SPEAKER_01 0:00

So one of the most common conversations that I have in my practice right now is about hormones. So women want to know should I be on them? Should I be getting my hormones checked? What does menopause actually feel like? And am I in it? And a lot of them are coming in with not great information or way too much information from social media, from friends, from their doctors. And they're all telling them different things. And these women are confused. So what to make this conversation about hormones a little less confusing, we have an incredibly special guest with us today on vitals and values. So we are uh here with Dr. Lisa Larkin. So she is a Yale and University of Chicago trained and board-certified internal medicine and women's health expert. And she's been practicing in Cincinnati for over 30 years. Half of that time about is at the University of Cincinnati and the Department of Internal Medicine and OBGYN, and about half in private practice. And she is the founder of and president of Concierge Medicine of Cincinnati, which is a multi-specialty primary care and women's health practice in three locations in Cincinnati where she continues to practice. And how I got to know uh Dr. Larkin was through uh she's also the founder and CEO of Ms. Medicine, which is a national women's health company. It is committed to advancing high-quality women's health care. It is female founded and focused on building an integrative health care network of concierge, women's health trained physicians and practitioners across the U.S. And so thanks to Lisa here is how I got my start in concierge medicine. So thank you for joining us today, Lisa.

SPEAKER_02 1:42

Thank you so much for having me and thank you for being part of the Ms. Medicine Network.

SPEAKER_01 1:47

Absolutely. It has been amazing. I tell people every time I see new patients, I'm like, I would not go back to what I was doing before. I love what I am doing now. So thank you for building this community. And I know David has uh not had a chance to meet Dr. Larkin until this uh a recording here today.

SPEAKER_00 2:05

I mean, technically, I was we were talking about before, I listened intently to a Zoom meeting that Dr. Larkin had on right after the black box warning conversation. And it was fascinating. It was I I I I was that was like an hour and 20 minute call, I think, ish. And I was on the couch listening attentively going.

SPEAKER_01 2:24

You asked great questions afterwards.

SPEAKER_00 2:26

I did, I did ask a couple things, and so it was it was a pleasure to to be on the wall listening to uh you speak on that topic.

SPEAKER_01 2:33

Yeah, I don't think when David, uh when we got engaged, I don't know that you ever thought that you would end up knowing and talking so much about menopause.

SPEAKER_02 2:40

So well, hopefully I would tell you just a funny anecdote in that way. So my husband is an emergency medicine physician, and he would tell you that he is the only ER doc in all of the United States that prescribes a lot of vaginal estrogen because he's heard me speak so many times about GSM and the importance of vaginal estrogen that he teaches all his ER residents about prescribing vaginal estrogen. And it's the big joke in his emergency room. It's awesome. I love it.

SPEAKER_01 3:08

Well, cool. Well, um, to get started, I kind of wanted to know, because I don't think I know this myself. I think I've heard bits and pieces, but what really has drawn you to women's health and menopause specifically? Was that always something that you were interested in? Or what pointed you in that direction?

SPEAKER_02 3:25

Oh, yeah, no, I mean, I'm I always describe my career as, you know, I've I'm always been a square peg and a round hole a little bit. And no, I mean, I had no idea I was going to do menopause and midlife women's health. But when I started on the faculty at the University of Cincinnati um in 1991, it was very clear, very quickly, as a young female internist in an academic practice, that no one was really doing midlife women's health. And so certainly what happened is, you know, as a new faculty female, everyone gravitated towards me. And I suddenly saw it was just glaring, this kind of gap in midlife women's health. And it really led me to say, hey, this is really an important area that we're neglecting. And so did my kind of advanced training have been involved in the menopause society since way back in the dark ages, right? I'm one of the OG, as they call it these days. Um, and it's really been a tremendous niche and focus for me in practice. But as you know, a lot has changed historically. Like I, when I talk about my career, I really describe how midlife women's health and menopause and the journey of menopausal hormone therapy has frankly defined my entire professional career. Because I started pre-WHI when we were really all, as an internist, we were all prescribing a lot of hormone therapy at that point because we had observational data, which really suggested that we were benefiting our women who were at highest risk for cardiovascular disease. We weren't really sure about what was happening with breast cancer risk, but we really believe the leading cause of death we know is cardiovascular disease and that we were benefiting more women than harming. And then the WHI in 2002. So we went from prescribing hormones to not prescribing hormones and all of the fallout of the WHI. Um, fast forward to now when the pendulum is going back the other direction. And so I've kind of my entire 35 year career has really been all about this winding circuitous journey of menopause and midlife women's health care. The thing that has remained constant is that we still, 35 years later, have a tremendous gap in care in midlife women's health. And that's really why, even with the founding of Ms. Medicine, right, in the concierge medicine space, in the executive health space, it's been very clear along the way that again, everything, the lens is focused on men. So the concierge practices that were founded is really, yes, primary care, but the platforms really developed around cardiovascular risk, largely men. If you look at executive health programs, they're really focused on cardiovascular risk. And again, in midlife, 50-year-old men, that's really much more of an issue than 50-year-old women, largely. And the things that women need at midlife are completely neglected in all of those platforms. And so my whole career has been about trying to move the needle on improving midlife women's healthcare. And I can tell you we still have a lot of work to do. So fast forward 35 years, and I'm not sure it's all that much better right now. Although finally, clearly, menopause is getting some attention and people are talking about it.

SPEAKER_01 6:43

I was to say from back, you've said you've been doing this 35 years. Is the conversation about menopause right now really significantly different than you've ever seen? Oh my gosh.

SPEAKER_02 6:54

I mean, so, you know, again, I mean, the world is so different, right? I mean, the way that we communicate and social media has just been such a game changer. I mean, I tell the story, and I have colleagues, right? I'm part of the old guard and the menopause society that, you know, we knew when the WHI data came out in 2002 that the way that we were messaging the data in print media at that time, remember, we still had magazines that people read that you picked up at the airport and you took on your flights, right? Like we used magazines, but we knew that the messaging wasn't getting out there, but we didn't have the platform to kind of correct the narrative. And so the narrative, of course, was that hormones are terrible and they're scary and they cause breast cancer. And at that point in time, I can tell you that being a menopause doctor, that cleared a room. Like nobody wanted to really talk menopause. Like that was like the horrible, you know, why would you ever be a menopause doctor? Even though there clearly was a need at the time, um, still is. But now, you know, thanks really to social media and really, I think an explosion in the way in which we, we doctors, but we society, we communities can connect with patients is so vastly different that finally the message is out there. And I think women have really come to say, hey, we are the forgotten area. You know, we do a good job of talking to teenagers about puberty and we certainly talk about pregnancy and postpartum. Menopause, right? You're old. That's a terrible thing too, right? And that's kind of, you know, no one wants to talk about that. Um, but of course, what else has happened is the business opportunity has become clear. Finally, the world has recognized that we've been neglecting midlife women. And not only do we need to do a better job taking care of them, but there's huge business opportunity here. So everything has really just accelerated in this incredible way. And as you kind of said in the opening, right, like there's been really tremendous positive things that have happened in the midlife women's health space, but it's a mixed bag, like many things are, because there's a lot of confusion and frankly some misinformation on social media. And it's very hard for women to really know if they're getting good information or not good information. Um so it's a little bit of, you know, crazy town out there now, too.

SPEAKER_01 9:11

And how do you feel do you feel like social media is a big, like a huge driver of that, or are there other things? Because to me, it's a lot of social media that I see. Is that kind of your perspective?

SPEAKER_02 9:22

I think social media has been an absolute game changer. I mean, I think the other thing that started the trend was, you know, celebrities and famous people started to become menopausal as well, right? So we have, you know, Gwyneth Paltro and we have Naomi Watts and, you know, we have Michelle Obama and, you know, many others. And, you know, Oprah's been talking about menopause for a while now. But I mean, I think that um interest uh of celebrities who really, really kind of stopped and said, hey, we don't feel old yet, and there is clearly something happening here hormonally, and no one's really talking about this. And we need to really elevate the level of conversation and care. You add that to the social media and the way that we can disseminate information. Um, it's just been an absolute game changer. And even in the Manipause Society, I mean, for you know, again, like an organization I've been involved in for 30 years, right? We could never get above. We were 1,200, we were 1,400 members, we were 1,600, like it was, we couldn't get above 2,000. And in the last three years, we've gone from 2,500 to 4,000 to 7,000 to 10,000, like exponentially. Um, just the growth has been incredible. And I really do think that's largely from the combination of social media and societal interests driven by celebrities largely.

SPEAKER_01 10:44

And I know because when I started practicing, I feel like menopause wasn't taught about that well. And I feel like when I was doing my when I would do my own research on it for patients, I would find that, well, this was like okay to do now, but I didn't feel like anybody was doing it. So when do you feel like that tide actually started changing, or do you feel like it hasn't really changed enough yet?

SPEAKER_02 11:05

Oh, I mean, I I'm very excited to see um, you know, in the next one, three, five years what the numbers are in terms of percentage of women who were actually taking menopausal hormone therapy. Because you probably know, right? So we were at basically around when the WHI came out, about 30% of the population of women were taking menopausal hormone therapy. And that plummeted almost overnight down to 7%, 9%, 5%. The most recent um data that I've seen presented at the menopause society was still that only 5% of appropriate candidates for menopausal hormone therapy are actually being prescribed it or taking it, right? And I can tell you that just based on the patients who come to see me right now, clearly, and in any lecture I give now, all doctors are saying, yes, patients for the first time are coming in actually asking for hormones. They want to have the discussion. They're hearing things on social media, they're seeing books, they are hearing that it's much more beneficial. It's being promoted kind of as a longevity medication now. And finally, doctors are actually saying, oh my gosh, like I do actually need to up my game and learn something about this because patients are asking. And really, we need to have thoughtful conversations with patients. And so I do think that we are going to quickly see a swing up. How quickly? I don't know. My guess is quickly. My guess is I don't know, it'll get to 10% quickly, 20%. I bet we get close to 30% again as we move forward. But if you look back to the 1950s, I mean, it's crazy. I have a slide that I use when I talk. I mean, it's literally been up and down, up and down, and up and down, depending on where we are with the data and what's been going on over the last 60, 70 years.

SPEAKER_01 12:50

What was that like in 2002 when this data came out?

SPEAKER_02 12:54

What were do you remember how you felt about it? I know exactly where I was standing. I I yes. I mean, so it's a crazy story. I mean, I had been at the university um from 1991 to 2002. I had left and started my own practice in April of 2002, just before the WHI data came out in July of 2002. And I had already been doing a lot of women's health, was already doing, I was known in the community as being a menopause doctor, and I was certainly prescribing a lot of hormones. And when the data came out, um, it was, I mean, it was earth-shattering, truly, in terms of the way that the media presented it. And I actually remember being horribly offended by Anna Quinlan, who wrote an op-ed in Newsweek magazine. I used to get Newsweek magazine, right? That really lambasted, and I took it very personally, doctors. And her quote was for willy-nilly prescribing hormones to all the for to women all these years. And we we had given all these women breast cancer, and we had just been horrible. And I really took offense to that at the time because I mean, you know me well enough to know, right? I really do believe in science and education and try to practice high-quality medicine and really believed in what I was doing all those years based on the nurses' health study and a lot of observational data. And we really had the best data we had at the time to tell me that we were doing good in the world for the majority of women. This turned that completely upside down. But the way that we were portrayed as doctors is we were really vilified as somehow having like almost, I mean, the quote she used was willy-nilly prescribed hormones. And I took great offense to that, really. And so, not surprisingly, right, um, I knew that the way that the dirt data was being presented, right? It's this whole discussion between absolute risk and relative risk, and that we were terrifying women the way the data was being presented. Even though, again, the risks were being overblown. We knew it at the time and the benefits being minimized. And so from the WHI fast forward, I continued in Cincinnati to be a big prescriber of menopausal hormone therapy. But largely every single one of my internal medicine colleagues and most of my OBGYN colleagues at the time stopped. And we stopped training doctors and we stopped researching menopausal hormone therapy, and the world kind of shut down in terms of thinking about menopause, which is terrible because we definitely harmed women from the WHI fast forward, particularly in women who have early or premature menopause, where again, those women benefit from hormone therapy, and we were applying this data that was presented in the wrong way, terrifying people that they were going to get breast cancer, without really recognizing that young women who have menopause at 40 or 42, they have harm when we don't give them menopausal hormone therapy. And we did, we harmed a lot of women by the way that data was presented. And again, I was out there, you know, at a time when social media didn't exist, when the menopause society was really small, trying to lecture. Like for a decade, I was doing evening lectures at our sports club all on varying topics of women's health and talking about um menopause. But again, it really there was so much negative messaging about the, you know, the negatives of hormone therapy that women, I tried to talk women into taking hormones at that point in time when I say that, who were highly symptomatic, where they clearly were going to have benefit, and I couldn't talk them into it. Today, fast forward now, now I'm trying to pry it out of their hands. Like I have women who are coming to me now who are not good candidates for hormone therapy, who want it and who are pushing me. And it's like it's it's really like come 360 degrees.

SPEAKER_01 16:56

And what kind of things you said they're not great candidates. What are you most commonly seen women want it for then? Right.

SPEAKER_02 17:04

So I just want you to think about dates, right? So think 2002 to now, right? 2026, so 24 years later. There are women who were age 50, 2002, when the data came out, whose doctors said to them, Oh, hormones are terrible. You can't take hormones. And now how old are they? They're 74. And now they're mad. They they're mad. They're mad that they didn't take hormones, they didn't get hormones, they have osteoporosis, they have early cardiovascular disease. They want hormones. And they're not good candidates anymore. Now, is it an absolute no? I'm sure there will be, I'll have colleagues here who will hear this and listen. And of course, it is never a hundred percent black and white. But of course, the way that we want to practice medicine is right, it's individualized. It's really looking at every single patient sitting in front of you and really understanding their past medical history, their family history, their current health issues, the likelihood of future health issues, and then why they're asking for hormones and really trying to weigh all of those things in balance and really try to help them understand the data in a way that together through shared decision making, you can come to the best decision. But there are women who frankly have had a prior cardiovascular event, a prior TIA, who have a very elevated coronary calcium score at 75, who have a history of a high-risk breast lesion, DCIS, or an abnormal prior biopsy. Like they're not the best candidates for hormone therapy. Now, again, would I ever say 100% I would never do it? I mean, again, it depends on the patient sitting in front of me and what symptoms she has, what she's trying to achieve with the hormone therapy, and really me talking to her about her risk-benefit ratio, as best I can tell, with prescribing hormone therapy. But some women, particularly older women with cardiovascular risk, are just not good candidates. And there's a lot of messaging on social media now about hormones being a longevity medication. And I just that think that that's something that we have to be careful with in terms of how we are messaging that. Um, because you know, it's, you know, if it sounds too good to be true, it's too good to be true in medicine, right? Like there, there isn't just um a longevity pill, and menopausal hormone therapy in the right patient can be helpful. There's no question and beneficial, but not in everyone. And in some women, it does carry risk.

SPEAKER_00 19:44

Well, I mean, from from a personal story of me, when I was by the time I was 15, I was on metformin and prediabetes medications, and now they're touting metformin as a longevity pill.

SPEAKER_02 19:55

Yes, for sure.

SPEAKER_00 19:55

So, I mean, I was just early to the to the Vogue topic, which is metformin being this like longevity pill. I just was cool before it was cool.

SPEAKER_01 20:05

You're very cool. Well, and I think there is um so much truth that that people want it for all these different reasons. So I hear it a lot that people, like you said, longevity, or people are worried about, I don't know, Alzheimer's or their heart or random uh bone stuff. And like, how do you have that conversation with your patients?

SPEAKER_02 20:26

So remember, um, this is an area, and if you've been um participating in any of my Monday night discussion groups, right, there's parts of this where not all of us who are practicing in the field 100% agree, right? So there's some areas where um either the data is not great data, or there's data gaps, or there's conflicting data. And specifically, I would use the example of menopause hormone therapy and dementia and cognitive decline and Alzheimer's. That is really an area where there are experts out there that disagree on this topic. I would tell you that my understanding from really knowing some of the experts quite well who have done the research in this space, is that the sum total of the data is that menopausal hormone therapy is not harmful, but it is not a home run. And that we should not be prescribing hormone therapy for dementia prevention, because the data just doesn't pan out that way. And what we all know about dementia is largely it's the same things that contribute to cardiovascular risk or the things that contribute to dementia. And so, really, I think where I worry that this trend is going with longevity goes back to once again, kind of looking at a quick fix and an easy solution, be it menopausal hormone therapy or GLP1s or peptides or whatever it is we're going to talk about, or metformin even. And we miss what we fundamentally know is the most important. Thing, which is really diet, lifestyle, maintaining an ideal body weight, exercise, weight bearing exercise. Like again, are there benefits of some of these other things? Yes, yes, yes, and maybe. But menopausal hormone therapy, I just again may be part of a healthy aging plan in the right woman. But I really think we risk doing what we did in 2002, except the other direction, which is in 2002, we really over-dramatized the risks and we ignored the benefits. And what I don't want to do now in 2026 is do the same thing except the opposite, right? Which is overplay the benefits and like ignore the risks, right? Like we just know that medicine is complicated and individual patients really deserve individualized risk-benefit assessment. Um, and not, you know, social media, the negative about social media is that sound bites and controversy drive algorithms, right? And medicine in general is complicated. And sound bites don't often take into consideration all the nuance that we need to have when it comes to medicine. And so I just, you know, if I'm the old guard, I'm the, you know, people will say I'm stuck in the mud. But the reality is when it comes to the longevity stuff that you even hear Dr. McCary spout out there, he's really going back and using the data from the 1990s. It's not like there's a whole bunch of new data to prove that menopausal hormone therapy is a longevity medication. He's going back to the nurses' health studies that I was using before the WHI, right? So again, we have to just be careful in our messaging about this.

SPEAKER_01 23:45

And in being careful, you are, I assume you're somewhat alluding to this black box warning conversation.

SPEAKER_02 23:53

Well, right. So it's really interesting. So, first of all, the home run is finally having the boxed warning taken off vaginal estrogen. I mean, vaginal estrogen, in my opinion, should be over the counter. Vaginal estrogen is safe. Vaginal estrogen, I mean, you know, we just we harmed women again by putting that boxed warning that never should have been there on the vaginal estrogen and terrifying women about vaginal estrogen. It's like hydrocortisone cream, right? It's not the same as getting a steroid injection or IV steroids. And um, so having that removed was a home run where I've struggled, and I do now that we've just had the first labels now actually get approved. So we're just seeing the new labels for the first time, is I do have concerns that the labels are still not really accurate, right? So, and what do I mean by that? Which is we are still applying data from the WHI, which is a specific formulation of hormones, and we're putting it on medications that aren't the same medication, right? And so conjugated equine estrogen, CEE, in the WHI is not the same as estradiol. And yet still we're putting data one to the other. The other thing is that we don't have a lot of data, good quality data, and there's huge data gaps when it comes to breast health and breast safety. And so I just think that now, again, even though the boxed warning was removed, hormone therapy in breast cancer survivors in the contraindications is still part of the label. And there is language in there about raising some concern about potential breast cancer increase in breast cancer risk. But again, we're still putting WHI data on label on products that don't exactly match. And so the problem for all of us in the space right now is we need more data. We need better science. We actually need to do the randomized control trials with the type of medication that we're actually using right now so we can have better conversations with women, more accurate conversations. Because when I lecture about this to other doctors and I explain to them how I talk to women about the impact of hormone therapy on their personal risk of developing breast cancer, what I say is I'm doing the best I can in terms of extrapolating data that's not perfect data to the patient sitting in front of me. What I wish I had was better data. And we really have to get to the place where I hope that we will be able to fund trials and actually get some of the data that we need to do a better job.

SPEAKER_00 26:32

That's one uh I was about to say, that's one of the downsides, if you ask me, of social media today, which is because of, and this is a this is a hard conversation uh to a certain subject, the whole COVID led people to understand like, okay, you got to see the scientific method in real time with a bunch of people that have no understanding of how scientific and science works, and like the true understanding that science takes time and a lot of money to truly do it correct. And social media loves instant graphication, it loves giving the answer now. And the reality is it could take a decade. I mean, my dad's uh favorite one is the whole idea of he was interventional cardiology, and we went through the phase in the 90s and early 2000s where it's like, oh, there's a blockage in the in the artery, blow it up. And dad's like, Well, should we do that? Like, just well, I mean, it's not gonna do anything. And it's like dad was even a person to go, just because we can doesn't mean we should. And it's that like, and it took another decade of him even pushing back on his own partners, going, Hey, let's come out, let's wait for the data to come out before we just start doing it everything we can. And everyone wants the answers now and time and money.

SPEAKER_02 27:51

Well, and that's and that's right. I mean, you're a hundred percent right. And a lot of the messaging on social media when it comes to testosterone, for example, also, and um just even uh the newer formulations where I push back and say we don't have the best data about this. So you can't, you can't make blanket statements. It doesn't increase your breast cancer risk. Do we really know that? Do we know it's a little bit? How do we make that statement, you know, based on an individual's baseline risk? But to your point, right? Like I understand the fact that A, it takes time for studies and it takes money. My bias, and this may or not be yours, Lara, I don't know, is just again, like the absence of data does not prove something is harmful. But the absence of data also does not prove that it's beneficial or that it doesn't have other downstream side effects that we don't know about. And I use the example of, I mean, it's only a hundred years ago that we were giving people arsenic treating syphilis, right? Like, I mean, it's not very long ago. Like, I mean, and if you even look in the hormone therapy, right, the initial surge in utilization in the 1950s and 60s of menopausal hormone therapy was before we had data. And we gave a lot of women endometrial cancer because we didn't understand that women who had a uterus needed to be on a progestin to protect them from getting endometrial cancer. So, like, there's real examples in my lifetime where the lack of data where we have actually harmed people, right? And so I'm just cautious. Like, you know, there's all this stuff in the peptide space right now about, you know, big pharma's bad and big pharma's never going to study this. And I get that. And like patients have a right to body autonomy. And so, I mean, I agree with that. Patients do have a right to body autonomy, and they absolutely adult patients can if they want to experiment with stuff where I go back, and this is me, and it it is not everybody. Um, but I take it very seriously what I prescribe for patients, which is I own it. If I prescribe it, I own the side effects, I own the complications, I own the problems. Like it's me. And without data, when we're doing that, when we're when it's gray or we have no data, like I think we have to all, I feel as physicians, we just have to make sure that we're appropriately informing patients about what we know and what we don't know to the best of our ability, with to your point, exactly the truth, which is the menopausal hormone therapy journey, the data evolves over time, right? We learn more. That's what science does. Like we don't have it all figured out right now. But I just want to make sure that I'm trying to be accurate with what I'm telling patients and cautious about not causing harm. I think that's great.

SPEAKER_01 30:39

Do you know? Are there any current studies going on in this space that you're you know of?

SPEAKER_02 30:45

So, yeah. So, in in the area that I'm um interested in, right? So there are studies looking at a medication called Doave ongoing, which um Carol Fabian is the main researcher. I think she's at the University of Kansas, but I just was at a conference with her, and she's hoping by December there will actually be real data at the SABCS meeting that she'll be able to present from that trial, really showing, again, there's some been some abstracts prevent presented and some small studies suggesting that that formulation that has that CEE that was in the WHI, plus another medication called vasodoxifine, that women can use that for menopausal hormone therapy, and it actually reduces breast cancer risk, right? We have animal model suggestions. Like I use a lot of that medication because it has a very good bleeding profile. It helps vasomotor symptoms. And in my women at high risk, with the data that I have, which is limited, I think that that's a good option for them if their baseline breast cancer risk is high, right? And so that will be something where I think the data will come out soon. Where there's lots of discussion in the breast space is again really trying to do a study. So Laura Esserman, who's um the head of the wisdom study, right, which is the study looking at whether or not we can use um modeling of a woman's breast cancer risk and then genetics to help us identify those women at higher risk to screen them differently than women at low risk. There's actually, I mean, work through her to be able to again use women at different risk levels and give them different formulations of hormone therapy so that we can actually see whether or not what we're using today with the estradiol actually is different, the same, better, worse than the CE that was used in the WHI.

SPEAKER_01 32:35

Well, that's awesome. I know you talk about do V a lot, and I I need to get better at that one.

SPEAKER_02 32:41

Yeah. So that is one that I would tell you. I think you should put in your toolbox and in the right patient, the right patient, consider that. Because again, even if you just use it for bleeding profile, like if you have your midlife woman who's spotting, bleeding, spotting, bleeding all the time, you just can't seem to get her bleeding to stop. Do a V is amazing in that regard.

SPEAKER_01 33:00

Awesome. Thanks for the tip. And um, another, okay, one of the biggest, I think, questions I get on hormones. I don't know if this is on your side too, but is the I need to check my hormones.

SPEAKER_02 33:12

Yeah.

SPEAKER_01 33:13

And how do you talk to patients about that and how it's not as simple as they might think?

SPEAKER_02 33:20

Yeah. So particularly in the perimenopause is often when women are still having irregular cycles and they know that things are changing, right? Like women will tell you when they're perimenopausal because they feel different and their bleeding pattern is changing. I mean, they just know. And the problem with hormone levels during that period of time is that they change day to day, frankly, minute to minute. And depending on, again, particularly in a woman who's having irregular cycles, you don't know exactly where she is. And you may get an estradiol level that's low and an FSH that's high and think that she's menopausal. And three weeks later she'll have another period, right? Like you just don't know. And one of the reasons that women feel so awful is because not absolute hormone levels, not levels, it's the range, it's the swing that they're having. And so again, I use the analogy with patients. It's like measuring a blood sugar when you're fasting or measuring a blood sugar after you've had a big Mac and fries, right? Like it's just gonna be different, even if it's a little bit elevated when you have had a Big Mac and a milkshake and fries. That doesn't necessarily tell you what your hemoglobin A1C is gonna be and whether or not you have prediabetes or not, right? Like, I mean, again, there's a range here. And in the perimenopause, it just a helpful, it doesn't help me clinically decide how to take care of the woman sitting in front of me, right? So the woman sitting in front of me is telling me what her problem is. Is it mood disturbance, sleep disturbance, intermittent hot flashes, decreased libido? Is it um bleeding is heavy, right? All of those things are going to be what influences me to how to treat her, not a blood test. In the post-menopausal woman, so a woman who hasn't had a period for, you know, 14 months, who's having terrible hot flashes, like I don't need to measure her hormone levels because I know what it's gonna be. Her estrogen is gonna be low and her FSH is gonna be high. Now, with that said, there are certain reasons to measure hormone levels. And there's a lot of talk about this on social media, which is um, you know, when women you prescribe a patch, let's say, and their symptoms don't get better, like a reasonable dose patch, you go up on the patch, you think their symptoms should get better and they don't. Well, there are those patients that don't absorb well through the transdermal patch. And so in that setting, I may check hormone levels to actually see if I can tell that they're absorbing it reasonably well. You know, the other circumstances in a patient who's had a hysterectomy where we can't use bleeding as a guideline, who's having symptoms, who's not sure where they are. So again, it's not that hormone levels never should be checked. It's just that the messaging that everyone needs to have their hormone levels to know where they are in the menopause transition just is not accurate.

SPEAKER_01 36:06

Yeah, I feel like when I explain that to patients, if I actually sit down and have that conversation about why this isn't helpful, I feel like they're like, oh, okay, that makes sense. And then I don't have to fight it anymore. So I think you if that's why I love what we do in concierge medicine, because we have the time to sit down and talk to people like I was I was actually gonna bring that one up.

SPEAKER_00 36:24

Like with your um because Dr. Larkin, how because obviously a lot of this is tough. You're deep you're having a deep conversation with someone. Has this were were you in this before getting into concierge? Um, so how was that transition? Yeah, because like you can actually have a lot of people.

SPEAKER_02 36:44

So again, I'm the square peg in a round hole, right? So I was 12 years in academics, then I was 10 years in private practice, 2002 to 2011, really nine uh in a traditional billing insurance, you know, in Medicare, running a traditional independent private practice. Sold my practice, went back into academics um in the OBGYN department for five years. And then it was really then when I left in 2016 when it was really clear. Like when I went back into academics, I thought I would retire there. That was my dream job, I thought. I really missed the teaching and the academics. But what became very clear, which is clear to all of us that do concierge medicine, right, is that the business model, particularly of doing primary care, and in my opinion, particularly doing complicated midlife women's health care, where there's a lot of education that has to happen and a lot of shared decision making, and it's time consuming. And the way medicine is funded and paid for in our country, is not by what you do with your brain, it's by what you do to people, right? So it's being a cardiologist and doing angiograms and a gastroenterologist and not that orthopedic surgeon and and and a medical oncologist, right? And not that those specialties are bad in any way, but you know, again, the payment model supports what they do to people. So when I was back in academics, I mean it was just crazy. I was, you know, really my ex the expectation was for me, A, to run a big women's center and see 26 patients a day doing a menopause and sexual medicine practice, right? Like complicated stuff and teaching the residents. There just was absolutely no business model that was going to support that. And so when I made the decision to leave, and again, I had run a practice for 10 years billing insurance, and I just could see the writing on the wall that if I really, and I have some guilt about this from a societal perspective, right? I believe that we as a country should figure out how to provide good quality health care to all of our citizens. Um, but that it was really, I was at the place where I said, you know what, I have to try to innovate from outside. Like I'm gonna try to do something different, and I'm gonna try to be okay with the fact that I'm gonna do a really good job and have more time to take care of the patients sitting in front of me, recognizing that unfortunately, because of the model that I have, this concierge model doesn't include everybody, which I do feel bad about. Um, but there just is not not a way to do it. And and again, my practice when I left academics in 2016 was really successful doing it this way. And I wouldn't go back. And that's why, truthfully, I founded Ms. Medicine to help other doctors like Lara and Jana, right? And and the other doctors in my network who, again, empowering female physicians to own their own businesses and to have a practice that's sustainable for the long term, right? Where they can feel really good about the care that they provide. Um, and that's how how I'm doing what I'm doing in practice myself and and how I got to Ms. Medicine.

SPEAKER_00 39:52

That's fun. Well, I and actually, just just and this is actually kind of a pivot, but it's a it's a good conversation on it. Um do you think the DP, because like now that DPC is coming into the mix, do you think that can kind of fill the void?

SPEAKER_02 40:05

Well, yeah. So it's interesting. I mean, you're smart to ask the question. And of course, Lara and Jana know this. I'm sure you understand this now as well, right? There are many concierge practices, including MDVIP, out there where they still bill insurance, right? So they charge a membership fee, but they still bill Medicare and they still bill commercial insurance. Direct primary care, the tenant of that is complete price transparency and outside of commercial insurance and Medicare. Now, DPC, compared to what we do in the model that we are in in Ms. Medicine, I mean, we're really like direct primary care in the sense that we don't balance bill, we are opted out of Medicare and commercial insurance. Our price point is a little bit higher, right? Than the standard direct primary care. But conceptually, it is the same thing, which is that, you know, and I feel really positive about this. I can tell you, when I when I launched Ms. Medicine in 2019, people told me I was nuts and I was leaving money on the table and that I was stupid not to continue to balance, you know, to build Medicare and commercial insurance because I was leaving money on the table. The problem is, again, I go back to it's not price transparent when you do it that way, right? Patients that have high deductible plans and get huge bills on top of the membership fee, you know, Medicare, it, you know, there's just it's questionable whether or not that gets you into trouble with balanced billing and all this kind of stuff. And I just really, really believe, and I believe today more than ever, is that the price transparency is the right thing. And I really believe in the direct primary care model too. Now, where the direct primary care kind of I think ties in, right, is when you really can have employer contracts with the DPC, right? So where a practice, Lara, Jana, in my practice as well, where you have a hundred patients of covered lives and you're getting a payment to provide that that is really price transparent. And I think that that really is the direction of the future, too, because um we should be able to deliver primary care much more cost effectively than we do when we bill insurance and Medicare. And, you know, and doctors that do a good job should get adequately compensated and have enough time with patients. Like we have to have a different model. And I do believe that the way that we're doing it at Ms. Medicine and the direct primary care is the way of the future for sure.

SPEAKER_01 42:36

I know I have I see so many some local DPC practitioners here, and they're always talking about the difference between conciers and DPC, and they always the difference is always that concierge still bills your insurance. And I'm always like, well, we don't.

SPEAKER_02 42:50

Like don't track that all on us. That's right. And so, and and there is a um DPC physician in Cincinnati, and he still pushes back on me that we're not really DPC because our price point is higher. Um, to me, and again, it's like semantics of language. Like, yeah, so I I say that we are DPC. We're we're direct, we're a direct care model, whether or not you call it concierge or not, we are direct care. We do not bill insurance, Medicare, or commercial insurance. It is what patients pay for. And I use the analogy, and I don't know how you describe it to patients, Lara, but you know, it's you're paying for my service, my expertise, what I do in the office with you, the same way you would pay for your attorney, right? Like it's you're paying, paying for their expertise, their training, their knowledge, their guidance, their whatever. And that the other procedure things, right? Your mammogram, your colonoscopy, your specialist stuff, you need to have physical therapy, right? Your insurance kicks in for those things. But for us, it is a completely price transparent model. You know exactly what you get, you know what it's going to cost for the year, no gain. Yeah, I love that.

SPEAKER_00 44:01

Yeah, it's always it's talking to my dad about it because obviously he he would have thought the the because obviously he won big in the in the 90s and 2000s as an international cardiologist. He he saw it, but like he thought the pivot, the pendulum was gonna swing back towards primary care and like the that really made and it just hasn't. And he's thoroughly surprised by like the and then when we talk about this, uh it's always fun because when we when I'm explaining DPC and concierge and all this kind of stuff, dad says the same thing. It's membership model and you know what you're getting. Yeah. It's just the price point and access. Okay, that makes sense. Yeah.

SPEAKER_02 44:41

Yeah. And um, yeah, for sure. I mean, again, I if we had a better plan for nationalized health care, some way that we had have a safety net. I mean, my husband is the ER doc now, would just I mean, he he has moral injury when he works now. I mean, it's just really, really tough. Um, he came home this weekend and was beside himself, right? You know, because health systems now are playing, you know, hot potato with patients who are not insured or are underinsured, who have bad diseases. Nobody wants them, right? And it's really not the way that our society should work. But I I just frankly don't know how to fix it. So, you know, I kind of have been just just making peace with I do the best I can for my panel of patients. And then I try to give back in other ways I can, which is, you know, my education nonprofit. That's kind of my way that I try to give back. We all do things differently, but you know, I wish it, I wish it was better. We have real problems for the next generation. You're young. I don't know, I don't know what healthcare is gonna be like for me in 10 years, never mind for you in 30 now.

SPEAKER_01 45:54

It's slightly terrifying sometimes, but you know, we'll get through it.

SPEAKER_00 45:58

And it's and coming coming from the physician's lens, it's always a fun one where people want to blame the physicians for this, and it's like it's so above their pay grade. Like they just they want to do good work, and yeah, it's uh it's a dumpster fire of it.

SPEAKER_02 46:13

It's a dumpster fire, it is a true dumpster fire.

SPEAKER_00 46:17

Well, and and the big one too is like the hard part in this whole aspect as we're kind of like just this kind of tangent, is um I've you just heard about like Manifest Health and Rick and Rick Abbott. I don't think she knows about it. And like um, I I find it fascinating where it uh so Rick Abbott was one of the top in command of priority health, and he left for this exact reason. He left because he was he was leading the corporate uh cash pay um insurance models, and he just saw his premiums going up by 20%, and he's like, this isn't gonna work anymore. And so he created a whole model with a couple other people where they're focusing and targeting all the specialties and main medical payment pro problems, your imaging, your primary care, your orthopedic surgeon, your your big boys that are all still privately owned by the doctors, not owned by the corporate systems, and creating basically an HMO, not HMO, to like kind of navigate better price, better access care. One of the things he did recently, and I just found fascinating, is he set up an event where priority for well every major organization was at this event with him and he was speaking of mission organizations, and he's like, At least I'm getting you guys all in the same room. And we're not, yeah, we're not here to say, we're not here because everyone wants to point one finger in one location, and it's like it's a complex problem insurance versus big corporate systems. And like, let's just but let's just all sit in a room and start talking this out and figuring it out instead of everyone just doing this.

SPEAKER_01 47:53

So there's people trying to make good change and see where it goes.

SPEAKER_00 47:56

And there's no reason that every single person, every doctor has to be the person that stands on the cross and like I I'm the one that has to take this and eat this. Like you can you can sit here and and do the best you can and help the people in front of you.

SPEAKER_01 48:09

That's what we try. Well, that was a great tangent. I had one last question, probably on uh more in the hormone side of things, because another I get a lot of women coming to me from other I don't know what these clinics are, but they're always coming to me on testosterone. And so that becomes a big conversation with people of like why are people taking that and who should actually be on that as a female?

SPEAKER_02 48:34

So are they on injectable testosterone or a lot of times?

SPEAKER_01 48:38

It's a lot of times injectable.

SPEAKER_02 48:40

Right. So um, I feel very strongly about this topic. So, first of all, let me preface by saying there is an indication for testosterone in women, right? We know that at the right dose um in um late perimetopausal and menopausal women, it can help desire. And so for sexual dysfunction at midlife, there is data about using dose appropriate testosterone. The problem is, of course, everybody wants a quick fix in the world these days. And the business of medicine is real, and injectable pellets and doing things to patients at these hormone centers is profitable. And so I see this all the time now, which is young 32-year-old women and 35-year-old women who have low libido are getting these implantable depot testosterone pellets early. So they are pre-menopausal. I certainly see it in the perimenopause and see it in menopausal women too. The issue with the pellets is it's it's like a little bit of a it's it is a game, right? You get the pellet. The first time a woman gets a pellet, she runs around and tells 1,000 of her friends that she's never felt better and they should all get a pellet. And the reason is it's real, right? In a woman who has never seen male dosing of testosterone, it they feel amazing. If they're having hot fleshes, their hot fleshes get better, their libido gets better. They do notice a little of fat loss and more muscle definition, right? This is this is a woman who at baseline has a testosterone level of 40 and now it's 1200, right? Like this woman feels amazing. Her orgasms are better, her libido is better, her energy level is better, she feels on her game. And really, the first pellet, it's a drug. Like women literally run around and tell every one of their friends to go to the hormone center and get a pellet. The problem is over time, and we know this, I have I have a transgender stepson, right, who's been on testosterone now for about three years, right? And again, we know that there are masculinizing effects of testosterone. That's what transgender, that's what my transgender stepson wants, right? Wants. And truthfully, now after two and a half or three years, I mean, you can't tell him apart from his brothers, right? In terms of the way he looks. And his dose, where we dose around, like his doctor keeps him around 400 to 600, right? These pellets, when they go in, women are getting, and women don't know that they're getting that high because the game is you get the pellet, it lasts three months, they feel amazing. Their level is really, really high. And then over the three months, it gradually goes down. And when they go to get their next pellet, they have their labs drawn the day they get their next pellet and they say, see, it's in the normal range. It's not that high, right? You're under 100. And they get the next pellet. So over time, right, each pellet doesn't have the same dramatic effect mood-wise, energy-wise. You develop what's called tachyphylaxis to that dose of testosterone. So you don't have the same euphoria anymore. Many women will then say, Oh, I need a higher dose. I don't feel as great. I want more, you know, this whole kind of thing. And over time, women start to have side effects that they don't want because they don't, they're not transgender, they're not trying to have the masculinizing effects. And they gain weight, their lipids are often higher, they get change in their facial structure, acne, hair loss. And the big thing that I've seen, I mean, I can put a woman up in stirrups and tell you every single woman who's been doing pellets for a while because they get clitoral, clitoral enlargement. And in fact, I had one patient come in recently who's like, ugh, just irritated all the time because it's rubbing in my underwear. Like I just don't feel right. And that was her thing. I had been trying to tell her that I thought she needed to get off pellets for a while. Um, and she's like, You're right, you're right, you're right. I need to get off. And the problem is for these women that have been doing the pellets for several years, they don't feel great when they come off, right? So it's really, again, this goes back to educating them that it's going to be a six-month transition and they have to hang in there, right? Because their brain has to downregulate the receptors. They have to get used to going back to their normal testosterone levels. And again, it's it's bumpy. Now, again, I prescribe a lot of testosterone, but at physiologic dosing for women for appropriate indications. But there is tremendous messaging out there right now about, again, preservation of lean muscle mass and body composition and other ancillary benefits of testosterone, which I don't believe there's enough data in at the doses that we should be using it, right? But um, again, if you're out there, there's people that would call me old school and that we don't have time to wait for the data. And, you know, that this is an area where there's disagreement. So what you're hearing is my professional opinion and the way that I do it in practice, which is dose appropriate for women. I never do pellets, and actually part of my consultative practice is getting women off pellets.

SPEAKER_01 53:55

Awesome. Love that. I think that's a hot topic, and so I think that's great to address. But in I think it is frustrating because I know you I think you've talked about this before, too, that there isn't a great women-specific testosterone medication.

SPEAKER_02 54:11

And that is a huge problem. And certainly it's one of the things that I do hope that we will see come out of kind of the push towards better women's health care. And will we, you know, now that the boxed warning is off the vaginal estrogen, which I think really is a huge win, can we get to the place where we have a dose appropriate female formulation that would be so helpful and a game changer, right? And I I do hope that we will get to that place. Love it.

SPEAKER_01 54:38

Any other questions you had, David?

SPEAKER_00 54:41

No, I was I was a fun little tangent. I was actually, I was like, I contributed. I will I will say one other contribution I've been learning uh from conversation with uh Lara is I'm always I used I always say hormone replacement therapy, but I've been told constantly it's not hormone replacement therapy for women. It is uh menopausal menopausal hormone therapy. He's learning.

SPEAKER_02 55:07

Here's the interesting thing, and I know good for you for learning, but since the label change, even McCary has gone back to the hormone replacement uh HRT language. And that's again, it feeds into the what we used to believe, right? The feminine forever, the longevity medication. You can't live without it. You gotta be, and and I don't, I don't think that's the right messaging, but that's out there now too. So as much as you're correct and Lara's correct, which is it should be MHT, menopausal hormone therapy. We should use it for the correct reason in the correct patient. Um, yeah, that HRT has been come back again like gangbusters. Keep trying.

SPEAKER_01 55:50

Well, um, any last uh comments you have, Lisa, or things you want to plug or anything from you at the end?

SPEAKER_02 55:57

No, just plug you and your sister. Thank you for all the good care you provide to patients. I love seeing all your stuff on social media. Keep up the great work with all the great exercising. I'm so impressed.

SPEAKER_01 56:10

Blow the way. It's amazing. We do what we can to practice what we preach around here. But I think um you said it really well in the middle, somewhere where medicine is complicated. And I think that's the important thing that I think a lot of people need to remember is that there is so much nuance to this, and it's not as simple as what social media sometimes portrays it to be. Yes, that's correct. So and thank you for starting Ms. Medicine. So that I'm able to do it.

SPEAKER_02 56:39

Thank you. It's gonna be fun. So the time.

SPEAKER_01 56:44

So we'll uh we'll see.