Transcript of Menopause and Heart Disease: What Every Woman Needs to Know with Dr. Jayne Morgan

Women, they're more likely to be admitted to hospitals for heart failure and three times as likely to die. That's why we need sex-specific, gender-specific research. Men and women are biologically different. Just like all of those women in my training where I knew something was going on, but I kept asking my professors, and they assured me that I was insane, and no, this is what the books say. Follow me, and I'm following the authority figures. Here's another great example love, we just got it wrong. The views and opinions expressed on Unpaused are those of the talent and the guests alone and are provided for informational and entertainment purposes only.

No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. Unpaused is not just another women's health podcast. It is a place to have bold, unfiltered conversations about what it really takes for women to thrive in the second half of life. Dr. Jane Morgan is a research cardiologist and the vice President of Medical Affairs at Hello Heart, where she's helping to shape the future of digital heart care with a special focus on women's health and equity. Dr. Morgan openly challenges the silence around menopause and workplace cardiovascular health. She is tireless in her messaging that menopause-related heart risk is virtually ignored and yet is a critical period for prevention. When I first heard Dr. Morgan speak at a menopause conference in New York City, it was the first time I had heard a cardiologist frame menopause as a risk factor in cardiovascular disease. I was riveted. This was information that is crucial to the health of every woman, and yet it's a message that still isn't being fully received. Well, I heard it, and this knowledge changed my life and how I counsel my patients around cardiovascular risk and disease.

So I am extremely happy to be here with Dr. Morgan today so we can go deep on women's heart health.

Thank you, Mary Claire. This is the first time I've heard that that was the first time you had heard it when I was there at that conference. So that really gladdens my heart.

So tell me why you went into medicine.

Why did I go into medicine? So when I grew up, most of my neighbors were physicians. My best friend lived across the street. Her father was an orthopedic surgeon. The guy lived next door to me. He was a family practitioner. One on the other side was a dermatologist. On the other side of him was an orthopedic surgeon. We were jammed in between all of these doctors. I think I grew up not understanding that doctors really in my community were rare because I was surrounded by lots of doctors. And so my friend Gina, who lived across the street. We played often at her house, and we would play on rainy days down in the basement, back when kids actually played. We didn't have all of these electronic games. And I would sneak into her dad's office and pull out his books with all the weird pictures. The anatomy. And I would look through them. It was just so fascinating to me. And then when he would come, we would close the books and throw them back on the shelves and run off so he wouldn't see them. But I think that started to foster my interest.

And believe it or not, I actually wanted to be a nurse because even though I talk about all these doctors in my neighborhood, they were all men. And I think in my mind, I thought men were doctors.

Daddies are the doctors.

So I wanted to be a nurse because of all of these physicians around me. And it really wasn't until high school until maybe a teacher even said to me, Why don't you think about being a doctor? And it's amazing the power of words. Literally someone speaking it to me was the first time I questioned, Why don't I become a doctor? I had never thought about that. And I couldn't think of a reason why I couldn't be a doctor. And it's interesting how you are socialized. I didn't realize that I wanted to become a nurse because of the socialization of the culture. Men were doctors and women were nurses. It was only a teacher challenging my thought, and I couldn't come up with an answer.

Why did you pick Cardiology as a specialty?

So I picked Cardiology because I went to medical school to be an orthopedic surgeon because that's what the doctors were in my neighborhood. I was going to be a pediatrician.

That's right.

And you know the story. You go in with one thing, you come out with something else. So by the time I graduated, I had no idea what I was going to do. So I did an internal medicine residency. And doing my internal medicine residency, rotated through ICU and CCU critical care units and really loved it. Now, I chose Cardiology over critical care because something else I learned in my residency, I don't really like phlegm. I don't like the sound of phlegm and the suctioning and the hacking and all that stuff in the ICU. I like the cerebral part. I I like taking care of the patient. I did not like those sounds. In fact, I would stand at the bedside and I would be trying not to throw up while they were suctioning the patient. The same reaction. I was like, Okay, drawing a line through this one. So I went over to cardiologist. Cardiology. So, yeah, that's how it ended up. Loved Cardiology, but that's how I chose it over critical care. It was not this phlegm.

Yeah, not for you. This phlegm situation. Every time I think of taking care of patients in the ICU, the sound of the suction, I was like, This is not for me. So let's dig deep. Heart disease is the leading cause of death for women. Most women don't realize that. Responsible for one in three deaths each year. And in 2024, the American Heart Association found that. They did a survey, and only 44% of women recognize heart disease as their leading killer. That's right. Down from 65% in 2009. That's right. So in the last 15 years, what do you think has happened that women don't think that they're going to die of a heart attack?

We're just dialing it backwards. But I'll tell you what has really happened is the success of the marketing campaign for breast cancer, Susan G. Coleman. And kudos to them. They've been very successful in raising the awareness of breast answer, to the point that now women think that this is the number one cause of death. But also, when we talked about culture and socialization, back to when I wanted to be a nurse and didn't even know why I wanted to be a nurse, I had already had decided that the socialization is that women's health is reproduction. That's all it is. It's just reproduction. It's nothing else. And so, of course, women would galvanize to that message about breast cancer and breast health because women's health is reproduction. It's not about anything else. And so Susan G. Cohen and the Breast Cancer Society have been very, very effective in making certain that we're getting mammograms It is also spilled over to a decreased rate in cervical cancer. We're getting PAP smears. All of this around reproductive health has been very successful. What that means is the message about the rest of our bodies has been lost. So the good thing is we see breast cancer decreasing, cervical cancer rates really decreasing.

The number one thing that's actually killing us, though, is still there.

It's still there. So cardiology training, what I've heard from other cardiologists now that I'm interested in, like female-specific specific heart disease, still seems to focus on the male model of the disease. Stacey Sims says it well, Dr. Sims, of women are not small men, and she really focuses on exercise physiology. But I see this repeated throughout multiple specialties. I trained in a bubble. I just took care of women, and the only penises I saw were baby boys, and I handed them back to their mothers after we delivered. And so it's fascinating to me. So you as a cardiologist, what are the discrepancies you see that you trained with?

I also trained in a bubble. And we need to get out of these bubbles. I know this is an aside. And it's part of what I work on with Resolutions with the Medical Association of Georgia and the state legislature, is that there's got to be cross-talk and cross-communication. So for me, I did internal medicine residency, Cardiology Fellowship. I really didn't know where the OB/GYNs were in the hospital. They were usually somewhere on some other side that we always, we refer to it as the happy side. They're over in the happy hospital, delivering babies and things are fun and everybody's happy. It's called labor and delivery. You had your own entrance to the hospital. Cardiology just never went over there. I mean, if a cardiologist had to go to labor and delivery, there was something seriously serious. Something's going down here.

We were calling cardiology for cardiomyopathy.

So you're coming in for an emergency. You're not coming in to be an integrated part of the team. So we all worked in these silos. Now, what did I notice during my Cardiology Fellowship is that women tended to have more atypical symptoms. It seemed to me I was always describing and dictating and charting women with these atypical symptoms. And it occurred to me, because oftentimes we really would send these women home. And it occurred to me, especially when some of them will return later and really have serious myocardial infarctions and serious events had happened, that I thought, why is this term... It wasn't a apply to women. It wasn't because of women, but women seem to be the ones encapsulating this term, this atypical, which meant really we weren't really acting as aggressively. That's actually what it meant. It just meant maybe it's a heart attack, but probably not. It's probably another hysterical woman. It's probably a panic attack, because generally, after atypical symptoms, it would say, rule out panic disorder, D/C.

Did you ever They almost never dictate that same sentence about a male patient?

We almost never ruled out a panic disorder in a man, right? In an emergency situation. But a man is coming in with the symptoms that are described. But the fact of the matter is, I began to notice during my Cardiology Fellowship that women didn't have these symptoms as often. And then I started to wonder, are we missing people? What's happening? And oftentimes in training, you're seeing people for a period of time, and then you're going off to other There were specialties and areas, and I wasn't really getting the follow-up. But it was a question that started to be placed in my mind. Even during medical school, I started to even question different things when we looked at races and dermatologist And I would ask, But what does that look like on dark skin? And people wouldn't have an answer. They would say exactly the same. I would pretty much know, I pretty much think it's not going to look the same. But I couldn't get any answer. I had these questions all through medical school, all through training. But nobody could give me answers because the people who are teaching the courses are the people who are driving the behavior and driving the culture.

And so I couldn't get the questions. And you're powerless, you're young, you're trying to listen to all the people who know so much more than you do. Right.

I had the same phenomena. Maybe. I'm a good girl. I check the boxes. I follow the guidelines.

I did everything. In my training, I was noticing these things, but I couldn't challenge the authority. Right. I actually didn't even want to challenge the authority. I asked, and I got the answer. The answer was, No, Jane, you are imagining these things, and we know best. We wrote the textbooks. We are teaching this course because we are I want five professors to be here. And I just left it at that. But you know, it's funny how the mind works. It just keeps bothering you. And the more you think about it, the more you start noticing it. You notice it again, and you notice it again. And then you ask somebody else, maybe Somebody different has a different answer, and they're giving you the same answer. It never occurs to you. Even though I'm asking different people, I'm asking the same person who's still from the same system, who's still from this same mindset. And how do we break out of this? And so then I started to think, well, the best thing I can do is just give care to my patients. And you're just determined to treat your patients. But at some point you realize, what about all the others?

Especially when your patients would say, oh, my God, You're the only person who's ever told that to me. You're the only person who said that to me. My mother died, and I started to hear these things, and I just didn't know what to do. I did not know what to do about it because I was told I was wrong. I didn't read anything that said I was right. And yet I've got this feeling, these experiences, your instincts, your ability to apply sound reasoning that has been taught to you. Now you're actually applying it, and it's coming up with an answer that is against the system, with the reasoning that you were taught. And so, again, the more you see, the more you think about it, the more you think about it, the more you notice, the more you notice, the more you ask questions, and you're in this vortex.

So when did you decide to take a stand?

I never actually made a decision to take a stand. I think it's an evolution of teaching my students and teaching interns. And I would start to give this different perspective, and here are the things you need to think about. This is not in the textbook, but here's what I've noticed. And I want you to have your antennas up for that. Nomenclature started to bother me.

For example, so for our listeners.

Pregnant patient, 35 years old. Me, they called me a geriatric patient, which, of course, I knew that because in training, you're called geriatric. We call the patient's geriatric until you get called the geriatric patient.

Yeah, at 35.

I remember going home to my husband going, Oh my God, I have become the geriatricPregnancy. Pregnant lady that I dictate. And all of a sudden, when it became me, it was wrong. This is not right. I should not have to go through my pregnancy with this label. That was actually the first thing. So the word atypical always bothered me in cardiology. Then when I got called geriatric, it didn't bother me when I was calling other people geriatric. I just charted a 35-year-old geriatric female. When I got called it, oh my gosh, the world changed for me. I was shocked. It increased my anxiety about my pregnancy. I worried about things that were going to happen that I didn't worry with my earlier pregnancies, the whole thing was not fair. It was unfair. And what was unfair about it as well was that I had also applied that label to other people. And psychologically, it was impacting me, and it was impacting my pregnancy, and impacting my enjoyment of my pregnancy. I was less stressed with my first two pregnancies. All I could think about were all the things that would happen to older pregnant women during my pregnancy, and every single symptom I had I, I perseverated over it, and I worried about it, and I stressed.

And there's nothing magical about being 34 and then 35, right? Hated that. That we just stick a label on women at the age of 35.

We do. And then I started noticing things like, the incompetent cervix. Why are women incompetent? So after you open the box, you can't put everything back in. Now you're hearing all of the terminology. And I just said, oh, my gosh, there is just no way women are getting good health care because we are driving thought by the words that we're using, and words are just so powerful.

So let's go back to atypical. When we talk about heart disease for our listeners, we're basically talking about atherosclerotic disease. So plaques in the coronary arteries that then lead to blockages. And if you don't feed the heart muscle, it doesn't like it, and it tries to die. And that's basically a heart attack. So let's talk about how heart attacks show up for women. These atypical symptoms. And why is that different? Why do men and women show up in the ER with different symptoms?

What you know of as, and your listeners maybe, as a heart attack, this crushing chest pain. We see so many times on television and in the movies, crushing chest pain. They clutch their chest. They have an elephant on their chest. There's a weight. They are short of breath. It's a sudden event that is not to be ignored. You may collapse. You may lose consciousness, right? Everybody calls 911. We may start CPR. It's a whole situation. Women, actually, they just maybe feel a little run down, feel tired. You're feeling fatigued. And women often do so much. Caregivers, running, children, spouses, all of these things. You have a million excuses, rightfully so, for why you might be fatigued. Fatigue isn't going to drive you to the hospital because you're having a heart attack. It should, but it doesn't, because there are any number of reasons that a woman could be tired. In fact, she's just working so hard for everybody else. Just tired. So the other thing, you could have just flu-like symptoms. You just feeling run down. You just can't shake the flu. Gi symptoms. You're feeling nauseous. Do you go to the doctor soon to feel nauseous?

No. You might take something for it. You might lie down. You may do all of your home remedies, whatever it is you're trying to do to control your nausea. You think about what you ate. You ask other people, are they feeling nauseous? Did you have the pees as well? You just go on and on and bite. Nobody ever tells you that nausea might be a symptom of heart disease. You get jaw pain. And sometimes the jaw pain is actually the one thing that will drive you to seek medical care, but it will send you to the dentists more often. And you will go to the dentists to say, Have that tooth looked at. Something's wrong. My jaw is hurting. And I'm actually going to be giving a talk at a dental society in November and going to talk about the recognition that dentists should have. And after they've done their oral exam and it's not a tooth issue, the conversation should be now directing that patient to the hospital, to the emergency room, to a cardiologist. And not just, It's not your tooth, ma'am. See you later. See you for your six month, your checkup.

She might be having a heart attack. That's right.

And that's the connection, hopefully, that I'll make for the dentist next month. But those are the kinds of symptoms that we relegate to- Are typical for women. Are really typical. But they are actually typical symptoms. These are the symptoms that come in and we say, rule out panic disorder. Atypical chest pain rule out panic disorder. Basically, we're telling the entire system that this woman's not having a heart attack and that she's just an emotional wreck. That's really what we're saying to the system. Now, what has been our saving grace? Cardiac enzymes. If we're lucky enough to get our blood drawn and those cardiac enzymes have bumped, finally-And what's a cardiac enzyme? A cardiac enzyme is when your heart is releasing a certain type of enzyme after it's under distress. Okay. So we call it troponin. Sometimes troponin is one of those enzymes.

And that's a blood test that's done?

It's a blood test. In the emergency room, we will measure the blood test, oftentimes sequentially every six hours to see if they rise. But if those numbers increase, that's an indicator that your heart is dying, is under oxygen deprivation, and that we need to do something.

Heart muscle. So there's specific enzymes inside of heart muscle that as the heart muscle is dying or trying to die, the cell, correct me if I'm wrong, will pop open and the enzymes will spill out and we can measure those in the blood.

We can measure them. And the higher the enzymes, the more severe the the damage is, the more stress, distress the heart is under, which is why we will measure them sequentially three, maybe over 18 hours, because when you first come in, they may not have bumped. So we may measure them a second time. We want to measure them. We call it rule out MI, rule out a myocardial infarction. So that would be the woman saving Grace. But let's think about that. We've got to wait for those results to come back. So while she's waiting, the man who came in with his big symptoms has gone off to get his artery opened in the cath lab. The woman's waiting for her labs to come back.

And a psych referral.

Right. Because she might be having a panic disorder. That delay is critical. That delay is the difference between not only life and death, but the difference between whether or not you can be restored back to full quality of life or whether you will have some deficits.

We're going to talk about the numbers. So women are far more likely to be mismanaged in the emergency department when presenting with heart attack symptoms. One, because we're trained, chest pain, shortness of breath, radiating down your left arm, where women are coming in with fatigue, abdominal symptoms, just very nonspecific, these atypical symptoms. One study found that women under 55, so younger than me, were seven times more likely than a man to be sent home from the ER while actively having a heart attack. Yeah.

Isn't that crazy? It's insane. And I'll tell you what's even more insane is that it's not that women don't recognize our symptoms. It's that the health system doesn't recognize them.

That's it. I don't want to lay this at the- So it's like a double- Yeah, we're not teaching women.

We don't teach women, and we don't even teach our doctors. So nobody knows. So the woman comes in after she's delayed her fatigue and nausea for a week or two. Finally, she can't take it anymore. She's She's done all of her home remedies. It's not working. Everybody's eating the same food. She doesn't know why she's nauseous, blah, blah, blah. She comes in, and then you get to the health system. You think they're going to jump right on it. No, they're not. You're coming in with nausea. You probably will sit in the waiting room because for someone who's more critical and more acute. So it's a double-edged sword, and we're getting it from both sides.

One of the things I've learned in the last probably two and a half years, which was never taught to me, was these symptoms are different because where these blockages occur are different. So explain to our listeners the differences between where the blockages occur in men and where the blockages typically occur in women.

Men, when we have these symptoms, this sudden onset of chest pain and shortness of breath, it's because there's a blockage in one of the main arteries that is feeding the heart. The widow maker. And a widow maker is very specific. But it can be at any of these arteries, but it blocks the artery, and therefore, It blocks oxygen immediately from reaching the heart muscle, and the muscle starts to die immediately, and you get these symptoms. Now, women, what happens to us? Our arteries are a little bit smaller, and we generally don't get this one big blockage. Think of it like a big ball that comes through and just gets lodged. We end up with a studied pattern of plaques. So atherosclerosis, those are plaques, like fatty plaque deposits. And we just get them studied along the arteries. And so blood can still go through, but it's meandering. And so over time, you have decreased blood supply, which means decreased oxygen supply, but it's not cut off entirely. So there are certain situations where you might feel worse, for instance, eating, where now blood is being driven more to the GI system, where you now will feel chest pain when you're eating because these blockages don't completely close off the artery and blood is able to get through.

And when I say blood, think about oxygen because oxygen is being carried in the blood. And so we get these vager symptoms.

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A couple of things. I would say it's still an appropriate diagnostic workup for women.

The stress test? The stress test. Okay. And so for our listeners, the stress test is we do something to stress the heart, put you on a treadmill or give you a medication that'll stress out the heart.

And the reason that I think is still a very valid test is because of what I just described. We've got this studying in the arteries where the woman is not symptomatic all of the time, but when her system is under stress, and even eating can be stressed because the blood can then be redeployed elsewhere. So when the body is under stress, then you get those symptoms. So a stress test would actually bring that out. If you've got just this studying, and if we do something that further decreases that blood supply, we'll be able to see if it's a change. There's definitely still a place for stress testing there and nuclear stress testing. Women also get something called microvascular disease, where we don't necessarily have blockages in these main arteries, right?

And they're harder to find.

That's right. They're much harder to find these microvascular capillaries studied. And oftentimes, this is what we see in women who still have chest pain, who are still complaining of symptoms, who are still complaining of feeling unwell when all of their cardiac workup has been normal. But the cardiac workup is looking at these big vessels, and those big vessels are more often impacted by men. Long way. We have a long way to go. Because even microvascular disease is still poorly recognized.

I've only heard of it in the last two years, one of your talks. And I'm like, Wait, what? We have diffuse microvascular disease instead of these big LADs or the larger arteries.

We can have that, but we-We can't.

But it's... Yeah, that's right. We tend to trend that way. That's right. All right, so let's talk about these risk factors. What are they? So you have a woman coming to your office, and she's 50 years old and says, Am I at risk for heart disease? So what are these risk factors we're going to talk to her about.

Yeah. So she's at risk for heart disease just based on her age. So let's start there, just at 50. And these are the conversations that women don't have. And oftentimes, they come in and maybe they, are feeling fine. You know how we always say that? If there's not something major going on with us, we say we're feeling fine. How are you feeling? I'm feeling fine. When really there are about 75 things going on with you that you haven't been able to figure out. And so what needs to happen is that doctors need to begin to probe women on any number of perimenopausal symptoms. The reason is not because it's bothering a woman to the point that maybe she wants to have some intervention. Every perimenopausal symptom is It's pretty tolerable. Is not intolerable. However, it gives an indicator, and it's a marker of an increased risk of heart disease. And that's why the question should be answered. You certainly also want to provide relief if she's suffering and is uncomfortable. But the other reason to ask is to try to get a determination about where she is in her heart health risk, because we know that prior to menopause, a woman's risk of heart disease is less than a man.

Than half that of a man. Not half, it's less. And then once she reaches menopause, it equals that. And then by the time she's in her 70s, it actually surpasses. And so what is happening during this time frame, where we're completely ignoring women. And the symptoms are good indicators of the fluctuations of the estrogen levels. It doesn't mean that your estrogen is just going straight downhill, but it could be fluct. And it's actually those fluctuations that are causing all of these different symptoms because So what specific symptoms are you referring to? So any number of symptoms, and people may not know, and I'll tell you what mine were, itchy ears. My ears just started to itch. Literally one day, my ears were itching. Now, I live in Georgia, big allergy person, so I assume that they were allergies. Didn't do anything other than, all of a sudden now, every single morning, I have to take a Q-tip and scratch my ear. And at first you think your ear's dirty, but your ear is never dirty. The Q-Tip is perfectly clean. You just have to scratch every morning, and then it would go away. So that's...

This is a great example. It just became a part of my morning routine. You don't think about it. It itches, you scratch it, it goes away. Yeah, most women...

That's a viral video for me is talking about itchy ears in perimenopause and menopause. And for the listeners, in menopause, we lose the ability, the trans epidermal water loss. We lose a tremendous amount of fluid through the skin. We lose collagen, and we lose oil production. So that makes dry, itchy skin, and all of that gets into the ear canal, and it's unbearable. You can't scratch in there on a regular basis to relieve that itch. And so that is one of the signs. Talk to me specifically about hot flashes. And most women don't realize that is tied directly to cardiovascular You know what's interesting is that at the American College of Cardiology Conference in 2024, they presented a paper looking at the number of hot flashes that a woman has.

They looked at the number from one to six in a week. And I know some of your listeners are screaming, In a week? I have six in an hour. I'm just telling you how the research was set up. So they looked at hot flashes one to six in a week, and they measured the carotid artery. So the carotid arteries There are two big arteries on either side of your neck that feed the blood to the brain. They feed oxygen to the brain. And they looked at what we call C-I-M-T, carotid intimal media thickness. That's a big term that basically just means we just were trying to see if the arteries were narrowing or not, whether they were getting narrower or not. And so when they looked at this, and they looked at the women who were having the most hot flashes, so six per week, they actually had a greater narrowing of their carotid the arteries, the lumen, the inside, than those who had one hot flash per week. And what that means, the interpretation for physicians is, as your carotid arteries narrow, your risk of stroke increases. So what inherently that paper was telling us was that women who had more hot flashes had a greater risk of stroke.

And then we went on to talk about what that means for heart disease and the narrowing of our our arteries as well with these numbers of hot flashes. And so it became clear that, as I often say, hot flashes are not just like, Ha ha. We see people, we laugh, we give them a fan, we see them take off their jackets, everyone's sweating, it's It's funny. Oh, she's having a hot flash. Actually, what this woman is screaming at you is, My risk of heart disease is increasing. My risk of stroke is increasing. If you look at it that way, it's not Ha ha. And women literally are sweating to tell you, please do something. My risk of heart disease is increasing. My risk of stroke is increasing. And so that's why it's incredibly important to continue to do this research, to make certain that we understand, again, connecting the dots. It's not all about feeling comfortable. It's not the complaining woman. Women have had hot flashes for centuries. Why? Is it a problem for you? Well, here's why it's a problem for me. It's a problem for me because it increases my risk of heart disease and stroke.

And I'll tell you something, when you talk about our ancestors and centuries, we didn't really live that long. Exactly. Mostly because we were dying of heart disease and stroke. And heart disease is still the number one killer of women. And heart and brain health are also closely interconnected And so what's happening to my heart is happening to my brain, and what's happening to my brain is happening to my heart. Thank you very much. Yeah.

Let's play a wishing game. You mentioned research. I've heard that the philanthropist, Melinda Gates, has committed $100 million to women's health research. Research. So if I wrote you a check right now, what would you... And particularly for areas like cardiovascular disease and menopause, what would you build?

I would design a study, probably looking at specific hormone levels and fluctuations and arterial disease, and not only the arteries of the heart, but also the vasculature of the body. And I think I would look to draw direct correlations between hormone windows, not necessarily what the actual level is, but the hormone windows, because they can fluctuate and dark line towards increased risk of heart disease, increased risk of stroke, and what that means. And I think so far, that's what we are missing in in this whole cardiology, menopause, women's health world. And quite frankly, it's not our fault. The reason we're missing it is because we're not included in clinical trials. And since we're not included in clinical trials, we don't get therapy for the things that we need. We just extrapolate data. And we really do harm, not only to women, we do harm to populations of color. We do these clinical trials, mostly on white men. The majority of research is done on them, and we just extrapolate it to everybody else. So the only thing we really know is that the drugs and devices work in white men. That's the only thing we can absolutely say for sure.

We don't know about anyone else. I just came from the European Society of Cardiology conference in Madrid this year. Fascinating and tragic paper presented, Looking at beta-blockers. Now beta-blockers are a type of blood pressure medication that we've used for decades in in cardiology to manage people after they've had a heart attack. It's supposed to prevent you from having another heart attack. All the trials have supported it. Of course, all the trials were done on men. Turns out now in the paper that was presented that when beta-blockers, these same medications are given to women after they've had a heart attack, they're more likely to go on to a second heart attack, more likely to be admitted to hospitals for heart failure, and three times as likely to die. That's why we need sex-specific, gender-specific research. Men and women are biologically different. And just like all of those women in my training where I knew something was going on, but I kept asking my professors, and they assured me that I was insane, and no, this is what the books say. Follow me, and I'm following the authority figures. Here's another great example of we just got it wrong, and we've got to begin to do research with women in them because we're killing women in a well-meaning fashion.

Right. No one We're simply applying information without knowing it. And I'm going to just defend my profession for just a moment. Doctors, like myself, have no idea where these drugs come from. We train, we teach. Our job is to learn what the medications are, how they act, what their physiologic purpose is, any side effects, what their interactions are. It never occurs to us to say, Hey, I wonder where this came from. And how did the research even get started? And how was the original compound?

How many women were in the trial?

How many people were in the trial? Nothing. Even for me, I didn't begin to think about that. I was definitely more of a mature doctor, and had started doing research. And as I started to do research, and we were enrolling in trials. That was the first time it occurred to me. Research now is big for students. But when I came along, we didn't really do research. No, me neither. The only the weird nerd who was getting the MD PhD was doing research. We didn't. The rest of us were studying clinical medicine. So So in defense of my profession, we assume that when we get an FDA-approved drug, and they tell us that it can be used on men and women, that in fact, it can be used on men and women. But now we know that that is not true.

It feels like the bad news keeps coming. Women are more likely than men to die after a first heart attack, more likely to develop heart failure after a heart attack, and more likely to be disabled by stroke. And you talk about, We've tolerated this, I've been seeing for a long time, but I'm really excited to hear your voice, other voices, really starting to point this out. I mean, and I live in the in the Miniverse. Yes, you do. And so my social media shows me a lot of menopause content, and I'm seeing more and more clinicians stepping forward to say, This is not okay. What changes do you see in your world and your social media? Like going to this conference and this paper being presented.

That is so critically important. American Stroke Association Association last year for the first time included Menopause Guidelines in the Stroke Association. Hello. We were so happy to hear that. That was just incredible. The American Heart Association this year has included for the first time pregnancy guidelines. And your listeners may say, what's the big deal about pregnancy guidelines? The big deal about pregnancy guidelines is that they showed up in the Cardiology Guidelines. What's the big deal?

Yeah, so if you have preeclampsia or pregnancy-induced hypertension. That's right. You are at increased risk. And if you're not screening your patients for this, you're going to miss an early heart attack. That's right.

Not only are you going to miss it, but- Or a window for opportunity. The window of opportunity. We talked earlier about all of us trained in these silos. There needs to be cross-talk because pregnancy complications are risk factors for heart disease. That handoff doesn't happen often. The integration of a cardiologist onto the team doesn't happen. Education to the patient doesn't happen. She has declared in her pregnancy that she has failed the stress test. And then for some reason, the system doesn't follow up on her failed stress test. She just goes off to have her heart attack. So that's why it's so exciting that for the first time, pregnancy is in the cardiology guideline. And here's what's going to be interesting. We are more immersed in this, and we talk about it a lot. But most cardiologists will have never, ever heard of this. Why is pregnancy in the guidelines? What is this? But when they even finally get around to reading the guidelines.

To reading the new guidelines, yeah.

Because everybody's busy. So the academicians will learn of it first. They're reading, Oh, what does this mean? But that's the scary part is that...

How long it takes to propagate.

How long it takes to get the information out. But getting it out and getting guidelines is at least the first step. And to see something that's considered obstetrics in the cardiology guidelines was just huge. So finally, hello. This is a cardiology issue. This is not just an obstetric gynecology issue. That's them over there in the happy land, over in the L&D. We should be involved, and we need to understand what women's health is all about. It's not just reproduction.

So let's talk about statins, specifically in my clinic, and this holds in the data. And something I did not understand about menopause is the effect on cardiovascular respect, or specifically lipids. So there's about a 20% elevation of LDL, and APO-Bs, they're getting more data about it. So talk about all these patients are coming in. My doctor told me to get on a statin because my cholesterol is elevated. And I feel like there's a gap on the cardiology end because they don't understand where hormones are, what the play is here. How would you counsel that patient?

A couple of things. I'm going to come at this, so it's from a number of angles. I'm first going to start with statins. Statins Statins are underprescribed to women, underutilized, underdiscussed, especially when we talk about men. Women don't get the same information on statins. Number two, we talk about statins. There has always in information that makes people wary of using them, and mostly because of a U-shaped curve where there is the lower dose is effective, and you get to higher doses, it might be toxic. And then if you mix in Menopause. And nobody really understanding it or talking about it, and doctors have no idea what's happening with the woman in front of them, and not understanding that cholesterol levels are rising because estrogen levels are dropping. There's not a big comprehensive focus and picture on it. So statins aren't discussed, estrogen is not discussed, menopause is not discussed. It's just not discussed. And off she goes, Try to lose weight. You should exercise.

Why don't you take a vacation? Tired advice.

Right. The same old thing. Have an antidepressant. It's the same old thing. And yet there really are options. Now, other thing is, I sit on the steering committee for LP Little 8 Therapy, for Novartis.

What is LP little a?

So LP little A is a genetic type of cholesterol that is actually more deleterious than LDL, which is what we call now the bad cholesterol. I hate these labels, bad and good. But the LDL, it's LP a that drives a lot of the genetic components of heart disease, because really, 80% of heart disease is preventable. There's only 20% that's some genetic component to it, some congenital anomalies or LP little a. The rest really is all lifestyle, behavior, choices, lack of medical information, lack of medical curiosity. And so when you look at Lp. A, when we talk about people with elevated cholesterol, it's something that women should measure, certainly if you are either black, African-American, or Southeast Asian, but it's still actually fairly common in the white population as well.

I do see it in our eyes. Check it on everyone. You should.

And so when we look at LP a, part of the reason that we haven't checked it in the past, and here's a little secret for medicine. The reason we haven't checked it is that there really isn't any therapy for it. There's nothing we can do about it. Here's one of the little dark secrets of medicine. We don't really like checking for stuff that we can't treat. We can't fix it. So why look for it? Because what am I going to do about it later? But here's the thing. You actually can do something about it. We can aggressively intervene, driving your LDL down very, very low, trying to get your HDL, the good cholesterol up, making sure your blood pressure is at goal or below, working on your weight. If you have diabetes, getting it under strict, strict, strict control. If you're smoking, quitting, if you're drinking alcohol, stopping, all of these things to actually decrease your risk. And again, diet, Diet, diet, diet. What kinds of foods are you eating? How are we going to adjust that? And then what's happening? So on Novartis, I'm on the steering committee of this, we are bringing forward a drug called Pelacarcin.

It looks as if as we are rounding out our phase three trials. I just looked at this data, this will be the first therapy that comes to market that is a treatment for LP a. Now, here's a couple of reasons why I bring that up. Speaking of women's health, we really don't know what's going on with LP a either. Here's how we're taught. Lp little a doesn't change in a lifetime, and you only need to draw it once. I'm challenging that personally, and I certainly have these discussions, because when we talk about women in menopause, you're making that statement without any information at all. We have no idea if LP little a changes during perimenopause and menopause. And so we actually do need to draw it more than once in women. That's the world, according to Dr. Jane Morgan, that women should have your LP little 8 drawn prior to menopause, and then it should also be drawn during perimenopause, and maybe even a third time on the other side, and get an idea of whether or not this value does change in women because The data that we have, via which we make the recommendation that Lp a is a once in a lifetime blood draw was based on men.

And we're just applying it to women.

So let's talk about hormone therapy and cardiovascular disease. Has hormone therapy shown reductions in cardiovascular mortality in women?

So when we look at this, go all the way back to the women's health initiative. And you know what was both interesting and tragic about this study is that there was a cohort of Black women in the study, all of whom had had hysterectomies for any number of historical reasons that Black women are advised to have hysterectomies more often than White women. This group of women, just They were not their own cohort. They were just in the trial. The whole women's health initiative just went off the rails. When we go back now and look at it and actually look at just the Black women, most of whom had had hysterectomies. And so they were on estrogen only? They were only on estrogen. This cohort that had really been abused by the medical system, they were there with their hysterectomies, like so many black women, were just mixed No one bothered to look at them as a group. And it turns out this might be the most important group because when we look at the subgroup analysis, these women, since they didn't have hysterectomies, only got estrogen. They didn't get estrogen and progesterone. Remember, it was the estrogen and progesterone combinations that were so dangerous for breast cancer.

They had a decreased rate of breast cancer and a decreased rate of heart disease in these women. That was never published because nobody ever bothered to look. Nobody ever thought about it. But this actually may be the most significant group when we take a look at that and continue to look at what their indices are going forward with regard to what estrogen does in the body.

The timing hypothesis. When they... Initially, the results were released and the world went crazy, and so much of it has been walked back. But in the AHA published in circulation in 2020, the El Cuhuhaudri big article, and then Hodes, I believe, and Mac looked at the article on it about time and timing. So When they went back and looked at the data, specifically age, so women who were within 10 years of menopause or before the age of 60 and started on either arm, so estrogen, so the histerectomy patients, largely African-American, And then the patients on both, it appeared that estrogen started early was protective. I even saw in the article, they were showing pictures of the arteries and what happens through the menopause process with an acceleration of the the calcification of the plaques. Whereas women on hormone therapy, you just held at the plaque stage and didn't progress to the more aggressive calcified plaques. I don't think most physicians realize that. I certainly did.

I would say almost no physician realizes that.

How protective. Now, once those plaques get calcified, estrogen is not helpful. So it seems like it's better-We don't know. We don't know.

What do we need? We don't know that. And I think the thought is changing. I think about these cases in our work on protocols, the window of opportunity. Does that mean that women over the age of 60 should not be started on estrogen? Does it mean that women who have some established heart disease Should not be started on estrogen currently? That answer is no, but it's maybe sliding. In the first year of starting estrogen, for women more than 10 years out than menopause, that you have an increased risk of a heart attack. Most of that risk is in the first four months. The question is, which is why we need studies, is the women who have some established heart disease, are they not the ones who actually could benefit the most from estrogen? What we really don't know, just like statins, one thing about statins is another positive thing about statins is statins are one of the only medications that actually have shown a regression of plaque lesions when you use them. I wonder if estrogen is another one that will show a regression of plaque lesions. I don't know that. I'm just saying there's a blind spot, again.

And now we are excluding women over the age of 60 because we've got this information, and we don't really know.

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Visit joinmitty. Com to meet with a Mitty clinician and start feeling your best for the years ahead. Many of us in the Menopause are If they have risk factors and we don't have a history of established heart disease, we send them for the calcium cardiac score. Now, explain to our listeners what that is, and do you think it's really... Is it something women should be doing? Yeah.

So the calcium score looks at the amount of calcified plaques in your arteries. And the calcium score does not determine what your workup is. It is a risk predictor model of 10-year risk. So So zero is your normal score. This is a test that you actually want to fail and get none of the questions correct. You want to get a zero. Zero means normal, no plaque at all. If your number is higher, let's say it's one or 10 or 14, how How is it scored?

Like to a thousand, right?

It can be scored, yes. But even one is considered abnormal. But you're right, they're different ranges, right? So zero to 100 may mean one thing. As far as your risk, it is a risk predictor. It does not It's not to drive you on to other types of tests. It is a risk predictor, and it helps us guide and give advice on a woman's health. It is a tool. It's like a tool to give us a risk prediction of what this heart disease risk is in this woman.

Do you have a cut off where you're like, I'm not going to give her hormone therapy?

So even though there's not really a cut off, I would say definitely calcium score is over 100. So far, probably are excluded. I am waffling because I don't want to be a part of this whole thought that has harmed women over years. On the other hand, I also don't want to harm women. So this is back where we're in this dearth of information, and we're trying to figure it out while we wait for trials to come forth.

So what would you tell a patient who comes to your office and she's bypassed her menopause specialist? She comes to you first, and she's symptomatic, late perimenopause, early menopause. No history of heart disease, but she's terrified of hormone therapy because of the WHI messaging around heart disease. How would you counsel her?

Okay, she's symptomatic with heart symptoms?

Sorry. I'm thinking of my end of the world. She's the classic menopause sometimes.

First of all, hormone therapy is not for everyone. Part of women's health is we have the autonomy to make decisions for ourselves. Decide for yourself. We are here to give you information. Now, the fear, I don't know what the fear would be of hormone therapy, but she sounds as if she's an ideal candidate for it. And so I think we began to counsel her about what's really bothering her. If her symptoms are very bothersome, she may want to consider taking it just for a period of time to relieve her symptoms, to see how she feels. It may be a way to start these conversations. But I think for me, the bigger conversation I like to have with women is heart disease risk. The life today that you want 20 years from now and looking out in your family and looking out in the women in your family. So it's not all about relieving your symptoms, but it's important to feel good, to relieve your symptoms. But also think that it decreases your risk of dementia. It decreases your risk of heart disease. How are you going to think about estrogen therapy in that context? And the prevention In the preventative context.

Beyond OB/GYN.

There's some pushback from people in charge, from the older messaging. We shouldn't be talking about prevention, even though it's FDA approved for the hormone therapy for the prevention of osteoporosis. But whenever I talk about the preventative aspects in brain health and in heart health, there's a little bit of pushback from the people who write some of the guidelines, not all. Do you feel like we're heading in that direction, that these guidelines will change?

So I think the guidelines will change. Now, how quickly they will change. Just in the whole political arena that we find ourselves in, where we're struggling to even use the word woman in research, which is just insane to me.

We need gender-specific research. I'm sorry. Our women are going to continue to suffer.

I had an editor write back because I had submitted a paper and was trying not to use the word woman because I thought that was the new rule. I was trying to and the female and the this. And literally, they wrote back, and I was happy to hear that. They said, woman is the appropriate term. And I thought, thank you. I'm struggling here. But people's research was slashed for using the word woman. So when you say, how long will it take? I would like to say not long, but then there's a part of me that just says this is just going to be a slog fest. Okay. Trying to break through the patriarchy that knows best and has always known best. And in knowing best, we've gotten beta blockers that have killed us. And we've gotten these terms that are showing us atypical and poor outcome.

And much, much poorer outcome than our brothers. If I had a twin brother, he has a 50 % higher chance of surviving a heart attack than I do. That's right. And that the system wasn't really built to serve us. That's why education and us, these conversations. Education is important.

And I'm working on legislation as well in the state of Georgia, just to see if we can even just start to teach it in medical schools, teach it in internal medicine training. And I'm not even saying, teach it at a deep level. Can we just say the word menopause? Have the students aware that, Oh, this is something I need to be thinking about. So I'm just starting at the very, very, very basics. But my legislation is focused more on heart health and menopause, but it's also generally focused on, could we just have some teaching?

The American Heart Association has called menopause a critical window for cardiovascular disease prevention, at least on paper. But Most midlife women aren't hearing this from their doctors yet. I mean, let's reiterate this one more time. This should be central to everybody's education, which is your point.

It should certainly be central to cardiology. And cardiology, in many ways, is the furthest away from menopause. I mean, we really-And there's such a tight link between the two. We really think of it as those people over there in labor and delivery. It's just a word that has no context to a cardiologist. Just baffling. Even if someone came to a cardiologist and was talking about menopause, cardiologist, you just be baffled as to what is going on. So there's even that level of just awareness. And again, if we can start to just at least get some of the words into our guidelines, then someone has said them. When we look up the guidelines, they're going to come up on somebody's screen to say, Wait, what is this?

Menopause.

Let me refresh my screen. What is this?

Let's talk about early menopause, premature ovarian insufficiency or surgical menopause or chemotherapy-induced irradiation, and the risk of heart disease. Right.

And the risk of heart disease does increase the earlier menopause. And it's one of the things I talk about, especially with black women, because we tend to go into menopause earlier. Eighteen months. And weathering is a big reason for that. And for weathering, it's just the constancy of high effort coping in a society that's both gender-conscious and race-conscious. And what it's like to live in a society that is constantly aware of those two things, and you're constantly trying to push against it, trying to validate your medical credentials. No matter how many times you walk into the room and introduce yourself as a doctor, they still are going to talk to the most junior person who's the white male or ask when the doctor is going to come into the room. Those kinds of things where it's just the socialization, the constancy of raising your children in this society. They have to be raised differently. You're cautioning them differently. Getting a driver's license is not such a fun time It's a celebratory, but now it's all this other worry of you're going to be profiled, especially if you've got sons. And Black women who are mothers of Black sons report the highest degree of stress and the highest degree of weathering.

So most of And so my thought comes from this weathering process that drives an earlier menopause in women, in Black women, and drives a more accelerated path towards heart disease and a more accelerated path towards stroke. And so we know from that information on the weathering that early menopause does increase your risk.

So I was taught that this was pure biology, that people of color had increased risk of disease because their genes were different, and they were just biologically programmed to do that. And that stress and lifestyle would compound that. But this is basically a biological difference.

Again, this is what I'm saying. We come through the system. I was taught the same thing, and I'm black. You know what I mean? You're just like, Oh, is that true? He said it's true. It doesn't sound true, but he's the professor. Is that true? You know what I mean? You get all these mixed things where inside, you're like, I don't think that's true. But he's the one with all the power, right? You're powerless, so you don't buck the system, and you just think about these things.

All right, let's talk about polycystic ovarian syndrome and the risk of heart disease. So it increases your risk, correct?

It increases your risk long term. But when we look at polycystic ovarian syndrome, we have to think about all of the cardiometabolic components that come with that. And it's almost very similar to LP little A without therapy. You got to drive all those risk factors down to almost being negligible. You've got to be able to focus on those risk factors.

The 80 % you talked about that we can control.

That's right. You can control that 80 %. Now, I'm saying this. I want to be clear. I'm not saying it's easy. It's hard. It's an upward battle. And we ask women to do so many things, and now we're saying, Hey, look, control your weight, control your exercise, make sure you're moving, do your cholesterol.

Sleep eight hours.

Sleep eight hours. You know what I mean? I know you're probably listening to me going, Lady, for crying out loud, I've got enough going on. But the fact of the matter is, trying to control those indices as much as possible continues to mitigate your risk.

So risk for heart disease for women, smoking, weight or visceral fat, blood pressure, lipids. So that's going to be cholesterol, specifically the LDL and the APOP, and Lp, and triglycerides. Okay. When should we be screening for that? When should you go get your blood work done for lipids? When would you, for an average woman?

I think you should be screened at every physical exam.

25?

25 years of age.

I agree. Because I totally agree.

Men get their blood work done. Why don't we get our blood work done? We don't get EKGs, we don't get blood panels.

We're just allI have my daughters checked.

That's right. So it should be a part of your annual physical exam, your battery of just standard blood tests that are being done. Routine screening.

Routine screening.

The reason that it's not done in women, I keep going back to this theme, is that women's health is considered to be all about reproduction. So you see your OB/GYN, and the OB/GYN is focused on those things to keep you healthy in their reproductive system. So you don't get the battery of bloodwork where the man is over with the primary care physician having another focus. And we really should be seeing both doctors. And probably about 15 years ago, I started to preach that to say, Women need a primary care physician and a gynecologist. We should be seeing both, which I know now it's two visits in a year. But the fact of the matter is, the two focus on two different things, and we should be doing that.

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Even for me, I Listen, I'm a doctor, and I'm in the system. I only saw OB/GYNs. I never had a primary... I had a pediatrician, and I had an OB/GYN for like 30 years. And sometimes I would just say, because I'm a doctor, say, Hey, could you draw my cholesterol? And it's never occurring to me that I'm doing a one-off medicine. I'm getting these things done because I'm asking my buddy to draw them for me. But what's the average woman?

And you've got 15 minutes for your well-woman exam, and 10 of that is in stirrups. Getting your specific important stuff. Right. Okay, so we talked about hot flashes or in medicine, we call vasomotor symptoms, but inflammatory markers, back to labs. Do you draw inflammatory markers? Do you find them helpful?

So here's the answer to that. Most people, especially when you look at black women, have chronic inflammation. You can oftentimes look at people or take their history and know they've got chronic inflammation. I don't know if the markers are going to give me any more information.

You just talk to the patient. I can just talking to the patient. Just talk to the patient.

Sometimes we do have to think about finances and what's going to be reimbursed and all those kinds of things.

Also sleep disturbance and depression during menopause have all been linked to higher cardiovascular disease risk. Should we be treating this as a cardiovascular red flag rather than just a quality of life issue?

Yeah. And at least sleep is recognized by the American Heart Association. In fact, it's the duration of sleep. How much sleep? Five hours or less is a risk factor for heart disease. We need to get five hours or more. Now, I think we probably need more than five hours, but that was the cut off for the study. And then what happens during menopause? We might get five hours, but it would be fractured. So it has to be five Continuous. Duration of five hours, not the fractured five hours of sleep that you might get, and you're in the bed for 10 hours, which you only really slept for five, and you were waking up and you had insomnia. That actually is a risk factor still for heart disease. Okay.

Talk to me about arterial stiffening. This is a new term for me, and menopause.

Because we have estrogen receptors on our arteries, we have them in our hearts, we have them in our arteries, we have them in our brains, we have them in our bones, we have them everywhere. Because we have them in our arteries, as we go through paramenopause, and our estrogen levels began to fluctuate and began to decrease, we have less binding of estrogen to the receptors on our arteries, our arterial walls, so inside of those arteries. Now, what does estrogen do to the arteries? Estrogen creates something called compliance, meaning it allows the arteries to expand and contract. Think of it that way, like a balloon or Stretchy or a rubber man. And that compliance allows us to regulate your blood pressure. The arteries expand and contract. When we have less estrogen binding to the receptors, the arteries then become stiffer, become more like tubes, rigid, and your blood pressure then starts to creep up. And that's important because you won't feel it. You feel the same. There is no symptom for high blood pressure for the most part. When it's very high, you might have headaches or If you have headaches or high blood pressure, you need to go to the ER.

But for the most part, high blood pressure as well as high cholesterol are silent. You don't necessarily feel them until you have an event. In cardiology, when we say an event, we mean a heart attack or a stroke. So you don't want to have an event. But that's what happens during perimenopause. And oftentimes, women are unaware of it because their whole lives, they've had normal blood pressure. And it literally can happen in between the one year that you last saw your physician and and your next physician. And I'll tell you what happened to me. Again, I'm just another cog in the wheel of the system. I have all of this information and all of these degrees and training, and literally, I didn't know what was happening. My doctors didn't know what was happening. So I go to my doctor one year, my blood pressure is high, and she says, Oh, your blood pressure is high. And I go, Oh, that's weird. She says, Oh, that ear is weird. You're probably rushing. And we went on with the physical exam, and off I go. That's it. That was it. Like, you're rushing. That I can't be right.

Your blood pressure has been normal your whole life. Didn't see her again for another year. Next year, came in, she says, blood pressure's up. She's like, Oh, you know what? It was up last year. Why don't you sit and let's just take a few breaths? You're just doing so much. I see you now. You're busy. So I stopped. We took the breath, blah, blah, blah. Pressure came down a little bit, but it didn't come down that much. She said, You know what? I think you just are coming in here and rushing in. Just go back home, and then next week or so, take your blood pressure somewhere and me the reading or whatever. And of course, I never did that. And even me, not only have I had normal blood pressure, my blood pressure ran low. So that can't be right.

How old were you?

Oh, my gosh. Was I 50? Okay. Now we're in the third year, right? I'm just living my life. Third year coming in for my physical exam. Blood pressure's up again. And she says, I don't know. Should I prescribe something for you? She says, You know what? I'm going to let you decide. She prescribed medication. I'm going to let you decide. And if you want to take it, take it. If you don't, don't. And I didn't want to take it. I was like, Why would I take blood pressure? I have normal blood pressure. I think I'm just running around when I come in here. Another year goes by, right? But I have a prescription now.

Got a prescription. You're in year four now.

Nobody's talking about perimenopause. Nobody's talking about... All they're talking about is, your blood pressure has always been low. This must just be some aberration for you. Nobody knows anything about menopause. So then I come in on year five, and now it's And we both decided, let's just take it for a while and see how it goes. And I've been on blood pressure ever since. It took five years to diagnose high blood pressure in me because it had always been normal, and no one knew anything, including myself. Have about perimenopause or menopause.

I've said those exact words to patients because I didn't know that there was a connection between hypertension and menopause in most of my career. I mean, I've admitted, freely, I was a horrible menopause doctor for probably 20 years. And those exact words, let's just recheck it. Blood pressure is a silent killer.

Cylent killer. So it's just insane that I'm in the system and I can't even get care. I don't even understand it. I didn't understand my itchy ears. I didn't understand that my blood pressure was going up. I developed vertigo, went to a neurologist. Nobody could find anything. You know what they told me? And eventually, I thought it worked. I'm a big pilates. I'm a pilates instructor, big pilates enthusiast. They said, Oh, you know the- That's right. You're going to invert doing pilates. Just, I said, Oh, my God, I'm going to fall over. No, but try to hold the pose as long as you can before you fall over. And over time, you'll reset your cochlear, your vestibular nucleus, and you'll get over there. But we can't find anything wrong with, so there I am in downward dog, and pilates, trying not to fall on my head and have a cervical fracture. So I mean, yeah.

Insane. Yeah, even you, the most educated, the most. Insane, right.

Same. Now, eventually, my vertigo went away, and I credited pilates with it.

You've heard me talk about the care gap in menopause, how women's symptoms are often dismissed or left untreated. I see it all the time in my practice. There are many women struggling for answers, unsure where to turn, and too often not getting the support they need. That's why I'm so excited to tell you about Midi Health. Midi Health is a telehealth clinic focused exclusively on women in midlife. Led by trusted medical leaders and clinicians, the team is committed to evidence-based, whole-person care. They're also the only National Women's Health teleclimate covered by major insurance, making expert care accessible and affordable. When you work with Mitty, you get a personalized plan that can include hormone therapy, nutrition guidance, weight management, and lifestyle support. It's care designed not just to help you feel better today, but to protect your heart, bone, and brain health for the future. This is such an exciting moment. Menopause care is finally evolving into what it should be, accessible and centered on women's real needs. It's inspiring to see the progress Smitty is making, helping women feel truly heard and supported. You deserve care that supports you now and protects your long term health.

Visit joinmitty. Com to meet with a Mitty clinician and start feeling your best for the years ahead. All right. I would be... Before we wrap up, talk to me about GLP-1s and the intersection between the use of this and cardiovascular disease.

Glp-1s definitely have a place in cardiology, and certainly we've seen the data. By GLP-1s, we mean this Ozempic, Wegovy. They definitely have a place in cardiology, as we have seen data showing that they decrease heart failure over time. What's also interesting about them is when we're talking about women in menopause, when we're talking about visceral fat and weight gain and cholesterol and hypertension, and all All those things go together. Where you see one, you see the other.

Metabolic syndrome.

Right. But it's not only... It's like bedfellows. They just hang out together. If you can really intervene on one, the others also benefit. Right. So if you can help a woman lose weight? She also has less visceral fat. Her blood pressure also decreases. Chlesterol also drops. So all of these things are actually great outcome. So what is the caveat? The The playout to that is that there seems to be no way to come off of them permanently. The patients who are on them either regain the weight or have to have some level of GLP-1 as a lifetime maintenance. And that is a choice that people will just have to make with regard to what they want to do with them. I am not against them. I think they certainly have a place in cardiology. They have a place in menopause as well. They have a place in health. We are seeing data decreased cancer rates as well. But I can imagine we'll start to see data on the other side of the coin at some point. The concern, if it's a concern, I guess the consideration is maybe a better term is, when you start this, think about it almost like blood pressure pills.

It's something you need to think about for the rest of your life currently because there is nothing else. And if you become dependent on the GLP-1s to control your weight and control your indices and your blood pressure, that's fine. You will still continue to have to use it from time to time. You'll have to have these little touch-ups. You'll have to keep using it.

To wrap it up for our listeners, what are the specific steps that women can take to decrease their risk of cardiovascular disease and stroke?

So if a woman is coming to me at midlife, I'm going to first ask about all kinds of paramenopausal symptoms. And they are like, depending on what you read, 35 to 60.

I've got about 70.

And I'm going to skew towards the high end. I've seen 35 to 60. I'm going to say 60. But now Mary Claire says 70. I'm going to agree with her 70, because I think it's probably 200, but we're still naming them. Having any number of symptoms related to perimenopause, I'm going to begin to talk with her about her cardiovascular risk. That conversation is going to include not only the control of symptoms for comfort, but what are we going to do to actually decrease that cardiovascular risk? And oftentimes, that's going to include a discussion about hormone therapy. It's going to include a discussion about estrogen and progesterone. Now, we no longer give oral estrogen. By the way, that's what the Women's Health Initiative was, oral doses of estrogen, meaning by mouth. So we're going to talk about other formulations, generally, usually the patch or a gel or cream, and make a determination about where you are. So every therapy is not right for every person, even if I think it's right for you. Part of women's health is also making the best decision for yourself with the most informed information, not with misinformation. And so that's something that I really want to talk with patients about, and that is utilizing hormone therapy to begin to control, mitigate the risk of heart disease as you are going through this transitional period.

The upside is that you'll have better control of all those basal motor symptoms, so the hot flashes. So I think people like to take it because they want to control the hot flashes. They want to control the night sweats.

I actually think- That's why it was created. Right.

But I actually think the upside is that you want to mitigate your heart disease risk. And the benefit is you get all of these basal motor symptoms that end up being under control as well. So I really want to focus on heart health. I also really want to focus on brain health because heart attacks and strokes are So intertwined. Dementia and heart disease, so intertwined. And where you see one, you generally see the other. And that's just another area we've got to begin to think about these two things together.

And what about lifestyle?

Lifestyle is always important. So we're talking about that 80 %, right? 80 % of people can do something about heart disease. It's not inevitable. So lifestyle is important. The human body is made to move. We don't move anymore. And I often liken it to a car, a car that you love. You love it so much, you don't even drive it. And then when you go to drive it, what happens? Has a hard time starting if it starts at all because it hasn't been utilized. Cars, in order for them to work optimally, actually have to be driven. The body also has to be used. So you've got to be able to move. Now, I'm in digital health, and part of what I do in digital health and artificial intelligence is make your life easier so you don't have to move. So this is an oxymoron, right? So this is the age in which we're living. We don't move anymore just with our activities of daily living. We used to get dressed and make your breakfast and walk out to the car and have to open the car door, close the car door, put on your seat belt, drive to work, get out of the car, walk into the office.

And then you generally maybe join a group of people. You walk down the street to lunch, you came back, you walked to meetings. So think about all of that activity. It was just built into You non-exercise. You weren't even exercising. You were just at work. What did you do the other day? I was just at work. And then you might come and exercise on the weekends. We don't even get that anymore. And so the body was made to move. Movement is probably the key index that I try to talk with people about all of the time. If there's one thing that you can do, I like for people to move. It's the second thing you can do. If you're prescribed medications, please take them. Don't be like me or my doctor on year four or whatever. They did prescribe it, and I I still didn't take it for another year because I still didn't believe that I had blood pressure.

So menopause often feels like society wants us to hit pause. But what have you decided to unpause for yourself in your personal journey? And what did that open up in your life?

I have decided to unpause societal limitations. I have decided to stop showing up the way society wants me to be. I love this. The good girl, the compliant person, always doing the the right thing, the good minority. Don't be afraid of me. Don't be intimidated. Don't be threatened. Let me do twice as much work for you so you can-Don't complain about your paycheck.

Continue to be dismissive of me because the more I do, actually, the less you respect me, not the more that you respect me.

I have decided to stop making people feel comfortable with my presence. I love that. That's what I have decided to stop doing.

I love that. I love that. And women are benefiting from it because you are standing up for them in the rooms and at the tables that they don't have access to. So thank you for that.

Thank you.

I really appreciate you coming. I think our listeners are going to learn so much from this and be so motivated and keep educating themselves and keep fighting for their own heart health and brain health. As a reminder to our audience, you can follow Dr. Morgan on social media, on Instagram, TikTok, YouTube, Facebook at Dr. Jane Morgan, J-A-Y-N-E, and on LinkedIn at Jane Morgan, MD. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Marie Claire and get honest, accurate information on health, fitness, and navigating midlife at thepawslife. Com. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and give us a like, and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Marie Claire. Unpaused is presented by Odyssey in conjunction with pod people. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and the guests alone, and are provided for informational and entertainment purposes only.

No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.