I am excited today to connect with my friend and colleague, Jackie Piasta. Jackie is Vanderbilt-trained and has been board-certified as a women’s and gender health nurse practitioner. She has been practicing since 2010. She serves on medical advisory committees for several foundations and co-hosts the justASK Podcast.
In our conversation, we dive into the challenges and complexities surrounding menopausal hormone replacement therapy and FDA-approved formulations, looking at the minute percentage of women currently on menopausal hormone replacement therapy. We discuss supraphysiologic-dosing of hormones and lab work strategies regarding prescribing lifestyle, and Jackie clarifies how she differentiates hypoactive sexual disorder from low libido and dysfunctional uterine bleeding from early menopause. We explore IUDs, ablations, and other long-term bleeding therapy options, explaining how endometriosis can impact the onset of menopause. Jackie also shares her approach to managing patients who have had ablations or are using IUD therapies and not getting regular menstrual cycles, helping them to determine when they transition into menopause.
This conversation is full of valuable insights, and we look forward to having Jackie back for a further deep dive into this pivotal stage of women’s health.
IN THIS EPISODE YOU WILL LEARN:
Jackie compares the varying information and lack of a one-size-fits-all approach in HRT with that of other medical treatments.
Overwhelming options and fear surrounding HRT can make it challenging for clinicians to prescribe those treatments.
How compounded HRT formulations differ from commercially available formulations
The difference between a normal physiologic and a supraphysiologic dose
How low libido differs from hypoactive sexual desire disorder
Challenges of diagnosing menopause in women who have had ablations or hysterectomies or use long-acting reversible contraceptives
Importance of evaluating postmenopausal bleeding to rule out endometrial cancer
Transparency and open communication with patients about the benefits and risks of HRT
Other health interventions to be addressed alongside HRT
How endometrial biopsies confirm the presence of uterine disease rather than ruling it out
“Micronized progesterone activates the calming pathways and can help with insomnia and anxiety and irritability.”
-Jackie Piasta
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The justASK Podcast
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.
[00:00:29] Today, I had the honor of connecting with friend and colleague Jackie Piasta, who is a Vanderbilt trained and board-certified Women's and Gender Health Nurse Practitioner and has been in practice since 2010. She serves on the Medical Advisory Committee for multiple foundations and is the cohost of The justASK Podcast.
[00:00:50] Today, we discussed the challenges that she sees with menopausal hormone replacement therapy. How there is degrees of varying information, questions around FDA-approved formulations and how less than 3% of women are currently taking menopausal hormone replacement therapy, challenges around supraphysiologic dosing of hormones and lab work strategies with regard to prescribing lifestyle, how she helps differentiate hypoactive sexual disorder versus just low libido, the impact of differentiating between dysfunctional uterine bleeding versus early menopause, the role of IUDs and ablations as well as other long-term options for bleeding therapies, the impact of endometriosis including its ability to impact when we go into menopause and lastly, how she likes to look at patients currently on IUD therapies as well as ablations that are no longer getting regular routine menstrual cycles and being able to help determine when they transition into menopause. You will find this to be an invaluable conversation with Jackie. She will absolutely be back for a second round with more questions and more focusing in on this very special transitional period in a woman's life.
[music]
[00:02:06] One of the things that I get asked a lot on the podcast is why don't I interview more nurse practitioners? So, I'm so excited to interview you today and have great admiration for the work that you do and how you serve women and serve so transparently, I was going through your social media content earlier this week and you have such great content.
Jackie Piasta: [00:02:26] Oh God. Thank you.
Cynthia Thurlow: [00:02:27] You're welcome. Let's initiate our conversation today talking about some of the challenges you see as a clinician with hormone replacement therapy management. What are some of the common challenges, concerns, issues that you see with your patients, either people that are new to hormone replacement therapy or people that maybe initiated therapy with another provider and are coming to you for a second opinion or to help troubleshoot.
Jackie Piasta: [00:02:55] Yeah, I think probably the most difficult thing is just the extent of varying information that's out there and the fact that menopausal hormone therapy isn't a one size fits all. It's so much different than, you going into your primary care doctors or NPs office and saying, “Oh, you have high blood pressure, here's ACE inhibitor or whatever, a diuretic for your blood pressure. That's like plug and play medicine, right? But menopausal hormone therapy is not like that. And then we add not even just what's FDA approved. The Menopause Society did a talk this year and they came up with a statistic that less than 3% of women in the United States are on FDA-approved menopausal hormone therapies. But we do know that there is a higher percentage of women than that are on different, varying.
[00:03:46] So it's just, all the noise of compounds and FDA approved and the pellet industry and all of this. And I think that the average woman coming into that conversation with their clinician doesn't know what to do. And sometimes as a clinician, it's like a kid in the cookie jar. We're like, “Okay, we have so many options.” It can even be overwhelming for us as clinicians. When I teach other clinicians about how to prescribe menopausal hormone therapy, a lot of them get really stuck of like, “Where do we go? Where do we even start? Because the roadmap isn't so clear as far as that. So, I do find that.
[00:04:27] And then in addition to that, I find that we still cannot rub the stain out of the clothing, so to speak, of all the fear around it. And even in the medical field, we're not all on the same page. If I'm a woman coming in, I'm getting all different types of messaging from my trusted healthcare individuals. And how do I know who to trust when I feel like everyone is someone I should trust? But I'm getting varying messages. So, I personally feel like that's probably the most difficult thing and thing that I am constantly regurgitating to women is that there's not a one size fits all. There's no perfect way of doing this. And yes, it's a hard pill to swallow that you will be receiving mixed messaging from many different areas of your life, medical and social.
Cynthia Thurlow: [00:05:19] I couldn't agree more. And it's interesting because I finished my nurse practitioner program right as the Women's Health Initiative study came out. And so even though I was isolated in cardiology as an NP, I had so many patients that would cry in my office about how they went from being on estrogen and having all these potent anti-inflammatory benefits and not having joint pain to suddenly having the floor literally pulled out from underneath them and trying to navigate being in menopause or even being in perimenopause without hormones. And you're right, when I prescribed antiplatelets, anti-hypertensives to my patients, it was pretty clear cut about understanding what's the best drug for the patient? What are the variables I need to be thinking about when we start prescribing hormones, it is very, very different.
[00:06:07] And I feel like there's been so much noise from the Women's Health Initiative in terms of fear mongering about the role of hormone replacement therapy. And even now, 20 years later, I feel like there's more amplification about helping women understand that data set was really misinterpreted. It was not a healthy data set to begin with of individuals as women that were 10 plus years into menopause, many of whom were obese, former smokers, etc. And helping them understand that hormones given in the right way, given diligently and thoughtfully, are designed to help support our bodies as we navigate this, additional 30% of our lifetime. And so, when we talk about compounded versus generic, let's help listeners understand what are the differentiators. Because it's not as if one is bad and one is good.
[00:07:00] I think for each patient it's what is going to best for that patient. Because I will be completely transparent. I use an estrogen patch, cheap, generic, easy, change it twice a week. But I use compounded progesterone because I actually need the sustained release progesterone to sleep.
Jackie Piasta: [00:07:18] Yeah, 100%. And that's so funny. Anytime I get a patient that sends me a message of wanting to be a new patient, they'll ask me, “Well, what type hormones do you prescribe? I'm like, “I prescribe anything and everything that there is on the market because I believe in patient choice and I believe in just the shared decision-making process and that.” Yeah, it's not black and white, it's not FDA-approved format. Now they are the gold standard. I won't deny that, but we do have the compounding industry for a reason. And they're able and allowed to legally operate because they do good work for the most part.
[00:07:55] Again, I'm very transparent. I actually personally need to use compounded micronized progesterone, Cynthia, not so much for the sustained release aspect of it, but I do love that aspect of it and a lot of my patients do. But I'm actually deathly allergic to the-- I actually think I did an Instagram post way back when I was taking over the counter, the little FDA-approved micronized progesterone pearls and I broke out from a head to toe horrifically itchy rash I have a peanut allergy. And most people will say that because the peanut oil in micronized progesterone is a super refined or ultra refined-- it's like people who say you can have chicken nuggets from people that fry them in peanut oil. But in some individuals like myself, that's not the case and we do have an allergic response to it.
[00:08:44] So, the compounding industry is fantastic for situations like this where people just need a different dose, a different route or a different formulation that isn't commercially available. But for the people that listen to your podcast and what I teach my patients is the difference between-- Oh, I was listening to actually a fantastic podcast with Dr. Lauren Streicher and she used this analogy and I thought it was actually really fantastic to describe the difference between a compounded formulation and a commercially available. And she used Chips Ahoy cookies versus the cookies that you would have at a bakery and the very end-- And sometimes I do kind of say that. I'm like, “It's like your mom-and-pop kind of small batch versus a very large industrialized process.
[00:09:31] And are there benefits to having a very large industrialized process in commercially available formulations? 100%. But there are situations where we do need compounding in order to tweak the formulation so that we can better serve our patients. And honestly, one really good example of this is testosterone. Testosterone, unfortunately, in our country, we don't have any FDA-approved, commercially-available female-dosed formulations. So, for the longest time, I'm much more comfortable prescribing the male formulations now. But sometimes, I just have female patients that really feel uneasy about that. They're like, “You know, it's so difficult for me.” First of all, I don't want to go to the pharmacy and pick up a seemingly biased like male product. I just don't need the side eye from my local, pharmacist about that.
[00:10:22] And unfortunately women still get a lot of pushback at large box pharmacies and they want just a product that is like a little dispenser that they know that every single pump that they're getting is in a female formulated dose and they don't have to sit there and try to figure out what size, legume, shape, sizing of a gel to put on. But again, the pricing can be slightly more expensive because it is small batch versus large FDA-approved formulations. But again, I try not to villainize one side or the other. It's like they all can be great, but again, lot of it is just a lack of understanding about how the varying pharmaceutical industries work. I don't know if you've found that too.
Cynthia Thurlow: [00:11:13] Yeah, well, I love your perspective because it's very balanced, it's very reasonable. I think that there can be a degree of polarization across social media. People will vilify one thing. I have some patients in my ecosystem that are on pellets and pellets work well for them. I don't provide pellet therapy, but I do find clinically when I'm talking to colleagues, whether they're physicians or PAs or nurse practitioners, that at some point it's less predictable.
Jackie Piasta: [00:11:40] Yeah.
Cynthia Thurlow: [00:11:40] And one of the things on social media that I was reading was you had a very thoughtful post talking about your concerns around pellet therapy are less about the pellets themselves and more about the lack of training. Like people will go to a weekend course and then they come back and they're suddenly doing a lot of pellets. What has been your experience clinically? Do you find that it's really dependent on the individual who's prescribing them, administering them? Because I got the sense from again, your very balanced perspective it's not that it's all bad. It's always that nuance of finding what works best for the patient, but also some predictability in terms of response.
Jackie Piasta: [00:12:19] Sure. So, I actually find that the largest problem is just the utter lack of transparency. It's again, remember, these are just ways of delivering medication. And as long as you counsel on the fact-- Now, one of the biggest problems with the pellets is that the dosing in them is highly variable. And that is just the nature of the beast of a testosterone pellet. And I think if you do talk to women that have been on hormone pellet therapy for several years, they will actually admit to that. They will say, “Oh, there are times where I go and I get a pellet and I feel like it did nothing that month” or I feel like, “Whoa, it did way too much.” Because these are super compressed little powdered-- They're slightly larger than a grain of rice and they're somewhere between a grain of rice and a Tic Tac. But it's compressed powder that's extruded through a machine and then it's cut into these individual size pellets. And the size of the pellet is based on the dosing.
[00:13:18] Well, of course, it's not like a perfect process. And the difference between a commercially available or commercial pharmaceuticals versus these compounds is difference in how they are regulated. And a lot of people don't understand that compounding pharmacies are not regulated by the same standards. But it's not that they're not regulated at all. They are regulated under things called the 503A and 503B laws. But again, there is an inherent issue with the dosing predictability of those.
Jackie Piasta: [00:13:50] But going back to where I feel the problem lies is that patients go into pelleting, a lot of the time into this all good and none of the bad. And again, on the other side of the coin, the lack of transparency, they'll go to their trusted OB/GYN or women's-- gender nurse practitioner or family nurse-- whoever their clinician is that they see in more mainstream medicine and they'll get an absolutely black and white, absolutely not-- Hormones are bad for you. And there's no transparency-- that's a form of no transparency either. And so, they leave that office feeling deflated and they don't know what to do.
[00:14:34] And all of a sudden there's this shiny, beautiful office that has a physician or a nurse practitioner or whomever in there saying, “This is going to be the answer to all your prayers. It is a very one-sided conversation. These are great. They're going to make you feel so much better.” And while a lot of times they do do that, the conversation is not balanced on the other side of, well, it's highly likely that these are going to give you super physiologic doses. And what does that mean? What do super physiologic doses do in the body? And most of the time they have a higher risk for the negative side effect potential of the medication.
[00:15:16] And in a lot of instances, we're not studying super physiologic doses in humans. We study super physiologic doses in rodents, we're not studying them in humans. And so that's where a lot of the beef comes from, is that we're not giving women balanced conversations on both sides of the fence. If I could get all my colleagues in a room and have them hash it out and be like, if anything, could we just give women both sides of the coin and then allow them to choose how they want to proceed with their healthcare. I feel like that would help us in a lot of different ways.
Cynthia Thurlow: [00:15:56] No, I so agree. And I think that sometimes we get widgeted into our perspective and then we lose the ability to think objectively. And I don't think that's intentional. I think we just get comfortable with what we know. And sometimes when we are challenged with an opposing opinion to what we have been taught or what we're comfortable with, it makes us uncomfortable. I'm not saying everyone is that way. I think that many people are that way. And I don't think it's unique to any one designation.
[00:16:27] I can objectively say that when I look retrospectively over 25 years in clinical medicine, I can see the clinicians that were a little bit more open minded are the ones that were a bit more flexible and gave patients a bit more opportunity to consider alternative perspectives as opposed to very rigid clinicians that I worked and it was like their way or no way. And if you didn't believe in their way, they would suggest that you find another clinician. And I guess that's both good and bad.
[00:16:55] Now, you mentioned the topic of super physiologic doses for individuals and listeners that are not familiar with what that is. Can we help explain that? This is one of these topics that I feel like more and more is coming up in conversation, whether they're talking about estrogen and women in menopause having menstrual cycles, forced menstrual cycles, or testosterone. I think it's important for people to understand. There's the normal physiologic doses of our hormones in menopause, which are pretty quiet versus super physiologic, which is much higher than what is expected.
Jackie Piasta: [00:17:37] Right. I do agree with you. I think that there has definitely been a little bit more chatter on this concept, whether or not it's new or it's just becoming more out in the open. I think that's probably the case is that we're just talking more about this. There's a lot of clinicians that have been continuing to prescribe hormones in the shadows since the WHI. There are some crusaders out there who really have continued to forge on. And these are the women that will show up in my office and they've trusted OB/GYN who been in practice for 50 plus years and finally, gave up the ghost and retired, has had them on, injectable estrogen for years.
[00:18:26] And a lot of people don't even know that estrogen can be delivered in an injectable form. It's called estradiol valerate. And a lot of times those women do have higher doses or higher levels. So, again like you say, we're so dogmatic about it, it's like, “Oh, it's this way or that way and it's always a patch and it's always in this dose. But super physiologic doses really refer to administering a dose of a medication that is far beyond what we would typically see in the general population. And so, we have fairly decently assessed established normal reference ranges for what we would typically find in women throughout their lifespan.
[00:19:10] So, if you were to go to the lab and get your estrogen levels checked by one of the major lab companies out there and look at that lab report on an estrogen level, you're actually going to see a tiered dose or a tiered level system. So, it'll say, “Well, if you're in this part of your menstrual cycle, this is where we expect it. Then if you're postmenopausal, you'd be in this part.” But what I actually love to point out to my patients that I find is quite comical is that actually the postmenopausal range reflects hormone therapy. It goes anywhere from basically zero to upwards of varying the labs, 130 to 150.
[00:19:50] There's really probably a very rare woman that's postmenopausal that's walking around with a level of 100 that's not on some form of estradiol hormone therapy. So that's what super physiologic means. We're just giving doses that are higher than, frankly, what we as clinicians are comfortable with. I think is that because again we hang a lot of this certainty in lab ranges, but we also don't know what's actually happening at the level of the cell and the receptor site. I know your listeners have a slightly higher degree of knowledge base just because you're so involved in the wellness space. So, I'll go one step further. But the blood is our trash system, right? That's what is like left over after our body has utilized its use or what's currently free circulating around as potential, as ready to be utilized. But we don't actually know what's happening at the cell, what your body's actually doing with that. It's almost like that episode of always refer back in my brain to the episode of The Magic School Bus where Mrs. Frizzle takes the kids in this school bus.
Cynthia Thurlow: [00:20:57] I love that series.
Jackie Piasta: [00:20:57] Yeah. And they're in the school bus and going through the human body and traveling through. And that's how I imagine it. It's like, I would really love to be able to know what's happening at the cell because that would actually help us better appreciate why there's so much variation and why do some women require much higher doses of estrogen in order to elicit the same effect or even much higher doses of testosterone to see any type of effect.
[00:21:28] And some women can be given a microscopic dose of testosterone and have horrible negative side effects and another woman could be given, you have these women that are walking around on pellets with estrogen or testosterone doses in the high 500-600 plus of where a lot of men aren't even living currently. And they're fine as fine as we know. That's where the argument is. We don't actually know if there's long-term health repercussions of that. But they're not losing their hair. They're not getting deepening voice and growing a beard.
[00:22:01] So again, this is bio-individuality and we haven't gotten there in medicine. I think there's a lot of people trying to get us there, but we're not there right now. So, we're taking population statistics, population numbers of what is happening in the average person and trying to apply that to individuals and being so dogmatic and so black and white about this hormone space and anybody that is a clinician that dares to prescribe a slightly higher dose or whatever is villainized. And I just feel like there's a way for us to meet in the middle on that and understand that I think most people are well meaning.
[00:22:43] And it goes back to our initial question. Your initial question in the conversation is like, “Where do women have difficulty in this space?” Well, [laughs] here, right? Again, it's so often I see women that come to me and they're like, “Well, I tried hormone therapy. It didn’t work for me.” And then I'll start talking to them about their experience and were given one dose and had maybe some breast tenderness or something or some abnormal bleeding and then they were given no guidance as to how to navigate that. It was like, “Oh, that doesn't work for you.” Okay, again we have a lot of work to do in cleaning up this mess and that we've created on both sides of the aisle. And I don't know, I just hope to be one little piece of trying to bridge the gap and bring some sense to this whole thing.
Cynthia Thurlow: [00:23:28] No, you do such a beautiful job of finessing the information and also keeping things pretty objective. I think when I think about super physiologic doses, I think about a conversation I had with Dr. Pam Smith, who's antiaging expert, former ER doctor, and she was talking about how she was seeing a constellation of patients that were prescribed testosterone pellet therapy and they were coming to her very symptomatic. So, they were super physiologic, have a pellet in the pellet. You can't just take the pellet out, unfortunately, you have to write out symptoms, but had values of 300, 500, 700, some of whom had myocardial infarctions, which are heart attacks.
[00:24:12] And so she was explaining that to your point, some people do fine on male levels of testosterone therapy without the side effects of acne, hair loss, and clitoromegaly, which, yes, you can actually get an enlarged clitoris that from what I understand, can be a permanent side effect.
Jackie Piasta: [00:24:32] It is not reversible.
Cynthia Thurlow: [00:24:34] Yeah. And deep voice, not like mine, from laryngitis, like actually from the drugs themselves. Now, when you're counseling women about where you're going to start them for dosing on testosterone, do you find that a lot of women are receptive to adding testosterone after estrogen and progesterone have been started? Do you start testosterone solely? The reason why I'm asking is I have some experts that will say, “Oh, I don't start testosterone until we've optimized estrogen because of receptor sensitivity.” I don't know if that's part of your philosophy or not, but I was curious how you go about addressing them.
Jackie Piasta: [00:25:12] Yeah, and I love this question. And again, this gets into how this really is an art. And there are so many different ways to do it that two things can both be true at the same time. So, when I teach other clinicians, I'll actually say you have to take the person sitting in front of you and decide what you think is the best. And that usually is the decision on whether to start, what to start at, what time comes from, taking in really great history of your patient. There are some individuals that actually only will require testosterone, maybe they're only dealing with low libido and perhaps they're right at the menopause transition.
[00:25:53] They're not really having many side effects or maybe they just aren't interested in the other medications and they just want to come for that. I don't think it's completely inappropriate to do single or sole therapy there. I've actually worked with some patients who have a history of breast cancer diagnosis, and for whatever reason, I need to sit down with my oncology colleagues more about this, but they're actually okay with the notion of them using a low-dose testosterone therapy, but they are not comfortable with them using the other two, micronized progesterone and estrogen. And sometimes we have to pick our battles. And so, I'll say, “Okay, maybe let's start this and see what this gets.”
[00:26:32] But a lot of times if you take that out of the equation and you're just looking at, the standard or the average person that's usually coming in and is a good candidate for perhaps all three. I use the swimming pool analogies. Your patient's either going to be somebody that is kind of like the person that gets out on the stairs of the swimming pool and they just want to dip their toes in and just get it acclimated to the water one step at a time and see how things go. And these are the individuals where I'm really going to be starting either progesterone by itself for a couple of weeks, especially if their symptoms are insomnia and debilitating anxiety and really just leveling out their stress response first.
[00:27:13] Estrogen and testosterone can both be excitatory and very energizing hormones. And for somebody whose central nervous system and sympathetic nervous system is already going haywire, those can actually antagonize for a lot of women and can actually backfire. And so, I'll say let's just get some micronized progesterone on board. Let's calm things down. If you're listening, you don't really know why that works. Micronized progesterone activates certain pathways in our nervous system that activate the calming pathways. And so, it can help with insomnia, anxiety, and irritability. And then if you have somebody who's really a very characteristic menopause, they're having hot flashes and night sweats and joint pain and the brain fog and then all the other, like I said, anxiety, insomnia, then I'll start dual therapy with estrogen and progesterone. And that's kind of my stair step approach.
[00:28:05] And then you'll see them back in however long the follow up is. And then we talk about adding that cherry on top, which is how I refer to testosterone and seeing if it makes sense to add that in. And then I just have some patients that come to me and the poor things have been to how many ever clinicians, they're so miserable. They're just at their wit's end and they've got every symptom under the sun. And for those individuals, I kind of call those individuals the diving board individuals. And they're just ready to jump in and get started and they don't really care about the potential of side effects. They're willing to work it out right and whatever.
[00:28:45] They just want to have the hormone therapy and to get started because the door has been shut in their face so many times and they've listened to podcasts or been on social media and they've heard that the potential for this helping them. And so those are my diving board folks and I love those folks. And so again, it's just having that nuance in your practice and being flexible and understanding that very rarely do I have a day in my practice where I am prescribing the same things. We're going to be prescribing like themes of things, but very rarely do people have the same treatment plan. And again, it's not all about hormones either.
[00:29:28] This is a perfect time in a lot of women's lives to really initiate various other health interventions for them as well, and just use that menopausal hormone therapy conversation sort of as a gateway into instituting other health principles. Because this is a big junction in a lot of women's lives where we're like, “Okay, I need to get into gear here and really shift the trajectory of how things are going.”
Cynthia Thurlow: [00:29:54] And I think so many women navigate late 30s or into early 40s, and if they're seeing a traditional allopathic provider, they may just be offered oral contraceptives or an IUD or an ablation or a hysterectomy. And let me be clear, if you chose any of those options, this does not come from a place of judgment. I'm just saying that there are more options than just that to navigate that time in our lives. Because I recall, first of all, I knew little to nothing about perimenopause, nor did I realize I was in it because I was in my early 40s with heavy menstrual cycles. And I just recall those were the four options that were offered to me. And I was like, “No, no, no, and no.”
[00:30:38] And I just recall being frustrated because I was like, “I'm a fairly knowledgeable person, but working in cardiology, we don't really deal with these issues.” And so, for me, I feel like the second half of my career has really been focused on just helping build awareness around what to be looking out for so that women don't need to suffer navigating perimenopause. Because I feel like for a lot of my patients and clients, perimenopause is the toughest part. That's the toughest part because it's as unique as we are as each individual. It's not like one person wakes up at 42, and that's when their symptoms start. They can start a whole lot earlier.
[00:31:13] And for me, because I had my second child at 36, I'm sure a lot of the symptoms I experienced were, I'm like, “Oh, I have two kids under the age of three, of course I'm going to be tired, making excuses for the symptoms I was experiencing, presuming it was work stress, kid stress, all the things that we go through.” Now, you touched on sometimes utilizing testosterone for low libido. How do you personally differentiate that from those that you suspect may actually have hypoactive sexual disorder? Which is something we've actually not talked about on the podcast before. But when you're counseling your patients, getting that good history. What are some of the things that help you differentiate one from the other.
Jackie Piasta: [00:31:58] In terms of using testosterone for low libido versus hypoactive sexual desire disorder, so I think hypoactive sexual desire disorder it's the medical term that we actually use for what most women refer to as low libido. What differentiates this and a lot of psychologists, colleagues are so informative about this. It's the aspect of distress that makes it the medical diagnosis of the hypoactive sexual desire disorder. So, it is actually very natural for men and women to have low libido. And it may come in different phases of life, or you may just be somebody who naturally has a lower-level libido than the next person. And that isn't necessarily pathologic. That's not a clinical diagnosis. There's nothing wrong with you if you are somebody that just doesn't have a high libido.
[00:32:56] It's the element of distress that changes it from a normal finding to something where we may want to discuss some type of intervention, because the distress element indicates that there's a problem. I want to have a libido. I want to want it. And that's where I find a lot of women in midlife, in perimenopause and menopause really are finding difficulty is that it's a change in their normal cadence of sexual desire that is really unnerving and very upsetting. And testosterone can actually really help here. Now, it doesn't help everyone. And that's actually a misnomer and something that I think on sometimes on social media people can get. There's only so much information you can impart in 90 seconds, right?
[00:33:49] And then you're also trying to get people's attention and you're trying to probably be maybe a little bit not inflammatory, but you know what I mean? You're trying to gauge attention. But testosterone is not a magic button for every woman. And so, I think somewhere between 60% and 70% of women are going to have an increase in sexual desire when they put testosterone on board and give that a try. But right now, the clinical guidelines do recommend utilizing testosterone as an intervention for hypoactive sexual desire disorder, not just low libido. And I should have differentiated that earlier and it is. Just because you have a low libido doesn't mean there is a problem.
[00:34:29] And this goes into also why sometimes testosterone is not the holy grail for libido and sorry to the men out there, but men's libido is slightly, I think, less complicated than female libido. And again, I'm probably underplaying this, but I'll tell women that for men it's usually a light switch. It's usually a matter of whether or not the blood is flowing to the body parts that are required for use. And then when we've got that going, then usually we can figure that out. For women, it tends to be a little bit more like a switchboard and there's a lot of knobs and bells and levers that need to be in just the right place in order to really target the aspects of our brain that lead to sexual desire.
[00:35:22] And for a lot of women it can be difficult to understand that there's a lot of elements there. It's not a low maintenance type of medical fix. It's not like just set it, put a pill on or whatever and get better. Oftentimes, we have to take a multidisciplinary approach and make sure that there isn't pain associated, there aren't relationship dynamics that have been going on for 20 plus years that need to be reckoned with, that there aren't body image aspects or there isn't a child sleeping in the bed, and as women, I think a lot of times we put a lot of that blame on ourselves. Like all these things can be discombobulated in our lives, but yet we still should have high sexual desire.
[00:36:06] And it's learning that no, you can actually admit that there are aspects and elements of your life that are contributing to the fact that you don't want to have sex all the time. And we need to address those. We don't just need to put testosterone on board. While testosterone can be very powerful and highly effective, I like to take a multidisciplinary approach and kind of have maybe a little bit of a reality check sometimes.
Cynthia Thurlow: [00:36:30] Well, not to mention the fact, if you look at what goes on in movies and streaming, if people were to perceive that what we see on screen or while we're streaming is the norm, of course we would think there's something wrong with us because we don't want to have sex four or five times a week. And as we transition from being single to being coupled, to being married or partnered, to having children or not having children, navigating all these hormonal fluctuations from perimenopause and menopause, it's a natural progression that they're going to be times in our lives when we're more interested in sex, less interested in sex, and so just acknowledging that is normal, I think is so helpful.
[00:37:14] The other thing that I find is that with very few exceptions, maybe just with my nursing and nurse practitioner friends, most of my girlfriends do not talk about sex. They'll tell me, I feel like when I was in college, we could talk about things. And now that we're older, I feel like because I'm coupled, I'm deemed disrespectful to my partner. And I remind women, sometimes it's just helpful to share your experiences with a trusted friend and feel comfortable doing so. And I think that needs to be encouraged instead of people feeling a degree of shame or discomfort, talking about what is a very private issue, but one that has plenty of things to remedy it with.
Jackie Piasta: [00:37:53] Oh, 100%. You're totally right. I mean, I think again, open and transparent, I don't know that any of us really are good at sex. And that's another thing is like being able to openly discuss with your partner what that looks like. And it's an awkward time of life because a lot of us go from. And of course, I'm talking about, hetero-normal couples here, and unfortunately, this conversation is maybe not inclusive of all relationships. But for the purpose of brevity, I think that most of us go from this lust driven-- we're meeting one another and we’re in our younger years and we're carefree and all that straight into having families and the doldrums of that and what that looks. And our relationships very much shift and our focus shifts in that aspect of our life.
[00:38:45] Maybe we're building our careers. And again, that's another stress point. And then we get to perimenopause and menopause maybe where things slow down. Our children are more grown and more independent and our careers are maybe more in a-- we're good at this now. We can put it in cruise control and although we might be stressed and that takes up a large portion of our time, but then we're looking at our partners like, “Oh, where do we go from here and then you add the aging process of like, maybe there's pain now, maybe there's vaginal dryness, maybe there is all these other-- or I don't even know who this person in the bed next to me is and what does that look like. And we go from a very-- In public in the media, all we see is this lust-driven sexual picture of, “Oh, it has to be spontaneous and it always has to be this passionate exchange.”
[00:39:37] And there's actually Esther Perel she wrote a book called Mating in Captivity and she says it's maintenance intimacy that we never see. It doesn't have to be this passion, a lot of maintenance. Sex is very healthy for relationships. So again, I'm not a sex counselor or sex therapist by any stretch, but I do think that it's important for women to just recognize that this is normal and this is an element of the midlife that we should discuss and we should talk about. And it's not as simple as-- and absolutely not appropriate to tell women that they should just have a glass of wine and suck it up and just get over it. This is a conversation that we all need to be having. This is not a one and done appointment. This is an opening of a book and then flipping through the pages at your own pace and bringing on a multidisciplinary kind of look at what is it going to take to improve this.
[00:40:34] And testosterone very well may be a great piece of that puzzle. But again, I think it just nods at the nuance of as individuals and then what the capabilities of hormone therapy are and what they are not. I think is oftentimes another misinformation that we get in the social media spaces. We think that hormone therapy is this panacea of I come in midlife and I'm going to go on hormones and it's going to fix everything that ails me. Oftentimes, we have to reel that in and say, “Okay, this is what we do expect and this is where maybe we need to start talking about some other things as well.”
Cynthia Thurlow: [00:41:11] So, well stated. And I love that you brought up Esther Perel's work. If anyone is not familiar with her work, she is this incredibly brilliant clinical psychologist and just has a breadth of perspective about human relationships and sexuality and does it in such a beautiful and transparent way. She is incredible.
[00:41:33] Now a lot of questions came in around how do we differentiate when we're in perimenopause? Maybe we've had an ablation, maybe we have an IUD. How do we figure out when we've actually transitioned into menopause? Because we're no longer getting menstrual cycles. And the other question that came off of that was, I thought I was in menopause, I went 13 months without a menstrual cycle, then I had a cycle. And it's like helping to differentiate dysfunctional uterine bleeding versus menopause versus how do we address that? So, lots of questions came in around these topics and I'm hoping you can provide some valuable insights as I know you will.
Jackie Piasta: [00:42:13] Yeah, no, I love these questions and they're so needed. So, there's actually been some discussion in the menopause space about changing our definition of menopause because right now the definition of menopause is one full year without a menstrual cycle. Well, that's good and all, but it does not account for a very large, not insignificant percentage of the female population. And this is the one that you refer to is the growing number of women that are choosing what we call LARCs, long-acting reversible contraceptives. Those are things like Nexplanon arm implant and the progesterone-releasing IUD options that we have. And those are fantastic.
[00:42:58] I love the IUDs, especially because they do help fix a couple of problems in perimenopause, which is still the need for contraception for a lot of women and the volatileness of some of our menstrual cycles during this phase of our life. But if you are somebody that has chosen a LARC, one of the problems is that you very well may experience a condition called amenorrhea, which means not having any menstrual cycles. And if you're 51 or 52 and you're somebody that has an IUD in place, we're not going to be able to tell.
[00:43:27] Another subset of the population is those individuals that have had something called an endometrial ablation, which is a heat source treatment to the lining of the uterus to help with dysfunctional or heavy menstrual bleeding that we often will offer in the gynecology space to women and that essentially ablates or destroys the lining of the uterus. So, you're not able to bleed or you bleed to a much lesser extent. And so again, this is another percentage of women who will not experience that 365 days without bleeding. And then we have women who have opted to have a hysterectomy and we have no way of noting their bleeding. And so there are a group of women who will not fit in this traditional definition of menopause.
[00:44:11] We also have things like women that have endometriosis and might have some earlier onset of menopause because the inflammatory condition actually affects the quality and the longevity of their eggs and may change that. So, there's different degrees here. But if you are somebody that does not have a regular menstrual cycle and cannot chart when the last time you had one is, the best way to determine it is number one, by your symptoms. If you start experiencing the classic low estrogen levels like hot flashes, joint pain and brain fog and vaginal dryness, really dryness of any sort in your skin, other mucous membranes, itchiness inside the ears, dry eyes, dry mouth, those are all classic signs and symptoms of estrogen is not coming out to play most days.
[00:45:06] And so we can draw a lab level called an FSH or a follicle stimulating hormone. And if that follicle stimulating hormone is consistently elevated. So, this is not a hormone that we can just check one and done. And we say you're menopausal because FSH is a hormone that's released from a gland in our brain called our pituitary gland, and it by nature is pulsatile, meaning it's released in little pulses all throughout the month. And so, you may catch it during a surge or you may catch it during a lull. And so, you do want to check it at least on two occasions, if not maybe even a third. And if it's consistently elevated and it varies by. I've had different clinicians say different things, some say over 30, some say over 50.
[00:45:53] But any who, it's more of a trend than what I would say, just a hard line in the sand. But if it's consistently elevated, then we pretty much can say, “Hey, you're in that age range, your FSH is showing that. So, this is likely it. But again, we don't have to always go to those lengths. A lot of times too this is pings off of your question is another misnomer that women get is they're told that they're not able to initiate any form of menopausal hormone therapy until they're fully menopausal. And we can very effectively treat perimenopausal symptoms with menopausal hormone therapy. I think we do this to ourselves. We call it menopausal hormone therapy.
[00:46:36] And so it lends-- it makes one think you can only use it during that time. And that couldn't be further from the truth. So again, you don't have to just leave women hanging, dangling out on this line, suffering in order to treat the symptoms of the condition that we know oftentimes are so blatant. Just add some estrogen. I mean, we're so comfortable, throwing women on birth control pills and we don't even recognize that the standard doses in a menopausal hormone therapy estrogen are significantly less. So that's kind of how I determine it in my office for those individuals who haven't had, you know, are not able to chart 365 days without a cycle.
Cynthia Thurlow: [00:47:23] I think that's really helpful and certainly a very reasonable approach. And I think that on the podcast, I don't think we've actually had someone say that endometriosis being an inflammatory condition, being autoimmune, can actually lead to an early menopause transition. And what's interesting to me is only in the past five or six years I had a GYN that said, “Oh, we were talking about symptoms that I used to get before my cycles.” And he actually said, “Oh, you probably had very mild endometriosis.” And I said, “Are you kidding me?” And he said, “Oh, yeah.” He said, “A lot of women that have these retroverted uteruses, which means my uterus is tilted.” He was explaining that endometriosis is so poorly understood and so poorly diagnosed that can become problematic. Do you see quite a bit of endometriosis in your patients?
Jackie Piasta: [00:48:10] Oh, certainly. I see a lot of endometriosis patients. I see a lot of patients actually come in with an earlier onset of menopause from an endometriosis, the process and so, yes, it is an inflammatory. We are learning more and more about it. Our understanding of endometriosis today is vastly different from what it was 15 years ago when I got out of school. And so, it has the ability to affect the quality of-- I mean, we are born with the amount of eggs that we're going to have and that predetermines when we are going to have menopause. When we run out of viable eggs, i.e., when our ovaries are unable to produce the amounts of estrogen required for a menstrual cycle. Actually, I forgot about the second half of your last question, but about the bleeding after they've reached menopause.
[00:49:03] And here's the interesting truth that I would say, actually, 9/10 people don't realize is that it's not that we produce no estrogen in menopause, and it's not that our ovaries do nothing in menopause. We actually don't really have a good understanding of what the ovaries do in menopause. This is why it burns me when I hear patients say, “Oh, my gynecologist just took my ovaries out. He says, I'm done with them.” They're done and shriveled up. And I look at them and I say, “I kind of have to bite my tongue or sometimes I don't, I'm not really good at that. But I'll say, “How does he know that you're done with them? How does he know?” Why is my husband's grandmother 96 years old and living independently and never used hormone replacement therapy? Her bone scan is completely normal and maybe a little bit of osteoporosis, I don't know. I would love to study her ovaries the last 50 or 40 years that she's been in menopause. We just simply don't know why there is such a different experience of menopause across the board. And so, our ovaries might very well may be doing something, producing some amount of estrogen in certain individuals. And so that's where this experience of bleeding can come up. Just because you've reached 365 days without a period doesn't mean that you're never going to experience a bleeding event ever again in your life.
[00:50:26] If you have a uterus and you have some ability to produce estrogen, there is the potential for you to have an acceleration or what we call a proliferation of that uterine lining, and you might experience a bleeding event. So, not all bleeding in post menopause is pathologic or medically worrisome. Actually, the vast majority of it is not. But because it could be an indication of uterine cancer, we always want to work that up. So, you never want to dismiss it. You never want to just be a woman in menopause who bleeds and never says boo about it. But just because you bleed doesn't mean it's abnormal. And that's something that a lot of women don't know about. And we don't know what our ovaries are doing in menopause. This is a data free zone. We don't know, which is so crazy. That blows my mind.
Cynthia Thurlow: [00:51:19] Well, I love everything around ovarian senescence. So, helping people understand that our ovaries actually are the pacemaker of aging in our bodies, which I find innately fascinating, but also disturbing that I was never taught any of that years and years ago. It's like only been over the last couple years that I've had this kind of realization. And so, understanding that there's a lot of ovarian research that needs to be done and understanding that we're just starting to understand just a little bit about how this organ system really functions and works. And so, if there's someone listening that is in menopause and has some bleeding, let's talk through some of the higher-level things that we typically will do in an office to evaluate the bleeding. Like you said, most of it tends to benign. And there are steps that we take to make sure that we help evaluate this. And then as you mentioned, most things end up not being a big deal. But we never want to miss an opportunity to diagnose endometrial cancer.
Jackie Piasta: [00:52:21] 100%. And that's why, honestly, endometrial cancer is one of the more survivable cancers because it's loud, [laughs] it bleeds, and it oftentimes is not shy. So as opposed to something like an ovarian cancer where oftentimes it's diagnosed in late stage because its symptoms are much quieter, it's not that they're not there, it's this, they tend to be more nebulous. But yes, so postmenopausal bleeding is something that we, I mean, being in the gynecologic world for the last 15 years, I've treated hundreds and hundreds and hundreds of women with postmenopausal bleeding. And again, this is where it gets tricky because I have heard all different ways that women have been worked up and managed for postmenopausal bleeding.
[00:53:03] So, I will just tell you how I typically or how I was trained to work it up because you will talk to women who will just be sort of-- biopsy will just be thrust upon them the second they utter the words, uterine bleeding and that'll be it. But I follow kind of gynecologist, Dr. Steven Goldstein, who probably is the person who speaks the most nationally and internationally on the topic of the uterine bleeding and he likes to call it the endometrial echo, I think, he does not like the word stripe, which is what we typically refer to it on an ultrasound. But essentially when somebody comes to me and they have an episode of spotting, oftentimes I'll just take a good history of that. What were the circumstances surrounding that? What happened? Did we just increase your dose of menopausal hormone therapy? Are you having any other symptoms that might indicate a potential, like a vaginal infection or a cervical inflammation? Do you have a new partner? Am I concerned about some type of condition like that?
[00:54:07] So, we'll just take a good clinical history, and if it's pretty mild and it's just kind of a blip in time, oftentimes we'll do what we call conservative management, which is literally just offering reassurance and just letting it play out and watching and waiting. But if it does persist, and that's usually upwards of six months. Now, again, I don't let women just bleed profusely for six months on end. So, if it's just happening all the time, take this with a grain of salt.
[00:54:35] But if it continues to persist, then typically what I'll do is I'll order an ultrasound of the uterus. Let me back up, first, I'll recommend an exam because it doesn't necessarily mean that it's coming from the uterus. So, we'll do an exam and make sure that there is not an polyp at the cervix, which is a benign growth of cells similar to looks like a skin tag, but it actually is the tissue that's on the inside of your mouth, so it easily bleeding. And I'll do a vaginal exam to make sure that the bleeding is for sure coming from up inside the uterus. And then we'll order an ultrasound of the uterus.
[00:55:09] And what this does is it allows us to visualize the inside of the uterus and see is that lining in there thicker than what we would typically be comfortable with. And there's usually somewhere between 3 and 6 mm is where we kind of determine this zone of going further. Depending on that and sometimes on an ultrasound, we can see other things like fibroids, or if you have a really good ultrasound, you can see polyps, which again, just like on the cervix, they're benign growths inside the uterus that tend to bleed.
[00:55:44] And those things are things that we need to typically resolve with surgical management, where we actually have to go in and remove the polyp or do something called a D&C, which a lot of women might know is a dilation and curettage, where we actually just remove the lining of the uterus surgically. There are more finesse procedures, hysteroscopies, which is the uterus version of a colonoscopy, I'll say. And we can have a little machine that does a more finesse version of a D&C. That's it. And then there are some clinicians-- I had the luxury of actually having surgeons that I worked with be able to do hysteroscopies in the office. So, we actually had gotten away from endometrial biopsies. Because what a lot of people don't realize and Dr Goldstein actually is the one who taught me about this, was that an endometrial biopsy does not rule out the presence of cancer, it rules in the presence of cancer.
[00:56:37] And so, if you get an endometrial biopsy and it comes back negative, the sad fact of the matter is it doesn't necessarily mean that you don't have cancer anywhere in your uterus. It just means that the little piece of tissue that they took out of the uterus doesn't have cancer. And this is actually very scary because we don't have standards of practice around. There are a lot of gynecologists and nurse practitioners in the country doing the opposite, doing a biopsy and saying, “Okay, you're good to go, clean bill of health, and you leave. And they never receive any follow up beyond that.
[00:57:08] So not to throw anybody under the bus, we need to be very clear that endometrial biopsy rules in, not out, the presence of uterine disease. So, ultrasound, maybe an endometrial biopsy and then let's hope most clinicians are actually going one step further. If we find that the uterine lining is thick enough to be concerned about it and actually removing that uterine lining so we can fully assess the uterine lining and make sure that you don't have an issue like a precancerous condition or a cancerous condition.
Cynthia Thurlow: [00:57:42] Thank you for that distinction. Because I think that there are probably still a lot of clinicians that are just focusing on that endometrial biopsy. Now, I have so many other topics I could talk to you about. I hope that I can entice you to come back. Please let listeners know how to connect with you on social media, how to work with you if you're still taking patients, and how to learn more about your cohosted podcast.
Jackie Piasta: [00:58:03] Sure. Thank you so much. So, I do cohost a podcast with my friend and colleague, Dr. Heather Quaile and it is The justASK Podcast. So, it is @justask, we have Instagram podcast, Spotify anywhere that you listen and we've had Cynthia on, great episode, we just launched actually this week. And then as far as myself in my practice, my practice is @mymonarchhealth on Instagram and I am taking a select number of patients in certain states, so you can find me through there. And then I do most of my Instagramming through my personal platform which is @jackiep_gynnp. So that's how I connected with you and just our crazy world of the social media space, which I love. But yes, please follow me and follow along.
Cynthia Thurlow: [00:58:47] Awesome. Thank you again for your time.
Jackie Piasta: [00:58:50] Yes, thanks for having me. I love this conversation. Thanks for having me and amplifying this important topic that I think so many women are dying to know more about.
Cynthia Thurlow: [00:58:59] Absolutely. If you love this podcast episode, please leave a rating in review, subscribe and tell a friend.
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