Ep. 502 Why Ovarian Cancer Is So Hard to Diagnose – Inside the Complex World of Gynecologic Oncology with Rachel Frankenthal

Today, I am honored to connect with Rachel Frankenthal, a board-certified physician assistant with a master's degree in public health, specializing in gynecologic oncology. Rachel is on the staff at UCLA Health, where she treats women with gynecologic cancers and women at high risk for uterine or ovarian cancer due to genetic mutations or a strong family history. 

In our discussion, we unpack GYN oncology, covering the five GYN cancers, why ovarian cancer is the silent killer, and the labs and ultrasounds to help screen for ovarian cancer. We dive into genetics, including BRCA mutations and Lynch syndrome, appropriate genetic counseling, and what Rachel considers when dealing with younger patients still at peak fertility versus older patients. We explore the importance of HRT utilization for cancer previvors, the effects of pelvic radiation, vaginal and sexual health, and what thriving looks like after cancer. Rachel shares her stepwise approach to hot flashes, and we also discuss the importance of lifestyle, bone health, and specific research on the benefits of GLP-1s for women with ovarian and endometrial cancer. 

This conversation is especially relevant as we are in GYN and Ovarian Cancer Awareness Month. I look forward to having Rachel back again, hopefully later this fall, to discuss the use of hormone replacement therapy with GYN oncology survivors.

IN THIS EPISODE, YOU WILL LEARN:

• How the lack of effective screening makes ovarian cancer hard to detect due to 

• How BRCA and Lynch syndrome influence cancer risk and treatment choices

• The benefits of HRT for cancer previvors

• Risks that arise from surgical menopause without sufficient or properly dosed HRT

• Why less than 50% of eligible women actually receive hormone therapy

• How pelvic radiation impacts menopause, vaginal tissue, bladder, and GI health

• The support that is crucial for cancer survivors after pelvic radiation

• Lifestyle factors to improve cancer treatment outcomes  

• Rachel shares her stepwise approach to managing hot flashes 

• What GLP-1 research reveals about reducing ovarian cancer mortality and endometrial cancer risk

Bio: Rachel Frankenthal

Rachel Frankenthal is a board-certified and licensed Physician Associate and Menopause Society Certified Practitioner with a Master's in Public Health. She specializes in gynecologic oncology, treating women with gynecologic cancers as well as women at high risk for uterine or ovarian cancer due to genetic mutations.

Rachel has a special passion for menopause and midlife women's healthcare. She developed the menopause clinic for gynecologic cancer survivors and previvors at UCLA and has played an integral role in developing the GYN cancer survivorship program, where she teaches the weekly yoga and meditation class.

Rachel lectures at UCLA and across the country on the importance of comprehensive menopause care in cancer survivorship and has created a course on hormone therapy for gynecologic cancer survivors through the Heather Hirsch Academy. In addition to being a medical practitioner, Rachel is a certified yoga and Pilates instructor, a prior Broadway performer, and an advocate for integrative, holistic health.

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"If you don’t need your ovaries anymore, get them out and put yourself on HRT."

– Rachel Frankenthal

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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. 

[Everyday Wellness podcast theme]

[00:00:29] Today, I had the honor of connecting with friend and colleague, Rachel Frankenthal. She's a board-certified physician's assistant with a Master's in Public Health. She specializes in gynecologic oncology and treats women with gynecologic cancers, as well as women at high risk for uterine or ovarian cancer due to genetic mutations or a strong family history. 

[00:00:49] She's on staff at UCLA Health. And today, I had the honor of talking to her about what comprises GYN oncology, the five GYN cancers, why ovarian cancer is the silent killer, specific labs and ultrasounds that can be utilized to help screen for ovarian cancers, the impact of genetics including BRCA mutations and Lynch syndrome, as well as appropriate genetic counseling, considerations that she thinks about when she's dealing with younger patients still at peak fertility versus older patients, why HRT utilization is very important for the previvors. 

[00:01:28] The impact of pelvic radiation, especially to vaginal and sexual health, what gaps she sees in survivorship and what thriving looks like after cancer, her stepwise approach to hot flashes, the impact of lifestyle as well as bone health. And last but not least, specific research to GLP-1 utilization with ovarian and endometrial cancers and its impact on mortality. 

[00:01:53] This is a particularly important conversation, especially because this is GYN Awareness Month as well as Ovarian Awareness Month. I will have Rachel back to talk about the utilization of hormone replacement therapy with GYN oncology survivors as well, hopefully later this fall. 

[00:02:14] Rachel, such an honor to have you on the podcast. Thank you for getting up early to join us on Everyday Wellness. 

Rachel Frankenthal: [00:02:20] I'm honored to be here. Thank you for having me. 

Cynthia Thurlow: [00:02:22] Yeah. I haven't really had a guest talk about gynecologic cancers. And I think for the benefits of listeners, giving them some geographic perspective about what organs are we talking about when we're speaking to gynecologic oncology, why is it so important? Because as you and I were discussing before we started recording, I think that breast cancers appropriately get a lot of focus, but there are a great amount of women, and we'll go through the statistics, that are impacted and diagnosed with gynecologic cancers every year. And yet, we don't have as much information. There's less awareness. I'm not sure how many women are even aware of some of these issues that can happen with our ovaries, our uterus, etc.

Rachel Frankenthal: [00:03:12] Yeah, thank you for bringing that up. It's actually GYN Cancer Awareness Month this month. 

Cynthia Thurlow: [00:03:17] Oh, perfect. 

Rachel Frankenthal: [00:03:17] This is perfect. But yeah, there are five gynecologic cancers, uterine cancer or endometrial cancer. So, most of these cancers arise from the lining of the uterus, which is called the endometrium or the endometrial lining. This is the innermost part of the uterus that sheds once a month when women have cycles. And that's where the vast majority of these cancers arise, is in that lining. And so, when that lining gets thickened due to the presence of precancerous or cancerous cells, women tend to have some abnormal, irregular bleeding, spotting, discharge. And that's usually the first sign of these uterine cancers.

[00:03:56] The second is ovarian cancer. And the term “ovarian cancer” is a term that we lump-- It's an umbrella term for fallopian tube, ovarian and primary peritoneal cancer. The peritoneum is like a Saran wrap that coats our organs. Most of these cancers actually arise in the fallopian tubes. And we can talk more about that later. But yeah, that's ovarian cancer. Again, that can arise in the ovary, the fallopian tube or the peritoneum.

[00:04:25] There's cervical cancer. The cervix is the mouth or the opening of the uterus. So, if you're doing a pelvic exam and you're looking into the vagina, it is what you see at the top of the vagina, it is the part of the uterus that dilates when women have vaginal births. Women can develop precancerous cells or cancerous cells anywhere within the uterus, on the uterus, within the endometrial, the cervical canal, the endocervix. So, that's cervical cancer. 

[00:04:51] There's also vaginal cancers. Those are the cancers that are going to arise in the vagina. Okay, so that's the open-- When you think about our structures, we have the vulva. You could have cancers that can arise from the vulva. It could be anywhere on the vulva, the mons, the clitoris, the labia, minora or majora. Those are all of our outer parts. But then, inside is the vagina. And so, cancers can arise anywhere within any of these organs. So, those are our five gynecologic cancers. 

Cynthia Thurlow: [00:05:20] Yeah. I would imagine this is one of many reasons of why having a pelvic exam every year is so important. Because objectively, you have a healthcare practitioner that's examining the vagina, the vulva, looking at the cervix. Obviously, uterine, endometrial and ovarian cancers, I know can be a little more tricky in terms of signs. I think one of the things that stood out to me as I'm dusting off cobwebs from my nurse practitioner program a thousand years ago, the vaginal bleeding, spotting, obviously, especially in menopausal women. 

[00:05:54] In terms of like ovarian cancers, fallopian tube cancers and the peritoneum, are there overt signs or are they very nonspecific, which is probably exacerbating or making it more challenging to actually diagnose them? 

Rachel Frankenthal: [00:06:12] Such an important point, Cynthia. So, ovarian cancer has been called the silent killer. That's because the vast majority of these cancers are diagnosed at late stages, stage III and IV. And that's because the earliest signs and symptoms of ovarian cancer are subtle, are nonspecific and are easy to brush off. There's no screening for ovarian cancer. So, that's why understanding your body and knowing these subtle signs and symptoms are critical for early diagnosis.

[00:06:45] Early diagnosis is so important, because these cancers, when diagnosed at early stages, have such a better prognosis. Like, if you diagnose someone with an ovarian cancer at stage I, they're going to have a 90% or greater prognosis. These early signs and symptoms, again, are subtle and vague. A lot of my patients talk about how they were having some bloating. They were feeling more full or feeling more full more quickly when eating. They may have had some pelvic pressure, they may have had to urinate more frequently, maybe a bit of discomfort with sex. But nothing that was screaming at them and easy for them to-- Again, if you're not really in tune with your body, if you have a million things going on, like so many women do, kind of easy to ignore.

[00:07:31] But it's really important to know your body because these are, again, the earliest signs and symptoms. And if you can pick up on this and go to a clinician, you can start the workup earlier. I do want to say that this is a rare cancer that most of the time, I don't want to scare women, it's not going to be ovarian cancer, especially in midlife when there are so many other things going on in the body that can contribute to these symptoms. But again, it's never wrong to do a pelvic ultrasound. It's never wrong to do a CA-125, which is a blood test for ovarian cancer and just rule it out. Because again, if you're going to pick up on this early, you're going to change the course of that person life. 

Cynthia Thurlow: [00:08:09] Yeah. And I think this is certainly helpful for encouraging women, if they're having persistent symptoms, to not to not think it's just the aging process. I think bloating is the most common symptom. And generally speaking, it could be food sensitivities, it could be underlying gut health issues. But if you're having persistent symptoms that are not getting better, they need to be evaluated. That is like the big picture, is make sure you are having a conversation. 

[00:08:36] A pelvic ultrasound and is pretty straightforward, generally inexpensive. You're not getting a dose of radiation. That's oftentimes what people, they're like, “I don't want to get a CAT scan, I don't want an MRI.” We're not talking about this. It's fairly, fairly, noninvasive. CA-125, let's talk about this, because back in the days when I worked in the ED, we sometimes would be diagnosing patients with oftentimes quite significant cancers, because they were kind of holding off. 

Rachel Frankenthal: [00:09:04] Yeah. 

Cynthia Thurlow: [00:09:04] Having things evaluated-- 

Rachel Frankenthal: [00:09:05] A lot of people get diagnosed, they end up in the ER, because they’re having significant symptoms. 

Cynthia Thurlow: [00:09:10] Yeah. And definitely not the place where you want to get diagnosed. There's nothing worse than someone came with shoulder pain, and you find out they have peau d'orange of their breast, and they have metastatic disease that has metastasized to their bone and that's actually why they've got pathologic fractures. But CA-125, explain to us what this represents and what this marker is utilized for in your environment.

Rachel Frankenthal: [00:09:35] Yeah, great question. This is a blood test. It's an ovarian cancer tumor marker. We used to use the CA-125 and pelvic ultrasounds as screening for our patients who were high risk for ovarian cancer. We don't have anything else. The problem with the CA-125 is that it is a nonspecific lab, meaning that it can be elevated for a multitude of reasons. It picks up on inflammation in the body. 

[00:10:02] In women who are having regular menstrual cycles or who have other inflammatory conditions, like endometriosis, for example, or PCOS or fibroids, or even that just have a virus or an illness, this CA-125 can be elevated. So, it's not a perfect value. It's only elevated about 50% of the time when people actually have ovarian cancer. So, it is a helpful marker when you are doing a workup and trying to get a diagnosis, especially if the CA-125 is very high. The normal range is 0 to 35. If you have someone who's having periods, it's not abnormal for their CA-125 to be in the 40s, even a little higher. But if someone has a CA-125 that's in the hundreds, thousands, that is clearly abnormal. So, it can be helpful, but it's certainly not the best way to diagnose this cancer. It's just part of the picture. 

Cynthia Thurlow: [00:10:58] Yeah, I think that's an important takeaway. There's a lot of genetic markers that are out there. I got questions in the free group which, purely coincidentally, I responded to it knowing that we were going to have a conversation today. For people that have genetic mutations or Lynch syndrome, how do we go about approaching-- Obviously, they're both different, but let's just say for BRCA mutations, can you talk about what they represent and how these make us more or less susceptible to going on to developing disease? 

Rachel Frankenthal: [00:11:32] Absolutely. This is a great question, and something that I was really hoping that we were going to talk about. Because one of the most proactive things that we can do to reduce our risk of cancer is to know our risk. And the only way to really know your inherited risk of cancer, so not lifestyle, how that's impacting our risk, but our genetic risk, is through getting genetic testing. It's very accessible these days. Anyone can essentially obtain genetic testing. 

[00:11:59] The testing reveals if you have a mutation in your cells, in your DNA. We all inherit a copy of our DNA from our mother and father. You can have mutations from either your mother or your father. Some of these mutations like BRCA, like Lynch syndrome, there are others predispose us to developing different cancers. Every mutation has a set of guidelines. So, a lot of people want to learn more about these mutations, our National Comprehensive Cancer Network or the NCCN has a great database of guidelines. You can go to them, you can type in a mutation and you will get a really robust document that goes into great detail on each mutation, the screening recommendations, the risk-reducing recommendations for every single mutation. 

[00:12:47] For example, BRCA, there are many different BRCA mutations. Even within BRCA1 and BRCA2, there are different variants. They're all different, which is why connecting with a genetic counselor and really understanding each mutation is very important, because they're all different and everyone carries its own risk. For example, BRCA mutation carriers are known to have significant increased lifetime risk of breast cancer, ovarian cancer and other cancers as well. But that's just one example. 

Cynthia Thurlow: [00:13:17] And do you feel that if someone is looking to be screened that they should concurrently be working with a genetics counselor? Because I think one of the concerns that I have, and it's not accessed information, it's what do you do with the information after you have it, because I cannot fathom how overwhelming and scary it would be as a patient. They're getting screened properly, but then they don't have the follow-up and the support that they need, because you have to-- In the context of having that information, helping determine what the next steps need to be. Is that more diagnostic testing? Does that proceed to having a surgical evaluation? So, helping people determine what are the next steps? Because again, there would be nothing worse than having the information. It's almost like having a hot potato. It's like, “What do I do with the hot potato? I don't know what to do with it. It's hot. I don't want it in my hands. I need to it move forward-“

Rachel Frankenthal: [00:14:10] Yeah, it’s very [crosstalk]

Cynthia Thurlow: [00:14:10] “-so that I can [crosstalk] develop the plan.” Yeah.

Rachel Frankenthal: [00:14:13] Absolutely. And that's why genetic counselors are an integral part of this conversation, because they are really the experts on these mutations. And exactly as you said, in a very proactive way, it can help a patient understand what the next steps are for them and their family members. Because it impacts not only an individual, but all of their family members as well. 

[00:14:34] For example, you mentioned Lynch syndrome. Let's just take Lynch syndrome. Let's say someone tests positive. Again, there are different Lynch syndrome mutations, so I am generalizing right now. But they are at increased risk of many different GI cancers. So, the genetic counselor would say, “Okay, from a GI standpoint, we would recommend you start upper endoscopies and colonoscopies at, let's say, 30 and have those done every year or two.” 

[00:14:59] “Let's break it down. For ovarian cancer, this is your risk. We would recommend for your mutation having those ovaries and tubes out at this age, because we see with this mutation that the incidence of ovarian cancer starts to rise at this age with this mutation. Let's talk about bladder cancer. Let's talk about this cancer.” 

[00:15:19] So, they're able to really go through and help create, again, a proactive approach to then reducing that inherited risk of cancer. And again, it can be through screenings, like endoscopies, colonoscopies, breast MRIs, mammograms. It could be through risk-reducing surgeries, like removal of the ovaries and tubes, the uterus. Lynch syndrome patients are also at increased risk of uterine cancer. So, for them, we'll do endometrial biopsies if they're having irregular bleeding. 

[00:15:47] Again, it's very detailed, it's very nuanced. But again, every mutation is different. Every mutation comes with its own set of recommendations. And that genetic counselor is going to help organize and synthesize all of that information for you, rather than you just freaking out, which is something I would do. Like, anyone would do if they get that information. 

Cynthia Thurlow: [00:16:05] Yeah, absolutely. I would imagine that the genetic counselors are probably connected to large research institutions where they have knowledgeable, proficient oncology teams that are very doing the actual research. I think on the East Coast, I think most people are thinking about Hopkins and Duke and Sloan Kettering. Obviously, you're on the West Coast. But do you find that most of the genetic counselors are also in these kind of comprehensive cancer centers? 

Rachel Frankenthal: [00:16:35] Yeah. I've only worked at UCLA, which is of course, a large institution cancer center. So, my only experience is working there. And yes, we're very multidisciplinary in approach. We have genetic counselors in our division. We have them in our office during clinic. So, we work really closely with them, and they're really great helping our patients navigate through this process. But I would imagine that genetic counselors, wherever they work, do have relationships with oncology clinics and oncology clinicians so they can help plug these patients in with the appropriate resources. 

Cynthia Thurlow: [00:17:08] What are some of the things that you experience as a clinician, as you're helping women navigate choices? I know that on another podcast, I was listening to you talk about how sometimes even having excellent physicians within an interdisciplinary team, sometimes there's information that may not be conveyed to younger women. So, let's talk about younger women first, especially those that are wanting to preserve fertility, wanting to offer as much as they can if they're hoping to have a family at some point, as opposed to older women who may already be in menopause. What are some of the different considerations based on age range?

Rachel Frankenthal: [00:17:50] Great question. Let's say I have a 30-year-old BRCA mutation carrier who just gets diagnosed with this mutation. She comes in and wants to know, “When should I have my ovaries and tubes out? I want to have a family. I don't have a family yet. How do I navigate all of this?” So, a few things you would say, “Well, one, let's look at your mutation. Your BRCA1 mutation carrier recommendations are to have ideally-- This is an ideal world, your ovaries and tubes out between the ages of 35 and 40, because that's when we start to see the incidence of ovarian cancer rise with BRCA1 mutation carriers.” That's one consideration. 

[00:18:32] Two, your family history. So, every family history is different, and we have to take it into consideration. We want those ovaries and tubes out about 10 years younger than the youngest person who is diagnosed with ovarian cancer. So, let's say that person had a mother who was diagnosed with ovarian cancer at 48. We would say, “Ideally, we would want your ovaries and tubes out by 38.”

[00:18:56] Then, we talk about family planning. “Okay, you want children, let's figure this out.” There are many ways to do this, and everyone's situation is different. But there are ways that we can go about this where we can both preserve fertility and reduce the risk of cancer. So, a lot of these patients, I would recommend seeing are reproductive endocrinology and infertility specialists, because they can preserve eggs. If you have eggs, you have options. Not only is that good from a fertility standpoint, meaning even if a person wanted to remove their ovaries and tubes, they could still then carry a pregnancy. We could put them on hormones, they can then work with our REI team to undergo IVF. But you have to have the eggs and the embryos to do that. So, I think preserving eggs is really good. 

[00:19:36] And those patients can also choose whether or not they want to pass this mutation onto their children. So, another great thing about working with REI is they can do genetic testing on these embryos, on these oocytes, on these eggs, and hand select which eggs and embryos they're going to implant. So, these women can choose to not pass along this mutation, which is a great gift as a mother, to not pass that on to your children. So, I usually recommend seeing REI. We talk about family history. We talk about mutation. And then, we come up with a plan. 

[00:20:08] There's always that option of what we call an opportunistic salpingectomy. Because we know that most of these ovarian cancers arise in the fallopian tubes, young women might say, “Look, I'm not ready to go into surgical menopause for whatever reason, but I want to do something to reduce my risk.” We might say, “Great. Let's talk about removing your fallopian tubes. You can still have a baby. It would require working with REI, IVF.” But there's a lot that we can do to support these women. These are just some examples of some of the factors that come into play with these conversations. 

Cynthia Thurlow: [00:20:42] Yeah. I would imagine that for a younger woman, knowing that they have options is really critically important, because they're probably trying to buffer the susceptibility, or the incidence of potentiality of developing cancerous or cancerous growth with trying to buffer the fact that they would like to be a parent and knowing that reproductive endocrinology can be involved to support them through this process.

[00:21:10] Buffering that with older women, and by older women, they could even be my age. We'll just say middle aged women and older who maybe have already gone into menopause, so their issues are not quite the same as a younger woman. Do you find that some of the middle aged and older women are more likely to have surgical removal of organs that there's either a concern about or the potentiality of their becoming an issue in the future versus younger women who may be dealing with multiple concerns related to earlier than expected surgical menopause? 

Rachel Frankenthal: [00:21:48] Absolutely. It's a totally different conversation. I'm not undermining the importance of these organs. However, if you don't need them anymore, if you're not going to use them for reproduction, then as someone who takes care of women with ovarian cancer every day, I would say get them out if you do not need them and put you on HRT because we do not have screening for this cancer, and it is a very lethal cancer.

[00:22:15] I say that, because I think people need to understand, I'm a hormone therapy specialist. I'm a menopause expert. I love hormones. I know the importance of hormones. And you have to balance that with the risk of the cancer that we are dealing with. And so, if someone is perimenopausal, if someone is menopausal, they've had children, this is not a part of the equation, I would strongly encourage them to consider having these organs removed. It's very different than a breast cancer where we have great screening and we can pick up on these cancers early. That is not what we're dealing with ovarian cancer. It is a different beast. 

[00:22:50] The other thing I will say, is that women who are perimenopausal, who are dealing with perimenopause, sometimes I'm like, “Let's get those ovaries out of there. Get you out of the chaos and put you on a really great regimen that works for you.” Sometimes, that's a blessing for these women, because especially if they have PMDD and they're suffering from these hormonal swings, sometimes it's a blessing in disguise. 

[00:23:11] I actually had a patient in her 40s who was very unwell from PMDD. And I said, “Let's just get those ovaries out of there. I think we'll treat your PMDD, will reduce your inherited risk of ovarian cancer.” And that's what happened. So, it is a very different conversation with our younger patients versus our patients who had children or they're perimenopausal or menopausal. 

Cynthia Thurlow: [00:23:32] It's really interesting. The more I understand about PMDD, those patients are really at much higher risk for an exacerbation in mood disorders as they navigate perimenopause and menopause. I just think there are women who are much more sensitive to the fluctuations in hormones. And in interviewing so many experts, the one thing that has really stood out for me is people that have the severe manifestations, not just PMS, but PMDD, they're miserable a week and a half out of every cycle. They are oftentimes the women that benefit the most from being, and I want to use the word “aggressive,” but being much more proactive about addressing those hormonal fluctuations earlier rather than later. Like, I have watched far too many women navigate perimenopause that are really suffering. There's still this prevalence of providers, who I have to believe are well meaning, who say things like, “Let's just wait until you're fully in menopause.” 

[00:24:30] Any woman that's listening that is not yet in menopause, you do not have to wait until you are 12 months without a menstrual cycle to start hormones. One of the things that I love about your messages and your messaging, is that you are talking about-- I deal with a very specific population of women. And once they are done with treatment, the options about hormone replacement therapy is dealt with very proactively. Do you feel like you spend a good amount of time helping to educate the general public and other clinicians that properly utilizing hormonal replacement therapy in these patients, is not just evidence based but also contributes to significant quality of life improvement? 

Rachel Frankenthal: [00:25:15] Yes, 100%. So, I think we're talking about previvors. You're talking about women at increased risk of cancer due to genetic mutations who do not yet have a cancer diagnosis. For example, let's take BRCA, because this is a very popular mutation that people know about. We're talking about increased risk of breast and ovarian cancer. As we've mentioned, there's no screening for ovarian cancer. So, the best thing these women can do, it is a lifesaving surgery for them to have their ovaries and tubes out. And standard of care, evidence-based medicine, data-driven medicine is giving those patients hormone replacement therapy, following that surgery until at least the average age of menopause, which is 51 in the United States. This is not just a quality-of-life issue. Of course, we're talking about a very different experience of going into menopause surgically versus naturally. So, it's a very different experience for the body and the brain.

[00:26:15] And these women are at significant increased risk of multiple medical conditions because of the early loss of hormones. So, we're talking a two-time lifetime increased risk of cardiovascular disease. We're talking about significant increased risk of osteoporosis, dementia, metabolic dysfunction, sexual health issues, mental health issues and an increased risk in all-cause mortality. 

[00:26:43] So, this is not just a quality-of-life issue. This is a health span and a longevity issue. Less than 50% we have data of these previvors receive any hormone therapy, okay, let alone, and they're only prescribed them for short amount of time. So, we're talking about women who are maybe in their 30s and 40s getting the lowest dose patch which is doing nothing for them for a few months to a few years. It is harming women. 

[00:27:14] And the problem, is that because women are becoming more educated and they're learning more about hormones and they're following people on social media who are giving them data, they are pushing off risk reducing lifesaving surgeries, having their ovaries and tubes removed, because they cannot find someone who will prescribe them their hormones. And that is further exposing these women to their inherited risk of ovarian cancer. And that to me is the biggest problem, is because we're not following evidence-based medicine, we are further, I'm going to say it again, exposing these women to their already increased risk of a cancer that we have no good screening for. 

Cynthia Thurlow: [00:27:54] Yeah, I think these conversations are so important, because you know, that free group that I have on Facebook and there's amazing women in there-- We get heartbreaking questions every single day. Some of which I can't even release in the group, because it's so detailed about their medical history. And I'm like, “I have no ability to shield you unless you identify that you want to be posting anonymously.” 

[00:28:20] And yet, I agree with you wholeheartedly. You and Corinne Menn have definitely helped educate me about how there's this huge disparity of care. I think in some instances, it's the discomfort of the provider that is prevailing over doing what's best for the patient. I think in many instances, if we're really looking at, as you said, the previvors, women that we know are at greater risk for the sequelae of this blunting of hormones for a far longer period of time than me at 54 or other individuals that are at that stage of life, we need to be protective of these women. 

[00:29:00] And so, I'm so grateful that you're utilizing your platform to help educate, not just me but other providers and my community. And so, when we're talking about these previvors versus individuals that have already been diagnosed with cancer, and then looking at the individuals that it runs the gamut from surgical intervention, chemo, radiation, et cetera. 

[00:29:26] When I was preparing for our conversation today, there's a lot about pelvic radiation that I have no clinical experience with, because that was never my area of expertise. Let's at least touch on, when you're counseling your patients, especially for those that need pelvic radiation, what are some of the unique aspects, side effects and sequelae of pelvic radiation that you think are important for people to understand at a deeper level? 

Rachel Frankenthal: [00:29:52] I am so glad you brought this up, because I think that cancer survivors who undergo pelvic radiation are kind of like forgotten survivors. This is an area of cancer therapy that receives little attention, little conversation. There are no standard recommendations right now for vaginal and sexual health following pelvic radiation therapy, which is something that my team, we're actually working on now. 

[00:30:17] I don't want to scare people, but the side effects from pelvic radiation can be very extreme. We'll just for one thing talk about menopause. Women whose ovaries remain in a radiation field, if they are not moved out of the radiation field, they will 100% be put into radiation induced menopause. The ovaries are sensitive organs. They cannot withstand the dose of radiation therapy. So, they'll just die. That's just what happens. 

[00:30:46] The first problem, is that most women don't have a conversation about this prior to these interventions. So, I cannot tell you how many patients I've met who just didn't know that this was going to happen to them. And so, they're dealing with side effects from chemo and radiation in addition to menopause, and they're really suffering, and they don't know what's going on. Like, what are these symptoms? Why am I feeling this way? It's a real disservice to the patients, because they're having menopausal symptoms, they're having symptoms from their treatments all mish-moshing together and they can't make sense of it. So, one is the menopause piece of it. 

[00:31:23] Even if ovaries are transposed, meaning, a surgical intervention where the ovaries are moved out of the radiation field into the abdomen, they're still at increased risk of going through menopause early, because we're dealing with losses of blood flow to ovaries. Anytime there's that happens with a hysterectomy or moving ovaries, that can happen. So, there's menopause and then there's the vaginal and sexual health side effects. 

[00:31:43] So, when you're talking about radiation, we have is a loss of blood flow to the tissue. And what happens is that there's scarring and fibrosis within the tissue. And so, the tissue gets very hypopigmented, it bleeds very easily, and again it scars very easily. And so, what happens is that without proper intervention, what happens is the vagina actually starts to close in on itself and can scar closed. And once that happens-- And this happens very fast. So, radiation changes happen very quickly.

[00:32:20] And within the first few months, first year, the damage has already been done. Obviously, this is going to impact sexual Health as well. What should happen is that patients should be started on vaginal hormones, whether that's estrogen or DHEA. They should be started on these interventions during treatment ideally. They should be starting with vaginal dilation therapy, which is to keep the space open. You want to keep the space open, so it doesn't scar shut. 

[00:32:50] Sexual activity is obviously very healthy, very important, but you do not need to do that to keep the space open. You can use the dilators. Pelvic floor, physical therapy should be-- I think the care package should be vaginal hormones, vaginal dilators, referral to pelvic floor, PT, and a referral to mental health. These are four really important aspects of vaginal and sexual health following radiation therapy. So, those are some side effects. 

[00:33:14] There's also side effects to the bladder and the GI tract. So, women can have, like, cystitis, they can have diarrhea, urgency, long-term, short-term. There's many side effects from pelvic radiation therapy. And again, this is something that is not talked about enough. One of the biggest problems is that we're not educating oncologists. Radiation oncologists, medical oncologists. So, radiation oncologists are the clinicians who are giving radiation therapy. They're not trained in this. They don't know how to prescribe vaginal hormones. They just don't know about it. And so, they're not prescribing it. 

[00:33:48] And so who's prescribing it? No one's communicating about it. And so, what you have are survivors who are undergoing this therapy and ending up sometimes with severe side effects that are, again, very hard to reverse. Once something is scarred shut-- It's not just a sexual health issue, it's a cancer surveillance issue. If we can't properly survey the vagina, the cervix, the pelvis, that's an issue as well. 

Cynthia Thurlow: [00:34:11] I'm sitting here thinking, I would imagine that there are many people who've undergone pelvic radiation with excellent clinicians that were never informed of the things that they needed to do. Hormones, physical therapy, dilators and then mental health. Because I would imagine it's a very sensitive part of your body, if you're suddenly dealing with chronic pain, unrelenting pain. 

[00:34:38] I think I didn't have vaginal deliveries. I had C-sections. But when everything is sore in that part of your body, I cannot imagine. Things that we take for granted, urination, defecation, things that seem so we don't even think about them. They're not even under conscious control, per se. All of a sudden, very simple things that we take for granted become nearly intolerable. 

Rachel Frankenthal: [00:35:02] It's so layered. It's so complex, especially when you're thinking about reproductive organs for women. It's like they're diagnosed with, let's say, cervical, vaginal, vulva, whatever, cancer. And then, they have to contend with, how do I seek pleasure and intimacy in a part of the body that was, again, had cancer? It's very complicated for these patients sometimes. It does require mental health support. 

[00:35:32] I am a yoga instructor. One of the things I offer through our survivorship program is yoga and meditation for our patients. And one of the things that we do a lot of work on is the second chakra. It is the pelvis. It is connecting with that part of the body after all of these therapies, because again, it is so personal, it is so complex. And that's why this multi-disciplinary care is so important following any treatment, I think, for gynecologic cancer. 

Cynthia Thurlow: [00:36:02] Oh, absolutely. I would imagine that the quality of care that you're delivering is both nuanced and unique. And having that perspective of bringing together complementary medicine to traditional allopathic medicine ultimately is leading to better care for your patients. 

[00:36:21] I know that you have developed a survivorship program within your practice. What gaps beyond, what we've already touched on, led you to develop the clinic where they have a survivorship program? And what does thriving look like after a cancer diagnosis? Because I think for many people, when they're in the midst of it, it's very hard to imagine what their lives will be like in the future. 

Rachel Frankenthal: [00:36:45] Yeah. Just to take the second part of the question, I think about this a lot. What does thriving mean after cancer? I think it probably means something different for everyone. I think a person has changed when they are diagnosed with a cancer. And so, I think it's unrealistic to expect to feel exactly the same. I think you're a changed person. 

[00:37:06] I think, however, though that if a person can come out on the other side with good physical health, good mental health, and that would require that supportive care starting at the time of diagnosis, through treatment and after, being able to find meaning in their lives through whatever that is, hobbies, work, being able to have meaningful relationships, those to me are parts of what it means to thrive after cancer. And I think the ability to feel like yourself, but your new self. 

Cynthia Thurlow: [00:37:39] I think that reframe is-- [crosstalk] Yeah, it's funny. I think finding that reframe-- And I have several, unfortunately, far too many girlfriends that have been diagnosed with breast cancer. So, that's the perspective as their friend. Ironically enough, many of them are also advanced practice nurses. I think that from an objective perspective as their friend, the people that have done the best after surgical intervention, treatment, chemotherapy, et cetera, are the ones that find a reframe of their purpose and the way that they want to continue living their lives. 

[00:38:10] I've had friends tell me they feel like the diagnosis of cancer, not at the time of diagnosis, but later they say that it was a gift, because now I appreciate my relationships, my life, so much differently than I did before. Before, I was on autopilot. Now, I'm very present. I'm noticing things. I'm much more engaged. I'm much more selective. I have better boundaries. I think that is certainly very important.

[00:38:34] When you're thinking about your patients and navigating them through this process, I would imagine there are people that during the course of treatment, there may be systemic hormones, may not be appropriate. How do you address hot flashes? This question came up a lot for people that are navigating treatment where, again, not may not be appropriate for systemic hormones. What are some of your ways that you address hot flashes, as an example? 

Rachel Frankenthal: [00:39:02] Sure. For all my patients, I talk about lifestyle because I have seen how lifestyle can improve menopausal symptoms significantly. So, I have patients when we adjust diet and movement and sleep, self-care, stress, those are foundational for all patients. And a lot of these patients will require pharmacology. They will require medicine as well. And thank God, we have them. 

[00:39:28] What I like to do is try to kill multiple birds with one stone. So, if I'm working with a patient that's having multiple menopausal symptoms, I'll try to find one medication at least to start with that will hopefully target multiple symptoms. So, for example, mental health issues are very common in cancer survivors, also very common in menopause. So, if someone's really struggling with anxiety, or depression or both, early morning awakenings associated with mental health issues and hot flashes, night sweats, I likely will start with some form of an SSRI or SNRI.

[00:40:03] If someone is struggling mostly with night sweats, so hot flashes aren't so much of the problem, but it's really those night sweats and maybe difficulty falling asleep or issues with sleep, I may use gabapentin. And of note, sometimes you have to get to higher doses of gabapentin to really target those night sweats and sleep. Sometimes upwards of 800 or 900 milligrams, just FYI. So, that might be a great option for someone. If someone's only struggling, let's say, with hot flashes or night sweats, that's it. Maybe we'll talk about VEOZAH fezolinetant. So, it's very individualized and I try to use as little medication as possible, and again, to try to kill multiple birds with one stone if I can. I also we use supplements and stuff like that as well. 

Cynthia Thurlow: [00:40:47] No, no, I love that approach. I think that for everyone listening, knowing that conscientiousness of personalizing for each patient based on, let's start with lifestyle, add in medication as needed, and then once we get through treatment, then we can discuss replenishing hormones. 

[00:41:08] When you think about lifestyle medicine, I think that-- You've touched on some of the things that are very important to you to discuss with your patients. Where does nutrition fit in for conversations with patients? I would imagine that's very important. Probably as people are going through treatment, there may be aversions, there may be things they are drawn to. 

[00:41:27] Obviously, knowing that our highly processed, hyper palatable nutrition that were food-like substances that we have here in the United States, they're probably not doing us any benefits. But when you're talking to patients about nutrition, what are some of your recommendations, kind of big picture? 

Rachel Frankenthal: [00:41:45] Sure. Well, anyone going through chemo, if they're struggling with nausea, decreased appetite, really what I-- We use medications for that to prevent that to treat nausea. But in terms of nutrition, I really want them to focus on protein, on hydration, healthy fats, foods that are going to sustain them, keep them strong. I try to have them avoid foods that are going to worsen nausea, worsen acid reflux, which are common side effects. So, we try to stay away from acidic foods, spicy foods.

[00:42:17] Smaller meals sometimes are helpful. Eating in smaller amounts throughout the day versus having these big meals. And if patients are really struggling with eating solid foods, I'll encourage bone broth, I'll encourage other broths and protein shakes, because again, I really want them hydrated. I really want them to make sure we're getting calories and good nutrients. 

[00:42:37] That being said, also if patients are really struggling and they're only, let's say, craving a certain kind of food, I'd rather them eat that than nothing. So, there's really no food restrictions. I just want my patients fed and feeling like they're feeding themselves with foods that feel good to them during this process. When it comes to menopause and hormone deficiency, I really focus on anti-inflammatory nutrition, because that's going to be really important for minimizing menopausal symptoms and optimizing their health. And so, we talk about a lot of anti-inflammatory nutrition and trying to hit different macros to support the body as well. 

Cynthia Thurlow: [00:43:15] Yeah, I love that. I would imagine certainly based on what I know, patients who come in and they're already undernourished, very thin, oftentimes do not fare as well as someone with a slightly higher BMI. And so, are some of the conversations that you're having certainly for people who are-- We live in a society where women are taught to be as skinny as possible and to thin as in and all this other nonsense that we're fed through societal pressures.

[00:43:47] I would imagine that your patients that are at a healthier weight generally do better with treatment than individuals who are starting off on the thinner side, you know, more sarcopenic. And yes, you can be thin and not have as much muscle mass. Do you find that that becomes problematic for some patients? 

Rachel Frankenthal: [00:44:06] Yeah. If you're not fed, it's really hard for your body tolerate some of these therapies. And if you're not eating, you're not drinking, you're not taking care of yourself, we start to see different level of toxicity and complications, for sure. And that's when things can start to really go downhill. Sometimes it's the way people come in, but oftentimes it's also just what happens, sadly with cancer and different therapies. But yes, I cannot overemphasize the importance of self-care in the form of feeding ourselves whole foods that are supporting the body and the brain throughout treatment and after. 

Cynthia Thurlow: [00:44:46] Yeah, it's interesting, because that whole concept of failure to thrive. We certainly had cardiology patients that were-- We call them cardiac cachexis. And for listeners, people, they just have very extensive heart disease, they lose their appetite, they stop eating, just puts them at risk for other illnesses, opportunistic infections, frailty, which we definitely want to avoid as much as possible. 

[00:45:10] We know that certainly whether it's surgical menopause at a younger age or biologic menopause, we know that there are changes that go on physiologically that will put us at greater risk for frailty, and we want to be conscientious about this. It's interesting how my perspective has shifted so enormously over the last 5 to 10 years. 

[00:45:31] So, when I'm out, like, I was just running errands in between podcasts, and I was standing in a store and I was looking at this woman who mentioned in front of me, “Oh, I just retired. I'm so excited.” She was so frail. All I could think of was if someone bumped into her, I genuinely would worry she'd fall over and break a bone. And here it is. She's so excited that she's hit this milestone. I'm looking at her thinking, gosh, I hope that she will invest in some weight training and maybe buffering her nutrition, because she's going to make it much harder to navigate the healing journey of moving forward. I would imagine that just gets magnified for your patient population. 

Rachel Frankenthal: [00:46:09] Yeah, absolutely. Especially with radiation therapy, you're going to increase risk of pelvic fractures, early premature menopause, which is why I'm just going to bring up a few points, because it's such an important-- What you're talking about is so important. 

[00:46:23] One, anyone who undergoes premature early menopause should have a bone density scan within a year. I just saw a 32-year-old yesterday with cervical cancer who already has osteoporosis. 

Cynthia Thurlow: [00:46:33] Oh, geez. 

Rachel Frankenthal: [00:46:34] I know. Important because we're bringing this up, the importance of movement and resistance training during chemotherapy. When I came into this work almost a decade ago, I had no experience in oncology, and I just thought, oh, when people are going through chemo, they should rest. It's important that they rest. But what I've learned through experience and through data, is that actually that people who are exercising, moving their bodies throughout treatment do so much better. They have better prognoses, better outcomes, they feel better. 

[00:47:07] But also, of course, when we're talking about menopause and the loss of hormones and radiation therapy, it is even more important that they are being proactive in terms of their bone density. One of the things that I do in my job is chemo teaching. So, all of our patients who get diagnosed, they get diagnosed, they meet with their oncologists and then they'll meet with myself or my partner Jessica, and we do all of the treatment teaching. So, we spend time with patients and families, and we go over therapies and how we can reduce side effects and all those things. 

[00:47:36] One of the things I always talk about is the importance of moving their bodies every single day. Even if they're tired, even if they have neuropathy, even if there's pain, there are ways to move your body every single day. And small amounts are going to go really long ways in terms of how they're feeling throughout the journey of cancer treatment. 

Cynthia Thurlow: [00:47:55] That's amazing. And I think, again, these conversations are so important, because it's bringing greater awareness to this community that these drugs have many applications and it's solely not-- Metabolic health is critically important. I'm not disparaging that. But I think that we will come to find, whether it's autoimmune, whether it's oncology, I think there's a lot of applications. 

[00:48:16] We were seeing improvements in outcomes for cardiovascular disease, post-MI. And so, from my perspective, I think it's really exciting to see that there is more applicability. I don't look at it as a negative thing. I think there's definitely in the great health and wellness space that's out there are people who feel like it's the worst thing that's ever happened, and there are many of us who think it's probably this revolutionary drug class. And so, I am much more in alignment with the latter, as opposed to the former. 

[00:48:47] I think that for people that look at GLP1s as a negative thing, it's a very much a reductionistic perspective. I think we have to think broadly and we have to remember that medicine is both an art and a science. This is the artistry of medicine where we're starting to see areas that we're seeing better benefits and patient outcomes with the utilization of these drugs probably not even at a full-strength dose. They're probably, I hate to use the term, microdose, but personalized dosing, where we're just seeing improvement in outcomes, which I think is really encouraging. 

[00:49:21] Well, I so love this conversation. Thank you so much for your time. Please let listeners know how to connect with you outside of this podcast, how to follow you on Instagram or learn more about your work. 

Rachel Frankenthal: [00:49:31] Thank you so much for having me. Very straightforward. You can find me on Instagram, just @rachelfrankenthal. And survivors who reach out to me know that, I'm very active there. And if you need help finding a clinician in terms of menopause support, I will always find someone for you across the country to help you. So, feel free to reach out anytime. 

[00:49:52] If you're a clinician and you want to learn more about hormone therapy for GYN cancer survivors, I'm on faculty at the Heather Hirsch Academy, so you can take my course on hormone therapy for GYN cancer survivors and previvors. And I think that, yeah, I think Instagram is probably the best way to find me at this point and reach out. 

Cynthia Thurlow: [00:50:10] Awesome. Thank you again for your time. 

Rachel Frankenthal: [00:50:12] Thanks for having me. 

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