Dr. Streicher: Episode Link

Dr. Streicher’s Website

TRANSCRIPTS:

Bridgett: – Welcome back to Hot Flashes and Cold Topics podcast. Today we’ve on Dr. Lauren Streicher. And we’re so excited to have her here. So welcome to the show.

Dr. Streicher:  – Well, thank you so much for having me. I’m excited to be here.

Bridgett: – Well, I’ve really enjoyed listening to your podcast, Dr. Streicher’s Inside Information Podcast. So it’s menopause, midlife, and more. And what I really love is how you are. So matter of fact, and you just get the answers out there, you’re also the author of many, many books and really great books that really go into detail. If you want the answers,

you need to check out her books. So we will have a link to books in our show

notes as well. So thank you so much for coming and, you know, your podcast answers

so many great, direct questions And Colleen and I are both post -menopausal now.

Colleen: – Finally.

Bridgett: – Finally, Colleen was like about to be the record holder.  And that is something I know I’ve listened to your podcast about women when

things are happening. They might be on birth control. They might be on nuva ring.

And they’re concerned that they’ve hit a certain age and they’re like, well, I don’t

know, I don’t know if I’ve stopped having my period for 12 months. And there’s a

lot of things you’ve addressed about the definition of when menopause really happens

and how to tell. Can you talk about the definition and how it should change?

Dr. Streicher:  It’s very tricky to know. Are you pre menopause? Are you perimenopause? Are you post menopause? Are you some other kind of pause? You know, where are you in this whole thing? And then it gets even more confusing because the standard definition is not

helpful. Now keep in mind that the definition of menopause is 12 months without a

period. That definition goes back like a thousand years, truly.

And when you look at today’s modern woman, that doesn’t necessarily mean anything

because we have roughly one third of the population that has had a hysterectomy. And

keep in mind that if you have removal of your uterus that does not mean you are

in menopause, it’s only if you have removal of the ovaries. So you have a huge

number of women who maybe had a hysterectomy when they were in their 30s or 40s

and don’t get a period, but they’re not in menopause. So that 12 month definition

doesn’t mean anything to them. And then you look at the women who, as you

mentioned, maybe using some form of hormonal contraception, such as a vaginal ring,

like a nuva ring or maybe birth control pills or maybe a progesterone IUD that is

also going to stop them from getting a period. But it doesn’t mean that they’re

postmenopausal. And then we have the final category, which is women who have had a

uterine ablation. Women who have very heavy periods sometimes have a surgical

procedure where the lining of the uterus is actually destroyed so that they no

longer bleed, which is a beautiful thing, but it doesn’t mean they’re in menopause

because they’re ovaries, they’re still pumping out estrogen. So my definition of

menopause is a little clearer, and that’s when your ovaries are out of business.

They are no longer making estrogen and they’re never gonna make estrogen again. And

that maybe because they’ve just naturally wound down as their time, or it may be

that they have been moved or it may be a consequence of cancer treatments such as

chemotherapy or radiation. But the point is, is that when we talk about 12 months

without a period, that’s helpful if you’re a woman who’s having regular periods and

then all of a sudden things stop. But it’s not helpful for a lot of other women.

And this also while we’re on the topic, the problem I have for these home menopause

kits, these home menopause kits are truly a waste of money. And let’s just start

with the fact that they don’t tell you up front that if you’ve had a hysterectomy

and that if you don’t get periods, they’re basically useless, because their whole

paradigm is about putting an algorithm into their app, which involves when was your

last period. So there’s a lot of other reasons why they’re useless, but that’s at

the top of the list.

Colleen: – Can we dive a little bit more into the hysterectomy, the first category, because

you’re saying a third of women are getting it. And some are getting their uterus

out and some are getting their uterus and ovaries. And when they have their uterus

and ovaries removed, they’re kind of shot into menopause, correct?

Dr. Streicher: You are exactly correct. And in fact, it is the only circumstance in which you bypass perimenopause.

There is no perimenopause, if you have had removal of your ovaries, you literally go

in one moment from being pre menopause, meaning that you have ovaries that are

functioning and pumping out estrogen to post menopause. Because perimenopause is of

course, when your ovaries are winding down when they’re fluctuating. But if you have

removal of your ovaries, that doesn’t happen. But the hysterectomy thing is actually

quite interesting, because you hear the term total hysterectomy, it’s kind of like

the popular term out there. It’s actually, that’s not a medical term. It’s if you

look total hysterectomy what you’re really talking about is removal of the entire

uterus. If you remove the ovaries, that’s a completely separate procedure and it’s

not automatic, but there is a lot of misconception about that. But when you again,

you talk about that number about one third of women and you think, wow, that sounds

really high. But it also depends where you live in this country. So if you look at

what is the most common cause for hysterectomy, the most common cause is fibroids or

abnormal bleeding. Less than 10 % of hysterectomies are done for either a cancer or

a pre -cancer. So who is the group that is most likely to have bleeding and

fibroids? First of all, it’s women who are in their early 40s because that’s when

the fibroids have grown large enough and then they might already be starting to get

into some perimenopausal abnormal bleeding. And the other group are black women

because black women tend to have fibroids that are larger and that grow more

quickly. So you put together this perfect storm of black women who have fibroids who

are bleeding heavily in their early are predominantly we do see much higher numbers

in the south who end up with a hysterectomy and all too often are not given the

choice about ovary removal. You know, very often their ovaries are just removed and

they’re really not educated about the fact that this is going to put them into

menopause and then they’re not offered hormone therapy. And when we look at the

those that are going to have the greatest benefit from hormone therapy, we know it’s

women that enter menopause young, either below the age of 40 or early 40.

But the number is close to one third of Americans have had removal of their uterus

by age in their 50s. So it’s a huge number of people that either are going to be

confused by the fact that they’re not getting periods and are not in menopause, or

that they actually are in menopause, but we’re not counseled appropriately.

Bridgett:  – Is there, what’s the advantage of removing ovaries? Is there an advantage?

– Dr. Streicher: Prevention of ovarian cancer. – Okay, so are there– – I mean, that’s exactly, that is the advantage. And what we know about ovarian cancer is roughly one out of 60 women are destined to develop ovarian cancer at some point in their life, early detection is

very, very limited. Unlike other gynecologic cancers, we really don’t have good early

detection. You know, you hear about things like doing a CA -125 or ultrasound, but

those have not been shown to really, really be adequate. So what you have is,

in the early stages of ovarian cancer, it’s very often a silent disease. So if

someone is concerned about ovarian cancer, the best way to prevent it, quite frankly,

is to remove the ovaries and the tubes. The feeling is a lot of ovarian cancer

starts in the tubes. And so, certainly it’s kind of a no -brainer for women who are

very, very high -risk. Women that have a genetic mutation, such as a BRCA mutation

or other mutations that are associated with ovarian cancer. The real dilemma is for

the woman who is not at high risk. And to me, it’s very straightforward if somebody

is in their, you know, 30s or 40s and has a hysterectomy unless they have

endometriosis or some other reason that they might consider ovary removal, you know,

you leave the ovaries there, you want to keep your ovaries. And then where it gets

a little bit, you know, a little bit controversial is in that kind of perimenopausal

mid to late 40s, early 50s, is it worth keeping your ovaries? From my point of

view, it also depends on how comfortable you are with hormone therapy. If you’re

someone who says I’m really not thinking I’m gonna go that route, hang on to your

ovaries. But if you’re, say, 60, 65, and you end up with a hysterectomy, your

ovaries are not doing a heck of a lot at that point. So if it was me, I’d be

like, thank you very much, take my ovaries with my uterus. But it’s a discussion is

the point. It shouldn’t be automatic. This is all about making an informed decision.

And you talked about my books, my very, very first book was the essential guide to

hysterectomy. And which is in its second edition, I should really do a third edition

because it sells better than all my other books, quite frankly. And because it is a

very specific guide, and I have one chapter called the ovary decision, I have

another chapter, the cervix decision, I look at hysterectomy is being an a la carte

menu for my old waitressing days, you know, figure out what do you want to keep?

What do you want removed? What are the issues? What are the pros? What are the

cons? This is shared decision making, but you need to have the information to make

that decision. Right.

Colleen:  This is fascinating because we really haven’t touched on the

hysterectomy component that much in our discussions on cause, what questions should

women be prepared to ask their doctor when they go in and they’re considering a

hysterectomy with or without their ovaries being removed?

Dr. Streicher:  I mean, it’s a terrific

question. It’s a long answer because there’s so many issues. You know, certainly you

want to know, are there alternative treatments that you would consider for me? And

then depending on the diagnosis and the why, sometimes there aren’t alternatives, you

know, particularly in the case of someone who has cancer. Very often there are

alternatives, but some women are just sick of the alternatives. They want to be done

with it already. And if you’ve had fibroids and have had six fibroid removals and

all kinds of other procedures, you just say, I’m tired of spending half my life at

home bleeding. So, you know, yes, you talk about alternatives. But once you have

decided, once you’ve decided, yes, I am ready, I’m in, take out my uterus. It’s not

my friends. I don’t want it there anymore, then it’s then there are a lot of

questions to ask in terms of you know, how are you going to do it? Is this going

to be an abdominal procedure, a vaginal procedure, a laparoscopic procedure? Are you

going to remove the cervix? Are you going to remove the ovaries? Are you thinking

what about the tubes? What about while you’re in there? What are you going to be

looking at in terms of other things? And most important, a lot of people ask me

how I got into this whole world of menopause long before it was popular. And it

really was because surgery and minimally invasive surgery and alternatives to

hysterectomy was my major area of interest. And I’m in Chicago Northwestern University

at one time, I was the busiest laparoscopic surgeon, a patient surgeon for

hysterectomies. And what I realized was a lot of my patients ended up in menopause

as a result of the surgery, their choice, you know, women who had opted to have

ovary  removal, but that I really didn’t feel completely equipped to manage that

menopause. So I started to really throw myself into that world more and more so

that I could learn about menopause. But to your point, when you’re talking with a

surgeon and you’re talking about potentially having a hysterectomy, the decision about

what is going to happen during surgery is no less important than what’s gonna happen

after surgery. You know, I was told early on as a surgeon that the most important

part of doing surgery is what comes after, but not what happens in the operating

room. And there’s a lot of truth to that because a lot of women have surgery,

hysterectomy or other surgeries, and they’re sent on their way without really being

hold some of the issues that that they may have. And so that discussion has to

happen. And sometimes you might have a surgeon who’s an excellent surgeon, but it’s

not a menopause expert. We all know that sometimes you got to go looking for that.

And but that’s part of your pre -op due diligence. I think you meet with the

menopause expert before you have your surgery, because it’s also going to impact on

some of the surgical decisions you’re going to make, you know, what you’re going to

do in terms of hormone therapy or non -hormonal options. So I think that’s why my

hysterectomy book does so well because it really addresses all of those issues. And

the reason I wrote it was because I found that my consultations with patients who

were coming to me for recommendations about hysterectomy, my consultations were like

an hour and a half long because there was just so much I needed to tell them. And

then I wrote the book and my receptionist would always laugh because it was a

requirement of having a consultation with me is we would send them the book. We

would say you must read this entire book before your consultation so that when you

see Dr. Streicher, you can have an informed discussion about your choices.

and it was a total game changer. For me and the patients, you could really make

use of our time. So that’s, if someone is out there listening and they’re thinking,

okay, and thinking I might need a hysterectomy, the best thing you can do to

prepare for that visit is to inform yourself. I honestly have no idea what else is

out there because I haven’t been following what’s going on in the hysterectomy world.

My book is still very relevant. However, there are some things about it that are

outdated. Don’t read the section on hormone therapy, I’ve written better stuff since

then. You know, don’t read some of the surgical techniques which have changed. But

as far as the decision tree and what to expect, that’s still pretty current.

Bridgett: Yeah, you know, another thing with that, with the whole thing,

not knowing, like you had a hysterectomy or you’ve had birth control. What is a

good age or what is a time that a woman should decide like, okay, I’ve hit this

point. Should I try hormone therapy now or what’s happening? Is there a certain

time?

Dr. Streicher:  – Yeah, well, so this is the thing. The short answer is whenever you’re having

symptoms. So often women are told you have to suffer for a year or not use the

word suffer. You have to have hot flashes for a year, be without a period for a

year, or, you know, fill in the blank, some kind of random idea of when they

should get treatment. And my approach is, as soon as you’re having bothersome

symptoms, is the time to have the discussion about what are my options?

Is it appropriate to start hormone therapy? Is it more appropriate to maybe do a

low dose birth control pill at this point, it really depends on where someone is in

terms of period menopause, postmenopause. It depends on the specific symptoms that

you’re addressing. You know, it’s very different. Someone who’s having half lashes

versus someone who’s having urinary urgency is an example. So it’s again, it’s a

nuanced discussion, but that discussion should start whenever someone is saying,

you know, I don’t feel good myself. And also to determine is it menopause or is it

midlife? You know, that’s always part of the, the tricky part too is not everything

is menopause and all manner of stuff happens to women in their 40s and 50s.

And sometimes it’s menopause, sometimes it’s midlife and more often than not as both,

which is actually when I named my podcast, that’s why I named it, you know,

menopause, midlife and more, ’cause the more part is sometimes, you know. – Yeah.

– The combination. – It’s right, right.

Colleen: – One last question that I have on the

hysterectomy is you were talking about removing the cervix. And I don’t think a lot

of women understand, number one, why would you decide cervical cancer? Why would you get your cervix removed? And if you do, what happens? –

Dr. Streicher:  You know, it’s such a phenomenal question because most women don’t even know what the cervix does beyond opening up to let a baby out. And when I look at the cervix, what I really look at is what is its role in terms of pelvic support, meaning the cervix and the ligaments associated with it, and it’s very closely related to the bladder and all

of that. But the other thing that is really not addressed, and quite frankly, most

gynecologists and most surgeons are not aware of is that for some women, not all

women, but for some women, the orgasm depends on the presence of the cervix.

I did a podcast episode on has your hysterectomy sabotaged your sex life.

And I really talked about the fact that while most women, absolutely most women,

their orgasm is from clitoral stimulation. and a hysterectomy will in no way impact

on their ability to have an orgasm. However, there are some women that have what we

think of as a vaginal orgasm, it’s actually a cervical orgasm, that stimulation of

the cervix causes an orgasm that’s a different kind of orgasm, but a lot of women

have those orgasms and they enjoy those orgasms and they’re different than their

clitoral orgasm and no one ever told them that they would lose that piece of their

orgasm with a hysterectomy and removal of the cervix. And this issue came up,

it was interesting, it was another podcaster that contacted me and said, “I listened

to your podcast and oh my god, that’s me. I had the best sex ever, I had amazing

orgasms, I had a hysterectomy, I was thrilled to have my hysterectomy because I was,

you know, bleeding constantly and was thrilled to get rid of my uterus. But I was

completely blindsided when I started to have sex again after my hysterectomy and

found that I was no longer to have an orgasm the same way I was before. No one

told me that was a possibility. So it’s not as,

I mean, it’s, I want to be clear. Most women have orgasms from clitoral stimulation

and nothing’s going to happen. But if you are someone, that’s how your orgasm is

going to change. And the only way to prevent that from happening is to keep the

cervix. So again, it’s part of the shared decision making.

In a perfect world, a surgeon would say to a patient, “When you have an orgasm,

Is your orgasm from clitoral stimulation? Or do you also have orgasms from deep

penetration and cervical stimulation? And women who have that know they have that.

And in a perfect world, if a woman were to say, “Oh yeah, I have orgasms from

deep penetration,” and then the surgeon hopefully would say, there is an option for

you to keep your cervix so that you will not lose that ability. Downside to keeping

the cervix, certainly cervical cancer, but we are excellent early detection and not

every woman is at risk for cervical cancer. Surgically, you can’t always do a

laparoscopic or vaginal hysterectomy if you’re going to leave the cervix. It’s a

little bit more limiting in terms of removal of the uterus, so that’s another little

thing. Then the final reason why you might leave the cervix is the problem with

leaving the cervix is you don’t want someone to have any bleeding after their

hysterectomy if there’s any uterine tissue that’s left there and sometimes surgically

it can be tricky to see where the uterus ends and the cervix begins and you know

a good surgeon will be able to figure that out but you know that’s sometimes people

will be very upset that they continue to have a little bit of bleeding after. the

the other advantage to keeping the cervix quite frankly is if you look at risks to

hysterectomy which are low you know in this in the hands of a skilled surgeon the

risks are very low but sometimes there can be a bladder injury or there can be an

injury to the ureter and that’s less likely to happen if you leave the cervix there

because the cervix is so anatomically close to the bladder and the ureters which are

the tubes that lead from the bladder to the kidneys So, you know, again, I mean, I

probably gave you more than you wanted there, but it’s a lot of, you know, it’s

very nuanced. And for people who are trying to make this decision, I think they

should have this information and then be able to figure out what they want to do.

Colleen: – I think, yeah. I think they have that book. – Knowledge of power

Bridgett:  – It is, and we

will have a link to that book and listen to everything that Dr. Stryker said about

it and what chapters to read and what or updated. Another thing,

you talked about orgasm here, and I know that is something that you’ve written books

about, you’ve written sex life. That is a big thing that women,

when they’ve reached menopause and postmenopausal, things change. And you really talk

about, I think that’s the most information I’ve had from yours is about just the

tissue changes and everything that happens there, postmenopausal.

Dr. Streicher: – Well, it is an

area of interest of mine. And when people say what draws me to a particular area

of interest or a topic, it’s usually, well, what’s no one else doing? What’s no one

else paying attention to? And when you look at postmenopause sexual function, the

number one thing that most people are looking at is vaginal and vulgar dryness,

genital urinary syndrome and menopause, which I know you guys have talked about about

nine million times. million times. But people are not talking about the problems with

having an orgasm postmenopause. And difficulty with orgasm is the second most common

sexual dysfunction postmenopause. We’re looking at over 50 % of women, and that number

goes up as women age. And the reason why women have so much difficulty with orgasm

is beyond the hormonal changes, what we’re looking at is neurologic and vascular

changes as a result of not only aging, but other medical problems. And so we are

in a world where there’s a lot of diabetes, there’s a lot of cardiovascular disease,

and all of those things impact on those teeny tiny little blood vessels, and those

teeny tiny little nerve nerve endings. And women just have no idea why suddenly all

the things that they used to do to have an orgasm, whether it’s in a partnered

relationship or self -pleasure, suddenly all that stuff isn’t working anymore. And if

they do get up the courage to go to their doctor or other healthcare clinician to

ask about it, and trust me, most women don’t, but if they do get up the courage,

More often than not, even really, really good doctors don’t know how to help them.

They themselves don’t know. And it’s a lecture that I’m actually asked to give a

lot at medical conferences because doctors do want to know,

but they really haven’t been educated. So it is an area of interest of mine because

the numbers are very high. And there are solutions. At the end of the day, we can

talk and talk and talk, but we need to be solution driven, because it doesn’t do

any good to say to a woman, well, of course, you can’t have an orgasm, you have

diabetes, heart disease, and you’re 60 years old, and you haven’t had a drop of

estrogen near your clitoris in the last 10 years. That’s not helpful. What’s helpful

is to say, how are we going to wake up those clitoral and nerve endings? How are

we going to increase blood flow to your clitoris? How are we going to get things

happening again? Instead of just saying, Oh, Well, you know, accept it.

Colleen: Right. And,

oh, go ahead. I just ask, so if a woman does come to your office and says that

she is struggling with having an orgasm post -menopause, and they don’t want to take

HRT for whatever reason, what are other options that they can do? Well, yeah. I

mean, the first thing you have to do, though, is it’s like everything else, there’s

kind of a stepwise approach. And not only talking about a very detailed history,

when did this start? Is this with every kind of sexual activity? Are you able to

have an orgasm with a vibrator? Are you having pain? We know that a lot of women,

the reason they can’t orgasm, has nothing to do with an unresponsive clitoris. It

has to do with this is your body’s response to pain. That’s always the first step

is are you having pain? Let’s eliminate the pain. What other medical issues are you

having? Are I mean, there’s just so many things that you have to go through before

you even get to what’s going on at the level of the clitoris medications. We’re

looking at almost one out of four women post menopause is not an SSRI SSRIs can

cause women to not have an orgasm. So my approach to that is different than someone

who maybe is a diabetic. So it’s so important. That’s why it’s, you know, we always

talk about it’s not nothing is one size fits all. Part of the job of a good

menopause expert or a good sexual medicine expert is essentially to be a detective,

to figure out, you know, the patient will tell us what the problem is. Our job is

to figure out why. Because until we figure out why, we really can’t help that

person. So, you know, it really depends. And even women who are not interested in

using systemic hormone therapy very often are amenable to using a little estrogen on

their vulva, which is a very different thing. And I always advise women, especially

if they’re having difficulty with orgasm, that if they are using particularly an

estrogen cream, and when they’re putting it inside their vagina, and of course, at

the opening of the vagina, and then don’t forget to go north and put some on your

urethra directly, which will help with a lot of that urgency, and then be sure and

apply it to the clitoris on a regular basis. You know, it’s not gonna help if you

do it 10 minutes before you have sex. This is what we’re talking about is improving

the health of the clitoris. But the other thing is that estrogen is a vasodilator.

It increases blood flow. And that’s one of the reasons why a local estrogen applied

to the clitoris helps. But there are other vasodilators. If you have someone who,

for whatever reason, chooses not to use a local vaginal estrogen, there are other

vasodilators we can use. Now, the question that comes up all the time, of course,

is Sildenafil, Viagra, because at the end of the day, a penis is just a large,

less sensitive clitoris. And if Viagra is going to work to help the penis have

increased blood flow and maintain an erection is Viagra going to work in terms of

helping women who are unable to have an orgasm. And the answer is sometimes.

One group that seems to be really helped with this are the women that are having

difficulty with orgasm specifically because of an SSRI. Now this is not FDA approved

for women. This is an off -label. Off -label does not mean illegal. It just means

that it’s not what the FDA approved it for. But you do have to be working with

someone who’s familiar with dosing and all of that. But are you familiar with the

topical sildenafil that’s in development right now? I think we’re talking about it on

one of your podcasts. That’s what I heard about it. The idea is, okay, well, you

can either take sildenafil by mouth or you can actually apply it directly to the

clitoris. And there is a company right now, the name of the company is Dare DA

area. By the way, I don’t work for any of these companies, I just throw this stuff

out there. But Dare is in the middle of doing clinical trials on a topical

soldentifil, they call it arousal as opposed, ’cause you have to have arousal before

you get orgasm. So it’s increase arousal.

And on one hand, you’re thinking, okay, this is great, this is good, because we

have used this compounded for some time and there does seem to be some improvement

in women who use a topical sildanafil. But don’t get all excited about this because

it turns out that they are only seeking FDA approval for premenopausal women,

premenopausal women. And you’re thinking, well, they’re not the ones having trouble

having an orgasm. So what’s with that? But that’s what they’re doing. and they have

their own reasons for that. But it doesn’t mean that you can’t use it off label in

post -menopausal, once it gets FDA approved, it just means that it’s gonna be an out

-of -pocket expense and it will likely be expensive. So, you know, there’s that. But

the point is, is that I have a long list of things to help women with orgasm.

And so I am, have developed a digital guide to orgasm,

which is called Come Again. And my digital guide to arousal orgasm libido can be

found on Substack. And basically, it’s learning modules that depending on which plan

you go with, you can either do it over a year or you can do it much quicker. But

basically, it’s a combination of my articles and drawings and videos,

which really will take a woman from no orgasm, no arousal, and no libido to

hopefully coming again. Hence the title. Come again. Great title, by the way.

I love it. I love it.

FRIDAY EPISODE

TRANSCRIPT:

Dr. Lauren Streicher: My feeling is, is if a woman comes to me and says I’m thinking about taking testosterone, what should I know? What I tell her is, if the libido is your issue,

there’s about a 50 % chance that it’s going to help you. If you’re looking to other

things, we really don’t have the data to show that it is going to necessarily be

beneficial. There are a lot of women that just say, “I feel better on it. I have

a better sense of well -being. I have more energy.” I can’t argue with that, and I

never would argue with that. I’m just telling people what the science is, and then

you’re grown up, you get to make your own decision. But you need to know how to

do it safely, meaning not pellets, pellets have all kinds of issues,

including an increase in side effects such as hair growth, acne,

male pattern baldness, enlargements of the clitoris, deepening of the voice.

Women are not always told that. We also know that with policy there’s been increased

risks of uterine cancer because of the high doses that are not really evened out.

So there’s a lot of issues. At the last menopause society meeting, there was an

otolaryngologist, you know, your known throat specialist, who was giving a talk

specifically about the impact of testosterone supplementation on the voice. And she

made the comment that even women who are in appropriate dosages of testosterone are

getting lowering of the voice, which for the average woman might not be a huge

deal. But if you’re a professional singer or over or someone who uses your voice a

lot, it is a very big deal. That’s not reversible. So women need to know that.

Again, you know, shared decision making. My job is to tell you everything we know

and what we don’t know. And then you get to decide what you want to do.

Colleen: Along those lines, there has become, there’s this big discussion now on the preventative health benefits of HRT. And I know that the menopause society came out with a statement about a month ago saying there’s no concrete evidence that says there’s

proactive benefits. What, you’ve been doing this a lot longer than a lot of the

doctors out there. What is your opinion right now on this controversy?

Dr. Lauren Streicher:  So this is the thing and this is where it gets muddy because we have a lot of data,

a lot of data that shows a very strong association with hormone therapy and the

impact specifically at the level of, you know, blood vessels and looking at

cardiovascular disease and looking at, you know, when you look at long -term things

that it decreases diabetes and all that. No one’s going to disagree that we have

data that shows those things. The problem is, is that the menopause society,

and they’re very conservative, and they are saying, yes, there is an association with

women that use hormone therapy, tend to have less plaque in their blood vessels.

They tend to have less tau tangles in their brain. You know, we have data that

shows that. But can you then extrapolate that data and say, therefore they’re going

to have less heart disease down the road and be less likely to die from heart

disease and that they’re going to be less likely to get Alzheimer’s. And so the

people who are out there saying, you know, the other side of it, if you will,

says, well, we don’t have those studies and we’re not going to wait for them. So

therefore we should just tell women to use it to prevent this stuff. And the

menopause society is saying, no, no, no, you should take it for what they call

primary prevention, meaning that you’re only taking it to prevent heart disease. And

of course, as someone who’s spent my life straddling both worlds, my approach is I

think you need to understand that if you are, as an example at risk for

cardiovascular disease, obviously you need to do every other thing in terms of

healthy diet, healthy, you’re maintaining a healthy weight, eliminating alcohol, you

know, the long list of things for cardiovascular health. And then to say, and if

you have hot flashes, bone issues, which we know hormone therapy is going to help

long term, then by all means, it’s also going to potentially protect you from having

heart disease. The hard question is, is the woman who comes in and says, I have no

hot flashes, my bones are amazing. I feel terrific,

but everyone in my family dropped dead of cardiovascular disease in their fifties.

Should I take hormone therapy? And what I would say to that woman is we have data

to suggest that it is going to be healthy for your heart and for your vessels and

all of this. Right now, it is not FDA approved for that purpose. However, I am

telling you what the data is, and When you decide, you know, again, it’s the same

message, but it’s framed a little differently. And at the menopause society meeting,

I was doing a panel discussion on hormone therapy with, it was me and like four

other people and they were, you know, and then you can picture it, it’s just in

the ballroom, there’s a thousand doctors and there are more and we’re having this

discussion and we were doing Q &A from the audience and someone said, is it okay to

prescribe it just for cardiovascular disease and Dr. Faubian, who’s a friend, and I

adore her, and she’s sitting next to me and says, “Absolutely not.” And I’m like,

“Oh, come on, Stephanie, “let’s talk about this.” We know that we have Rebecca

Thurston’s data, which is amazing, that shows that there is this dramatic, dramatic

decrease in cardiovascular markers and vascular changes in women who are taking

and, you know, strictly speaking, should we be using it for primary prevention? No,

but I think we can certainly tell our patients that there’s a case to be made. So,

you know, I don’t know. Is that a confusing message to give?

Bridgett: I don’t think so.

Dr. Streicher: I think it’s really just, again, you know, my mantra isn’t on every single web and everything I’ve ever done, it says, you know, give women good information and they

can make good choices for themselves. And To say, you know, that’s what the

story is. That’s where we are, you know, and I think Are we going to

have that kind of what they call longitudinal data where you take? 10 ,000 women and

give half of them hormone therapy and the other half you don’t And then look and

see where they are 20 years later. It’s not gonna happen. It’s too expensive It’s

gonna take too long and even when we look at, I don’t know if you’re familiar with

the SWAN study, the SWAN data, which is, that’s where we get most of this data

from that talks about these associations. But that’s observational, meaning they’re not

manipulating these women, they’re not putting half of them on hormones and half of

them not, they’re just looking to see what happens to people who are taking hormones

and not. It’s great data, but it’s different kind of data. And you know, people

always talk about the WHI being a bad study. The WHI was an outstanding study.

It was a beautifully designed study. It just asked the wrong question. The question

it asked was, what happens if you give women over the age of 60 an oral estrogen

and a synthetic progesterone? They had answered that question real well, but it

didn’t answer the question of, you know, the way we treat hormone therapy, you know,

the way we, it did not answer the question of the way we prescribe hormone therapy

now in terms of starting at younger and using different progestogens that are safer

and giving a lot of different options. So, you know, it’s confusing to women because

it’s confusing. It is. Right.

Colleen:  And I would even say, because Bridgett, I was telling

Bridgett, I had gone to the doctor’s recently, I’m not on HRT, Bridgett is. And I

had gone to the doctor recently because I’m osteopenic. And my fall risk wasn’t high

enough to do like Evenity or the other bone density shots. So I had two doctors

in the room. One was semi -retired, brilliant man. One was a young resident who was

doing her rounds with him. And he was like, why don’t you start on HRT? I don’t

have any other symptoms that were worse. And she’s like, no, why don’t we wait and

see? And they were going back and forth and I’m like, hello, I’m the patient, could

someone ask me?

Dr. Streicher: – I mean, so to me, that’s very straightforward. The data is very

clear that if you’re trying to prevent the progression from osteopenia to

osteoporosis, then estrogen will do that. That’s not controversial.

We know that it will do it. And certainly, you want to do all the other things

you already know about, vitamin D and exercise and all that. But the piece of it

that they don’t tell you sometimes is that you have to stay on it forever.

Because this is the thing, if you take, if you have osteopenia and if you are

prescribed estrogen to prevent progression of osteopenia,

it will do that. And then if five years, 10 years, 15 years later, whenever you go

off, you will lose whatever bone that you have maintained. You will immediately start

to lose bone very, very fast. So That’s again, it’s a, you know, you have to give

people good information

Colleen: they didn’t say that at all.

Dr. Streicher: No, but you need to

know that you need to know that that if you’re going to do it, you are really

making a commitment. And, uh, which again,

you know, it’s not that it’s a bad thing. You just need to know that that if you

go off your hormone therapy, you’re going to lose bone. Wow. That’s so we would

have, they – I never heard that one. – I just went for a Evenity or a Poliear or

something. And they were like, no, you’re not a high enough fall risk. And I’m

like, well, can I get it so that I don’t become a high enough fall risk? And they

were like, no, it was just interesting ’cause it was a young person and an older

doctor and it was watching them have this discussion.

Bridgett:  – Yeah, it was surprising when

she got back home.

Colleen: – Yeah, I was still confused. I was like, I still don’t know

what I should be doing because he was like, well, you’re hot flashes. I don’t have

hot flashes anymore. I did but it’s just it’s interesting how this conversation

because we’ve said it before we we’ve talked about the controversy with several

doctors and sometimes it comes back to bite us in the butt because they other

people get mad at us but you know it’s we feel like tell women the information and

let them make the decision. We are smart.

Dr. Streicher: Absolutely. And Women are smart. I won’t

get into politics now where women are not treated like they’re very smart. You can

get out, but the truth is women are smart. And they’re smart when it comes to

their own bodies, but they need to be given the right information. And one of the

reasons why my books and my podcasts have done so well, quite frankly, is that it’s

high level. I don’t dumb it down. And I found out that about 30 % of my listeners

are healthcare clinicians, doctors and nurse practitioners who tell me that you are

my only source for menopause education. And you will see,

you know, if you listen to my podcast, yeah, I explain the language, I try and

keep it in understandable language, but it’s high level. I mean, when I talk about

my podcast about, you know, orgasm and orgasmic dysfunction, you are going to know

by the end of that podcast, more than about 99 % of doctors out there. And, and I

think that that’s important. And when I wrote my my first book, my hysterectomy

book, and one of the things that I got into with the editor is, they want you to

write a book that is going to be accessible and understandable by the general

population. Well, the medical literacy of the general population is right now between

third and fifth grade level. That’s a problem. And that’s why when you read so much

stuff, you’re thinking, what? It’s like they’re saying, “Hi, you have a uterus “and

your uterus bleeds once a month “and this is called the period.” And you’re

thinking, “This is not the level of information I’m looking for.” But that’s where

it’s coming from because they want this to be accessible to everybody. And I told

the editor, I said, I’m not interested in writing that book. My book is not gonna

be for everyone. My book is going to be for New York Times, not USA Today. And

for the person who is looking for more information. And we went back and forth and

back and forth and back and forth and I finally basically won. And the book has

done very, very well as have my podcasts and all that and everything else I’ve

written. I will tell you that a digital guide to orgasm on sub -stack,

I fully anticipate that I’m going to have as many healthcare clinicians doing that

program as women because it is very high level.

I mean, I basically have one entire section on the neurology of the clitoris

you know those little clitoral nerves stop feeling what’s going on and and why

vibration works better than soft touch and all that kind of stuff and and my

attitude is always if this is deeper than people want or it’s too much okay they’ll

skip over that yeah there’s they’ll skip around they’ll read what is

important to them or what they want to know but you know that’s the thing is

is women want they’re angry that they’re not getting good information that

they go to their doctor and their symptoms are dismissed or they’re not really given

their options. And on one hand, it’s great if you go to a doctor and you said,

I’m interested in hormone therapy, and he or she writes a prescription. But do they,

you know, but then they don’t give you any choices. They know one thing, you know,

they have their thing, and they write that prescription, instead of sitting down and

having a nuanced conversation with you about this is the difference between an oral

and a transdermal. And these are your different options to protect the lining of

your uterus. Does this stuff take time? Yeah, it does. And that’s why people really

need to see a menopause expert, which is frustrating because we know that women,

even if they like their doctor, their doctor may not be a menopause expert. If you

live in LA, Chicago, or New York, you probably can find someone and hope that

they’re not concierge and don’t have a six month wait list. But if you’re out there

in the rest of the world, you’re kind of stuck, you’re really stuck. You know, I

work with MIDI, I don’t, did you know that? I’m the medical director of, I do all

their education work. We do, you know, well, obviously I’m with them. And what

people don’t understand about MIDI is that it’s not telehealth in terms of selling

drugs, it’s healthcare, it’s no different than going to a doctor’s office, except you

do it from your kitchen and you’re not getting an exam, but you are meeting with a

very, very well -informed educated menopause expert who will sit there and go through

all the kinds of things that we’ve been talking about so that you can make an

informed decision and they are covered by insurance, you know, this isn’t Concierge’s

medicine. So I think that’s the kind of thing that’s really critically important in

terms of women getting the information we needed because we’ve spent really this

whole time talking about the fact that it can be confusing, that women are given

mixed messages. How are they supposed to know who’s right, who’s not right?

And at the end of the day, how are they supposed to make a decision about what

they want to do for themselves? And it really comes down to having someone guide

you along the way. Because it’s unfair, it’s unfair to expect women to figure this

out on their own. You know, it took me 30 years of practice, four years of medical

school, four years of residency, and you know, really the last 15 years of doing

very high -level menopause care to be able to sit down and really guide someone

through all of their options and their best decision. You know, a woman’s not going

to be able to figure that out from going to Dr. Google or tTikTol, right? What do

they want to? I’m not saying that they get stuck. They get stuck. But that’s again,

you know, when people say, why do you do the stuff you do? That’s why I do it.

You know, all my books are like that. And this new digital program is going to be,

it’s going to be fun. I mean, it’s not going to be boring. It’s, you know, it’s

going to be fun. You’re not boring. I mean, I promise you, it will not be boring.

It will not be boring. One of the advantages of doing this as opposed to writing a

book is when I’m writing another big book right now that is going to be published

probably in about a year and a half, two years. And, you know, I have an editor.

They, they tell you, you know, they take out what I consider to be the fun stuff

or the funny stuff. And they’re like, Oh, no, no, no, no, you can’t say that. But

when it’s my own thing, when it’s my own digital guide that I do all the writing,

there’s no one who’s shaking their finger at me and saying, No, you can’t do that.

So I can do it everyone. So it’ll be fun. Oh, that’s what I like. That’s what I

like.

Bridgett: One of the reasons I love your podcast so much is the way you say, I’ll

never forget the one with the vestibule talking about the the

Dr. Lauren Streicher: Oh, it doesn’t matter

how nice the room is if you can’t get through the door. I love that.

Yeah. But you know, but that’s, but look, this stuff doesn’t need to be boring. It’s actually

pretty interesting. It’s just, it’s, it’s about how you frame it. And I did not

start off going to medical, wanting to go to medical school. I was an English major

and dance, but I was English and dance, I was going to be a writer. I thought I

would be a journalist. I applied to medical school for reasons that are unimportant.

I didn’t think I would get in and then I did. I always intended to be a writer,

to be a journalist. And that’s what I have fun doing. So that’s been the fun of

my podcasts and of this new project that I’m doing is I get to be me instead of

someone’s version of what they want me to be, so it’s kind of fun. And I’m also,

I’m going to have a lot of, in this digital guide to orgasm and menopause,

I’m going to have all kinds of town halls and panel discussions and excerpts. So

it’s not just going to be written stuff, there’s going to be videos, there’s going

to be discussions, and there’s also going to be the opportunity for people to sign

up for Zoom question and answer so they can really interact with me. And that’s

actually one of the things that I love my doing my podcast, one of the things

that’s frustrating is no one talks to me. I’m there alone in my room, you know.

Bridgett: – We get to talk to each other, but yeah.

Dr. Lauren Streicher: – I don’t even have that, I’m the only

host. I would have, you know, co -host might have been nice, but I like to do live

talks. That’s what I’ve always liked. And of course, COVID took care of that.

Tonight I’m doing a talk for a group of women. I think they told me they were

gonna be about hundred women there and in the room, which is fun. That’s what I

like to do, you know, and get live questions and see what’s on someone’s face when

you say something and get an interaction. It’s very different than doing the

podcasts. I’m not in my closet right now, but my home was under renovation for a

while. So I was podcasting in my closet for about six months, and I thought I was

going to tear my hair out.

Bridgett:  We’re in closets right now. That’s where the sound is

good.

Colleen;  Yeah, exactly. You got to do what you got to do though. So it’s not

depressing, the no window thing, you know. Yeah. Well, that’s why we’re only in here

to tape. Yeah, that’s it.

  Yeah. So this program will be on Substack,

your own personal Substack.

Dt. Lauren Streicher: Correct. And it’s basically on Substack. A lot of people

aren’t familiar with Substack. Substack started off really as a writer’s platform. But

it has really expanded So that people do videos and writing and it is a free

platform and meaning anyone can go to substack .com and start to look around and see

what’s there and there’s terrific terrific writers and a lot of names that you

already know are already they’re doing substack. Kelly Casperson has a sub stack a

lot of people do. And, and then usually for most of them, there’s a free portion

and then a subscription portion. And that will be the case with mine as well, is

that I will have a free portion where there’ll be a ridiculous amount of content

because I have a lot of content and I’m gonna be doing a lot of new content. And

then there will be the paid subscription which is really going to be a much higher

level, all kinds of things available. And then more of Zoom,

Q and A’s and stuff like that, but Substack is terrific and you can certainly go

there for free and look around and on my Substack, there will be plenty of free

material.

Bridgett: That’s great. Yes. Thank you so much.

Colleen: . No, I was just going to say thank you so much for coming on and

please do a re -write number three of the Hysterectomy book because I think that

would be really, really helpful.

Dr. Lauren Streicher: Oh, so I’ll put that on my list of projects.

Exactly. Just put it down, you know, maybe number 300 or something. Yeah, yeah. But

that was fantastic.

Colleen: Thank you so much. We really appreciate you taking the time to

come here today.

Dr. Lauren Streicher: Well, thank you for having me.