Transcription:
The Menopause "Feel Good" Masterclass

Maggie McKay: This is the Menopause Feel Good Master Class where we'll talk about ways to survive it and feel good in the process. But first, can you please introduce yourself, Dr. Beckerman?

Dr. Tobie Beckerman: Yes. My name is Dr. Tobie Beckerman. I am a gynecologist and I have been practicing for 34 years and loving it. I've gone through a lot of different transitions in what I've done from OB-GYN now to just GYN. And I have a phenomenal little practice that spends really long quality time with patients. So, I really can delve into this menopause subject and what goes on with women and how they're doing, how they're feeling, results of what I give them. So, I'm just loving it.

Maggie McKay: And you work out of Maryland?

Dr. Tobie Beckerman: I am. I'm in North Bethesda, Maryland presently, yes.

Maggie McKay: Years ago, my mom's generation, it seemed like that's just what you did, you took hormones when you went through menopause. And then, it wasn't so popular. So, what is the story now fast forward to 2022? What are the real risks and benefits of hormones?

Dr. Tobie Beckerman: Great. So, let me address what you said just for a second in terms of your mother. So yes, estrogen, people had symptoms. They went to their doctor. They gave them a big whopping injection of medication and it usually helped and took away symptoms. Of course, there were side effects and things that happened that we didn't really know at the time, and that we now have delved into.

So, up until 2002, almost all doctors or a large amount, I should say, gave their patients hormone replacement therapy. Whether you were a family practitioner or an OB-GYN or a cardiologist, we gave women hormone replacement therapy because we said it really improves the quality and the quantity of their life because, as you know, we had said when we defined menopause, when a woman no longer makes estrogen, there are certain body systems that are being affected by that; the bones and your risk for bone loss and osteopenia and osteoporosis; the heart in terms of cardiovascular disease, which is the number one killer of women, is heart disease; and the general body systems that need estrogen, such as the vagina and your mood and your sleep and your hot flashes and your energy levels and so forth.

So, most doctors gave their patients hormone replacement therapy. And then in 2002, a study came out from the Women's Health Initiative. It was a huge study, and it was the first study that actually was very big, randomized, well-controlled study. And it took a group that they gave hormones to and matched it with another group that they didn't give hormones to. And they said the primary finding that they were looking for was what is the risk of coronary artery disease. And after a year of the study going on, they stopped the study and they said, "Oh my goodness, we cannot give hormone replacement therapy anymore because there's an increased risk of heart disease. There is an increased risk of breast cancer. And this is unethical to give women hormone replacement therapy." And that was a crazy time because so many women were on it, loving it, feeling good. And all of a sudden, this big summer happening came out and doctors got scared, pulled their patients off hormone therapy. And it was really a disaster for a lot of women that went from feeling good to absolutely feeling terrible.

So, let me fast forward now to what you asked. What's the real deal with the risk? So, what happened with the study? The bad thing about that study was they took all takers, which means if you were in your late 60s or in your 70s and you decided you wanted to join this study, you were able to. So, the data clearly in terms of risk is going to be skewed when you have a woman who goes through menopause at 51, which is the average age, 51 and a half, and now waits 20 years or 15 years or 25 years to start hormones. So, whatever risk of coronary artery disease or bone breakdown or things of that nature has already happened in that period of time that she's been without hormones. And then, you give them hormones at that stage of their life. And of course, they had a risk that was a little bit higher. And even in that population, it was a very small risk, maybe eight more out of 10,000 women had an increased risk of heart disease.

So in looking at that study and knowing this, what's the actual conclusion? We'll sort of get down to numbers. Everybody who has breast has a risk of breast cancer. The risk of breast cancer increased from 1.3% per year to 1.4% per year in that Women's Health Initiative. And that started five years after estrogen use. So, it's a very small, very small number. In terms of the risk of heart disease, the risk of heart disease in a woman who started hormone replacement therapy at the time that she goes through menopause, we've clearly found looking back at the 50-year-old group when they went back on the study, there was a protection against heart disease. And then, of course, all of the other good things that are out there in terms of protecting your bones and keeping you feeling good and sleeping and hot flashes and libido and vaginal dryness, those things clearly were positive by being on hormone replacement therapy.

Maggie McKay: So, are gynecologists now more apt to prescribe hormone therapy?

Dr. Tobie Beckerman: Unfortunately, not all. Not, you know. I see it every day. Patients come in every day and they say, "I went to this doctor. They told me to come off." "I went to this doctor. They won't put me on." there's a thing out there. I'm going to call it a thing. I don't even know what to call it, a bad rap that estrogen gets. And yes, people don't want to take risk, particularly with their life and with their health. I understand that. But everything we do in life is a risk-benefit. You get in your car to drive, it's a risk-benefit. You eat sushi, raw fish, it's a risk-benefit. And everything we do, it doesn't even have to be a sport that has such a high risk to it, but everything in life is a risk-benefit. And I think when I speak to my patients, we talk about that, what is the benefit? All the things I just talked about. And what are the actual risks?

So why is it that when you go to so many doctors, they're so averse to giving hormone replacement therapy? And I think that, as a doctor, we want to do no harm and they don't want anything that could remotely associate with breast problem or breast cancer. They don't want to be responsible for that. But I feel like women are really missing out because they should make that decision. They should have the facts. They should know what the real risks and benefits are, and then make a good, educated decision about what's right for each person.

I saw a patient in the office today. She has depression and migraines, and her doctor wants her off hormone therapy. Why? Just because. No particular reason, no excessive increased risk of breast cancer. And we spoke. She said, "I can't live with depression and migraines. And this risk-benefit is completely worth it for me." And I think that that is the take home message, is that there is so much good and so little bad. It is really how you present it and how you educate each patient.

Maggie McKay: That's so interesting, because I don't know too many people on hormones currently. But I guess like what you're saying, a lot of doctors are still a little wary of it. Usually, we don't hear too much positive information about menopause, so please tell us how we can feel good throughout it and beyond, if that's even possible.

Dr. Tobie Beckerman: Well, I think it's definitely possible. So first, everybody is different. So, I think it's important to find a doctor that listens to you and aligns with you in terms of what you need and what isn't feeling good, and then it gives you the options of how to fix it. So for example, typical menopausal symptoms. If someone's having hot flashes, if somebody's having vaginal dryness, if someone has no libido and no energy and no muscle strength, those are things that all need to be discussed. There are supplements that can help. There are other medications. There's various kinds of hormones. There's testosterone. So, it's very important to align with somebody who's going to listen to you, listen to what your needs are, and then begin to tackle each problem.

I think, as a doctor who's been practicing a long time and as a woman who runs a business, that we get smarter when we get older. We have more life experience, we have more knowledge, we have a lot to give. And so, it's unfortunate if you let these symptoms of menopause go untreated. And you take all this good, how do you take away the bad symptoms that you have, and then you focus on just all of the good that you have to really feel good in the menopause time.

So, fix your issues with hormones. Fix your issues with other medications that you might need. Get plenty of exercise. Protect your bones. Use all of the other ancillary meditations and yogas and things of that nature to keep your mind sharp and to keep yourself feeling good and take this menopause time and make it positive because we can make it good with everything that we have in terms of our day to day.

Maggie McKay: Right. This is so hopeful because I know a lot of people are like, "Well, it's just something you have to live through." And I think, "No, it's not. You got to talk to your doctor. And if they don't help you, get a doctor that will." But nevertheless, Dr. Beckerman, let's talk about one side effect of menopause, vaginal dryness and how the MonaLisa Touch laser factors in.

Dr. Tobie Beckerman: The MonaLisa is incredible. I've been doing the MonaLisa Touch laser for, I think, at least eight years. It's a laser that came out of Italy in 2008, and it is painless. It takes three to five minutes to do, and it actually reverses the menopausal vagina. So, how does it do it? Very typical to any other laser. Every time you hit the laser beam and the beam forms of beep inside the vagina, it causes a small, microscopic injury. It doesn't hurt, it doesn't injure anything, but it's a microscopic injury. The body sees that as something that needs to be healed. And so, it activates cells that have been dormant because of menopause. And those cells activate fibroblasts that begin to lay down new collagen and basically regenerate the vaginal tissues from being very dry and down to the very basal layer that we have. And it stimulates that collagen growth and brings back those nice upper cells that then produce mucus and moisture. It is nothing short of amazing. I've had patients beyond feel like it's miraculous, which I think it is. I would say upward of 95 plus percent of people get incredible relief from their menopausal vagina using the MonaLisa.

Maggie McKay: Is it just a one-time treatment or do you have to keep going back?

Dr. Tobie Beckerman: It's a three-time treatment, is the entire protocol. So, you do three treatments, six weeks apart. And then, I generally recommend depending on what else a woman is doing. So if she is on hormone replacement therapy, she may need just the three treatments and that will be the nice booster she needs to improve her dryness. If she is not on any hormone therapy and not using any vaginal estrogen, I usually recommend a booster treatment, which is a once-a-year treatment. You come in and just have a one-time treatment. Sometimes, I double it up depending on what a patient needs.

Maggie McKay: Sounds doable and well worth it.

Dr. Tobie Beckerman: Easy. Easy and unbelievably successful.

Maggie McKay: It sounds like it from your statistics.

Dr. Tobie Beckerman: I love it. I love when a patient comes in and says to me, "This is amazing. I just lay here. I have this three minute procedure and it takes care of my issues. I love it."

Maggie McKay: That's so great. And you said you've been using it about eight years. How long has it been around?

Dr. Tobie Beckerman: Yes, 2008, it came on the market in Italy and it's been here a few years, maybe five years or something out of Italy.

Maggie McKay: Oh, awesome. So, another challenging effect of menopause is urinary incontinence, which is not fun for anyone. What should we expect? Why does it happen? And what is the EMSELLA chair?

Dr. Tobie Beckerman: So, urinary incontinence, there's two kinds of urinary incontinence. There's stress urinary incontinence, which is when you cough or sneeze or laugh, and as you well know, not just menopause, right? Lot of women in their 40s and depending on how many babies you've had and so forth. But stress incontinence is an anatomic problem. Your bladder is no longer positioned up where it should be, but it hangs down because the pelvic floor is not strong anymore, and that happens in menopause, certainly with lack of hormones. It happens with age. It's dependent on childbirth, how many babies you've had, how long you pushed and your genetics. Sometimes people have genetics where their pelvic floor is just weaker than others. So, that's one kind of stress incontinence.

The second kind of stress incontinence is more of an urge incontinence where you're just running to the bathroom. You're getting up at nighttime to urinate many times. You're taking a walk and all of a sudden, "Oh my gosh, I have to go--" Uh, too late and you lose your urine. So, two different kinds of incontinence.

What the EMSELLA is, is a magnet. It's actually electromagnetic energy. It's a chair that you sit on and it causes vibration to the pelvic floor. Each session lasts for 28 minutes and each 28 minutes, get this, is the equivalent of 11,000 Kegel exercises. So, you sit there passively for 28 minutes. You get this intense vibration to the pelvic floor, and it basically does what your body would do. But of course, nobody can do 11,000 Kegel exercises with that degree of strength in 28 minutes. And so, it strengthens your pelvic floor. And it's easy to do twice a week for three weeks, is the initial treatment and it has been shown to be at least or approximately, I guess, 80% successful. What I've been doing lately for stress incontinence is putting people on the maintenance plan, and I find that's been incredible. The initial six treatment is great, that's what was studied. But I feel like if you have somebody on a regular program where you're constantly keeping their pelvic floor strong, you're going to be that much better in terms of alleviating that kind of incontinence. It also can help with the urinary frequency and the getting up at night and the running to the bathroom and the urgency. I don't think they're quite clear as to how that works because it's not as much a pelvic floor issue, although it's felt the electromagnetic energy can also do something to the top, to the dome in the bladder.

The other thing that can be very helpful for that kind of urinary incontinence is actually the MonaLisa. Besides reversing the menopausal vagina, it is great for urinary frequency and that getting up to the bathroom many times at night, running to go, not being able to control it. The MonaLisa, because it controls the collagen formation, can really be very supportive of the bladder.

Maggie McKay: And does it matter your age on that one? Like let's say you're 70, 80, is it too late for you? Or would that help somebody elderly?

Dr. Tobie Beckerman: It's never too late. I think you have to work harder, right? I think that if your pelvic floor is weaker, then you're going to have to probably do more sessions, but it is never too late. The only contraindication is metal that is close to your pelvic floor. So if you've had hip replacement, you're not a candidate. Because it's electromagnetic, think of an MRI on steroids kind of thing. You don't want it to be able to heat the joint. So if you've had metal in your body in terms of hip replacement, that is a contraindication. If it's knee replacement, shoulder or other joints, generally that's not contraindicated. So, it can work at any age. In fact, we're starting to push it for postpartum women who just had a big baby and aren't feeling so hot as it is, kind of blobby, not feeling great, and they do the EMSELLA, strengthens the pelvic floor, controls that urinary issue much more. It's great for them too.

Maggie McKay: Oh, wow, that's exciting. I mean, I hadn't heard of that. So, let's talk about our skin. Didn't we do our time, Dr. Beckerman, when we were teenagers with acne? Now, we're going through menopause and as if all the things on the list aren't enough to deal with, we have to worry about our skin. What are the changes we can expect and what can we do about it?

Dr. Tobie Beckerman: So, interestingly enough, when estrogen first came on the market, there was a lot of data on the good old Premarin, which is a very older estrogen, not one that we use typically right now, but they did a lot of research in terms of skin and building collagen. So, I think there is some help from estrogen. But a lot of skin changes is age. We call it menopause because menopause, the average age is 51 and a half, but it may or may not be menopause. It may just be genetics and aging. We lose collagen starting at the age of 30.

Maggie McKay: Uh-oh.

Dr. Tobie Beckerman: Thirty, yes.

Maggie McKay: No.

Dr. Tobie Beckerman: Red alert. Red alert. I know. That's what happens. And so, imagine once you hit 50, you've already lost more and 60 and 70 and as things go on.

So fortunately, we live in a day and age of just fantastic technology to improve our skin. Number one, products that we use, they make a tremendous difference. You know, the good old Oil of Olay, I've seen women come in using Oil of Olay their whole life, gorgeous skin like I have never seen.

Maggie McKay: I agree.

Dr. Tobie Beckerman: Right. That is the exception rather than the rule. But there are fantastic skin products. You need to get on a good product. You need to exfoliate, wash your face with good products, build collagen in your skin with growth factors and things of that nature. So, products we use is crucial. And then, we have so many wonderful, just like the laser we talked about with MonaLisa, how it causes this microscopic injury that builds, that then it causes cells to build collagen similarly with the face. So, whether you're using a laser or whether you're using something called IPL, which takes away the reds and the brown spots and so forth on your face, whether you're using microneedling, we also are using PRP now. Do you know what PRP is?

Maggie McKay: No, I don't.

Dr. Tobie Beckerman: You draw your blood, you spin it, you take off the upper layer, which is very rich in growth factors, and you can put it on your skin. You can inject it in your skin. So, we have wonderful, incredible technologies for skin changes and build skin collagen and feeling good. You know, when you look at yourself in the mirror, you want to like what you see. And if you feel like you're looking old and you feel like you're looking drawn, a lot of times that affects your mood. When you take a look in the mirror and you like what you see-- And, of course, it's in the eye of the beholder. I have patients who don't do anything and patients that do everything, but we have just great technology now. We have wonderful products. And it's an aging process, more than a menopausal process. But the fact of life, the fact is that at that end-stage of life, we are going to be menopausal and therefore I think women should take advantage of feeling good in whatever way that is.

Maggie McKay: I agree. My husband said just yesterday, out of the blue, "I had no idea how hard aging would be." And I thought, "Listen, try being

Dr. Tobie Beckerman: a

Maggie McKay: woman. I'll show you."

Dr. Tobie Beckerman: Absolutely. Men too.

Maggie McKay: But it's true, it's both sexes. Just today, I ran into a good friend and she seemed kind of down. I said, "What's going on?" And she said, "Menopause. It just started and I don't even know where to begin. I am so down." And I thought, "Okay, I'm going to ask Dr. Beckerman." How do you help a friend going through that? Because, you know, having gone through it, you know that it can be a struggle. And I didn't know what to say, you know? I said, "Oh, it'll pass." That's not helpful. So, what should you say to somebody?

Dr. Tobie Beckerman: Not helpful at all. So, when patients come to me sometimes after having gone to a lot of doctors, I have the luxury of a very time-based practice. So, a little bit of the conversation that we had today, I go into in even more extensive detail with them. What is menopause? What are the body systems that are being deprived now of estrogen? What are you experiencing personally and how do we fix it? I love to educate. So, you have to find a doctor that will educate you into real risks and benefits of hormone therapy. Real risks and benefits of all of these other supplemental things we talked about, and then you make choices with the doctor. It's a constant followup. "What's going to make you feel good?" "I'm going to go on estrogen." Great. "I'm going to get rid of my hot flashes and begin to sleep. What are my real risks?" "Oh, that very tiny 0.1% risk, that's not bothering me. I'm miserable and I want to get my life back. I have no libido. I have no desire to have sex with my husband or boyfriend or whoever it may be, and I don't like that. I used to be vibrant and feel good and have sexual energy. I don't have any of that anymore."

What are the things that can help you with that? "I have no energy. I can't build muscle. I go to the gym and I try to work out and I can't even get the energy up to do it." What are the things that can help you do that? And so, you need to start by saying, "You're not the first person that's going through menopause and you're not the last, but educate yourself." What are the deficits that are happening to you? What do you not want to live with? How do you fix it? And what are the real risks and benefit with the therapies that you're taking? Not the word on the street. Not estrogen causes cancer. None of this kind of shotgun feeling about something, but really what is the risk and benefit? And then, what's going to work for you? What fits into your lifestyle based on your family history, based on your fears, based on things you're not afraid of? And then, you make a plan, and that is how you get through menopause, and that's how you get through the bad menopausal symptoms. And then, you can enjoy all the good that you have at this stage of your life.

Maggie McKay: Dr. Beckerman, what would you like women to take away from our conversation today? Because you've given us so much, number one, hopeful information and helpful. What would you like women to really feel after hearing this information?

Dr. Tobie Beckerman: So, being an advocate for yourself. Don't accept that somebody says, "You know, you're just going to have to live with it" because that's not true. And educate yourself, so that you feel comfortable in the treatments that you're getting, and you don't have to be skewed by what you're hearing and being terrified every time you take your estrogen pill or you put on an estrogen gel or you're using your testosterone or you're deciding you want to do MonaLisa and you hear out there rumors or word on the streets. So, be educated so that you really can understand.

I had a patient and she plays cards with a lot of women. So, they're sitting around the table and she's on hormones and nobody else is. And she's like, "Why? They talk about it, they say cancer. Their doctor won't let them go on. Like, are you sure this is okay?" And I said to her, "Look at you. Look what you look like. Do your friends look like that?" And she's happy. She's feels comfortable in her decision because she's trying to block out the noise and there is a lot of noise out there. So, take your life in your hands, understand that there are really bad changes with menopause, but not everybody. Some people actually sail through menopause. There are those. They have no symptoms. They barely have a hot flash. And when they come into my office and we talk about menopause, they're like, "Hmm, I'm menopausal really? I had no idea." However, the medical things like your bones and heart protection and vaginal dryness, that will come over time too. So, to the sail through menopause is that bad symptom period that most women will experience and that that's what brings people to you. And there are lucky people who do sort of sail through it. But it is very important to have those medical considerations always on the front edge so that we know that your bones are being protected and the vaginal tissues are being protected and so forth.

But my best advice is be your own advocate. Understand that these problems can be solved and it may take a little bit of time. It might not be black and white. Every single person I put on X or Y, "Oh, they're better," you know, that would be lovely. That's not realistic. Many do. Some you have to work a little harder for, but you will get there and you can believe that you'll get there.

Maggie McKay: Dr. Beckerman, thank you so much for helping us understand all that menopause involves, and sharing your expertise about treatment options, as well as tools to help ourselves in some areas and resources. It's so great to have somebody speaking positively and talking about the proactive side of menopause for a change.

So again, we've been talking with Dr. Tobie Beckerman, an integrative gynecologist at Beckerman Women's Health in Maryland. To find out more, call 301-230-1488 or visit beckermangyn.net. If you found this podcast helpful, please share it on your social channels, and please check out our entire podcast library for topics of interest to you. This is Top Docs Podcast. Thank you for joining us. I'm Maggie McKay. Be well.