Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And today, we're focusing on advancing women's health, key updates on screening and treatment. And joining me is Dr. Alexandra King. She's an Assistant Attending Physician at New York-Presbyterian Hospital - Weill Cornell Medical Center, and an Assistant Professor of Medicine at Weill Cornell Medical College Cornell University. Dr. King, thank you so much for joining us today. And you recently shared revised innovative screening guidelines for women's health, including cervical cancer, breast cancer, bacterial vaginosis, and menopause. I'd like you to first tell us how this came about and what were your role in these revised screening guidelines.

Alexandra King, MD: Yeah. I just want to thank you so much for having me on, Melanie. I'm really excited to be here. I do primary care here at Cornell, and I take care of a lot of women, and women's health is really important to me. And so, staying on top of these guidelines is something that I get really excited about. And I think whenever we have updates, it's really important that we are paying attention to them. And so, there have been a bunch of updates recently. And we look to these groups.

There's one called the USPSTF, which is the US Preventive Services Task Force, and they kind of gather a lot of data. They sometimes generate their own data to figure out what are the right ways to screen for certain cancers and other preventable diseases. And they recently just put out some new guidelines for breast cancer screening and some draft recommendations for updates for cervical cancer screening, which means that they're getting some feedback from the community, which is really cool before they finalize those recommendations. And so, we can definitely chat about those today.

Melanie Cole, MS: That is great. Certainly always important. And as a woman in post menopause, I know how important these kinds of guidelines and screenings are, and we're not always sure. Sometimes there's conflicting information and we all know that there's a lot swirling around in the media today about some things. So, this is great that you're coming on to help clarify some of it. So, why don't we start with cervical cancer? Tell us what the recommendations are, because now that has changed. And our Pap tests along with HPV has changed. All of this has changed as we've come up with this HPV vaccine. So, speak about cervical cancer for us.

Alexandra King, MD: Yeah, definitely. I mean, the cool thing about cervical cancer screening is actually we're doing a pretty good job of it. Women are pretty great at going in and getting their Paps when they're needed. And so, we've seen incidents and also deaths from cervical cancer decrease really dramatically in recent years. So, that's really awesome.

But like you said, we've kind of consistently been doing Pap smears, which involve going into your doctor, getting a sample of cells from the cervix, which is like nobody's favorite thing to do. It's really uncomfortable. But that's always been kind of what we call the gold standard of care and how we are able to kind of get really good information.

But in recent years, we've started checking for HPV, which is the human papilloma virus, which is also kind of essential in cervical cancer. It can cause a lot of cervical cancer cases. And these new guidelines actually advocate for what they call HPV primary screening, which when you break it down really means just a vaginal swab rather than a full Pap smear. So, definitely a lot less discomfort for women, maybe a lot less anxiety about going in and getting that done. And then, we only have to do that full Pap smear, including those brushes for cervical cells if that HPV comes back positive.

And I think why this is really, really cool is not only can you get that done at your doctor's office. But in the future, as we kind of look towards what this could look like, it means women might be able to do this sort of thing at home. And again, if our goal is like just to increase access for people and help them get this done easily, I think that's a really cool way to do it. So, that's not quite available yet, although there are a few companies that are in the midst of figuring it out, and I think it's definitely on the horizon for us.

Melanie Cole, MS: I think so too, and thanks for that. So now, onto something that not many women want to think about, much less discuss, and that's something you and I are going to touch on before this episode's over is advocating for ourselves and being not afraid to ask you and talk to our doctors about these things. You know, that's just so important. But okay, bacterial vaginosis or BV, tell us a little bit first about what that is, why it's so uncomfortable for women to discuss and what we can do about it.

Alexandra King, MD: So, bacterial vaginosis or BV is a type of vaginitis, which is an inflammation in the vagina. A lot of women are suffering from it. It's actually really common, but a lot don't even know how to name it or, you know, like you just kind of insinuated before, they maybe are afraid to talk to their doctor about it, they're embarrassed.

But what happens is there can be a shift in the normal vaginal microbiome, so all those nice, healthy, good bacteria. And when you have that shift, you can actually see things like vaginal discharge, discomfort, odor. And some women that have BV can deal with it multiple times in their life or even in a year, which is just incredibly frustrating.

The good news about BV is that we do have good treatment for it. It's this antibiotic called metronidazole. But even when we treat it successfully, it has this tendency to come back. It's really, really stubborn. So, like almost 50% of women that have BV can see recurrence within even 12 weeks, so like three months.

This really cool study came out this year. I really love it. Very nerdy of me. But they did this study in Australia, and they basically decided what happens if we not only treat the women with BV, but we treat their male partners who they're sexually active with, could that help? And they actually found that when they treated the male partners for BV at the same time as they treated the women, that rate of recurrence went down hugely. They actually had to stop the trial early because it was so effective that they felt like the group that wasn't getting that partner treatment was actually at a disadvantage. So, that's something that we can now really put into practice. It's something that I've started doing for women that have recurrent BV, asking them, "Is there a male partner in the picture that we can treat?" I think can be incredibly powerful.

Of course, there are some limitations here. They didn't do this study on women with same-sex partners or with multiple partners, but my hope is that we can get maybe some more data in the future and we can start using this really for all women and treating it more like a sexually transmitted infection as opposed to just something that has to do only with a woman and is only her burden to take care of.

Melanie Cole, MS: How important. That is just really great that we're looking at it in a new way. Women have always taken the burden of so many of these things. So, that's fantastic. Now, breast cancer, latest info. We hear different information about when mammograms should start and how often. And tell us a little bit about the screening recommendations as they are right now.

Alexandra King, MD: I think this one can be especially tough for women, because they're going to their primary care doctor who might say start at 50. And then, they're going to their OB-GYN, who says start at 40. Friends are having differing experiences. And so, what I think is really helpful here is we're going to come back to our friends at the USPSTF. We talked about them earlier for cervical cancer. They actually put out updated recommendations about a year ago, and they have kind of like evened the playing field and they said you should be starting at 40.

That decade from 40 to 50 has always been kind of a tough one. There's not really great information about whether or not it's helpful to women, meaning are we actually diagnosing breast cancers and doing a better job of managing them? Are we helping people feel better and be healthier? And so, to have the USPSTF come out and say, "Yes, we are going to recommend that you do it starting at 40," I think is a really big statement that they made.

They also have said-- I think like the traditional paradigm that a lot of women are used to is that we go for a mammogram every year, but they've actually spaced that out so that you don't have to get your mammogram every year, but every other year is actually the best. That kind of balances out getting that information about what's going on in your breast, which is incredibly important, but also not overdoing it. And what I mean by that is like false positives that send people down roads that cause them a lot of anxiety or they have to get biopsies for no reason, right?

And so, we'd like to minimize that and maximize the benefit. And so, doing that every other year can be really helpful. So, pretty much all of the organizations are saying at this point, start at 40, get it done every other year. And then, depending on what those results look like, you might have to get some more screening or some more diagnostic testing. But that's really been a standardization, which I think is super nice, much less confusing for women.

Melanie Cole, MS: So, there's a lot of different screening methods now for breast cancer. There's mammograms, the 2D, then there's 3D tomosynthesis, and ABUS and MRI and ultrasound. Tell us about those screening methods and which ones we're looking to right now.

Alexandra King, MD: Again, this is another place where women get kind of confused, and they want to make sure they're getting the right care and they're just not sure. We always start with a mammogram. That can be just your traditional mammogram versus your tomosynthesis, which if you think about it, it's kind of like a 3D reconstruction of the breast. Both of those are actually really effective. And when the USPSTF made their updated guidelines, they actually checked, they compared them to each other, and they kind of found that they were-- a word we use as non-inferior, meaning they both were kind of equal to each other. There wasn't one that was better. So, whichever one of those your doctor prefers or they're doing at your healthcare institution is totally fine.

And then, you know, in terms of MRIs, I think we're seeing them become more and more important for women. We're going to be using them more for women who have a higher risk of breast cancer. So, women with a family history or certain genetic mutations that they carry might be going to do perhaps an MRI, and then six months later a mammogram and kind of doing those things in conjunction. But that kind of will depend a little bit based on what we think your risk is. And I think, again, we'll see MRIs maybe used a little bit more in the future. But for right now, mammograms are still going to be our first step and that can be a digital one with tomosynthesis or just kind of your straight up usual. Both of those are totally fine.

Melanie Cole, MS: Absolutely. And I mean, really, the field is advancing and we're learning so much more with all these different screenings. So, that's great. Now, menopause, latest recommendations. I know that a lot of women have questions about hormone replacement therapy. They have questions about side effects and symptoms, things they're going through. I mean, it's a whole life change, right? What are we recommending for discussions as well with our doctors about those types of therapies?

Alexandra King, MD: Absolutely. I'm really glad that we get to chat about this. I think it's such an important space. We are paying a lot more attention to it lately, and I think that's phenomenal. If you think about it, like half of the population is going to go through menopause. And so, we should be talking more about it.

I think the history here is really important. So for a long time, the medical community has been kind of hesitant surrounding hormone replacement therapy. And I think that hesitation has trickled down a little bit to women. This comes from this big trial in the 1990s called the Women's Health Initiative. And in that trial, they found some increased risk in blood clots and in breast cancer in certain groups of patients on certain hormone regimens.

But as we really look at that data and kind of drill down into it in terms of kind of who these outcomes were happening to and how often, we really see that, especially for women close to that menopause transition, so within about 10 years, but really the earlier the better, so around 50-ish years old. If they're otherwise healthy, hormones can be really safe. And these additional risks, we can really minimize them with a lot of good counseling. So, my take here is that, you know, as doctors, we should be offering these really effective hormone regimens to our patients because they're suffering. Brain fog, hot flashes, night sweats, anxiety, irritability, there's so many things that we really aren't saying out loud that women in perimenopause and menopause can be suffering from. I think super important.

And I think really, when we don't offer these evidence-based medicines, women are going to take this into their own hands. And so, I see a lot of my patients and a lot of my colleagues' patients, they're trying to find their own solutions on the internet via supplements, other kind of powders, drinks, things like that. And some of these things are not effective, and sometimes they're not even safe. I think we're doing women a disservice. They're suffering. They just want to feel better. And we should be offering them evidence-based solutions that are effective for them.

Really, I think the takeaway totally for me is to encourage women to talk about this with their primary care doctors and their OB-GYNs. And if those doctors aren't comfortable with hormone therapy, and some of them might not be, they should be able to connect you with somebody who is, and who can talk about the risks and benefits for you and help you make the right decision.

Melanie Cole, MS: Dr. King, tell us a little bit about nutrition. What are we supposed to be thinking about? Because as we think about getting older and our health needs change, one of the big things is we gain some weight. As our hormones change, we all gain a little weight around the middle and, you know, our bodies change and we want to really get that exercise and think about what we're putting into our body as well. So, just touch on nutrition for us. And what do you think are some of the most important aspects as we're looking at, you know, our diet, what we're feeding our families, what are some of the more important aspects for us?

Alexandra King, MD: So, I'll start by saying that I'm certainly not an expert here. I'm really lucky we work with some phenomenal dietician at Cornell, and they take really great care of our patients. But I think, in broad strokes, what's really key for women as they move through different stages of life and especially through menopause is prioritizing this idea of a well-balanced diet that's high in protein. So, protein's going to be the building blocks of muscle. We know it can be really hard to build and maintain muscle mass as you age, especially through menopause as the estrogen kind of drops. This muscle mass is really important, not only for your strength and your mobility, but also for your bone health, which we don't talk about as much. But that's also really important for women to avoid low bone density and osteoporosis. And so, proteins going to be really essential.

But beyond that, thinking about kind of good healthy fats, especially making sure that your diet has some nice omega-3 fatty acids that's going to be great for brain and heart health. We talk about them being in fish primarily, but you can take supplements as well and they're found in other foods.

And then, I think like the unsung hero of the diet is fiber, which really kind of keeps you regular and, for a whole host of reasons, can keep you healthy. It can be kind of tough actually in the usual diet, but we should be prioritizing things like whole grains and green veggies, beans, sweet potatoes. Gut health is going to be hugely helped when you have high fiber, and we're really seeing that gut health connects to all sorts of other parameters. So, those are kind of like my broad strokes.

Melanie Cole, MS: We are learning more about gut health and the microbiome and its link to so many things. One thing I would like to ask you about as we're looking at the screening, I'd love for you to give us some of your best advice about advocacy for ourselves. As we mentioned, talking to our doctor and some things might not be comfortable, whether it's incontinence or stress, mental health issues, which we certainly know we're all going through stuff right now. You know, there's sort of a worldwide feeling of this. And then, our sleep might be interfered with. There's all this stuff that we're learning and that we see and that's going on. Can you wrap this up a little bit? This is a big ask. But give us your best advice for advocating because if we can't advocate for ourselves, we cannot take care of those we love. And as we know Dr. King, we are the caregivers to society, and we must put our own masks on first.

Alexandra King, MD: Absolutely. I can't say how much I agree with that. I think taking care of yourself is the number one, because, you know, all of these women I take care of, they have families that are dependent upon them, parents, siblings, children. If the idea of doing it for yourself feels selfish, which it shouldn't. But if it does, then thinking about all of these other people who also rely on you being healthy and having that longevity, I think, can be really helpful for women.

The question is a tough one because, I think, it can just be hard. You have 20 minutes with your doctor, you get in there, you're a little anxious. Maybe you forget what you came in for. You feel like you don't want to talk about that one embarrassing symptom. But I think my biggest advice is to just remember that, if you're a good fit with your doctor, and maybe that's, you know, something that you should be thinking about, you should find a doctor that really works well with you, that you feel your styles are complementary, that you feel comfortable with. And if you find that physician, it should be much easier to talk about these things because you're going to be met with compassion and empathy and hopefully some solutions. But even if there's not a solution, just listening I think can be incredibly powerful. So, I think number one is just finding that doctor that really works well with you.

And then, I think number two, something that I have found is helpful for my patients is keeping a list of what you want to talk about beforehand so that when your brain goes blank when you get into that appointment, you've got that list that you created when you were really thinking about it the night before.

I think those two things can help. Certainly, that's not the whole solution. But I really hope that we can convince women to start talking about these things more. There are studies about how often women bring up these symptoms in clinic when they're suffering from them, and something like almost 50% of them don't even bring up, for example, menopausal symptoms or incontinence symptoms or other things that they find are impacting their quality of life, but maybe they're embarrassed about. And so, just being brave, taking that step, making a list, finding a doctor who really listens to you. I think those are really the building blocks.

Melanie Cole, MS: Such great information, really great advice. And I'm a list maker. So whenever I go sit with my doctor, she's always like, "Okay, break out the list, you know?" And we go through it part by part, because it's really important. And we can't always remember what we want to say. So, that's really great advice and you've given us a lot to think about today. Dr. King, thank you so much for joining us and sharing your incredible expertise. It was really great.

Alexandra King, MD: Thank you.

Melanie Cole, MS: And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcast, Spotify, iHeart, and Pandora. For more health tips, please visit weillcornell.org and search podcasts. We have so many great ones there. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole. Thanks so much for joining us today.

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