In this episode of LymphaCure, Dr. James Simon, a highly esteemed gynecologist and reproductive endocrinologist, discusses critical gaps in menopause education. Despite living in the 21st century, many women remain unaware of menopause until they experience it, largely due to societal reluctance to embrace aging and a healthcare system that lost knowledge when hormone therapy fell out of favor. Dr. Simon explains how a lack of training in this area affects healthcare providers today. He also addresses common concerns about hormone replacement therapy, including age limitations.

Dominique:
Welcome to LymphaCure. Our guest today is a renowned doctor and board-certified gynecologist and reproductive endocrinologist. He also holds certifications as sexuality counselor and menopause specialist. He serves as clinical professor at George Washington University and owns his own practice in team medicine. Throughout his career, he has received many awards among which, Top Washington, D.C. Physicians, America’s Top Obstetricians and Gynecologists, and Super Doctor of Baltimore, Washington, D.C. and Northern Virginia, just to name a few.

So, let’s welcome Dr. James Simon. Dr. Simon, thank you so much for taking the time to answer our questions today. And I have been sending you clients for many years. I’m so excited because now I can just show them this video and-

Dr. James Simon:
Happy to help, anyway.

Dominique:
… just to get them started. So here is my first question. Apparently, most women don’t know much or don’t know anything about menopause until they go through it. So how come we are in the 21st century and there is such a lack of education in an aspect of a woman’s health that is life-changing?

Dr. James Simon:
So, I think it’s multifactorial, Dominique. It’s one thing that’s very pervasive in the first world is that no one wants to be or appear to be older. And so, women don’t want to admit that they’re of a menopausal age, which would typically be around age 50. They want to look at and be younger, and so there’s a certain element of being in denial or not wanting to be old enough for menopause. And the other is much more the fault of the healthcare system in that for many, many years, hormone therapy was the typical approach to menopause, and then it became very out of favor and mostly about side effects and risks. And as a result, there was an entire generation of practitioners, nurse practitioners, doctors, physician’s assistants, nurses, midwives, that did not get educated, and now have lost some institutional memory from those older practitioners because there was a whole generation of practitioners that did not get trained.

Dominique:
A lot of women were curious about the hormone replacement therapy. Is there an age limit for that?

Dr. James Simon:
So, this is a complicated question. I’ll try and break it up into two different answers, but they both tend to get at your question. The first is, what is the age that a woman is starting on her hormone therapy? And I would say that if a woman starts on her hormone therapy early in menopause or even before her last menstrual period, which is the beginning of menopause, she can be on her hormones for an extremely long time, maybe until she dies. Barring some reason for her to go off her hormones, she can be on it for decades.

That’s different from a woman who is contemplating starting her hormones at an advanced age. We know from large studies that one size doesn’t fit all people, and your audience knows that because their diets are different, their clothes and dress sizes are different, their lifestyles are different, everybody’s different. In, for the most part, younger, healthy women can start on hormones and go for a very long time. The older a woman is and the longer it’s been since her menopause, the more likely it is that going on hormones will be a mixed bag of both benefits and risks, and it’s individualized where the balance between risk and benefit is for her.

So to your question, is a woman ever too old? Well, it depends. Are we talking about staying on your hormones that you started early or going on hormones late? And those are two different questions.

Dominique:
Mm-hmm. Okay, so what are the risks? This is a question that comes up all the time because I think there was a study that was done over 10 years ago where we found out that giving hormones to older women caused cancer. So is that still true?

Dr. James Simon:
So, I would need to know which study we’re talking about, but the largest major study, the so-called Women’s Health Initiative study, which is now 20 years old-

Dominique:
Right.

Dr. James Simon:
… was what upset the entire field because they included women who started their hormones as late as age 79. So, they were quite elderly when they started. And in keeping with my last answer, there were lots of risks that came up in those older women, typically age 70 to 79 when they started, not up to age 70 or 79, having started at age 50. It’s a very different question. And some of us would argue, and I would be one of them, that even in those studies of those much older women, 70 to 79, there was no increase in cancer risk at all. It was an aberration about the way the scientists analyzed the data, and they analyzed it in a way that was inconsistent with their original published analysis plan. So they said, “We’re going to do this research by the book and analyze the data in this way,” and then when it didn’t show anything, when you analyze it this way, they went for the headlines and changed the way they did it. And that’s not okay.

Dominique:
When women are on menopause, a question that comes up a lot is the decrease in libido, but also discomfort associated with intercourse. So, what can these women do to alleviate those symptoms?

Dr. James Simon:
So, let’s divide the symptoms into two different ones, desire for sex and pain with sex, but they’re not completely separate because a woman that’s having pain with sex is going to have a decreased desire for sex. So, a woman that’s having pain with sex is going to obviously avoid engaging in that behavior because it’s painful. That decreases her libido. And sometimes it’s not even clear to that woman that the pain that she’s having is actually playing with her head, so to speak, and decreasing her interest. But it’s pretty universal.

So in a patient with pain, we got to fix the pain first before we can expect her interest to come back. And if we fix the pain and her interest didn’t come back, then she becomes more like the woman that has no interest and no pain. Those are two different scenarios, and we have different treatments for both. So if a woman has pain, we usually treat the pain, which is a result of very low hormones during menopause, with both local hormones in the vagina, or on the vulva and in the vagina, and we also suggest once she’s better or better enough, to use a lubricant for sexual penetration and a moisturizer. And those are different things. So first we treat the tissue by giving it back the hormones that are missing, then we give a woman moisturizer like she would put on her face-

Dominique:
Right.

Dr. James Simon:
… or on her skin. [inaudible 00:10:03]-

Dominique:
Avoid dryness.

Dr. James Simon:
Dryness, to take care of the dryness and to moisturize the vagina. And then, in addition to that and separate from it, we suggest a lubricant during sex. A lubricant is not a moisturizer, and a moisturizer is not a lubricant. They can help painful sex, one, the other or both. So that’s the woman with pain.

For the woman who has low desire, we need to figure out if her low desire is related to her relationship. That’s the first thing. I don’t know of too many women who want to engage in sexual intimacy if they don’t like their partner. This is a de facto thing, but in couples who are married for a long time or cohabitating for a long time, they may drift apart, emotionally, psychologically, and she or he may not be interested in sex. That’s a different issue.

Hormonally, interest in sex is driven by reproductive hormones. Nearly all women notice when they’re having a menstrual cycle that they have an increased interest in sex right around mid-cycle when they’re ovulating and fertile. That is pretty typical. That’s mother nature speaking loudly, “Dominique, your hormones are peaking. It’s time to make babies.” [inaudible 00:11:39] to make babies, you have to have sex. That’s a hormonally driven event that in menopause, because women are not having their own hormones or they’re not having cycles, is all of a sudden absent from those triggers in her brain that now, after menopause, are gone. And we can simulate them, fake that woman’s brain into thinking that she’s ovulating by giving her back some of those missing hormones that are lost at menopause, and just by hormone replacement therapy that is systemic in nature, not only local for her vagina. And in addition to that, there are medications that are used mostly in pre-menopausal women, younger menopausal, younger women who are not menopausal, to trigger sexual thoughts and fantasies, but that work equally well, whether tested or not, in post-menopausal women. And so we have those, they are on the market.

They’re a little bit tricky to prescribe for post-menopausal women because the insurance companies don’t want to pay for them because they’re FDA approved for those younger women.

Dominique:
Yes.

Dr. James Simon:
But the answer is, they work for older women just as well. And we did all of that research, and the mechanisms are exactly the same in younger women, older women, and by the way, in men also. There are men who have very low desire, whether they’re 20 or 30-year-old men, or they’re 50 or 60 or 70-year-old men. And if their hormones are normal, some of them still have low sexual desire, low libido, and these medications work in them as well.

Dominique:
I have a newer question about the pain. Can you define for us stenosis and vulvodynia, and does that happen only to women who had cancer or can it happen to any woman during menopause?

Dr. James Simon:
So vulvodynia, on its surface, means just painful vulva.

Dominique:
Oh, right.

Dr. James Simon:
That’s all that it really means, but it has come to mean many different kinds of pain in the vulva area or at the initiation of penetration, not deep in the vagina, but very superficial. I can show you with my vulvar puppet.

Dominique:
That’s beautiful. I love that.

Dr. James Simon:
So right at the opening is where the vulva is and where vulvodynia is, not deep in the vagina, but right at the opening. And that’s where most women experience pain after menopause. If it’s pain in the vulva, related only to a lack of hormones, that’s one kind of vulvodynia. But there are other kinds of vulvodynia that occur in women of all ages, and they need to be treated according to the proper diagnosis.

There are some where the nerves at the vaginal opening are very near the surface, and that’s called neuroproliferative vulvodynia. We’ve all had the experience of nerves being too close to the surface. I’ll give you an example. I’ll give you a cooking example.

Dominique:
Okay.

Dr. James Simon:
So you reach into your oven and you burn the top of your hand on the rack above where you’re grabbing the dish.

Dominique:
Yeah, I do that frequently.

Dr. James Simon:
Everybody’s done it at least one. You get a blister on the top of your hand, and the skin that’s been protecting the top of your hand comes off, and the skin underneath is very thin, very red, very new and very sensitive. And at menopause, that very thin skin, with the nerves very close to the surface, sometimes even poking out of the surface of the skin, are very sensitive, just like the skin underneath that blister when the blister comes off. And so we need to thicken the skin on the vulva to toughen it up. So the nerves are still there, just not so sensitive.

Dominique:
Okay.

Dr. James Simon:
And everybody’s experienced when that blister heals and the skin’s back the way it was, it’s still sensitive. You still can feel, you just don’t have pain, you have sensation. That’s neuroproliferative vestibulodynia or vulvodynia. Then we have some that are hormone mediated, some that are congenital and some that are caused by other diseases. And so, a careful exam by a practitioner that can see with his or her eyes open because you need special training to see. Sometimes we need to use magnification, like fancy binoculars to see, but the answer is that’s what vulvodynia is. You asked also about…

Dominique:
Stenosis.

Dr. James Simon:
Stenosis. So, stenosis just means that the opening is small or in fact small enough and stuck closed. And that can happen usually in women who have poor hormonal support or are much older. Now sometimes stenosis can occur because of a disease or because of radiation to the vagina or vulva, or due to some kind of trauma. Regardless, stenosis is a very, very tight vagina that won’t stretch. And so, penetration becomes very, very difficult because of no stretching. And it’s usually treated with a combination of hormones, tissue strengtheners and relaxers, and sometimes dilators to progressively stretch it, or physical therapy. So, for example, a woman who may not have had sex in 20 years is now found her new love of life and her vagina’s going to be a whole new story because she doesn’t have hormones, she hasn’t had penetration, she hasn’t had sex. It’s very tight, it’s very small, and she may need some remedial physical therapy before she can engage in any kind of penetration.

Dominique:
Okay, so it is treatable?

Dr. James Simon:
Usually, yes, but it doesn’t get treated in one day or one week.

Dominique:
Right.

Dr. James Simon:
It takes several months of very active, directed treatment, usually multiple prongs of that treatment, to get that stenotic vagina back to a place where she can have painless penetrative sex.

Dominique:
It’s re-education.

Dr. James Simon:
Re-education is a good name, but we also need to treat the underlying cause of the stenosis. So, if it’s absence of hormones, we need to give hormones. If it’s previous trauma, we need to undo that trauma. Sometimes it’s trauma in that woman’s experience. Sometimes it’s trauma to the actual tissues. Sometimes the trauma is a treatment for a previous disease, could be vaginal cancer or rectal cancer, radiation or other treatments. So we have to really know a lot about the history. It’s not just, the vagina’s too small.

Dominique:
Every time I talk to you, I learn something new. I didn’t know there was physical therapy for that. Would that be done by a gynecologist or a nurse practitioner?

Dr. James Simon:
So usually, the physical therapy is done by a physical therapist. And these are specially trained physical therapists, just like you get if you have rehab on a broken leg, or rehab on a new knee or a new hip. It’s a physical therapist who’s trained to do what we call internal work, meaning in that woman’s vagina, that would help with stretching, muscle re-education, because the muscles around the vagina have to be re-educated to both relax when penetration occurs and then to tighten the before orgasm. And so, there’s to be had if those muscles hadn’t been used in a long time, just like any other muscle. If I said to a woman who’s been a couch potato for 20 years, “Go out and run a marathon tomorrow,” that’s not happening or it’s not going to be very successful. She needs to train the muscles-

Dominique:
Right.

Dr. James Simon:
… and get back into shape. And that’s a really important, but oftentimes overlooked, part of sexual re-education for women who are menopause.

Dominique:
I have a couple more question, then we will wrap on menopause. There are two different schools of thought. There are people who say that a women’s sexuality actually peaks at menopause because we are done with babies, we are done worrying about getting pregnant and we can just partying all the time. And then, of course, there are now women saying during menopause they lose the desire. So, is there any truth to that, to the fact that our sexuality peaks much older than men?

Dr. James Simon:
So I think that it’s highly individual.

Dominique:
Okay.

Dr. James Simon:
So, a woman whose libido, whose interest in sex has been largely under wrap because she’s got five children and she’s got a very tough schedule, or her husband works days and she works nights, this is a formula for very difficult sexual relationships. But for her, having her kids off in college, or married off, or whatever, and no teenagers at home, for example, or getting her schedule with her partner on the same page, can be very liberating, sexually. And for her, it may be the first of her real self-expression, sexually.

For women who are very sexual when they’re younger and don’t find a new partner or don’t rediscover themselves and their long-standing partner until she’s much older, for whatever reason, her libido may not catch up or ever be back the way it was, simply because of age, or hormones, or circumstance. And so, it’s really different for everybody. The reason that many women feel a burst of sexual energy in the early menopausal stages of their lives is that, for them, the testosterone that they have, even though it’s half as much as they had when they were 30, is now more than the estrogen that they have, and so they have a testosterone-dominant effect. And we see this in many, many older women. They start to get a few little hairs-

Dominique:
Yeah.

Dr. James Simon:
… hairs on their lip or on their chin. That’s because they have more testosterone than estrogen, and in those women, many of them have an increase in sexual desire. It doesn’t mean that they don’t have pain with sex, it doesn’t mean that they have a really good lubrication for sex, but it means they have more desire. And we can help women in all those categories by getting their hormones as close to what they were when they were in their 30s or 40s, and at the same time getting rid of pain and talking to them about their relationship and how to re-cement their sexual lives.

Dominique:
So, each person responds differently to this stage of life, is what I’m hearing.

Dr. James Simon:
That’s correct. Now there’s one other stage of life I want to bring up because I think it’s very important, and that’s not menopause or early menopause, as we’ve been discussing, but it’s older couples, and I’m going to define it very clear. So, if you look at large samples of people in the first world, let’s say the US, couples tend to remain sexually active until somewhere in their early 60s, say 60 to 65, and they stop having sex, in large numbers, even though they’re still together, around that 60 to 65-year-old age range. And there may be some psychological, some relationship, some other issues involved, for sure, but some of those issues are physical.

She may have pain with sex that it becomes intolerable, without treatment, around age 60. She may have joint stiffness, particularly in her hips, that prevent her from having intercourse because she can’t spread her legs due to hip pain. He may have erectile dysfunction or the inability to attain or maintain an erection that’s adequate for sex, and because of a constellation of those things, sex stops. And we can treat many of those things that I just mentioned, but there’s also another opportunity for aging couples, aging couples of any age, and that is to transition from what had been their typical paradigm or their typical sexual script that they’ve evolved together since they first got together, up until say age 65, evolve that script to a different script. What we call, evolving a script of intercourse to a script of outercourse-

Dominique:
Aha.

Dr. James Simon:
… meaning, no penetration. So, she doesn’t have to be able to spread her legs or have painful penetration. Most women, not all, enjoy clitoral stimulation, manual, oral or whatever. Most men can enjoy the same kind of sexual pleasure, manual, oral or whatever. And both of them can avoid the pitfalls of stopping sex altogether by figuring out new stuff. But because the script has been evolving over the last, I don’t know, 20, 30, 40, 50 years, it represents a change for them that needs to be talked out and evolved together.

Dominique:
So basically, when it comes to sex at that age, you have to think of it as a fun adventure and be creative.

Dr. James Simon:
Absolutely agree, and sometimes people are not too creative. So we have he dolls, pipe cleaners, she dolls, pipe cleaners, and we have to show them how they can-

Dominique:
Have fun.

Dr. James Simon:
… do those new creative things and have fun because people can be very concrete in their thinking, especially when it means trying new things that they’re not used to doing together. It’s quite surprising to me because, when you tell people, “Well, what about this?” They say, “Oh, yeah, of course. Why didn’t I think of that?” And it’s just because we tend to fall into these ruts, or scripts, or standard practice that it’s difficult to get out of. We need to think creatively, and have fun, and do things that we hadn’t done before, not because they’re bad, or dirty, or painful, or anything else, just that we’ve evolved together to do what works for us together. And many times, the easiest thing is to say, “Mr. and Mrs. Smith, when you first got together, when you didn’t know each other’s bodies, when you hadn’t had sex, but maybe once or twice, what did you guys do?”

Dominique:
Yeah, that’s a really good question.

Dr. James Simon:
Remember the times when you were having just fun and not just, okay, honey, we got 17 minutes and 30 seconds to get it done before we get picked up by the Uber, those kinds of things are really important. And a corollary there is, women take a lot longer to get warmed up, that is to have arousal, and get interested, and get to the point where they can enjoy pleasure than men do. But as couples get older together, everybody’s in a big hurry. The five kids, the teenagers that are-

Dominique:
Right.

Dr. James Simon:
… coming home from their date, we got this, we got that. Grandma just went to sleep in the next room. We got to get all of our stuff done before anybody comes home or wakes up.

Dominique:
And by then, usually one is too tired to care. Yeah.

Dr. James Simon:
Or the mood is gone. You have to be in the right mood.

Dominique:
Right.

Dr. James Simon:
And we recommend for couples, believe it or not, even if they have a house that’s paid for, sometimes we recommend go to the hotel a mile away, spend the money on a room, you don’t have to sleep there, go there to have sex. Enjoy each other, spend the money every once in a while, and then go back home where the kids are making noise, the TV’s running, the grandparents are in the next room, et cetera, et cetera. I mean, you know-

Dominique:
That is really a good idea because being in a new environment can also be stimulating.

Dr. James Simon:
Correct and you can make it even more of a fantasy. I commonly recommend to couples, long-standing couples where sex is penis in vagina, face-to-face, missionary position, boom, boom, boom, to talk about what their fantasies are, because even in that context of their tried-and-true sexual script, she may be thinking about, I don’t know, getting tied up. He may be thinking that he’s having sex with some movie star. Let’s allow the fantasies to come out, to allow play, and new, and different, and in a different place, as you’ve mentioned, can be great, and then do a little role playing. If she wants to be tied up and never has told him, talk about it and have a little kind of that play in your sex. If-

Dominique:
Spice things up.

Dr. James Simon:
Spice things up. He wants to have sex with some movie star that was in some movie, dressed up as a maid, get dressed up as a maid and be the maid.

Dominique:
Yeah, put on a costume. Exactly.

Dr. James Simon:
Put on a costume, whatever, but-

Dominique:
I think if people did that, they would be a lot less stressed out.

Dr. James Simon:
I agree, but they have to communicate-

Dominique:
Yeah, it’s-

Dr. James Simon:
… and they have to be willing, and they both have to be willing.

Dominique:
Right.

Dr. James Simon:
So, this is a very important part of communication and oftentimes never happens.

Dominique:
Yeah.

Dr. James Simon:
Sometimes it happens in my office, and I have to be the-

Dominique:
Facilitator.

Dr. James Simon:
… the referee and the facilitator.

Dominique:
That’s a fun job, Dr. Simon.

Dr. James Simon:
It can be. It can also be terrifying because not everybody is in a very good, stable, monogamous relationship where they’re telling their partners everything. Sometimes it might be better not to tell your partner some things, but… And so, it’s delicate, but there’s a big, big payoff, particularly since we are living such a long time and we’re trying to stay together as couples, as part of the normal-

Dominique:
Aging process together.

Dr. James Simon:
Yes, and sometimes it’s very difficult because people age differently also.

Dominique:
Thank you. That is really an eye-opener because, from where I stand, I know nothing about elderly sex and lots of people don’t think that at that stage in life people are still sexual, they still have desire.

Dr. James Simon:
This is really important and it’s natural. So, when we’re young adults, just starting into our sexual stories and starting to have sexual thoughts and fantasies, the concept that your parents or, heaven forbid, your grandparents are having sex, everybody just says, “Yuck.”

Dr. James Simon:
But eventually we get to be the parents’ age, or we get to be the grandparents’ age and it’s just natural to have sexual thoughts, intimate fantasies, et cetera, and it doesn’t seem so yucky when you’re that age.

Dominique:
Yeah, and if we are lucky, we’ll all get there.

Dr. James Simon:
If we are, and hopefully people will still have strong, intimate bonds with their best friend or with their intimate partner, and they can still express their sexuality and have it reciprocated.

Dominique:
So, thank you very much. It’s unusual to get that kind of information. It’s very difficult. I have one more question. Osteoporosis can be triggered by menopause, can also be triggered by, if someone had cancer, triggered by the treatments. So, what are the best treatments out there for osteoporosis?

Dr. James Simon:
So we now have fantastic treatments for osteoporosis, and we have good drugs for preventing osteoporosis also.

Dominique:
I’m all ears.

Dr. James Simon:
And so one of the issues is that osteoporosis is a silent disease. It sneaks up on people, they oftentimes don’t know that they are losing bone, or they have osteoporosis until they have a fracture, or they break something even with a minor trauma. And this is one of the travesties of osteoporosis and we have great medications now. If osteoporosis is discovered early, it can be treated and the medications we have now can actually reverse the osteoporosis and return a woman’s or a man’s bones from being very low density and brittle to being normal, and I mean really normal again. One of the problems is we have to know when the problem exists. It takes a very long time to fix the problem because bones change, both for the worse and in this case for the better, very slowly. If someone has a urinary tract infection, you give them antibiotics for three days and it’s gone. If someone has osteoporosis, you give them medications for their osteoporosis for the next five to 10 years-

Dominique:
Yeah, it’s a very-

Dr. James Simon:
… then it’s gone.

Dominique:
… slow process.

Dr. James Simon:
Slow process, and many of the medications that are best for some patients are also expensive. So, the insurance companies, A, don’t want to know that you have osteoporosis, and B, they don’t want to treat you with the really great drugs because there are cheaper, less good ones available.

Dominique:
Okay. I have a question about Prolia, and I was reading recently that one of the risks is bone loss in the jaw. Is there any truth to that?

Dr. James Simon:
So, all of the medications that treat osteoporosis have similar, rare side effects, bone loss in the jaw, what we sometimes call BONJ, bone… I forget what it stands for, but it’s osteonecrosis of the jaw, related to the treatments. Those are extremely rare events, so rare in fact that we seldom ever see them. In fact, I’ve only seen one case of bone drug-related osteonecrosis of the jaw in 44 years of practice. So, bone-related osteonecrosis of the jaw, atypical fractures of the lower leg, these are extremely rare events and happen across the spectrum of all the drugs.

Dominique:
Oh, I see. So, it’s not just one or-

Dr. James Simon:
Not just one. In fact, I like Prolia because even though those risks are small, like the other drugs, the benefits are much bigger than some of the other drugs, and so the ratio of risk to benefit is better for the patient. To give you some idea of how rare these events are, for example, atypical fracture of the hip is one of those common… Common is the wrong word, universal, across osteoporosis treatments but very rare, occurs about the same frequency of getting struck by lightning. It’s about one to four in a hundred thousand.

Dominique:
That is very low.

Dr. James Simon:
And so, it’s there, it’s real, it’s just very, very uncommon. On the other hand, osteoporosis and fractures are very, very common. So, many women, and by the way, men, steer clear of these treatments for fear of osteonecrosis of the jaw, atypical fractures of the hip or of the femur, that’s the upper leg bone, to their own peril because the balance of risk and benefit is way out of whack. Yes, those are risks but extremely rare. The benefits are extremely large and very common. So, we need to get risk and benefit understood for these different drugs so that people can make educated and knowledgeable decisions about using them.

Dominique:
And I think that’s the problem. Lots of people are doing all this Googling and finding, sometimes it’s just a rumor, like soy causes cancer, there is nothing more false than that, and then they just run with it and avoid a treatment that could be so beneficial and avoid so many health problems down the road.

Dr. James Simon:
Absolutely. What patients need to do, or at least what I like my patients to do, do all the Googling you want, do all the research you want, come to my office, educated, print out the this or the that from this clinic, this doctor or whatever, I don’t care. But let’s put it in a context specific to your case at this time, not some future date, not some historical whatever, not some imaginary person. What about you and what about this data applies to you right now? And then let’s make a decision together what we want to do to reduce your risk, not some mythical person’s risk.

Dominique:
We’re going to move towards the member’s questions. Monica from Idaho says, “I had a complete hysterectomy due to cancer in 2016 and I’m desperate for hormones. My body feels like it’s drying out and shriveling up from the inside out. My oncologist believes the cancer was caused by the bioidentical hormones I took for 10 years. He says, ‘Hormones of any kind are not an option for me.’ At 66, I’m starting to feel like my brain is turning into mush. Please help.”

Dr. James Simon:
It’s a very complicated question. I think you said she was in her mid-60s-

Dominique:
Yes.

Dr. James Simon:
… and she had a complete hysterectomy for a hormone-type-sensitive cancer that her doctor said was caused by her use of hormones.

Dominique:
Correct.

Dr. James Simon:
So for her, the question really is, has she been cured of the cancer or not? If she’s been cured of the cancer and has been cancer free for the better part of a decade, then I think she might be a candidate for hormone therapy and that her doctors are just being ultra conservative, fearing that there might be a cancer cell here or there are somewhere else.

On the other hand, many women may actually have residual cancer that is just lying there and not doing anything, and we do not want to give her hormones and trigger its reemergence or recurrence. So, everybody’s a little different. Even if she, that older woman, 66 let’s say, or 65, is clear of her cancer, it may be that giving her hormones can be risky in and of themselves, unrelated to her cancer. She might be like that older woman we talked about, starting on hormones in those research studies. Remember we talked about the 70- to 79-year-olds having an increased risk of cancer. They also had an increased risk of heart attack and stroke. So we need to assess her individual risks and her individual benefits and make an independent judgment for her. In her case, we got cancer as one of the potential risks just to put it in that bucket, but also to assess whether she’s been cured of her cancer, which would be great and might open the possibility of her being on hormones as she suggests.

Dominique:
So, one other question, so if a woman has been on these hormone replacement therapies, say at age 50, can she continue to take them until the end of her life?

Dr. James Simon:
If she’s healthy and if nothing comes up that would require her, for treatment, to go off her hormones, I would say, “Yes.” If she’s benefiting from them, she can stay on them. It falls into, if it’s not broken, don’t try and fix it.

Dominique:
Next question from Judy in Georgia, what treatments are available for urinary and bowel incontinence resulting from radiation therapy?

Dr. James Simon:
This is a very, very, very difficult problem.

Dominique:
Yeah.

Dr. James Simon:
The treatments can be challenging because the tissues that one wants to rehabilitate, the tissues, meaning the muscles that keep us continent, the tissues that surround the muscles that help them keep us continent, of urine or fecal matter, can be completely damaged with radiation and difficult or impossible to repair. Now, there’s a unusual approach to some of these things, these incontinence issues, that I think I can bring to the forefront, at least for discussion.

So one of the ways that we remain continent is that we have control over the muscles. We squeeze the muscles when we’re three years old to learn how not to pee and poop in our diapers, and those muscles are damaged by radiation. They’re damaged by chemotherapy, and they’re damaged by older age, unrelated to anything that we’re doing, even if we’re don’t have cancer and radiation. Keeping those muscles really strong can help anyone remain more continent and individuals that have been unfortunate enough to have radiation, same thing applies.

So, we can work hard with physical therapy, we talked about that, to re-strengthen and re-educate those muscles. That’s number one. And I believe that in some women, giving them to testosterone can help strengthen those muscles, even if they’ve been damaged by radiation or by the cancer itself. So, this can be a little bit of a unusual approach, say, giving a 65-year-old woman testosterone, giving it to her not for sex or anything like that, but let’s make a bodybuilder of her pelvic floor muscles, focused on continent.

Dominique:
Okay, Amber from Virginia says, “Are there options for women who cannot take hormones due to the high risk of breast cancer?” She had a biopsy two years ago that showed pre-cancer cells and she has history of breast cancer on both sides, going back two generations.

Dr. James Simon:
So first, I think that she should have additional testing to see if her family carries any genes that are breast cancer predisposing genes.

Those genes can be tested these days and even if she had testing for them five or more years ago, she should be tested again because the number of genes and the sensitivity of our testing continues to get better and better. Absent that, a direct answer to her question is, what are we looking to treat? So a woman who can’t use hormones, assuming she can’t, that’s having hot flashes, we now have drugs known to specifically treat hot flashes. They are not hormonal. If she has vaginal dryness or pain with sex, we have drugs, moisturizers and lubricants that are either not hormonal or not absorbed into the bloodstream, so they never get to the breast, that can be used in those women at high risk. We have completely non-hormonal drugs to prevent and treat osteoporosis. And so we have, rather than hormones that have an effect on all of those things, we have to treat them individually, but we do have treatments that are FDA approved and documented to benefit each one of those menopausal problems.

Dominique:
Okay, thank you. Last question is from Christine, in Alabama. She says, she had cervical cancer 10 years ago. She has lymphedema and she thinks she has anal cancer. She has no symptoms. She wants to know where she can get tested.

Dr. James Simon:
So anal cancer, if it’s very early, can be difficult to diagnose, but a colorectal surgeon or her primary care internist might be able to help her at least rule out the fact that she has colon cancer or colorectal cancer. And the gastroenterologists, who do colonoscopies, can obviously test directly to see if there’s colon cancer and to do, believe it or not, an anal pap smear or a pap smear of the rectum when they’re in there doing a colonoscopy, or a biopsy if they actually see something, to make sure that she does or doesn’t have colon or colorectal cancer. And hopefully she’ll get that done. Hopefully it’ll be negative. Hopefully she’ll be reassured and then she won’t have to worry about it until her next colonoscopy, which could be a year from then, five years from then, or 10 years from then depending upon what they see when they do her colonoscopy.

Dominique:
I didn’t know that they could biopsy that region while they do a colonoscopy. That’s good information.

Dr. James Simon:
Absolutely can do. If they see a polyp, a lesion, an early cancer, a growth they don’t even know what it is, they can check it. The pathologist can make a diagnosis, usually five to seven days after the colonoscopy, and we’ll know is it just a pimple or is it a early cancer, a pre-cancer or something that’s really more worrisome.

Dominique:
Thank you so much, Dr. Simon, for taking the time to answer all these questions and educating us. We do need lots and lots of information, but there is lots of information. The problem is getting the information that’s accurate from the right source.

Dr. James Simon:
Well, I’m happy to do it. And if your listeners need more care or another consult, I do have licenses in Washington, D.C., Colorado, Maryland, Michigan, Ohio, Tennessee, and Virginia. So, if people live in any of those jurisdictions, I can do telemedicine visits with them and I’m happy to do that. If you live somewhere else, for example, you had a woman from Alabama, a woman from Idaho, I don’t have licenses there, but I could do, what we call, a educational visit with them and I can coordinate with their doctors in their home cities to provide them with recommendations for that individual who lives in Idaho, or Alabama, or a place where I don’t have a license.

Dominique:
This has been really a fantastic, educational moment. I certainly learned a lot as usual. I’ve been coming to see you for over 20 years and the difference-

Dr. James Simon:
So, you were a teenager when I saw you first

Dominique:
I’m not going to comment on that. Actually, I should say, it’s more than 20 years, but I’m not giving you the exact number. I had one patient a few years ago, this is really the difference between you and a lot of other doctors. I had this patient who came to see me and she said she went to see her doctor because her weight was going up and he told her, “Oh, just go on a low-carb diet.” And she goes, “I’m already working with a nutritionist. It’s not working.” And he said, “Or get some rest or maybe you need some counseling.” She said she was so upset. She got in her car, and she just started crying. So, I sent her to you, several years ago, and what she needed was estrogen and progesterone because she was in early menopause. She’s now thriving. It’s been over six years. She’s really thriving, she’s beautiful and she’s in excellent health. So, I think if we can bring that education to all women, we can save so many people from the heartache and the trauma of menopause.

Dr. James Simon:
Yeah, I think that it’s a big problem, one that is not always the same treatments for the different people, but there are lots of benefits that have evolved over the millennia of hormones as women get older. And we just need to dig deep, and understand risks and benefits, and make a decision together. Shared decision making, and I think that’s been my mantra for a long time. Seems to be working. I don’t feel any reason to change.

Dominique:
No, please don’t change. Thank you, Dr. Simon, thank you so much for your time today.

Dr. James Simon:
No problem. Have a great day and good luck to everybody.

Dominique:
Thank you.

For more information about menopausal health, contact Dr. Simon at IntimMedicine Specialists. To schedule an appointment, call our office at (202) 293-1000 or https://intimmedicine.com/contact-us/.