Medically Speaking #9

Hey, Amy's on too. Great. So we are going to try to switch it up a little bit tonight rather than doing just the presentation with the PowerPoints. And Dr. Forrest and I are just going to kind of have a conversation. We want this to be super interactive. There's a microphone somewhere right over here. If anyone has a question during this time at all, please just go up there and ask a question. You have a very, very smart OBGYN specialist here with us tonight. So again, I'll just start with a self-introduction. I'm Matt Logan. I'm the president and CEO at Self Regional Healthcare. I've been with Self Regional for over 19 years in a variety of clinical administrative roles. And I say just excited to be with you guys here tonight. I love seeing all these Lander students and hopefully there's some others here as well. But again, thank you all for being here. So we'll start out. Dr. Forrest, maybe you can just introduce yourself. Tell us a little bit about your background and your education and training and those type things okay well I am dr. Amy Forrest I am originally from Saluda South Carolina and I have been in practice private practicing Greenwood for 22 years now we recently became self-employed two months ago and so it's been it's been a great great career here. Awesome. Great community. I love it. That's awesome. So where did you go to college and medical school and undergrad? I went to undergrad at Wofford. So I have a degree in biology and in history. Then I went to MUSC for medical school and I trained for my OBGYN residency in Asheville, North Carolina. And then I came here. Awesome. So how did you decide on this topic. It's a great topic. Well, you know, I think for me, I'm always trying to learn new things about women's health care. And there have been a lot of innovations that have come recently for all age women. And I think it's just important for women to be aware of what's out there, what's new, because medicine, it moves fast. Absolutely. So let's start with maybe some questions around Just health screening in general. Maybe let's talk about some health screening that's specific to women. Okay, for women, we do have some unique health screenings that we do. And it starts with, the first is pap smears. It's recommended that pap smears, you start screening at age 21. And they're different. The recommendations are every three years when you're doing from 21 to 29. And then at age 30, we start adding something called HPV testing to it. And that's when we test for the human papillomavirus. We test for the high-risk subtypes. And at that point, it's recommended every five years. I don't necessarily follow the guidelines specifically because I remember when they first started coming out with the ability to test for the HPV. The original article, it actually said you have to be willing to miss a few. And that always struck me, like, well, a pap smear is not a very invasive test, so why would I want to miss anyone? And so I don't necessarily follow the guidelines to a T for that reason. I don't want to miss anyone. That's fair. Well, let's talk about cervical cancer for a minute then. Like, what are the risk factors for cervical cancer? Well, they used to not know what really caused it, but they knew that it was disease of women. and usually the average age is around 50, the diagnosis. But what they know now that it is absolutely caused by the human papillomavirus, and that is a virus that is sexually transmitted. As many as 80% of sexually active adults carry at least one subtype of the human papillomavirus. So you have high-risk subtypes and low-risk subtypes, and it's the high-risk subtypes that causes the cancers. There is a vaccine now available. It's offered to children starting at age 9. but it helps protect you against nine of the most common subtypes of the human papillomavirus. Seven of them are the high-risk subtypes, and two are the low-risk subtypes. The low-risk subtypes is what's going to cause the genital warts. So I recommend all patients get vaccinated starting as early as possible. If you start before the age 15, you only have to get two of the vaccinations. If it's after age 15, it's a series of three shots. Gotcha. In your experience, do the vaccines work pretty well? Yeah, the side effects, women don't really have any side effects from them. It's not like the COVID vaccine where you kind of felt crummy for 24 hours potentially. It's like getting a flu shot. Patients do well with it. Good. And it's a lifelong immunity. You don't have to get any boosters once you get your series of vaccinations. Yeah, that's one of those, in my opinion, one of the preventative things that you can do to prevent future lifetime risk for a variety of cancers. Oral pharyngeal cancers? – They're starting to associate with oral pharyngeal cancers, rectal cancers, anal cancers. So they're starting to associate it with many different other types of cancers, but the problem is is there's no screening for those yet. And it's coming. They're gonna have some sort of screening. I assume it's gonna be coming down the line pretty soon, but as of yet, there's no screening for it. They just know that it is associated with them. Good, good. Does anyone in the audience have any questions about, like, past mirrors or cervical cancer or anything they want to ask before we go to the next topic? All right, very good. I have patients who always ask me, how long do I have to get these? And, you know, the guidelines are up to age 65. And I think it depends on a patient's sexual history. So I have a lot of patients who, you know, their first husbands have died or they've divorced and they've remarried. So if you have a new sexual partner, your risk might be different than someone who's been married for 50 years. So I think that I try to take each patient individually and decide, you know, what is her risk factor and decide whether or not I want to continue screening. And it's more of a joint decision. Okay. So another common screening that's somewhat unique to females, males can get too, actually, is breast cancer. Absolutely. And mammograms. So let's talk about breast cancer and mammograms for a minute. Well, there are different societies who have different recommendations on when to start screening and how often to screen. And I've always followed ACOG's guideline. That's the American College of OBGYN. And they recommend that you start mammography at age 40. And I usually recommend that you start annual screening at age 40. Now here in Greenwood, we have 3D mammography that has been around here for two years now. So any screening mammogram is a 3D mammogram. And the difference is that that particular type of mammogram, it's able to detect earlier cancers. They say probably about a year and a half, anywhere from a year and a half to four years sooner with that technology. And women with dense breasts, paramenopausal women, and premenopausal is supposed to have better detection rates. And so the U.S. Preventative Task Force, they used to say start screening at 50. And just this last month, now they've decreased their age to 40 also. And it's because we were seeing more and more African-American women who were dying from breast cancer in their 40s. and they typically have more aggressive cancers. And so with breast cancer, early diagnosis is the key. If you look at the risk of dying from breast cancer, the risk of death dropped drastically from the 1960s on, and the difference was that's when mammography came about. And it's just getting better and better with the technologies. And something else new that they're doing here in Greenwood is when you have your screening mammography, and they just started this this year, they will put a lifetime risk of being diagnosed with breast cancer on your mammogram report. And so every woman, our baseline average risk is 13 percent is your lifetime risk. And so if you fall into a category where your lifetime risk is greater than 20 percent, they're going to recommend that you be referred to the high-risk breast clinic, which we have in Greenwood now. And so the patients that go there, they meet with one of the oncologists, so it is housed at this time at the cancer center. So I always try to warn patients, you're going to the cancer center, but it's because of who's there, not because you have cancer. But anyway, so the women who go there, they figure out what is their, what can they do to help reduce their risk and so for some women it's they do every six months mammogram with alternating with breast MRI imaging I have some patients who are eligible for chemo preventative where they go on medicines to help reduce the risk of breast cancer so I think it's a it's a great thing for women if your risk is anywhere from 15 to 20 percent lifetime then they usually the recommendation is to use a yearly ultrasound in addition to the mammography. I have some patients who still ask me about screening with mammography, which is a heat imaging of the breast, but the only modality that's been associated with decreased mortality from breast cancer is mammogram. That's the only one so that's what I recommend good so clearly family history is important and breast cancer what are some other risk factors that may be modifiable that things we can do to try to reduce our risk of breast cancer well with breast cancer a lot of times it is hormone driven and so for women the big thing is weight. When you carry extra weight, there's a low-potency estrogen. It's called estrone that's stored in fat cells. And so your estrogen levels are higher. And so your breast tissue, your uterus, it all sees higher estrogen levels for as long as you carry extra weight. And it puts you in a higher risk category. The other thing is childbearing. If you wait until age 30 or above, you increase your risk, actually. Sometimes that's not modifiable, depending on what your career path is, but that's another thing. And breastfeeding. If you breastfeed it has an absolute protective benefit anything that's going to reduce your your ovulation time in life will help decrease anything specific around lifestyle choices like smoking or absolutely that goes without saying yeah yeah and um i think you know diet uh making sure that you i've seen different things about um there's some protective benefit when when you You eat more of the Mediterranean diets and less high-fat foods. So I think it's all the same things that reduce your risk for other cancers also. So put down the fried chicken. Put it down. And don't smoke cigarettes. Right. And have babies before you're 30. And breastfeed. And breastfeed. Yes. Okay, all right, got it, got it. I think I got it. Yeah. We're good, good. And then for a lot of postmenopausal women, there's the whole hormonal issue. And so that, it does increase your risk of being diagnosed for breast cancer whenever you take hormones. And for women who've had hysterectomies, they are eligible to take just estrogen alone. And that risk is, it's a, you know, instead of a relative risk of 1.0, it's a 1.1 relative risk, which is a slight increased risk. That risk doesn't escalate over time. It stays that same elevated risk. But it's the women who still have their uterus, and they have to take progesterone with it. For those women, the risk absolutely escalates. And so from zero to four years, you have the same relative risk as those who take estrogen alone is at 1.1. But after that five-year mark, you have a five-fold increased risk of being diagnosed with breast cancer if you take combination hormone therapy. And then after nine years, that risk goes up to tenfold. At that point, they stop the study, but I suspect that it continues to escalate over time with the combination hormones. So what do you typically recommend for your patients, say someone who's in menopause but has significant menopausal symptoms and is also like, gosh, I'm worried about the breast cancer risk? Well, you know, I think that a short course of hormones can help you get through the rough period. Most of the time, the symptoms do get better after the first two years. So if you're really struggling, we can talk about short-term use of hormones, even combination hormones. You know, if you keep it to that four mark or less, yes, there's a slight increased risk, but it doesn't escalate until that five-year mark. There's also a new medicine out now. It's called Vazoa, and it's brand new. It just came in April. But it's a daily pill that you take for the symptomatic relief of hot flashes and night sweats, and that's all it does. And women tolerate it well and it works. So it's not hormonal at all. The only women who cannot take it, it is metabolized by the liver. So if you have liver issues, you're not eligible. – Okay, gotcha. Another, I guess, not uncommon problem as we get older is reduced bone density and osteoporosis. And it seems to affect women more than men. Maybe you can comment on that And what are some testing recommendations around bone density? So for the bone density, as long as we have estrogen in our bodies, our bones stay pretty strong. And so if you do anything to decrease the estrogen, then your risk of osteoporosis will be higher. So for postmenopausal women, if you look at the graphs of bone loss, in the first five years, it's a really sharp curve. So without any hormone replacement therapy with menopause, it's a curve like this for the first five years. And then after that, we continue to lose bone mass, but the curve is more like this, so it flattens out. You continue to lose it throughout the rest of your life, but it's at a much slower pace. So for women, it's a good idea to check after you've been in menopause for five years and no hormones to see where you stand. A lot of insurance companies don't agree with that. I know some women I see, they have to wait until Medicare age to know. But by this point, most women have been in menopause for up to 15 years. But there are certain things that do put you at higher risk, and that's early menopause will put you at higher risk, and that's just because without estrogen, you start to lose bone mass. And medicine, certain medicines can, like the proton pump inhibitors, everyone takes those. That can cause it. Thyroid medicines can cause it. Steroids, if you're on long-term steroids. So there are different medications that can put you at higher risk too. And family history is a big one. If you've got a mom who had osteoporosis, then you need to be checked sooner than most. Or if you've broken a bone, you need to get checked regardless. Sure. So there are some things that people can do, right? Like exercise and certain diet things or maybe it's weight-bearing exercises so some women tell me while i walk well walking is okay but if you if you put some weights on you um then that's going to be even better so um i say weight lifting is good um you know if you're gonna like if you play golf then carry the golf bag you know that's it's weight-bearing it's going to be it'll be good for your bones so weight-bearing exercises they used to be really big on supplementing with calcium but now that's They've backed off of calcium supplementation. The big one is vitamin D. And vitamin D supplements, it's important because if you don't have the adequate vitamin D, you can't keep your bones as strong as they would be. And even if you're getting treated for endometriosis, you can't replace bone without that vitamin D. Well, good. Thanks, Amy. So talking about hormones a little bit. So let's maybe talk me through the normal, I guess, progression of a woman's life from the time that, say, someone goes through puberty up until menopause and the hormones in the body. And then also, like, some questions I hear sometimes, like, how do birth control pills work? Like, just those type questions. Well, there are many different types of birth control options out there for women now. And most young women opt for a combination birth control pills, which means there's estrogen and progesterone. So, once you go through menarche and you start having your periods, it takes about two years for the axis to mature completely, but by that time you're gonna be cycling every month. Every month you're gonna have your estrogen levels as they increase, you're gonna ovulate, and then after that you start making progesterone. If you're not pregnant, then what will happen is there's gonna be a sharp decline of the the estrogen and progesterone, and that's when you have your period. You have your period that week, and then it all starts over. Now, birth control pills, what they do is they give you a continuous level of hormones, so they suppress ovulation. So a lot of patients, they may get a roller coaster where they get mood swings, but those are women who take seven days off from the pill, and the only reason they do that is so that it'll more mimic the natural cycle, and a lot of women like the reassurance, okay, I'm not pregnant, so they want to have a period, but you don't have to have one every month, as long as you're on birth control pills, and I know why you're not having it. It's not unsafe, but as far as the hormones, if you take seven days off, a lot of women, it gives their ovaries just enough time to wake up, and so when they wake up just a little bit. They'll produce a little bit, but then it'll get suppressed again, but a lot of women, they'll get this roller coaster effect on birth control pills, and they'll tell me I'm having horrible mood swings, and so there's ways around it. You move them to the 24-day regimen where they take active pills for 24 days. They only take four days off, and their ovaries don't have time to wake up, so they're much more even keeled. They have three-month birth control pills now where you take pills continuously for three months, and you have a period once a season. Seasonal is the one that I thought the name was ingenious, but you have a period once a season, so four times a year you'll menstruate, and women, they love it, but as far as the internal hormones, those, when you take birth control pills, it's going to be, the levels of your hormones are going to be lower than your natural level of hormones, so a lot of women are always worried about, well, am I going to increase my risk of breast cancer there's no evidence that it does that and that's the reason it's because it's actually lower than what a natural cycle hormone levels will be so i've heard some some folks have concern around well i've been on birth control pills for a long time is it going to make it where it's hard for me to get pregnant when i want to get pregnant yeah a lot of women do have that fear but what i always tell them is that when you when you're on birth control pills once you stop, your fertility goes immediately back to baseline. And there's going to be 10% of the population of couples will have difficulties getting pregnant. And I don't know if you're that 10% or not until you try. So you don't stop until you're ready to be a mom, because usually when you take that, you're going to be most fertile those first few months that you come off, especially if you have any other like confounding factors. If you're one who doesn't ovulate consistently. Maybe you have polycystic ovarian syndrome, endometriosis. Any of those processes is going to be important that you get pregnant quickly, and you're going to be most fertile as soon as you come off of it. Now, if you're on the progesterone-only form, like the Depo shots, there is a delay in return of fertility, and it can be up to 18 months before you can start cycling again 18 months 18 months wow so that was actually one of my next questions was uh talk to us about that the the long-acting injectable birth control so with with the there's the next one on so a rod that goes in the upper arm for three years um and then there's the depo shots that you get once every three years i mean every three months rather those um those progesterone only forms of birth control and women love them because they don't have cycles on it or it drives them crazy they can have a lot of breakthrough bleeding because without that estrogen to stabilize the endometrium you can get a lot of breakthrough bleeding but if you're one of the women who achieves no period then you'll love it but the problem is is that it it decreases your estrogen levels you've suppressed everything so if you stay on it too long then you have to worry about your bones because you're not getting the estrogen that you need to keep your bones strong so a lot of times you know the if you're on the my son kids a lot of times if you're on the the Depo-Provera specifically then you know I don't recommend that you take it very long term just because of the bone health and the next one on is the same you know you're gonna you're gonna be decreasing your your bone mass in the end. So I guess another form of birth control would be like the IUD. Who do you recommend that? The IUD has a, I think it's a wonderful form of birth control and it has more of a local effect. So you don't get the same, you don't get the same worry about the bone loss as you do with it. But the IUDs come in, I call them different flavors. You can have the higher dose 52 milligram or the lower dose, 19 and a half milligram. And the difference is the 52 milligram, you're going to get suppression. You're not going to have periods with that. And that if you're after not having periods, that's the one you want. The problem is, is that I do have a lot of patients. They're not supposed to have systemic side effects, but they absolutely do. And so I usually try to steer people away from the higher dose to the lower dose because you might still have periods. Sometimes you stop after you've had it for a while, but they're going to be lighter, but you're not going to get that systemic effect that some women do. Gotcha. So there are a lot of other conditions that only affect women, and maybe we can talk about some of those for a minute. One would be like, say, uterine fibroids. Tell us what those are, and like, what are the risk factors for those? Well, we don't really, fibroids are benign tumors that grow inside the muscle of the uterus. The uterus is a big muscle. And so you can get these tumors that grow, and they say as many as 50% of women over the age of 35 have at least one. And so it's very common. We know that it's more common in African-American women, but we don't know what causes them, and we don't know why. It would be very unlikely that these tumors, they continue to grow throughout your reproductive life, so they can get to be really large. The symptoms that they cause is they cause very heavy menstrual bleeding, and they can cause pain. Sometimes they can interfere with getting pregnant with fertility, but most of the time it's the bleeding and pain that bring patients to me. But I think there are, even with fibroids, there are new medicines now that you can take by mouth that we used to not be able to offer, but they've been out for maybe one or two years now, and they work. You know, I've got several patients who take them now. It's a daily pill you take, and it reduces their menstrual flow by, like, 60%. So it works. When do you decide that it's time to try surgery for those? How do you make that decision? Well, if we try… You know, I always try to be conservative, So if a woman, especially if she's trying to have more children, you want to do the medicines for a while, and then if it is interfering with her ability to get pregnant, I had a patient not long ago, she was wanting to have a baby, and she had a fire boy that was causing heavy periods, and she had been trying to get pregnant, she had had two other babies and couldn't get pregnant, so I did a procedure called a myomectomy, and in years past, a myomectomy meant that you ended up with a big incision. We took out the fibroid, closed up the uterus in multiple layers, worried about scar tissue. And it was a long, morbid recovery. But now that we have a robot at Self Regional, I'm able to do those surgeries robotically now. And it is amazing the difference in recovery. I did one, the patient that I'm speaking of, She never took anything for pain, and I saw her the next week, and she was fine. In years past, those same women would have still been kind of bent over, walking into my office a week later, still hurting, but she was fine. So she was like, now, when can I get pregnant? And I was like, not yet. You've got to heal first. So it's been pretty amazing, the advances that I can offer medicines now. I can offer to take them out robotically. And it doesn't slow us down. Women can keep going. I'm glad you brought up robotic surgery. That's one of the new offerings we've just had now for, I guess, a year and a half or so at Self Regional. And we kind of started in urology, and you're doing a lot of robotic surgery. Can you maybe tell us about some of the types of surgeries that you do other than, like, for fibroids, some of the other type procedures you do robotically? Yeah, so the robot, it's been around for a long time, but it's just been available here for a year. And so, you know, I'd heard about it, read about it, and I'm like, I don't need a robot. But when I really got serious about looking into it, you know, I started watching lots of videos. And it's amazing the difference in what you can accomplish. And so with the robot, I do hysterectomies. I've been able to do really complex surgeries now, minimally invasive. the patient went home, they go home the same day with a hysterectomy. On patients who would have required, I mean, huge midline incisions just last year, you know, that's the difference. Because with the robot, you can, you can take these complicated surgeries and make them minimally invasive. It's, it's amazing. I'm a true convert and believer now. But you can do, you know, I've done myomectomies, hysterectomies. You can do complex, if you have endometriosis, you can do excision of endometriosis. A lot of women, they'll have frozen pelvises. It allows you to be able to do all of these surgeries, minimally invasive, where you just get better faster. You don't hurt as badly, and the recovery is so much faster. That's great. So endometriosis, let's talk about that for a second. What is it? What causes it? What are the symptoms of it? And what do you do to treat it? Well, with endometriosis, it's where the lining of the uterus gets out into the abdominal cavity. And it can implant anywhere. I've even read about it getting into the lungs, the brain. And what happens is every time you cycle, every time you have a period, wherever this tissue is implanted, it also swells and it bleeds. Well, blood anywhere in the abdominal cavity hurts If it's in the lungs, you could cough up blood. So it's a disease that we, it can happen early. I see teenagers with it. We don't really know why some people get it and some don't. But we know that there's a genetic component because there's always usually a family history if you get to talking to women. It's often underdiagnosed in African-American women. And I'm not quite sure why that is, but it's a true statement. But it's something that it causes pain with periods. Typically, it starts where women will hurt with their periods, and then they'll get to where they hurt a few days before their period, and then a few weeks, and then they get to where they're just hurting all the time. Sometimes the only thing they present with is pain with intercourse. You get scarring behind the uterus usually, what we call the uterus sacral ligaments, which are, they're suspension ligaments for the uterus, and when you get those implants there, it hurts when you try to have intercourse. So as far as treatment, the only way I can know if you have it is to operate, and operating on everyone who you think has endometriosis is not feasible or not really good, because the problem is with endometriosis, it's an unrelenting disease. So you treat it and within two years, 60% of women are going to be hurting again from their endometriosis. So it just keeps coming back and keeps coming back. And the reason is, is that feeds off the estrogen that the ovaries makes. So that's why it's a recurring problem. And so when you get to the point where medication, like where birth control is not working, which is not controlling the pain, they do have new medicines now that you can take that helps relieve endometriosis pain also, and those are the medicine is called Orlissa, and it's been on the market for about three or four years now, but it's a daily pill that you take. There are two different doses. Women can never tolerate the higher dose, so I don't even try it anymore. It's kind of interesting because in years past, all we had to offer was a shot. It's called Depo-Lupron that shut down the ovaries completely, and women tolerated that pretty well believe it or not they some complained of headaches but this or lissa the higher dose they complain they don't feel good but the lower dose they they tolerate it well and they it's a daily pill that you can take for up to two years and it helps relieve the pain but when that doesn't work there's always surgery and with surgery there are different ways that you can approach the endometriosis so a lot of times i ablate any of the endometriotic implants that i see. You can do complete excision, where you excise all that peritoneal lining where it is, and then hysterectomy is the ultimate, where you, sometimes women, you know, it's all, it's a very personal conversation about whether or not I take out the ovaries, because you run the risk you're going to hurt again if I leave those ovaries, because that's what's feeding met. Gotcha. Another thing specific to females, a lot of folks after they have a baby may have some pelvic organ prolapse. Maybe talk about that a little bit, some of the symptoms of that. So it's usually, it's a more of a problem with menopause. And I think, you know, the reason is, is that with menopause, with estrogen levels, as they drop in the body, one of the organs that takes a hit is the vagina. And so with that, the vagina is normally an elastic organ. And without the estrogen, it becomes more, it loses that, that nature. And it becomes, the tissues become very thin. They become very easy to tear and become irritated. And so with that comes problems with the, with, with support. So women start to develop, I always, I always explain it as you have a hernia. So the way to think about it is you have a hernia of the vagina, and any part of it can herniate. So you can have the bladder that herniates, and that would be more of an anterior problem. You can have the bottom that herniates, and that's what we call a rectocele. Or you can have the uterus and cervix itself, where that's what's prolapsing. So it comes in varying forms and degrees. But with that, you know, I always tell patients that if it's not bothering you, leave it alone. But if it's bothersome, then there are only two treatment options. And one is called a pessary. It's a rubber device that I put in in the office. And if it's the right one, it's the right size, the patient never doesn't know that it's there. But they come in for me to remove it and clean it every three to four months. So that's one treatment option. then the other is surgical and so it all depends on what I'm looking at as to what I would recommend as far as surgical correction but the problem is is that you have weak tissue and so even if I let's say that you've your bladders what's dropped and if I operate and tack that up well you still have this weak tissue here so you can develop more there can be more problems coming and so It all depends on what I'm looking at is what I can fix. If it's not broken, I can't fix it. I always tell patients it might not be the only surgery you have to have. If it's the entire cervix and all prolapsing, then now I used to have to send patients out of town, but now we can handle that here with the robot. I usually do the hysterectomy portion, and then Dr. Hansen, the urologist, comes in and does It's called a sacral copopexy, where you take mesh and you attach it to the cervix and you pull it up and attach it to the sacrum, and it works. I mean, it would be very rare that, you know, you would have a recurrence problem after that. So I think that's been a fantastic addition to our health care here. Absolutely. You know, another thing kind of along these lines is, like, urinary incontinence in women, particularly after babies. maybe comment on that maybe similar surgery yeah there's like that um there you know i think with that um kegel exercises every woman needs to be doing them um they even have apps on your phone now that can remind you um and help you with the training but um i think if you've if you've had a baby start doing them and the longer you do them the less likely you are to have problems with urinary incontinence, with pelvic organ prolapse, because you help keep all that network of muscle strong. But if you should have problems, most of the time it develops, you know, I would say in the 40s is when I start to, patients start to talk to me about it. And I think it probably has to do with the decreasing estrogen levels also. So sometimes something as simple as some vaginal estrogen replacement um that's all you need to help keep that tissue healthy it helps prevent bladder infections you know i see patients um often who are well into menopause and they're having problems with the current utis or bladder infections and so that is one of the mainstays of treatment put estrogen in um and so even women i had a patient who i saw the other day she had had a history of breast cancer and I'm like, well, you're in luck. There's a new study. It came out from the Dutch this year. Over 20,000 women, breast cancer survivors, who they used vaginal estrogens. Even those who are on CIRMS, who are still taking tamoxifen, they use vaginal estrogen. No increased risk of recurrence. The only women who could not were the ones who were on the aromatase inhibitors. Those had an increased risk of recurrence. I don't know why my brain can't figure that out yet. I'm going to have to think about it some more. But the average time to recurrence was 150 days, which is unreal to me. You put it in once a week. It's a blueberry-sized amount that's inserted once a week into the vagina. But I think every woman should do that lifelong. There's no harm in it, in my mind, unless you're on a aromatase inhibitor, then don't do it. Okay. Well, gosh, Amy, I think that's the bulk of the questions that I had. Do you have any other topics that you want to talk about? Oh, I almost forgot. Birth control is about to be over the counter. It's called the O-pill. It's coming in 2024. It's a progesterone-only pill, and it's going to be available. There's going to be no restrictions, and I think it's a fantastic thing. Well, maybe I'll go get some. I don't need any more kids. Just kidding, of course. Yeah, just kidding. It's bad for my business, but I do, you know, I think the unintended pregnancy rate in the United States is 46%, and so, believe it or not, I had an unintended pregnancy. I could have used some of that over-the-counter birth control, but it's common, it's called an O-pill it's a norgestrel progesterone only and I bet the combination hormone is probably going to follow soon it's in the making great, well this has been great Amy does anyone have any questions any burning questions that you may have about women's health or really anything yes so if you're at a certain age you remember that I think it was in the 90's but all the reports came out about hormones and a lot of doctors pulled those kind of out of their tools because they were used for women. It sounds like what you've been talking about, that maybe those are making an interest, again, very restricted to the individual. Have you seen a change from early in the 90s timeframe when the reports came out about hormones being in people pulling them back and doing practice? The problem, I never really backed off of them because I think, you know, hormones are fantastic. And if you looked at those studies, the WHO study from the 90s, the problem with that study is they took women who were much older than menopause and started them on hormones. Those are not the women I start on hormones. So they were taking 65-year-olds and putting them on hormones. But if you start them at the time of menopause, the average age of menopause is 51, then you're going to have a much different patient that you're dealing with. And so that study had problems from the get-go. So most gynecologist, we, we, we didn't really take heed to that study, um, for that reason. Yes. Um, with the vaginal estrogen that you highly recommend, is the notorubin a source of that? The new, the, so when, when you're, this, for the vaginal estrogen, that's only intended for women who've gone through menopause and have no estrogen in their body. So the NuvaRing is a 20 microgram equivalent, 20 microgram estrogen. So that's enough. The vaginal replacement is 10 micrograms that's used when you use the vaginal estrogen pill. So it's half of that. But any pre-menopause or any woman who is still having cycles or using any sort of birth control, they don't typically have those problems. Occasionally, I see women who do have different problems with birth control, like when they've been on Depo for a long time, sometimes you can get some vaginal atrophy-type symptoms, and I'll give them vaginal estrogen. But if you're on a combination hormone, you don't have to worry. Your vagina's going to be fine with that amount that's in there. There are some other side effects from taking combination. I see some women, And I have some women who come in and they have loss of sex drive with the birth control pills. And I had one who came to me and she was on testosterone. And I'm like, why are you taking this? And she didn't know any better. But whoever got a hold of her put her on this thinking it would help with her sex drive. And I'm like, it's your pills. And any form of birth control, when you take medicines by mouth, they have the first pass effect through the liver. And so there's certain things that it causes when it does that first pass effect. And one of the things is it revs up the production of your sex-binding hormone globulin. And so it'll bind up all your hormones. It's not specific on which one it binds. And so that's why some women will lose their sex drive on birth control pills. It's that effect. So most of the time, if you switch them to the NuvaRing or put the patch, use the birth control patch and bypass that system, it's better. And there are some new studies to suggest that by using the things that you don't put in your mouth, you also don't get the activation of the cascade for the clotting disorders. And so even postmenopausal women, a lot of times they'll say, well, I think the patch is probably safer. You don't get the first pass effect through the liver, so there's no adverse effect on your cholesterol levels. And there's probably decreased risk of blood clots. That brings up a good question. I'm glad you mentioned that. So that is one of the risk factors of taking hormone therapy is blood clots. What is that risk approximately? Well, for birth control pills, it all depends on it's dose dependent. And so when they first came out with birth control pills, the combination pills, they were like 50 microgram pills. And when they did mass production, you know, this was back in the 1960s when birth control was first available to women. The first one was a progesterone-only pill, so they didn't see that. It wasn't until the late 60s when they came out with a combination therapy of the 50 micrograms. It didn't take long for them to start seeing women having heart attacks, strokes, and so they learned. But when they backed down, it went to a 35-microgram pill pretty quickly without losing its efficacy. And so now most pills are 20 micrograms, so the risk is even less. But again, you know, when you're talking about risk, it's four per 100,000. And so the incidence is really low, but does it increase your risk? Absolutely. But we're talking about four out of 100,000. So the risk is low. And even with hormone replacement therapy, the risk is probably lower. But the problem is that we get more mature, our risk of blood clots goes up. And so that's why I think if you use the patch, I think it's probably safer in that regard. But they do have a new, like, they have new natural bioidentical hormones coming out that's going to act differently in the body that probably will not adversely affect the cholesterol, like, and it's by mouth. Good. Thank you. Any other questions? Yes. Dr. Parsley, can you talk a little bit about the diagnosis of polycystic ovarian disease? Okay, so it is a diagnosis of exclusion, And that's what I tell patients. So most of the time, it's something that women know very early on in the teenage years. They will present with not having regular cycles. And it's usually something that starts from the get-go. And it's not occasionally, you know, I see patients who aren't having regular cycles and they think that's what they have, but they just haven't given themselves long enough for that access to mature. But if you've been having cycles for three to four years and they're irregular, then that's usually a diagnosis. It's my number one diagnosis, but it's a diagnosis of exclusion. So I'm going to do lab work to make sure that it's not your thyroid, to make sure that you don't have any sort of pituitary growths. And if all that's negative, then that's what it is. And the estimates are as many as 10% of women suffer from polycystic ovarian syndrome. And I've listened to some recent, read some recent articles about using over-the-counter inositol, which is, it's a myonositol. There's an imbalance they found in the two inositol levels within the ovary. So just by supplementing, you can, a lot of women have restored normal menses. And so I thought it was pretty interesting. You can get that in a supplement. Yeah. Good question. Anybody else? Yeah. When you need an inconsistency, are you talking about like skipping a lot of times or like not having an inconsistency at the same time? Well, not, well, it could be either. You know, some, it all depends. The polycystic ovarian syndrome is a, like it's a, there's a whole myriad of symptoms that women can have, but you may have, let's say if you, If you're not having ovulatory cycles, that's the number one reason why you don't have ovulatory cycles. And not every woman ovulates every single month, but you should the majority of the month. So, like, I'd say 10 out of 12 months, you should be ovulating. And when you do that, when you have regular cycles, your cycles are going to be, when you count from your start date to your next period start date, it should be anywhere from 20, 21 to 28, maybe 30 days. If you start stretching out much more than 33 days, then you're not ovulating. So for someone with polycystic ovarian syndrome, they might have cycles every 35, 40 days. That's pretty regular for them, but it's still not ovulatory. So those women probably have polycystic ovarian syndrome. And the more a woman who has that syndrome, the more they weigh, the worse it becomes. So if you have someone who's having cycles every 35 to 40 days, let's say they gain 30 pounds over a few years, Then it might stretch out where they're only having cycles every three months, six months. I had a patient that I just operated on a couple months ago. She's in her mid-30s, but she went years without a period. And unfortunately, she didn't come see me before she has cancer. You've got to have periods. I know it's not nice, but you just can't not have ovulatory periods. Because the problem is that she was producing estrogen, estrogen, estrogen, and it builds up that lining and it's making it just so supple in case there's a baby to be implanted that it turns into cancer. If it's not, it's got to all be cleaned out. Yes. Can you talk a little bit between the window side and the bridge side? So the way to think about it is the amount of suppression you get. So, like, you know, I told you about our normal cycle hormones. It might be usually our estrogen levels are around 80 to 90 if they measure levels in the body. If you're on birth control pills, it depends on which type pill I'm giving you. So it could be like 35 micrograms is what you'll measure in the blood. So these pills that I'm talking about, they decrease it to like 20 or 10. So they cut it in half from what birth control pills can. And it depends on which dose you take as to how much suppression you get. Now, Lupron, it'll shut you down. So the shots, that's the most suppression you can get of your ovaries. And these pills are just a step above that. But it still works. For most patients that I have with endometriosis, I can use the lower dose, and they get relief. It's pretty remarkable. But the Lupron, that's all we used to have to offer. So if I operated on someone and I saw that they had endometriosis, at that time it was recommended that you do six months of Lupron therapy because we knew that you were going to hurt again. And the problem is when you're operating with a straight laparoscopy, you're looking at a two-dimensional screen. Well, you're not a two-dimensional person, so the endometriosis implant may be deeper than what you think you're treating. And so that's why the Lupron shots were used to help treat the deeper implants that you didn't necessarily get. Yes? I'm a two-person, my age. Do you stop those vaccines? Do you just look for them? Well, you know, it's all, I think it's dependent on the person and her risk factors. If you're someone who's been married for 60 years or 50 years and you've never had an abnormal pap, your risk is low. The problem is that I've had patients who've had hysterectomies and, you know, their primary care doctor was telling them they didn't need pap smears anymore, and no one was examining these women. So I've had several patients who had vulvar cancers. Clear. Like, I looked at it, and I knew that she had a cancer. I've had a couple that had vaginal cancers. Nobody was looking. So I do think that there's still benefit to see me, to let me look and make sure that everything is okay and in working order. Yes. Yes, ma'am. Is there a change for the menopause? Well, if you read some of the society, like I said, there's different societies who have different recommendations. But the truth is, the more birthdays you have, the more likely you are to be diagnosed, period. Your risk goes up and up and up. But I always tell patients, the time, as long as you want to know the answers to the questions, you keep asking. So you keep doing the test. If you're to the point in your life where you're like, well, I don't want to know the answers to that question, you stop doing the screening. So I've had some patients in there. I had a spunky patient who was 83, I remember. She had breast cancer. It was early stage because it was caught with mammography. She had surgery and she did great. No chemo, no radiation, nothing else was needed. So I think the test can, it still has value if you still are willing to do something with the answer. – Thank you very much. Amy, this has been great. Ken, I'm gonna turn it over to you. – I'll sign us out. – Amy, thank you very much. Matt. Thank you both for sharing your time and your talents and your wisdom with us for this program. As some of you know, this is the season finale for Medically Speaking for 2023. We've done six of these now, and I think we've got it pretty well figured out. Would love to have some input from any of you folks, you can send us ideas for programs for next year to foundation itself, regional.org. If you want, if you have some topics that you'd like to see us try to put out here, we'll be happy to do so. These things don't happen by themselves. There's a lot of people behind the scenes that help us with these things. And I want to thank Mark Hyatt, Kendall Gunner, Andy Westbrook over here. Mark, you got a new team member with you here tonight? Allison down here. The marketing team, that's the four of them, they do the marketing for the entire hospital and us. Thank you very much for your efforts, you guys. We really appreciate that. Of course, I've got to thank my staff, Jessica Garcia and Lisa Bishop right here. They're right and left arms for me, and they make things happen in our foundation office. Ladies, thank you. I've got to say thank you also to Trenci Williams and the Chamber of Commerce for your support of this effort. I know you've been promoting this a little more heavily here the last couple of times among your membership. I think those results are paying off by virtue of the crowd that we get. So, Trans-EU and Amman and your group down there, we thank you for your support. But last, but certainly not least, are my friends at Lander University. We couldn't do this program without Lander. This is a world-class facility for us to offer these programs. Lander does not charge us. Um, they provide the food and some of you have partaken in that food in the past. Uh, there's a little reception upstairs after, after we're done here. Uh, but, uh, I just want to go through the list. Dr. Rich Cosentino, Dr. Halissa Wharton, Sadie Irwin. There's some guys up there, uh, up top, uh, Eddie Shaw, Frank McVeigh, and Robert Mitchum, who are the tech guys up there. Thank you, fellas. Uh, appreciate you. Um, Elizabeth McEwen and Megan Varner, who helps with the promotional piece. And then last but not least, I mentioned the food. The Lander University food and nutrition team is second probably to Self Regional's food and nutrition team. So I don't want to get in too trouble with our team. But we've got some good food lined up upstairs, so please avail yourselves to that. Thank you for being here. We appreciate your continued interest in these kinds of programs. Thank you.