I am thrilled to connect with Dr. Kathleen Jordan today. She is an internist, menopause-certified provider, and the Chief Medical Officer at Midi Health, where she leads a team of clinicians on a telehealth platform serving women across the USA.
In our conversation today, we explore key trends and regional differences in prescribing hormone replacement therapy, contrasting the traditional allopathic approach with integrative care. Dr. Jordan shares her philosophy on lab results and symptoms when addressing estrogen, progesterone, and testosterone utilization and highlights the need to access medications and insurance. We also dive into weight loss resistance, sleep, exercise, alcohol, and the research on GLP-1s.
This insightful conversation with Dr. Kathleen Jordan is invaluable, so you will likely want to listen to it more than once.
IN THIS EPISODE YOU WILL LEARN:
Why many clinicians are reluctant to prescribe HRT
How testosterone use varies across the different states, and the challenges of prescribing it due to its controlled substance status
Why must testosterone levels be monitored?
The benefits of combining GLP-1 therapy with HRT
How does regular exercise improve metabolic health?
Why it is hard to maintain a healthy weight in midlife
How alcohol increases the risk of cancer
The benefits of stress management and optimizing hormone levels for better sleep
Common sexual health issues in midlife
How hormone fluctuations can affect mental health
“There are evidence-based solutions that don't need to be expensive. Some are simple lifestyle interventions, and some are hormone therapies.”
-Dr. Kathleen Jordan
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Connect with Dr. Kathleen Jordan
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I'm your host, Nurse Practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. Today, I had the honor of connecting with Dr. Kathleen Jordan. She's an internist and menopause certified provider. She's also the Chief Medical Officer at Midi Health that leads a team of clinicians that serves women on a telehealth platform in all 50 states.
[00:00:44] Today, we spoke about trends and regional differences in prescribing of hormone replacement therapy, differences between traditional allopathic care versus integrative care, the role of testosterone, her philosophy around labs and symptoms specific to utilizing estrogen, progesterone and testosterone, the importance of access to medications and utilizing insurance, research on GLP-1s, the impact of weight loss resistance, exercise, alcohol, and more. This will be an invaluable conversation with Dr. Jordan and one that you'll want to listen to more than once.
[00:01:23] Dr. Jordan, I've been so looking forward to this discussion today. Welcome to the podcast.
Dr. Kathleen Jordan: [00:01:28] Thanks for having me. I've been looking forward to meeting you.
Cynthia Thurlow: [00:01:30] Yes, I would love to initiate the conversation we were talking about this before we started recording. What are some of the common trends that you're seeing across prescribing practices here in the United States right now for hormone replacement therapy?
Dr. Kathleen Jordan: [00:01:45] Well, unfortunately, I think there's still a lot of hesitancy around prescribing hormone replacement therapy. There is more conversation around it. I'm certainly in more conversations around it. There's menopause is hot. There's more headlines. There's New York Times articles. But I went to the Menopause Society Conference this year, and still there were two posters looking at prevalence percentage of women postmenopausal that are on hormone replacement therapy. And it was crushing. One study showed 2% and the other showed 4%, both low and both not seriously impacted.
[00:02:19] Now, I do have to qualify that and say that it's very hard to collect the data that's why there's differences in the two. And they don't pick up people getting compounded. But I would say we're not even close to double that. And it's not half of women getting compounded. So, we're still in single digits of women receiving hormone replacement therapy. I don't think hormone replacement therapy is for everyone, by any means, but I do think it's for more than 2% or 4% of women, for sure. And I don't think enough women are having informed conversations around it. And there's still a lot of hesitancy in community clinicians.
[00:02:55] So, our patients love their brick-and-mortar clinician from their hometown, and they come to us on telemedicine, and they're coming to us because they've listened to your podcast and they've read about it and they understand some of the benefits of hormone replacement therapy and they're seeking that conversation. But too often they're met by their local clinician with I don't know or they report getting a shrug or just this is part of aging, bear with it, kind of response. So, we don't have enough informed conversations going on in those clinic offices. And that's really why we created Midi. I've been hoping to impact that for women across the U.S.
Cynthia Thurlow: [00:03:34] Well, I think it's so needed. And I talk to fellow nurse practitioners, physician friends, who they themselves are navigating perimenopause and menopause, and I laugh at some of the conversations that they will share, either that they've had with a GYN or an internist where they've talked about, “Yeah, you probably could benefit from some vaginal estrogen.” And they're like, “Well, are you going to prescribe it for me?” And they're like, “Oh, I'd prefer the GYN do it or I'd prefer this person do it.” It's almost like there's still this fear and concern over replacing hormones.
[00:04:05] I still think that the WHI, the Women's Health Initiative, has a lot of clinicians still fearful, even though we've spoken certainly extensively on this podcast, some of the limitations related to that study, how much of it is provider discomfort or the desire not to have to learn more about what options are available for patients. Do you think it's a combination of things? The lack of education for most clinicians combined with some fear of the potentiality of problems. I say potentiality, we really know that it tends to be very safe for most individuals.
Dr. Kathleen Jordan: [00:04:44] I do think it's multifactorial. I do think that the amount of science and data coming out in healthcare is enormous. We have national databases. You know, I read somewhere that the amount of medical information actually doubles every 72 days. So, it is impossible to keep up on everything. And what tends to happen is we lean into curing illness. So, we're looking at how are we going to save the person in the hospital. And so much of our medical education, and mine included, I was really hospital based for a long time, was really focused on curing illness. And when you get into things like menopause and managing midlife care and hormone replacement therapy, even the word replacement is actually controversial. It's really talking about wellness. So, really, we should be keeping people well.
[00:05:34] And that's really not been the focus of our healthcare system either in education or in care delivery. So, I think people are interested in it. It's been pushed and pulled by really the anti-aging community, which for good or for bad, what they're doing. They're getting people interested though in how to live well and how to live longer and they're putting data out there, some of it well informed, some of it not my cup of tea. But they are actually drawing people and it shows that people are interested in wellness, not just illness.
Cynthia Thurlow: [00:06:08] Yeah. I think it's so important because I say this with great love. I'm in my 50s, I am currently doing some physical therapy, occupational therapy after a fall. Thankfully, I didn't break anything, but I had a pretty good sprain and a good bone contusion. And I was saying to the physical therapist this morning, I'm like, “I'm probably your healthiest person that you have here and I'm so grateful that I can do physical therapy to improve my functionality because I don't want to get a frozen shoulder.” And she was saying that, “She's younger and she was talking about some of the shifts that she's seeing happening.” She's like, “We're starting to get people who have like a minor injury that are requesting physical therapy, occupational therapy because they don't want to lose functionality.”
[00:06:49] And I said, that's fantastic. Although I looked around the room and I was easily significantly younger than everyone else, which is okay. But I do agree with you that the anti-aging movement or the proactive preventative health movement is starting to gain tremendous momentum because I feel like our generation is demanding better care for themselves than maybe like our parent’s generation might not have been aware of their own advocacy, the own things that they could be asking and requesting for. And I know when we're talking, prior to starting the recording, you have been witness to some practice variations about hormone replacement therapy. We don't have to speak specifically about which states, but what are some of the practice variations that you're seeing within the prohormone replacement or replenishment movement when you're looking broadly at clinicians.
Dr. Kathleen Jordan: [00:07:41] I think probably the biggest variance that we see, because we're in all 50 states and we started in California just because founders were there, so we have the longest experience there. But as we grew into other states, I think the biggest difference was in testosterone and both the level of consumer interest in testosterone as well as what the current community are doing. And I think testosterone is super interesting. It's not part of routine hormone replacement therapy or hormone therapy as people are now calling it. Generally, hormone therapy is estrogen, progesterone and then probably the best, most accepted by the medical community's broadly use of testosterone for women is for libido. And that's really based on-- it was really a smallish study that was in The Lancet that didn't actually have the best outcomes.
[00:08:29] It showed you libido was a little bit better. But for whatever reason, it was a major publication. The study itself was done well and that indication is broadly accepted. I'll just say in Texas, though, which is home of Biote, which is a company that's long been using testosterone and actually does a lot of community education of providers, there's much more interest in testosterone as well as much more baseline use of testosterone. And remember, testosterone is not approved for women at all. It's for men. [laughs] So, women take about a tenth the dose that men take, and you have a narrower therapeutic window, which means that if you float too high and you're dosing, you can get some negative effects, such as male pattern baldness, acne, facial hair, things you probably don't want.
[00:09:21] So, for women, you have to be tighter on the dosing, and it's definitely lower dosing than in men. But there's a lot of interest coming from patients in these communities. And there's a growing amount of literature. I love the stuff Lisa Mosconi does from Cornell and the menopause brain. There's a lot of emerging things on testosterone. In men, we've known for a long time that it helps with muscle mass. In fact, that's why it's a controlled substance, I think, is people, bodybuilders and athlete types were abusing it. So, it's regulated in the Olympics.
[00:09:51] So, it's a very regulated drug as well, which is a barrier to getting it out there. But we've long known in men it helps with muscle mass. In women, we know we're more prone to osteoporosis, we're more prone to fractures, we're more prone to debility, we know that muscle mass impacts bone health. It affects our fragility and whole aging process. And there's been a few studies in women that show testosterone can help, but there's some different interpretations of that. Is it enough to start recommending it routinely in women? Probably the most societies say no, some people say yes. So, that's where we're seeing some variation in practice patterns.
Cynthia Thurlow: [00:10:35] Yeah, it's interesting to me because whether it's 25% of women or 40% of women, not every woman in perimenopause and menopause per se needs testosterone replacement therapy. So, there's certainly that perspective, I think, about different routes of administration. So, I have some colleagues that are using an Androgel pack and they're dosing one tenth of the pack, which is really hard for people to manage, probably getting a little underdosing and overdosing at a time. Then we've got compounded creams. Then I've seen some practice variations that are looking at other routes of administration, even subcutaneous or intramuscular. And so, what has been your high-level perspective in terms of-- what is the research suggesting or what has been your clinical experience?
[00:11:25] Obviously, bio-individuality is certainly important, and I know you and I are probably both more on the conservative end, but when you're seeing those practice variations, what does it suggest? Is there one route that's better than others or do you tend to be conservative as well?
Dr. Kathleen Jordan: [00:11:40] So, as I mentioned, the women's dosing is about one-tenth the men's. The only FDA-approved products on the market are for men. So, you'd be telling people to take one-tenth of a packet, which is, as you mentioned, just logistically tough to do. But in fact, because of regulations, because it's a controlled substance, we're not allowed to give you 10 month’s supply. So, I cannot order you a month supply for a man and tell you to do a tenth of it. It varies by state, but the most I can give usually is a one-month supply with refills to three or you can do up to five months in some states.
[00:12:15] So, just by regulation, I really shouldn't be giving anybody the male formulation unless you can convince a pharmacy to break up the packaging and give you sort of a third of a month of men's supply but most don't do it. So, because then there is no FDA-approved formulation for women and the regulations don't allow me to give you the mass quantities of a male and tell you to break it up. We are using compounded for testosterone for women who are seeking solutions that testosterone may help with.
Cynthia Thurlow: [00:12:46] Yeah, I think that for a lot of people it's both reassuring that they can have a compounded dose of testosterone that's designed for them, it is made for them based on their physician, their nurse practitioner’s stipulations. When you are prescribing hormone replacement therapy, are you monitoring with blood, with saliva, with urinary metabolites? Do you have a preference or do you just go based off of symptoms? And the reason why I'm asking this, it's not to put you on the spot. For listeners, there's so much practice variation and this is where medicine is art and a science and for many providers it's really figuring out what works best for their patients. And so, how do you go about monitoring? Is it all based on symptoms or are you also looking at concurrent lab work?
Dr. Kathleen Jordan: [00:13:32] Oh, I love this question. So, putting in the setting of hormone replacement therapy in general, I will say for estrogen and progesterone, you don't really need to go by levels. The guidelines, the experience, the published literature supports actually doing quite a bit on clinical symptoms alone. That doesn't mean we don't do levels for those things because I think if you present an atypical age, I would do levels. Or if you're uncertain if the symptom is classic from perimenopause in particular, you might do lab work, but you don't need to do lab work for estrogen, progesterone. Testosterone is different and I mentioned there's a therapeutic window that's smaller, which means that if you give too little, you're not going to get the benefit of it. And if you give too much, you may get into some changes and most of those changes are reversible. But there is evidence, however, that the deepening of the voice and the voice changes are not reversible.
[00:14:25] So, I don't want to float people into too high levels and have any irreversible changes. So, if we are going to do testosterone replacement at Midi, we usually get baseline levels which will help us give us a better estimate of your appropriate dosing. And then we'll check a level once you're at your symptom relief zone and make sure that we've not floated too high. So, we do usually have you get at least those and then occasional levels just to make sure it hasn't changed much. But what's interesting is we check baseline levels and you mentioned before that people are coming, taking it different ways.
[00:14:57] We get some patients that come, they're converting from pellet therapy. So, pellets are not covered by insurance. They're put in subcutaneously usually in a clinician's office and they emit hormones over months and months. First of all, once they're in, they’re in. You're not getting them out. And then it's hard to control and know when the levels come off. So, they want to convert to more insurance covered care, so they'll come to Midi, for example. But they like the way testosterone made them feel. So, we check baseline levels and it's been amazing. We have gotten women whose levels are 10, 20 times what they really should be for women. So, I think if you're going to do pellets, [laughs] it's not generally what we recommend. I think I would prefer more control and a titration that you can get with transdermal or orally administered drugs. But be careful because the dosing in it can be way off. And once they're in, they are in.
Cynthia Thurlow: [00:15:56] Yeah. It's interesting. I was actually at an event that Dr. Pam Smith was speaking at and she was giving the example of there was a patient that came to her, she has practice in Florida and Michigan and I can't recall which location she was at, but she said she had a very young woman, late 30s, had their first MI, so first heart attack in their late 30s. And when they looked at her lab work, her total testosterone was in the 700s. And for listeners like we have a much narrow, remember, we need one-tenth of the dose of men. And she had gotten this whopping dose of testosterone in a pellet and in her body it really became problematic. And Dr. Smith was talking about how they were going about addressing this.
[00:16:42] Obviously, this young woman was so young and they're like, “These are the severe side effects you mentioned. You can get clitoromegaly, you can get permanent voice changes.” So, it's not to suggest that some of these outlier options may not be a good option in the hands of a very attuned conservative practitioner. But by the same token, you have to be careful. That's why I think it's so important to go to a clinician to not go to like a pellet mill or a freestanding clinic where they don't have providers that are actually hands on determining what the correct dosing, whether it's compounded, whether it's a patch, whether it's oral micronized progesterone, etc.
[00:17:25] And let's talk about the fact that for a lot of individuals, they want hormone replacement therapy, but it becomes cost prohibitive because so many of these products are not per se covered by insurance. What has been your experience about women that come to you that are like, “I'm on a budget or I need to be conscientious of the cost of things?” How do you go about, you know, talking to them about their options versus individuals that are like, “Cost is no concern. I can have everything compounded versus individuals that are trying to be conscientious about costs.”
Dr. Kathleen Jordan: [00:17:59] Well, access to ongoing care is really going to best delivered with what's covered by insurance because people may do it initially, then they lose their coverage or they lose their disposable income or expendable income. So, we at Midi try to do optimized insurance covered care. So, our most typical prescriptions are going to be for very commonly available hormone patches from your local pharmacy, micronized progesterone. These are bioidentical. I think people confuse bioidentical with compounding. You don't need to be compounded to be bioidentical. So, there's FDA-approved, insurance-covered hormone therapies for estrogen and progesterone, not for testosterone, unfortunately, that are covered really by almost all insurances. There's even generics available for both of these. So, if you don't have insurance for whatever reason, there's actually fairly affordable solutions for that.
[00:18:55] So, compounding just means that you're having a pharmacy drop a unique formulation for you. It can be expensive because they're making a unique formulation for you. We do use compounding for some things and women's health is long driven compounding. So, for example, the micronized progesterone that we use, typically the formulation that's in the FDA approved has some peanut oil in it. So, if you are highly allergic to peanuts, you need to have a peanut free custom formulation. So, then we would use compounding. For testosterone, use compounding for the reasons we talked about before. So, women's health has long been the consumer from compounding pharmacies. Now with the birth of GLP-1s and that compounding that's really exploded the compounding industry, as more people access it, and it's gone beyond women's care. But women's health in general has leaned into compounding for decades.
Cynthia Thurlow: [00:19:47] Yeah, it's so interesting. And again, we were talking about some research earlier, prior to recording, about the utilization of GLP-1s alone versus hormone replacement therapy and also GLP-1s. Can we speak to this? Because I think this is really interesting. I think that GLP-1s in many ways revolutionizing the care that we're delivering to patients if they're being used properly and judiciously and emphasis on properly and judiciously. I have many, many patients that have been prescribed GLP-1s by their providers. They come to me and they talk about how being on tirzepatide, which is a second generation, suddenly they have all this quieting of cravings. They used to be craving food all the time and now that's all quieted, it's gone away.
[00:20:34] They've finally been able to stick to more nutrient-dense whole foods diet than they were before. But what is the research suggesting when we're looking at GLP-1 utilization versus GLP-1 in concomitant use of hormone replacement therapy too?
Dr. Kathleen Jordan: [00:20:50] There's been a few trials, there's been early small trials that look at use of hormone therapy with GLP-1s and they've compared it to postmenopausal women who don't take hormone replacement therapy and look at GLP-1s and the early evidence, and these were not large-scale trials. They had less than 100 participants, 106, I think, was the participant. So, if you are on hormone replacement therapy, you actually have an improved response to GLP-1s, which should not be surprising. We have long known. This was in the WHI trial, that our hormones and taking hormone therapy actually impacts our metabolism. So, you take hormones, you sleep better. Sleep has long been connected with poor sleep, weight gain, good sleep, weight loss. We know from the WHI trial if you took hormone replacement therapy, you had 20% less diabetes.
[00:21:45] If you had diabetes and you went on hormone replacement therapy, you had better glucose control. So, we know that hormones help with our metabolism, it helps with our insulin sensitivity, it helps with how we use energy. So, it's not surprising then that if you look at persons seeking weight loss and going in GLP-1s and you add hormone replacement therapy into the mix, you're going to have better response rates. And that's what we're seeing. So, now they're doing larger trials. But I can tell you, we serve women, hundreds of thousands of women across the US and 87% of the women that come to Midi will say when asked that they are struggling with weight management. Because we know menopause makes you struggle with weight management. It changes your metabolism.
[00:22:30] People say, “I'm doing the same thing I've done for 20 years, but I'm gaining weight and suddenly I've gained 30 pounds.” It's crept up on them with the changes. So, we know that menopause brings extra challenges with weight management. And we actually know that hormone therapy can actually help with quite a bit of these metabolic changes. It helps with glucose metabolism. It changes your lipid. It changes central adiposity. So central weight gain is a bad predictor for cardiovascular outcomes. So, it changes your weight distribution to be a healthier weight distribution.
Cynthia Thurlow: [00:23:05] Now they're also very important. I feel like the weight loss resistance piece is probably the most common complaint that my team and I hear about that women are the same thing that you just said, “I'm doing everything I used to do and now it no longer serves me.” The only time in my life I've ever experienced a degree of weight loss resistance was actually in perimenopause when I was fully in the throes of it and didn't fully recognize it. And it wasn't until I really dialed in on the lifestyle piece, which mine wasn't all that bad. So, it just goes to show you that it really does make a big difference, that weight loss resistance piece became less problematic. What are some of the other contributory factors to weight loss resistance? What is it about lifestyle in middle age that really can set us up for success? Or the opposite, actually failure with maintaining good metabolic health, maintaining a healthy weight, etc.
Dr. Kathleen Jordan: [00:24:01] I mean, I think that there is an increasing appreciation about the role of exercise. And myself included women, I think people in general clinicians looked at like, “You run on a treadmill for an hour, it burns 400 calories.” So, it's not just about the calorie count of exercise and energy expenditure. It actually changes your metabolism. So, exercise, I mean, it definitely impacts lean mass and it also impacts bone health, which is good for women, and women have challenges there, particularly postmenopausal, but it actually changes your insulin sensitivity. I like to try all our treatment programs at Midi. So, I did an experiment where I wore a glucose monitor for a few weeks, and I did different things every day, but I ate the same thing.
[00:24:53] So, one day I exercised before and one day I didn't. And it was a very different experience on my glucose monitor based on whether I exercised that morning or not, but that was eating the same thing. So, this was after and it affected my glucose for the whole day. And exercise in the day also changes our serotonin activity. So, it actually helps you sleep at night. So, it can be a part of stress management. It's definitely a part of bone health. It changes our metabolism, and I think it does combat frailty, which is really the looming. I think many women want to avoid right. Midlife, you're taking care of your aging parents or you're seeing your aging neighbors or colleagues, and you're really aware that that's what's coming. And what we do now in our midlife really affects our 60s, 70s, 80s, and hopefully 90s.
Cynthia Thurlow: [00:25:44] No, I think you bring up so many good points, and I think for anyone listening, Dr. Lisa Mosconi speaks to this, that we set up our brains for later life in our 40s and 50s. So, it's really important that we're managing lifestyle. And I think our generation was conditioned to believe that fat was bad, more heart-healthy grains, really teeny, tiny portions of protein. And I feel like the movement is starting to shift, it's not to suggest that one macronutrient is better than any other. It's helping people understand that as we're getting older, we actually need more protein. We need the right types of carbohydrates. We need healthy fats, but the right types of healthy fats.
[00:26:30] Where does alcohol fit into the mix when you're talking to patients? Because I feel like, I was never much of a drinker at all. I would be the social drinker. I'd have a martini once or twice a month. But I started to notice that every time I drank, it was the only time I would get night sweats. It was the only time I would experience significant vasomotor symptoms. What is it about alcohol that can be challenging for us to navigate in middle age?
Dr. Kathleen Jordan: [00:26:51] Ooh, that's a big question. I think we're learning a lot about alcohol, right? So, we've long known alcohol disinhibits our sleep. It's poorly impacts our sleep. So, separating alcohol from sleep in time is definitely good for you. And sleep, we know, has many health impacts. I mean, it's tied to cardiovascular outcomes, all sorts of things. So, it negatively impacts sleep. I think what people don't realize also is that there are seven alcohol-related cancers. So, drinking alcohol-- and so what is too much is actually a question that's being debated about quite a bit. So, WHI and some others really loosely categorize as less than seven drinks a week, 7 to 14 drinks a week, or 14 or more and that's low, medium and high.
[00:27:38] But what's super interesting is if you have one more drink per day increases your risk of some of these cancers by 10%. And one of these cancers is breast cancer. So, your baseline risk is one in eight women will get breast cancer. And if you're drinking more than 14 drinks per week, you have a 60% increase. So, that's a lot of women. So, alcohol alone is attributed to over a hundred thousand cases of breast cancer. So, probably any amount of drinking is not positively impacting you. But definitely less is better than more. So, it is incremental. So, it's more about having that decision when you decide to have alcohol. And I love the growth industry around mocktails and I've certainly, I mean, I throw parties, have people over, you have a bartender, you serve wine and drinks. I live in California, we have wineries. But I think increasing offerings around non-alcoholic ways to have community is really a positive influence on our overall health.
Cynthia Thurlow: [00:28:41] Yeah, it's interesting more and more events that I go to in the health and wellness industry, less and less people drink alcohol. And it used to be that I was the outlier when I would go to events and it would make people uncomfortable when they would say, “Would you like a glass of wine? Would you like a spirits? Would you like a beer?” And I'm like, “I don't drink.” And then instantly people feel uncomfortable. And I'm like, “Listen, I'm really good with sparkling water with a lime in the side.” No one knows the difference. I'm totally in a good place with this. But I do love that there's growing awareness around the use of alcohol, alcohol use disorder, growing awareness around the risks around alcohol, and then helping patients make decisions about, “It's the holidays. I want to have a glass of wine on Thanksgiving. Great. I want to have a martini on Christmas or whatever holiday that you're celebrating.” But knowing that daily use of alcohol is probably something to discourage or to at least help patients understand their own risk profile specific to that lifestyle choice.
Dr. Kathleen Jordan: [00:29:40] Absolutely, I think it's hard to just be absolute and say absolutely no drinking. But I think people should realize they're making a choice when you choose to have a wine or a drink. The other thing that's interesting about alcohol is that one of the few health risk factors that is actually worse if you're college educated and if you are in a higher socioeconomic group. So, I think it's about two-thirds of Americans drink, but if you're college educated, it's over 80%.
Cynthia Thurlow: [00:30:05] Really?
Dr. Kathleen Jordan: [00:30:06] Yeah. So, the more education you have and the more money you have, the more you drink, apparently. So, it's one of the reverse risk factors. Typically, we see it going the other way. I do think it does mean some social circles are drinking more than others.
Cynthia Thurlow: [00:30:21] Yeah, it makes a great deal of sense. And where does conversations around sleep disturbances. How to get good quality sleep. As we're navigating these hormonal changes, which I think for many people, they don't realize that progesterone and estrogen have a significant impact on initiation of sleep, staying asleep. And why educating people around this as an example, I'll have women say, “Oh, I started progesterone, I have no trouble falling asleep, but I still wake up in the middle of the night.” And so, helping them understand that there is some hormonal play around here along with cortisol. Like how many of us are just chronically stressed? And part of what's precipitating waking at night is either dysregulated cortisol, dysregulated glucose, could be so many factors.
Dr. Kathleen Jordan: [00:31:07] Well, sleep is really complex. You need stress management. I think optimizing hormones definitely helps. It's one of our most common presenting complaints at Midi. But I'm proud to say that over 90% of people are sleeping better after two months. And we don't really use sleeping medications. We use some supplements, some lifestyle adjustments, progesterone. And then it matters with progesterone what type you take. So, the bioidentical and sometimes the higher dosing actually helps with sleep more than the synthetic progesterone. So, it varies. And if you're in perimenopause, often you're getting the synthetic progesterone. But I think in perimenopause is when people are really hurting on the sleep factor. So, there is a role to have an informed conversation around what you're taking, how much you're taking, because it does impact sleep. But it's not all about hormones.
[00:31:54] It's stress management, it's eating, it's drinking alcohol, it's sleep environment. I think if your room temperature is, I think 67 degrees is the optimal room for sleep. If you're having night sweats, it clearly impacts sleep. So, you need to do all of that. And it's not just a come get one thing, leave with a pill and then it's better, which I think is really what's happening in healthcare. And I have to say I did that. So out of training, you take care of their acute illness, they ask you on the way out the door, I'm not sleeping. You think they want as needed sleeping meds and you write a prescription, we'll have this for your bad nights and leave. But sleep is much more complex than that and really needs dedicated attention.
Cynthia Thurlow: [00:32:38] Yeah, no, I completely agree with you. And it's funny how when I was a new nurse practitioner years ago, I took Ambien, the first six months intermittently because I would wake up in the middle of the night and I'd be convinced I had forgotten to write an order. And this is back when there was no electronic medical record, it was a pen to paper order. And that's how it worked. Thankfully, we've evolved now to electronic medical records. But having said that, these episodic times in our lives when sleep is disrupted, it could be, you lost your job, you're going through a divorce, there's a move, someone in your family is sick, you're just not sleeping as well.
[00:33:13] And I agree that, pill may help in the short term, but ultimately, we do have to adjust our lifestyle. We do need to sleep more than four or five hours a night. I still see women that will disclose how many hours a night they're sleeping. And I'm like, “You need another hour or two.” Let's get into bed 30 minutes earlier, let's try to carve out that time. Like stop doing the laundry, stop getting on email, like, go to bed, you're going to better served. I think in many ways we sometimes can, what we can navigate and get away with when we're younger as we're navigating this middle-age sandwich, I'm going to use the term that another guest used, the middle-aged sandwich. As we're navigating this, it's recalibrating and forcing us to make changes to our lifestyle that allow us to better serve our own needs.
Dr. Kathleen Jordan: [00:34:02] Right. And prioritizing sleep, I think should be one of the needs we prioritize. And it's super hard. Jobs have increasing responsibility. Sometimes, there's financial pressures from either looming retirement or kids at college or whatever. So, it can be a very stressful time. And prioritizing sleep is helpful. I do think that's one of the benefits of people not commuting to work though. You get that I've certainly gotten my extra 45 minutes. I've put it towards sleep rather than commute time. And that's actually been very helpful.
Cynthia Thurlow: [00:34:33] Yeah, I think that the pandemic in many ways forced us to recalibrate our lives. It's like, “What was I not doing a good job with?” And if it's, you're not commuting for an hour and a half every day. My husband was commuting 45 minutes each way for years and years and years. The pandemic happened and all of a sudden, he was like, “Oh, I can sleep a little longer. I can maybe get my exercise in.” It's amazing, how that changes and shifts things. You mentioned supplements so specific to sleep disturbances. Are we talking about adaptogens? What types of supplements? Again, a high-level thing. We're not giving specific medical advice. What are some of the supplements that you find are helpful for women navigating, waking up in the middle of the night or overall sleep support or helping to buffer cortisol response?
Dr. Kathleen Jordan: [00:35:20] Yeah, I think we talked to them about what their sleep is like. Is it falling asleep that's the problem or is it getting up in the middle of the night? Do you have stress and anxiety? I mean, if you have hot flashes and night sweats at night, you're going to have more of an impact if you're managing the temperature of the room and actually managing the hot flashes, that's going to positively impact your sleep. How many hours are they sleeping? Maybe it's more about a schedule thing or there are some people that just come in, they have high stress anxiety. I think it's over half of women in midlife report pretty high stress and anxiety. So, if you're going to do that, we may talk more about things like ashwagandha and things that might decrease your stress. Whereas if it's more pure sleep and you're not having stress. We may talk to you more about magnesium glycinate, things like that.
Cynthia Thurlow: [00:36:07] No, I think they all can be certainly very helpful. And one thing that we haven't talked about today is sexual health and libido. And I think for so many women, they're sometimes embarrassed to have these conversations, they're uncomfortable. Where do you tend to focus your efforts when a woman reports that she either has painful sex, she's having recurrent urinary tract infection, things that are suggestive of, you know, there's this horrible acronym, GUSM, genitourinary symptoms of menopause. It's not a question of if but when. It seems seemingly like it will happen to us to some degree or another. But I do find that women that are taking systemic estrogen tend to do better than women that are not on systemic estrogen. By that I mean transdermal absorption. So, skin absorbed estrogen tend to have less of those sexual side effects.
Dr. Kathleen Jordan: [00:37:03] It's very funny. I think a lot of women come in saying, I don't have any libido and they phrase it as libido, but libido is really desire. So, that's very different than painful sex and not sleeping. So, we asked everybody. So, instead of just listening to what they want to tell you about, let's look at this holistically. Okay, so, you're not sleeping [laughs] actually you have vaginal dryness and pain with sex. So, I can give you all the medications in the world to try to boost your desire, but it's not going to work and then there may be relationship issues. So, it's really kind of multidisciplinary. So, often the genitourinary syndrome of menopause, which really more simply, it's driven by changes in vaginal and vulvar tissues from the estrogen depletion.
[00:37:52] So, you get a lot of dryness, you get pain. Two-thirds of women have it. Not enough women will come in and realize that there is really easy solutions for this. There's cream, there's insurance covered, stuff you can get from your local pharmacy. So, we send in the prescriptions. There's estrogen-based creams, there's vaginal moisturizers. So, you can do hormones, you can do nonhormones, you can do systemic hormones, you can do topical hormones, you can do moisturizers, and then you can do lubricants. You can also do pelvic floor therapy, it sort of depends but I would say many, many women benefit from systemic hormone replacement therapy plus/minus the topical hormone replacement therapy. And if you truly have genitourinary syndrome of menopause, you probably need to do something topically, which there's a thing called Estring.
[00:38:39] There's a ring that emits for three months. You can do a simple cream that you just apply yourself, post the shower a couple times a week. So, simple, easy, really cost-efficient solutions. We tend to make sure that's first a lot of times then the libido issue has improved. But there are also libido specific medications. So, there's Addyi, there's Vyleesi, and then there's data that testosterone helps. So, but we tend to get you sleeping better, solve the vaginal dryness and pain issues, and then have a conversation around libido. And I'll tell you, at that point, we have many women who no longer have a libido issue.
[laughter]
Dr. Kathleen Jordan: [00:39:22] Because it's hard to desire it when it hurts, tight? So, that's how we think about it. But then there are specific things to libido that you can actually do.
Cynthia Thurlow: [00:39:33] I think that for so many women, it's tough having those conversations, even if they are feeling like they're in a safe place, they feel comfortable with their clinician. I think there's still some degree of taboo and discomfort. I mean, there's obviously extremes. On social media, it goes one extreme to the other. But I do find a lot of women, they feel tremendous shame about having those conversations, and yet they love their partner, their significant other, but they're trying to figure out what they need to do specifically. And it sounds like there's a very comprehensive approach that is exceedingly helpful.
Dr. Kathleen Jordan: [00:40:06] Well and I think we just routinely ask it, and I think the fact that we're routinely ask it makes people realize that it's a normal thing. So, we normalize it a bit. I think your podcast is normalizing it a bit. I think the books, I think this whole movement about menopause is hot. It’s sort of making like normalizing it. I have a patient who, it's funny, I do some employer education webinars. I'm on a webinar to a software company. Thousands of people are on it. But I see my patient is on it and I'm thinking, well, what is she getting here that she's not getting from me?
[laughter]
And, in her next visit, she said, it was just very comforting for me to know that people in my building were actually going through the same thing. She said, didn't really go for more information. I went just for that.
Cynthia Thurlow: [00:40:51] The community.
Dr. Kathleen Jordan: [00:40:52] The community. And really understanding that it's normal. Its normal.
Cynthia Thurlow: [00:40:56] Well, and I think on so many levels, and this is where I think the mental health piece comes in. There are so many women that are suffering either from depression, anxiety, overall, a mental lability. Someone said to me, it wasn't until I got in hormone replacement therapy that I realized I didn't hate my spouse. I actually was just grumpy because my hormones were low. And so, I think on a lot of different levels, it's helping women understand that this is such a common—So many of these symptoms are so commonly experienced. We may not be talking about them. Because nurses talk about these things all the time. And it's funny to listen to my nursing friends because they're so open about what they're experiencing.
[00:41:38] I tell them, like, you need to talk to all your friends about this. It's so important that we normalize our experiences. When we're talking about mental health and a patient comes to you and maybe it's depression and anxiety, maybe it's overall just irritability. I think irritability is what I seem to hear more often. People are just like, “I'm irritated by everyone.” It's like, it's not just pejorative towards one person. I'm just generally irritated. Where does lifestyle plus/minus hormone replacement therapy fit in? And when do you feel like you're at a point where we have to look at antidepressants, antianxiety agents? Where does that come into the picture?
Dr. Kathleen Jordan: [00:42:18] Wow, It's a big topic. I'm picturing. I have a patient. I'm just going to tell you to normalize it. The woman, she was doing her visit from her car, just crying and upset. She said, “I was just really mean at work. It's not me. It's not me.” So, first of all, it's happening. And I think the hardest time is actually perimenopause for this. So, in our fertile years, which for most people, 20s, 30s, our hormone levels are super high in the hundreds, 400, 500 below 10 post-menopause. But that roller coaster of perimenopause is really tough. And I think the stuff that Lisa Mosconi does with the brain initiative shows that the swings are actually worse than the nadir, if that makes sense. So, very stressful. But also realize it does impact like serotonin, norepinephrine, and GABA.
[00:43:14] There are physiologic challenges that you're getting from these hormone swings. I am a huge fan of hormone replacement therapy because I think it takes that swing out of perimenopause. I mean, birth control pills are progesterone and estrogen and actually really take the swing out because they control ovulation. So that's going to really flatten that curve and prevent some of these swings. Hormone replacement therapy later in life, do the same thing, but you don't have to worry about ovulation because you're not ovulating at that point. But you can also use hormone replacement therapy in perimenopause, which can help as well. So, I am a fan of hormone replacement therapy as method. I don't think it's the only thing needed.
[00:43:55] I mean, there's relationship stressors, there's job stressors, I think there's stress management techniques, whether it be yoga or exercise or mindfulness apps or relationship work. Sometimes it's a job change, maybe the job. [laughs] So, it's multifactorial. But first understanding that it's happening and triggering and then working on it is helpful. I mean, our role in it, because we are clinicians is really supporting with hormone replacement therapy. We find that to be effective, but also introducing them to other lifestyle things that they can do to gain control again.
Cynthia Thurlow: [00:44:31] Yeah, it's so interesting to me, like when I look back retrospectively as a new mom, like in my mid-30s, in my late-30s, not realizing that some of the trouble sleeping, the anxiety around my cycle was probably the very beginning stages of perimenopause. And yet we sometimes don't have those conversations with our patients until they're a little bit older. And yet they've been navigating many, many years of changes and fluctuations in hormones that are impacting not just their physical health, but also their mental health. Where do you see trends going? You obviously are part of a very large organization. You see lots of practice patterns throughout the United States. What are some of the trends that you see emerging heading into 2025 with regard to care for middle-aged women?
Dr. Kathleen Jordan: [00:45:18] I think the most exciting thing happening for women's health to me is GLP-1s right. And it's not about weight and aesthetics. There is a lot in there. There's a lot in there. There's huge potential neuroprotective effects, cardiovascular avoidance, improved longevity, decreased inflammation, changes in dementia and Parkinson's. And remember, women are disproportionately affected by all of this. We live longer, we have more Alzheimer's disease, we have more of this. We have more autoimmune disease, more inflammatory conditions, and we're disproportionately affected by obesity. So, I think the GLP-1s are incredibly exciting and they are going to impact our longevity, our life expectancy, our quality of life everything, cardiovascular outcomes, everything. And I hope it prevent, and I think they're going to prevent hundreds of thousands of women from being in nursing homes post strokes, things like that.
[00:46:12] So, I am super excited to be part of this rollout. I trained in the era of HIV, so it was scary. We had no cure. Now, we have a cure. Now, if you are on therapy, your life expectancy can be the same if you stay on antiretrovirals. It was hugely exciting to be part of that and really offer a solution that worked. This is the same thing. We are making women live longer. So, if you are morbidly obese, your life expectancy is 10 years less than someone else. So, I see midlife women. So, if your life expectancy is 75, your now life expectancy is 65. And I'm seeing you when you're 55. So, you have 10 years. So, I can get you out of GLP-1 and double your life expectancy, like it's huge.
Cynthia Thurlow: [00:47:03] It's really exciting and it's interesting. I came about into medicine. I trained in Baltimore during the HIV, AIDS crisis and I can recall taking care of patients that were younger than me that were dying of HIV and AIDS. And it is exciting to see these kinds of evolution not only in treatment for, not just middle-aged women, but metabolic health overall and looking at long-term causality, long-term mentality seeing the quality of life. Because women, yes, we statistically typically will live longer than men, but once we become menopausal in many ways, our quality of life starts to diminish. And this is why it's so important to help women understand what's happening below this surface.
[00:47:48] I have a lot of women that will reach out and they'll say, “I feel great, I'm middle aged, I'm menopausal, I'm not in hormone replacement therapy, I sleep well, I eat well, I exercise.” And I always say, “There's stuff brewing beneath the surface that many people do not realize.” And inflammation, oxidative stress, insulin resistance is slow and simmering all the way along. And so, I love that you are bringing greater attention to a lot of these, very needed topics. Please let listeners know how to connect with you, how to connect with Midi if they would like to do telemedicine to have access to physicians and nurse practitioners that are licensed in their state that can talk to them about their own unique needs and goals.
Dr. Kathleen Jordan: [00:48:30] Oh, thanks for asking. So, I work with hundreds of clinicians that work at Midi Health, which is joinmidi.com and we serve women in all 50 states. We're an insurance covered platform. We are on most PPO insurances. We're not on yours yet. We will because we're working on all of them across the nation. But we're on most PPOs in the nation. But there's also a cash pay option that we work very hard to keep it at affordable rates because we really believe that all women deserve this informed care, particularly in midlife. I think as you mentioned, menopause adversely affects many things in women's health and giving an informed solution on this is super important to everyone at Midi and to you.
Cynthia Thurlow: [00:49:16] Yeah, thank you so much for the work that you do and it's a pleasure for me to interview you because you and Midi are doing such great things for women's care. I think that one thing that I'm very attuned to is women's middle age care should be covered by insurance. Women's middle age care should not be just for the few, it should be care for everyone. And I think that you all are really doing great work and making it accessible and making it easy for women. They don't have to leave their state to get care. Sometimes, I feel like when we're making suggestions or referrals to providers, it's like people will say, “There's no one in my state.” And I'm like, “We need to find you someone in your state” because it's not realistic for you to have to leave your state of origin to go get the care that you deserve to have. So, thank you for the work that you do.
Dr. Kathleen Jordan: [00:50:05] Yeah, no, that happened to me. I was going through perimenopause and I went to my regular doctor who's lovely, who's a friend of mine and I would trust her immensely to do procedures, surgeries, deliver my babies, but was not a perimenopause or menopause provider by her own definition. And I really didn't get answers nor could she direct me anywhere. I searched and searched, there were some few high-end concierge practices that do this work but the mission then became with myself and the founding team was to really bring this informed care to more women. Because we can feel better. We don't need to be debilitated. We can feel better. There's evidence-based solutions out there. They don't need to be expensive. Some of them are simple, some of them are lifestyle interventions, some of them are hormone therapies, some of them are prescribed, but some of them are not.
Cynthia Thurlow: [00:50:57] Thank you again.
Dr. Kathleen Jordan: [00:50:59] Thank you.
Cynthia Thurlow: [00:51:02] If you love this podcast episode, please leave a rating in review, subscribe and tell a friend.
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