Instagram answer, and then there's the Dr. Rubin answer.” And I feel very similarly in my practice, I will say there, of course, is the textbook answer, which very rarely do our patients ever read the textbook. 

[00:03:38] How many times have you had a patient in your clinic? And they are the exact replication of what the textbook says, especially because the textbooks are written under a male model, and we bring female patients into the mix, and a lot goes on with the dynamics of female hormones and the influences that have on our bodies. And so that bio individuality piece is so important. 

[00:03:58] But what do you do when you go into your clinician's office and they haven't been updated, they haven't been trained, they're not in a space where their medical upbringing has been able to educate them on that particular subject. And then once they get into clinical practice, there's not enough hours in the day in order to learn that stuff. 

[00:04:17] I always say I come at it from my lens. I know your lens is Cardiology, and my lens is obstetrics and gynecology. And I look at those, the responsibilities in obstetrics and gynecology are tremendous. They're huge. We have to know everything there is to know about primary care, women's health, obstetrical health, postpartum, menopause, there's so many topics. And what are the two primary things that obstetrician, gynecologist is going to get sued for? It's going to be a bad outcome with a pregnancy and a bad outcome with the surgery. 

[00:04:50] So, if I'm an OB/GYN who has very little time in the day to learn and upkeep my skills, what things am I going to invest my time and my money in trying to further my practice in? And it's going to be those areas, and unfortunately, the rest of the penguins just fall off the iceberg. And that's what we've found ourselves in this space with menopause. 

[00:05:10] But back to the podcast with Dr. Rubin and Peter Attia, one of the biggest things that they harped on. And I actually listened to a lecture a week and a half ago from another Nurse Practitioner Jen Lanoff out of DC. And she gave an ethical lecture on Dr. Lisa Larkin's healthcare platform about ethical dilemmas in treating women's health. And one of the biggest pearls that I took away from that is that we go into medicine or into nursing and we swear this oath to do no harm. But there is another side of harm, so we don't want to give somebody a medication because it's going to harm them. And this is always the scenario that comes up with menopausal hormone therapy. We always counsel out of fear, it's fear based, “Oh, you can't take this. This might cause breast cancer. This might give you a blood clot. This might--” 

[00:05:57] Dismissal is also a form of harm. Not doing something, not counseling. And we talked about this in our first episode, the flipside of the coin, having a balanced discussion. Okay, so if this is-- I'm not proposing that it does increase your risk of breast cancer because we have many now studies and data to show that hormone therapy does not increase breast cancer and certainly not death from breast cancer. But let's say if it does, then what is the positive flipside of this? Because women are far more than just their breasts and their genitals and we have all sorts of other organ systems just like men, and so where can we find the benefits and have that balanced discussion? 

[00:06:35] I think that's the biggest thing is it's we don't recognize that dismissal is a form of harm. And I think that's the context that a lot of individuals find themselves in the medical setting is that if somebody doesn't know how to prescribe something or doesn't know how to do this or doesn't feel comfortable, we are still dismissing people and kicking that can down the road rather than trying to intervene in a different way, whether that's referral to another colleague or whatever, what have you. 

Cynthia Thurlow: [00:07:01] Well, and it's interesting. I was just on a brief vacation with my cousin who is an OB/GYN, and we were talking about a lot of the changes that she has seen in medicine, especially OB/GYN medicine, over the past 25 years. And she said, even as an OB/GYN, pelvic floor push, that discussion, the open discussion about pelvic floor issues, menopausal hormone replacement therapy. She oftentimes will ask me questions and will say, put your finger on the pulse of X, Y or Z like what are you hearing? Because she said it is so hard in a very noisy environment to be able to be on top of everything. 

[00:07:41] And to your point, when someone is caring for a fetus and a patient or fetuses or someone is dealing with high-risk surgical outcomes and issues, that is very different than a clinician that's in an office who has a little bit more time to be able to spend with patients to get more information, to get a better sense of the direction things need to go in. And you in particular have done a really nice job. I was looking at one of your posts last night and you were talking about all the subspecialties within gynecology and whether it is reproductive endocrinology or pelvic floor specialists or looking at gynecologic oncology, just really kind of looking at this broad perspective and admitting that we don't know everything, but we need to have those resources. We need to know when to refer a patient on. We need to know when we are beyond our comfort level or even saying to a patient, “I don't know, but I'm going to find out.” 

[00:08:37] And I think that, ourselves and many of our colleagues, we're not so proud to not be able to admit when we don't know what we don't know. And I feel I will be learning till the day I die, hopefully. But I think for a lot of individuals, I think the conversation has gotten very nuanced which I think is good. But I also think by the same token, it's been very confusing for consumers, people that are following us on social media, they're hearing that bio individuality rules, which is super important. And then they might hear in other echo chambers, this is bad. Oral contraceptives are bad. Oral estrogen is bad. God forbid, you use the inexpensive generic vaginal estrogen instead of compounded. And I think we're kind of missing the boat is that everyone has different budgets, everyone has different bandwidth. I find some patients, they're like, “I don't want to be on ten different things. I want it to be simplified.” Other people are fine with that, but I think for a lot of individuals. 

[00:09:33] And I was having a conversation with my pharmacist, I was picking up my estrogen patches yesterday and she said to me, you're so lucky that your insurance covers your estrogen patch. So, I pay about $5 a month, literally $5 a month. And I said, I just submitted a publication for a book and I was giving resources in the book for people that were looking for telemedicine options if they live in an area where they can't find a provider. And I said, there are companies that will as an example and I'm not trying to throw anyone on a bus, but they'll charge you $150 a month for an estrogen patch, which probably costs a dollar a box. I mean, so the markup is considerable. And so, I think that consumers in many instances just feel a sense of overwhelm, like, who do I trust, where do I go? How do I find someone in my area? That's why I think the podcast is such an important opportunity to connect people or in your state, in the states where you have licenses, like here's a provider that is like minded, is going to give you an opportunity to be able to run through like what are your goals, what is your budget and what work best for you. And I think that sometimes is what's forgotten in conversation. There's no one size fits all. It's not as if compounded options are bad and only FDA-approved estrogen patches are good. It's really just finding what works best for that patient. And then just a degree of nuance that I think sometimes is forgotten in the conversation. 

Jackie Piasta: [00:10:57] Yeah, so I mean, I echo everything that you just said. And probably one of the largest issues that we have currently right now is that there's a lot of people that have the argument-- Well, okay, we're no longer in a menopause silence era. Menopause is having a moment. Unless you're living under a rock, it doesn't even really know what blend of or what area of medicine that you were in, like you know about it. For God's sakes, my husband's an airline pilot. He's constantly talking about it with his co-pilots. Every time he comes back from a trip, he's like “Okay, guess what came up again? Menopause.” So, it is being talked about widely now.

[00:11:41] The problem is is that menopause hormone therapy is not so easy. And we talked about this a little bit in the first-- Again, I'm harping back on our first episode, but about this is not algorithmic care. We do not have a beautiful chart that is published in a scientific journal somewhere that says, “If this, then that, if this, then that, if this, then that.” These are so nice, especially, when you're running behind. You're seeing 30 patients in the clinic and you're like, “Oh, shoot, I forgot about that. Let me pull up my little index and run it through.” We don't have that in menopausal medicine.

[00:12:21] And we have had 20-- How many years now? 2002. Now we’re at 23 years of a void of healthcare education on menopause. And so, no one knows how to prescribe hormone therapy. So, while they might be open to the idea of it, so now we've gotten to a place where everybody's talking about it, cool. We're open to it, all right, maybe we can convince you that it's not going to cause breast cancer, it's not going to cause blood clots. Maybe you're progressive and you are on the leading edge of this. But now you have a patient staring at you in the face miserable, asking you for treatment. 

[00:13:06] Well, back to my OB/GYN upbringing is that we were all taught how to prescribe birth control pills left, right and center. We know how to do that. We know how to prescribe about 50 different types of them too. We're very comfortable with sitting with that. And so oftentimes, this is where women get that conversation with OB/GYNs. And I'm not ragging on my OB/GYN colleagues, but even in your primary care office, wherever you are trying to receive care. And the answer is, “Well, birth control pills for this.” And so now we have vilified a really useful tool in our toolbox in some spaces, because women feel dismissed. Back to the dismissal thing because they're only being given one option. They're only being given that one option because that's the only option that's really been taught over the last 20 plus years to deal with women's hormonal concerns. 

[00:14:00] And so, when I work with a patient, and this is what the next evolution I think of menopausal medicine needs to be is we need to start teaching and training people how to actually do this. Not that menopause is important, not that it causes all these diseases and all these things. Yes, we got that. We know that. But how do I actually put pen to paper to write this prescription because its jaw dropping when you realize, “Oh, I have no idea how to do this. Or like you said, your patch, that's great. Well, there's six different doses of patches. Where the hell do I start? Do I start with 0.5, 0.25, 0.1 what do I do? Oh my God, how much progesterone do I need?” These are all decisions that need to be thought through. 

[00:14:47] And here's the next kicker and the thing that I was going to bring this back to of your comments is, I always sit down with my patient and ask them what is important to you? What is your goal? And I always ask the question in three months, if there was a healthier version of you, what would it look like? And what is important to you? Because I have individuals that come into my office and they're like “I don't want any fillers. I don't want any preservatives. I don't want any titanium dioxide.” If people listening don't know what that is, it's a filler that's used in commercial pharmaceuticals. But some people in the health and wellness space are against that. “I don't want any red dyes. I don't want any of those things.” Okay, that's what's important to you. How can I as a clinician work in the most evidence-based way in order to provide you care that is congruous with your needs and desires and allow you to exercise your autonomy and make a decision for yourself given the information? So that's my biggest thing. Because a patch for you, Cynthia, might be fantastic, but for me, it might come cause me to break out in a rash, it might not stick, I might not absorb that estrogen, I might actually frankly just prefer to take a pill at bedtime. And as long as I don't have any medical contraindications to taking a form of estradiol in an oral formulation, then why isn't that a good form for me? 

[00:16:09] And so again, this is not an algorithm. This is sitting down with people, talking to them, getting to know them. What's important to you? Because that matters. I think we have these conversations in other areas of medicine, but for whatever reason we're still having trouble allowing women to have full reins on these medical decisions when it comes to hormone therapy. 

[00:16:32] And the same is, I think is true for not only type of hormone therapy, but duration of hormone therapy is still questioned. Starting when you're outside of this ideal beautiful window. My friend Dr. Corinne Menn calls that the “Menopause Barbie.” If you're not the Menopause Barbie, [Cynthia laughs] news flash, none of us are the Menopause Barbie. So, any who, I digress and I just ramble at this point. But yeah, what is important to you because that's not going to look the same for everybody. And this is where we get in trouble with these 90-second clips on Instagram. 

Cynthia Thurlow: [00:17:02] Absolutely. And I think for listeners, just to give them context, Cardiology as an example, is pretty concrete about specific things. If you have X arrhythmia, this is the algorithm for treating that. If you have high blood pressure, this is the algorithm based on guidelines that you use. If you've had a myocardial infarction, heart attack, heart disease, these are the things that you do. What we're speaking to is that there is not as much certainty about, these are the things that we need to do in this order. I think a lot of is left to share decision making between provider and patient, which I think is both good and bad. I think for a lot of clinicians, I say this transparently, “I'm always learning. And I finished Dr. Heather Hirsch's course and I'm in an amazing dynamic group of-- It's a Facebook group with physicians, nurse practitioners, PAs.” I mean you have a medical license and you're in this group. And it is so clear to me, to your point, many of us are just like “Where do we start? What do we need to do?” And it's because we don't have these consensus statements, we don't have this algorithm with which to work.

[00:18:04] In many people, it's trial and error figuring out what works. I always think about-- I had a guest earlier this year who was talking about vaginal estrogen on her face and how she has found that to be really helpful. And I would say 50% of people were like, “Oh, my gosh, I didn't know I could do that. Let me talk to my provider.” And then the other 50% were like “Do you know what's in the vaginal estrogen? It's generic and relatively inexpensive parabens.” And I thought, well, this is like the big crux. People are like great, I'm doing something and then on the other side, there's someone that's like “Oh, there's an ingredient that I don't want on my face.” And so, it's navigating these kinds of tricky waters and acknowledging that many people, especially with 23 years of--

[00:18:47] I do have clinician colleagues that were still prescribing menopausal hormone replacement therapy throughout that time period, but the majority of clinicians were not. And we're still coming off of this “fearful to prescribe, fearful to take.” And I say this because it's every day on social media or every day we get emails or messages. So, it's still this education process that will be an ongoing endeavor. And so, my hope and my intent is that these conversations will get people thinking about what do they need to look for in a provider and have the shared decision making to ensure that they're getting the quality of care that they would like. I do have a question for you. What is the big deal about oral estrogen from your perspective? As a clinician prescribing oral estrogen for appropriate patients, why is everyone so flummoxed over this option for replacement? 

Jackie Piasta: [00:19:37] Sure. First of all, I think it comes from the fact that the hormone that got us into all this trouble in the first place was taken orally. And I'm referring back to the Women's Health Initiative trial, also known as the WHI which is the study that was released or the initial findings were released in 2002. And it's where we had a press conference about, “Oh my gosh, hormones are going to kill us all and take us all down.” And again, radio silence for the next  20 plus years. 

[00:20:07] The primary medication used in that trial was Premarin and Prempro is the most widely prescribed medication hormone replacement therapy at the time. And it was an oral form. Premarin was oral conjugated equine estrogen, which is estrogen synthetically derived from the urine of pregnant horses. And then Prempro was its friend that was for women that had a uterus. It had a progestin component called Provera, also known as medroxyprogesterone acetate. And that was also in a pill form. 

[00:20:37] And when we administered this medication to women outside of the preferred, what we now have established as this window of opportunity, which essentially just refers to that there is a time frame within the first 10 years of menopause where these anatomical changes that are associated with menopause, like increased cardiovascular risk, insulin resistance, bone, all of that doesn't-- Is not as firmly set down in stone as it is beyond those 10 years. 

[00:21:10] And so, we administered these medications, these oral formulations to women from the age-- Average age of women in that trial was 60 to 63. I didn't study before this, so don't misquote me-- Don't knock me on misquoting that. But essentially, here we go. We have women that hadn't been on hormone therapy for many years, and we administered them in oral form of estrogen, which actually is a cocktail of estrogens. I think we've counted at least over 30 different forms of estrogen in Premarin. Now, I'm not ragging on Premarin. There are some actually really fantastic side notes on Premarin and we may see a resurgence coming in the next several years in the breast cancer community, and we can talk about that too. 

[00:21:49] But essentially, when taken orally, Premarin does increase certain clotting factors, because it is metabolized via the liver in something called the first pass effect and increases these inflammatory markers, including C-reactive protein, and can increase the likelihood of an event. The problem is that we didn't really get the message across that it really increases the event individuals that have pre-existing atherosclerosis, which is plaque buildup in your arteries. Cynthia, you're way better at this than I am. But if you are a woman who is healthy and you do not have pre-existing atherosclerosis, then it's really doesn't matter if it transiently increases your clotting factors because you don't have any plaque theoretically to rupture.

[00:22:31] So, this is what happened and we said, “Okay, well oral estrogens are bad, they're going to cause everybody to have strokes and heart attacks and all these things.” And we applied that to all women, not this narrow range of women with this certain increased biologic risk or physiologic risk. We applied it to all women and so that came downstream effects to oral estradiol, which estradiol is derived from plant sources, primarily soy. And I wish we had better head-to-head studies on all this. This is where we have a research void. But there is some argument out there that oral estradiol has less of an impact on these factors as Premarin, because Premarin again is a more potent form of estrogen. And so, this is why people don't like oral estrogen, because they think it's going to-- The primary fear is the VTE risk, the clotting risk.

[00:23:28] And then when we look at it too, so I also wear the hat of sexual medicine clinician and I work with a lot of women and couples, men and women in sexual health. And so oral estradiol increases also a protein in your liver called sex hormone binding globulin, which can attach to your free levels of testosterone and it can lower libido. It all can also have impacts on the genitourinary tissue. And so, there are some effects there. But I think in the grand scheme of things, if you are a person that has a fairly low risk of having a blood clot, then really there isn't-- You shouldn't be afraid of oral estrogen. You certainly shouldn't count it out completely. I think again, it just lends itself to having a full conversation. 

[00:24:12] And then there's also some argument and debate probably within more of the holistic community, functional medicine community on oral estrogen metabolizing and downstream effects into estrone, which estrone is another form of estrogen that is produced in our fat cells and people believe that it also fuels breast cancer. And so, to avoid that, but again, we don't have any good studies that actually show correlation-- Or showing a causation effect here. This is all corollary information and a lot of it is hypothetical at best. So hopefully I did that justice. It's a difficult situation because I think there's a lot of cooks in that kitchen. 

Cynthia Thurlow: [00:24:53] Yeah, no. Again, it's one of those very nuanced conversations and I have friends who are doing really well on low-dose oral estrogen because they didn't tolerate the adhesive in the patch. They didn't like the rubbing estrogen on their skin every day and that is what works for them and they're doing great. And to your point about cardiovascular risk assessment, for most people that are going to get started on oral estrogen, they're going to get some degree of cardiovascular risk assessment, whether it's with labs and/or imaging like a CT Angio or a CAC, coronary artery calcification and/or a stress test if necessary. 

[00:25:28] I think for a lot of individuals it's really that personalization that we're looking for and we don't want to fear monger anyone because if you do well, periods are insanely heavy and you cannot manage, you’re becoming iron-deficient anemic, you don't want surgery, you don't want an IUD, then maybe oral contraceptives for a few years until your hormone levels are less variable might be a good option. I never want to be someone that's absolutist about things. I think it's very important to work with someone that's going to give you options and going to honor your own unique circumstances. 

[00:26:03] I was one of those people. I used to get horrible migraines from being on the pill. So, when my period was really heavy, I was offered oral contraceptives, and IUD and ablation or a hysterectomy, because I think I was 43, and at that time I kept saying, “Is there anything else?” Not realizing that oral progesterone at that point would have been probably really beneficial. Having said that, again, finding the right provider so they can help honor what you are wanting and desiring, I think is also key. And feeling heard, I think that's the other piece of it is irrespective of which specialty we are seeing, we want to feel our provider is hearing us, supporting us, and trying and endeavoring to make sure that the resources that are available are going to be of benefit in helping us make the right decision for ourselves. 

Jackie Piasta: [00:26:48] No, 100%. Again, not to go too long on this, but yeah, this goes back to the fact that we have not done a really good job in the menopause space of differentiating between the different forms of hormones that we have out there. When I have a patient sitting in front of me, I always say, “Look, I want an all expenses paid trip to Home Depot. I don't want any [unintelligible 00:27:10] borrow my tools.” I got a toolbox, I'm going to fill it up with every single thing that I possibly can. So, when I get home to get a job done, I have got every possible piece of equipment that I might need, because you might start a patch and you might do great the first few months, but oh my gosh, nope, I need to pivot and I need to go do this, that or the other thing. 

[00:27:31] And so again, it's not talking in terms of vilification of our tools here and not generalizing, which is the hardest thing to do because we want to generalize everything. I was actually just giving a talk in Miami on testosterone for women. And at the end of the talk, somebody stood up and asked a question on the microphone and she said, “Well, you said it to do this way, but my doctor is having me do it this way. Is that bad? Is my doctor bad? Do I need to go to somebody else?” And I said, “Absolutely not. This is the party line. This is the preferred method. But just because you and your clinician have decided on a different approach, as long as you've been educated on the ‘why’ for that and you've exercised your autonomy to make that decision, why not do it that way? Great.” And so, we want everything to be so black and white.

[00:28:17] It also doesn't help that the FDA is not throwing us solid bone and they still have outdated, incorrect information on our package inserts for hormone therapies. Basically, you’ve got what's called blanket package warnings on everything that is a hormone. We know it's possible to change because the testosterone labeling for male testosterone just got changed this year, but women's hormone therapy all has blanket boxed warnings on it that is very incorrect in a lot of different ways. 

[00:28:47] So again, we still have so much work to do. And so, the best thing that somebody can to in this phase of their life is just find somebody with a license to prescribe medications that is willing to partner with you and have that fullness of a conversation to talk about the ins and outs of why things are good and why things are bad. 

Cynthia Thurlow: [00:29:10] Yeah, I think that's absolutely key. And kind of pivoting and talking about new guidelines that just came out from the American Urological Society, which I was really excited to see because I feel there has not been enough consensus or certainly enough discussion around symptoms that women can experience, even in perimenopause, but perimenopause into menopause, kind of addressing vulva, vaginal, urinary and sexual symptoms. This is significant. 

[00:29:36] And certainly, if you follow any of the kind of menopause advocates on social media, everyone's been talking about these guidelines. And so, I think it's really exciting because it's not a question of if, but when. The physical changes that are going on for a lot of people, I think they assume, well, “If I'm 52, 53 and I'm not having atrophy, reduced moisture, painful sex, etc., then that's never going to happen.” 

[00:30:04] The research suggests the prevalence is anywhere from to 13% to 87%. So, it's not a question of if, but when. And I think the sooner we can intervene and have these conversations and utilize treatment modalities that are going to alleviate symptoms, the better off we are. Because when I talk to girlfriends, the ones that are willing to talk about this stuff, it becomes this running joke of everyone is experiencing painful sex, changes in urinary frequency, especially if they're not utilizing vaginal estrogens in particular. I mean the women that are up two to three times a night, the first thing I ask is, “Are using vaginal estrogen more often than not?” They're not or they're getting chronic urinary tract infections or they just have a lot of irritation and dryness. 

[00:30:48] So I'm curious, are you as equally excited and hopeful with these new guidelines as I am? I feel I've read the paper and then the MenoNotes that come from the Menopause Society multiple times. Because I'm like “This is exciting. This at least gives some direction and some feasibility.” 

Jackie Piasta: [00:31:06] Yeah, no, believe me, I am so excited for more direction to be in a very concrete space where clinicians of all walks will look at it and it's validated to them. And, oh, yes, okay, this is important. I was going to bring up, you said 13% to 86% of individuals suffer from these symptoms. And I think that the reason why there's even a statistic in the 13% range is because we're not asking the right questions. Half the time, we're not even asking the questions at all. 

[00:31:39] And so, speaking again from my OB/GYN hat here, I was taught by one of the best nursing schools in the country, but we were not adequately taught to examine the vulva, which is the outside tissue of the female genitals. And we were like “Oh, get your Pap, do your Pap and be done with it.” And there's so much more to gynecologic anatomy than just that. And how many women, every year we go, we're like, “Oh, we're going for our Pap. Oh, we're going for our Pap” And so, I think that we've sort of dumbed this down. And so, I love guidelines that look at the nuance of things. 

[00:32:11] They're actually by a colleague, Dr. Chailee Moss, who's an OB/GYN out of GW. She was just published in JAMA on a study that they looked at. And of course, it was a survey study. And so, it's got its limitations, but they came out with the statistic that 40% of participants in their study, females were told that they needed to relax more when they were experiencing pelvic pain, and 20% of individuals were recommended to drink more alcohol. 

[00:32:35] I don't know about you, but I'm pretty certain that alcohol has no redeeming qualities within a medical context. So, the fact that somebody with a medical or a nursing license is recommending that as a treatment modality, is frankly unacceptable. And so, when we look at having the American Urological Society posting guidelines about how to treat a condition that a lot of people don't even realize is even a condition at all is major. Is major. 

[00:33:02] The next major thing will be, and not to harp on this or beat this dead horse, but will be to remove the package warning on vaginal estrogen products that still carry the same risk as all other hormones. We say probable dementia, stroke, heart attack, breast cancer, all these things are untrue. And so, we can have these guidelines out here, but if clinicians are still afraid to prescribe them or patients are still afraid to take them when they're able to get them from the pharmacy, we're not getting much further along here. 

[00:33:33] So, I love this. I love that they-- And if you haven't been able to read them as a layperson or even as a clinician, they did a really nice job of separating out the therapies, which as Cynthia, we were talking about pre-recording. And I think that's really nice because back to what we were talking about before, people don't know how to prescribe these. We can understand and we can conceptualize. Okay, vaginal dryness, urinary issues. Okay, great. Yeah, I think vaginal estrogen would be a really good thing for you. Okay, it's a tube. Well, what do you do with this tube? How much of this tube do you use? And so, I think that it's nice to have some concrete guidelines and to really set in stone. We need to be more forthcoming with these medications and these treatments, modalities, and addressing it in the first place.

Cynthia Thurlow: [00:34:22] I agree. It's interesting. Heather Quaile’s did a really awesome job. She was talking about thinking about your vaginal estrogen like a tube of toothpaste. She's like, “Throw away the applicator.” Over her shoulder, she tossed it and she said, “It's like a tube, like one knuckle, one knuckle worth of vaginal estrogen. Don't just put it internally, put it externally.” And I thought to myself, even myself, I was like, “Oh, my gosh, this is absolutely brilliant. Why aren't we talking about this?” 

Jackie Piasta: [00:34:48] Yeah. Yeah. 

Cynthia Thurlow: [00:34:49] Because I think a lot of people, they have both internal and external symptoms and they're assuming that if they just put it internally, it helps everything. And I'm here to say, just both personally and professionally, that we have to get a little bit creative. I'm not suggesting you use half a tube. I'm just saying a knuckle's worth of product on your finger, utilizing it to encompass both external and internal tissues so that-- a lot of people are just really experiencing-- I think about the things that get ruled out when you have a physical examination. So obviously if you're doing telemedicine, someone is not looking at your internal, external tissues. But if you're privy to be in front of your gyn, your nurse practitioner, your PA to rule out other things like infections. I think everyone fears lichen sclerosis. I personally feel every person I know that is a clinician, everyone's worried about that autoimmune changes that can happen or the chronic urinary tract infections that a lot of people kind of get dismissed. It's another round of antibiotics to address what is really a low estrogen state in the urethra. It's not just the vagina. The urethra is also very, very sensitive to that loss of estrogen. Do you agree that we're probably not-- I know that you are, but we're probably not having enough of those discussions to help women understand it is not just a painful sex issue. It can be the entire genitourinary system can be impacted quite significantly.

Jackie Piasta: [00:36:14] So I think 100%, you hit the nail on the head. We really have to lean in as a medical workforce into this genitourinary syndrome previous to being medically classified as GSM, genitourinary syndrome of menopause, it was called atrophic vaginitis- 

Cynthia Thurlow: [00:36:33] Senile.

Jackie Piasta: [00:36:34] -which is just like-- Well, yeah, the senile vagina, my God, yeah, that is not fake news that actually did happen. But so, it was atrophic vaginitis. And so, okay, this is very problematic because it completely takes out the vast majority of what is happening here, which is there are changes to the urinary system and there are changes to, here it goes that outside part, again, that vulva, particularly something called the vulva vestibule, which is the-- When you pull away the labia minora and separate them, it's that kind of reddened area right before you see the opening of the vagina. 

[00:37:14] And so, when they reclassified this or renamed it in 2014, so this is just barely 10 years, 10 or 11 years ago that this is-- And remember, we've already talked about how poorly trained we all are in this. Not everybody read the memo that we renamed it. That urinary was now added to it. And so, it's really important to lean into those because-- And we'll go back to Dr. Rachel Rubin, because she does it better than anybody else on this. The vaginal symptoms are not what kill women. It's the urinary symptoms, specifically the undiagnosed urinary tract infections that lead to urosepsis, kill women. And so, if we are not having the urinary system as a primary thought on our brains as part of this condition. That's what I teach women about that come to my office on vaginal estrogen and I'll say-- I'll ask the questions. Are you having pain with sex? Are you having any dryness? Are you noticing your vagina more? Is it changing all those things? Because estrogen helps to control the microbiome along with the elasticity and the collagen and the general makeup and the secretions. 

[00:38:25] But I will always ask the urinary symptoms. “Are you waking up in the middle of the night to go to the bathroom? Are you having more frequency, urgency, all these things? and do you want to be stuck in a nursing home having urosepsis?” I remember when my grandmother was in the nursing home and she had dementia and couldn't advocate for herself. And every other week I felt my mom was calling saying, “Grandma's been put on antibiotics again for urinary tract infection.” 

[00:38:54] So, it's really, really important for us to lean into all aspects of this condition and to know that it may, we may find out that it is likely as ubiquitous as menopause in and of itself. A very large percentage of women in menopause will experience this. And also, to recognize that women not in menopause can experience this. There're other hormones [unintelligible 00:39:15] actually put a manuscript together and had a poster this year at the International Society for Women's Sexual Health on the other states like lactation, postpartum, on long-term use of oral contraceptives. There’re all different states in which a woman can experience this as well. But yes, I think not ignoring that. 

[00:39:37] And this is one of the-- In the American Urological Society guidelines on GSM, I think it's really important that they touch on all the different modalities. But this is one of the areas where I so vouch hardcore for vaginal estrogen or some type of vaginal hormone product being not necessarily pushed, but heavily encouraged because this is a hormone deprivation state and there's no amount of lubricant out there that is going to make the necessary changes that hormone can provide in this circumstance. And there's really not one medical condition I can think of that is a contraindication for utilizing vaginal estrogen. So not all of my colleagues are there. Some people are still very skittish about this, but the data does not support that it's harmful. And that was brought up in the AUA guidelines is that we need to inform particularly breast cancer survivors, breast cancer patients that maybe we don't need to just have a glass of wine. 

Cynthia Thurlow: [00:40:37] Yeah, well, and I think it's-- You know as someone that took care of a lot of ICU patients working in Cardiology and Critical Care Medicine for over 16 years, almost every single one of my north of 65-year-old female patients were on chronic low-dose antibiotics. That was the norm. And you can't appreciate urosepsis, which means you get a urinary tract infection, it gets into the bloodstream and it becomes systemic. So, these are patients oftentimes that were acutely they'd have a change in mental status. So, they didn't know who they were, where they were, they didn't know what year it was, running wild fevers, oftentimes, very hypotensive. So, they had very low blood pressure. Sometimes we had them on powerful drugs to maintain their blood pressure.

[00:41:28] And usually in that setting they would have an infarct and meaning they would have a heart attack. And that's usually why we get pulled in. And having conversations with family members about how active was this individual understanding how debilitated people get lying in a hospital bed. Trust me, I was hospitalized in 2019. I tell everyone how much muscle mass I lost just laying in a hospital bed. I think for a lot of individuals they just can't fully appreciate urosepsis. And that is not something that necessarily people depending on what organism is cultured. And I don't say this to scare people, but some of these bugs, they can be really tough for older people to fight off. So, knowing that vaginal estrogen is both inexpensive and can be easily and readily used, I think that everyone needs to be having that conversation with their providers. 

[00:42:13] With that being said, these guidelines do a really nice job of talking about the things that do work. And then we’re talking before we started recording about some of the things that scare the bejesus out of me. I jokingly say like “Laser on my face. I can rationalize.” Laser in the vulva, vaginal area is something that I think has to be-- You really have to be-- And I think even the guidelines mentioned like CO2 laser for those who cannot otherwise take hormones in that area. But a lot of these laser therapies don't have a lot of good research and in the hands of a non-clinician could potentially be problematic, because as you and I were talking about, if an individual is a post breast cancer patient or post GYN cancer. Even if they utilize a laser, those tissues may not be able to rebound the way that they might in an otherwise differently treated individual. And I think it begs the conversation of really getting granular and clear about what is effective and what we know to be potentially ineffective or even harmful.

Jackie Piasta: [00:43:17] Certainly. I would never-- I think we need to be clear that this is-- While it is an FDA-cleared treatment modality, there is not really any convincing evidence to show that it is useful to treat vulvovaginal dryness, discomfort, irritation, pain with urination, pain with-- We just don't-- There's plenty of sham studies out there and they're not great. And a sham study, basically, the sham is where they just use a nonactive laser and they're not actually lasering out anything. 

[00:43:50] But again, I've always died on this hill, which is this like-- if the tissue is not in a place to heal itself, why are we implementing microscopic tissue damage to tissue that is incapable of really adequately healing itself? So, I think that there is area where actually more harm than good can be done in some of these circumstances, especially if women are only being offered vaginal laser therapy as an option. Sometimes I think-- and we were talking off record on this about sometimes I feel like this can get a little predatory on our breast cancer survivor patients because they're marketed to, they get Breast Cancer Survivor month where clinics will do discounts on these lasers. And in my humble opinion, I just think that's false advertising. And I just think it can slightly lean into being predatory because we're preying on these fears and we're offering them an inferior treatment when newer data really suggests that there's not a contraindication for the gold standard, which is vaginal estrogen therapies. And so, I think that--

[00:44:55] Of course, if somebody opts out of their own free will to have a laser after they've been adequately counseled on what it can do and what it does do and what it's been actually clinically proven to do, that's totally fine. But again, to be shepherded into this one modality as the end all be all is in my mind that is a form of doing harm. So, I'm, yeah, I have a lot of beef with the CO2 laser.

[laughter]

Cynthia Thurlow: [00:45:22] Let the buyer beware and just to kind of to reaffirm the vaginal estrogen piece. Those that use vaginal estrogen have a 73% less mortality, 51% less sepsis, 22% less hospitalization, so the data really supports. Again, have a conversation with your provider. But I just say this humbly as someone that took care of a lot of these patients over the years, really just being conscientious and sensitive to the fact that it can be a long-term solution for a lot of potentially unpleasant, even catastrophic issues that can happen with age. 

[00:45:58] I know in our last conversation we talked quite a bit about LARCs, these long-acting contraceptives. A lot of questions came in, Jackie around if I'm on a long-acting contraceptive, how do I know where I am in terms of am I closer to menopause? I think for a lot of people that are in their late 40s, maybe even early 50s, maybe still have an IUD in, there's a lot of concern. And I think now it seems-- Anti-Müllerian hormone seems to be one of these things to be helpful. And in terms of looking at egg quality, ovarian aging, is this something that you're using with your patients? How do you counsel your patients around these kinds of topics? 

Jackie Piasta: [00:46:40] Sure, sure. So, if you're listening and you're not familiar with what Anti-Müllerian hormone is, it's basically a hormone that's produced by the granulosa cells in the ovarian follicle. So, they're little cells that surround the little follicles in our ovary. And AMH has historically been used as a fertility predictor to assess for fertility. Although, I do know that in the fertility space, I think is relying on this less and less. It's also sometimes been utilized as something to diagnose other conditions like polycystic ovarian syndrome and hormonal disorders like that.

[00:47:17] As of right now, it is not standard of care to be utilizing AMH levels to define menopause. So, I have a lot of patients that come into my clinic at the time of menopause. I get that junction and they're like, “I really just don't want to get pregnant.” And they're like “Can you please just do a test to see if I'm going to be able to get pregnant?” And sometimes if AMH levels can show us that oh, if your AMH is really, really low, then is that really a good sign of whether or not you're going to be able to conceive? Probably not. But I still have the asterisks next to it. Listen, I don't need you back in here in three months saying that I said your AMH was low and now you're pregnant. This is not a line in the sand. 

[00:48:06] So as of right now, we are not utilizing AMH as a menopause indicator. Now, will that change in the future? Maybe, but just generally as a marker of ovarian reserve, yes, we can look at it in that regard, but I don't think anyone is utilizing it as this diagnostic criteria.

[00:48:26] Now as far as having a long-acting reversible contraceptive like a Mirena IUD-- the most popular, there're some other ones out there as well. The simple answer is if you're not bleeding regularly and if you're not having symptoms like hot flashes and night sweats, then the simple answer is you really won't know if you're menopausal until you remove that IUD and then you don't have periods. So, if you remove it around the average age of menopause, which is 51 to 52, then that's how you know. 

[00:48:59] However, this is one of the cases where I actually will entertain more the checking of the hormone levels to give people an idea because-- So, we can check an FSH, which is a follicle stimulating hormone, which is the primary driver from the brain getting your ovary to produce follicles and therefore to produce estrogen. And then I'll check an estrogen level. But here's the caveat, you have to do it more than once. You can't just rely one level. And so, if an FSH level is very, very high, it's an indication that the brain is trying to get a response from the ovary and no one is home. FSH just don't just go high for no reason. They go high because they're not getting a feedback response from the ovary. 

[00:49:43] And then if your estradiol is very, very low, say less than 30 pg/mL, then usually that gives us the picture that there is less ovarian function happening on a daily basis than there is activity there, okay, but again, because this relies on a multiple data set issue, it's not a perfect world. My perfect world would be if Santa Claus brought me a continuous glucose monitor for female reproductive hormones, that's what I want, that's all I want. [Cynthia laughs] So, whoever's in the biotech industry that's listening to this, make me a machine that can register women's hormones through perimenopause. And because we track everything, we're the tracking generation, we love tracking, we love data. And this is one area where there still is somewhat of a void in the tracking world.

[00:50:31] The long story short is we base your diagnosis and your treatment off of your clinical symptoms and sometimes we use labs to guide our clinical decision making, that's the big one. I am of the school of thought where I am not maybe as traditional as some of my colleagues that really toe the party line of do not ever check hormone levels for women's reproductive hormones. I like more of being judicious with hormone checking and knowing when it will be useful and helping to round out that clinical picture and help somebody kind of guide the clinical decision-making process with symptoms. 

Cynthia Thurlow: [00:51:11] Well, I think that's important, you know that open mindedness. I had to laugh. I forget which physician I follow on Instagram, but she plugged in her AMH and her FSH score in ChatGPT was like “You will be in menopause within a year.” And so, [crosstalk] I thought to myself, I was like “What a cool-- now we have all this AI that can help with predictive models.” To reaffirm some of what you said, you need at least two sets of labs. It is not a one and done especially in perimenopause because we know you can get tremendous fluctuation anywhere from 20% to 30% shifts in estrogen throughout the perimenopausal transition.

[00:51:47] I think it's really important to just mention that some providers and it doesn't make this good or bad, like one is good, one is bad. Some providers go based on symptoms, they will start and initiate hormones based on symptoms. Others don't check labs and that's okay, that is a different practice pattern. And so, it's not saying that one is good and one is bad. I like data. That's just my nerdy brain. Because coming out of Cardiology where there's so much data to work with, I think it's helpful to say there are different ways that we can look at this picture. Looking at symptoms, looking at bleeding. I think for a lot of people that got tremendous relief from copper IUDs or other types of IUDs. For them they're like having no symptoms, so they have no idea-- They just like, they don't love the ambiguity and I think they like a more definitive sense of where they are. 

Jackie Piasta: [00:52:34] Sure.

Cynthia Thurlow: [00:52:35] And I think that this can certainly be part of that. Are you of the belief system that-- And there are some experts that say that's why I'm asking. When a woman is in menopause, so looking at FSH, they like to see FSH, “normalize.” Let's say the FSH in menopause is 80. They like to see the FSH in the 20 to 30 range. And so, what I find interesting is when I'm listening or reading to people saying that who are physicians, my first question is to get your FSH to be that low again, you'd have to be getting quite a bit of estrogen. Just intellectually, that is what I was thinking. Are you seeing any emerging science or anyone in the space that's talking about using that as a metric to determine whether or not someone's estrogen levels are within a sufficient range to protect brain bone, etc.?

Jackie Piasta: [00:53:24] Yeah. So, I think this is again another area where we get ourselves into trouble with our little blips and the art of medicine is not necessarily a bad thing because not everybody practices the same. And I don't think we all should. And I think, never mind, I'm going to scratch that. I do think that we should have standard of care and that we should have evidence-based guidelines, but I do think that there is some art within the hormone space and I think there can be more than one truth here or more than one thing can be correct. 

[00:53:52] I know there's a very esteemed gynecologist out there who preaches and likes that and says that hormone therapy is only correct if your patient is regularly bleeding and that the bleeding is an indication of the estrogen levels being in a space that is protective. Do we actually have any firm randomized controlled clinical trials that prove that? I am not aware of any. Does it make sense on paper that if we get somebody back to a menstruating level, that all the health risks start when we're not menstruating and so if we get them menstruating again, it fixes it? Yeah, I think it makes sense logically. But have we been able to have data? No. 

[00:54:31] And so I think that's to your point with the FSH is if we drive back down that hypothalamic feedback mechanism, and now the brain is in a space where it's saying, “Oh, okay, cool, we've got enough estrogen on board, we don't need to be coaxing the ovary to produce estrogen.” Then logically and on paper, that looks really nice to say the pituitary gland is normalizing back to a state, so all must be well. But I think that that oversimplifies the whole hypothalamic-pituitary-ovarian axis, and we don't actually know that that is happening. 

[00:55:12] Also to your point, do we have levels, do we have serum or blood levels where we know that somebody is not going to fracture their hip or somebody's not going to develop plaque in their arteries? I wish we did and I just don't think that we do. There's some people that do speak on this. There're physicians out of the UK, most notably Dr. Louise Newson, Sarah Glynne as some of her colleagues over there, that do a lot of independent research on these sorts of things. They published a great study recently in the Menopause Journal on the variability in absorption on estrogen patches, which I think has gotten a lot of us in this community thinking about whether or not we need to be poo-pooing lab results so much. But I think that the conversation is going there. I don't think that we're there yet, but God help us, I really think that conversation needs to go there because I've never been able to fully wrap my brain around the fact that this is the only endocrine state where we don't check levels and we don't at least utilize them. It's in some fashion as a guide for our clinical practice, we've just completely decided that they're irrelevant and I disagree with that.

[00:56:23] But I do have-- So, when I have a patient in front of me, certainly I do have levels where I like to see my patient’s living. But every lab-- Labs are different, reference ranges. I don't want to just throw out a number because I don't want people chasing obscure numbers, but I do think that we will find in the coming years that there are levels that are required to take hot flashes away. There are levels that are required to preserve-- This is the next forefront of the conversation, is the bone. I think bone will get us there the fastest because currently, right now, hormone replacement therapy is only FDA approved for the prevention of osteoporosis, but we know estrogen can build bone. We just have yet to agree on how much estrogen it takes to get us there and to have commercially available doses for that and so, I think that's the next conversation is. 

[00:57:15] We know this is what it takes to take away hot flashes. This is what it takes to preserve bone. This is what it takes to build bone. Similarly, we don't know, this is what it takes-- This is why hormone therapy is not FDA approved for the primary prevention of cardiovascular disease, because we know it's favorable on cardiovascular outcomes, but we don't know what dose it takes to preserve nitric oxide production in the vasculature so that we keep the arteries nice and open and flexible and pliable. We don't know what it takes to stop the plaque to build up or even if we can stop the atherosclerotic plaque from building up. And then if the atherosclerotic plaque is there, is there a dose of estrogen that can reverse some of that plaque formation? We don't know. We don't have the answers to these questions. 

[00:58:01] I can't even start to think about how many billions of dollars it would take to actually get us the answers of these questions and who's motivated enough to get us there. But this is the problem and the current inter infighting, I think, within the menopause professional community, as do labs, don't do labs, whatever. I am never a proponent of doing unvalidated labs. And so, I think that that's a red flag if you're a person out there trying to receive care and somebody is just trying to nickel and dime you to get unvalidated lab tests done every three months or so. I would just start to question what the motivations there are because you can get good answers from good old LabCorp and Quest not to rip them in any way. 

Cynthia Thurlow: [00:58:44] Yeah, no, and thank you for answering that question in a way that is thought provoking and open minded because that's really-- From my perspective, having taken care of tens of thousands of patients in Cardiology and knowing that's the number one killer of women. A lot of those questions are what I have running through my brain. And I find it innately interesting. Nitric oxygen dioxide is one of these signaling molecules. I did a whole podcast with Nathan Bryan talking about this in particular, but it's something that we don't talk about enough. 

[00:59:15] In fact, I laugh-- When I was an undergrad, I had this really, what I thought was mean A&P teacher, so anatomy and physiology. And her feeling was, if you cannot get through my class with an A or B, then you don't deserve to be in medicine. That was her prevailing philosophy. So, we had to study a lot to do really well. And nitric oxide that I'm dating myself was just kind of discovered in the 1990s. And so that was like her baby. And so, every time I think about nitric oxide, I get a little chuckle thinking about good old Dr. Hart from many years ago. I was like she was really ahead of her time. But in that setting of low estrogen, our nitric oxide kind of plummets. And so, it becomes very important. Also, interestingly enough, it buttresses again those NAD levels in our bodies. And we did a whole podcast on NAD recently as well. 

[00:59:59] Well, Jackie, I always enjoy our conversations, not only for your open mindedness, as I mentioned, but just being receptive to having these nuanced conversations. As listeners are listening to this, it just gives you a sense of what is going on in a clinician's brain understanding like there's existing research that we need. Certainly, for those of us that are looking at labs, being hopeful that at some point we will know definitively this is the level we know that protects bone. Hopefully we'll get to a point. This is a level that's going to plummet vasomotor symptoms. Eventually maybe we'll get to a point we'll be able to say this is what confers cardiovascular disease prevention, protection, because for so many of us, that is the number one killer of women and needs to be studied as such. Please let listeners know how to connect with you? You have a Multistate License, so there are multiple states that you work within, if they'd like to work with you directly or learn more about your work. 

Jackie Piasta: [01:00:54] Sure, sure. So, my practice is Monarch Health. It's physically located in Marietta, Georgia, but I also have state licenses in Florida, Texas and Arkansas. So, if you're in the southern part of the US, I would love to have you and you can look for me there. And then for everyone else or even if you're in those states, I am relatively active on social media through my account @jackiep_gynnp and yeah, that's it.

Cynthia Thurlow: [01:01:21] Awesome. Thank you again for your time. 

Jackie Piasta: [01:01:23] Yeah, thanks for having me. 

Cynthia Thurlow: [01:01:23] If you love this podcast episode, please leave a rating and review. Subscribe and tell a friend. 

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