Speaker 1: 0:30

My name is Dr Christine Hart-Kress, my name of my business is Dr Christine Hart-Kress, dmp, and I am a board-certified women's health nurse practitioner and a certified menopause practitioner by the Menopause Society.

Speaker 2: 0:48

Wow, how did you?

Speaker 1: 0:49

get into this field, so I've always been in women's health. I'm 30 plus years in women's health. I started my career as a labor and delivery nurse. I was on active duty for the Air Force for 27 years.

Speaker 2: 1:03

Thank you for your service.

Speaker 1: 1:04

Thank you and had the great fortune to be able to go to school to become a women's health nurse practitioner. And just because the military has some places where you can do OB, I mostly did GYN and so you know my love has always been GYN more than OB. And then I had my own menopause experience that even I had no idea what was wrong with me and I started doing a bunch of research and found some of the menopause greats and realized that what was happening to me was perimenopause, but I just didn't even recognize it. And so for the last 18 months I have just dedicated myself to learning more about midlife care and perimenopause and menopause and decided to do the board certification for menopause. And then, next thing, I knew my whole life became about taking care of my patients that are my peers, which has been a really interesting journey because I feel like I have grown and aged with my patients. I used to, you know, be a Lamaze.

Speaker 2: 2:23

Do all the OB and the babies and now I'm kind of seeing them grow up into this next stage.

Speaker 1: 2:28

Yeah. So it's a fun post-retirement career and just really satisfying because it's pretty easy for me not for all providers, but it's pretty easy to help women feel their best and to help them with longevity.

Speaker 2: 2:44

Yeah, and because you actually understand what they're going through. Right, right, yeah, so that's huge too.

Speaker 1: 2:50

Right and I can say well, this is what happened when I used this medication and these were my symptoms and this is what got better. So I do bring in a lot of my own personal experience when I'm counseling patients. But you know, women are 50% of the US population and there are 75 million women today that are in menopause. 6,000 women every day will enter menopause and in the next two to three years, 1.2 billion women will be either in perimenopause, menopause or postmenopause. Those are huge statistics, huge statistics and 75% of women have symptoms. But only one out of four women are on any treatment plan and if they go to their provider, they have a 10% chance of actually getting one a knowledgeable conversation, two acknowledgement and three if you walk out of there with a prescription probably not going to happen.

Speaker 2: 3:57

Yes, yeah, and I can attest to all of that as. I'm going through it myself and have had those same conversations with my doctor that oh, it's normal and don't worry about it, and I'm like well, really struggling here. And yeah, no prescriptions, no hormones, given nothing. Menopause is such a hot topic right now. Why do you think, especially this past year, what do you think has like unlocked this that women of our age are actually talking about this more and just being open about it?

Speaker 1: 4:28

Yeah, you know, I think Gen X, I think we're a little bit of a different breed than our parents, the boomers, who, by the way, are pretty mad right now because they've missed the window of opportunity. But you know, covid, you know, was a big catalyst. You know women were isolated, locked down. Their resiliency was not as strong as you know, pre-covid. And then, you know, we had lots of celebrities who came screaming out of COVID, like Oprah and Drew Barrymore, and they're like enough is enough, and so that really gave an opportunity, you know, for a grassroots movement. That's really what this is. It's women getting loud and putting their foot down and just saying enough's, enough, I'm tired of being gaslit, I'm tired of nobody taking my symptoms seriously and I'm done, yeah.

Speaker 2: 5:29

And I'm tired of feeling crazy.

Speaker 1: 5:31

Right, right. And you know we're going to spend over a third of our lives in a post-menopausal state. So you know that's a long time. And now you know that you know 20, 30 years ago women weren't living, as a general rule, into their 80s. The average life expectancy because you know we have great food and we have great healthcare is 82 years old, and so you know, average age of menopause in the United States is like 51 and a half. I usually round up to 52. So that's 30 more years of your life that you could live as a vivacious, healthy, active person or you could live in a nursing home.

Speaker 2: 6:16

Right If you're not taking the right steps.

Speaker 1: 6:19

If you're not taking the right steps, Exactly and the three things that'll land a woman in the nursing home a urinary tract infection that spreads to urosepsis, or you get a bloodstream infection, a fractured hip. A woman over age 65, if she fractures her hip, she has a 29% chance of dying in the first year. If she has surgery, If she doesn't, 79%.

Speaker 2: 6:47

Why is that percentage so high? Because of bone density loss or Correct.

Speaker 1: 6:53

Estrogen is so important for bones. You know all of your life. I was just listening to a podcast on the way here and I thought this was this one of the menopause greats was explaining. You know you for your whole life, your bone, your bones. You eat up your bones and she described it like Pac-Man and then you poop it out.

Speaker 1: 7:13

But as, as you get closer to menopause even at age 30, the rate at which you're eating them up is greater than the rate that you can make new, so the bone density that you were born with is not the bone density you have now, and so, with the decline in estrogen, the bone becomes more porous, and so, instead of thick and strong, it looks like Swiss cheese.

Speaker 1: 7:39

And so, without that estrogen, you're more inclined to have a fracture. A woman over the age of 50, one out of two women over the age of 50 with osteoporosis will suffer a fracture, and there's just so many complications. You know women will get infections and blood clots, and so you know. So you know getting that protection. And then the third thing that will land a woman in a nursing home is Alzheimer's. So the largest receptor site in your body for estrogen. And you have them head to toe in your body for estrogen, and you have them head to toe is your brain, and so we know that women who start hormone therapy within 10 years of their final menstrual period have a decreased risk of Alzheimer's disease.

Speaker 2: 8:25

Wow, that's interesting. Yeah, explain estrogen to me a little bit more and why that's so important.

Speaker 1: 8:34

Yeah, go ahead. So you have. So your ovaries make three hormones and they're all very important and sometimes they're naughty and sometimes they're nice. So you have estrogen, progesterone and testosterone and you have receptor sites from your head to your toes that need those hormones for optimal performance. So if you look at hormones, those hormones are needed to tell your cells, your organs, your tissues what to do. They're messengers.

Speaker 1: 9:03

So when those hormones start to decline which actually starts at age 30 for testosterone, 35 for progesterone and 10 years prior to your final menstrual period for estrogen when those start to decline, the cells get part of the message and your adrenal glands, which live on top of your kidneys, they produce those hormones. So they try to give a little bit. But it's like you know being, you know being on the highway and getting every third word on a phone call, and so your cells are not getting those hormones to tell them what to do, how to function, and so you just have suboptimal performance of your organs. And so you know, most people are familiar with hot flashes, night sweats, vaginal dryness. I mean, we talk about that all over.

Speaker 1: 9:56

Yeah, like those are the standard things, yeah, but the things that I found really interesting in some of my own symptoms heart palpitations. I had no idea that heart palpitations were a symptom of perimenopause. Do you know how many women get million dollar workups going to cardiologists to be told there's nothing wrong with your?

Speaker 2: 10:17

heart Sure a lot, and you're checking everything. At this point it's like okay, is it this? Is it that it can't just be menopause, can it? Yes, it can.

Speaker 1: 10:28

Most of the time when I talk to women, they have been to multiple ologists.

Speaker 1: 10:32

They have been to the cardiologist, the rheumatologist not an ologist, but the orthopedic for joint pain, hip pain, tennis elbow, plantar fasciitis, frozen shoulder all related to decreased estrogen.

Speaker 1: 10:48

When you have decreased estrogen, your joints are more inflamed, your body is more inflamed. Your body looks at it as a you know there's an activity happening here and it's not a good one, and so it rushes blood to the area, it rushes fluids, you get swelling, you get redness, and so a lot of women have those musculoskeletal syndrome of menopause is what it's called. But then we see women go to urologists because they're urinating more often, they have leaky bladder, they think they have more urinary tract infections or all these crazy symptoms of a urinary tract infection, only to go to urgent care 12 times and be told you don't have an infection and women are like, but I still have the symptoms. And be told you don't have an infection and women are like, but I still have the symptoms. Because from your pubic bone to your tailbone, that's the second largest receptor site for estrogen and it loves estrogen, and that whole area gets really mad when it's missing it, when it's missing.

Speaker 2: 11:49

When it's missing. Yeah, what advice do you have for women that aren't getting these answers, as you said, from their primary care physicians? Where do they go? I mean, they're seeing all these different doctors. What advice do you have to help streamline the process in getting the proper care?

Speaker 1: 12:06

I'm finding that most women are going to social media. I'm finding that most women are going to social media. There's been lots of good surveys here lately about where are women seeking their answers. Because, to kind of put it in context, so since the Women's Health Initiative study, which is the one most people are aware of, it was published in 2002, social media scared women. Estrogen is the one most people are aware of. It was published in 2002. Social media scared women. Estrogen is going to cause heart attack and breast cancer.

Speaker 1: 12:37

So now in practice are the doctors and the nurse practitioners that were trained since that study was launched. So they stopped teaching it. If you were lucky, you might have heard in education periods stop, they might have a hot flash. If you have to give them some hormones, you can but make sure it's really little dose, super, super short period of time. And so you know there's not a lot of providers. It's not their fault. If they haven't had an interest, then they just haven't sought their own education. That's why women are seeking care through telemedicine platforms. You know the health care system is hard broke anyway and it's really hard. So I just left private practice, and you know the reason why I did is because menopause, perimenopause, midlife women's care, any women's care, to be honest, 15 minute, you know, annual exam. You can barely get what you need to get done.

Speaker 2: 13:56

Yes, you can barely get your words out, and that was 15 minutes right.

Speaker 1: 14:00

Exactly, and, as a provider, if you have a patient who wants to have a lot of words, you're like taking deep, slow breaths because the waiting room you are backing up. You're now an hour late and you need to listen to this person, yeah, and so you know, a 15 minute appointment is just not adequate and you can't add it to your annual exam. So many women you know think, well, the only reason why I came for an annual exam is because I'm having problems, but the insurance companies have set up an annual exam to only be about doing a pap smear, ordering a mammogram and doing a pelvic exam.

Speaker 2: 14:35

And that's it yeah, correct.

Speaker 1: 14:37

So if you bring up any problems in an annual exam, you're still going to get billed for an office visit. The insurance company isn't going to cover it, and so what's always best is to separate those appointments. Make a different appointment to talk about your symptoms that you want to go over. If your provider is educated, you are more likely to get some sort of answer that makes sense, that's great advice because I never thought about doing that.

Speaker 2: 15:04

I always wait for my annual and then I'm like, oh, let me just bring up all of my topics from the whole year.

Speaker 1: 15:10

Yes, your provider is completely stressed out at that point? Yes, unless it's the first appointment in the morning or the first after lunch. But you know, women can go to menopauseorg, the Menopause Society it should be the North American Menopause Society and you can look up menopause certified providers. There are providers on there that are just members of the organization, but what you're looking for is someone that has that certification, the MSCP details. I will say in the Northern Virginia area there are very, very few.

Speaker 1: 15:51

I built a pretty good following when I was in private practice for menopause, so that's an option, though there are some in the outlying areas or the telemedicine practices, and there are telemedicine practices that accept insurance. You get much shorter visits. Sometimes you have to purchase their hormone therapy and then you can do other telemedicine practices, like the one I'm associated with. Initial visit is an hour, usually more. I do a lot of communication back and forth with patients and then you're in. So they are. You know we we are cash pay, and the reason why we are is because insurance companies do not let us practice how we want to, and so now we don't have to worry about it. So if it's an hour and 20 minutes, I've booked. I've blocked that time.

Speaker 2: 16:41

It's your and you know, truly listen to the patient's needs. Yeah, tell me a little bit more about how hormone therapy has changed over the years since that study in 2002, because I know a lot of people that are still skeptical on that because of breast cancer and and blood clots and all sorts of other reasons. How has that treatment changed over the years?

Speaker 1: 17:03

So that study um, which you know has had huge numbers of women, it had good funding. It was the first time that women's health actually had a funded study. Less than 4% of funding is for actual women's health. They study men and then just extrapolate things to women. So those women were on synthetic hormones. They were on conjugated equine estrogen, which is pregnant mare's urine. It actually there's nothing more natural and those mares are treated like queens. It is there is nothing you know negative that happens to those queens. And then medroxyprogesterone, which is a synthetic progestogen. So they looked at women who did not have a uterus. They were on Premarin. Conjugated equine estrogen is also called Premarin, so they were on Premarin only. And then they had another group of women without a uterus that were on no hormones at all. And then they had two other groups, one with a uterus that were on the Premarin and Medroxyprogesterone, because you have to have a progestogen when you have a uterus if you're taking estrogen.

Speaker 2: 18:22

Yeah, this is all a lot of information, Right? Otherwise it's going to cause cancer.

Speaker 1: 18:26

And then women who had a uterus and were on no medications. And so you know, I'd say with that particular study the purpose was to see whether or not hormone replacement therapy was beneficial for primary prevention of cardiovascular disease. So high cholesterol, high blood pressure, heart attacks. That was the purpose, and the women ranged from 49 to, I believe, 78. The average age of the woman was 64. So those women had not been on hormone therapy before. The biggest concern I think women have is breast cancer. That's what I've heard. I just did a survey. We had 3,033 women answer it and breast cancer was the number one concern and they think it's the estrogen. The women without a uterus who were on estrogen only had a 23% decreased risk of breast cancer. It is not the estrogen.

Speaker 2: 19:31

So that is no longer a thought process that we need to be worrying about when it comes to hormone replacement, no.

Speaker 1: 19:38

And now women who are breast cancer survivors, even if they're estrogen receptor positive meaning their cancer had estrogen, was estrogen positive we now can give them hormone therapy estrogen therapy when they are out of treatment. There have been 26 studies that have looked at breast cancer survivors on estrogen and only one showed any increased risk of recurrence. They actually showed an 18% decreased risk. And the one that showed the increased risk they didn't do the mammograms before they put them on hormones. So we know, if you have a tumor in your breast that needs estrogen to grow, it's going to grow, right.

Speaker 1: 20:22

So then, when you looked at the women with a uterus, they had an increased risk of breast cancer and the media reported what we call a relative risk, and that was 25%. Media reported what we call a relative risk, and that was 25%. And when you think about, well, 25% of those 10,000 women could have developed breast cancer. There were less in that group. That seems like a big deal, but absolute risk is what's important, and it was 0.8%, which is a statistically insignificant risk of non-fatal breast cancer. They didn't die, wow, because breast cancer is really easily curable and treatable and really the estrogen caused that tumor to grow. They found it earlier.

Speaker 1: 21:09

It was smaller, it was less likely to metastasize Right. And so then, when we look at things like blood clot, we know that when we give hormone therapy in a pill, it increases the risk of stroke and blood clots for the first year when we give it transdermally, which is a patch, a gel, a spray a ring.

Speaker 2: 21:32

Is that what you're rubbing on your wrist?

Speaker 1: 21:33

You can a little spray, there's no increased risk of stroke or blood clot. So, like women who have had a history of a blood clot, depending on the type of blood clot, we'll put them on a transdermal. Women who've had a heart attack we can put them on a transdermal because we know that's not the problem. But from that study what we learned is timing is important. You get the greatest benefit if you start hormone therapy within 10 years.

Speaker 2: 22:02

So 10 years post-menopause. So when you're done having your cycle for is it a year?

Speaker 1: 22:09

One year is the definition.

Speaker 2: 22:10

One year and one day, one year and one day I love it and then start hormone replacement Correct.

Speaker 1: 22:17

You get the biggest benefit then, and so you get the decreased risk of Alzheimer's, decreased risk of having a heart attack. So I said in the beginning was the average age of those women were 64. So they had been a decade or two into menopause. Those women did have an increased risk of stroke, blood clots, heart attacks, because when you are low in estrogen you're in a very inflamed state, everything is constricted, which is why we tend to see women have high blood pressure that all of a sudden appears after menopause. You have more, your arteries get a little bit tighter and squeezed and you can develop plaques. It makes it sticky, so plaques can harbor in there, and so if you give that woman estrogen, it dilates, it relaxes, it decreases inflammation, opens things up. So those women through a few strokes, blood clots, heart attacks, and so that's why we will give women over age 60 hormone therapy. But we like to do a few studies on their heart, yeah.

Speaker 2: 23:31

And how do women find all this out? Through their blood work.

Speaker 1: 23:35

So blood work, you mean if they're menopausal.

Speaker 2: 23:38

Or if they need the hormone replacement.

Speaker 1: 23:41

So symptoms, if you have symptoms which can be the normal ones, but other ones heart palpitations, ringing in the ears, burning tongue, itchy ears, to give you a few that people are like that's a symptom of menopause. There's like 82 and growing symptoms of menopause. I tell women, if it didn't happen before and it's happening now and you are between the ages of 35 and 55, it's probably your hormones. So symptoms is how we decide to treat. I'm an outlier. I love labs, I love data, and the reason is is because you know, as a woman, you're humming along and you're feeling great and then, all of a sudden, things start to shift and change and it feels like, before you know it, you are just not you.

Speaker 2: 24:35

Yes.

Speaker 1: 24:36

You're wrestling with. Am I crazy? Am I broken? Am I just getting old?

Speaker 2: 24:43

And then Am I having a midlife crisis Right?

Speaker 1: 24:46

And so, and depending on if your friends are talking about it which you know, I'm finding now people are starting to talk about it, yeah, which I'm finding now people are starting to talk about it then maybe you're connecting the dots right and maybe you found a great provider who can connect all those dots, but burning tongue and joint pain don't seem like they're connected right.

Speaker 1: 25:11

And so then what happens is women go and they're like I want to, I want hormone testing. I want, I want to have my hormones tested. They're most often told no, and the reason is is we don't need them to diagnose perimenopause or menopause? It's really a clinical diagnosis, at least perimenopause is. But I find that giving women that information, if nothing else, gives them a sense of relief, a sense of validation. I know how to interpret those, even for a 35-year-old, and it gives them a good baseline.

Speaker 2: 25:45

right Like this is where I'm at right, yeah, I think we like that.

Speaker 1: 25:50

And then for me, I use it in treatment. I use it to, you know, to help women make decisions. You know, if we see, you know, in menopause we want your estrogen level between 40 and 80 or so. And so if you, if I start you on a therapy and we draw your blood three months later and your estrogen is 30, and maybe you're a little concerned about the Women's Health Initiative study, and you know, and concerned about the Women's Health Initiative study, and you know, and I say to you well, let's increase it. If you don't have data, you might be hesitant. When I give you data, you're usually like I really don't feel good. Yes, and it's like you give yourself permission to feel even better.

Speaker 2: 26:32

Yes, like, yes, I need this. Yes, I'm deficient. As we kind of wrap up here, I wanted you to tell me a little bit about the event you have coming up in July.

Speaker 1: 26:40

Yeah, so super excited. So, um, my uh mentor is Dr Heather Hirsch. I took her prescribing hormone therapy class, which, um, and then she offered, you know me a job, which, um, you know I'm I'm my own contractor, but I work through her private telemedicine practice. She is going to be joining me on the 18th of July at 7 pm in Centerville and we are going to do an education seminar for women. And, if you don't know Dr Hurst, she wrote the book Unlocking your Menopause Type and she was on the Oprah panel. So she is one of the leading experts in midlife care and I'm excited to sit alongside of her and to be able to, you know, answer questions for women.

Speaker 1: 27:29

And you know, I think that's the most fun part about this job is meeting women, hearing their stories, and women are just so. You know, being in the military, you know like we mostly all do the same thing. And now that I'm in civilian practice, I'm like, oh, my goodness, women are fascinating, they do all these fun things. It's like it's opened up this whole. I'm like, oh, there's other people out here, outside of the military.

Speaker 2: 27:56

Yeah, well, this is certainly information I needed to hear today, so thank you for coming in today. I loved hearing your story and opening up the conversation about menopause, which is so hard for so many people to talk about. So thank you for shedding some light on all of it and thank you for being here today and thank you for having me Pleasure.