JoAnn Pinkerton, MD, NCMP, is theExecutive Director of the North American Menopause Society. She is also a Professor of Obstetrics and Gynecology, Division Director of Midlife Health Center, University of Virginia Health System. I interviewed her at the North American Menopause Society conference in Orlando, in October.
MB I’ve interviewed a couple of practitioners, but what I’ve tried to avoid is everybody’s gynecologist; I don’t think that’s enough, and I’m looking for people who are working on a very high level who have expertise that informs and influences what practitioners do. I would like to ask you about NAMS, because I know you’re the past President and current Executive Director. What has made you so passionate about your work here?
JP As a person taking care of women, I developed an interest in menopause; it’s fascinating—why do people get hot flashes, what happens to their bones, their brains, their vaginas, and how can we help them. I am a believer in preventive health, so I want my patients at 80, 90 and 100 to be in good health with their minds and bodies working. As a practitioner, I found my way to my first NAMS meeting and discovered a multidisciplinary group of people all of whom were looking at all aspects of menopause—neurologists, cardiologists, oncologists, orthopedists—and asking how can we reduce the incidence of disease and make women healthier. So while I was involved in publishing papers and working in research and on a number of different clinical trials I began giving talks, and eventually I was asked to join the NAMS board, which was more of the same about how we educate our providers. The conversations I have in my office every day about protecting your bones or painful sex or fear of hormones—I wanted to be able to address these issues not just in my community but nationally, because so many people don’t have access to an expert. My patients have me and my other colleagues at our midlife health center available to them, and they get to talk about all their fears and anxieties any time they come in. But many women don’t have access to that kind of resource.
MB No, they don’t have access at all, and part of the idea of the Sanity Papers website is to provide access.
JP Yes, and women are frightened, they’re fearful, and if you even get over the decisions to say okay, I’ll take a prescription for hormones—and then they look at the boxed warning, which is the same warning whether I give you a super-high dose of estrogen or if I give you a low-dose vaginal estrogen that has the same level as the one you had before you took it. So you’re always frightened—frightened to take it, sometimes you’re frightened not to take it, and now my biggest passion is to move us away from fear, let our conversation be about individual evidence and what looks to be best for you, and how to maximize your health as we move through this. Does everybody need estrogen—no; are some women going to do better if they have estrogen—yes; but how we balance that out is the question.
MB I’m thinking about my own experience, and really the experiences of everyone I’ve spoken to, and no one has told me that they went to a midlife health center, no one has said that their OB/GYN had any medical schooling beyond about five hours in menopause. I know you’re doing a training program with a thousand people, which is a lot, but not in the context of our population.
JP You’re right. The whole piece about education about menopause is difficult. I have residents who come through my clinic in family practice, psychiatry and internal medicine as well as OB/GYN, but the truth is that the majority of things you do in your practice during training are not about menopause. It’s not until you finish your training and go out and practice that you start running into these questions. Our residents come back and say they want more time, but they have to do so many vaginal hysterectomies and cesarean sections, so we as an organization are struggling with how do we come up with online training, how do we do case-based training so that we can reach out to more people. And I know that there aren’t many midlife health centers, because when my patients move away they come back—they come from Florida and Hawaii, I’ve got people who come here internationally to see me so they can get a mammogram or a bone density, and that’s what women deserve, to have somebody focus on them. If you’re busy seeing patients every ten minutes or you’ve got somebody in labor, it’s hard to sit down and listen to the concerns—I’m depressed, I’m anxious, I’m not sleeping, I’m constipated, I’m leaking stool or urine—and have the time and energy to say let’s try and change that for you.
MB I’m sure that’s true, and I’ve found out at NAMS that there are actually more of these clinics than I knew.
JP Yes, and we periodically hold seminars on how to establish these kinds of clinics. We communicate with each other, and I have colleagues who will come and visit my center, and I also wrote a brochure when I was on the board about how to establish a midlife health center. And now we have newer people coming along setting them up and they visit and talk with each other, because there are issues about reimbursement and how do you get paid because nobody wants to give you the time you need. And education is the way to prevent future medical illness, but again, it takes time.
MB I was told in one of my interviews here that among the problems is that the cash flow is just not there. You’re paid to do surgery or for a referral of some major kind, but doctors aren’t necessarily paid to spend half an hour talking to a patient.
JP Well, you have to be creative. Our center was definitely in the red for many years, and the hospital and the department supported it, but one day we got a new chair and he said you know what, you’ve got to be in the black. So we looked at how that was going to happen and what it needed to look like. Part of it is that I do problems as well as routine care, so I do consults for all the complicated breast cancer patients or those who’ve had stroke or heart attack and are having symptoms, and we have a procedure base for other abnormalities. Part of it is just trying to find your way towards expertise, whether you’re treating bone density or something else, so that you have things that are reimbursed. But it does take time and work to develop a knowledge base, and also to figure out what’s going to work in your particular state. And whether or not you have hospital support is a big issue too.
MB What is the expertise that you have at your disposal—what are the different disciplines?
JP When you do your training you learn about a specific field, but when you come to NAMS you hear from everyone. So, we have a neurologist who talks about cognition, and we learned this year that there is no evidence that taking estrogen at menopause has a short-term affect on cognition, but there are some observational studies that suggest it may prolong the timing of Alzheimer’s disease. We have a cardiologist who talked today about managing lipids—I didn’t learn about heart and don’t feel comfortable managing lipids so I’m going to partner with my patient’s primary care physician for that, but I now know what risk stratification I should be using. I never expected to become an expert in sexuality—it wasn’t something I was interested in—but all of a sudden everybody went off estrogen, and now it’s been five years and they haven’t had sex in four because intercourse is painful, so presently I’m having to learn about dilators and stretching and pelvic floor therapy and how to counsel these women. Another example was mood changes. Our clinic had a psychiatrist—anxiety, depression, I’m sending them to you. Well, it overwhelmed them and they couldn’t handle it, so I had to learn how to recognize and treat basic depression, what are some of the products I could use, and why does anxiety accelerate for some women at menopause. And post-traumatic stress syndrome, I never learned about that, but we certainly have a lot of women who have it—not only returning military veterans, but people who’ve had car accidents, people who’ve had childhood events, these things all come up at menopause, and suddenly you’re sitting in your office and the patient says they’ve just realized they had some bad experiences and are starting not to be able to sleep. You have to know who to refer them to and how to manage that. So those are examples of where NAMS, being so multidisciplinary, is important. For example, I’ll say we don’t know enough about stroke, and so we’re going to bring in a neurologist next year to talk about that—prevention, does aspirin work, what’s the difference between ischemic and hemorrhagic strokes, how can we get those brains back, and what’s the role of estrogen in either preventing or accelerating the risk of stroke.
MB Well that’s a big thing for me because I’ve recently been told that I have a genetic propensity for stroke.
JP Does that mean you had your APOE (apolipoprotein) tested?
JP That’s interesting, because I asked our institution about testing for that and they’re not doing it routinely. I actually want to be tested because my mother and grandmother had really bad strokes.
MB Well, my dad died at 61 and I’m 67, and his father died at 42, though I don’t know of what.
JP My grandmother never took hormones and she had a bad stroke, my mother took hormones and when she stopped them she had a bad stroke. One of the questions that we’ve raised is not only is hormone replacement safe for women under 60 and within ten years of menopause and how do we minimize risk and maximize benefits, but is there a risk to stopping it and if so how do we minimize that, which plays into heart attack and stroke. The question for you is going to be about aspirin, and if so how much aspirin, because that’s one of the issues.
MB There’s the whole question about NSAIDs (non-steroidal anti-inflammatory drugs) which include aspirin and if they’re good or not.
JP Yes, and I don’t know the answer to that question because I’m not a stroke expert, but if you ask me next year what I know about stroke it will be more! I know what stroke does to people, and I know I don’t want to give anybody a stroke. One of the things we looked at in the position statement is that for women under 60 there was either no increased risk of stroke or very rare risk of stroke, but as you age your risk for heart disease and blood clots and stroke goes up, so it becomes more of a concern, particularly if you’re adding in estrogen and progesterone therapy. Maybe the ones that are administered through the skin have less risk, but as women age that’s something we think about in terms of lowering doses and going to the transdermal patch.
MB I’ve just read these extraordinary things about reversing menopause, for example a case in India and another in Germany.
JP You mean where they’re transplanting ovaries?
MB I don’t think they are, they’re doing it with hormones.
JP I don’t know about that, but what I do know is that at menopause you still have ten thousand eggs, and so particularly for all of these young women who go through an early menopause to be able to reverse that would be amazing. I know they’re trying to do some transplant ovaries and they’re having a little bit of success, but it’s not prime time so what you’re talking about is something different. There was also a study on epigenetic ageing. As women go through menopause and their estrogen levels decrease they accelerate their aging, which is reversed if they take estrogen, and that’s part of this complex question of what we call the critical window—is estrogen when given near menopause beneficial, because if you start it in older women it may make everything worse.
I did want to say that anyone can go to the NAMS website (www.menopause.org) and enter their Zip code to find a list of prudential practitioners within various distances of where they live. Every time I have a patient who moves away I utilize this. There are also a number of nurse practitioners and physician’s assistants who’ve gotten very interested in menopausal women’s health, because sometimes going to a busy internist or OB/GYN isn’t going to get you the information that you need. The question for you is where are you now and what types of things should you be doing for prevention. You now know that you’re at risk for stroke, but that also plays into preventing heart disease. And then also how do you prevent fracture—if you’re big-boned you’re less likely to have fracture, but what is your vitamin D level and are you getting enough? And your immune system, how do we help maintain functioning immune systems as we age?
MB It’s so complex, and I don’t make clinical or medical or functional recommendations on my website.
JP Well, you can’t, even if you wanted to. When I have somebody in my office and we start talking, I have no idea where we’re going to end up—I have no idea whether we’re going to end up talking only about prevention because you’re a healthy person, or we’re going to need to talk about additional testing or seeing other specialists, or if there might be a medicine that may have an advantage for you to take. Even when I know what the problem is, there are times I can’t figure out what the answer’s going to be. We’ll do the exam and the history and then I’ll say I want you to think about these things while you’re dressing, and then we’re going to go into my office and see if we can find our way to what seems like a reasonable approach for you. And that’s where the whole individualization comes in, because we’re not all the same, and even if our bodies were the same what’s important to us in our quality of life could be very different. It might be one woman’s need to have vaginal sex; someone else might say their mother had a hip fracture and they never want that to happen to them, so please focus on me so I don’t have a fracture; another woman may have taken care of aging parents with dementia and will tell me I don’t want to have dementia, but there’s a case where the science isn’t there yet.
MB My ex-husband has dementia and it’s not something good to deal with. He divorced me because he was crazy.
JP Part of what happens when you watch somebody who’s developing dementia, particularly if they lose some of their executive functioning, is that they do start doing crazy things, and you can’t tell if it’s their personality, who they’re becoming as they age, or that they have something going on in their brain.
MB What would you tell somebody who is going into menopause about what their first stop should be?
JP Find someone who listens and understands what’s going to happen with menopause, and who is open to helping you navigate through it based on what you want, and that’s probably not going to be a busy obstetrician or family practice doctor seeing patients every ten minutes. If you’re not getting your needs met look around. Some of the hospitals do educational programs, and as I said before you can get good information on our website. There’s a NAMS guidebook for women that I give to each new patient who comes through– it’s easy to read and talks about heart and bone and breast and vagina so you can become knowledgeable. And if your provider doesn’t want you to be knowledgeable they’re the wrong provider.
If women are really having bothersome symptoms and they’re frightened to take hormones, and they’re under 60 or within ten years of menopause, they should know that we have evidence of safety and that it works. It’s also a myth that compounded identical hormone therapies are safer or have no risk or prevent breast cancer. We have FDA approved bioidentical products, so think about using those instead of going the route of doing compounding where there’s actually more risk. And lastly, if you have vaginal symptoms and you buy a vaginal estrogen product and you see that black-box warning, you should know that it doesn’t apply.
MB That last point is important, because I’ve had people who’ve gone off using those creams and stopped having sex as a result.
JP NAMS has a citizen’s petition at the FDA right now—it’s open until November 14th—so if anybody has had an experience where they purchased vaginal creams with estrogen and were afraid to use them, they can write in and NAMS has a link that will let everybody make their comments.