Maggie McKay (Host): Welcome to Celebrate Health, presented by San Juan Regional Medical Center. I'm your host, Maggie McKay. Joining us today is Dr. Suzanne Ciotti, board-certified family medicine physician, to discuss women's health. Thank you so much for being here today.

Dr. Suzanne Ciotti: Thank you. It's great to be here, Maggie.

Host: Well, I would love to learn more about your clinic, San Juan Health Partners Family and Specialty Medicine, what they do there and what you do there.

Dr. Suzanne Ciotti: Oh, great. Yeah. We're a multi-specialty clinic here in Durango, Colorado. We have five primary care providers who offer a range of services including chronic management of medical problems, preventative wellness visits, immunizations. And we also have a cardiologist here as well, Dr. Rachel Chaney, who does stress echocardiograms, echocardiograms and consultations. We have a lab as well. So, we're really happy to provide a range of services for our clients.

I specifically do a lot of women's health. I do do also management of other conditions like high blood pressure, diabetes, care of strains and sprains, low back pain, well-child checks, a lot of teenage, well-child checks. And in addition, I provide women's health and contraception management, including IUDs and Nexplanon, Pap smears, referrals for mammograms, MRIs, so a range of services.

Host: And how does preventive care differ from women at various life stages?

Dr. Suzanne Ciotti: Well, I mean, and you're really talking about probably adults. Usually, prevention when we're talking about women's health specifically, we're focusing on when do we do Pap smears, when do we do mammograms, and that's definitely part of it. But then, we're also talking about when we'll do lipid screening or management of blood pressure issues.

So usually, with the Pap smears, we'll start doing screening for HPV or abnormal Pap starting at age 21. And then, we'll do that every three years with a regular Pap smear, which is just cytology. And then, starting at age 30, women can start having just HPV testing and with their Pap smears, which lengthens the interval for screening to every five years. And then, we generally stop doing all Pap smears at age 65. So, that's kind of an overview of Pap smears. Mammograms generally start at age 40, and they're at least every other year, depending on your risk factors.

And then, we have other sorts of interventions we're managing preventatively, like if you had your HPV vaccination for women, in addition, also men. We'll do some screening with labs like cholesterol management, starting at age 35, also checking blood sugar, screening for diabetes. So, those are just kind of the overview of women's health that we'll typically do.

Host: Dr. Ciotti, what is functional medicine, and how do you incorporate it into your practice?

Dr. Suzanne Ciotti: Yeah. Functional medicine is a lot like really good primary care, so there's a lot of overlap in what we do for both functional medicine and family medicine. Functional medicine probably focuses more on looking at the whole human, the whole being, the interrelationship of different organ systems. It focuses on a lot of prevention and ultraprevention and lifestyle management. But we also do that in primary care, in family medicine as well.

Dr. Jay Ciotti, one of our providers here in the office is certified in functional medicine by the Institute of Functional Medicine. So, that's actually a training program with testing that you have to do in order to get that certification.

And I also have a lot of experience with functional medicine. We'll usually do a lot more in-depth testing when we're doing more of a functional medicine approach, like checking things like hormones. We'll also check vitamins and sometimes even go so far as doing earlier bone density, body fat analysis, muscle analysis. So, that's functional medicine. And in general, we don't do all of that at this clinic right now. We have done it in the past. So, that's kind of an overview of it. And I feel like our primary care also, there's a lot of really good interventions like that as well.

Host: It seems like when you reach a certain point in your life, the conversation starts turning to longevity. And, you know, just in the media, we're hearing a lot about it recently. What are the most important lifestyle changes patients can make to support longevity and quality of life?

Dr. Suzanne Ciotti: Yeah, that's a such a good question. And you're right, there's a lot of emphasis on it. People are really living much older, retiring a little earlier and want to have a good quality of life. And you think that typically diet, exercise are very important. And they are very important. So, kind of more of a plant-based diet, high fiber, low in any kind of processed foods, rich in omega-3s and 6s, that is a very good diet to have. And then, getting exercise, but not necessarily what you think. It doesn't have to be real rigorous exercise. Like when they've done the studies on Blue Zones, it's been really beneficial for people to have just active lifestyles where they, throughout the day, incorporate activity. So if they're big into gardening or walking, making sure they're just active throughout the day, that's what keeps you living longer. There's been some more studies on women's health and what's important for women, especially after menopause. This is also true for men as well, but I think they do this more regularly. But strength training is becoming more important, especially heavy weights for women. So, making sure that we're doing that as well, even in our 40s and 60s when we're building our peak bone mass. So, those are definitely important parts.

And then, there's this component of longevity, which involves creating a community and connecting with other people. So, continuing to be engaged in different activities or groups is really important as we get older and continuing to have a purpose in life and reinventing yourself even after retirement. That's extremely important for longevity.

Host: Let's talk a little bit about menopause and perimenopause. What's the difference between the two and how can you tell when you're in each stage?

Dr. Suzanne Ciotti: It's tricky, because we usually define menopause as having no periods for 12 months, which sometimes you may have this time where you stop having periods, and then, all of a sudden, you feel like you're going through probably menopause-- haven't had a period for three months, and then wham, you have a period. So, that resets the clock, that 12-month clock for when we determine that you are in full bloom menopause. So, it's defined as 12 months after the last period.

And then, perimenopause is typically up to 10 years prior to that. And for a lot of people, it's very intense that three years prior to menopause. So, it's hard to determine. Typically, women will have as a hint kind of periods that are closer together and heavier, which you intuitively think that probably if you're going through menopause, they just get to be less and less or further apart and maybe not as heavy. But typically, women have heavier periods that are closer together and more moodiness, a lot of issues with trouble sleeping. So, those are really common symptoms of perimenopause, and then the definition of menopause.

Host: Okay. So, you touched on this a little bit, but how can women distinguish between normal menopausal symptoms and signs of underlying conditions that may warrant medical evaluation?

Dr. Suzanne Ciotti: It's a really good question, because it's very tricky. You can feel really, really bad in perimenopause. And also, definitely, those first six months after your last period of full-blown menopause with all the hot flashes. So, people are generally feeling pretty bad and not very clearheaded. So, it's good to know when you should seek intervention.

When you've gone 12 months with no period, and then you start having periods, then we worry about that a little bit as being a sign of something going on in the uterus, like an endometrial cancer. So, that's definitely a line in the sand where if you stop having periods and then restart them again. Then, we'd need to do more testing, including ultrasound and endometrial biopsy. So, that definitely would need to involve a physician. Or if you're having really heavy periods, and a lot of clotting and they're really close together, getting really fatigued or anemic, then sometimes that can be a sign of a fibroid and may require more intervention as well.

And it's always reasonable to see a provider if you're feeling like you can't do your usual activities that keep you functioning well, because you're not sleeping well, you're having a lot of hot flashes, then very reasonable to see a provider for possible hormone replacement therapy in order to get you feeling a little better. So at any point, you sure could go see a provider. Even in that perimenopause, I think women tolerate really heavy periods for a long time, but there's a lot of interventions we can do.

Host: Better safe than sorry. Always. What are some persistent misconceptions about menopause, hormone therapy, natural remedies, that you feel patients most need to be clarified.

Dr. Suzanne Ciotti: Yeah. There's a lot of attention on perimenopause and menopause. So, a lot of people come in asking about it. And one of the misconceptions is about testing, especially in perimenopause when you're in that time, that 10 years prior to the last period. Women will come in wanting to get their hormones tested. And hormone testing is extremely tricky because if you think about a woman's cycle, the hormones progesterone and estrogen are going up and down normally throughout the cycle. So, any specific day of the cycle, if you test, hormones may be low and that might be normal. But then, 10 days later in that same cycle, they might be higher. So, testing is tricky when we're evaluating perimenopause and it's not necessary to do for treatment always. So, that's one misconception, is testing in pre menopause. We can certainly test post-menopausal because usually, at that point, all the hormones have gone to zero. There's not those fluctuations anymore, and we're getting this kind of baseline of low hormones that help us decide, "Do you need testosterone? Do you need progesterone, estrogen? What would be the most beneficial for your constellation of symptoms?"

The other misconception is about bioidentical hormone therapy. So, I do prescribe compounded hormones for patients, but they often will come in asking for bioidentical hormones, which I think the conception is that these are ones that are made specifically for them based on certain testing. And the bioidentical hormones are really similar to the hormones that are in regular prescriptions. So, they contain estradiol and prometrium just like in regular prescriptions. But we can do them in much smaller increments than what we can get in a standard prescription. So, that there's more dosing possibilities including creams, capsules, troches, vaginal treatments. So, Those are the two biggest misconceptions, I'd say.

Host: In closing, is there anything else you'd like to add that we didn't discuss?

Dr. Suzanne Ciotti: I just think it's a good idea to have a provider when you're going through hormonal changes that is knowledgeable about all sorts of different treatments, because there are a lot of treatments out there. So if you feel like your provider isn't giving you the right answers, then please reach out, do some research, talk to your friends, see who they may see. There are a lot more providers becoming knowledgeable about hormone treatments and what are beneficial at all ages, so even perimenopause, menopause, and even far postmenopausal, we'll use some hormone treatments if needed for things like vaginal dryness. So if you're not getting the right answers, then definitely go seek a provider who can help you feel better.

Host: Well, thank you so much for sharing your expertise. This has been very informative and helpful. We appreciate it.

Dr. Suzanne Ciotti: Yeah. Thank you so much for giving me the opportunity.

Host: Of course. Again, that's Dr. Suzanne Ciotti. To learn more about the services offered by Dr. Ciotti and her colleagues at San Juan Health Partners Family and Specialty Medicine, visit sanjuanregional.com/durango. I'm Maggie McKay. Thank you for listening to Celebrate Health.