GOOD MORNING. THE JOINT HEARING
OF THE SENATE COMMITTEE ON
HEALTH AND THE ASSEMBLY SELECT
COMMITTEE ON REPRODUCTIVE HEALTH
WILL CONVENE THIS MORNING. THANK
YOU FOR BEING HERE. THE SUBJECT
TODAY IS MENOPAUSE. ACCESS TO
TREATMENT AND COVERAGE. I DON'T
HAVE TO TELL YOU, BUT THIS IS A
VERY IMPORTANT ISSUE FOR WOMEN
AROUND THE STATE, THE NATION AND
FRANKLY, AROUND THE WORLD. AND
IT'S A VERY IMPORTANT ISSUE FOR
MEN AS WELL. MEN WITH WIVES AND
MEN WITH ADULT DAUGHTERS. WE ARE
EXPERIENCING THIS AS WELL. SO
IT'S APPROPRIATE THAT WE HAVE
THIS CONVERSATION, THIS HEARING
HAS BEEN LONG IN PLANNING BY MY
COLLEAGUE TO MY LEFT, MY FORMER
CHAIR. THE MUCH BRIGHTER AND
HARDER WORKING CHAIR EVER OF THE
SENATE HEALTH COMMITTEE AND HER
COLLEAGUE IN THE ASSEMBLY. AND
SO I'M GOING TO TURN THE HEARING
OVER TO THEM AND LOOK FORWARD TO
THE CONVERSATION. SENATOR
EGGMAN, THE FLOOR IS YOURS.
THANK YOU, SENATOR ROTH, IT'S
BEEN A REAL GENTLEMAN TO, TO
PROVIDE THE SPACE FOR US TO DO
THIS. SO WELCOME TO EVERYBODY.
WELCOME TO ALL OF OUR OUR GUESTS
, OUR DISTINGUISHED PANEL, AND
MY COLLEAGUES HERE. I AM IN MY
LAST YEAR IN THE IN THE STATE
SENATE. I HAVE I START IN
ELECTED OFFICE WHEN I WAS 2000
AND 2006. IT IS NOW 2000. AND
WHATEVER IT IS, AND I WENT FROM
BEING UNDER 50 TO 63 DURING MY
TIME IN ELECTED OFFICE AND AS I
REFLECT ON THAT AND HAVE SERVED
WITH AND ALSO HAVE WORKED VERY
HARD TO GET MORE WOMEN IN THE
LEGISLATURE, WHEN I GOT HERE,
THERE WERE 23 OF US, AND I'M
VERY PROUD TO SAY WE'RE ALMOST
GOING TO HIT PARITY BY THE TIME
I LEAVE, THAT WE'VE MADE A
CONCENTRATED EFFORT TO MAKE SURE
THAT THERE'S PARITY SO THAT WE
CAN HAVE THESE KINDS OF
CONVERSATIONS RIGHT. BECAUSE
BEFORE WOMEN'S AND WOMEN'S
BODIES AND WOMEN'S HEALTH WASN'T
EVEN ON THE AGENDA FOR ANYBODY
TO BE TALKING ABOUT, WE WEREN'T
SITTING HERE. AND SO IT DIDN'T
COME UP IN THE SAME KIND OF WAY.
SO AS I THOUGHT ABOUT MY LAST
YEAR AND REFLECTING ON IT, WE'VE
DONE A LOT OF WORK DURING MY
TIME HERE ON MENSTRUAL EQUITY.
WE'VE DONE A LOT OF WORK ON
CHOICE AND WOMEN'S BODIES, BUT
THE ONE TOPIC THAT WE HAVE NOT
SPENT A LOT OF TIME ON IS
MENOPAUSE, AND I HAVE CERTAINLY
GONE THROUGH THE PROCESS AS
I'VE, YOU KNOW, BEEN A MEMBER,
DIDN'T TALK MUCH ABOUT IT,
DIDN'T HAVE MANY CONVERSATIONS
ABOUT IT BESIDES THE, YOU KNOW,
IS IT HOT IN HERE, KINDS OF
CONVERSATIONS THAT WE HAVE, AND
I THINK THERE'S A LOT OF US THAT
GO LIKE THAT, AND WE SHOULDN'T
HAVE TO DO IT IN SILENCE. RIGHT,
I REMEMBER GROWING UP, MY MOM
NEVER REALLY TALKED ABOUT IT.
SHE SAID IT WAS A WHITE LADY
THING BECAUSE WE DIDN'T HAVE
TIME, AS LATINAS. RIGHT. AND WE
KNOW THAT'S NOT TRUE. WE KNOW
THAT ESPECIALLY FOR WOMEN OF
COLOR, THE SYMPTOMS ARE EVEN
MORE PRONOUNCED. BUT OFTENTIMES
THERE'S NO SPACE OR TIME TO
THINK ABOUT THOSE THINGS OR
THOUGHT OF AS MORE OF A
PRIVILEGE FOR OTHERS TO THINK
ABOUT. SO I WANT TO THANK
EVERYBODY TODAY FOR BEING HERE
AS, AS AS AS I WIND DOWN. BUT AS
WE REALLY START TALKING ABOUT
THIS AND PRIORITIZING WOMEN'S
HEALTH AND, AND MENOPAUSE, A
WOMEN CAN LIVE LONG, HEALTHY
LIVES WITH FULL SEXUAL ACTIVITY
AND JOY AND ALL THE THINGS THAT
THAT WE ALL WANT TO HAVE AS
HUMAN BEINGS. RIGHT? FREUD SAID
IT WAS IT WAS HE WAS WRONG ABOUT
A LOT OF THINGS. BUT SEX, LOVE
AND WORK, RIGHT. AND THOSE
THINGS STILL, I THINK, MAINTAIN
VERY CENTRAL TO ALL OF OUR
LIVES. SO I'M GLAD TO BE HERE
WITH ALL OF YOU. I WANT TO THANK
THE STAFF FOR PUTTING THIS
TOGETHER AND TURN IT OVER TO MY
COLLEAGUE ON THE ASSEMBLY SIDE.
THANK YOU BOTH. SENATORS EGGMAN
AND ROTH. IT'S A REAL PRIVILEGE
TO BE HERE, CO-CHAIRING THIS
HEARING. BOTH HOUSES TOGETHER.
BIPARTISAN. THIS IS AN ISSUE
THAT CROSSES EVERY BARRIER,
EVERY WOMAN WHO IS A WOMAN WHO'S
FORTUNATE TO LIVE LONG ENOUGH
WILL GO THROUGH MENOPAUSE. AND
YET, YOU KNOW, WE ALL GREW UP
WITH MOTHERS WHO WERE TOLD TO
GRIN AND BEAR IT. I REMEMBER MY
MOTHER BEING HOSPITALIZED FOR
DAYS BECAUSE SHE WAS TURNING
BLUE, AND THEY COULDN'T FIGURE
OUT WHY. AND THEY DID EVERY TEST
UNDER THE SUN, ONLY TO SAY SHE
WAS PERFECTLY FINE AND THEN
TELLING A GIRLFRIEND THE STORY
AT A, LUNCHEON A COUPLE OF WEEKS
LATER AND THE FRIEND SAID, OH,
IT'S PROBABLY JUST MENOPAUSE.
AND THEN SHE WAS TOLD, OH,
YOU'RE FINE. JUST KEEP GOING.
AND I THINK THAT WAS THE LESSON
THAT WE WERE EACH GIVEN AS WE
WERE RAISED. WE WEREN'T TAUGHT
ABOUT MENOPAUSE. WE WEREN'T TOLD
WE HAD A RIGHT TO BE TREATED FOR
MENOPAUSE. AND AS I APPROACH
PERIMENOPAUSE, I REALIZED
SPEAKING TO MY OWN PHYSICIANS,
MANY OF WHOM ARE WOMEN, THEY
WEREN'T TRAINED TO UNDERSTAND
HOW TO TREAT ME, HOW TO CARE FOR
MY BODY AS IT TRANSITIONED OUT
OF THE YEARS, THE CHILDBEARING
YEARS, AND INTO THE REST OF MY
LIFE. AND YOU KNOW, AS I STARTED
TO HAVE THESE CONVERSATIONS WITH
MY COLLEAGUES AT WOMEN'S CAUCUS
AND OTHER PLACES, WE ALL STARTED
TO REALIZE THAT WE WEREN'T
GETTING THE ATTENTION WE
DESERVED AS MORE THAN HALF OF
THE POPULATION, AND THAT WE AS
LEADERS WITH THESE PLATFORMS. WE
NEEDED TO BRING THIS TO BEAR. WE
AS THE STATE OF CALIFORNIA, THE
FIFTH LARGEST ECONOMY IN THE
WORLD, SOME OF THE BEST MEDICAL
INSTITUTIONS IN THE WORLD, SOME
OF THE BEST PHYSICIANS. SO MUCH
RESEARCH FUNDED BY THIS BUILDING
, IT WASN'T NECESSARILY GOING TO
THIS. AND YET EVERY SINGLE WOMAN
WHO LIVES LONG ENOUGH WILL
EXPERIENCE IT. AND SO I THINK IT
IS SO CRITICALLY IMPORTANT THAT
WE HAVE THESE CONVERSATIONS. WE
LEARN ABOUT THE WAYS THAT IT
AFFECTS OUR CONSTITUENTS, OUR
BODIES, AND WHAT WE CAN DO TO
CHANGE THE GAME FOR WOMEN MOVING
FORWARD, WOMEN GO THROUGH
MENOPAUSE JUST AS SENATOR EGGMAN
HIGHLIGHTED AT THE HEIGHT OF OUR
CAREER, RIGHT WHEN WE'RE ABOUT
TO TAKE OFF, WE'VE WE KNOW WHAT
WE'RE DOING AND WE'RE READY. AND
YET WE HIT THIS POINT IN OUR
LIVES WHERE WE START TO HAVE
THESE SYMPTOMS THAT CAUSE BRAIN
FOG AND SLEEPLESSNESS AND THINGS
THAT REALLY IMPACT OUR
PRODUCTIVITY, AND IS NO SURPRISE
THAT WE AREN'T BREAKING MORE
GLASS CEILINGS AND SO IT FEELS
LIKE TAKING THIS STEP AND CARING
FOR WOMEN'S BODIES AT THIS POINT
IN THEIR LIVES CAN ACTUALLY BE
GAME CHANGING WELL BEYOND JUST
OUR HEALTH AND WELL BEING. AND
SO IT HAS REALLY BEEN A
PRIVILEGE TO BE IN THESE
CONVERSATIONS AND TO LEARN MORE
AND TO START TO DO THE WORK WE
HAVE. YOU KNOW, I HAVE A BILL
MOVING THIS YEAR THAT WILL DEAL
WITH, INSURANCE COVERAGE FOR
MENOPAUSAL CARE. LET'S START TO
HAVE THE CONVERSATIONS OF WHAT
IT MEANS TO COVER WOMEN AND TO
CARE FOR THEM IN ALL THE WAYS.
BUT THERE IS SO MUCH MORE
LEARNING TO DO. SO I WANT TO
THANK OUR PANELISTS FOR BEING
HERE. I ALSO WANT TO THANK OUR
COLLEAGUES WHO ARE JOINING US
BECAUSE WE SHOULD ALL BE
ENGAGING IN THIS. I AM EAGER FOR
SOME OF OUR MALE COLLEAGUES TO
SHOW UP TO LEARN MORE, I KNOW
THEY WILL JOIN US AT SOME POINT
IN THIS CONVERSATION AND SO I
JUST WANT TO THANK YOU FOR
PUTTING THIS TOGETHER AND THE
STAFF WHO I KNOW HAVE PUT IN
INCREDIBLE WORK TO GET THIS
AGENDA TO WHERE IT IS TODAY, BUT
I JUST WANT WOMEN TO KNOW THAT
WE ARE PAYING ATTENTION TO YOUR
HEALTH. WE CARE ABOUT IT, AND WE
ARE GOING TO BE FIGHTING FOR IT.
AND AND, YOU KNOW, I THINK IT'S
CRITICAL THAT WE SAY THINGS LIKE
VAGINAL DRYNESS AND HEARINGS
BECAUSE IT'S REAL, IT AFFECTS
US, AND WE NEED TO BE ADDRESSING
IT. AND THAT BRAIN FOG, I MEAN,
WE GIVE SPEECHES, WE'RE OUT
TALKING EVERYWHERE. I CAN'T TELL
YOU THE AMOUNT OF TIMES I SAY,
PLEASE GOD, PLEASE LET ME HAVE
MY WORDS. LET ME FIND MY WORDS
BECAUSE, RIGHT, YOU'RE GETTING
UP TO DO SOMETHING BIG AND THEN
OH, OH, OH, I JUST WANT TO GIVE
A MOMENT TO MY OTHER TWO
COLLEAGUES HERE ON THE DAIS. IF
THEY WANTED TO SHARE ANYTHING
OR. NOPE. OKAY, OKAY. I REMEMBER
MY MOTHER SWEATING. YEAH. AND
THEN SHE WAS DIAGNOSED WITH
PRIMARY PERITONEAL CANCER, WHICH
IS VERY SIMILAR TO OVARIAN
CANCER. AND IT TOOK A HECK OF A
LONG TIME TO GET TO THAT
DIAGNOSIS. AND SHE LASTED FIVE
YEARS, BUT NOT ENOUGH IS TALKED
ABOUT. SO I'M DELIGHTED TO BE
HERE. THANK YOU ALL FOR PUTTING
THIS ON. THANK YOU TO OUR
WITNESSES FOR BEING HERE. TAKE
IT AWAY. ALL RIGHT. FANTASTIC.
OKAY. AND WE'RE GOING TO, START
WITH SOME TREATMENT PROVIDER
KNOWLEDGE GAPS. WE'RE GOING TO
THEN TALK ABOUT ADDRESSING SOME
DISPARITIES AND INTEGRATING
CARE. WHAT THE COVERAGE LOOKS
LIKE IN CALIFORNIA. AND THEN
WHAT DO WE THINK THE NEXT STEPS
SHOULD BE. SO THOSE OF YOU WHO
WILL BE HERE LONGER THAN CAN
TAKE THESE IDEAS AND DO THE NEXT
STEPS. THIS IS THE BEGINNING OF
THE CONVERSATIONS, CERTAINLY NOT
THE END, SO AND I THINK WE'LL
JUST HAVE EVERYONE STAY UP HERE
AND THEN SPEAK, AND THEN WE'LL
ASK QUESTIONS AFTER EACH SPEAKER
GOES, IF THAT'S OKAY, WE'RE
GOING TO START OFF WITH DOCTOR,
GITA PATEL, WHO'S ASSISTANT
CLINICAL PROFESSOR, DIRECTOR OF
THE UCLA COMPREHENSIVE MENOPAUSE
PROGRAM, AND THE AND A LOT OF
PLACES. YEAH PLEASE. THANK YOU.
I'M JUST GOING TO GET MY SLIDES
UP HERE. ALL RIGHT. SO HI,
EVERYONE. THANK YOU FOR HAVING
ME HERE TODAY. I REALLY WANTED
TO TALK TODAY ABOUT MENOPAUSE AS
A CRITICAL WINDOW OF OPPORTUNITY
THAT NEEDS TO BE BETTER
ADDRESSED. AND HERE IN
CALIFORNIA AND FRANKLY, ALL OVER
THE UNITED STATES. SO FIRST, WE
REALLY JUST NEED TO UNDERSTAND
THE PROBLEM, WHY IT EXISTS
BEFORE WE REALLY TALK ABOUT THE
NEEDS AND THE SOLUTIONS TO THE
PROBLEM. MENOPAUSE AS WE KNOW,
IS DEFINED BY CESSATION OF
MENSTRUAL CYCLES FOR 12 MONTHS.
AND IT HAPPENS AT THE AVERAGE
AGE OF 51. IN THIS COUNTRY, 50,
THAT IS, EVERY PERSON WITH AN
OVARY GOES THROUGH MENOPAUSE IN
THIS COUNTRY. AN ESTIMATED 6000
WOMEN IN THE UNITED STATES REACH
MENOPAUSE DAILY AND 1.3 MILLION
ANNUALLY, WITH AN AVERAGE LIFE
EXPECTANCY CURRENTLY BEING 81.
IN THIS COUNTRY, THAT MEANS THAT
THERE'S UP TO 40% OF LIFE TO
LIVE IN. MENOPAUSE AND THE
MENOPAUSE TRANSITION IS MARKED
BY A SUDDEN FLUCTUATION OF
HORMONES, FOR WHICH THERE ARE
RECEPTORS ALL OVER THE BODY AND
UP TO 80% ARE SYMPTOMATIC, WITH
SYMPTOMS LIKE SLEEP
DISTURBANCES, HOT FLASHES,
VAGINAL DRYNESS, MOOD, COGNITION
DISTURBANCES AND THESE AVERAGE
SYMPTOMS REALLY DO NOT LAST FOR
A SHORT PERIOD OF TIME. ON
AVERAGE, THEY LAST FOR 7 TO 10
YEARS, WITH 10% HAVING LIFELONG
SYMPTOMS. BUT THE PROBLEM REALLY
IS, IS THAT ONLY 50% OF PEOPLE
IN MENOPAUSE RECEIVE CARE IN THE
UNITED STATES TODAY, AND IT'S
EVEN WORSE FOR THOSE OF LOWER
SOCIOECONOMIC STATUS AND PEOPLE
OF COLOR. SO WHY DO WE CARE SO
MUCH? WELL, WE REALLY WANT TO
MAXIMIZE THAT QUALITY OF LIFE
FOR PEOPLE THAT LIVE GREATER
THAN ONE THIRD OF THEIR LIFE IN
MENOPAUSE. IN THE SHORT TERM,
THESE SYMPTOMS THAT ARE SUDDEN
REALLY CAUSE A NEGATIVE EFFECT
ON QUALITY OF LIFE MEASURES AT
HOME AND AT WORK, AND JUST LIKE
REBECCA BAUER-KAHAN JUST SAID,
WAS THAT IT REALLY HAPPENS AT A
TIME WHEN WOMEN ARE JUGGLING
ENORMOUS RESPONSIBILITY AT HOME
AND AT WORK. THEY'RE OFTEN AT
THE PEAK OF THEIR CAREER AND
REQUIRING HIGH LEVELS OF
EXECUTIVE FUNCTION. AND AT HOME,
THEY MAY BE TAKING CARE OF
CHILDREN STILL, BUT ALSO ELDERLY
AT WORK. WE KNOW THAT THERE'S
MORE PRESENTEEISM, THERE'S MORE
SICK DAYS TAKEN. THERE'S
ACTUALLY A STUDY OUT OF MAYO
CLINIC IN 2019 THAT ESTIMATED A
$1.8 BILLION ANNUAL LOSS TO THE
UNITED STATES ECONOMY BASED ON
MISSED WORKDAYS DUE TO. AND THIS
IS DUE TO MENOPAUSE SYMPTOMS AND
A $26 BILLION ANNUAL LOSS DUE TO
THE ECONOMIC BURDEN ASSOCIATED
WITH MENOPAUSE SYMPTOMS. FROM A
LONG TERM PERSPECTIVE, IT'S
REALLY IMPORTANT TO UNDERSTAND
THAT ESTROGEN IS PROTECTIVE TO
THE BODY AND IT IS REALLY
PROTECTIVE TO ALL THE ORGANS, SO
WHEN ESTROGEN DECLINES, WE SEE
THAT THE CHRONIC DISEASE RISK
PROFILE DRASTICALLY CHANGES,
INCREASING THE RISK OF
CARDIOVASCULAR DISEASE, BREAST
CANCER, OSTEOPOROSIS, COGNITIVE
IMPAIRMENT AND DEMENTIA. SLEEP
AND MOOD DISORDERS. SO THE
BOTTOM LINE IS THAT THERE IS A
WINDOW OF OPPORTUNITY THAT
EXISTS DURING EARLY MENOPAUSE TO
REALLY OPTIMIZE A PERSON'S
QUALITY OF LIFE IN THE SHORT
TERM BY TREATING SYMPTOMS, BUT
ALSO THEIR FUTURE CHRONIC
DISEASE RISK PROFILE BY USING
PREVENTATIVE MEASURES AND
CURRENTLY, THIS WINDOW REMAINS
UNADDRESSED. SO WHY DOES THIS
PROBLEM EXIST? WELL BECAUSE NO
ONE HAS REALLY BEEN TALKING
ABOUT IT UNTIL RECENTLY.
MENOPAUSE HAS BEEN STIGMATIZED
AND FRAMED AS IF IT WAS A
DISEASE INSTEAD OF A NATURAL
PART OF THE WOMEN'S REPRODUCTIVE
LIFE CYCLE. THERE'S BEEN A
NEGATIVE SOCIAL STIGMA AROUND
THE IDEA OF MENOPAUSE, AND THIS
CONCERN FOR AGING AND LOSS OF
FEMINISM. PEOPLE HAVE HAD
NOWHERE TO GO. AND SO INSTEAD,
WHAT THEY DO IS THEY THEY DON'T
DO ANYTHING ABOUT IT AT ALL.
RIGHT AND THEIR HEALTH SUFFERS
FOR IT. OR THEY TRY TO NAVIGATE
THEMSELVES BY GOING ONLINE AND
TRYING TO MAKE SENSE OF ALL THAT
INFORMATION. OFTEN THAT IS
CONTRADICTORY. THERE'S A LOT OF
MISINFORMATION. OFTEN THEY MAY
START TO TAKE SUPPLEMENTS OR TRY
TO FIX IT THEMSELVES. AND THESE
SUPPLEMENTS ARE NOT FDA APPROVED
. AND THERE'S REALLY NO
REGULATION AROUND THE PURITY,
SAFETY OR EFFICACY. OR THEY MAY
ACTUALLY TRY TO GO FIND
PROVIDERS, BUT THERE REALLY
AREN'T VERY MANY PROVIDERS
CURRENTLY THAT ARE COMFORTABLE
IN CARING FOR MENOPAUSE. AND SO
THEY'RE OFTEN PRESCRIBED UNSAFE
TREATMENTS OR THEIR RISK FACTORS
ARE DISMISSED BEFORE THEY'RE
EVEN GIVEN THOSE TREATMENTS. SO
THIS REALLY BRINGS US TO THE
ROOT OF THE PROBLEM, WHICH IS I
HAVE TO SAY, PART OF IT IS THE
WHY. AND IT'S REALLY THE
KNOWLEDGE GAP THAT EXISTS WITH
PROVIDERS BECAUSE OF THE WHY. IN
PART IN 2002, THE WOMEN'S HEALTH
INITIATIVE CONCLUDED THAT THE
POTENTIAL BENEFITS OF HRT DID
NOT OUTWEIGH THE RISKS AND
SHOULD NOT BE USED FOR
PREVENTATIVE TREATMENT FOR
CHRONIC HEALTH CONDITIONS.
HOWEVER, THIS STUDY DID NOT
STUDY YOUNGER PATIENTS. THOSE
THAT ARE IN EARLY MENOPAUSE WHO
ARE VERY SYMPTOMATIC AND THAT
DID NOT REALLY STUDY THE EFFECT
OF THIS HORMONE REPLACEMENT
THERAPY ON MENOPAUSE SYMPTOMS.
BUT NEVERTHELESS, THE RESULTS
WERE WIDELY COVERED IN THE MEDIA
AND PRESENTED IN A VERY SKEWED
FASHION. DISSUADE USE AND
PRESENTING FEAR WITH USE OF HRT
FOR BOTH PROVIDERS AND PATIENTS,
AND THIS RESULTED IN A CHILLING
EFFECT CAUSING A DRAMATIC
DECLINE IN USE. FURTHERMORE THE
FDA ISSUED A BLACK BOX WARNING
AGAINST USE OF HRT, BUT SINCE
THIS TIME, FURTHER ANALYSIS HAVE
REALLY SHOWN THE BENEFITS FOR
MENOPAUSE SYMPTOMS AND THAT THE
RISK FOR HORMONE THERAPY FOR
USING IN YOUNGER POPULATIONS.
THÀNH, WHO'S HEALTHY WITH NO
HIGH RISK CONDITIONS, IS
ACTUALLY QUITE HAS A QUITE
FAVORABLE RISK PROFILE AND IS
APPROPRIATE BASED ON EXPERT
OPINION. BUT THE BIGGER PROBLEM
AS A RESULT OF THE. WHY WAS THAT
NEARLY ALL EDUCATION AND
TRAINING IN THE AREA HALTED OR
SLOWED. I PERSONALLY WENT
THROUGH RESIDENCY IN 2002 TO
2006, AND I REMEMBER ONE LECTURE
ON MENOPAUSE, AND IT WAS RELATED
TO THE WAY AND I AM NOT ALONE.
THIS WAS ALL ACROSS THE NATION
HAPPENING. MENOPAUSE IN GENERAL
STILL IS NOT PART OF THE
CURRICULUM IN MOST MEDICAL
SCHOOLS OR RESIDENCY PROGRAMS OR
LISTENERS. COULD YOU? WHY SORRY.
CAN DOUBLE HORMONE REPLACEMENT
THEORY HORMONE REPLACEMENT I'M
SORRY. HORMONE REPLACEMENT
THERAPY. YEAH AND IT HAS NOT
BEEN REALLY ADDRESSED OR IN THE
CURRICULUMS OR EVEN TAUGHT IN
TRAINING, IN THE MALE. THERE'S A
STUDY OUT OF MAYO CLINIC IN 2019
WHERE THEY DID A SURVEY OF ALL
THE RESIDENTS COMING OUT FROM
PRIMARY CARE PROVIDER
SPECIALTIES AS WELL AS OB GYN,
AND ONLY 8% FELT ADEQUATELY
PREPARED TO TAKE CARE OF
MENOPAUSE. PATIENTS SO PROVIDERS
NOT BEING TRAINED MEANS THAT
THEY DON'T WANT TO TAKE CARE OF
MENOPAUSE PATIENTS. THEY DON'T
WANT TO ASK QUESTIONS THEY DON'T
KNOW HOW TO ANSWER. AND THERE'S
A FEAR AROUND USING OR
PRESCRIBING HRT, SO THEY'RE NOT
GIVEN TO APPROPRIATE PATIENTS,
OR THEY MIGHT USE IT UNSAFELY.
AND THERE'S ALSO A LOT OF
KNOWLEDGE LOST IN UNDERSTANDING
WHAT NON-PHARMACOLOGIC OR
NONHORMONAL TREATMENTS ARE
AVAILABLE. THE OTHER REASON FOR
THE KNOWLEDGE GAP IS THAT IT'S
REALLY UNDERFUNDED. THERE'S A
HUGE SCIENCE SCIENTIFIC
KNOWLEDGE GAP, AND WE KNOW THAT
WOMEN'S RESEARCH IN GENERAL IS
UNDERFUNDED, BUT IT'S EVEN LESS
FOR THIS SPECIFIC PART OF THE
LIFESPAN WHEN YOU COMPARE IT TO
THINGS LIKE PREGNANCY, IN
GENERAL, WE NEED MORE RESEARCH
IN THIS AREA. BUT EVEN IF YOU
LOOK AT WHAT KIND OF STUDIES ARE
OUT THERE, IT'S ON WHITE WOMEN
AND HIGHER SOCIOECONOMIC
STATUSES. SO TO SOLVE THE
PROBLEM, I ALONG THIS IS JUST
THE START. BUT I ALONG WITH TWO
CERTIFIED MENOPAUSE PROVIDERS
AND OVER 30 SPECIALISTS AT UCLA,
WORKED REALLY HARD OVER THE LAST
TWO YEARS TO BUILD THE
COMPREHENSIVE MENOPAUSE PROGRAM
THAT WENT LIVE LAST SUMMER IN
THE CLINICAL ARM OF THIS
PROGRAM. AT THE CORE OF THE
PROGRAM, WE HAVE SIX CERTIFIED
MENOPAUSE PROVIDERS WHO HAVE
SPECIALIZED TRAINING IN
MENOPAUSE AND PROVIDE A PLACE
FOR PATIENTS TO GET TRUSTED
INFORMATION TO PROVIDE EFFECTIVE
TREATMENTS, WHETHER IT'S
HORMONAL, NONHORMONAL,
PHARMACOLOGIC OR
NON-PHARMACOLOGIC, AS WELL AS
ADDRESS LONG TERM HEALTH. WITH
OUR OVER 30 COLLABORATING
SPECIALISTS IN THE AREAS OF
COGNITION, HEART, BONES, BREAST
SLEEP, CANCER, SURVIVORSHIP AND
MENTAL HEALTH. AND WE'VE ALSO
PARTNERED WITH OUR INTEGRATIVE
HEALTH SPECIALISTS TO PROVIDE
WHOLE PERSON CARE. AND WE'VE
DEVELOPED A VERY STANDARDIZED
METHODOLOGY IN TERMS OF HOW TO
SEE A PATIENT USING WHAT WE'VE
CREATED, OUR MENOPAUSAL CARE
ALGORITHMS THAT HAVE BEEN CODED
FOR DECISION SUPPORT TOOL THAT
CAN REALLY HELP GUIDE HOW TO
TAKE CARE OF PATIENTS, AND NOT
IGNORING THEIR PATIENT SPECIFIC
FACTORS. ENGAGE IN THAT SHARED
DECISION MAKING AND REALLY
EMPOWER THE PATIENT TO MAKE THE
RIGHT DECISION FOR THEMSELVES.
WE HAVE A WHOLE ARM DEDICATED TO
BRIDGING THAT KNOWLEDGE GAP. WE
HAVE AN IN-DEPTH LECTURE SERIES
AND DIDACTICS TO OUR MEDICAL
STUDENTS, RESIDENCY PROGRAMS AND
FACULTY. WE ALSO HAVE A WHOLE
PATIENT EDUCATION PIECE WITH A
GROWING LIBRARY OF ASYNCHRONOUS
AND SYNCHRONOUS MATERIALS. AND
THEN ALL OF WHAT WE'RE DOING
LENDS VERY, VERY WELL TO
MEANINGFUL RESEARCH BECAUSE WE
HAVE LOTS OF CLINICAL QUESTIONS
THAT NEED TO BE ANSWERED. SO THE
RESULT HAS BEEN PROVIDERS ARE
FEELING A GREAT DEAL OF
SATISFACTION, BUT PATIENTS HAVE
REALLY APPRECIATED THE PROGRAM
AND SHOWED A GREAT DEAL OF
GRATITUDE. BUT I WILL TELL YOU
THAT EVEN THOUGH THIS SEEMS LIKE
A GREAT MODEL AND WE NEED TO
REPLICATE THIS ALL OVER
CALIFORNIA AND UNITED STATES, IT
HAS BEEN VERY CHALLENGING. I
REALLY IT REALLY HAPPENED
BECAUSE OF MY OWN STRONG PASSION
TO WANT TO MAKE A DIFFERENCE, MY
GRIT, MY DETERMINATION. BUT I
REALLY DID NOT HAVE ANY FUNDING
EXTERNALLY OR INTERNALLY TO HELP
WITH THIS PROCESS. MY CHAIR WAS
VERY SUPPORTIVE. THAT'S WHY IT
HAPPENED. SHE HAPPENS TO BE A
WOMAN, BUT WE REALLY HAD TO
UTILIZE JUST THE RESOURCES
WITHIN THE OB-GYN DEPARTMENT.
AND I REALLY DID THIS ON THE
OUTSKIRTS OF MY ENTIRE FULL TIME
JOB. SO IT REALLY TOOK A LOT OF
PASSION AND GRIT, AND I DON'T
THINK IT SHOULD BE THIS
DIFFICULT. I THINK THAT WHAT
I'VE REALIZED IS THAT PEOPLE
DON'T THINK MENOPAUSE IS
IMPORTANT IN THE INSTITUTIONS,
AND ALSO THAT I WILL BE HONEST,
THAT IT'S THERE'S LESS INCENTIVE
TO PROVIDE SUCH CARE WHEN YOU
COMPARE IT TO OB GYN PROCEDURES
AND OBSTETRICS, WHICH MAKE A LOT
MORE MONEY. SO I FIND THIS MIND
BLOWING BECAUSE HONESTLY,
THERE'S NO REASON FOR THIS TO BE
SO DIFFICULT WHEN OVER 50% OF
THE POPULATION GOES THROUGH THIS
. SO WHAT WE NEED, WHAT WE NEED
IS TO REALLY SET ASIDE FUNDING
AND SUPPORT TO START CENTERS OF
EXCELLENCE LIKE OURS ALL OVER
THE GREAT STATE OF CALIFORNIA,
BUT ALSO TO SET A GOLD STANDARD
FOR THE ENTIRE UNITED STATES. WE
NEED TO PROVIDE RESEARCH
RESOURCE GUIDES AS TO HOW TO
IMPLEMENT THIS USING SUCCESSFUL
TEMPLATES LIKE OURS. CREATE
LEGISLATION AND GUIDANCE TO
PUBLIC INSTITUTIONS TO
PRIORITIZE THIS TYPE OF CARE.
SUPPORT AND INCENTIVIZE
PHYSICIANS TO PROVIDE THIS CARE
BY REWARDING THEIR TIME AND
EFFORT PUT INTO IT. WE NEED VERY
MUCH TO DIRECT OUR RESOURCES
TOWARDS INCREASING AWARENESS AND
PUBLIC KNOWLEDGE IN THIS SPACE.
SO WE NEED TO CHALLENGE THAT
STIGMA AND NORMALIZE IT MORE IN
SOCIETY AND HELP BRIDGE THIS
TRANSITION. AND WE DO NEED TO
REALLY ADDRESS MENOPAUSE IN THE
WORKPLACE AND PROVIDE
PROTECTIONS AND POLICIES FOR
THOSE GOING THROUGH THIS.
SIMILAR TO OTHER COUNTRIES
OUTSIDE OF THE UNITED STATES,
LIKE THE UK AND AUSTRALIA. AND
FINALLY, WE DO NEED TO WORK ON
CLOSING THAT KNOWLEDGE GAP BY
INCREASING FUNDING AND SUPPORT
TO MEDICAL SCHOOLS, RESIDENCY
PROGRAMS, TO EXISTING PROVIDERS
WHO ARE TAKING CARE OF MIDLIFE
WOMEN, AND TO REALLY ADDRESS
THAT KNOWLEDGE GAP BY
PRIORITIZING FUNDING AND REALLY
INVEST IN THE MENOPAUSAL
RESEARCH AT ALL LEVELS AT THE
STATE AND THE NATIONAL LEVEL. I
THANK YOU FOR YOUR TIME, AND I
LOOK FORWARD TO QUESTIONS. ARE
YOU FULLY FUNDED? NOT NOW. NOPE
STILL NOT NOT AT ALL. STILL JUST
SCRATCHING BY. SHAME ON UCLA?
WELL, I. I YOU KNOW, ONE THING
THAT I THINK IT'S REALLY
IMPORTANT FOR US TO SAY IS THAT
WE ARE OBVIOUSLY IN TOUGH BUDGET
TIMES. THAT IS NO SECRET TO
ANYBODY WHO'S PAYING ATTENTION.
AND I DON'T THINK THIS IS AN
ISSUE OF MORE MONEY TO THESE
INSTITUTIONS. I PERSONALLY THINK
IT IS AN ISSUE OF
PRIORITIZATION, AND I THINK THAT
WE HAVE, FOR A LONG TIME,
DEPRIORITIZED WOMEN AND WOMEN'S
HEALTH. WHEN MEN WENT THROUGH
ERECTILE DYSFUNCTION THAT WAS
NOT IGNORED. BUT YET OUR
TRANSITION IS IGNORED. AND SO I
THINK THAT, YOU KNOW, WE NEED TO
LOOK AT HOW WE ARE SPENDING
MONEY AND ENSURE THAT JUST LIKE
EVERYTHING ELSE, IT IS EQUITABLE
FOR WOMEN'S HEALTH. AND I THINK
ONE OF THE POINTS YOU MADE THAT
I'M SURE WE'LL HEAR FROM OTHERS
IS THAT WHEN WE FAIL TO CARE FOR
WOMEN THROUGH THIS TRANSITION,
THE LASTING IMPACT ON WOMEN'S
HEALTH ARE INCREDIBLE. AND THIS
IS ESPECIALLY TRUE. AND YOU
TOUCHED THIS BRIEFLY FOR WOMEN
OF COLOR, WHICH I LEARNED
THROUGH THIS RESEARCH. GO
THROUGH SURGICALLY INDUCED
MENOPAUSE AT MUCH GREATER
NUMBERS MUCH EARLIER. AND HAVE
MUCH LONGER HEALTH IMPACTS. AND
SO WE'RE TAKING WOMEN OF COLOR
WHO WE KNOW HAVE NEVER GOTTEN
THE ATTENTION OF OUR FUNDING.
AND OUR RESOURCES, AND WE ARE
UNDER RESOURCING THAT RESEARCH,
THAT TRAINING AND ALL THAT GOES
WITH IT. AND SO I THINK IT IS
INCUMBENT UPON US TO LOOK AT THE
WAY OUR STATE DOLLARS ARE BEING
SPENT BY THESE INSTITUTIONS AND
ENSURE EQUITY. AND SO, YOU KNOW,
I, I DO THINK THAT THE NEXT STEP
IN OUR WORK TOGETHER IS THE
SENATOR AND I JOINT AUTHORING AN
AUDIT REQUEST TO LOOK DEEPLY
INTO THESE INSTITUTIONS AND HOW
THIS MONEY IS BEING SPENT,
BECAUSE IT IS APPALLING TO ME
THAT YOU ARE YOU ARE CARING FOR
WOMEN IN A WAY THAT WILL ENSURE
BRAIN HEALTH AND HEART HEALTH
FOR THE REST OF THEIR LIVES. AND
BY THE WAY, ESPECIALLY FOR OUR
MEDICAL PATIENTS, SAVE US
INCREDIBLE DOLLARS IF WE
ACTUALLY PREVENT THOSE IMPACTS.
AND YET WE'RE NOT RESOURCING IT
AND TAKING CARE OF THEM. AND SO,
YOU KNOW, I THINK THAT IS ONE OF
THE THINGS THAT WE MUST DO. ALL
RIGHT. AND I SEE, DOCTOR, TAMMY
ROWAN FROM UCSF, GETTING READY
TO GO. SO I WILL TURN IT OVER TO
YOU NOW AND WE'LL SEE IF YOUR
INSTITUTION IS ANY MORE
SUPPORTIVE, LET ME. HOLD ON.
WHERE IS THE PRESENTATION? YEAH,
THANK YOU SO MUCH FOR THE
OPPORTUNITY TO SPEAK. SO I'M
TAMMY SERENE ROWAN. I'M A
ASSOCIATE PROFESSOR AT UCSF, AND
I WEAR MANY HATS AT UCSF,
INCLUDING THE DIRECTOR OF OUR
SEXUAL MEDICINE PROGRAM. I'M THE
LEAD GYNECOLOGIST IN OUR IN OUR
NEWLY DEVELOPING MENOPAUSE
CLINIC, WHICH I'M TAKING LOTS OF
HINTS OF HOW TO MAKE SUCCESSFUL
BEALL. AND THEN I'M ALSO A
MEMBER OF OUR GENDER AFFIRMING
HEALTH CARE PROGRAM. AND I
ALWAYS MENTION THAT BECAUSE WHEN
WE TALK ABOUT WOMEN, I ALSO WANT
TO ADDRESS THE FACT THAT THERE
ARE PEOPLE WHO DON'T IDENTIFY AS
WOMEN WHO ALSO GO THROUGH
MENOPAUSE, AND THEY DESERVE OUR
ATTENTION AND JUST ACKNOWLEDGE
THAT AS WELL. SO I REALLY
APPRECIATED, REBECCA FARRAKHAN'S
MENTION OF TALKING ABOUT THE
VULVA AND VAGINA, AND THAT IS
I'M PUTTING THAT ON LARGE SCREEN
HERE, BECAUSE WHAT I'M GOING TO
TALK TODAY ABOUT IS SEX AND THE
VULVA AND VAGINA IN MENOPAUSE.
WE TALK A LOT ABOUT HOT FLASHES,
COGNITIVE CHANGES, BRAIN FOG,
AND THE WAY THAT AFFECTS OUR
ABILITY TO WORK. BUT WE DON'T
TALK ABOUT WHAT OUR ACTUAL SOME
PHYSICAL ASPECTS OF WHAT
MENOPAUSE DOES TO OUR BODIES AND
HOW THAT AFFECTS OUR
RELATIONSHIPS. AND I THINK THAT
THOSE ARE REALLY KEY. SO HOW
MANY SYMPTOMS ARE WE TALKING
ABOUT WHEN IT COMES TO WHAT
HAPPENS TO THE VULVA AND VAGINA?
THIS IS JUST A LIKE A SMATTERING
RIGHT. SO THERE ARE SIGNS AND
SYMPTOMS OF SOMETHING CALLED
GENITOURINARY SYNDROME OF
MENOPAUSE. SO THESE ARE THE
VAGINAL AND VULVA CHANGES THAT
ARE A RESULT OF DECREASING
ESTROGENS AND ANDROGENS.
ANDROGENS INCLUDE TESTOSTERONE
AS WELL. THOSE ARE NOT JUST
ABOUT SEX AND VAGINAL DRYNESS.
ONE OF THE MAIN SYMPTOMS IS
ACTUALLY URINARY SYMPTOMS. AND
PEOPLE GET RECURRENT UTIS. THEY
GET INFECTIONS. THESE INFECTIONS
COST LOTS OF HEALTH DOLLARS, AND
THEY CAN ACTUALLY BE TREATED
VERY SIMPLY, NOT WITH
ANTIBIOTICS, BUT ACTUALLY WITH
LOCAL HORMONES. OBVIOUSLY,
THERE'S MORE GENITAL CHANGES
THAT HAPPEN. THE TISSUE GETS
FRAGILE, PAINFUL, IT LOOKS
DIFFERENT AND IT FEELS
DIFFERENT. AND SO PEOPLE HAVE
VERY CHANGING EXPERIENCES OF
SEXUAL FUNCTION AND IN FACT,
SEXUALITY. K¾T, SEXUAL
DYSFUNCTION REALLY PEAKS AS
PEOPLE AGE, ALL RIGHT. SO THE
VAGINAL SYMPTOMS, IT USED TO BE
CALLED VULVOVAGINAL ATROPHY, AND
IT RANGES IN UPWARDS OF UP TO
90% OF PEOPLE IN VARIOUS
STUDIES. WOMEN IN THE UNITED
STATES HAVE MUCH HIGHER RATES OF
DISCOMFORT DISCUSSING THIS WITH
A PROVIDER. BUT ONE THING THAT I
THINK IS IMPORTANT IS THAT THE
SYMPTOMS OF GSM ACTUALLY CAN
OCCUR AT MANY STAGES OF THE
REPRODUCTIVE CYCLE. IT CAN
HAPPEN IN PREMENOPAUSAL
PERIMENOPAUSAL, AND IT ACTUALLY
HAPPENS IN LACTATING WOMEN
ESPECIALLY. SO THESE ARE
PREMENOPAUSAL WOMEN WHO ARE
BREASTFEED ING BECAUSE THE
BREASTFEEDING SUPPRESSES THEIR
OVARIES AND THEY DON'T HAVE
ANDROGENS AND ESTROGENS. AND
THIS IS IMPORTANT WHEN WE TALK
ABOUT MEDICAL COVERAGE, BECAUSE
THE DRUGS THAT ARE APPROVED FOR
GENITAL ATROPHY WOULD THEN THE
QUESTION WOULD BE, HOW CAN WE
GIVE THIS TO A PREMENOPAUSAL
WOMAN WHO ACTUALLY IS SUFFERING
FROM THOSE SAME SYMPTOMS? FEWER
THAN 10% OF WOMEN WITH GSM, AND
WE'RE TALKING ABOUT PROBABLY
ABOUT HALF TO THE MAJORITY. AND
I SEE GSM AT ALL STAGES. IT
HAPPENS TO WOMEN IN THEIR 40S,
50S, 60S, 70S, 80S. I SEE THEM
PRESENT AT DIFFERENT AGES, BUT
ALMOST EVERYONE IS GOING TO GET
IT AT SOME POINT. FEWER THAN 10%
ARE ACTUALLY TREATED, AND IT'S
A, IT'S A HUGE UNDERUTILIZATION,
AND IT'S PROBABLY RELATED TO A
LACK OF BOTH THE PATIENT AND
PROVIDER, KNOWING HOW TO ASK AND
ALSO WHAT MEDICATIONS ARE
AVAILABLE. SO PATIENTS ARE
UNCOMFORTABLE DISCUSSING THIS.
RIGHT. WE'RE TOLD IT'S DIRTY.
IT'S DOWN THERE. I'M TALKING IN
FRONT OF THE LEGISLATURE ABOUT
THE VAGINA AND VULVA, AND I'M
EXCITED BECAUSE THIS IS
CALIFORNIA, PROVIDERS ARE
UNCOMFORTABLE ASKING ABOUT
SYMPTOMS. THERE'S LIMITED
KNOWLEDGE ABOUT TREATMENT
OPTIONS, AND THERE'S BIG
CONCERNS REGARDING THE SAFETY OF
TREATMENT. AND THIS IS REALLY A
RESULT OF THE WOMEN'S HEALTH
INITIATIVE. WHEN THE BLACK BOX
WARNING GOT PUT ON SYSTEMIC
ESTROGEN PRODUCTS, THERE WAS
ALSO A BLACK BOX WARNING ON
LOCAL ESTROGEN PRODUCTS AS WELL,
SAYING THAT THEY ALSO CAUSE
HEART DISEASE AND BREAST CANCER
AND BLOOD CLOTS. EVEN THOUGH NO
STUDY HAS EVER SHOWN IT. AND
THERE IS NO PHYSIOLOGIC
EXPLANATION FOR HOW THAT COULD
HAPPEN GIVEN THE SYSTEMIC
ABSORPTION. RIGHT? IT'S NOT
GETTING INTO THE BLOODSTREAM,
BUT THOSE PRODUCTS HAVE A BLACK
BOX WARNING THAT PATIENTS SEE
WHEN THEY GO TO THE PHARMACY TO
PICK THEM UP. THESE MEDICATIONS
ARE ALSO CONSIDERED LIFESTYLE
MEDICATIONS. AND SO WHEN THEY
ARE GOING UP FOR APPROVAL OR
COVERAGE, IT'S THIS IS FOR
LIFESTYLE. THIS IS QUALITY OF
LIFE. AND I WILL ARGUE THAT
RECURRENT UTIS SEPSIS FROM THOSE
IS NOT A LIFESTYLE. BUT ALSO SEX
IS NOT ABOUT LIFESTYLE, IT IS
ABOUT RELATIONSHIPS. AND IF YOU
LOOK AT RESEARCH, 75% OF WOMEN
WILL SAY THAT SEX IS INCREDIBLY
IMPORTANT TO MAINTAINING A
HEALTHY RELATIONSHIP. AND
HEALTHY RELATIONSHIPS ARE HUGE
DRIVERS AND QUALITY OF LIFE AND
PEOPLE'S SEXUAL HEALTH RELATES
VERY MUCH TO THEIR OVERALL
PHYSICAL HEALTH. AND THEN
ADDITIONALLY, THERE ARE HUGE
COST BARRIERS TO TREATMENT. AND
SO WHILE WE SAY THAT THERE IS
APPROVAL, RIGHT. SO EVEN FOR
PUBLIC INSURANCE, THEY WILL SAY
THAT A DRUG IN THIS CATEGORY
THREE IS APPROVED. THAT DOESN'T
MEAN THE RIGHT DRUG IS APPROVED
FOR OUR PATIENT. SO THIS IS JUST
SHOWING A STUDY THAT I THINK IS
REALLY IMPORTANT, NOT JUST ABOUT
GSM BUT ABOUT SEXUAL DESIRE. SO
THIS WAS A RESEARCH DONE FROM
SOMEONE AT UCSF, AND IT WAS
PUBLISHED. IT WAS THE LARGEST
STUDY LOOKING AT SEXUAL
DYSFUNCTION. AND I SHOW THIS
BECAUSE I WANT YOU TO LOOK AT
THIS IS ALL TYPES OF SEXUAL
DYSFUNCTION. AND IT'S DESIRE
AROUSAL. AND THEN ANY SEXUAL
DYSFUNCTION. AND YOU CAN SEE
WHERE DOES IT PEAK IN THE 50S.
AND WHAT I ALWAYS EXPLAIN TO MY
PATIENTS IS IT'S NOT BECAUSE AS
PEOPLE GET OLDER THEY'RE
NECESSARILY HAVING BETTER SEX
AND THEIR SEXUAL FUNCTION GOES
DOWN. IT'S BECAUSE THIS
SIGNIFICANT CHANGES THAT HAPPEN
IN THE MENOPAUSE TRANSITION
AFFECT EVERY ASPECT OF
SEXUALITY. AND THAT REALLY
AFFECTS PEOPLE'S LIVES. AND I
HAVE PATIENTS CRYING IN MY
OFFICE EVERY WEEK ABOUT THE
SEXUAL CHANGES THAT ARE
HAPPENING BECAUSE OF MENOPAUSE.
SO WHAT ARE THE LIMITATIONS? SO
FOR SEXUAL DESIRE LÀ IN
MENOPAUSE, THE FDA APPROVED
MEDICATIONS ARE ONLY FOR
PREMENOPAUSAL WOMEN. SO THEY ARE
NOT APPROVED FOR POST-MENOPAUSAL
WOMEN WHO HAVE THE HIGHEST RATES
OF SEXUAL DYSFUNCTION. AND THE
REASON FOR THAT IS THAT IN ORDER
TO GET A DRUG APPROVED BY THE
FDA FOR SEXUAL PROBLEMS, IT HAS
TO GO THROUGH THE SAME
COMMITTEES THAT WOULD APPROVE
HORMONE THERAPY, RIGHT. BUT EVEN
THOUGH THESE ARE PSYCHOTROPIC
MEDICATIONS, THEY ACTUALLY WORK
ON SEROTONIN RECEPTORS. PROZAC
DIDN'T YOU DIDN'T HAVE TO PROVE
THAT PROZAC DOESN'T CAUSE BREAST
CANCER, BUT YOU HAVE TO PROVE
THAT THESE DRUGS DO, BECAUSE SEX
IS CONSIDERED PART OF THE
HORMONE THERAPY ARM. MANY WOMEN
ARE SEEKING OFF LABEL
MEDICATIONS, ESPECIALLY
TESTOSTERONE, WHICH IS NOT
APPROVED FOR WOMEN. BUT THERE IS
SIGNIFICANT EVIDENCE FOR USE. IT
WAS ACTUALLY IT WENT TO THE FDA
IN THE MID TO LATE 2000. AND
THEY SAID, WE ACKNOWLEDGE THAT
IT WORKS, BUT WE DON'T HAVE
SAFETY DATA BECAUSE NO HORMONE
THERAPY WAS GOING TO GET
APPROVED IN THE WAKE OF THE WHI,
THE LACK OF APPROVED PRODUCTS
LEAVES MANY TO SEEK CARE WITH
PEOPLE WHO DO NOT FOLLOW ANY
GUIDELINES ON PRESCRIPTIONS AND
EXPOSE OUR PATIENTS TO HARM. AND
WE CAN TELL YOU LOTS OF STORIES
OF THE HARMFUL TREATMENTS PEOPLE
ARE GETTING FOR SEXUAL
DYSFUNCTION IN MENOPAUSE. SO
RECOMMENDATIONS. I THINK IT'S
REALLY IMPORTANT TO CONSIDER THE
DIFFERENT TYPES OF MEDICATIONS
THAT ARE OUT THERE FOR GSM,
THERE'S LOCAL VAGINAL HORMONES
AND THEY COME IN DIFFERENT
FORMS. SO THERE'S ESTRADIOL AND
THEN THERE'S ALSO PRASTERONE
WHICH IS A PRO PRE HORMONE.
BASICALLY OR PRO HORMONE DHEA.
THAT'S LOCAL. THERE'S ALSO
MEDICATIONS THAT CAN BE TAKEN
ORALLY TO HELP GSM. AND THESE
ARE GREAT FOR MY RADIATION
PATIENTS I DO A LOT OF
SURVIVORSHIP FOR PATIENTS WITH
CANCER. AND THEY NEED ORAL MEDS.
SO AS I SAID THE RIGHT
MEDICATION FOR THE RIGHT PATIENT
AND MANY OF THE LAWS THAT WE
HAVE IN THE COVERAGE IS REALLY
ONE MEDICATION FROM THIS CLASS.
CREAMS WELL, WE CAN'T GIVE
CREAMS TO WOMEN WITH HORMONE
SENSITIVE BREAST CANCER BECAUSE
THOSE ARE MORE LIKELY TO GET
ABSORBED. I WANT TO GIVE THEM A
LOWER DOSE VAGINAL ESTROGEN.
THEY CAN'T ACCESS IT. THEIR
INSURANCE WON'T COVER IT. AND SO
WE NEED TO HAVE MORE COVERAGE
FOR A VARIETY OF MEDICATIONS. WE
NEED COVERAGE FOR PERIMENOPAUSAL
WOMEN TO GET ACCESS TO THE FDA
APPROVED MEDICATIONS FOR LOW
DESIRE FOR, THEY ARE FDA
APPROVED IN PREMENOPAUSE, SO
PERIMENOPAUSE DOES QUALIFY, BUT
THERE'S VERY LIMITED COVERAGE
FOR THESE MEDICATIONS. AND THIS
IS AND THIS IS, YOU KNOW,
DIFFERENT, WELL, PEOPLE ALWAYS
ASK ME, IS THIS DIFFERENT THAN
WHAT'S APPROVED FOR MEN? I'M
ACTUALLY MARRIED TO A SEXUAL
MEDICINE EXPERT UROLOGIST, AND I
SPEND A LOT OF TIME TALKING
ABOUT THE RESEARCH AND THE DATA
AND THE COVERAGE FOR MEN VERSUS
WOMEN, HE'D BE HAPPY TO TESTIFY,
TOO, BECAUSE HE'LL. HE ARGUES
WITH ME THAT IT'S THE SAME FOR
MEN. IT'S NOT TRUE, WE NEED
REGULATION AND OVERSIGHT FOR OFF
LABEL USE OF HORMONES, FOCUSING
ON THE ROLE OF PROFESSIONAL
GUIDELINES FOR OFF LABEL USE.
TESTOSTERONE IS NOT GOING AWAY.
THERE WILL NEVER BE AN FDA
APPROVED PRODUCT. SO IF PEOPLE
ARE GOING TO BE USING IT, WE
NEED EDUCATION AND WE NEED
REGULATION FOR HOW PEOPLE ARE
USING IT. AND WITH THAT, I THANK
YOU FOR YOUR ATTENTION AND I
LOOK FORWARD TO QUESTIONS LATER
IN THE. THANK YOU VERY MUCH. I
JUST HAVE ONE QUESTION WHICH IS
YOU MENTIONED AND MAYBE I
MISHEARD YOU ARE THESE
MEDICATIONS YOU'RE TALKING ABOUT
PSYCHOTROPIC. SO THEY'RE, THEY
WORK ON NEUROTRANSMITTERS. SO WE
CALL THEM PSYCHOTROPIC. WE CALL
THEM PSYCHOTROPIC MEDICATIONS,
BASICALLY. SO THE LARGEST SEX
ORGAN IS THE BRAIN. AND SO THE
LOCUS OF DESIRE IS IN THE BRAIN.
AND THE NEUROTRANSMITTERS
SPECIFICALLY ARE DOPAMINE IS THE
MAIN NEUROTRANSMITTER. AND SO
DRUGS THAT AFFECT DOPAMINE ARE
GOING TO BE THE ONES THAT ARE
GOING TO INCREASE DESIRE. AND SO
THE FIRST FDA APPROVED
MEDICATION IS CALLED FLIBANSERIN
. IT WAS APPROVED IN 2015 UNDER
LOTS OF CONTROVERSY. I CAN TELL
THAT STORY ALL DAY LONG, IT'S
GOT DATA IN POSTMENOPAUSAL
WOMEN, BUT IT IS NOT APPROVED
FOR THEM. AGAIN, BECAUSE THE
STANDARDS OF GETTING APPROVAL
ARE SO MUCH HIGHER, EVEN THOUGH
IT'S A SEROTONIN DRUG. RIGHT. IT
WORKS KIND OF THE OPPOSITE, BUT
IN SOME WAYS TO THE SEROTONERGIC
DRUGS THAT WE'RE FAMILIAR WITH,
THE SECOND DRUG WAS APPROVED IN
2019 CALLED BREMELANOTIDE, WHICH
WORKS ON MELANOCORTIN FOUR
RECEPTORS. IT IS AN AUTOINJECTOR
FOR, AND IT ALSO IS ONLY
APPROVED FOR PREMENOPAUSAL
WOMEN, AGAIN, BECAUSE IT'S MUCH
EASIER TO GET APPROVAL FOR THEM
THAN POSTMENOPAUSAL WOMEN. THAT
IS FASCINATING. AND I THINK WE
KNOW, YOU KNOW, AND THERE HAS
BEEN AND SENATOR EGGMAN HAS DONE
WORK ON THE HEALTH OF PEOPLE AS
THEY AGE AND AS YOU MENTIONED,
WE KNOW THAT OUR SENIORS AGE,
WITH BETTER BRAIN HEALTH AND
OTHER THINGS WHEN THEY ARE IN
RELATIONSHIP. RIGHT WHEN THEY
ARE NOT. YOU KNOW, LONELINESS IS
A REAL INDICATOR OF PROTECTIVE
FACTOR. YES. SO I THINK IT'S
REALLY CRITICAL THAT WE LOOK OUT
FOR THAT. SO THANK YOU. THANK
YOU. I WANT TO ACKNOWLEDGE THAT
WE'VE BEEN JOINED BY THE CHAIR
OF HEALTH ON THE ASSEMBLY SIDE,
SALLY MEMBER MIA BONTA. DOCTOR
WEBER. GOOD MORNING. THANK YOU
SO MUCH FOR BOTH OF THOSE
PRESENTATIONS. I WAS JUST
WONDERING FROM FOR EITHER ONE OF
YOU WHO'S, PREVIOUSLY SPOKE,
WHAT IS IT THAT YOU THINK THAT
WE COULD DO BETTER AT THIS STATE
LEVEL? BECAUSE A LOT OF WHAT
YOU'RE REFERRING TO IS, EITHER
WE NEED MORE STUDIES. THE FDA
NEEDS TO MOVE QUICKER, AS FAR AS
YOU KNOW, MED SCHOOL TRAINING
AND CURRICULUM THAT'S REALLY
UNDER THE PURVIEW OF ACGME. AND
YOU KNOW, ACOG GUIDELINES AS TO
WHAT OUR RESIDENTS SHOULD BE
TRAINED IN. BUT AS FAR AS FROM A
STATE'S PERSPECTIVE, GIVEN THE
FACT THAT THIS IS A FIELD THAT
IS SO I MEAN, IT'S COMPLETELY
EVOLVING SO QUICKLY. I MEAN,
WHEN I WAS A RESIDENT, WE DIDN'T
HAVE HALF THE THINGS THAT WE
HAVE TODAY. AND WE WANT TO
ENSURE THAT WE'RE DOING ALL THAT
WE POSSIBLY CAN FROM THE STATE
IN A SAFE MANNER BECAUSE, LIKE
YOU SAID, PATIENTS ARE SEEKING
THESE THINGS OUT. AND OFTENTIMES
GOING TO PEOPLE WHO ARE
UNTRAINED AND GETTING ALL OF
THESE, YOU KNOW, NON FDA
APPROVED BIOIDENTICAL HORMONES
AND PUTTING THEMSELVES AT
INCREASED RISK FOR OTHER THINGS
LIKE, YOU KNOW, UTERINE CANCER.
SO WHAT IS IT THAT YOU THINK
THAT WE COULD TAKE AWAY TODAY
THAT WE COULD DO FROM A STATE
PERSPECTIVE? WELL, I THINK THAT
ONE OF THE BIG THINGS IS REALLY
NUMBER ONE, RAISING AWARENESS,
BECAUSE I DO THINK THAT WE NEED
TO SPEND EFFORT AND TIME AND
MONEY ON JUST AWARENESS OF THAT
MENOPAUSE. WHAT IS MENOPAUSE,
FIRST OF ALL, WHAT IS THE WHAT
ARE THE SYMPTOMS THAT ARE
ASSOCIATED IT HOW DOES IT IMPACT
SHORT TERM LONG TERM HEALTH?
JUST EDUCATION. BUT ALSO I DO
THINK THAT THERE HAS TO BE
EFFORT PLACED AND PRIORITY
PLACED ON THE INSTITUTIONS TO
THEY GET THE MONEY, BUT THEN
WHAT DO THEY DO WITH THE MONEY
AND, AND YOU KNOW, I DON'T THINK
LIKE YOU SAID, IT'S NOT
NECESSARILY THAT THEY'RE NOT
GETTING MONEY, BUT THEY'RE NOT
PRIORITIZING, THIS AND I'M NOT
I'M NOT SURE FROM THE STATE
LEVEL HOW THAT CAN BE SORT OF
INCENTIVIZED TO THE INSTITUTIONS
OR MANDATED OR, YOU KNOW,
BECAUSE I DON'T THINK THAT THIS
IS GOING TO WORK WHERE WE JUST
LEAVE IT TO THE INSTITUTIONS TO
FIGURE IT OUT, IT DEPENDS WHO'S
RUNNING THE PLACE. AND I WOULD
ALSO ADD THAT MY UNDERSTANDING
IS THAT THERE THE STATE DOES
HAVE THE POWER IN SOME WAYS TO
MANDATE COVERAGE FOR CERTAIN
TYPES OF TREATMENTS. AND SO ONE
OF THE FOCUSES THAT I REALLY
WANTED TO EMPHASIZE IS THAT WE
NEED TO EXPAND COVERAGE FOR THE
RIGHT MEDICATION, FOR THE RIGHT
PATIENT, AND, AND THERE'S
DIFFERENT MEDICATIONS THAT
TARGET DIFFERENT ASPECTS OF THE
MENOPAUSE TRANSITION. YEAH. AND
I WANT TO HIGHLIGHT, THESE TWO
LADIES OVER HERE BECAUSE THEY DO
HAVE A BILL THAT DOES EXPAND
COVERAGE, BUT I THINK EVEN WITH
THAT ONE, ONE OF THE CONCERNS
WAS ORIGINALLY WAS LIKE BIO
IDENTICAL HORMONES, WHICH IS
VERY BROAD. AND IT'S LIKE, OKAY,
WE NEED TO BRING IT BACK TO FDA
APPROVED BIOIDENTICAL HORMONES,
SO, YOU KNOW, WE ARE I THINK
IT'S A GREAT BILL, AND SO I
THINK THAT BUT THE AND THERE ARE
THERE ARE OTHER CATEGORIES OF
MEDICATIONS ALSO, THAT I THINK
FIT INTO THE MENOPAUSE
TRANSITION THAT COULD BE
CONSIDERED. AND I DEFINITELY
AGREE THAT THIS THE KIND OF
EXPLAINING WHAT BIOIDENTICAL
HORMONES MEANS FROM THE LAY
PERSON'S MIND VERSUS THE
PHYSICIAN OR CLINICIANS
UNDERSTANDING, IS A LITTLE BIT
DIFFERENT. THANK YOU. AND I'LL
JUST ADD ON THAT, ONE OF THE
THINGS THAT WAS CHALLENGING
ABOUT DRAFTING THAT BILL IS
THERE IS NOT CONSENSUS RIGHT
NOW. SO WHEN YOU DRAFT A BILL
AND SAY MENOPAUSAL CARE, WE KNEW
WE WERE LEAVING THAT IN THE
HANDS OF THE PLANS. AND SO YOU
HAVE TO THAT IS PART OF OUR, YOU
KNOW, CHALLENGE IN ALL OF THIS
BECAUSE WHEN WE DON'T HAVE
CONSENSUS AROUND WHAT SHOULD BE
COVERED, AT WHAT STAGE IN LIFE,
IT IS HARDER TO ENSURE THAT THE
RIGHT THINGS ARE PROTECTED. BUT
THAT'S THE WORK THAT WE HAVE
AHEAD OF US. AND I KNOW DOCTOR
WEBER HAS BEEN A HUGE HELP IN
THAT. YEAH. AND I THINK AND
THAT'S AGAIN, ONE REASON WHY I'M
ASKING, BECAUSE A LOT OF THIS
HAS TO BE FLESHED OUT FROM
STUDIES AND WHAT, YOU KNOW, FDA
APPROVED, EVEN THOUGH THIS IS,
YOU KNOW, VERY VARIABLE. THIS IS
ONE OF THE, THE AREAS IN
MEDICINE WHERE IT IS VERY
INDIVIDUALIZED. RIGHT? IT'S NOT
LIKE A ONE SIZE FITS ALL, BUT WE
DO NEED MORE INFORMATION ABOUT
ABOUT THIS. AND UNFORTUNATELY,
WHAT HAS HAPPENED WITH THE WAC
STUDY THAT REALLY JUST KIND OF
HALTED THINGS. SO, BUT JUST
WONDERING WHAT YOUR THOUGHTS
WERE, WHAT WE COULD DO MORE FROM
THE STATE LEVEL. THANK YOU. AND
THAT'S WHAT, DECEMBER AND I WERE
JUST SAYING THAT THAT HOPEFULLY
DOING AN AUDIT ON WHAT THE
PERCENTAGE OF THE FUNDING IS
GOING FOR EVERYTHING. AT LEAST
WE CAN GET A BASELINE. LOOK, AND
THEN WE CAN START ORDERING IF WE
NEED TO. ALL RIGHT. WE'RE GOING
TO MOVE ON NOW WITH, DR. DOCTOR
KATRINA MITCHELL, BREAST SURGEON
AT SUTTER. THANK YOU. SO IS
THIS. YEAH. THANK YOU FOR THE
OPPORTUNITY TO BE HERE TODAY, MY
NAME IS KATRINA MITCHELL. I'M A
BREAST SURGEON AND LACTATION
CONSULTANT AND PERINATAL MENTAL
HEALTH PROVIDER IN SANTA
BARBARA. AND I'M GOING TO BE
SPEAKING BRIEFLY HERE ON THE
UNIQUE NEEDS OF BREAST CANCER
PATIENTS IN RELATION TO THE
HORMONAL CHANGES THEY EXPERIENCE
IN THEIR BREAST CANCER CARE.
LET'S SEE. OH, OKAY, SO THIS IS
JUST KIND OF THE AGE SPAN OF THE
PATIENTS THAT I TOOK CARE OF IN
2023. AND AND YOU'LL SEE THAT
THE OVER 50 AGE GROUP THAT'S
LARGER SEE MY BREAST CANCER
PATIENTS. SO I WILL SAY I HAVE A
HANDFUL OF LACTATING PATIENTS IN
THEIR EARLY 50S, UNDER 50. THIS
IS LARGELY MY PERINATAL MENTAL
HEALTH AND LACTATION POPULATION,
BUT UNFORTUNATELY, WITH THE
INCREASING PREVALENCE OF YOUNG
WOMEN'S BREAST CANCER,
UNFORTUNATELY THERE IS A DECENT
PROPORTION OF THESE PATIENTS
THAT ARE ALSO MY BREAST CANCER
PATIENTS. AND IN FACT, PATIENTS
THAT OVERLAP WITH LACTATION AND
BREAST CANCER. SO THIS IMAGE
HERE IS ACTUALLY ONE OF MY
PATIENTS FROM ENGLAND WHO WAS
BREASTFEEDING HER TODDLER AT THE
TIME OF HER RIGHT BREAST CANCER
DIAGNOSIS, AND SHE HAD A RIGHT
MASTECTOMY AND CONTINUED TO
BREASTFEED HER. HER BABY DURING
THAT TIME. SO THIS IS IMPORTANT
BECAUSE WITH VERY FEW
EXCEPTIONS, BREAST CANCER
PATIENTS WILL RECEIVE
CHEMOTHERAPY AND OR ENDOCRINE
THERAPY, WHICH IS HORMONE
BLOCKING MEDICATION THAT RESULTS
IN PREMATURE MENOPAUSE OR
WORSENING OF THEIR EXISTING
SYMPTOMS. SO EVERY DAY I HEAR
PATIENTS TALK ABOUT VAGINAL
DRYNESS, URINARY COMPLAINTS.
JOINT PAIN IS A HUGE ONE. HAIR,
SKIN AND NAIL CHANGES, LIBIDO,
SEXUALITY, CONCERNS ENERGY,
COGNITION, THE BRAIN FOG WE'RE
TALKING ABOUT. THIS HAPPENS TO
WOMEN, EVEN IN THEIR 30S AND
20S, WHEN THEY'RE UNDERGOING
BREAST CANCER CARE, AND THIS
PATIENT HERE IS MIRIAM DANCE.
SHE'S ONE OF MY PATIENTS WHO
BECAME THE FACE OF THE BREAST
CANCER RESEARCH FOUNDATION AD
CAMPAIGN IN 2021. AND I HAVE
THIS FRAMED IN ONE OF MY EXAM
ROOMS, AND I LOOK AT IT EVERY
DAY AND THINK ABOUT WHAT CAN WE
DO BETTER FOR MIRIAM AND FOR
PATIENTS LIKE HER? SO THESE ARE
OUR NON-OPERATIVE REQUIREMENTS
FOR OUR BREAST SURGICAL ONCOLOGY
FELLOWSHIP. AND AS YOU CAN SEE,
NONE OF THESE RELATE TO HELPING
PATIENTS WITH THE MAIN SIDE
EFFECT OF OUR THERAPY, WHICH IS
THE HORMONAL CHANGES.
FORTUNATELY, THERE IS INCREASING
RESEARCH AND AWARENESS OF THE
FACT THAT VAGINAL ESTROGEN
THERAPY IS SAFE FOR BREAST
CANCER SURVIVORS, BUT I THINK,
AS DOCTOR ROWAN HAD MENTIONED,
THAT COVERAGE CAN BE VARIABLE.
SO THE LOWER DOSES OF VAGINAL
ESTROGEN THAT WE WANT TO USE IN
SOME OF THESE PATIENTS IS
PROHIBITIVELY EXPENSIVE, IN
TERMS OF PATIENTS ACTUALLY
UTILIZING THIS CARE. AND I'M
ALSO SO GLAD THAT SHE MENTIONED
THE GENITOURINARY SYNDROME OF
LACTATION, BECAUSE THIS IS, I
THINK, PROBABLY EVEN MORE
UNDER-RECOGNIZED, COMPARED TO
THE GENITAL URINARY SYNDROME OF
MENOPAUSE, THOUGH, THE SYMPTOMS
ARE THE SAME. AND FORTUNATELY,
THIS IS STARTING TO BE MORE
TALKED ABOUT IN THE
BREASTFEEDING LACTATION MEDICINE
WORLD. BUT WE STILL HAVE A LONG
WAY TO GO. SO WHEN I THINK ABOUT
WHAT LEGISLATURA THÀNH CAN DO TO
IMPROVE THESE BARRIERS TO CARE
AND EDUCATION, I REALLY THINK
ABOUT DIVERSIFYING THE PHYSICIAN
AND PROVIDER WORKFORCE, THIS IS
MY OR SCRUB NAKURA AND MY
MEDICAL ASSISTANT MARIA, AND
THEY BOTH WANT TO FURTHER THEIR
MEDICAL EDUCATION BUT HAVE
DIFFERENT CHALLENGES TO DO SO.
AND I JUST THINK ABOUT WHERE WE
WOULD BE TODAY IF PEOPLE LIKE
NAKURA AND MARIA HAD A SEAT AT
THE TABLE TO BEGIN WITH. AND I
REALLY, ACTUALLY CAN'T BE HERE
TODAY WITHOUT JUST MENTIONING
ONE SLIDE ON THIS TOPIC THAT
BEYOND THE HORMONAL CHANGES WITH
BREAST CANCER CARE, THERE'S A
HUGE PSYCHOSOCIAL IMPACT OF CARE
RELATED TO BREAST CANCER
RECONSTRUCTION. SO THIS IS MY
COLLEAGUE MARK SUAREZ, WHO WAS
THE LAST PLASTIC SURGEON BETWEEN
LOS ANGELES AND SAN FRANCISCO TO
OFFER INSURANCE COVERAGE FOR
BREAST CANCER, RECONSTRUCTIVE
SURGERY. HE RECENTLY HAD TO DROP
THIS COVERAGE BECAUSE THE
PROVIDER REIMBURSEMENTS ARE SO
LOW THAT HE COULDN'T AFFORD TO
KEEP HIS PRACTICE OPEN. SO NOW,
IF A PATIENT NEEDS A MASTECTOMY
IN THE CENTRAL COAST REGION,
THEY EITHER HAVE NO
RECONSTRUCTION, THEY HAVE TO PAY
CASH, OR THEY HAVE TO GO TO LOS
ANGELES OR SAN FRANCISCO. SO IF
ANYONE WANTS TO TALK SEPARATELY
ABOUT THIS AFTER, I'M HAPPY TO
DO THAT AS WELL, SO JUST IN
CONCLUSION, MANY SPECIALTIES
INTERACT WITH PATIENTS AT TIMES
OF HORMONAL CHANGE AND OFTEN
HAVE NO EDUCATION ON THE TOPIC.
SO I THINK WHEN WE'RE TALKING
ABOUT JUST EXPANDING ACCESS AND
EXPANDING, UNDERSTANDING, IT'S
BEYOND OB-GYNS AND REALLY JUST
SHOULD BE ACCESSIBLE TO ALL
PROVIDER EDUCATION. AND WE DO
NEED INCREASED AWARENESS
REGARDING SAFETY INFORMATION FOR
VAGINAL ESTROGEN, EVEN AMONG
PEOPLE LIKE PHARMACISTS THAT MAY
WARN PATIENTS THAT THEY
SHOULDN'T TALK ABOUT CREAMS AND
SUCH. RIGHT, RIGHT. VAGINAL
ESTROGEN. YEAH BUT THEY LIKE
THEY, DOCTOR, ROWAN SAID WE
THERE'S BLACK BOX, BLACK BOX
WARNINGS. SO YOU. DOCTOR ROWAN
MENTIONED ESTRADIOL WHEN SHE WAS
TALKING ABOUT VAGINAL ESTROGEN.
SO ARE THE PATCHES ALSO
CONSIDERED VAGINAL ESTROGEN
PATCHES ARE. YEAH, DIFFERENT.
SORRY. I JUST WANT TO MAKE SURE
WE ALL ARE TALKING ABOUT THE
SAME THING. YEAH. SO THERE'S A
DIFFERENCE BETWEEN SYSTEMIC
HORMONES AND LOCAL HORMONES. BUT
THE HORMONES WERE MAINLY TALKING
ABOUT ARE ESTRADIOL. SO WHEN YOU
HAVE A PATCH THAT'S GOING INTO
YOUR BLOODSTREAM TO HELP WITH
HOT FLASHES, COGNITIVE CHANGES,
SLEEP DISTURBANCES, WHEN YOU
HAVE VAGINAL SYMPTOMS, WE
RECOMMEND PLACING THE ESTRADIOL
DIRECTLY INTO THE VAGINA AND
THAT IT'S NOT GOING TO ABSORB AS
MUCH. AND SO THAT IS THE CREAMS
THAT WE'RE TALKING ABOUT. BUT
THE MAIN THING TO UNDERSTAND IS
THERE'S ACTUALLY SEVERAL
DIFFERENT ESTRADIOL PRODUCTS.
THE CREAMS ARE THE ONES THAT
ABSORB THE MOST AND THE ONES WE
DON'T RECOMMEND FOR BREAST
CANCER PATIENTS. SO THERE ARE
TABLETS AND THERE IS A RING, AND
THERE ALSO IS A TABLET OF
PRASTERONE. SORRY, I KNOW YOU
KNOW THIS AS WELL, BUT THERE'S
DIFFERENT PRODUCTS AND
UNFORTUNATELY COVERAGE USUALLY
ONLY IS FOR ONE OF THE CREAMS
AND THOSE ACTUALLY ARE NOT SAFE
FOR BREAST CANCER PATIENTS. AND
THEN IT'S TOO EXPENSIVE TO GET
ANY OF THE ALTERNATIVES. OKAY
AND CAN YOU GET A PATCH AND
CREAM. NOT A BREAST CANCER
SURVIVORSHIP OKAY. BECAUSE THE
PATCH WILL BE SYSTEMIC ESTROGEN.
AND WE'RE TALKING ABOUT
RELIEVING THE SYMPTOMS IN THE
GENITAL URINARY TRACT OKAY. BUT
FOR TRADITIONAL MENOPAUSE
ABSOLUTELY. COVERAGE FOR
INSURANCE COVERAGE YOU CAN
BECAUSE THEY ARE TREATING TWO
DIFFERENT SYMPTOMS. NOW
SOMETIMES PHARMACISTS DON'T
UNDERSTAND THAT. AND SO THEY'LL
BE GIVING PATIENTS WARNINGS. BUT
THIS IS LIKE THE SYMPTOMS OF
LIKE I SAID THE SYSTEMIC
SYMPTOMS. THAT'S WHERE THE
SYSTEMIC TREATMENT GOES. HOT
FLASHES BRAIN FOG. BUT THE
GENITAL URINARY SYMPTOMS THAT'S
LOCAL. AND BOTH ARE SAFE TO
COMBINE TOGETHER IF YOU DON'T
HAVE A HORMONE SENSITIVE CANCER.
THANK YOU. SORRY TO STOP YOU,
BUT NO, I'M GLAD. I'M GLAD YOU
ASKED BECAUSE THIS IS PART OF
BREAKING THE SILENCE ABOUT
EVERYTHING. AND I ACTUALLY HAVE,
AFRAID I'LL FORGET MY QUESTION.
I HAVE A FRAMED, IN BOTH OF MY
EXAM ROOMS AND MY LACTATION ROOM
AND MY BREAST CANCER ROOM THAT
SAYS, ASK ME ABOUT VAGINAL
ESTROGEN. AND I THINK IT'S
REALLY HELPFUL FOR BREAKING THE
SILENCE AND JUST HAVING PATIENTS
SAY, OH, OKAY, THIS IS UP THERE,
WE NEED TO ASK ABOUT IT. AND
PEOPLE DO EVERY SINGLE DAY, WHAT
HAVE YOU FINISHED? I HAVE MORE
OF MY COLLEAGUES WANT TO ASK
QUESTIONS, BUT WE'LL HAVE YOU
FINISH, AND THEN WE'LL GET TO
THE QUESTIONS FOR THIS, SO WE
JUST TALKED ABOUT THE COST OF
VAGINAL ESTROGEN, BEING
PROHIBITIVE, FOR MANY, MANY,
MANY PATIENTS, AND JUST THE
IMPACT OF CARE IS NOT HORMONAL,
ONLY WE NEED TO ADDRESS ACCESS
TO CARE ISSUES AND BREAST
RECONSTRUCTION IN RURAL
COMMUNITIES. SO IF ANYONE HAS
ANY ADDITIONAL QUESTIONS, THIS
IS MY WEBSITE AND IT IS
DEDICATED TO BREASTFEEDING AND
PERINATAL MENTAL HEALTH. AND THE
INTERSECTION OF BREAST CANCER
AND LACTATION. SO PLEASE REACH
OUT. THANK YOU SO MUCH. THANK
YOU TO ALL THREE PHYSICIANS AND
I, SENATOR RUBIO, THANK YOU. AND
I KNOW WE'RE HERE TO BREAK THE
CYCLE OF SILENCE HERE. BUT
EARLIER YOU SAID I'M NOT SURE
WHO MADE A STATEMENT. LIKE
THERE'S SO MANY STORIES I CAN
TELL YOU ABOUT WOMEN GOING, YOU
KNOW, OFF, OFF THE COUNTER AND
THESE EFFECTS THAT, THAT ARE
HAVING ON WOMEN CAN GIVE US AN
EXAMPLE. I KNOW, I HEARD
SOMETHING LIKE IT'S TERRIBLE
STORIES, BUT THIS IS WHY WE'RE
HERE. I WANT TO HEAR EXAMPLES OF
WHEN WOMEN GO OUTSIDE A DOCTOR
TO, YOU KNOW, GET THESE, YOU
KNOW, PRODUCTS THAT ARE NOT
APPROVED. GIVE US EXAMPLE, LIKE
MAYBE TOP TWO HORRIFIC STORIES
THAT YOU'VE HEARD OF WOMEN
HAVING TO GO OUTSIDE A DOCTOR
AND THEN THE EFFECTS. WELL, I
MEAN, THE BIGGEST ONE THAT COMES
TO MIND AND IT'S STILL GOING TO
A PROVIDER, BUT NOT NECESSARILY
SOMEONE WHO'S TRAINED TO PROVIDE
EVIDENCE BASED MEDICINE, BUT
IT'S REALLY PELLET USE. I THINK
ALL OF US HERE TESTOSTERONE
PELLETS AND YEAH, TESTOSTERONE
PELLETS. BUT EVEN, YOU KNOW,
ESTROGEN AND PROGESTERONE
PELLETS AND SOMETIMES THEY'RE
ALL COMBINED IN ONE. AND THE
PROBLEM WITH PELLETS IS THAT
THEY ARE UNREGULATED ONCE THEY
GET INTO THE BODY SYSTEM. AND SO
THE SERUM LEVELS, THE LEVELS IN
THE BLOODSTREAM JUST GO
UNCHECKED. AND THEY I OFTEN SEE
TIMES WILL SEE PATIENTS WITH
TESTOSTERONE LEVELS THAT ARE
LIKE 3 TO 4 TIMES WHAT THEY
SHOULD BE, WHICH IS EXTREMELY
DANGEROUS. AND SO THAT'S AN
EXAMPLE OF LIKE A PATIENT TRYING
TO THEY'RE TRYING TO JUST GO
FIND SOMEONE WHO'S GOING TO HELP
THEM, BUT IT DOESN'T NECESSARILY
MEAN THEY'RE FINDING THE RIGHT
PROVIDERS THAT REALLY KNOW WHAT
HOW TO KIND OF MANAGE A SAFE,
LIKE, REALLY HELP THEM SAFELY. I
WOULD SAY THE OTHER THING IS
SUPPLEMENTS, BECAUSE THEY REALLY
ARE ON MULTIPLE, MULTIPLE
SUPPLEMENTS, AND A LOT OF THEM
DO HAVE ESTROGEN IN THEM, OR
FORMS OF ESTROGEN AND ALL SORTS
OF OTHER, INGREDIENTS THAT
REALLY HAVE NOT BEEN STUDIED,
BUT ALSO WE DON'T REALLY KNOW
WHAT'S IN THEM. AND SO THEY'RE
NOT REALLY REGULATED. SO CAN I
JUST ADD I'M SORRY TO INTERJECT
ON THIS BECAUSE I KNOW SOMEONE
WHO WAS TAKING THE PELLETS MANY
YEARS AGO SAYING, I'M TAKING
THEM FOR YEARS. YOU KNOW, THAT
WAS THE HER SUGGESTION IN THE
FUTURE FOR ME. AND, YOU KNOW,
CURRENTLY SHE'S GOING THROUGH
CANCER. I'M NOT SUGGESTING, BUT
IS THERE ANY CORRELATION THAT
YOU'VE SEEN SO WELL? SO I THINK
THAT, DEPENDING ON WHAT TYPE OF
CANCER SO THE THING ABOUT THE
PELLETS TO UNDERSTAND IS THAT
THE THIS IS PROBABLY MORE
MEDICAL, BUT TESTOSTERONE HAS
BEEN SHOWN TO IMPROVE LIBIDO.
IT'S THERE'S LOTS OF GUIDELINES
THAT SHOW THAT. AND IT CAN HELP
PEOPLE WITH ENERGY, MUSCLE MASS
AND VARIOUS OTHER SYMPTOMS. AND
SO WHEN WE GIVE TRANSDERMAL
TESTOSTERONE AND WE MONITOR IT
SAFELY, IT ACTUALLY IS QUITE
SAFE TO USE THE ISSUE WITH THE
PELLETS IS THAT THEY COME IN IN
SPECIFIED DOSES. THE
TESTOSTERONE LEVEL OF A WOMAN IS
ONE TENTH OF THAT OF A MAN, AND
SO MEN GET TEN PELLETS. AND SO
IN THEORY, IT MAKES SENSE TO
GIVE A WOMAN ONE PELLET. BUT THE
DIFFERENCE IS THAT DIFFERENT
WOMEN ARE GOING TO ABSORB IT
DIFFERENTLY, AND THEY'RE GOING
TO HAVE DIFFERENT SYMPTOMS. AND
SO SOME OF THEM GET VERY HIGH
LEVELS. AND THERE ARE SOME
CANCERS THAT ARE SENSITIVE TO
TESTOSTERONE. MOST BREAST
CANCER, AS FAR AS I KNOW, IS NOT
CURRENTLY BEING TESTED FOR
TESTOSTERONE RECEPTORS, BUT THAT
THERE ARE DEFINITELY HORMONE
SENSITIVE ANDROGEN RECEPTORS,
WHICH TESTOSTERONE IS AN
ANDROGEN. AND THEN THERE IS SOME
CONCERN ABOUT ANDROGENS AND
OTHER TYPES OF CANCERS AS WELL.
BUT IN GENERAL, THE DATA IS
ACTUALLY QUITE REASSURING IN
TERMS OF TESTOSTERONE NOT
CAUSING CANCER. SO I, I WOULD
ACTUALLY SAY AS AN EXPERT IN
THIS THAT I DON'T THINK
TESTOSTERONE OAN HAS A HIGH
RISK OF CAUSING CANCER. I CAN
DEFER TO, IN THE BREAST CANCER
WORLD A LITTLE DIFFERENT. YEAH,
I THINK IT'S MORE THE ISSUE OF
THE LACK OF REGULATION. AND YOU
IT'S ONE THING IF YOU'RE ABLE TO
ACTUALLY STUDY THE MEDICATIONS
AND HAVE LARGE PATIENT COHORTS
AND MAKE CLEAR DETERMINATIONS
ABOUT RISK BENEFIT. BUT WHEN YOU
HAVE PEOPLE THAT ARE PROVIDERS
THAT ARE NOT TRAINED AND
EXISTING BECAUSE OF THE VOID OF
MEDICAL EDUCATION, ON THE TOPIC
THAT THAT'S WHEN YOU GET INTO
TROUBLE. AND I CAN SAY THAT
EXISTS WITH LACTATION. ALSO,
EVEN THOUGH THE WE ARE MAMMALS
BECAUSE WE HAVE MAMMARY GLANDS,
THERE IS NO EDUCATION IN MEDICAL
SCHOOL OR ANY OTHER HEALTH
PROFESSIONS ON LACTATION. THÀNH.
AND I WANT TO ADD ALSO THAT WE
HAVE REALLY WE HAVE GOOD LONG
TERM DATA ON PATIENTS ON GENDER
AFFIRMING HORMONE THERAPY,
ESPECIALLY HIGH DOSES OF
TESTOSTERONE, THOSE HIGH DOSES,
MUCH HIGHER LEVELS THAN WHAT
WE'RE GIVING TO ANYBODY FOR
MENOPAUSAL SYMPTOMS OR LIBIDO.
THOSE STUDIES ARE QUITE
REASSURING IN TERMS OF HEALTH
SIDE EFFECTS, CARDIOVASCULAR
DISEASE, BREAST CANCER. THERE'S
ACTUALLY LOWER RATES OF BREAST
CANCER IN ONE STUDY THAT FOR
PEOPLE THAT HADN'T HAD
MASTECTOMIES ON HIGH DOSE
TESTOSTERONE THERAPY. BUT AGAIN,
IF SOMEONE GETS A CANCER THAT IS
HORMONE SENSITIVE AND THEY HAVE
A PELLET IN THEM, YOU CANNOT
TAKE THAT PELLET OUT AND IT CAN
LAST FOR MONTHS. THE OTHER KIND
OF NOT HORROR STORY, BUT ONE
THING I DO WANT TO BRING TO
ATTENTION IS THAT HORMONE
THERAPY, THE BIG CANCER THAT
HORMONE THERAPY DOES CAUSE, IS
ENDOMETRIAL CANCER, SPECIFICALLY
ESTROGEN. UNOPPOSED AND WHAT
THAT MEANS IS WHEN WE GIVE
ESTROGEN, IT STIMULATES THE
LINING OF THE UTERUS. AND IF YOU
DON'T DO SOMETHING TO OPPOSE
THAT, YOU WILL DEVELOP
ENDOMETRIAL CANCER. WHAT WE GIVE
TO OPPOSE IT IS PROGESTINS OR
PROGESTERONE. MANY PEOPLE WHO
ARE NOT TRAINED AND ARE NOT
FAMILIAR WITH THESE CANCERS ARE
GIVING PEOPLE HIGH DOSES OF
ESTROGEN, AND THEY ARE NOT
PROPERLY GIVING THEM
PROGESTERONE. THEY ARE GIVING
THEM, BIOIDENTICAL COMPOUNDED
PRODUCTS. THEY PUT THEM ON THE
SKIN. IT DOES NOT GET ABSORBED
THROUGH THE SKIN. THEY'RE GIVING
THEM SUBTHERAPEUTIC MAYBE ORAL.
HOWEVER THEY'RE DOING IT. THEY
ARE NOT GIVING THEM PROPER
PROGESTERONE. SO I HAVE
DIAGNOSED SEVERAL WOMEN WITH
CANCER, BECAUSE THEY WERE BEING
GIVEN ESTROGEN AND NOT COUNSELED
OR UNDERSTOOD APPROPRIATELY HOW
TO USE AND HOW MUCH PROGESTINS
OR PROGESTERONES THEY NEEDED.
AGAIN, WHY THIS IS SO
FRIGHTENING AND WHY WE NEED TO
DO SO MUCH WORK ON IT. AND I SEE
DOCTOR GUNTER IS ITCHING TO GET
IN. SO YOU HAVEN'T GONE YET.
BUT, DOCTOR GIBSON, GIBSON, I
JUST WANT TO NOTE ONE ANOTHER
THING THAT I SEE THAT PEOPLE ARE
DOING KIND OF ON THEIR OWN FOR
SELF-MEDICATING, ESPECIALLY FOR
MENOPAUSE SYMPTOMS LIKE SLEEP
DIFFICULTY, THE JOINT ACHES AND
PAINS, AND MOOD IS
SELF-MEDICATING WITH CANNABIS.
AND WE JUST DON'T KNOW ABOUT
KIND OF HOW HELPFUL OR HARMFUL
THAT MAY BE, OF COURSE, IF
SOMEBODY IS SMOKING ANYTHING ON
A DAILY BASIS, WHICH YOU MAY DO
IF YOU'RE HAVING SLEEP,
DIFFICULTY AND PAIN AND ANXIETY
ON A DAILY BASIS, SOME LIKELY
HEALTH CONCERNS THERE, AS WELL
AS POTENTIAL FOR, DEPENDANCE AND
CANNABIS USE DISORDER. SO THAT'S
AN AREA OF ACTIVE RESEARCH. BUT,
DEFINITELY SOMETHING THAT WE'RE
STARTING TO SEE A LOT OF HINTS
AROUND. CHAIR, MAY I ASK JUST
THIS LAST COMMENT AND I THINK
I'M SO THANKFUL THAT YOU'RE
HAVING THIS, BECAUSE JUST LIKE I
EXPLAINED TO YOU THAT I'M
GETTING ADVICE. THAT'S WHAT,
BECAUSE THERE'S NOT ENOUGH.
EVERYBODY GIVES US ADVICE. YOU
RELY ON YOUR FRIENDS TELLING YOU
WHAT TO TAKE AND WHEN TO TAKE,
AND YOU KNOW HOW IT HELPS. AND
YET WE'RE ALL RELYING ON, YOU
KNOW, JUST WORD OF MOUTH, WHICH
IS REALLY SCARY. AND SO THANK
YOU FOR PUTTING A JUST
HIGHLIGHTING THIS ISSUE. AND WE
NEED TO BRING IT TO THE
FOREFRONT. SO THANK YOU TO ALL
OF YOU FOR PUTTING THIS
TOGETHER. APPRECIATE IT. THANK
YOU. AND THANK YOU FOR THIS
PRESENTATION. VERY FAMILIAR WITH
DOCTOR MITCHELL'S WORK, AND BIG
FAN OF HERS. YOU KNOW, ONE OF
THE THINGS THAT I THINK THAT
CAME UP WAS JUST THESE DESSERTS
WE HAVE, AND SO I'M WONDERING IF
IN THE AUDIT REPORT, IN ADDITION
TO LOOKING TO FINANCE, WE CAN
THINK MORE BROADLY ALSO ABOUT
WHERE THE DESSERTS ARE. I YOU
KNOW, RURAL CALIFORNIA CERTAINLY
IS GOING TO SEE WE KNOW THIS AND
EVERY SPECIALTY AREA. THERE'S NO
QUESTION ABOUT IT. WE SEE IT ON
A REGULAR BASIS. BUT TO ONLY SAY
THAT YOU KNOW THAT OR TO ONLY
HAVE PROVIDERS IN LOS ANGELES
AND SAN FRANCISCO REALLY LEAVES
OUT, YOU KNOW, MAYBE 40% OF THE
PEOPLE THAT LIVE ON THE COAST.
THAT'S A LOT, AND THERE'S A LOT
OF DIFFERENT REASONS WHY THAT
HAPPENS. BUT I DO WANT TO
ACKNOWLEDGE THAT POINT THAT WAS
MADE AND HOW SERIOUS THAT IS IN
TERMS OF GETTING CARE, YOU KNOW,
IT'S NOT PEOPLE CAN'T ALWAYS GO
TO LOS ANGELES OR SAN FRANCISCO.
THEY CAN'T MAKE THAT TRIP. AND
THAT MEANS THAT THEY WILL BE,
YOU KNOW, THEY WILL WE WILL HAVE
LIMITS TO THE ACCESS TO CARE.
AND CERTAINLY THIS IS NOT THE
ONLY SPACE WE SEE ON A REGULAR
BASIS, PARTICULARLY IN RURAL
CALIFORNIA. SO I JUST WANT TO
ACKNOWLEDGE THAT AND THANK YOU
ALL FOR YOUR WORK AND REALLY
HELPING US THINK THROUGH THIS
ISSUE. AND SAN DIEGO, LIKE THE
BIG CITIES, RIGHT? LIKE THE BIG
CITIES. YEAH YEAH. BUT I
REPRESENT THE CENTRAL VALLEY,
RIGHT? YOU HAVE A HIGH, HIGH
DEGREE OF IMMIGRATION. YOU HAVE
A HIGH DEGREE OF POVERTY, AND
YOU HAVE A VERY LOW DEGREE OF
HEALTH CARE AND ACCESS. AND, YOU
KNOW, AGAIN, 50% OF US ARE
WOMEN. AND I'LL POINT OUT OUR
MEDI-CAL DESERTS IN OUR URBAN
ENVIRONMENTS AS WELL. SO WE HAVE
OUR OWN VERSION OF THESE HEALTH
CARE DESERTS FOR PEOPLE WHO
CAN'T AFFORD IT. I'LL TURN IT
OVER TO YEAH, I JUST WANTED TO
SPEAK SPECIFICALLY TO THE
REIMBURSEMENT RATES THAT YOU
MENTIONED, ARE YOU FINDING THAT
THERE'S A DIFFERENTIAL IN
REIMBURSEMENT RATES FOR
DIFFERENT REGIONS OF THE, OF THE
STATE THAT ARE CAUSING. ARE YOU
ASKING ABOUT THE BREAST CANCER
RECONSTRUCTION? YES. SO THE WAY
IT'S DESIGNED IS THAT THE
INSURANCE COMPANIES WANT PEOPLE
TO GO TO CENTRALIZED AREAS LIKE
LOS ANGELES OR SAN FRANCISCO,
AND BIG CENTERS. SO IN THE RURAL
AREAS, THE COMPENSATION TO
HOSPITALS THAT DON'T HAVE
COMPETITION IS HIGHER. AND THE
PHYSICIAN REIMBURSEMENT IS
INCREDIBLY LOW TO THE POINT THAT
THEY LITERALLY CAN'T AFFORD TO
KEEP THEIR PRACTICE OPEN. THEY,
YOU KNOW, MOST OF THEM, LIKE
DOCTOR SOAREZ, HE HE WAS
SUPPORTING HIS BREAST
RECONSTRUCTION PRACTICE WITH
COSMETIC, PRACTICE ON THE SIDE.
BUT THEN THERE'S JUST A POINT
WHERE WHEN YOU GET PAID $500 TO
DO A 12 HOUR, FLAP
RECONSTRUCTION FOR BREAST
CANCER, YOU JUST YOU CAN'T YOU
CAN'T DO THAT. AND WHAT'S THE
RATIONALE THAT THE INSURANCE
PROVIDERS GIVE FOR TRYING TO
CENTRALIZE, THAT'S PROBABLY, A
MORE COMPLICATED QUESTION FOR
INSURANCE COMPANIES, BUT I THINK
IT REALLY DOES HAVE TO DO WITH
THE ABILITY TO LOBBY BIGGER
HOSPITAL GROUPS CAN LOBBY THE
INSURANCE COMPANIES BETTER THAN
AN INDIVIDUAL. PHYSICIAN
PRACTICES IN RURAL COMMUNITIES.
BUT IT'S ABSOLUTELY DEVASTATING.
AND HE JUST DROPPED INSURANCE
THIS MONTH. AND IT'S AWFUL TO
TALK TO A WOMAN. AND I FEEL LIKE
THE MESSAGE IS THAT WE AS A
CULTURE AND, A MEDICAL
PROFESSION DON'T CARE ABOUT YOU,
YOU KNOW, THERE'S JUST NO OTHER
MESSAGE FOR A WOMAN TO BE
SITTING THERE WITH AN, YOU KNOW,
A REALLY LIFE CHANGING BREAST
CANCER DIAGNOSIS. AND THEN TO BE
TOLD THAT SHE, SHE'S GOING TO
HAVE TO PAY CASH OR GET NØ
RECONSTRUCTION OR, YOU KNOW, IF
YOU'RE FROM SAN LUIS OBISPO,
DRIVE ALL THE WAY TO LA OR DRIVE
ALL THE WAY TO SAN FRANCISCO IF
YOU WANT RECONSTRUCTION, WHICH
IS OBVIOUSLY AN INCREDIBLE
FINANCIAL HARDSHIP AND DELAYS
CARE. AND IS THERE A SCARCITY? I
MEAN, THE IDEA THAT YOU'D HAVE
TO GO TO LA OR SAN FRANCISCO OR
OR OR SAN DIEGO, IS IT BECAUSE
THERE'S A SCARCITY OF PROVIDERS
OR. NO, THE SCARCITY IS IN THE
FACT THAT THERE'S ENOUGH PLASTIC
SURGEONS, BUT THEY'RE REIMBURSED
SO POORLY FOR BREAST CANCER
RECONSTRUCTION THÀNH THAT THEY
DON'T ACCEPT INSURANCE. IT'S NOT
THAT IT'S A LAW, OBVIOUSLY, THAT
INSURANCE COMPANIES HAVE TO
COVER BREAST CANCER
RECONSTRUCTION, BUT THEIR
PHYSICIAN REIMBURSEMENT RATES
ARE SO LOW THAT THEY CAN'T
AFFORD TO DO THAT. BUT IN THE
LARGER AREAS, THEY CAN BECAUSE
THERE'S A LARGER LOBBY, THERE'S
THE HOSPITAL SYSTEM CAN ABSORB
THE COST OF, FOR EXAMPLE, FLAP
RECONSTRUCTION, WHERE YOU USE
YOUR OWN TISSUE TO RECONSTRUCT
THE BREAST IS THE BEST AND MOST
DURABLE RECONSTRUCTION, BUT IT
IS LABOR INTENSIVE FOR THE
HOSPITAL AND FOR THE SURGEON.
COMMERCIAL INSURERS, NOT JUST
MEDI-CAL RATES. THAT'S
COMMERCIAL INSURANCE.
COMMERCIAL? YES OKAY. YEAH.
BECAUSE MEDI-CAL PAY THE
MEDI-CAL REIMBURSEMENTS ARE
PROBABLY HORRIBLE TOO. IT'S NOT
GREAT. MEDICARE REALLY, WHICH,
YOU KNOW, THE INSURANCE THE
COMMERCIAL INSURANCE DOES FOLLOW
MEDICARE. SO THE DROP IN
PHYSICIAN REIMBURSEMENTS FOR
THAT. AND IT'S NOT THAT PEOPLE
PEOPLE THINK THAT PLASTIC
SURGEONS ARE JUST TRYING TO MAKE
A BUNCH OF MONEY ON, ON
PATIENTS. AND REALLY, THIS IS
PROVIDING SERVICE TO WOMEN AT
INCREDIBLY VULNERABLE TIMES IN
THEIR LIFE. AND IT'S JUST
DEVASTATING IN. WELL, I WANT TO
THANK YOU. I HAD A FRIEND WHO
HAD TO HAVE A COMPLETE
HYSTERECTOMY, AND SHE WAS IN
PERIMENOPAUSE, SAID TO HER
SURGEON, DOES THIS MEAN I SHOULD
GO ON HORMONES? THE SURGEON
SAID, I DON'T KNOW ABOUT THAT. I
JUST DO THE SURGERIES. AND SO
SHE DIDN'T. AND NOW SHE'S SEEING
INJURIES FROM THE JOINT IMPACTS
OF SUCH RAPID MENOPAUSE AND THE
LIKE. AND SO IT'S JUST SO
CRITICAL THAT PEOPLE WHO SEE
THESE PATIENTS THAT HAVE THESE
MEDICALLY INDUCED MENOPAUSAL
SYMPTOMS ARE TREATING THEM,
THEIR WHOLE BODY AND NOT JUST,
YOU KNOW, THE SPECIFIC THING
THEY'RE IN THERE TO DO. SO I
REALLY APPRECIATE YOUR RESEARCH
AND TALKING ABOUT IT AND THE
PUSH FOR EDUCATION AND CARE,
BECAUSE IT IS REALLY, REALLY
IMPORTANT, SO AND ONE OF THE
THINGS YOU GUYS MENTIONED THAT I
JUST WANTED TO TOUCH ON WAS SORT
OF THIS WAY IN WHICH THE
INSURANCE ONLY COVERS PEOPLE AT
CERTAIN PHASES. RIGHT? SO YOU
MENTIONED WOMEN, I THINK IN
THERE, WHO ARE LACTATING AND
THEIR NEED FOR CARE, SO DOES THE
INSURANCE COMPANY ACTUALLY
DICTATE WHEN IN SOMEONE'S LIFE
THEY CAN HAVE COVERAGE FOR THIS
SPECIFIC DRUG BECAUSE OR IS THAT
OR IS THAT BECAUSE OF APPROVAL,
FDA APPROVAL? OH, OKAY. YEAH,
IT'S FDA APPROVAL. AND SO YOU
HAVE TO BE VERY SPECIFIC. SO
AGAIN, FOR DRUGS THAT ARE,
CONSIDERED FOR MENOPAUSE. RIGHT.
SO THESE ARE LIKE THE VAGINAL
HORMONES, FOR EXAMPLE, THESE ARE
MENOPAUSAL DRUGS CONSIDERED FOR
VAGINAL DRYNESS IN MENOPAUSE. IF
YOU'RE PREMENOPAUSAL IT'S GOING
TO BE HARDER TO GET THEM. SOME
PEOPLE CAN GET COVERAGE, BUT
THEY'RE GOING TO DICTATE EXACTLY
WHICH ONES YOU CAN GET. AND SOME
OF THEM ARE A LITTLE MORE
EFFECTIVE AND ALSO MORE
TOLERATED BY PATIENTS THAN
OTHERS. AND THEN THE SEXUAL
DESIRE DRUGS THAT I MENTIONED,
THAT'S FDA APPROVAL COMPLETELY.
FDA DOES NOT APPROVE POST
MENOPAUSE, BUT VERY FEW
INSURANCES EVEN COVER FOR
PREMENOPAUSAL WOMEN. THESE
MEDICATIONS. INTERESTING. THANK
YOU. YEAH, OKAY. THANK YOU. THE
THREE OF YOU VERY MUCH. I'M SURE
WE'LL HAVE MORE QUESTIONS AS WE
MOVE ON, BUT MOVING ON, TALK
ABOUT ADDRESSING DISPARITIES.
AND WE'RE GOING TO HEAR FROM
KIMBERLY ROBINSON, COMMUNITY
LIAISON FOR BLACK WOMEN FOR
WELLNESS NORTHERN CALIFORNIA.
AND CAROLYN GIBSON, PHD, MPH,
ASSISTANT PROFESSOR, DEPARTMENT
OF PSYCHIATRY AND BEHAVIORAL
SCIENCES, UCSF. MISS GIBSON.
HELLO, EVERYONE, AND THANK YOU.
I AM HONORED TO BE A PART OF
THIS DISCUSSION AND I HAVE
LEARNED A LOT, JUST IN THE TIME
BEING HERE. SO I APPRECIATE THIS
, I AM KIM ROBINSON, THE
COMMUNITY LIAISON FOR BLACK
WOMEN FOR WELLNESS, AND I WORK
OUT OF OUR NORTHERN CALIFORNIA
OFFICE IN STOCKTON AND BLACK
WOMEN FOR WELLNESS. WE ARE A
STATEWIDE REPRODUCTIVE JUSTICE
ORGANIZATION COMMITTED TO
IMPROVING THE OVERALL HEALTH
STATUS AND WELL-BEING OF BLACK
WOMEN AND GIRLS AND WE WORK TO
ACHIEVE THIS BY BUILDING THE
POLITICAL AND ELECTORAL POWER OF
BLACK WOMEN THROUGHOUT
CALIFORNIA. AND SO WE BELIEVE IN
A JUST AND EQUITABLE FUTURE FOR
BLACK WOMEN, AND AS SUCH,
ENGAGES IN POLICY AND
LEGISLATION THAT ADVANCES EQUITY
AS TO AFFECT SYSTEMIC CHANGE.
AND SO THIS CONVERSATION IS
IMPORTANT TO MYSELF, BEING A
WOMAN OF COLOR OVER THE AGE OF
50, I CAN'T BELIEVE I'M SAYING
THAT. BUT AND ALSO MY
ORGANIZATION AND THE COMMUNITY
THAT WE SERVE BECAUSE WE BEAR
THE DISPROPORTIONATE BURDEN OF
THE INSTITUTIONAL AND SYSTEMIC
INEQUITIES THAT LEAD TO POOR
HEALTH OUTCOMES, WE ALSO HAVE
DEVASTATING AND LASTING IMPACTS
ON THE BLACK COMMUNITY. AND A
CORE TENANT OF THE REPRODUCTIVE
JUSTICE FRAMEWORK, WHICH GUIDES
OUR WORK, IS A RECOGNITION OF
BASIC HUMAN DIGNITY, WITH
MOUNTING RESEARCH THAT
ESTABLISHES THE ROLE OF IMPLICIT
BIAS IN HEALTH OUTCOMES,
RIGOROUS TRAININGS THAT'S
GROUNDED IN REPRODUCTIVE JUSTICE
VALUES THAT STAND TO IMPROVE THE
QUALITY OF CARE WE'RE SEEKING,
IS A SIMPLE STEP AND A MINIMAL
ASK FOR THE HARMS THAT ARE
INFLICTED DUE TO NOT ADDRESSING
ONE'S BIAS, UNCONSCIOUS RACISM,
AND IMPLICIT BIAS IS ALSO A
DETERMINANT OF HEALTH
DISPARITIES. DISCRIMINATION DUE
TO IMPLICIT BIAS MUST BE
ADDRESSED BECAUSE IT IS
UNNECESSARILY DECREASES THE
QUALITY AND LENGTH OF LIFE OF
PEOPLE IN OUR COUNTRY WHO ARE
NOT WHITE. UNFORTUNATELY,
IMPLICIT BIAS IS A KEY
DETERMINANT OF HEALTH THAT
CURRENT CIVIL RIGHTS AND OTHER
LEGAL FRAMEWORKS ARE ILL
EQUIPPED TO ADDRESS EFFECTIVELY.
BLACK CALIFORNIANS EXPERIENCE
DISPARITIES IN CARE AND OUTCOMES
DUE TO OBGYN AND DEPARTMENT
CLOSURES ACROSS CALIFORNIA,
WHICH HAVE BEEN MENTIONED HERE
TODAY, THERE'S A LACK OF
REPRODUCTIVE HEALTH SERVICES AND
EXPERTISE IN MEDICALLY
UNDERSERVED COMMUNITIES, WHICH
HAVE ALSO BEEN DISCUSSED AS
WELL. IMPLICIT BIAS
SIGNIFICANTLY AFFECTS
INTERACTIONS BETWEEN PATIENTS
AND PROVIDERS, PROVIDING
TREATMENT DECISIONS, ADHERENCE
TO TREATMENT, AND ACTUAL HEALTH
OUTCOMES. STUDIES HAVE SHOWN AN
ASSOCIATION BETWEEN IMPLICIT
RACIST BIAS AND DIAGNOSTIC
UNCERTAINTY, AND FOR BLACK
PATIENTS, NEGATIVE RATINGS OF
THIS CLINICAL INTERACTIONS
CAUSES LESS PATIENT
CENTEREDNESS. POOR PROVIDER
COMMUNICATION, UNDERTREATMENT
UNDERTREATMENT OF PAIN, AND
PROVIDERS VIEWS OF BLACK
PATIENTS AS LESS COMPLETE WITH
TREATMENT RECOMMENDATIONS. IN
SOME TESTING, IMPLICIT ATTITUDES
WERE FOUND TO BE SIGNIFICANTLY
RELATED TO PATIENT AND PROVIDER
INTERACTIONS, AND HEALTH
OUTCOMES ARE MORE OFTEN THAN
TREATMENT PROCESSES. THIS
EVIDENCE SUGGESTS THAT IMPLICIT
BIAS CAN HINDER THE PROVIDERS
ABILITY TO ACCURATELY ASSESS
PATIENTS VIEWS ON TREATMENTS.
KURT TILL PRODUCTIVE
DISCUSSIONS, AND UNDERMINE TRUST
AND ENGAGEMENT IN CARE, LEADING
TO LESS FOLLOW UP AND WORSENED
ADHERENCE TO TREATMENT PLANS.
CHANGING THE WAY THE HEALTH CARE
PROVIDER RECOGNIZES AND OVERCOME
THEIR OWN IMPLICIT BIAS WHEN
TREATING BLACK WOMEN IS A
CRITICAL STEP IN ADDRESSING THE
RACIAL DISPARITIES. I HAVE
PERSONAL EXPERIENCE WITH THE
HEALTH CARE SYSTEM, WHERE MY
CONCERNS ABOUT MY HEALTH WAS NOT
ADDRESSED. AFTER THREE YEARS OF
HAVING IRREGULAR MENSTRUAL
CYCLES, I THOUGHT I WAS
PREMENOPAUSAL, AND THEN I BEGAN
HAVING REALLY HEAVY MENSTRUAL
FLOWS, OFTEN TIMES HAVING TO
CALL OUT SICK FROM WORK BECAUSE
OF FEAR OF BLEEDING THROUGH MY
CLOTHES. I CONTACTED MY PROVIDER
MONTHLY BECAUSE I WAS CONCERNED
THAT I WOULD BLEED TO DEATH. I'M
ALSO ANEMIC AND SO I WAS A
CONCERNED ABOUT THE AMOUNT OF
BLEEDING THAT I WAS THAT WAS
HAPPENING MONTHLY. I WAS TOLD
OVER AND OVER THAT I WAS
PROBABLY ENTERING MENOPAUSE, AND
I HAD TO JUST WAIT IT OUT. I
CHANGED MY MEDICAL PROVIDER
THREE TIMES BECAUSE MY CONCERNS
WERE NOT ADDRESSED. I FINALLY
FOUND A PROVIDER THAT LISTENED
TO ME AFTER SEVERAL SERIES OF
TESTS, IT WAS DETERMINED THAT I
WAS NOWHERE NEAR PREMENOPAUSAL,
I WAS IT WAS FINALLY DETERMINED
THAT I HAD THREE FIBROIDS THAT
HAD VARIOUS SIZES, AND I WAS
ALSO SEVERELY ANEMIC AT THAT
TIME. MY HEMOGLOBIN WAS A EIGHT.
THE DOCTOR ADVISED ME THAT IF MY
HEMOGLOBIN WENT ANY LOWER, I
WOULD NEED TO BE HOSPITALIZED
AND RECEIVE A BLOOD TRANSFUSION.
SO THIS HAPPENED TO ME. SOMEONE
WHO KNOWS HOW TO NAVIGATE THE
SYSTEM. SOMEONE WHO KNOWS HOW TO
UPLIFT MY VOICE. AND SO THIS IS
CONCERNING TO ME, BECAUSE WHAT
IS HAPPENING TO THOSE WHO CAN'T
ADVOCATE FOR THEMSELVES OR DON'T
KNOW HOW TO NAVIGATE THE
SYSTEMS? SO I CRINGE TO THINK OF
WHAT IS GOING TO HAPPEN MOVING
FORWARD IN ADDITION TO MY
SITUATION. LAST YEAR, I HAD FIVE
FRIENDS WHO WAS EXPERIENCING
SIMILAR SYMPTOMS AND THE
RECOMMENDATION THAT WAS GIVEN TO
THEM WAS TO HAVE A COMPLETE
HYSTERECTOMY AS TREATMENT. I
ALSO HAD A FRIEND WHO TRAGICALLY
DIED BECAUSE HER CONCERNS WERE
IGNORED AND SHE HEMORRHAGED TO
DEATH IN HER HOME ALONE. SO I
THANK YOU ALL FOR BEING
CHAMPIONS ON THIS ISSUE. BLACK
WOMEN ACROSS CALIFORNIA DESERVE
BETTER TREATMENT BY HEALTH CARE
SYSTEMS. WE DESERVE HEALTH CARE.
THAT'S GROUNDED IN
COMPREHENSIVE, EVIDENCE BASED
APPROACH. WE DESERVE PROVIDERS
THAT WILL LISTEN TO OUR CONCERNS
BECAUSE WE KNOW OUR BODIES BEST
AND WE DESERVE POLICIES THAT
WILL HOLD THESE SYSTEMS
ACCOUNTABLE. SO PLEASE CONTINUE
TO UPLIFT THE VOICES OF OUR
BLACK PATIENTS. THANK YOU. THANK
YOU SO MUCH FOR SHARING THAT
STORY. AND I COULD SEE THE
PHYSICIANS OVER HERE JUST BEING
HORRIFIED, AS YOU WERE
DESCRIBING WHAT WAS GOING ON,
CRINGING. RIGHT. BECAUSE, IT'S
IN HINDSIGHT NOW, BUT AS YOU'RE
LIVING IT RIGHT, THE, AND AGAIN,
YOU ARE NOT ALONE IN THAT
EXPERIENCE. I THINK THAT THAT IS
THE POINT THAT YOU'RE TRYING TO
MAKE, THAT THIS HAPPENS EVERY
SINGLE DAY, IN A, IN A WORLD OF
ABUNDANCE. YEAH. I WANT TO THANK
YOU. HAD A CHANCE TO HEAR IN A
DIFFERENT HEARING FROM A
RESEARCHER AT STANFORD WHO'S
RESEARCHING THESE EXACT ISSUES
ABOUT, FIBROIDS. THE
HYSTERECTOMY THAT ARE RESULTING
WHEN FULL IN WOMEN GOING INTO
EARLY MENOPAUSE AND THE WAY
BLACK WOMEN ARE BEING CARED FOR,
THEIR HEART HEALTH AND ALL THE
OTHER WAYS THAT IT IMPACTS WOMEN
AND, THAT RESEARCH IS SO
IMPORTANT. AND THEN IT'S ALSO
IMPORTANT FOR OUR PHYSICIANS TO
BE TRAINED ON THAT RESEARCH SO
THAT IT CAN GET TO THE PATIENTS
WHO NEED IT. BUT, IT'S JUST SO
UPSETTING TO HEAR THE AGAIN AND
AGAIN ABOUT, YOU KNOW, PEOPLE
WHO ARE SEEKING CARE AND AREN'T
GETTING THE CARE THEY NEED. AND
OUR GREAT STATE. RIGHT. WE ARE
SUPPOSED TO PROVIDE SOME OF THE
BEST CARE IN THE WORLD. AND YET
THIS IS HAPPENING TO WOMEN OF
COLOR. SO I JUST WANT TO THANK
YOU FOR GIVING VOICE TO THAT AND
REMINDING US SORT OF WHO WE NEED
TO PAY ATTENTION TO HAPPENING TO
ALL WOMEN, BUT ESPECIALLY TO
WOMEN OF COLOR. THANK YOU. THANK
YOU SO MUCH. THANK YOU, MOVING
ON NOW TO, DOCTOR CAROLYN GIBSON
, ASSISTANT PROFESSOR,
DEPARTMENT OF PSYCHIATRY AND
BEHAVIORAL HEALTH, UCSF. AND YOU
ALSO HAVE AN AFFILIATION WITH
THE VA. I ALSO WANT TO LIFT UP
SOMETHING THAT DOCTOR, MITCHELL
SAID THAT RELATES TO THE
TESTIMONY. WE JUST HEARD, WHICH
IS IF WE DIVERSIFIED OUR HEALTH
CARE PROVIDER WORKFORCE, I THINK
IT WOULD ALSO MAKE A HUGE
DIFFERENCE IN WHAT WE'RE TALKING
ABOUT. REMEMBER WHEN ALL DOCTORS
WERE MEN, RIGHT? AND I WON'T SAY
THAT INTO THE MIC, BUT SHOCKING.
SOMETIMES IT'S LIKE AN
INTERGENERATIONAL TRAUMA, THAT
SOME FEMALE PHYSICIANS HAVE NOT
HAD GOOD CARE THEMSELVES. AND
THEN UNFORTUNATELY, THAT
TRANSLATES INTO THEIR PERSONAL
EXPERIENCES TRANSLATE INTO THE
CARE THAT THEY PROVIDE OTHER
PATIENTS. I THINK WE SEE THAT IN
SURGERY, CERTAINLY WITH THE
INTERGENERATIONAL TRAUMA OF
SURGERY TRAINING. YEAH, I THINK
I MEAN, I HAD TWO WOMEN
PHYSICIANS WHO BOTH SAID TO ME
WHAT I WAS TOLD MY WHOLE LIFE,
LIKE, WE JUST SUFFER THROUGH IT.
I THINK THAT WE AS WOMEN ARE
TAUGHT AND THAT OUR WOMEN
PROVIDERS HEARD THAT THEIR WHOLE
LIFE. AND I FINALLY FOUND A MALE
PROVIDER WHO HAD TRAINED
HIMSELF, HE SAID, BECAUSE HIS
FEMALE COLLEAGUES WERE SAYING
THIS. AND HE THOUGHT, WHY DO
THEY ALL THINK THEY NEED TO
SUFFER THROUGH THIS? BECAUSE HE
HAD NOT BEEN GIVEN THAT MESSAGE
AS A MAN AND IT WAS FASCINATING
TO ME TO SORT OF HE PUT THAT
TOGETHER FOR ME. HE SAID. I KEPT
SAYING TO MY WOMEN COLLEAGUES,
WHY AREN'T YOU, YOU KNOW, WHY
AREN'T WE DOING MORE? AND
THEY'RE LIKE, WELL, WE JUST WHAT
WE DO. AND THAT DOES NOT HAVE TO
BE WHAT WE DO. I ALSO DO THINK,
AND I WAS THINKING THIS, DURING
LOTS OF THE SPEAKING, THAT
THERE'S THIS INTERESTING ELEMENT
ABOUT MENOPAUSE THAT PEOPLE ONLY
PAY ATTENTION TO IT WHEN THEY GO
THROUGH IT, AND WE DON'T TALK
ABOUT THAT WITH LIKE,
CARDIOLOGY. RIGHT IT'S NOT LIKE
SOMEONE'S INTERESTED IN A HEART
ATTACK BECAUSE THEY KNOW SOMEONE
THAT WENT THROUGH IT. WHY IS
THIS THING THAT'S AFFECTING HALF
THE POPULATION ONLY BECOMES
RELEVANT WHEN YOU ACTUALLY
EXPERIENCE IT, AND IT HAS SO
MANY MEDICAL SIDE EFFECTS. AND I
THINK IT'S ALSO THE RISK OF THAT
IS EXACTLY WHAT WE JUST HEARD,
WHICH IS WE NEED TO KNOW. AND
THE AGE SPAN AT WHICH WOMEN GO
THROUGH IT, WHICH YOU ALL KNOW
BETTER, IS ACTUALLY INCREDIBLY
BROAD. AND SO WE NEED TO KNOW
ENOUGH TO BE ABLE TO SEEK THE
TREATMENT, ASK THE RIGHT
QUESTIONS, KNOW IF THIS IS WHAT
IT IS OR NOT, AND YOU HAVE TO
LEARN THAT BEFORE OR ELSE
THERE'S NO WAY. YEAH I'M ECHOING
THAT IS JUST THAT, YOU KNOW,
IT'S NOT IT'S BETTER TO BE AWARE
WE NEED TO START YOUNGER BECAUSE
IT'S NOT JUST ABOUT THE SHORT
TERM EFFECTS AND THE SMOOTH
TRANSITION. IT'S ACTUALLY THE
LONG TERM IMPACTS THAT I MEAN,
REALLY ALL THE ORGAN SYSTEMS ARE
TRULY AFFECTED. AND SO WE HAVE
WE SHOULD BE WE SHOULD BE DOING
BETTER FROM AN EARLIER AGE. SO I
WOULD EVEN SAY THAT, YOU KNOW,
JUST LIKE EVERYBODY KNOWS WHAT
PUBERTY GOES, GOES TO THE
PEDIATRICIAN FOR A PUBERTY.
DURING PUBERTY THEY HAVE A PLACE
TO GO FOR PREGNANCY. THEY HAVE A
PLACE. BUT THERE IS NOT THAT
FEELING THAT YOU SHOULD REALLY
GET THAT UNDERSTANDING OF WHAT
YOU'RE GOING TO GO THROUGH
BEFORE YOU EVEN GO THROUGH IT IN
MENOPAUSE. YEAH. SO I JUST
WANTED TO THANK MISS ROBINSON
FOR YOUR TESTIMONY. YOU KNOW, AS
A BLACK LATINA, THIS IS A
PARTICULARLY IMPORTANT FOR ME.
AND I JUST WANTED TO HIGHLIGHT
SOME OF THE THINGS THAT YOU,
TALKED ABOUT KIND OF IN THE
RESEARCH, IN THE BACKGROUND
MATERIALS THAT WE GET THAT BLACK
WOMEN ARE HALF AS, HALF AS
LIKELY TO USE HORMONE THERAPY TO
TREAT MENOPAUSAL SYMPTOMS AS
WHITE WOMEN, DESPITE HAVING
GREATER SYMPTOM BURDEN. THERE
ARE THE KIND OF SECONDARY ISSUES
OF HIGHER INCIDENCE OF DEMENTIA,
MORE LIKELY HOOD OF SUFFERING
FROM ALZHEIMER'S AND OTHER
RELATED ISSUES MORE LIKELY TO
SUFFER FROM CARDIOVASCULAR
ISSUES. SO THERE ARE ALL THESE
KIND OF SECONDARY, UNTREATED
ISSUES BECAUSE THE MENOPAUSAL
TRANSITION IS COMPLETELY IGNORED
, FOR THE MAJORITY OF THE BLACK
COMMUNITY IN PARTICULAR AND
LATINO COMMUNITY AS WELL. SO YOU
KNOW, IT'S, I THINK, INCREDIBLY
IMPORTANT THAT WE HAVE
CULTURALLY CONCORDANT CARE
PROVIDERS FOR SURE. I ALSO THINK
THAT THAT THERE'S AN INCREDIBLE
DEARTH OF RESEARCH THAT IS
CENTERED AROUND BLACK AND LATINO
WOMEN AND THEIR EXPERIENCE
THROUGH MENOPAUSAL TRANSITION
AND IF WHAT WE CAN DO AS A STATE
IS MAKING SURE TO FOCUS OUR
RESEARCH DOLLARS FROM THE
BRIGHTEST MINDS ON MAKING SURE
THAT WE'RE WE'RE CENTERING THAT
EXPERIENCE IN A WAY THAT WE'RE
NOT DOING RIGHT NOW. THANK YOU
FOR UPLIFTING THAT. AND I WANT
TO ADD, MY MOTHER, AT AGE 60,
SHE STARTED WITH EARLY SIGNS OF
DEMENTIA. AND NOW AT AGE 70, IS
IN THE OTHER THE OTHER SIDE OF
THAT, DECLINING. AND SO THANK
YOU SO MUCH FOR UPLIFTING THAT.
AND WHEN TALKING WITH PROVIDERS,
ABOUT, YOU KNOW, SYMPTOMS AND,
AND WHAT SHE'S EXPERIENCING AND
EVEN WHEN ME GOING THROUGH WHAT
I WAS EXPERIENCING, I ASKED MY
PROVIDER, I SAID, DO YOU EVER
THINK OUTSIDE THE BOX BECAUSE
WHAT IS RIGHT FOR ONE PERSON IS
NOT RIGHT FOR EVERYONE. AND SHE
LOOKED AT ME AND SHE WAS LIKE,
NO, NOT REALLY. AND I SAID,
WELL, THAT MIGHT BE A PART OF
THE PROBLEM. SO SO YES, THANK
YOU SO MUCH FOR UPLIFTING THAT
Ó. I WAS JUST GOING TO SAY
THAT, YOU KNOW. EXACTLY. IT'S
NOT ONE SIZE FITS ALL. IT TRULY
IS. EVERYBODY'S COMING INTO
MENOPAUSE WITH DIFFERENT HEALTH
HISTORY, DIFFERENT ETHNICITIES,
DIFFERENT GENETIC
PREDISPOSITIONS, DIFFERENT
LIFESTYLE PRACTICES, ALL OF THAT
MATTERS. AND ACTUALLY, WHAT EVEN
MATTERS MOST IS REALLY WHAT DO
THE PATIENTS WANT? WHAT DO THEY
VALUE? AND ALL OF THAT HAS TO BE
TAKEN INTO ACCOUNT WHEN WE SEE
THOSE PATIENTS, WHEN WE SEE A
PATIENT AND THEY'RE COMING TO US
DURING THAT MENOPAUSAL
TRANSITION. AND LET'S TALK ABOUT
THE IMPACT ON OUR MENTAL HEALTH.
YES, THAT'S WHAT I WANT TO HEAR.
ALL RIGHT. THANKS I'M CARRIE
GIBSON, I'M A PSYCHOLOGIST AND
HEALTH SERVICES RESEARCHER. I
MUST TALK BRIEFLY ABOUT MENTAL
AND BEHAVIORAL HEALTH AND THE
MENOPAUSE TRANSITION. SO WHEN WE
THINK ABOUT THOSE MOST COMMONLY
REPORTED AND MOST COMMONLY
REPORTED AS NEGATIVELY IMPACTFUL
DURING THIS PERIOD IN THE
LIFESPAN, SYMPTOMS, MOOD
SYMPTOMS ARE KIND OF AT THE TOP
OF THE LIST RIGHT THERE WITH HOT
FLASHES AND NIGHT SWEATS, SLEEP
DIFFICULTY, AND GENITOURINARY
SYMPTOMS. AND THOSE MOOD
SYMPTOMS CAN BE DEPRESSIVE
SYMPTOMS, ANXIETY, VÆ,
IRRITABILITY, COMPLAINTS OF JUST
NOT FEELING LIKE MYSELF, OR A
DIFFERENT ASPECTS OF MOOD AND
WELL-BEING THAT AFFECT OUR
HEALTH AND DAY TO DAY
FUNCTIONING AND MOOD. SYMPTOMS
ARE OFTEN COINCIDE WITH
INFLUENCE AND ARE INFLUENCED BY
THESE OTHER COMMON MENOPAUSE
SYMPTOMS, WE SPOKE ALREADY ABOUT
POTENTIALLY THE IMPACT OF
GENITOURINARY SYMPTOMS ON SEXUAL
FUNCTION, ON RELATIONSHIPS, HOW
THAT CAN AFFECT OUR MOOD AND
WELL-BEING ON A REGULAR BASIS
CAN MAKE THE SAME CASE FOR THE
CO-OCCURRENCE. AND,
BIDIRECTIONAL RELATIONSHIPS
BETWEEN MOOD, SYMPTOMS AND ALL
OF THESE COMMON MENOPAUSE
SYMPTOMS, THE MENOPAUSE
TRANSITION HAS ALSO BEEN
EXAMINED AS A WINDOW OF
VULNERABILITY, NOT JUST FOR MOOD
SYMPTOMS, BUT FOR CLINICALLY
SIGNIFICANT MENTAL HEALTH
DIAGNOSES, JUST LIKE WE THINK
ABOUT OTHER PERIODS OF
REPRODUCTIVE CHANGE ACROSS THE
LIFESPAN, LIKE THE POSTPARTUM OR
PUBERTY, THIS HAS BEEN MOST WELL
EXAMINED WITH DEPRESSION, WHICH
IS STILL A BIT CONTROVERSIAL,
BUT GENERALLY EVIDENCE SHOWS
THAT, WOMEN MAY BE 2 TO 4 TIMES
MORE LIKELY TO HAVE A DEPRESSIVE
EPISODE IN THE MENOPAUSE
TRANSITION THAN OTHER PERIODS IN
THE LIFESPAN. THAT MAY BE
PARTICULARLY OR FOR OR LIMITED
TO THOSE WOMEN WITH A HISTORY OF
DEPRESSION PRIOR TO MENOPAUSE.
BUT, OVER HALF OF WOMEN REPORT
PROBLEMATIC SLEEP DIFFICULTY
DURING THIS PERIOD THAT MAY BE
RAISED TO A LEVEL OF CLINICAL
INSOMNIA FOR UP TO 1 IN 4 WOMEN
IN THE MENOPAUSE TRANSITION. WE
KNOW INSOMNIA IS A RISK FACTOR
FOR A NUMBER OF MENTAL HEALTH
CONCERNS, AS WELL AS COINCIDES,
AND THEN MORE RESEARCH IS NEEDED
. BUT THERE IS A SUGGESTIVE
EVIDENCE THAT THE MENOPAUSE
TRANSITION OR A HIGHER LEVEL OF
MENOPAUSE SYMPTOM BURDEN IS
RELATED TO INCREASED RISK FOR OR
WORSENING OF A RANGE OF OTHER
MENTAL HEALTH CONCERNS,
INCLUDING SUBSTANCE USE
DISORDERS, EATING DISORDERS,
PTSD, ANXIETY DISORDERS, SERIOUS
MENTAL ILLNESS AND SUICIDE RISK.
AND SO WHERE IS THIS
VULNERABILITY COMING FROM? AT
EVERY POINT IN THE LIFESPAN, WE
THINK ABOUT THE BIOPSYCHOSOCIAL
MODEL TO EXPLAIN MENTAL HEALTH
AND WELL-BEING. BASICALLY THAT
THERE ARE BIOLOGICAL,
PSYCHOLOGICAL AND SOCIAL FACTORS
THAT CONTRIBUTE TO RISK. AND WE
THINK ABOUT THE MENOPAUSE
TRANSITION. THERE'S A LOT OF
EXTRA BIOLOGICAL AND SOCIAL
FACTORS THAT ARE AT PLAY. SO
THINGS LIKE HORMONES, AGING,
PHYSICAL HEALTH AND OTHER, YOU
KNOW, THESE MEDICAL CONDITIONS,
PAIN, THOSE OTHER MENOPAUSE
SYMPTOMS AND SOCIAL FACTORS,
ASPECTS OF UPBRINGING, OF
BACKGROUND TRAUMA, STRESSORS,
THINGS THAT AFFECT HEALTH ACROSS
THE LIFESPAN ARE IMPORTANT
SOCIAL CONNECTION. AND THEN ALSO
THINK ABOUT THE NUMBER OF LIFE
EVENTS, ROLE TRANSITIONS. AS
PREVIOUSLY MENTIONED, PEAK
CAREER, COMPLICATED CAREGIVING
RESPONSIBILITIES, THE AMOUNT OF
THINGS THAT WOMEN ARE JUGGLING,
PARTICULARLY IN THEIR 40S, 50S
AND 60S WHEN THEY'RE MOST LIKELY
TO BE ALSO MANAGING THESE
SYMPTOMS AND RISKS. AND THEN
ALSO PSYCHOLOGICAL FACTORS LIKE
ENGAGEMENT AND PROTECTIVE OR
ADAPTIVE OR LESS ADAPTIVE COPING
SKILLS, HEALTH BEHAVIORS,
COGNITIVE APPRAISAL, OR THE WAY
WE'RE PERCEIVING SYMPTOMS AND
EXPERIENCES. AND AGAIN, THAT
PSYCHIATRIC HISTORY. AND SO WHAT
DO WE DO ABOUT IT WHEN WE HAVE A
NUMBER OF EVIDENCE BASED
TREATMENT OPTIONS THAT ARE HAVE
BEEN SHOWN TO BE EFFECTIVE FOR
DEPRESSION, FOR INSOMNIA, FOR
OTHER MENTAL AND BEHAVIORAL
HEALTH CONCERNS AND THE
MENOPAUSE TRANSITION, I'M A
PSYCHOLOGIST, SO I FOCUS ON THE
NON-PHARMACOLOGICAL TREATMENT
OPTIONS THAT ARE KIND OF PART OF
OUR GOLD STANDARD. FOREMOST
AMONG THESE ARE COGNITIVE
BEHAVIORAL THERAPY, WHICH HAS
BEEN SHOWN TO BE EFFECTIVE FOR
DEPRESSION, FOR INSOMNIA, AND
EVEN FOR REDUCING THE NEGATIVE
IMPACT OF HOT FLASHES AND NIGHT
SWEATS, FOR WOMEN SPECIFICALLY
IN THE MENOPAUSE TRANSITION, BUT
IDEALLY, I'M NOT WORKING ALONE,
RIGHT? THAT I'M WORKING AS PART
OF AN INTERDISCIPLINARY
INTEGRATED CARE TEAM THAT IS
USING ALL OF THE EVIDENCE BASED
APPROACHES AND OUR ARSENAL AND A
COORDINATED FASHION WITH KIND OF
KNOWLEDGE AND INFORMATION ABOUT
ALL OF THE UNIQUE CONCERNS THAT
COME UP DURING THIS PERIOD IN
THE LIFESPAN, TO EFFECTIVELY
TREAT ALL OF THESE MENOPAUSE
SYMPTOMS AND TO ADDRESS MENTAL
HEALTH AND BEHAVIORAL HEALTH
CONCERNS DURING THIS PERIOD TO
ADDRESS THE WHOLE HEALTH OF
WOMEN. SO THANK YOU FOR YOUR
TIME, SOME REFERENCES AND MY
CONTACT INFORMATION. AND HOW
OFTEN DOES THAT HAPPEN? I WE
TREAT THE WHOLE THE WHOLE
PERSON. THAT'S THE GOAL, RIGHT?
I'M EXCITED TO LEARN MORE ABOUT
THE UCLA CENTER. I'M PART OF THE
WORK GROUP TRYING TO ESTABLISH
THIS AT UCSF. I THINK WE'RE
INCREASINGLY SEEING THESE TYPES
OF CENTERS ACROSS THE US. I'M
EXCITED ABOUT THEM AND THINK
IT'S IMPORTANT THAT MENTAL
HEALTH HAS A PLACE AT THE TABLE.
AND THESE TYPES OF CENTERS AND I
DON'T THINK WE KNOW YET. IT'S
PRETTY NEW. AND I WAS GOING TO
SAY ALL THREE OF THE PHYSICIANS,
WHEN YOU'RE TREATING PATIENTS,
ARE YOU ALSO ADDRESSING AND
REFERRING FOR MENTAL HEALTH
ISSUES? YES, WE ARE. I WILL SAY
THE MAJOR LIMITATION IS
INSURANCE COVERAGE. SO EVEN AT
UCSF, WHERE WE'RE RELATIVELY
INSURANCE AGNOSTIC, I SEE
EVERYBODY AND IT'S ONE OF THE
THINGS I LOVE ABOUT WORKING AT A
PUBLIC INSTITUTION LIKE THAT. SO
WE HAVE, YOU KNOW, PUBLIC
PRIVATE INSURANCE. BUT WHEN I
REFER FOR PSYCHIATRIC SERVICES,
THEY WILL NOT TAKE ANY PUBLIC
INSURANCE, AND THEY WON'T TAKE A
LOT OF PRIVATE INSURANCE AS
WELL. AND NO ONE IN THE
COMMUNITY WILL TAKE ANY
INSURANCE. YEAH, WE HAVE A
SIMILAR PROBLEM, WE AND IF WE DO
HAVE SOME COVERAGE, WE ARE ABLE
TO SEE SOME OF THOSE PATIENTS.
BUT THERE'S SUCH LIMITED ACCESS
AND THERE'S SO FEW. HONESTLY
PSYCHOLOGISTS AND PSYCHIATRISTS
THAT ACTUALLY WANT TO TAKE
MENOPAUSE SERIOUSLY. SO WE ARE
LOOKING AND REALLY TRYING TO
KIND OF FIND THOSE REPRODUCTIVE
PSYCHIATRISTS HONESTLY, BECAUSE
THEY TAKE THEY TAKE A LOT OF
INTEREST IN WANTING TO TAKE CARE
OF OUR PATIENTS. BUT, WE HAVE
NOT BEEN ABLE TO REALLY GET BUY
IN. IT'S REALLY HARD TO GET,
PSYCHIATRISTS AND PSYCHOLOGISTS
THAT REALLY WANT TO FOCUS ON,
ON, ON THIS, YOU KNOW, AND WE
AND I WILL TELL YOU THAT OUT OF
THE 500 PATIENTS WE'VE SEEN SO
FAR, 1 IN 3 PATIENTS NEEDS TO
SEE SOMEONE. AND EITHER IT'S
BECAUSE OF THE FIRST TIME HAVING
SYMPTOMS OR IT'S, THAT THEY'RE
HAVING A RELAPSE OF PRIOR, YOU
KNOW, CLINICAL DEPRESSION OR
ANXIETY OR RELATIONSHIP
TRANSITIONS, A HUGE NEED. YEAH,
I WOULD SAY THAT'S THAT'S WHY I
DID THE PERINATAL MENTAL HEALTH
TRAINING, BECAUSE I WAS SEEING
SO MUCH NEED IN MY LACTATION AND
MY BREAST CANCER PATIENTS AND
OUR, OUR, OUR GROUP THAT OFFERS
INSURANCE COVERAGE HAS A TWO
YEAR WAIT FOR PSYCHIATRY AND
PSYCHIATRIST CGRTS THAT ARE IN
PRIVATE PRACTICE IN OUR
COMMUNITY START AT 7 OR $800 A
VISIT. I SAID, I'M IN THE WRONG
SPECIALTY, BUT, THE, YOU KNOW,
SO JUST BEING ABLE TO PROVIDE
WHAT I CALL BASIC PRIMARY,
PRIMARY CARE OF MENTAL HEALTH,
WHAT I'M DOING IS NOT
COMPLICATED. AND I DO REFER TO
UCLA'S REPRODUCTIVE HEALTH
CENTER FOR TRULY COMPLICATED
MENTAL HEALTH. COM, CONDITIONS.
BUT A LOT OF IT IS JUST THINGS
THAT OTHER PROVIDERS CAN DO
ALONGSIDE THEIR DAILY PRACTICE
WITH JUST A LITTLE BIT OF
EDUCATION. AND I THINK THAT IS
SUCH A CRITICAL POINT. I MEAN,
WE ALL KNOW AS PEOPLE WHO HEAD
INTO THE DOCTOR, I AM ALMOST
NEVER ASKED ABOUT MY MENTAL
HEALTH AT MY CHECKUP, WHETHER
IT'S MY OB OR MY PRIMARY CARE
PHYSICIAN. AND I THINK WE'VE
DONE A REALLY GOOD JOB IN THE
POSTNATAL PERIOD OF INTEGRATING
THAT INTO CARE. BUT WE HAVE NOT
DONE THE SAME THING AS IT
RELATES TO MENOPAUSAL CARE, AND
SO I THINK IT IS SOMETHING WE
SHOULD WORK ON. AND AGAIN, I
THINK WE'RE DOING IT MORE AT THE
PEDIATRIC PHASE NOW. SO WE'RE
THINKING ABOUT WHOLE HEALTH CARE
IN CERTAIN PHASES. BUT THIS IS
NOT ONE OF THEM. ONE POINT I
THINK THAT'S REALLY INTERESTING
IS I'VE SEEN SEVERAL PATIENTS
WHO WERE TREATED FOR PSYCHIATRIC
SYMPTOMS OF MENOPAUSE WITH
PSYCHIATRIC MEDICATIONS THAT
CAUSE SIGNIFICANT SIDE EFFECTS.
I SAW A PATIENT GET DIABETES.
I'VE SEEN PATIENTS GET SUICIDAL
WHEN WHAT THEY NEEDED WAS SOME
HORMONE THERAPY. AND IT'S REALLY
FASCINATING HOW THE DOWNSTREAM
EFFECTS OF THE WHY THAT MOST OF
THE PEOPLE IN PRACTICE RIGHT NOW
ARE SO UNFAMILIAR AND
UNCOMFORTABLE WITH EVEN THE IDEA
OF MEDICATIONS THAT THEY CAN'T
RECOGNIZE THAT THESE PSYCHIATRIC
SYMPTOMS MAY ACTUALLY BE CURED
WITH SOME HORMONES. NOT ALL. AND
WE DEFINITELY NEED MORE, WE NEED
MORE THERAPIES AND MORE ACCESS
AND ADDITIONALLY, YOU KNOW, AT
UCSF, WE'VE HAD AN INCREDIBLY
CHALLENGING TIME HOLDING ON OR
RETAINING ANY, ANY MENTAL HEALTH
PROVIDER BECAUSE THEY ARE VERY
INTERESTED IN IT. THEY WILL
START FOR A FEW YEARS. THEY WILL
GET BURNT OUT REAL FAST AND
REALIZE THEY CAN MAKE $800 AN
HOUR IN THE COMMUNITY, SEEING
THE SAME PATIENTS WHO ACTUALLY
HAVE MORE RESOURCES. AND IT'S SO
UNFORTUNATE AND VERY
FRUSTRATING. WE HAVE WE'VE BEEN
WORKING ON OUR PIPELINE, BUT WE
HAVE TO DO MORE. AND I WILL SAY
THAT I HAD A COLLEAGUE COMMENT
TO ME RECENTLY OUT OF THE BLUE
TO SAY, GOD, YOU SEEM SO MUCH
HAPPIER. AND I SAID, OH, IT'S MY
HORMONES. SENATOR ROSS AND THEN
ASSEMBLY MEMBER AGRA AND THEN
SENATOR RUBIO. WELL, I'M A
LITTLE RELUCTANT TO ASK A
QUESTION IN THIS FORUM, BUT I
HAVE TO ASK THIS. IS THERE A WAY
TO INTRODUCE THIS SUBJECT? IF
IT'S NOT INTRODUCED EFFECTIVELY
AT MEDICAL SCHOOL AT THE
BEGINNING OF THE MEDICAL
EDUCATION PROCESS, WHERE WE
PERHAPS COULD INTRODUCE MEDICAL
STUDENTS IN MOVING INTO SOME OF
THESE AREAS, WHETHER IT'S THE
MENTAL HEALTH AREA OR PROVIDE
MORE INFORMATION. TO THE EXTENT
WE AREN'T IN SOME OF THE AREAS
THAT YOU WERE TALKING ABOUT,
DOCTORS, IS THAT A FAIR QUESTION
FOR SOMEBODY WHO'S OUT OF PLACE
HERE? NO, YOU'RE NOT YOU'RE NOT
OUT OF PLACE. WE NEED MORE MEN.
NO, I THINK THAT IT'S A GREAT
QUESTION. I MEAN, I DON'T KNOW.
YEAH. I THINK STEMMING FROM LIKE
WHY THERE'S NOT THERE'S A NEED
FOR MORE PSYCHIATRISTS, MORE
PSYCHOLOGISTS. BUT I THINK AND
I'M NOT SURE WHAT I ACTUALLY
DON'T KNOW HOW MANY LIKE, WHAT
IS THE SUPPLY NEED. LIKE WHAT'S
THAT BALANCE LIKE. BUT WE DON'T
HAVE VERY MANY PSYCHIATRISTS,
YOU KNOW, THAT. WELL, I AGREE
THAT THERE'S JUST HARD TO ALSO
JUST RETAIN BECAUSE THEY JUST
LEAVE. THEY DO LEAVE FOR
PRACTICES BECAUSE THEY'RE MAKING
MORE MONEY. AND I DON'T KNOW IF
THAT'S THE PROBLEM VERSUS
THERE'S JUST NOT ENOUGH GOING
INTO THAT SPECIALTY. I DON'T I
DON'T KNOW. DO YOU KNOW THE
ANSWER TO THAT? I THINK IT DOES
BEGIN WITH THE RESIDENCY
EDUCATION AND THE MEDICAL SCHOOL
EDUCATION. I LEARNED FROM THE
REPRODUCTIVE PSYCHIATRISTS THAT
THEY HAVE ONE LECTURE IN THEIR
GENERAL PSYCHIATRY RESIDENCY ON
REPRODUCTIVE MENTAL HEALTH, I.E.
MENTAL HEALTH AT TIMES OF
HORMONAL TRANSITION. AND THAT
INCLUDES CANCER CARE, MENOPAUSE,
PERINATAL CARE. SO I THINK.
RIGHT. SO IT'S AND THAT'S JUST
CRAZY RIGHT. BECAUSE ONE LECTURE
IN THEIR WHOLE RESIDENCY I MEAN
WOMEN HAVE MORE MENTAL HEALTH
DISTURBANCE THAN MEN BY TWOFOLD
OR MORE. AND YET WE HAVE TO HAVE
SOMETHING CALLED A REPRODUCTIVE
PSYCHIATRIST, JUST LIKE, WHY
DOES THAT EVEN EXIST? I ALSO
THINK IT'S FASCINATING HOW
REGIONAL IT IS, YOU KNOW, I
MEAN, SO I GIVE THE MEDICAL I'M
IN CHARGE OF THE MENOPAUSE
CURRICULUM AT UCSF. AND ONE OF
THE THINGS THAT'S HAPPENING IN
MEDICAL SCHOOLS IS THAT PEOPLE
ARE MOVING OUT OF THE
PRECLINICAL OR KIND OF BASIC
EDUCATION YEARS AND MOVING INTO
THE HOSPITAL SPACE A LOT SOONER.
SO THERE'S MUCH SMALLER WINDOW
TO TEACH THEM SOME KIND OF
REALLY Kò, WHAT WE CALL
OUTPATIENT QUALITY OF LIFE
ISSUES. AND SO THERE'S A BIG
GAP. AND SO THEY'RE TRYING TO
FIT A LOT INTO A SMALL PERIOD OF
TIME. AND THEN ONCE IN THE
HOSPITAL, THE WAY OUR MEDICAL
TRAINING WORKS IS IT'S VERY
INPATIENT FOCUSED. AND THAT
PEOPLE BOTH IN MEDICAL SCHOOL
AND IN RESIDENCY DON'T SPEND
TIME IN CLINICS. IT'S PRETTY
RARE. I HAVE SEEN PSYCHIATRIC
INPATIENTS RELATED TO MENOPAUSE
OR PERIMENOPAUSE, BUT THAT'S NOT
WHERE YOU'RE SEEING THEM. WE'RE
SEEING THEM IN THE CLINIC, AND
THAT'S NOT WHERE OUR EDUCATION
DOLLARS ARE REALLY BEING SPENT.
AND MY UNDERSTANDING AND MY
UNDERSTANDING ANECDOTALLY, IN
TALKING TO MEDICAL STUDENTS AND
TALKING TO A LOT OF THE,
DIRECTION THAT MEDICAL STUDENTS
ULTIMATELY MOVE IN IS THE RESULT
OF CONVERSATIONS AND
INTERACTIONS THAT THEY HAVE
EARLY ON IN MEDICAL SCHOOL WITH
THEIR PROFESSORS AND OTHER
CLINICIANS THAT THEY COME IN
CONTACT WITH. AND IF THEY DON'T
HAVE A LOT OF CONTACT WITH
PEOPLE WHO ARE TALKING ABOUT THE
VERY ISSUES THAT YOU'RE TALKING
ABOUT HERE NOW, THIS AFTERNOON,
THIS MORNING, THEN THEY MOVE IN
ANOTHER DIRECTION IS WHAT I
GUESS HAPPENS. AND THAT'S
UNFORTUNATE. BASED ON WHAT I'VE
BEEN HEARING TODAY. THANK YOU
FOR LETTING ME ASK A QUESTION.
AGUIAR-CURRY. AND THEN RUBIO AND
WE HAVE TWO MORE SPEAKERS AND
WE'LL TRY TO FINISH BY NOON. SO
I'LL MAKE IT QUICK. FIRST OF
ALL, THANK YOU VERY MUCH FOR
BEING HERE. I ONLY WISH I HAD
THIS INFORMATION 35 YEARS AGO
BECAUSE I WENT THROUGH MENOPAUSE
YOUNGER AND IT WAS MISERABLE AND
NO ONE WOULD EVER HAVE A
CONVERSATION WITH ME BECAUSE I
KNEW SOMETHING WAS OFF. AND I
TRIED TO FIGURE IT OUT BECAUSE I
WAS VERY YOUNG AND I HAD THREE
QUARTERS OF MY ONE OVARY TAKEN
OUT AND OVER MY HALF, THE OTHER,
AND NO ONE TOLD ME WHAT THE
RAMIFICATIONS COULD BE FROM ALL
THAT AND HOW MY BODY WAS GOING
TO BE HAVE A DIFFICULT FIGHT.
AND SO, AFTER ONE OF THESE, WE
HAD A COUPLE OF MONTHS AGO,
MAYBE A MONTH AGO, THERE WAS A
LIST GIVEN TO US OF SIGNS OF
MENOPAUSE. AND IRONICALLY, I
WENT TO A REALLY NICE DINNER
WITH FIVE OF MY GIRLFRIENDS AND
I PULLED IT OUT OF MY PURSE AND
I STARTED READING SOME OF THEM
AND THEY GO, ARE YOU KIDDING ME?
WHY DON'T WE KNOW THIS? AND SO
IT'S I THINK IT'S A LOT OF IT
JUST HAS TO DO WITH EDUCATION,
WHO TO GO TO AND ASK THE RIGHT
QUESTIONS. IF YOUR PROVIDER,
IT'S NOT NOT ALL OF THEM ARE
GOING TO HAVE THAT ANSWER. BUT
TO STRUGGLE AS MANY YEARS THAT I
DID, FOR SLEEPLESS NIGHTS AND
BEING CRABBY. AND HAVE THEY
DIAGNOSED ME WITH FIBROMYALGIA?
YOU NAME IT, I GOT IT. ANXIETY,
HEART PALPITATIONS. IT WAS
MISERABLE. I WEATHERED THE STORM
BECAUSE MY MOTHER HAD BREAST
CANCER AND THEY SAID YOU
COULDN'T TAKE ANY HORMONES AND
YOU COULDN'T TAKE ANYTHING. NOW
TIMES HAVE CHANGED, BUT I JUST
WANT TO SAY THAT WE NEED TO GET
MORE EDUCATION OUT THERE SO THAT
WOMEN AREN'T AFRAID TO HAVE
THESE QUESTIONS. BUT I WANT TO
JUST COMMEND SENATOR ROTH FOR
BEING HERE TODAY, BECAUSE HOW
IMPORTANT IT IS THAT OUR MEN
FRIENDS KNOW WHAT'S GOING ON AS
WELL AND HAVE SOME COMPASSION
AND EMPATHY AND UNDERSTANDING
WHILE WE GO THROUGH THIS TIME,
AND IT WILL SAVE THEM A LOT OF
HEADACHES AS WELL. BUT I JUST
WANT TO COMMEND YOU FOR BEING
HERE TODAY, I WOULD LOVE TO STAY
LONGER, BUT I HAVE BEEN CALLED
ELSEWHERE. BUT THANK YOU VERY
MUCH AND THANK YOU FOR PUTTING
THIS ON, SENATORS AND ASSEMBLY
MEMBERS. IT MAKES A BIG
DIFFERENCE TO ME AND I'M GOING
TO TAKE THIS TAPE FROM ALL THREE
OF THOSE AND GIVE IT TO MY KIDS.
ALL RIGHT, SENATOR RUBIO, THANK
YOU, YEAH, IT'S A LOT OF MOMENTS
FOR ME. JUST IN TERMS OF NEVER
HAVING HEARD NOT NOT THERE YET,
BUT NEVER HAVING HEARD THAT FROM
MY PARENTS. RIGHT. BECAUSE WE'RE
TAUGHT TO EVEN SEX. RIGHT YOU
KNOW, WE COME FROM A LATINO
FAMILY THAT YOU JUST DON'T TALK
ABOUT THESE THINGS, BUT NOW I'M
GOING TO TRANSITION IN MY ROLE
AS A TEACHER BECAUSE, YOU KNOW,
AS A ADMINISTRATOR, ASSISTANT
PRINCIPAL, I'VE HAD TO CHAPERON
A LOT OF THE SEX EDUCATION
COURSES THAT WE GIVE OUR KIDS,
LIKE IN FIFTH GRADE. AND IT JUST
OCCURRED TO ME THAT, I MEAN, I
KNOW WE SEPARATE THE BOYS AND
THE GIRLS, AND THEN WE TEACH
THEM, BUT IT'S ALL ABOUT SEX AND
PUBERTY. BUT I DON'T RECALL EVER
HEARING ANYTHING ABOUT
MENOPAUSE. AND I THINK IT'S, I
THINK CRITICALLY IMPORTANT THAT
IF WE'RE GOING TO TEACH GIRLS
ABOUT SEX AND, AND, YOU KNOW,
THEIR PERIODS AND EVERYTHING
THAT THEY'RE GOING TO
EXPERIENCE, YOU KNOW, I THINK WE
CATCH THEM ABOUT I THINK IT'S
TEN YEARS OLD. I THINK THAT WE
SHOULD INCLUDE THE OTHER END,
NOT JUST, YOU KNOW, YOU'RE GOING
TO GET YOUR PERIOD AND THIS IS
WHAT'S GOING TO HAPPEN TO YOU.
BUT LOOK OUT FOR WHEN YOU'RE 50,
YOU KNOW, THIS IS MENOPAUSE.
EVEN JUST SAYING THE WORD AND
MAKING SURE THEY KNOW WHAT IT
IS. AND BECAUSE IT'S INTERESTING
THAT WE TEACH AT THE BEGINNING
END, BUT WE DON'T DO IT. AND I
WAS JUST THINKING, YOU KNOW,
POSSIBLE. BILL IDEA IS MAKING
SURE THAT THAT SEX EDUCATION
INCLUDES THE OTHER END, WHICH IS
MENOPAUSE. BUT AS I WAS HEARING
YOU TALK ABOUT HOW WE HAVE A
HARD TIME RETAINING PEOPLE IN
THAT PROFESSION, SAME THING. MY
EXPERIENCE AS A TEACHER, WE'RE
OFFERED THESE GRANTS THAT IF WE
PUT IN TEN YEARS OF OUR, OF OUR
TEACHING, LIFE CYCLE INTO A
LOWER INCOME COMMUNITY, THEY PAY
SOME OF YOUR, YOUR EDUCATION
OFF. AND I WAS THINKING ALSO
POSSIBLY A GRANT PROGRAM THAT
WOULD INCENTIVIZE US, YOU KNOW,
MEDICAL STUDENT. I KNOW THAT
IT'S VERY EXPENSIVE BASED ON,
YOU KNOW, WHAT I HEAR FROM
FRIENDS AND OTHER PEOPLE, IT'S
SO EXPENSIVE. BUT MAYBE HAVING A
PROGRAM WHERE WE REIMBURSE
SOMEONE FOR STAYING FIVE YEARS
OR TEN YEARS. THAT'S HOW THE
TEACHER, GRANT PROGRAM WORKED. I
THINK YOU HAD TO. AFTER FIVE
YEARS, YOU'D GET A CERTAIN
AMOUNT OF MONEY AFTER TEN. THEN
THEY WOULD PAY THE REST. AND SO
THAT'S SO IMPORTANT BECAUSE
INSTEAD OF WANTING TO TAKE OFF
AND GO MAKE $800 AN HOUR, THEY
WOULD BE COMMITTED TO STAYING
BECAUSE THAT'S GOING TO PAY OFF
THEIR LOANS. RIGHT SO ANYWAYS,
JUST SOME THOUGHTS TO PUT OUT
THERE AND WE HAVE TO SAY IT OUT
LOUD BECAUSE, YOU KNOW, THE
BUDGET IS HAVING A HARD TIME
THESE DAYS. RIGHT. BUT THIS
THESE ARE IMPORTANT
CONVERSATIONS. AND IT'S SO
IMPORTANT THAT WE PUT FUNDING
INTO THE RESEARCH AND TO GRANTS
WHATEVER WE NEED TO DO TO
EDUCATE AND MAKE SURE THAT
THERE'S ACCESS, ESPECIALLY IN
THE BLACK AND BROWN COMMUNITIES.
SO THANK YOU FOR THAT. I JUST
WANTED TO PUT THAT OUT THERE.
THANK YOU. ANOTHER AREA I WORK
ON IS END OF LIFE. NO ONE LIKES
TO TALK ABOUT THAT EITHER IN THE
HEALTH CARE FIELD. RIGHT WE ALL
GO THROUGH MENOPAUSE AND WE ALL
DIE. JOHN LEWIS, MPH AND YOU'RE
GOING TO TALK ABOUT CALIFORNIA
HEALTH BENEFITS. SO THANK YOU.
MY NAME IS JOHN LEWIS. I WORK
WITH THE CALIFORNIA HEALTH
BENEFITS REVIEW PROGRAM, AND I
WANT TO FOCUS ON BENEFIT
COVERAGE FOR THE PHARMACEUTICAL
DRUGS THAT ARE GENERALLY
DISCUSSED AROUND TREATMENT FOR
SYMPTOMS OF MENOPAUSE. AND WHAT
IS THAT BENEFIT COVERAGE LOOK
LIKE AMONG PEOPLE ENROLLED IN
COMMERCIAL HEALTH INSURANCE? IN
IN GENERAL, WHEN WE'RE TALKING
ABOUT THESE DRUGS, THEY KIND OF
FALL INTO TWO BIG CATEGORIES,
THE HORMONAL, IS THE FIRST SET.
AND FOR THOSE THAT ARE
MANUFACTURED, THERE ARE ABOUT
FIVE THERAPEUTIC CATEGORIES AND
ABOUT 24 DRUGS, MANY ARE
AVAILABLE UNDER MULTIPLE BRAND
NAMES. THEY CAN BE ORAL,
TOPICAL, TRANSDERMAL OR VAGINAL.
AND BY THE WAY, THIS SET
INCLUDES THE MANUFACTURED
BIOIDENTICAL HORMONES. AND I
WANT TO UNDERLINE THAT BECAUSE
THEN THERE'S THIS SEPARATE GROUP
THE COMPOUNDED BIOIDENTICAL
HORMONES. THOSE ARE PRODUCED ON
DEMAND BY A COMPOUNDING
PHARMACY. AND THEIR PRODUCTION
IS NOT REGULATED BY THE FDA.
THEY ALSO THOUGH CAN VARY. SO
THEY CAN BE ORAL OR VAGINAL OR
TOPICAL IN TERMS OF COMMERCIAL
HEALTH INSURANCE, ENROLLEES WITH
ON FORMULARY COVERAGE, WE LOOKED
RECENTLY AND WE THINK ABOUT 100%
OF THESE ENROLLEES HAVE COVERAGE
FOR ONE OR MORE OF THE DRUGS.
FOR ALMOST ALL THE THERAPEUTIC
GROUPS. BUT THERE ARE
EXCEPTIONS, AND SOME OF THEM
NOTABLE, ONLY ABOUT 8% OF
ENROLLEES HAD COVERAGE FOR THE
VAGINAL ESTROGEN, HIGH DOSE RING
OR FIM RING IS ITS COMMERCIAL
NAME, AND ABOUT 91, EVEN THOUGH
THAT'S STILL A FAIR NUMBER, HAD
COVERAGE FOR THE COMPOUNDED
BIOIDENTICAL HORMONES. IN TERMS
OF THE OTHER BIG SET, THE
NON-HORMONAL DRUGS, THESE ARE
GENERALLY ORAL, AND THEY INCLUDE
ABOUT FIVE THERAPEUTIC
CATEGORIES FOR THE
ANTIDEPRESSANTS ABOUT EIGHT
DRUGS, ANTICONVULSANTS, ABOUT
TWO DRUGS, DRUGS TO PREVENT OR
TREAT BONE LOSS, ABOUT NINE
DRUGS. THERE ARE TWO OUTLIERS,
THOUGH, THAT ARE ESSENTIALLY
SORT OF, CATEGORIES UNTO
THEMSELVES AT THIS POINT, THE
NEUROKININ RECEPTOR ANTAGONIST,
THE PFIZER, AND ALSO THE
SELECTIVE ESTROGEN RECEPTOR
MODULATOR, OSPEMIFENE AND IN
TERMS OF COVERAGE FOR FOLKS, FOR
ENROLLEES IN THE COMMERCIAL
WORLD ON FORMULARY COVERAGE IS,
YOU KNOW, PRETTY CLOSE TO 100%
FOR ONE OR MORE OF THE DRUGS FOR
ALMOST ALL THE THERAPEUTIC
GROUPS. BUT THE EXCEPTIONS HERE,
ONLY ABOUT 7% FOR PFIZER AND
ONLY ABOUT 13% FOR OSPEMIFENE. I
WOULD NOTE THAT THESE VERY LOW
NUMBERS WE SEE THEY'RE GENERALLY
NEWER DRUGS, AND THAT'S FAIRLY
COMMON AS DRUGS COME OUT.
COVERAGE IS OFTEN FAIRLY
LIMITED. AND AS THEY ARE AROUND
LONGER, THEY MAY BECOME MORE
COMMONLY COVERED. IT'S SOMEWHAT
OF HOW THE, THE, THE CONSTANTLY
EVOLVING SCIENCE BEHIND MEDICINE
IS REFLECTED IN A CONSTANTLY
EVOLVING WAYS IN WHICH HEALTH
INSURANCE ADDRESSES VARIOUS
THINGS. THEN DO WE JUDGE
EFFICACY BY USE IT VARIES.
THERE'S A THAT'S A THAT'S A LONG
AND COMPLICATED QUESTION, AND
IT'S BACK TO NOT ONLY THE
INSURANCE COMPANIES THEMSELVES,
BUT AS WAS BROUGHT UP EARLIER,
WHAT IS THE FDA WILLING TO
ACTUALLY MAKE STATEMENTS ABOUT.
AND THIS IS ALSO SOMEWHAT ALL
OVER THE BOARD, AS THE
SUGGESTION WAS MADE, THERE'S
SOME REAL HESITANCY AROUND
GETTING THINGS APPROVED, AND
PARTICULARLY FOR MENOPAUSAL
WOMEN, THIS IS BEYOND MY
PROGRAM'S SCOPE, BUT WE'RE AWARE
OF THAT FEDERAL ISSUE IS LARGE.
I DID WANT TO JUST REALLY
UNDERSCORE, AGAIN, THERE ARE
MEDICALLY EFFECTIVE PRESCRIPTION
DRUGS THAT CAN REDUCE OR ABATE
MENOPAUSE SYMPTOMS. AND THE ON
FORMULARY BENEFIT COVERAGE IS
PRETTY BROADLY PRESENT, THOUGH
LIKELY ANY ONE COULD BE ONLY FOR
ONE IF THERE'S A SET OF
COMPETING BRAND NAMES, IT MAY
TAKE A WHILE FOR NEWER DRUGS TO
BE ON FORMULARY FOR MOST
ENROLLEES. ANY QUESTIONS? SO I
SAW THE DOCTORS SEEM TO HAVE
SOME THOUGHTS ABOUT THIS
PRESENTATION, SO I WOULD BE
CURIOUS THEIR THOUGHTS. WELL, I
THINK FIRST OF ALL, JUST TALKING
A LITTLE BIT ABOUT COMPOUNDING.
AND I THINK THAT THERE'S THIS
NOTION OF COMPOUNDING
BIOIDENTICAL LIKE A LOT OF OUR
PATIENTS DON'T UNDERSTAND IT.
I'M CURIOUS IF YOU ALL
UNDERSTAND BECAUSE I FEEL THAT
LIKE WHEN PEOPLE TALK ABOUT THEY
FEEL THAT IT'S BETTER PATIENTS
REALLY FEEL THAT COMPOUNDING IS
BETTER, WHEN IN FACT IT'S NOT
REGULATED NECESSARILY. AND WE
HAVE BIOIDENTICAL FDA APPROVED
MEDICATIONS. SO WE WERE JUST
TALKING ABOUT THE FACT THAT WHY
ARE WE CALLING THEM COMPOUNDING
BIOIDENTICAL. EVERYTHING COMES
FROM A PLANT. EVEN BIOCHEMICALS
THAT ARE FDA APPROVED OR
COMPOUNDED. THEY'RE ALL COMING
FROM A PLANT BIOIDENTICAL JUST
MEANS THAT IT'S IDENTICAL TO
CHEMICAL STRUCTURE OF THE
HORMONES THAT ARE ENDOGENOUS IN
THE BODY. BUT THAT COMPOUNDING
IS JUST IT'S THEY FEEL THAT IT'S
MORE IT'S FORMULATED. WE DON'T
KNOW WHAT'S GOING IN THERE
HONESTLY. SO WE DO USE IT. BUT
IT'S DEFINITELY NOT THE
MAINSTAY. I WOULD SAY THAT WE
TRY TO STICK WITH THE FDA
FORMULATIONS IF POSSIBLE, JUST
BECAUSE WE KNOW WHAT'S GOING IN
THERE, I THINK THAT WE WERE JUST
TALKING ABOUT THE FACT THAT,
SOME OF THE, SOME OF THE TIMES
WHEN WE GET, YOU KNOW, DENIALS
FOR MEDICATION ÓRDENES, THE
ALTERNATIVES THAT ARE BROUGHT
BACK TO US DON'T MAKE ANY SENSE.
RIGHT? SO THEY'LL BE LIKE, OH,
WE WON'T, APPROVE A VAGINAL
ESTROGEN. AND THEY'LL SAY TO USE
BECAUSE YOU NEED TO TRY A
SYSTEMIC ESTROGEN FIRST, WHICH
DOESN'T MAKE ANY SENSE BECAUSE
TOTALLY DIFFERENT PURPOSE. SO WE
WERE JUST TALKING ABOUT THAT. WE
WERE ALSO, WE WERE ALSO TALKING
ABOUT THERE'S LOTS OF DIFFERENT
TYPES OF MEDICATIONS THAT ARE
OUT THERE. AND SO THE COVERAGE
IS VARY. AND WHAT'S INTERESTING
ABOUT HORMONAL MEDICATIONS IS
THEY CAN BE USED NOT JUST FOR
MENOPAUSAL PURPOSES. BUT I WAS
JUST TALKING ABOUT, YOU KNOW,
THERE'S MANY, REPRODUCTIVE
RELATED MENTAL HEALTH
CONDITIONS. RIGHT? SO I SEE A
LOT OF PATIENTS WITH
PREMENSTRUAL DYSPHORIC DISORDER,
FOR EXAMPLE, AND THOSE THAT CAN
BE THAT IS A HORMONE SENSITIVITY
. IT IS A PSYCHIATRIC DIAGNOSIS,
BUT IT ACTUALLY IS A
PROGESTERONE SENSITIVITY. AND SO
I OFTENTIMES USE MENOPAUSAL
MANAGEMENT AND KIND OF MY
KNOWLEDGE AND UNDERSTANDING OF
THAT PHYSIOLOGY. AND IT IS
EXTREMELY HARD TO GET THESE
MEDICATIONS COVERED FOR THAT
INDICATION, AND THESE ARE REALLY
SEVERE MENTAL HEALTH ISSUES THAT
CAN BE CURED REALLY WITH SOME
HORMONE THERAPY. SO WE WERE JUST
TALKING ABOUT THE DIFFERENT
DRUGS THAT WE USE AND THE HOW
HARD IT IS TO GET SOME OF THEM
COVERED. AND YOU FEEL LIKE THE
PUBLIC THINKS COMPOUNDING IS
BETTER. YES YES. A LOT OF OUR
EDUCATION WHEN WE SEE OUR
PATIENTS FOR THE FIRST TIME IS
THAT WE REALLY HAVE TO TALK
ABOUT WHAT IS COMPOUNDING. IT'S
SOMEWHAT OF A MARKETING GIMMICK
IN SOME WAYS, RIGHT? I MEAN,
IT'S PEOPLE FEEL THAT IT'S
BETTER. IT'S FORMULATED FOR
THEM. IT'S EXTREMELY EXPENSIVE.
I WAS WE WERE SURPRISED THAT
THERE WAS EVEN COVERAGE. I
DIDN'T EVEN KNOW THERE WAS
COVERAGE. BUT BUT REALLY IT'S
THEY FEEL THAT IT'S BETTER AND
IT'S NOT. THAT'S JUST NOT SO.
AND SO WE REALLY DO SPEND A LOT
OF TIME EDUCATING. SORRY. NOT.
YEAH. AND I THINK IT'S BECAUSE
WE SAY COMPOUNDED BIOIDENTICAL.
AND REALLY WHAT WE NEED TO SAY
IS COMPOUNDED HORMONES AND FDA
APPROVED HORMONES. THAT IS THE
TERMINOLOGY. BECAUSE THE
COMPOUNDED ONES. YES. ARE THEY,
YOU KNOW, IN GENERAL ARE
IDENTICAL TO WHAT OUR OVARIES
MAKE. BUT THE FDA APPROVED
THERAPIES, THE MAJORITY OF THEM
ARE BIOIDENTICAL AS WELL. AND
THAT'S THE CONFUSION. THÀNH. SO
WHEN WE REEDUCATE OUR PATIENTS
AND OUR PROVIDERS THAT THE
MAJORITY OF THE MEDICATIONS,
ESPECIALLY WHEN IT COMES TO
ESTROGENS, ARE BIOIDENTICAL,
THEN THEY WILL COME AROUND. THE
ROLE OF COMPOUNDING PHARMACIES
IS ACTUALLY IMPORTANT, AND I
DON'T THINK THEY SHOULD BE TAKEN
AWAY. MANY OF THE MANY OF THE
INGREDIENTS AND THE ADDITIVES TO
THE FDA APPROVED PRODUCTS CAUSE
ALLERGIES OR CAUSE PROBLEMS FOR
OUR PATIENTS, AND THEN WE CAN
COMPOUND THEM WITH DIFFERENT
ADDITIVES THAT THEY'RE NOT
ALLERGIC TO, FOR EXAMPLE. AND
WE'LL DO THAT CERTAINLY FOR
VAGINAL PRODUCTS AND SOME
SYSTEMIC, THOUGH I'M I'M VERY
CAUTIOUS WITH SYSTEMIC PRODUCTS
AGAIN, BECAUSE ESTRADIOL CAN
CAUSE ENDOMETRIAL CANCER, I WANT
TO KNOW EXACTLY WHAT'S GOING
INTO MY PATIENT. ADDITIONALLY
PROGESTERONE IS WHERE WE GET
REALLY THERE'S A LOT OF NUANCE.
AND PROGESTERONE. THERE'S ONLY
ONE BIOIDENTICAL FDA APPROVED
PROGESTERONE PRODUCT, AND IT'S
POORLY ABSORBED. IT'S A GREAT
MEDICATION, BUT YOU HAVE TO KNOW
HOW TO USE IT. AND THERE ARE
SYNTHETIC PROGESTINS THAT ARE
FDA APPROVED THAT ARE STRONGER
AND CAN BE MORE EFFECTIVE. BUT
THERE IS CONCERN ABOUT THEIR
SAFETY PROFILE WHEN IT COMES TO
BREAST CANCER. SO THERE'S A LOT
OF NUANCE TO HORMONE THERAPY.
BUT BIOIDENTICAL OR COMPOUNDED
PROGESTERONE IS WHERE I AM MOST
CONCERNED, BECAUSE THIS IS WHERE
I SEE PATIENTS COMING IN WITH
CREAMS. THEY'RE COMING IN WITH
SUBTHERAPEUTIC DOSAGES. AND
REMEMBER, PROGESTERONE HAS MANY
FUNCTIONS, BUT THE PRIMARY ONE
IS TO PREVENT ENDOMETRIAL
CANCER, WHICH THEY WILL GET IF
THEY USE UNOPPOSED ESTROGEN FOR
LONG ENOUGH. SO I MEAN, PART OF
WHAT I'M HEARING TODAY
THROUGHOUT THESE CONVERSATIONS
IS THAT WOMEN AND ANYONE GOING
THROUGH MENOPAUSE, THEY DON'T
KNOW WHAT TO ASK AND THEY DON'T
KNOW WHAT WORKS. AND I KNOW THAT
WE'VE FELT THAT WAY. I GUESS
PART OF IT IS THEY SHOULDN'T
HAVE THE ANSWERS. THEY SHOULD BE
ABLE TO GO TO THEIR PHYSICIAN
AND GET THE ANSWERS. BUT I THINK
THAT WOMEN NEED IS THERE
SOMEWHERE THEY CAN GO TO KNOW
WHAT TO ASK? LIKE, IS THERE SOME
RESOURCE OUT THERE YOU WOULD
POINT WOMEN TO? I MEAN,
DEFINITELY A CERTIFIED MENOPAUSE
PROVIDER IS GOING TO BE A GOOD
ONE. THERE'S A WHOLE LIST OF
CERTIFIED MENOPAUSE PROVIDERS
ALL OVER THE COUNTRY, AND SO
THAT'S LIKE A THOSE ARE
DEFINITELY PEOPLE THAT
PHYSICIANS AND ALL ALL TYPES OF
PHYSICIANS, NOT JUST OB-GYNS,
BUT THEY ALL HAVE, YOU KNOW,
THEY ARE REALLY INTERESTED IN
THIS FIELD. THEY'RE TRAINED,
THEY WANT TO PROVIDE EVIDENCE
BASED MEDICINE. NOT THAT YOU
DON'T YOU DON'T HAVE TO HAVE
GOOD PROVIDERS BE, YOU KNOW,
CERTIFIED. BUT THIS IS JUST ONE
SOURCE. HOW DO YOU FIND WHERE
THERE'S A WHOLE LIST IF YOU JUST
GO TO THE MENOPAUSE SOCIETY?
MENOPAUSE SOCIETY. YEAH. AND
THEY HAVE A WHOLE POSTING ON OUR
SOCIAL MEDIA. YEAH, YEAH, YEAH
THAT'S ONE. BUT HONESTLY A LOT
OF THE CENTERS WILL ALSO HAVE
GOOD. JUST LIKE OUR CENTER. WE
HAVE A REALLY GOOD WEBSITE FOR
RESOURCES FOR FAQS LIKE TRUSTED
INFORMATION'S PLACED ON THERE.
SO I THINK GOING TO ACADEMICS
CENTERS, LOOKING AT THEIR
WEBSITES, THAT'S ANOTHER GOOD
PLACE TO GET GOOD INFORMATION. I
REFER MY PATIENTS TO MENOPAUSE
.ORG. SO THE NORTH AMERICAN
MENOPAUSE SOCIETY, NOW CALLED
THE MENOPAUSE SOCIETY, IS WHERE
THE CERTIFICATION COMES FROM.
AND AGAIN, IT TAKES EXTRA STEPS
AND RESOURCES. NOT EVERYBODY
THAT DOES MENOPAUSE HAS TO BE
CERTIFIED BY THEM. BUT I
ACTUALLY SEND MOST OF MY
PATIENTS TO THEIR WEBSITE WHERE
IT HAS A FOR PATIENTS SECTION. I
ALSO REFER EVERYBODY TO, YOU
KNOW, IT WAS THE TO THE NEW YORK
TIMES ARTICLE. WOMEN HAVE BEEN
MISLED ABOUT MENOPAUSE. IT IS
THE BEST ARTICLE THAT HAS EVER
BEEN WRITTEN EVER ABOUT
MENOPAUSE. THAT TAKES COMPLEX
MEDICAL, UNDERSTANDINGS AND PUTS
IT INTO SOMETHING THAT IS
PALATABLE FOR PATIENTS TO READ.
SO THAT I STARTED SENDING
EVERYBODY THERE. AND THEN THERE
ALSO ARE YOU MAY BE FAMILIAR
WITH DIFFERENT TYPES OF
TELEHEALTH COMPANIES THAT ARE
POPPING UP. UNFORTUNATELY, THE
MAJORITY OF THOSE COMPANIES ARE
CASH BASED. THEY DON'T TAKE
INSURANCE, I ACTUALLY AM A
MEDICAL DIRECTOR FOR ONE THAT
DOES TAKE I'M A MEDICAL DIRECTOR
LIAISON WITH UCSF FOR ONE THAT
REALLY DOES TAKE INSURANCE. AND
THEIR GOAL IS TO TAKE ALL
INSURANCES. AND I DO THINK, YOU
KNOW, THERE'S QUESTIONS ABOUT
TELEHEALTH COMPANIES AND PEOPLE
SHOULD JUST BE GOING TO THEIR
PROVIDERS. BUT AS WE'VE
ESTABLISHED HERE, MOST PEOPLE'S
PROVIDERS KNOW NOTHING ABOUT
MENOPAUSE. AND SO THERE ARE
THESE KIND OF SPECIAL COMPANIES
THAT ARE POPPING UP THAT ARE
GOING TO BE ABLE TO PROVIDE
ACCESS TO THOSE THAT DON'T HAVE
LOCAL ACCESS. THE BIG ISSUE IS
GOING TO BE COVERAGE FOR THEM.
AND WE HAVE ONE MORE. WE HAVE
ONE MORE SPEAKER, ON ZOOM,
DOCTOR JEN GUNTER, WHO'S GOING
TO CLOSE US OUT WITH THE AUTHOR
OF THE VAGINA BIBLE, THE
MENOPAUSE MANIFESTO AND BLOOD,
THE SCIENCE AND MEDICINE AND
MYTHOLOGY OF MENSTRUATION. THANK
YOU. YEAH. THANK YOU SO MUCH FOR
HAVING ME. AND ALLOWING ME TO
COME REMOTELY. MY SON IS HAVING
OPEN HEART SURGERY NEXT WEEK AND
I DON'T WANT TO RISK CATCHING
ANY, ANYTHING BY BEING OUT OF
THE HOUSE IN PUBLIC. SO, YEAH.
SO, SO FIRST OF ALL, I'M GOING
TO TRY TO BRING ALL THIS HOME.
SO THERE'S A BIG SORT OF THEME
ABOUT LACK OF EDUCATION. AND I
THINK THAT WE COULD BE DOING
THINGS AT A STATE LEVEL BY
BRINGING EDUCATION INTO THE
SCHOOLS WE CENTER SEX EDUCATION
AROUND SEX, AS OPPOSED TO AROUND
THE BIOLOGY OF THE REPRODUCTIVE
TRACT, AND HOW THAT HAS
WIDESPREAD SCOPING INFLUENCES.
SO PEOPLE ARE GRADUATING SCHOOL
KNOWING MORE ABOUT FROG BIOLOGY
THAN HUMAN BIOLOGY. BUT WHEN WE
JUST SPOKE JUST NOW ABOUT WHERE
CAN PEOPLE GO TO GET INFORMATION
ABOUT MENOPAUSE, WHY COULD WE
NOT DESIGN A MODULE THAT LIVES
IN ON THE CALIFORNIA DEPARTMENT
OF HEALTH'S WEBSITE, WHERE
PEOPLE CAN GO TO AND THIS IS AN
EVIDENCE BASED PLACE TO GET
INFORMATION SO THE STATE CAN
CERTAINLY TAKE SOME INTEREST
THERE, AND WE CAN HAVE THAT TYPE
OF THING THAT COULD BE
AVAILABLE. NOW, ONE THING THAT'S
BEEN TOUCHED ON, AND THIS IS A
SUPER IMPORTANT THEME, IS WHEN
THE WOMEN'S HEALTH INITIATIVE
CAME OUT AND THAT SORT OF WAS
MISINTERPRETED BY MANY PEOPLE.
I'VE BEEN DOING THIS FOR 30
YEARS, SO I PRACTICED LONG
BEFORE THE Y AS WELL. WHEN THAT
STUDY CAME OUT AND WAS
MISINTERPRETED, I BELIEVE IT WAS
REALLY A GOLDEN OPPORTUNITY FOR
MANY PEOPLE TO STOP GETTING
INVOLVED WITH MENOPAUSE BECAUSE
IT IS SO POORLY REIMBURSED. AND
YOU'VE HEARD THIS THREAD OVER
AND OVER AGAIN, PRIMARY CARE,
MEANING SITTING IN THE OFFICE OR
TALKING TO YOUR DOCTOR ABOUT THE
SYMPTOMS THAT YOU'RE HAVING,
SOMETHING THAT DOESN'T NEED
SURGERY, DOESN'T NEED EXPENSIVE
CARDIAC STUFF, DOESN'T NEED A
LOT OF TESTS, PAYS SO POORLY.
AND SO THE REASON WHY WE HEARD
IT'S SO DIFFICULT TO GET IT SET
UP AT A UNIVERSITY IS THEY HAD
TO USE FUNDING FROM THE DEAN,
FUNDING FROM THE CHAIR. THEY
CAN'T PAY TO SORT OF MAKE THAT
CLINIC RUN BY ITSELF WITH WHAT
THEY MAKE FROM SEEING PATIENTS.
SO THAT'S A REALLY IMPORTANT
PART OF SORT OF THIS DESERT OF
MENOPAUSE CARE IS THAT PEOPLE
ARE SIMPLY NOT REIMBURSED.
ANOTHER IMPORTANT THING THAT
THAT, YOU KNOW, WE REALLY NEED
TO TALK ABOUT, WHICH ISN'T
HAPPENING, I THINK RIGHT NOW AS
MUCH IN CALIFORNIA, BUT I
UNDERSTAND THERE'S A BILL AROUND
THAT THAT COULD HAVE AN IMPACT
IN IT IS THE INFLUENCE OF
PRIVATE EQUITY. SO IN OTHER
STATES, WE ARE SEEING PRIVATE
EQUITY FIRMS COME IN AND
BASICALLY SHUTTERING THE GYN
COMPONENT OF OBSTETRICS
PRACTICES THAT THEY BUY, BECAUSE
YOU CAN MAKE MONEY DOING A HIGH
VOLUME OBSTETRICS MEDICAID'S IN
DIFFERENT STATES PAY QUITE WELL
FOR OB, BUT YOU CAN'T MAKE MONEY
SEEING GYN PATIENTS IN THE
OFFICE. SO THAT'S AN IMPORTANT
THING TO KEEP ON THE RADAR FOR
OUR STATE. I ALSO WANT TO TALK A
LITTLE ABOUT THE ONLINE CARE
THAT WAS BROUGHT UP. SO ALL OF
THESE VC FUNDED ONLINE CARE
PLATFORMS ARE COMING OUT FOR
MENOPAUSE. AND ON ONE HAND, IT'S
GREAT BECAUSE IF YOU LIVE IN THE
CENTRAL VALLEY AND THERE ISN'T A
MENOPAUSE PRACTITIONER CLOSE BY,
YOU CAN FIND ONE ONLINE. BUT VC
FUNDING EXISTS TO MAKE MONEY FOR
THE VCS. AND I JUST TOLD YOU HOW
YOU CAN'T MAKE MONEY SEEING
MENOPAUSE PATIENTS IN THE
CLINIC. SO MANY OF THESE
PLATFORMS MAKE MONEY BY SELLING
UNTESTED SUPPLEMENTS, BY SELLING
COMPOUNDED HORMONES, COMPOUNDED
ESTROGEN FACE CREAM, COMPOUNDED
ESTROGEN BODY CREAM. AND SO
THERE'S ABSOLUTELY NO REGULATION
FOR THAT. AND SO THAT'S JUST AN
IMPORTANT THING WHEN YOU KEEP IN
MIND ABOUT THESE ONLINE
PLATFORMS IS THEY HAVE GOOD.
THEY MANY OF THEM HAVE NORTH
AMERICAN MENOPAUSE CERTIFIED
PRACTITIONERS, MENOPAUSE SOCIETY
PRACTITIONERS. BUT THEY ALSO
HAVE THIS OTHER ARM. THAT IS
WHAT MAKES MONEY. SO YOU HAVE TO
KEEP THAT IN MIND. I WANT TO
TALK A LITTLE BIT MORE. THIS HAS
BEEN SORT OF EMPHASIZED OR
TALKED BY SEVERAL PEOPLE ABOUT
COMPOUNDED BIOIDENTICAL HORMONES
, WHICH IS OF COURSE A BIT OF A
MISNOMER, IF YOU WILL, BECAUSE
THE WORST THING YOU CAN DO IS TO
HAVE SOMETHING THAT'S NOT
REGULATED AND NOT MADE IN A WAY
THAT PEOPLE KNOW WHAT THEY'RE
GETTING. SO ONLY 14% OF THE
POPULATION KNOWS THAT COMPOUNDED
HORMONES ARE NOT FDA APPROVED. I
DON'T UNDERSTAND WHY WE COULDN'T
HAVE LEGISLATION IN CALIFORNIA
THAT REQUIRES THAT IF YOU'RE
GETTING A COMPOUNDED HORMONE
THAT PEOPLE ARE GIVEN A, YOU
KNOW, A DOCUMENT THAT SAYS, YOU
MUST KNOW THAT THIS IS NOT FDA
APPROVED, RIGHT? YOU KNOW, WE
CAN HAVE THOSE KINDS OF
REGULATIONS AND THAT WHEN PEOPLE
GO AND THEY TRY THINGS LIKE
PELLETS, WHICH YOU'VE HEARD,
TALKED ABOUT, WHICH CAUSED SO
MUCH HARM, 94% OF PEOPLE WHO
CHOOSE PELLETS DIDN'T KNOW ABOUT
THE STANDARD MENOPAUSAL HORMONE
THERAPY THAT WE'RE TALKING
ABOUT. AND WHEN YOU TALK ABOUT
HOW MUCH HARM THESE PELLETS
HAVE, THEY CARRY NO WARNING
LABEL. SO IF I PRESCRIBE AN
ESTROGEN PATCH FOR SOMEBODY,
THEY GET THE WARNING LABEL FROM
THE FDA. YOU KNOW, WE CAN ARGUE
ABOUT WHETHER THE WARNING LABEL
SHOULD HAVE WHAT IT SAYS, BUT MY
PATIENTS GOING TO GET A WARNING
LABEL IF I SEND SOMEONE TO A
COMPOUNDING PHARMACY OR GIVE
THEM A PELLET, THEY GET NO
WARNING LABEL. SO THEY THINK
IT'S SAFER, WHEN IN FACT IT'S
NOT. WE KNOW THESE PELLETS
AREN'T RECOMMENDED BY ANY
HORMONE SOCIETY. AND THERE IS
THE ONE OF THE LARGEST COMPANIES
THAT MAKES THESE PELLETS. BIO TÊ
HAD OVER 4000 ADVERSE EVENTS
THAT WENT UNREPORTED TO THE FDA,
AND MANY OF THESE PELLETS ARE
MADE HERE BY PHARMACIES IN
CALIFORNIA. VÀ SO IS THERE SOME
WAY THAT WE CAN HAVE LEGISLATION
THAT AFFECTS, YOU KNOW, WHETHER
PHARMACIES IN CALIFORNIA, AT
LEAST AREN'T CONTRIBUTING TO THE
PELLET PROBLEM? AND THEN WE HAVE
OTHER NON-PHYSICIAN PROVIDERS
STEPPING IN. SO IF YOU DON'T GET
YOUR CARE FROM A PHYSICIAN,
YOU'VE UNFORTUNATELY FALLEN INTO
ONE OF THE MANY GAPS WE'VE HEARD
ABOUT. YOU COULD END UP GETTING
OZONE THERAPY FROM A NATUROPATH.
YOU COULD GET A GAS THAT HAS IS
TOXIC, THAT HAS NO KNOWN HEALTH
BENEFITS AT ALL, ACCORDING TO
THE CDC. BUT YET YOU CAN STILL
GET IT IN CALIFORNIA. AND THE
WEBSITES LOOK REALLY COOL. SO
THERE ARE SO MANY GAPS THAT HAVE
BEEN CREATED. AND I'M NOT SURE
WHY THERE COULDN'T BE SOME TYPE
OF LEGISLATION TO NOT ONLY FOCUS
ON FUNDING AND FOCUS ON HOW WE
CAN IMPROVE LABELING, BUT ALSO
TIGHTEN THESE GAPS BECAUSE
PEOPLE ARE MAKING MONEY HAND
OVER FIST IN THESE GAPS. AND SO
THAT'S WHY WE'RE SEEING KIND OF
THAT WHOLE SHIFT. I THINK IT'S
REALLY IMPORTANT. SO I KIND OF
WANT TO BRING IT HOME THAT
MANDATING TRAINING, WHETHER
IT'S, YOU KNOW, IN, AT THE
SCHOOL LEVEL, IN MEDICAL SCHOOL
LEVEL, RESIDENCY LEVEL, I TRAIN
IN CANADA, WHICH IS AN
ADDITIONAL YEAR PROGRAM. AND WE
SPENT ALMOST SIX MONTHS DOING
IN-OFFICE SORT OF HORMONE
MANAGEMENT, COMPLEX BIRTH
CONTROL, PILL MANAGEMENT,
COMPLEX HORMONE MANAGEMENT,
THOSE TYPES OF THINGS. SO IT'S
KIND OF A DIFFERENT LEVEL OF
TRAINING. WE CAN TALK ABOUT
MANDATING APPROPRIATE
REIMBURSEMENT. WE CAN TALK ABOUT
MANDATING AFFORDABLE THERAPIES.
AND THAT WOULD INCLUDE NOT JUST
THE IMPORTANT VAGINAL HORMONE
THERAPIES. WE'VE HEARD ABOUT,
BUT THE COMPOUNDED BUT NOT THE
COMPOUND HORMONES. THE CBT AND
ALSO THE NEWER THERAPIES LIKE
THE NEUROKININ THREE INHIBITORS
THAT ARE JUST NOT AFFORDABLE FOR
SO MANY PEOPLE. AND WE CAN TALK
ALSO ABOUT, YOU KNOW, MAKING
ONLINE MODULES THAT HAVE BEEN
APPROVED BY THE STATE SO PEOPLE
CAN GO TO A PLACE AND LEARN
THAT, YOU KNOW, MAYBE WHAT
THEY'VE HEARD FROM THEIR
PROVIDER IS INCORRECT AND REALLY
FOCUS ON CONSUMER PROTECTION AT
MULTIPLE DIFFERENT LEVELS. THANK
YOU SO MUCH. THAT WAS A LOT.
YOU'VE CLEARLY BEEN LISTENING
THE WHOLE TIME, AND WE'RE READY
TO CLOSE IT OUT WITH A LOT OF
GOOD, CONCRETE IDEAS. YEAH. AND
WE ARE, OUT OF TIME. BUT I
REALLY, REALLY, REALLY WANT TO
THANK ALL THE PRESENTERS TODAY
FOR BEING HERE, FOR SHARING WITH
US AGAIN. I WISH I HAD DONE THIS
HEARING WHEN I WAS 40 AND NOT
63, BUT HERE WE ARE NOW. YEAH
YOU'RE WELCOME, WITH A LOT MORE
WORK TO GO, AND I AND WHILE WE
DIDN'T HAVE A LOT HERE, I KNOW
THERE WERE A LOT PEOPLE WATCHING
AND LISTENING BECAUSE PEOPLE
KEEP TEXTING ME, ABOUT DIFFERENT
THINGS. THEY'VE HEARD. SO THANK
YOU ALL FOR YOUR WORK. IT'S VERY
VALUABLE. THANK YOU FOR BRINGING
IT TO THE LEGISLATURE. AND I'M
AND I THINK GET READY TO MAKE
THIS TRIP BECAUSE I HOPEFULLY
WE'RE GOING TO DO A LOT MORE
WORK IN THIS SPACE AND MAKE SURE
WOMEN CAN AGE AS WELL AS WE CAN.
YEAH. I WANT TO THANK YOU. I,
YOU KNOW, BEFORE I WAS
PERIMENOPAUSAL THE FIRST
CONVERSATION I THINK I EVER HAD
WITH MY GIRLFRIENDS ABOUT THIS
WAS TWO OF MY GIRLFRIENDS WHO
WERE FIGHTING ABOUT WHETHER
PELLETS WERE A GOOD IDEA OR NOT.
ONE WHO HAD A CERTIFIED
MENOPAUSE PRACTITIONER WHO HAD
WARNED HER AGAINST PELLETS, AND
THE OTHER WHO WAS USING PELLETS,
AND YOU KNOW, THIS IS HOW WE'RE
GETTING OUR ADVICE, RIGHT,
SITTING AROUND A KITCHEN TABLE.
AND SO I THINK IT IS SO CRITICAL
THAT YOU GUYS BE HERE TO HELP
EDUCATE US. I REALLY WANT TO
THANK, OUR LAST WITNESS, DOCTOR
GUNTER, FOR SOME REALLY CONCRETE
SUGGESTIONS. BUT ALL OF YOU, FOR
REALLY COMING HERE AND TELLING
US HOW WE CAN HELP MOVE THE BALL
FORWARD FOR WOMEN AS THEY
TRANSITION THROUGH MENOPAUSE. I
GUESS I'M THE LUCKY ONE, BECAUSE
I'M ONLY 45 AND I'M GETTING TO
HAVE THIS CONVERSATION, AND I'M
SURE I WILL BENEFIT FROM
EVERYTHING I'M LEARNING. BUT SO
WILL EVERYONE WHO'S LISTENING
AND THOSE WHO COME, AFTER US. I
HAVE A 12 YEAR OLD DAUGHTER, AND
SHE THINKS IT'S HILARIOUS THAT
WE'RE ON OPPOSITE ENDS OF THIS
JOURNEY, BUT THAT'S WHERE WE
ARE. SO THANK YOU, THANK YOU,
THANK YOU ALL VERY MUCH. THANK
YOU. AND THANK YOU TO SENATOR
ROSS FOR LETTING US HIJACK HIS
HEARING. YOU KNOW, I HAVE TO SAY
THAT THIS WAS VERY, VERY
INFORMATIVE. I AM DISAPPOINTED
THAT MORE OF MY MALE COLLEAGUES,
MEMBERS OF THE HEALTH COMMITTEE,
WERE NOT HERE, WE DO HAVE A ROLE
IN THIS PROCESS. AND I THINK
IT'S VERY IMPORTANT THAT WE
LEARN ALL THAT WE CAN. KNOWLEDGE
IS POWER. IT'S OUR
RESPONSIBILITY TO BE BOTH
SUPPORTIVE AND SENSITIVE TO
THOSE THAT WE LOVE AS THEY GO
THROUGH THIS. AND, HOPEFULLY
NEXT TIME WE'LL HAVE MORE OF MY
MALE COLLEAGUES HERE. THANK YOU
VERY MUCH FOR WHAT YOU PRESENTED
. THIS HEARING IS NOW CLOSED