You've probably heard of cancer survivors, but have you heard of previvors? These are women with genetic mutations like BRCA1, BRCA2, or CHECK2 who are at higher risk for cancer but don't have it yet. October is both Breast Cancer Awareness Month and Menopause Awareness Month, making it the perfect time to discuss genetic testing, cancer risk assessment, and what previvors need to know about their options.

Using a 28-year-old patient with CHECK2 mutation as an example, I walk through when genetic testing makes sense, how to calculate your lifetime risk, and what screening protocols change when your risk is elevated.

I cover modifiable lifestyle factors that account for 30% of breast cancer cases, including alcohol intake, diet, exercise, and optimal body weight. The key message: genetic testing is about empowerment and prevention, not fear.

I also address surgical menopause after risk-reducing procedures. When you remove ovaries in your 30s or 40s to prevent cancer, you fall off a hormonal cliff with immediate consequences.

The critical issue: estrogen therapy is NOT contraindicated for previvors without personal cancer history, yet surgical patients are rarely given a menopause plan before going under anesthesia. Early estrogen loss increases cardiovascular disease, dementia, osteoporosis, and all-cause mortality risks.

Highlights:

• What CHECK2, BRCA1/2, and other mutations mean for lifetime cancer risk.
• How removing ovaries before age 45 without HRT increases all-cause mortality risk.
• Why previvors without cancer CAN and SHOULD take estrogen after preventative surgery.
• Why you should demand a menopause plan BEFORE risk-reducing surgery, not after.

If this episode empowered you to have conversations about family history and genetic testing, or helped you understand why hormone replacement matters after preventative surgery, please share it with women who need this information.

Subscribe and leave a review to help more people discover these critical discussions about cancer prevention and quality of life.

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GSM Collective

The GSM Collective - Chicago Boutique concierge gynecology practice Led by Dr. Sameena Rahman, specialist in sexual medicine & menopause Unrushed appointments in a beautiful, private setting Personalized care for women's health, hormones, and pelvic floor issues Multiple membership options available Ready for personalized women's healthcare? Visit our Chicago office today.

GSM Collective

GSM Collective

The GSM Collective - Chicago Boutique concierge gynecology practice Led by Dr. Sameena Rahman, specialist in sexual medicine & menopause Unrushed appointments in a beautiful, private setting Personalized care for women's health, hormones, and pelvic floor issues Multiple membership options available Ready for personalized women's healthcare? Visit our Chicago office today.

GSM Collective

Hey y'all, it's me, Dr. Samina Rahman, Gyno Girl. Welcome to another episode of Gyno Girl Presents, Sex, Drugs, and Hormones. I'm Dr. Samina Rahman. I am a gynecologist with an expertise in sexual medicine and menopause management. Today I'm doing a solo podcast, and so I hope you guys enjoy a little reflections that I'm having today, but I am located in downtown Chicago.

With a practice that is now a concierge practice called the G wine and sexual medicine collective along with my nurse practitioner Karen Bradley and My physical therapist Grace Preet who you both met last week and my last episode

Today I want to talk to you guys about really what is the hidden cost of preventative disease. We want to get into it is breast cancer awareness month, is menopause awareness month, and what is the intersection when they collide in hopefully a good way. But the reality is we have many patients that have genetic susceptibility to cancer genes, to cancer mutations.

mutations on genes. They have a genetic susceptibility to mutations on certain genes that we know can cause cancer. And so this is called hereditary cancer genes. That means it's passed on from parent to child and generation to generation. And this month,

We also celebrated hereditary cancer awareness as well as pre-viver day. The pre-viver day was October 1st. So what is actually is a pre-viver. A pre-viver is, you know, we always talk about, you know, survivors and how, what are the consequences to the cancer treatments that they've had and the hidden cost of that. And we like to celebrate our survivors, but

We also have what are called pre-vibes. These are the women who are empowered with information who do not have cancer yet, but maybe a larger genetic susceptibility to the cancer. And so they are treated differently in the medical setting because we might aggressively screen them and put them on a different screening protocol. And sometimes they have risk reducing procedures that are done. And so those are all very important to remember.

have been thinking about a patient of mine that I saw recently who had a very significant, she was young in her 20s, she has a very significant family history of breast cancer. think her mom was diagnosed at age 43. Her maternal grandmother had it at around age 60, so it was surprising that her daughter, who happens to be the patient's mom, ended up with breast cancer.

The patient's maternal aunt also had it at age 45. So she has this increased risk. I saw her before the age of 30. We were talking about her risks. When we do risk assessments, that's a big part of what you should have done on your annual visits, especially if you know your family history. If you don't know your family history, maybe ask your family. Maybe see if you can open up.

the can of worms whether or not you want to but talk to your mom about you know when she if you're lucky enough to still have your mom around or have a relationship with your mom talk to her about when she went through menopause and talk to her about you know your aunts and uncles and do you know the family history a lot of times that is very quiet and culturally some people don't like to talk about it but it's really important to get the information because at the end of the day your genetics affect your

longevity and your quality of life and whether or not you have cancer risk. So when I had this patient in the office, we talked about her cancer risk. She's we look at things like, you know, what is your heritage? You know, do you are you, for instance, like certain ethnic backgrounds have a greater family history, certain ancestries, right? Ashkenazi Jewish, sometimes South Asian, Black Caribbean, they sometimes will have higher

mutation rates. And so we look at some of these. We look at family history of breast cancer, ovarian cancer, pancreatic cancer, prostate cancer, melanoma. And really a lot of times looking at early onset. In my office, we do genetic testing through myriad genetics, which is a very qualified national clinic, I'm sorry, lab actually that will do blood screens for I think up to 48 different genetic mutations now.

And so we want to know are there early onset of things like breast cancer, know, less we're looking at really at women that have had it in pre menopause before they had their final menstrual period. We want to look at whether or not colon cancer exists in your family before the age of 50. We want to look at early onset of prostate cancer and A actually ovarian cancer in the family will potentially put you at higher risk. So we look at that. And so this patient had three family members.

That had cancer and two of them were pre menopausal And so she qualified for cancer testing for genetic testing for hereditary cancers We also look at personal factors, right? We want to know what was the age of your onset of your menstrual cycle or Menarche we want to look at purity. How many pregnancies have you had? We want to look at your age at first birth. Like what was the age?

that you had your first child. We want to look at your breast density. Those are very important factors too, is how dense are your breast tissue based on your previous assessments, because those all play into your overall risks. was your mammogram report, did it talk about fatty breast tissue? Did it talk about scattered density? Did it talk about heterogeneous density? Was it extremely dense?

These are things that we're looking at from your breast density from your mammogram report. So that is really important. We want to look and see whether or not you've had any prior biopsies on your breast. So those are also things that we are looking to see. And then we also look at things like your hormone use, right?

We look at whether or not you're taking menopausal hormonal therapy. We look at whether or not you've been on different types of birth controls. All of these things are put into an equation. There's a couple of different equations that we can use, either to tire or cuisic. We have a lot of different ways to calculate your risks. The Gale model, the IBIS version 8, will also...

put all this information in there and we can calculate your risks. I like that the myriad company that we use actually will calculate the risk themselves. So this patient that I had who was like 28 years old, we sent her for the genetics because she had a mom and a maternal aunt and a maternal grandmother with breast cancer. She did not have any of the other things. She didn't have early onset of her menses or menarche. I think she had an average age of like 13.

So it wasn't anything significant. And so we did her calculation and we sent her for her evaluation and it came back positive for a mutation called CHECK2. CHECK2 is one of the mutations. It's the location of a gene genetic mutation that confers a higher lifetime risk, usually around the order of 25 % or less.

sometimes higher. So when you take into consideration family history and personal history and you know whether or not you drink alcohol and some of these other factors then your risk can go up and so this patient just had a risk of like 60 % which is a lot for a 28 year old or you know less than 30 year old patient to hear about and so you know we have a big discussion around you know what is it that we can do about it? What can we do about these elevated risks?

And so it's always important to know what age that person in your family might have had cancer. So if you had someone in your family that had cancer at the age of 40, we will start screening you at the age of 30, 10 years before. So that could be, and we won't usually do it before the age of 30 unless we feel something on exam.

You know, obviously, so our screening changes if you have a lifetime risk above 20%. So if average patient has a one in eight lifetime risk of breast cancer or around 13%, if yours goes above 20 % when we calculate it, we will start changing the way we screen you for things like breast cancer. And so we'll look at potentially starting mammograms and breast MRIs at an earlier age. This patient will...

started around age 30, she will have breast cancer screening with MRIs, mammograms, and then ideally every six month clinical breast exams, as well as monthly self breast exams. And so those are all very important part of risk reduction. And then we look at a lot of other things too, like how else can you reduce your risk of something like breast cancer, right? We can talk about...

ovarian cancer risk reduction for things like BRCA1 and 2. Those genes you guys hear about a lot, know, I think Angelina Jolie, some of these actresses have come out and told us that they are BRCA1 and 2 positive. Those risks go higher, you know, up to 60 to 72%, depending on which one. But again, your personal risk will change based on some of your family history and lifestyle issues. And so,

We wanna try to reduce those risks as much as possible, but we can take some steps, some lifestyle changes, right? So we can do, because about 30 % of breast cancer in the US is really related to lifestyle factors. So what are some of the lifestyle factors? We can try to adopt as close to a plant-based diet as we can, right? Reducing alcohol limit intake also is a huge thing, right? Alcohol is a big carcinogen.

If you limit your alcohol intake to fewer than three drinks a week, that can reduce your risk. You want to aim for optimal body weight, keep the ideal BMI in the 21 to 25 range. Want to try to exercise with moderate intensity to reduce your risk, four to five hours a week, conduct those self-breast exams as I talked about. So some of those ways that you can reduce risks, right?

really important to consider all of that. Because remember, like I said, we should always be aware of what our cancer risks are. And in this day and age, when there's so many opportunities to provide prevention, why not act on those, right? I know it's scary. It's a scary thing. My patient was crying. They oftentimes are very upset by the fact that their lifetime risk is so elevated.

Of course that would happen to anyone But it is very empowering to know that you have the ability to do something about it Because early screening and early detection saves lives So that's definitely something that we should consider in the equation actually, you know, you should really consider the fact that Knowledge is power and So we do these models we do these assessments we want to see

Because these numbers matter. They don't just tell you your risk. They tell you this prevention plan Some people that have like a greater than a 60 % lifetime risk, you know might choose to do some you know more Prominent things, you know, but I just want to emphasize that genetic testing really isn't about fear It's about relief foresight insight into what's happening Between BRCA one and two would check to there's other mutations like ATM

or TP53, you know, sometimes the lifetime risk goes up really high, like I said, up to 80%. We always will do an offer genetic counseling, Myriad offers that. We can go to see a genetic counselor to actually kind of reel out, reduce your anxiety really. You know, we really want to make sure that you're not going to get, well, it is obviously, hold on, carry.

let's read the backtrack. We offer genetic testing to a lot of our patients and it's a real form of empowerment really because having the genetic testing really can translate knowledge into action and that's really important. We want to make sure that we're not silent about it, that we're not sitting on this. And so, you know, these are the things that we're looking at and what we want to try to improve. So this patient I was talking about earlier,

you know, is now on a rigorous screening plan. But the reality is, if you carry a pathogenic mutation, you have to face decisions that no one has potentially prepared you for, right? I did have a conversation with her about risk reducing mastectomies. That was something that we talked about. Some people will also opt because some of these increase your ovarian cancer risk because...

We know that some of these cancers and risk-reducing surgeries can reduce your risk by up to 90%. And so some people will also choose to have what we call a salpingo-oophorectomy, which is the removal of your tubes and ovaries. So these are things to consider, but if you're really young and you're considering this, what do you do after childbearing? Most people will recommend doing it after childbearing. But some people will...

opt to go ahead and freeze eggs and embryos and so reproductive endocrinology infertility should be in the equation as well because you want to make sure that you are coming up with a plan of action. And so these are decisions that have to be made that cannot be made lightly. They should be made with great thought about what the consequences of these surgeries are.

which oftentimes people don't talk about. Because for women in their 30s and 40s, especially say you're done with childbearing. Like the patient I was talking about earlier was not done. She's not even started her journey. I know she wants to have children. So this is gonna be really just her being rigorous with risk reduction, with reducing alcohol intake, with optimizing her lifestyle.

and with rigorous screening, including diet, exercise modifications, including mammograms, MRIs, clinical breast exams, and self-breast exams, right? And then for some patients who have a higher risk of ovarian cancer because of their mutations, going on oral contraceptive pills has been shown to demonstrate reduction of ovarian cancer risks. So those are other things we can consider. We don't have a great way to screen and pre-screen for ovarian cancer.

Some people will have, you know, yearly ultrasounds done as part of that pre-vibration program. But say you're in your 30s and 40s, you know, maybe you've had kids, maybe you're kind of thinking you're done with kids, but you want to make sure you're there for your kids. And so a lot of times they start considering surgery, start considering the mastectomy. They start considering the removal of your ovaries, that castration that happens.

surgical castration is real. It is an issue. And the thing is, if we were to say castrate men in this country by, you know, reducing their testosterone, there is a discussion that is had about replacement of hormones. And this discussion is rarely had for women who are going through this instant menopause.

It is immediate. You wake up from that surgery many times with hot flashes. This is not a gradual transition. This is not perimenopause, one month this happening, one month that happening. It's not a gentle slope. It is a hormonal cliff that you fall off of. And so it's really important for the discussion about menopausal hormone therapy to happen for these patients because when they do not get replacement of their hormones after their ovaries are removed and their tubes are removed.

then they're increasing their cardiovascular risk, their dementia risks, risks of all-cause mortality actually. Forget about the risks of disease. The symptoms can be very traumatic too for so many patients, right? You wake up in hot flashes. You wake up with night sweats. Insomnia, right? We know that sleep is a vital part of our quality of life.

and longevity and for disease prevention. And oftentimes when you take out your ovaries, you're losing estrogen, progesterone, and at least 50 % of your testosterone production. So brain fog, insomnia, hot flashes are real. And forget about the fact that now the estrogen's not available for your brain, right? So we had said brain fog, but we also talk about mood disruption. People all of sudden get more anxiety, they get more depression.

Obviously dealing with this catastrophic issue around losing your hormones and losing these organs that you didn't expect to lose anxiety and depression start to become into the equation. And then of course we have to think about our sexual health as well. so libido is tanked, right? Some people as if they've had the removal of their breasts, you know that

was a real part of their femininity and their sexuality. so most of time they will get a replacement and their body image can slowly start to come back. But with that and with body image issues that come up, of course libido is in the tank. Like you are just not feeling like yourself and you don't really want to have sex. And then the pain with sex becomes an issue, right? When you have the loss of your androgens, your testosterone and the loss of estrogen.

the genitourinary syndrome of menopause is real and it happens fast for some of these patients. They can get vaginal dryness of course. They can have you know labia regression. That means your little labia minora are disappearing and your clitoris is shrinking down. The vaginal microbiome goes from acidic to basic. You have all these concerns that happen with the elasticity of the vagina but a vagina might become shorter.

and become more difficult to have sex. And remember our vulvar vest, to be able to talk about a lot on this podcast, becomes inflamed, it can become red, it can become thin, and it can cause a lot of pain within the course, not only at initial penetration, sometimes at deep penetration as well. And so you get all these symptoms, and this is just the beginning. Because like I said, long-term, early estrogen loss affects every organ system.

You know a lot of times patients will say I have a lot of patients that are BRCA positive They say that you know, yeah, it saved my life, but I totally lost the spark in my life But it saved my life. So it's really a quality of life issue, but also longevity to remember cardiovascular health brain health bone health and so

These are all really important. When estrogen disappears overnight, your body really does lose more than just that hot flash control, right? It loses those protective effects. And we know when you lose it at a younger age, you're really putting yourself more at risk. And so you have to have a real full hormone replacement therapy, just not symptomatic relief. So the heart becomes...

sorry, your cardiovascular risk increase, right? Because your cholesterol starts changing, the arteries start to change, the bones, remember, the bone health becomes weaker, you get more issues around osteopenia and osteoporosis, remember the brain and the cognition and the mood, all of these things, generally your nerve track. And so, you know, without replacement of the full estrogen, people are at more risk for heart disease, stroke.

cognitive decline, osteoporosis, sexual pain and incontinence. And again, like I said earlier, based on some studies that have been done, women that had had an oophrectomy or removal of their ovaries before the age of 45 and they don't take hormones, they actually have higher risks of early death. So higher risk of overall mortality.

So you may be told that you can't take hormones because you're at high risk. No, that is not true. You can and absolutely should replace these hormones as pre-vivors. And it is a real disservice if you're given this talk before your surgery. And if you're not placed on a patch before you go under anesthesia. So, I mean, you know, if you want to clear things up a little bit, you know,

you have a mutation but you do not have cancer, right? You've had your ovaries removed. Estrogen therapy is not a contraindication for pre-vibors. In fact, most studies show it doesn't increase breast cancer incidence in BRC carriers without personal family history. So we know it can, again, reduce your risk of heart disease, reduce your risk of...

those fragility fractures. Remember we talked about this before but when a woman with osteoporosis falls and breaks her hip there is up to almost a 30 % mortality within that first year of blood. And so it's not only a matter of function it's really a life and death situation for so many patients.

So we can't let fear of hormones really impact an entire generation of women's health. And so if you're choosing to do something to improve your survivorship or to prevent cancer, you you don't want to then fall prey to a heart attack or an osteoporotic fracture or a stroke. So let's...

be smart about this, let's be educated about this, and find someone that can really help you navigate this in the best way possible.

Once you have had these preventative surgeries done, you really want to make sure you're doing your DEXA scans. You want to make sure you're doing your cardiovascular screening, blood pressure, lipid panel, get on some good exercise programs. You want to make sure you're getting on vaginal estrogen or vaginal DHEA in that menopausal full hormone replacement therapy. Because for so many people, it's not just quality of life, it's longevity, but quality of life is also...

is also so important for longevity, right? Like if you don't have a good enough quality of life that you can't go socialize and make those connections that we know are important for your longevity, then a lot of people, you know, are then reducing their longevity in the process.

Anyway, my point in all of this is that, you know, we're thinking about cancer this month, we're thinking about menopause this month, I would argue we should think about it every month. And I do bring this up with everyone in my patients when I ask their family history, we want to make sure we're getting to the bottom of everything that they know about. And so if you want to really feel empowered, you know, like I said, try to have those conversations with family members if they're still around, try to figure out what's going on in your family.

But really we have to really be proactive in this day and age, right? A lot of times I'll even offer my patients to get the pre-nuvo full body MRI scan. Fun fact, I did this myself. I had a pre-nuvo full body MRI scan. We have one in Chicago. It was, you know, I don't like being in closed MRIs because I do have a little bit of claustrophobia, but you know what? They gave me an anxiolytic beforehand. It was a very much

a spa like experience, I have to say. Like it was kind of like, you you lay there, I got to watch Netflix while I was getting my MRI done. So I watched like two episodes of how I met your mother. It was really nice. And it was, I was done before you know it. So the good news about doing something like a full body scan is that you're kind of seeing everything that may be happening.

But again, you're kind of seeing everything that may be happening. So we get all these things like incidentalomas that are found. And so you then have to follow them because now you know something is there that probably doesn't mean anything, but we should know in case. But I've had patients that, you know, had, I had a patient that had an aneurysm discovered before it ruptured. So that was life-saving for her. Some people do like when they have the MRIs, they might detect early cancers in some cases.

So that is another thing you can do as part of advanced screening if you know that you have certain cancers in your family. It's not covered by insurance. It can be costly, but like myself, our practice at the GYN and Sexual Medicine Collective, we are partnering with PreNuvo now, so our patients will get a discount. So a good takeaway for you guys is really to know your numbers, right? Like get in there.

Talk to your clinician about what's happening in your family. What are the percentage of people that have cancers? What does your history look like? What does your family history look like? And what does your lifestyle look like? And then we can calculate what your lifetime risk is for things like breast cancer. And then if your family history warrants it, try to get the genetic testing. I do have patients who are telling me, I'm adopted. I don't have any relationship with my family. But I am curious to know.

A lot of times you can do the genetic testing outside of insurance. And I think myriad genetics out of pocket cost isn't more than 250, maybe 249, something like that. I mean, know it's less than $300. So if that's something you're interested in and you feel like, I don't even know my family that much. I don't have a good relationship with the people in my family, which happens to a lot of my patients, or they're adopted, then hey, you know what? Go get the genetic testing anyway.

and figure out if you are at a higher risk. And then, you know, if you get to a point, you're done with childbearing, you wanna go through with surgical menopause and potentially prophylactic surgery to prevent cancer, you know, make sure you're comfortable with the surgeons that are doing it, but this is important. You have to demand a menopause plan before you go to the operating room. This should be in place.

If you have someone that is not talking to you about surgical menopause, then you need to find someone else. And so I think that's really important. And really don't let fear of hormones cost you your health at the end of the day. You need to make sure that you're doing the best thing for your overall health, right? Heart disease is still the number one killer in women. The morbidity associated with osteoporotic fracture exceeds stroke.

heart attack and cancer combined. So there are other things to consider other than cancer. But when you have a higher genetic predisposition to cancer because you are considered a pre-vivor, you have to consider that into your equation as well. Anyway, so I wanted just to review that with you because I did have some patients that we have screened recently that have come back positive. And it's really important for you to know what to do.

and those scenarios and why it's important to get screened and why it's important for prevention, right? We shouldn't be a society that is always acting on the act of disease. We should be a society that acts on preventing disease so that we can improve quality of life and longevity. And so yeah, that's my spiel for you today. So hopefully, you you got motivated to get a little bit of your own health prevention started. And so...

I'm Dr. Smeena Arman, Gyno Girl. This is Gyno Girl Presents Sex, Drugs, and Hormones. If this episode spoke to you or if you know someone that you wanna have this conversation with, a friend, a sister, anyone else, then please share this episode, like this episode, and subscribe to my channel. Remember, I'm here to educate so you can advocate for yourself. Please join me for another episode next week.