Perimenopause is typically attributed to the hallmark symptoms—hot flashes and irregular bleeding. But that represents only a fraction of the clinical picture. The reality encompasses a range of symptoms that often emerge gradually and go unrecognized as perimenopausal.

Dr. Amy Jean Voedisch is a gynecologist whose clinical approach mirrors mine. We practice evidence-based medicine through extended patient visits that allow for precision diagnosis and individualized treatment plans.

Sleep is one of the foundational pillars Amy emphasizes. It's become central to her practice, and addressing sleep disturbance often requires specialty consultation with a sleep medicine specialist.

We also discuss hormone therapy. While it can be an effective therapeutic tool, it's not a panacea and won't serve as a singular solution for all perimenopausal symptoms. This conversation is about what real perimenopause treatment looks like.

Episode Highlights

• The same symptoms may react different to treatment in each patient.
• Menopause education could have a larger role in medical school training.
• Birth control might be part of a patient's treatment plan, not just contraception.
• Reframing expectations about your body and grieving what you had before.
• The role of life circumstances and stress colliding with perimenopause.
• Understanding responsive desire in relationships.

If you're in your 40s and something feels off, this episode is for you. Perimenopause is something you just have to tolerate and there are doctors who care and want to help. Make sure to subscribe so you don't miss future conversations about what real women's health care looks like.

Get in Touch with Dr. Voedisch:

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Hey y'all, it's me, Dr. Smeena Ramon Gyno Girl. Welcome back to another edition of Gyno Girl Presents Sex Drugs and Hormones. I'm Dr. Smeena Ramon. Today I I'm a sex med gynecologist and menopause expert in downtown Chicago. today I'm super excited. This has been like nine months in the making. I've got my amazing colleague and friend

Perfect.

Yeah.

Dr. Amy Vodish Voodish right sorry vodish okay my my amazing colleague and friend Dr. Amy Vodish she is a Stanford gynecologist menopause expert co-host of the popular cop podcast Overreactive overreactive overreactive yeah it's a sound toaster and co-authoring an upcoming book called Estrogen Interrupted we're gonna dive into stages one of the most misunderstood stages in women's health and life

Votish. Votish. Yep.

I know, it's a it's a tongue twister.

And that's perimenopause. And we're gonna talk about why why it seems like our bodies have suddenly just left the chat and trying to figure out what to go from there. why why so many people are told they're too young for hormonal changes, what evidence based medicine should look like and really hormone symptom management management in this period and all the good things. So thank you, Amy, for joining me today.

Well, thank you so much for having me. This is so exciting. I just love I love talking about I'll talk about anything having to do with perimenopause and menopause till the cows come home. So this is like my most fun morning ever. Thank you.

Yeah, so

Yes. Agreed. Agreed. I love it. okay. So I'm Gyno Girl. I love a good backstory. So tell me tell me what your backstory is. What brought you into women's health? Those you end and then like you know, la how did you how'd you land into this space? 'Cause you know, it's not there's not a track to get into perimenopause in health yet. But but you know this is all something we do independently because we want to learn something we were never taught. So

Yeah, yet I know, right?

That exactly. I mean, we really are self self taught apprentices. I mean, you know, that's exactly that's exactly right. If you're not lucky enough to have a mentor in your current practice setting, you have to go find it. This is not something that is handed there's no sort of set pathway to get to where we are. So I wanna

Yeah. Yeah.

Yeah.

I mean, what did you learn when in your training? I always ask people like, Do you do you remember what you like, was there a s lecture? Was there a person?

We had maybe a lecture or two every other year. So we had a four year residency program and then the curriculum sort of followed like a one to two. I was I went to so I went to medical school at the Mayo Clinic in the middle of nowhere, Minnesota. And I'm from Minnesota, so I'm, you know, I'm very proud of my state. And then I went out to I went out to California and I did residency at Kaiser Santa Clara, which is a community-based program and

Where were you at?

Okay. Yeah, okay. Yeah.

Incredible training in just sort of like the bread and butter of OBGYN. It was great. My clinical training is so strong. But just like most OBGYN programs, there was very little on menopause. And we had one attending, Dr. Catherine Brubaker, who has since retired and is enjoying her fabulous life, who was really passionate about it. And she would give these lectures. And she kind of came every other year. So maybe total out of four years of residency, I had about

Yeah, yeah.

Yeah.

four hours of someone talking about menopause and perimenopause. But our lecture time, I'm I know at least two of those hours. I was post-call, which meant I had been up all night. And then I was sitting during the lectures and I literally you just you just want to die because you're so tired. So probably I personally had about two hours of actual listening and paying attention to anything dealing with menopause. And mostly we just talked about the WHI study because this was in the early two thousands.

Yeah, that's sure.

Yeah, yeah.

Yeah, yes.

And how, you know, the information that we had at the time was at that point, like hormone replacement therapy wasn't considered safe, really. So that was sort of the messaging that you got, right? You were like, well, I just gotta tough it out. I don't know what to tell ya. and then so then I went on and I did a complex family planning fellowship at Stanford. So I became an expert in abortion and contraception. And

Mm, mm, right. Yeah, yeah. Yeah, yeah, yeah, yeah.

You're kind of like, well, how did that lead you to perimenopause and menopause? And there's a beautiful, there's just like a really beautiful transition because with complex family planning, we're talking about contraception, we're talking about preventing unplanned pregnancies in in patients either because they don't it's not a good time for them to be pregnant or because maybe they have pretty complex medical problems and really shouldn't get pregnant. And then so I had all these patients and then they were getting older.

Yeah.

Yeah.

And they needed contraception, but then they were having all these perimenopausal symptoms. And it's like this perfect blend of you still have to meet their contraceptive need and treat what's happening with their perimenopause, which is kind of a weird, it's like a kind of a weird time because they're not thinking about getting pregnant, but they need to be thinking about that. That's actually still a real issue. But they're much more concerned. Right. Yeah, you're like, I don't want to get, I'm 48.

Yes.

Yeah, yeah, yeah.

Yeah. Try how how did that get pregnant? Yeah.

I don't want to get pregnant, but I'm not, it's not on my radar. I'm like, well, it's still on your ovaries radars. So they're still thinking about it. yeah, so it's just kind of an interesting. so those became my favorite patients because I got to talk about, got to use my complex family planning brain, but then I became really interested in the puzzle of perimenopause and menopause, and how do we help people? Because so many people come into your office. You and I were talking offline beforehand, and this practice sort of generates itself, and you're going,

Yeah. Yeah exact. You need to think we need to think

I don't know. These people come to see you and you're like, I don't know what to tell you. And then you realize, okay, I gotta dig deep. Like I gotta figure this out because this is so unsatisfying for everybody. We don't we didn't become doctors to be like, I don't know. Yeah. You know, you like want to meet their needs and you want patients to feel better. and I didn't have the skill set to do that. Not for lack of trying by, you know, poor Dr. Brewbaker, who was doing her best with the two hours she was allotted, you know, every two years, but that wasn't enough to to make it happen. So I had to

Yeah.

I have to do

Yeah, yeah.

Teach myself, basically. Yeah.

Exactly. Because I mean, obviously we we like to practice evidence based medicine, but that does include your own clinical that includes not only the, you know, the clinical guidelines and data and and whatever, but also your own expert like your own clin clinical experiences and expertise, which you can't get until you start seeing the patients, but you get you it's like this this weird like roundabout thing, like, okay, I can't be I can't do that treat I can't really do evidence based medicine because I don't have any experience, but I'm gonna try to move toward that.

Mm-hmm.

And then you get enough experience and you're like, I'm doing evidence case with

Yeah, exactly. And it's interesting because there are there are guidelines and things that can help you. But until you s until you start seeing patients, that's the art. We always talk about the art of medicine. I I liken this a lot to like a potions class where you have to take a little tincture of this and a tincture of that. And and and the the ingredients that you use and the recipe you come up with is so different depending on the patient that's sitting in front of you. it's not there's not like a black and white algorithm of like,

Yeah, yeah, yeah, yeah.

Yeah.

Yeah.

every person needs X, Y, and Z and then they're gonna feel better. You know.

Right. Right. yeah, and people always ask me, like, why do I have an algorithm? And I'm like, listen, there are guidelines, but like an algorithm is great for like an urgent care where you have to go fast, right? You have to you have to know what to do in a code. You need an algorithm for that. But when you're talking about someone's life functions, you know, preventative medicine, all the things that it's really precision based. It has to be nuanced and it has to be based on that person in front of you, what their social determinants of health are, what all the other factors.

Yep, exactly.

Absolutely.

their family history, what where they want to go with this. Like you have to meet them where they are too. Like we're not paternalistic people trying practicing paternalistic medicine. So

Right. And it's always hard because sometimes patients will say, like, what do you think I should do? You know, because they want someone to sort of tell them. And I'm like, I can't tell you what to do. I can I have to sort of help you along your path and your journey and really take a step back from that paternalistic way we used to think about medicine where we're like, Well, this is what's best for you and this is what you should do. You know? and I think sometimes they're used to being treated that way instead of being like, No, this is a shared decision making.

Okay.

Yeah.

Yes, yes, yes.

conversation. Like you're an equal partner in what we're gonna do. I'm not gonna do anything that's unsafe, but within the safety confines, like we've got to just figure out what's gonna work for you. Yeah.

Yes.

We we Yeah. Yeah. No, I definitely do that and I always when I talk to patients sometimes, you know, you have to put yourself in their shoes sometimes and and that I think is part of being like a reflect like it's it actually like helps to reduce your bias and your implicit bias against the people in front of you because reflexivity in medicine is something that we should all be doing and and you can't do that in a ten minute visit and you know, forty patients a day. But you know, like I was telling you I I now have a concierge practice and I talk to my patients and I'm like

no.

Okay, so you're our CEO of this. You take, you know, you have to take this transportation to get there. And then after there, you have to do this. Okay. In my mind, physical therapy is on like on the boundary of your list, but I want you to have it. So let's see how we can make this happen, you know? And so really it's it's it's taking that step to show see how you show up for your patient, just as much as what part of you shows up for them.

Exactly.

absolutely. And that's where the benefit of time comes in, right? Like you said, you have this concierge practice, so you have the ability to spend time with them to dig into their lives and figure out what are the barriers, you know, that are preventing them from accessing the care that we think that they need or that they deserve. And and like you can't get that in a 10 minute visit. Like I I just I can't practice in that kind of model where they're like, well, you have 10 minutes for a prenatal and 15 minutes for a GYN.

Mm-hmm.

you know, visit and you're just like, I what am I gonna talk about in that time? I'm barely getting past, you know, tell me what brings you in the door, you know? Yeah.

Yeah, yeah, exactly. What I think, you know, Amy, what I've been thinking about a lot and I did a podcast yesterday with Dr. Ami But I don't know if you know her, she's at Harvard and she's a cardiologist. She's amazing. She and I like 'cause I I have done a lot of deep research and sort of understanding of what happens in the AI world and how you know, how destructive it might be, but how helpful it could be. And she she was like, you know, we have to think of it as like co intelligence and stuff like that. And I had really like

cool.

Mm-hmm.

interesting.

an enlightening, you know, discussion with her about it. And I get it because I and I was telling her some examples in my own office where I see patients who either like culturally or neurodivergently or other for a one reason or another, like our cultural health capital is based on our best ability to communicate with our physician in front of us, right? Like whoever has the highest cultural health capital, meaning they're not their body language is open enough for to receive a discussion.

Mm-hmm, mm-hmm.

their ability to communicate words and and and and and no proper anatomical terms and all the things helps us better to get the answers. And so we were talking about how AI is like an adjunct, especially for those people who can't communicate their best because one reason or another, you know? And and that's where I've seen people succeed with it. That's where I've seen people succeed with it. I think it's not a replacement by any means, but like as an adjunct to give people the words.

Mm-hmm.

No.

I agree. I mean, it's interesting. So my husband is an AI guru, so it's and I'm live in Silicon Valley, right? So I have a lot of thoughts and conflicted thoughts about it. and so we have some interesting, and then I have a 14-year-old daughter and a 10-year-old daughter. And so the 14-year-old daughter's a and a seven right. So we have similar similar ages, but that's AI is coming up in their how do you use it in school and how don't you use it in school? And

yes, yeah.

Me too. Me too.

I'm a fourteen year old and a seven year old. We're very close. Yeah. Yeah. my God. my God. Yeah.

And I think there are some really amazing tools in how do you think about it? And how do we use it thoughtfully? And I like the idea of sort of the co the co-intelligence. Like they can't take over, you know, it it can't take over the sort of the human thought process. Like you can't do a surgery, right? And have AI do it because there's just things that are gonna crop up and you, you know, that's a hands-on approach. And I think we can utilize those tools, but we have to be thoughtful for how we do it. But that's an interesting idea, right? With can patients communicate.

Yeah, yeah. Yeah.

Yes.

more effectively to us so we really understand what's going on with them and can we do it in a more effective and efficient manner.

Right, 'cause then if you only have fifteen minutes and you did all this pre work, well, maybe if I am effectively telling her or describing the pain the way it would make her think that it's meaningful, right? Or him think. Right. Half the time, you know, patients don't feel trusted in the system and so they don't you know feel like maybe they can especially, you know, women of color, black women, they're not telling us everything because of the way they've been treated historically, right? And so a lot of times, you know, they're just like

Mm-hmm.

yeah.

they're the difficult patient. No, actually they're like, you know, guiding themselves, guarding themselves almost because of the way that you know

Well, the way they've been treated. Absolutely. I mean, this it doesn't c it's didn't happen in a vacuum. I mean, this is, you know. yeah, it's really I think you're right. That could be a really interesting way to utilize that. That what an interesting conversation you had yesterday. How cool.

Yeah. Well.

my it was really good. Yeah, I'll let you know when that one comes out because it was a good conversation. yeah, and the other thing I have been thinking a lot about when it comes to some of this stuff is you know, how perimenopause, you know, you're always we're we're both on the OBG wine groups on Facebook and and you do you you have all the OBG wines that are, you know, and I get it because I used to be in a full academic practice where I saw OB and I'd see 30 to 40 patients a day and it gets very exhausting. And you hear other clinicians, OBG wines.

definitely.

yeah.

upset because of some of the information they see on social media and they bring it to you and and they're just they're you know they're they're angry, they're upset, they're this, they're that. And so, you know, and and why are people turning to certain ulterior ways of getting treated? You know, all of those things that come up in my mind when I think about, you know, what the status of women's health is, right? We're one of the most predatory markets around, right? Like menopause is a multi-billion dollar market that will be

yeah. Mm-hmm.

you know, even more growing in the in the future. So I think, you know, we have to address these things in a way that, you know, how is somebody using their Ring to help figure out like their sleep pattern that might be, you know, an early sign of perimenopause? You know, some of these things we have to think, but it's hard in those short periods of time, right?

Right? And yeah, and think through it. It is. It's really difficult. And what I find, and I think we've this has been talked about before, is, you know, how we've we have failed, women in many ways. you know, it's a system that isn't designed to give you the time that you need to be with patients, but also as a society, we really haven't educated. We barely educate on puberty and contraception. We sure the hell haven't.

educated on what's happening in perimenopause, which I always liken as like your second puberty.

And forget about actual sex, like not just preventing S T D's, but what happens with your sexual function, arousal orgasm, your clitoris is your pleasure organ, your body touches it. I mean, you know, this is the kind of stuff we talk about at Ishwash all day long, but like it's something that is very like, you know, lacking. Lack.

Mm-hmm.

Yeah, just the lack the lack of education. And I just had Dr. Julie Whiteloff on my podcast two days ago. We were just recording an episode about libido and she's a a sex therapist and talked about how much how now the new like DSM four actually brings in like the partner skill set. Like, is it really low libido if you're with a partner who can't provide pleasure? You know what I mean? You're like, well, is it low libido or is it just a bad lover?

Yeah. Right.

Yeah, yeah, yeah.

but I think that's so, but that comes from a lack of education. Like we just don't talk about, like you said, we don't talk about the clitoris, we don't talk about the erosocycle. We don't, you know, like you said, we talk about STDs and contraception, sort of, depending on where you live in the country. But other than that, you know, that's about it. And then you come to perimenopause and it is like just a wasteland. I mean, there's nothing out there. And when there isn't anything there, people will come in to fill the space.

Yeah. Yeah.

Well west. Yeah.

Yes, absolutely.

And so that's where we're getting a lot of misinformation. and I have no problem, zero problem with physicians being on a social media platform to get education out. I think that is amazing. I think it's a way for us to do it. You have to. It's you have to tap into that communication tool. It's an easy way, it's an accessible way to get information out there, but it's also filled with folks who are, you know, sending out misinformation or

Yeah. You have to be. You really have to be

you know, kind of filling this void, or like you said, it's a predatory place. Like, if you buy this particular thing, I promise you're gonna feel better. and then that's and it's because we we are not in charge of the narrative, because there has been no narrative. We haven't done anything to help fill it. So other people are going to fill it for us. And that's partly why I got into doing the podcast that I do and why I wrote the book that I

Yeah.

Yeah. Yeah.

wrote because estrogen interrupted is is all about kind of what's happening in perimenopause. We have some really good books that have come out on menopause, which is awesome. I'm super happy about it. But we don't have very many on perimenopause and and that's a different time. And so it's just hoping to get information out there. And as you said, y you know, in your practice it's like we see patients, but we can only see one person at a time. And there's millions of people whose needs are not being met. and so this is just, you know, hopefully just trying to close

Yeah, yeah, yeah.

Yeah. Yeah.

Course.

close the gap a little bit in terms of people understanding what's going on.

Yeah, yeah. Yeah, and you never know who will resonate with which book, right? Like different people are gonna like the style of somebody writing and you know, whatever, you know. And so or the more the more you read, the better even though. So like it's

Absolutely. The better I mean, get get evidence-based medicine out there. And then also, because there hasn't been a lot of research done on women in general, and very and not as much done in perimenopause and menopause.

Nineteen ninety three, that was when we were allowed in research and that's like, What? Yeah. Yeah.

I know. I'm always like, and we have no data on that. Then you have to fill in with expert opinion or this is what we think we know. This is where we really don't have the this is our best guess on how to move forward with this while we wait for more information to come. And so just being honest with people what what we know, what we don't know, the limitations of the data that's out there, and then kind of helping them make the best, you know, educated guess for themselves, you know, educated decision for themselves. Yeah. It's a lot.

a lot. Yeah, I gave a very compelling lecture to the Kellogg School at Northwestern, the business school. They asked me to come talk about you know, the women's health market. And you know, they're all in there like, you know, like they're about, let's hear about the women's health market. Where should we be going? And I really spun it in a way of them understanding because you know I don't want more predators out there. Right. So I you yeah.

Mm-hmm. yeah.

Right. Right. Being like, this is the space, let me fill it with, you know, some garbage that I'm gonna decide you need.

Yeah, so I so I really like gave him a historical lens of, you know, okay, first of all, women's health is historical GY and sex historical being very s very racist, right? Like we have racist roots where, you know, slaves were being treated unanesthetized by Marion Sims as an example, you know. Now I was telling about the the roots of sexism and how, you know, we used everything was hysteria until it wasn't, you know, and the fact that we still say hysterectomy, like we need we need a name change. But yeah.

horrible.

we need a rebrand. Just like PCOS had a recent rebrand, we need a rebrand.

We need a rebrand. I love it. We need a rebrand. So I and I gave him all of this information and I talked about the WHI I said, you know, the reality is what's happened in women's health is that they women no longer because of the chronic dismissal, like women no longer trust their physicians. They don't trust the same person that told them to relax and have a glass of wine for their sex pain. But you know, you know what I'm saying? Which apparently one out of five women with vovovaginal disease have been told that, which is

Yeah.

Yes. god.

You know, one out of five. I mean, I hear it every day in my office because I teach so much sexual pain. But so it's like how do we rebuild this trust? You know, you and I are doctors, we're in this space, we we're evidence-based, but I feel like, you know, the problem is this industry is booming, which is great for some people, I guess. And it's not a problem, but it is a problem when we start harming the patients that shouldn't that don't know any better. And so now we're in a situation where we've

Appalling.

Yeah. That is appalling.

Yeah.

had centuries of mistrust, you know, that has evolved into an empty space that's getting filled with, you know, wellness this, wellness that, gummies this, gummies that, you know. And so, and so what, you know, where should we go? I mean, that's why I'm on social media, that's why I'm podcasting probably the same for you. But what else can we do? We need we need women to trust us again.

Longevity Yep.

I know. And how do you I don't know how you do that? I mean, it's you you do your best, but it's it's hard. I mean, one of the big things I see in perimenopause all the time is by the time patients will come see me, they're so mad at the doctors that they saw before. They're so angry. And they'll be like, they just wanted to give me birth control pills. They weren't listening. And so one of the episodes on my podcast that's actually ended up being the most one of our more popular ones is about.

Seven.

Yeah, yeah.

Contraception versus hormone therapy and why you choose one versus the other. And I talk a lot about I'm like, I I don't think your doctor necessarily was dismissing you. They may not have been explaining to you why this was a good choice. And because they have ten minutes.

Yeah. Yeah.

Exactly. Exactly. Because yeah, and they also like that's what the answer to everyone's problems has always been. you think you have you have pelvic pain, try it birth control pills. you're not getting your cycle because you have PCOS, try birth control pills. So, like, you know, people think of it as just like our our reflex as opposed to saying this is actually a treatment for this medication because of the way it works, right?

Right.

Yep.

Right, exactly. And then you're also trying to, you know, but they have all of their girlfriends and their mothers and their aunties and their family members who have been like, if the doctor tells you to do this, they don't know what they're talking about because they've had terrible experiences. So you're you're like, basically you're already behind by the time you even walk in the door because they are bringing in all of, you know, their shared traumas or experiences and preconceived notions of what needs to happen. And and so it takes time to build that trust and

We just Amy, we need a rebranding OBG OBGYN specifically, not all physicians, maybe some primary kers, but especially all I see is well my OBGYN did this and my and then you hear other doctors saying, Well, those those OBGYNs out there are going Do you know what I'm saying? so

Let me

Well, we get it from all sides. I mean, we really do, because we have the birth stories, right? So so the kind of this idea, like all about how your pregnancy's supposed to go and how your delivery is supposed to go. And it's Mother Nature, like we can't predict what's gonna happen. And so people are disappointed about that, right? Because it's a it's it is a medicalized experience in your life, but that a lot of people don't want to be medicalized.

Exactly.

But unfortunately

But it's but life saving endeavors, or else, you know.

Right. I'm like, well, you know, we're trying to really work on maternal mortality rates. And then we so we get it from, you know, that group, and then we get it from other doctors who basically and you and then the parents sorry, I'll go back to the patients. So patients are upset about their birth story. Then they're upset about their pain being dismissed and ignored forever, right? Endometriosis, how long it takes to diagnose it. It's terrible. And then you get into perimenopause and menopause, and that's just a whole cluster.

But then we get it from our colleagues. I mean, we get it from our surgery colleagues who think we're terrible surgeons, like, they don't how to operate. I mean, they're afraid of ovaries. They take one look at an ovary and they scream. But sure, we don't know anything. You know.

Yes. Yeah. Yeah. Yeah. It calls. Yeah, exactly. God forbid you're ever in a topic with a with a with a belly full of blood, right?

Right. I mean, how many people have you and I saved in our lives? I mean, a lot. We've saved a lot of people. literally. I'm not just being, you know, dramatic about that, but a lot of babies. We've saved a lot of mamas. We've saved a lot of babies. And you know, but we get it, we get it from those colleagues. We get it from, you know, primary care colleagues who are like mad because we put somebody on hormone replacement therapy because they think they shouldn't be on it. But we know the data.

Yes. And babies. We've saved a lot of babies. Yeah. Yeah.

Yes. Yeah.

so much more deeply than they do, but they are from the era of the WHI study and hormones are terrible and bad. So it's like mistrust within our system, within our colleagues. And then we have mistrust from the public and we're kind of just like, we're in a little bit of a like we can't win. I mean, I think you and I are both on some OBGYN Facebook groups, but there's other physician only, like physician Facebook groups that have a variety of different people coming from different subspecialties and subspecialties.

Yeah, yeah, yeah.

Faccio.

The OBGYN bashing on those is horrible. And

It makes me sad actually. And I I mean, I'm just like just imagine for one minute that you're seeing 30 patients a day and one of them goes into labor and you have to leave and then you have to come back. You know, like they don't even have an understanding of the scope of what a general OBGYN in a town that doesn't have many would have to do. And and and it makes me really mad. It makes me 'cause we all I think we like I've lived that life for a short time. You know, I was

It does.

It's never in sort of a small town, but I've lived the life of being an OBGY and doing both of a generalist. And and yeah I'm

Yeah.

A generalist, yep.

I mean, you're up all night, you're trying to keep people alive, you're doing your best. I mean, you're really in I mean, I look back at my residency and, you know, I have very positive experiences about the type of training that I received and how grateful I am for that. But it was a war zone at times. I mean, you're just, you know, you're you're traumatized and you think about all those people's lives that you've saved, but then there's like the one thing that maybe you didn't do perfectly, but people fixate on that and they're like, but you did this. And I'm like, well, look at all these other things that I

Total. Total.

Yeah, yeah.

really put my heart and soul into and it's it's a disheartening time.

And I I mean I don't know how but I I think we trained at around the same time when I mean the 80 hour work week was just starting when I was like, you know, so brand new and it was kind of like not really implemented. And so people were yeah. And it was always like, Well, this is not how we learned how to do and it's so funny. I also had someone on podcast who's a who's a coach for intergenerational workplace navigation, navigating intergenerational workplaces and how to understand

Mm-hmm. Brand new.

no. I mean that's hilarious. Huh.

cool.

Gen Z and she was telling me all the time, she's like, you know, I was like, Well, let me give you an example. If I tell a if I was in an academic setting and I thought a resident was lazy because she was da da da and he she and she she was like, See, that resident is gonna she was just describing the typical Gen Z to me and the millennials and and all the things. And so it really is an understanding of, you know, the cultural environment that they were also raised in and how we you have to be more gingerly now. Like, you know, it has to be Yeah.

Yeah. You have to be more sensitive, you know. And sometimes that's hard because I just want to be like, dude, you gotta you gotta pull yourself up by your bootstraps. Like let's g let's get your big girl pants on, let's go. And then other times you're like, Well, just because I was treated that way, like there are things that need to change, right? And so it's an interesting and I feel like we're a little bit in that generation of sort of between the two, because there's colleagues of mine who are, you know, a decade older, two decades older, and they're just like, I don't I'm not I'm not

Mm-hmm. Yeah.

Yeah, yeah, yeah.

I know.

Between

I don't have time for that. Like they won't even entertain. They don't even entertain it. Yeah. Yeah.

I don't time for that. Yep. Nope. They're like, I'm not, I'm not engaging. You know, the other thing that I think is hard, and you've been in private practice, now you're in a concierge model, you've been in an academic setting, is when we think about, I mean, people always think about doctors and like, you're a doctor, you're rich. Which I just I'm like, no, that's not. And no, not that anybody's gonna feel bad for us, but like it we're not. And we think about like what we're reimbursed for taking care of from an insurance perspective, what we are reimbursed for taking care.

Yeah, yeah, yeah. Yeah.

Of someone through their pregnancy and their delivery, which is so many things can go wrong. And it's it's ridiculous. And

Imagine. Yeah, yeah.

doesn't even account for the amount of hours that you're in the hospital, the postpartum care that you get, the postpartum in the office. Like people, it's bundled. It's a bundled rate of like, and it's not great.

Yeah. You

And it and it isn't, it's not great. And when I look at insurance companies, when you look at procedures, and you probably know this more intimately than I do, when you look at procedures, like if it's the same procedure that's being done on a male patient and a female patient, kind of depending on who does the procedure, it's reimbursed at different rates, which is bullshit, right? Absolute, it's such misogyny. Like, why do we devalue ourselves so much that we take

Yeah, exactly. Misogyny.

Yeah. Uh-uh.

Pennies on the dollar compared to our male colleagues for the same procedure that we're both performing. Like what happened? You know.

So crazy. It's so crazy. It's also how we I think as women have always been, you know, what are acculturated to, you know, or whatever. Because I think that, you know, you can like we don't know how to learn to negotiate contracts, right? Like we don't like it's so funny because I was talking to my husband who's an inertial pain doctor and he's hired different people along the way. And it was interesting to me like when he hired a woman versus a man. And I'd always point this out to him. He was like

I the baseline salary would start out similar, but the but the woman would accept it, you know, because we don't argument. The guys would be like, I think I deserve blah blah blah plus blah blah blah plus a bonus structure. And so I remember I was like, dude, what the hell? He's like, Well, I'm not gonna argue with someone that you know that doesn't want to argue with their own, you know.

Mm-hmm.

Yep. And the men yeah.

yeah.

Right. If they're not gonna negotiate then great. If I can get for cheaper

If they don't value themselves, then what am I gonna do? You know, I'm still running a business. And I was like, All right, you know, like I was basically saying, give her more because she the one she doesn't she didn't ask for it, right? Like she didn't ask for it also, also like, you know, like we have to run a business. So if you can you know

Right? But it's terrible.

Right. And he's like, Well she didn't ask for it, so I'm not gonna So we

If you can get somebody for cheaper and get the same quality of work, you know, as a business owner, you'll do it, right? But women have to learn that we deserve more and we should ask for what's fair. I mean, I had a conversation with a colleague and I was really angry about sort of the pay disparity that was happening. And she said to me, Well, don't you think you make enough? And I said, It isn't about whether I make enough. It's about that it's fair and that I make the same. I deserve to be paid the same as a male colleague doing the exact same thing.

I mean because

Yeah. Yeah.

And it's bullshit that I'm not. And we have a little bit of this, like you kind of go into medicine because you want to make the world a better place. That's great, but we're just perpetuating our own cycle. Like we're just perpetuating this. And it's like sometimes we're so grateful to have a seat at the table that we're happy to take a seat at the kitty table than rather than at the then rather than at the adult table at Thanksgiving. Like, I don't want to be at the kitty table. I worked my ass off. I deserve to be over here and and be recognized for what I'm bringing, you know, what my expertise is.

Hundred time. Yes.

It yes. Yeah.

Yeah. Yeah. Yeah.

Yeah. It's so true. And I was on this podcast, taboo truth a few months like last month, and and the person asked me that she's like, You talk about a lot about health equity, and this is a you know talk I I give a lot. And she goes, you know, but you are a concierge doctor now. And I was Yeah. I said act absolutely. I said I gave probably eleven years to private practice where I did not collect probably forty percent of what I made, I did not go after patients for those payments.

Mm-hmm.

Mm-hmm.

I lived in, you know, like in a depth situation in terms of what I was getting. You know, like and this is the only way for me to practice medicine the way it should be, the way the patients are heard, the way, you know, that I can support this practice and actually earn a living, you know, versus like, you know, I'm not saying I wanna like be a multi millionaire, you know what I'm saying? I wanna earn my living. I need to be able to pay my overhead.

Mm-hmm.

Right.

No, but you need to but you need to be able Exactly, you need to be able to pay your overhead. You need to make a living after that, and you deserve that. Like any other white man would walk in and and there wouldn't be a question of it. But we not one question, not even a blink. I mean, I was I have a colleague who was working at an academic institution and she was negotiat renegotiating her salary and she was a she was a single mom. She had two kids, single mom.

Deserve that. Yes. Not even a question. Yeah. Yeah.

And she said, You're paying male colleague this, and I deserve to be paid the same. And the response to her was, Well, they're the breadwinner for their family, so they deserve to get paid more. Literally the direct words. Not at my institution, it was a different institution, but unbelievable. And this was in 2000s. Like this was not like in 1982, where they were like, Well, you're taking a job from a man, so you better be happy with what you got, you know? I mean, and she's like, I'm sorry. I'm

Not

Yeah

paying for my family. I mean, you could but this was like total mental mindset, like, yeah, no, this is it.

I mean, that's the bias that exists, right? Across the board. These systemic problems that we have to deal with. And it's just it's it can be very maddening. I mean, the same the same podcast I was telling about, there was this comment that was like, Well, doctors are so greedy. And I was like, What? I hate that rhetoric. And I was like going in there and I was like, you know, doctors are allowed to get compensated for the time, effort, and their experience. Just like a lawyer does, just like a construction person, you know.

Yep, exactly.

Yes.

Whatever it is, you know, like my plumber was making more an hour than I was when I was in insurance. Yes, yeah, yeah.

Exactly.

no, my kids' tutors do. I mean, you know, it's like, this is it. I mean, my husband's a lawyer, he bills by like the 30 second increment, and I'm over here just working for free. And it's it's frustrating. And with the advent of the electronic medical record, we are expected to do more and more work for the same amount of money. So patients are like, well, you didn't get back to me on my I sent you an email. I don't get paid to do patient emails. That is not, that's just considered a part of the job.

That's what I was gonna say. Yeah.

Yeah. Yeah. That's the thing. Yeah. Yeah.

But it's a half day a week. I mean, at least it's four hours, at minimum, I am emailing patients four hours a week. Minimum. And not getting paid for that time. Because it's done in the weekends and the evenings and it's unseen labor and it's this sort of easy access. And I think it's really hard too because doctors were providing what is considered to be a fundamental human right, right? The right to health care. And so there's this thought that we, you know.

I mean yeah, yes, yes, yeah, yeah.

Yeah. Yeah.

We shouldn't be compensated for our time and it's a broken system, right? The insurance company 'cause they're Well, I'm paying for insurance, why do I have to pay a copay? I'm paying for insurance, why do I have to Yeah, but that but that insurance doesn't pay us. They'll do anything they can not to pay us. It's a it's

Right?

Yeah. Yeah, yes, okay. Wherever

Yeah. Yeah. Yeah. A hundred percent. It's totally broken. I say this er almost every episode. We have a broken system, it's broken for doctors and it's broken for the women that need the most help. So yeah.

Absolutely. Yeah. It's very it's very discouraging. I don't know. Sometimes I'm like, you just have to like there's this really interesting on the podcast I was on Wednesday talking about the Jenga pieces of life and how sometimes you just need to let it all fall to the ground and rebuild. And I'm like, I don't know, maybe we need to Jenga healthcare and figure out how to like rebuild it so people are getting their needs met.

Jenga, this I mean it's on the wor it's on the verge. It's on the verge of Jenga, so

It is. We're gonna we're gonna jenga it and then we're gonna f then we're gonna figure it out and and find a way that everybody's getting their needs met, right? And that's shouldn't be that hard. Yet here we are.

Yeah.

Yeah, here we are. And I and I think the the the women that struggle the most are the most vulnerable or you know, obviously women of color, they're the ones vulvo vaginal pain that's been, you dismissed year after year. the perimenopausal and menopausal women who are just like, you know, half the time just told to suffer it and and live through it. but you know, we're here. So we weren't we're gonna s we're gonna switch it to positive now.

I know.

ignored.

Yeah, we're switching to positive. That was our that was our therap. Welcome to our therapy. Yep.

We're done with our bitch session. That was our therapy session. We needed to do that for each other. I can't Yeah, I can't even tell. Like offline, I'll tell you what I've been experiencing for those 10 days. It's been awful. But anyway, I want to talk to you also about you know, perimenopause, how what's your best way of going about treating patients? Like I you a patient comes in, not with the typical complaints. They're like,

Be like, we're not alone, we're not crazy. Yeah.

The big one, NFL I just don't feel like myself. I can't put my fingers on it. I'm more anxious than I used to be. This is every s every single patient we see probably You know, I don't feel like myself. So talk to me how you talk to like that, how you would talk to that patient.

Yep. Yeah.

Yeah, everyone. I just don't feel like myself. Mm-hmm.

Yeah, I mean it's this is where I'm grateful for the practice model I have because I do have time. And so I have to when they come in, I basically say, tell me everything, leave nothing out, even if you think it's not related. And they'll usually talk nonstop for at least five minutes. And then this happened, and then this happened, and then, you know, and they might go back ten years. They're forty eight, but like, well, when I was thirty-eight, this all start these things I started noticing. So I let them get everything out. Those are

Yeah.

Yeah.

Yeah. But those are important pieces of the puzzle, usually.

The key pieces because I figure out what is the most maybe they can't put it into a concrete description, but what is the top three to five symptoms that are really impacting their quality of life? What is throwing them off so they feel this so they don't feel like themselves. and often it's like you said, it's the invisible things. Because we talk a lot about hot flashes and ear regular bleeding and all of those things. And absolutely those are sort of hallmark symptoms of perimenopause. But the other ones.

The anxiety, the sleep, the nuance at panic attacks, maybe a worsening of their depression, joint pain. They're just stiff. They feel tired. They're fatigued. They hate their partner. They're grouchy. They're irritable. They hate their kids. Mad at their parents. They're just angry. They're so angry. And so I let them sort of launch into everything. And then I obviously validate. I'm like, you're hitting all the punch lists. This is very typical. And

You're angry.

Yeah.

Do you watch my friends and neighbours, by the way?

No, you are the second person who's told me in the last twenty-four hours that I need to watch your friends and neighbors. So clearly I need to get on this.

Okay. Okay, yeah. It's really good. It's really good first of all. And second of all, she's going through perimenopauses. She's so angry. I'm like sh

So angry. These patients are so mad. I think back as I'm of the age

I mean, I'm so angry. I'm in the middle of it. I'm so angry all the time. And I'm a normal.

I'm so angry. I mean, I know how to tr I know how to treat myself and I'm still just like breathing real deep so I don't punch my poor lovely husband, you know, who's like, I just walked in the room, what did I do?

Yeah. Yeah, same. Same. Yes. Yes. What do you have you have a problem with my chewing that much? 'Cause I'm just looking at him as he chews like

I know. I'm like, why do you have to breathe? Why are you breathing so loud? Like, stop it. You know? And you're just like, my God, I am not, I am unhinged over here.

That's how I felt. I felt unhinged to the other end.

So unhinged. And I and I talk about why. Why is this happening? So we dig into the physiology. What is going on with our hormones? You may still be having regular, predictable menstrual cycles, but that doesn't mean you're not having hormonal fluctuations where things are little bananas. They're going up and down, they're kind of chaotic and crazy. Our brain doesn't like that. Our brain does not like when hormones aren't in their nice, beautiful, predictable pattern. It it throws things off.

So I explained the physiology. I'm like, there's nothing that you can do to make that different, other than we can talk about therapeutic options, but you can't will it away. You know, you can't be like, don't, don't do that, ovary and brain, like get in line. And then I talk a lot about sort of the social construct of where you're at in your life and why things are coming to roost now. Like you used to be able to get away with five hours of sleep. We can't do that anymore.

Yeah. Yeah.

Or your terrible sleep hygiene is that you've been like, it's fine. You know, I can get through it. But you're like, no, all of those things are catching up with you. Sort of our, I think of the Ed Sharon song, our bad habits. and the sort of I've always, this is the big one. I haven't changed a thing about how I eat or exercise, but I'm gaining weight. And saying we have to mix things up. We're in a transition. Just like with puberty, we're transitioning, we're in this transition and we have to figure out what's the new.

Yeah, yeah.

the new way for our body to move and groove, you know, the new way to make us feel like our best selves and a reframing of we're not going to feel like we did when we were 25 or 30. We're older. And it's hard. And that's hard to be like, but I'm kind of creaky when I wake up and like my face is like melting down. Like my skin is just like a saggy mess. And so reframing that these things are

Yeah. Yeah. Yeah.

Yeah, yeah. Yeah. Mm.

normal, they're supposed to be happening. There's nothing pathologically wrong with you. assuming we've ruled out, you know, other causes of that can mimic these symptoms. and then we say we need to live the best version of ourselves for who we're at right now and try to let go of the person we were at 30, which is really difficult. And I think we talked about this, we actually talked about this with the low libido episode that's going to come out about we're our sex life might look different than it did when we were

19 or 25 or 30. That doesn't mean it's wrong. And we can mourn the loss of that. Like, and that's okay to grieve that, to be like, I wish things were still like that. And then kind of reframing into the reality of where are we at now and what tools do we have in our toolbox to make ourselves feel better with who we are at this moment. And and that's sort of my general like gestalt of how I approach it. What do you get? I mean, you what do you do when you see patients? Is this similar?

Yeah. Yeah.

Yeah. Yeah.

Yeah, I mean that's that's very similar to what I do. I you know, really get a sense of what are the biggest things that are like in like what are the biggest reasons they don't feel like themselves, you know? Where are we coming out? Or is it it's it's you know, this ruminating thoughts I have all the time. It's it's the fact that like I've gained five pounds and I can't fit the clothes that I want anymore, you know. It's the fact that I, you know, I'm just I'm hot all the time, you know, whatever, my muscles are aching. And then really getting into it and then talking to them about the physiology, some of them do come in with this.

Yeah.

Yes.

horrible libido and and difficulty with sex and orgasms and you know, really for them to understand what is a s normal sexual response cycle for a woman in a long term relationship. It's not you see your husband and you're hot and horny for them. No, it's a responsive desire, right? Like you need to be aroused first. You need to look at him in his outfit that he's cleaning your bed bathroom for you and all of a sudden you're more attracted to him because he's doing chores we call that chore play for a reason. Like, you know

Right.

Sure.

Like like we call it you know, it's like just like those memes that go around where you have like a man that's shirtless carrying a baby and holding a vacuum and doing dishes at the same time. This is this is this is porn for women. Yes, it absolutely is because there's something huge about how heteronormative roles and relationships have such a negative impact on your sex life. You know, if you're the one that's also working till five every day and you come home and your husband's on the couch.

Sure play.

Yes, exactly. Poor yeah. Mom porn.

'Cause he was working 'til five. But you gotta go take the kids here here and make dinner. You're not you're like what the hell? This is bullshit. I don't wanna Who's signed up for I'm not having sex with that? Yeah.

It is bullshit. Like who signed up for this? This isn't the this isn't what we were promised. You know, women can have it all. Well, yeah, if you break your own back in the process of doing it, you know, your husbands are just like, I gotta go work out. I've you know, I've been at work all day. I'm exhausted, I gotta get this stress off. And I'm like, I'm literally like covered, yeah, covered in like applesauce and chicken nuggets, you know, when my kids were little, and you're just like, what do you think I've been doing all day? You know?

Yeah, exactly. Exactly. Yeah. Yeah.

Yeah. What about these things? Yeah.

Yeah.

Yeah. Don't you think I want that too? So yeah. And then sometimes sometimes it is just like my good sex therapist friend Laurie mitz was always says sometimes she's in a therapy session telling people that they need to separate their tours. Like you after school will do this and this and it makes their lives better and then they want to go have sex, you know? And so that so that makes it there's less resentment. So I think when people understand though, you know, they understand that responsive desire.

So yeah.

Exactly.

I love that

I love it when their husbands come in too and you're just like, You gotta understand the whole thing and how it works and how yeah, if I have pain I'm not gonna wanna have sex or yeah, sure, those SSRI messed up my arouse. Like all the things, right? So

All the things. Yep. And it's really complicated. And that's where again the tincture of time, I think, in education is so helpful. And bringing in those team members because I'm not a sex therapist. you know, I'm I don't have a therapy background, but who are my people that I can bring in to help patients? Like I sort of view myself as the quarterback of the perimenopausal team. I've got and you have to dig in. You have to dig into their sleep. Like what is happening?

Yeah. Right.

Yeah, yes.

Yes, yes.

Yes, hundred percent.

Because you can't survive on crappy sleep. You're gonna feel awful. Everything is worse when you haven't had a decent night's sleep. And how many of these people come in? They're I really haven't slept since I had my kids. I'm like, Well, your children are in college. Like, what is happening? You know what I mean? Like, this is no, this is not okay. And I'll say, I need you to see a sleep specialist. And they'll be like, I don't have sleep apnea. I'm like, first of all, you might, and you may not know it because women are underdiagnosed and

Mm-hmm.

Yeah. Yeah, exactly. What's happening at night? Like

You might yeah. Right.

You know, we're just and it becomes more prevalent at this time frame, but for you know, a variety of reasons. But there's other underlying sleep things, and we need to get you into sort of potentially cognitive behavioral therapy for insomnia. And they're like, I don't want to do that. I'm like, it is the biggest bang for your buck. And once you're sleeping, you don't want to kill everybody around you, you know, but the anxiety is.

Yeah. A hundred percent. my god, don't you remember being a resident on sleepless nights or when you were still doing OB? Like I was this is one of the reasons because I was a whole bee hostile. My husband's like, You need to start a practice where you can control your life because you've become a different person. I was like, Yeah, because I've been working six weeks of nights in a row, you know? That is not

Amy Voedisch (47:10.736)

And it's horrible. Like it's just you're up all night and you are bone tired. And if you think about carrying that for decades, no. And then you put your hormonal, crazy hormonal fluctuations of perimenopause on there, you're like, I'm I'm out. Like it's this is just a mess. And the anxiety, I mean, you mentioned sort of this like crippling anxiety, or people will perseverate on something. They'll wake up at three in the morning and they're thinking about something that is not.

Have a party. Just go have party.

An emergency, but feels like it at the time. New onset panic attacks, those are that's rough. That is real. And you're just like, I feel I'm having like an out of body experience. Like I'm not in control of myself. And that feels very disconcerting to people. Yeah. And you're really validating. You just have to validate, like, yes, yes, yes. You know.

Yeah. Yeah. Yes. Yes. Yeah. And so you

Exactly. I think it's very yeah. And then they're always like, is everything carrying menopause then? And I'm like, well a lot of it is, but a lot of it is your life and it's the come it's the collision. It's a collision course. Right. Yeah.

Yep. And it's hard to tease those apart, right? Because if your lifestyle isn't if your life isn't changing, let's you know, you're not like it's can be hard to tease them apart, but sometimes you don't really have to tease them apart. You just have to figure out how you're gonna treat them as a whole. But you we can't blame hormones for everything. You just can't. Like there are other things that are going on. Like I said, all of your bat your you know, or the dis various dysfunctions in your life that are coming up that you used to be able to,

Yeah.

Yeah. Yeah. Yeah.

you know, compensate for and now you just you can't compensate anymore 'cause you're just out of compensation. You're just like I I can't handle all these balls in the air anymore. It's too much. Yeah, it's so hard.

Yeah. Yeah, exactly. Exactly. So well then what do you what do you how do you usually treat some of these patients? Do you go straight to hormotherapy? Do give them first

I talk a lot about hormone therapy. I certainly go into I'll get into hormones in a moment because that's a that's a big piece. But I have, like I said, all my my players and my team. So we talk about sleep. We talk about your relationship and sort of the quality of your relationship. And this might be a time to address some of the maybe disparities in your relationship with your partner, or is this still the same partner that I want to have? Or can I make things better with them? so we we talk a lot about that. I talk about

sort of nutrition, we talk about exercise and and sort of this idea that we have to kind of get away from the focus on just cardio and really get into the strength training for our body composition. I talk a lot about how your workouts are going to change and they're going to look different because now we're all about function, kind of motion is lotion. We want to keep those, keep those joints lubricated, keep that body moving. I do a lot of Pilates. When I was 30, I'd be like, what are you people doing in there? And now I'm like, I need to be able to bend over and pick something off the floor. So this is what I'm doing.

Yes.

Yeah.

Yeah, yeah exactly. Exactly. huh.

Because I my focus is different. And and then I'll get into hormones. And I talk a lot about, I kind of have three categories that I'll get into. And and I talk about sort of non-hormonal therapies, of course, like if someone's having debilitating depression or anxiety, we can talk about do we want to use a medication that's more tailored for that? But hormone replacement therapy or menopausal hormone therapy or hormone therapy in general can be helpful for depression and anxiety because you're getting to that.

underlying basis of these crazy hormonal fluctuations, right? So the three categories I talk about are birth control pills. Again, one, we have to talk about contraception. Where what are your contraceptive desires at this moment? Do you need to be contracepting? So we talk about that. But I also talk about contraception because what happens with hormonal with most combined hormonal contraceptives, which are your typical birth, usually your birth control pills, your birth control patches, your birth control, the Nuva ring.

Right. Do that. Yes.

they suppress ovulation. So they are hormonal suppressives. And so then you're not having the erratic hormones that are there. And so when I really get into that and I'm drawing pictures, I'll show them loop cycles. I've, you know, the whole thing. I'm like, this is why this medication can work so incredibly well. Not only are you going to regulate your periods if your periods are crazy and heavy, but we can get that crazy hormonal fluctuations to calm down, kind of flatten the curve, so to speak, on those so that you're not having

Yeah. Yeah, yeah.

such highs and lows, which can be so helpful, right? So we talk about that. I also talk about how in the combined hormonal contraceptives, the type of estrogen that's in there is is an estrogen called ethanol estradiol. And that works at the estrogen receptor a little bit differently than estradiol, which is what our ovary makes. And so ethanol estradiol is great to help control bleeding. Like it's that's why it's part of these combined hormonal contraceptives, but doesn't always do a great job

With perimenopausal symptoms. So if you're somebody who's on a birth control pill but you're having breakthrough perimetopausal symptoms, I'm like, it's probably time for us to change up the formulation. And then I can either go to menopausal hormone therapy, which could work if they don't need contraception, because menopausal hormone therapy does not prevent pregnancy, or I do a combination of estradiol, which is what the predominant estrogen that's the most popular now that people use in.

hormone, you know, menopausal hormone therapy, and I combine it with a progestin only birth control and we put the two of them together. So, and one of my favorites now is the use of the oral draw spirit, or it's the trade name is Slind. I love it, right? Because you're suppressing ovulation, but then you get your estrogen from a different source. And then you kind of are treating both things. So that's one of my, that's that's my one of my favorites. It's what I'm personally on. I'm like, I love that one.

Yes, me too. I love that one. Yeah.

Yeah. Yeah. For those that really have that progesterone sensitivity and they or progesterone sensitivity or they have like you know maybe the more erratic bleeding on the standard OMP, you know, just let's shut it all down and just give you what you need after that.

But I also love

Yeah.

Just give you what you need. I was having a lot of migraines because of the hormonal fluctuations. So it was great because it sort of calmed all of that down. And then I could treat my night sweats and my all my other stuff with the with an estradiol. And I love the use of an IUD with this. I love, you know, the leaving adestral containing IUDs. They don't suppress ovulation, so you're still gonna have some of those hormonal swings. But you know, often if you can add estradiol on top of it in whatever way, shape, or form.

Yeah, yeah, yeah.

you can get to a place where you're feeling pretty steady. So that's sort of my general gestalt when somebody comes in and they want to talk about hormonal options. Then those are sort of the sort of three buckets that I kind of talk.

Agreed. And and how do you feel about testosterone, I have to ask, 'cause it's all the

yeah. I mean, so I think testosterone has a place in terms of for me, I use it in my practice for low libido, so hypoactive sexual desire disorder. I think there's a lot of claims online that testosterone is sort of the new fountain of youth, like the new vitality longevity medication. And there's a lot of claims out there about what testosterone is going to do for you with not a lot of data behind that.

Mm. Yeah. Yeah.

Yeah.

or we do have data and we're like, it actually doesn't really work for that. So I don't use it because people will come in and they're like, but I need to have testosterone. I'm like, well, how's your how's your libido? my liquid is fine. I don't have any problems with my libido. And I'm like, well, you know, I'd I for my practice, I don't throw it in routinely. I I tell folks, I'm like, you know, for me, I worry that if you're using it for vitality purposes, like you want to put on muscle, you want to have more energy.

I worry about the doses that you need in order to achieve those effects. And now we're getting into

You have to be a much higher than the the prement prepausal just. Yeah.

Then the Yeah, exactly. And then I worry about side effects for those which are, you know, not reversible. So, but I know that's all over social media right now. And so I try to say, well, you know, there's a lot of claims out there, but we don't have a lot to, you know, I I just I personally am much more sort of I don't want to say restrictive, but much more careful with my use my use of that just because you need to make sure that you're not getting yourself into trouble.

Yeah. Yeah.

Right, right. And I think, you know, part of what's so hard about hormones is because they w because it's so different for everyone, because you know, I think we don't know the status of everyone's receptor at that organ, right? Like that's even like it really comes down to that lock and key that you learn about way back in the day with the receptor and the hormone and and like how it's gonna interact, right? Like is it gonna cause me to like really a small amount do really well for me, or am I gonna have to like

Right?

Yep.

push the limit for that part of my body to get the most bang for their buck. And then the other side effects are gonna be wherever, you know? So I mean, that I think is is the problem that we have in terms of why some people get benefits with lower doses. And you know, obviously we know there's a magical placebo effect for so many things, but you know, some people get benefit from smaller doses and other people need much larger to feel anything.

Mm-hmm.

Yeah.

And you know, testosterone like all the sex med drugs are like fifty fifty to sixty percent, right? Nothing's a nothing's a a dark short thing. So

A sure n nothing is a sure thing. And I tell them like fifty fifty, this is gonna help. So

Yeah. If they wanna try it, great. I feel like, you know, let's try it in the right way and try.

Absolutely. If we're gonna try it, let's try it. And then we we reevaluate, we make sure that for you, you're not a hyper responder, you know, where you have like your levels are getting really high. Check your side effects to see how you're feeling. and if we're not seeing anything, then we can say, well, this isn't this isn't maybe necessarily you're not needed for your sort of potions class. Your po yes, your little your little tincture of all the things that we're putting together. But it's big. Everybody wants testosterone right

Right. Right.

Yeah, that's interesting.

Yeah.

It's like it's it's having a moment. And there's a little part of me that's sort of like, haven't we been there with these hormones? Like I feel the cycle keeps coming with like feminine forever in the 60s. And then it was like, wait, maybe we need to add some progestogen to this because it's gonna cause uterine cancer. wait, maybe this causes breast cancer. wait. And then it's like comes back, we're like, no, everyone needs to be on estrogen or testosterone or whatever it is. And you're like, not everybody needs everything.

Yeah.

Right.

And every person is so different. So you really have to tailor it to the person who's in front of you. But I feel like we're on this like upswing of like hormones are gonna fix and change everything.

Yes.

Well, there's just a lot of FOMO, like yeah. And there's some of my patients that come in and I'm like, So yeah, why do you want to be on the yeah, is there some like 'cause your symptoms don't sound it we can do a dex that we can see what your bone health is. I'm not gonna say I'm not gonna give it to you, but I'm just wondering where you're at with this. She's like, I have so much FOMO. And I was like, well, FOMO's not enough of I guess I'm not in gatekeeping it for you, but I just want you to understand what it can and can't do. And so like you might.

the FOMO.

So much FOMO.

Yeah.

Exactly. You the promises that are being made, the promises are very if something if someone's promising you the moon, you have to be very weary about that, right?

Yeah.

And the reality is, yeah, maybe Oprah did see v see color for the first time when she had hormones because she was in such a dark place before, right? Like, but you're s you're coming from a different place. You didn't have those hot flashes, night sweats, basal motorism, sleep disturbance. Da da da. That wasn't for you. So what is it gonna help you? Probably it'll help your bones for sure. We can say that. Yeah. Yeah.

Yep.

We can say that. We we can say that. So I do I get a lot of you know, bone scans. I do it early than the recommended age sixty five, because I it's part of my algorithm of, you know, when somebody's on the fence and they're like, I don't know, should I be on it? Should I not? Maybe we're we're wrestling with a couple of things that can become kind of part of our decision making tree of like, does this seem like it's gonna be helpful for you or not? But the FOMO. And I get a lot, are you getting a lot of patients like, the poor patients who like missed it?

Yeah.

Yeah. Yeah.

Yes.

miss the window because of the WHI and now they're like late sixties and like, but I want to be on hormones. I'm like, like because they just want to be on hormones. Like they think they need it for their longevity. And you're like, this is no it it's gonna be okay. We're

Dr. Sameena Rahman (59:05.71)

Well that's

Yeah. Yeah. Yeah, yeah. Okay. But no. I mean I'll entertain anyone's ideas and we'll talk about it, right? Like just I won't I won't yeah.

for sure. Absolutely. Just have the have the conversation. But you're like like you said, you have to be very honest about what this is going to do for you. Yeah. What what what's in the you know, what are the realistic so we have realistic expectations because I don't want to tell somebody like I'm going to put you on this and suddenly like your whole life is going to improve. You know, because I c it hormones are not going to treat, you know, a challenging marriage or a dissatisfying job or, you know,

What was the more? Yeah.

Right.

the fourteen c you know, the kids and the sandwich generation of taking care of your kids and your parents and being squished and I and hormones aren't gonna give you more hours in your day, you know? So you have to be realistic.

Yeah. Yeah. Yeah. It's so funny because we have the opposite too, where like I have patients who come to me like they want to try like Addy or whatever. Like my last doctor wouldn't give it to me because he told me that I'd want sex all the time. And I'm like, no, no, that's not how this works either. Like let's get realistic here. You might not reject five times out of month. You might only reject them two times out of the month.

Yeah.

Right, exactly.

The month. Right. Exactly. Exactly. This is not going to turn you into like a hornbot, I promise. Yeah, exactly. And so having some of that. And I think there's also like a so much frustration with patients, right? Because men get Viagra and Cialis and all the things, and they just like have this immediate response and everything. Like they can start to feel a little bit more like they did when they were younger.

So

Yeah, exactly.

Yeah.

I mean there's some of them don't actually. I have patients who are like, My that does nothing for my husband. I'm like Yeah. That's why I was branded. That's the b that's the marketing. Yeah.

Yeah, totally right. Doesn't work for everybody.

It's the marketing. Exactly. It's this perceived what this is going to do for me. And so they're mad that we don't have a version of that for them. And I get that. It's frustrating. and I also get, you know, their frustration where like, their husband's Viagra is covered by insurance, but their vaginal estrogen isn't. And they're like, well, what would you like him to do with this Viagra situation that you've now created? Because don't this is a this is a do-not-enter zone if I don't have my vaginal estrogen, right?

Yeah.

Yeah, exactly. Don't put it here. Don't cut it here.

We have to fix it. Yeah, exactly. That's so funny. Well, Amy, this has been wonderful. I want to be cognizant of your time because I know we both have stuff we have to get to. But I really appreciate you being on today. this has been wonderful. I know we did a little bit of a bitch session, guys. Sorry about that. But we we were venting our realities of how we practice by the subdiscountry. So it's just the truth. Some people need to hear it.

Yeah no.

Gotta hear. But you know, but really we love our jobs. We love taking care of our patients. It's why we do what we do. And I have a lot of hope. Like I love the fact that these conversations are forefront, that we're being honest about it. I love that perimenopause and menopause are having a moment. And I'm happy to be here for it and just be part of trying to get, you know, information out there for patients to be able to choose the right path for them. So it is really a time of some great hope as well. So yeah.

I love it. A hundred percent.

Yes, absolutely. Absolutely. It's perfect. Yeah, of course. Now we're looking forward for your book. When is your book coming out? Esther. soon. wow. I'm gonna have to get it.

Thank you so much for having me on. I really appreciate it. This has been a lot of fun.

June sixteenth. Yep. It drops in yeah. Yes. So June sixteenth, it is available all places where you buy your books online and will be available. We have a couple of events. Yeah. So we're doing an event at Virginia Commonwealth University, at their big women's health education event that they do that the university does, which will be really fun. And then we're doing some we're going to Seattle, we're gonna be in Santa Rosa, California, and then we're working on getting a few more events going. And then

Are you guys doing a little hook signing thing where you're going around the places?

I hope.

And then now I guess the newest thing is you are on people's podcasts and that's how you talk about your book as well, which is kind of fun. and our hope is it is just to be a great reference guide, an honest reference guide for women so they can pick it up and be like, okay, I'm having hot flashes, what's happening? And they can go to the hot flash chapter and be like, okay, this is what's going on, you know. So well, thank you so much for having me. I really appreciate it.

Yeah. Yeah.

wonderful one. Yeah.

Yeah, it was fun. Thanks so much, Amy. Take care. Remember, thanks everyone for listening. I'm Dr. Smeen Rahman. Remember, I'm here to educate so you could advocate for yourself. Please join me next week. Yay.