789_Mindy Goldman
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[00:00:00] JJ Virgin: Hey, I am JJ Virgin, PhD Dropout. Sorry, mom. Turn four time New York Times bestselling author. As a certified nutrition specialist, fitness Hall of Famer and globally recognized leader in health. I’m driven to keep asking the tough questions and use my podcast to simplify the science of health. Into actionable strategies that help you thrive.

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[00:01:20] JJ Virgin: We are gonna go deep into a subject that has come up time and time and time again, and it is. Can you go on hormone replacement therapy if you are a breast cancer survivor? This is a subject we’ve talked about on some of the other podcasts. I will link to those within these show notes, along with some other options for how to do early detection.

[00:01:44] JJ Virgin: Today we’re gonna go a little bit more allopathic. You’re going to, we’re gonna hear, um, the doctor here talking a little bit more about some of the different drugs, but she’s also gonna talk about some of the natural alternatives as well. Here’s the thing. I think we need to look at all the tools in the toolbox when we are in a life-threatening situation.

[00:02:03] JJ Virgin: I know that when my son Grant was hit by a car and left for dead in the street. I was like, bring it all in. And what I got through modern medicine and trauma centers saved his life. And then what we did on the backend through some of the more innovative techniques and natural alternatives brought him back to life.

[00:02:24] JJ Virgin: So we used it all. And that’s what you’re gonna hear today as well. You’re gonna hear some of the things that you can do naturally. Some of the things that you can do with drug interventions. And this is really important because you wanna be able to look at all of these things and then make the decision that’s best for you.

[00:02:41] JJ Virgin: And what I love the most about Dr. Mindy Goldman is that’s really her message, is get all the information, be critically open-minded, and then work with your doctor. Work with your care team to make the best decision for you. Looking at all the tools available. So Dr. Mindy Goldman, I was really fortunate to sit across from her at a dinner table the night before.

[00:03:06] JJ Virgin: Tamson Fidel’s, world’s hottest menopause party. Dr. Mindy is part of the M Factor, part of the How to Menopause book and a major resource because she really works within the intersection. Of breast cancer oncology and gynecology, and I actually don’t know anybody else really working within that intersection.

[00:03:30] JJ Virgin: She’s the Chief Clinical Officer at MIDI Health. You’ll hear more about that during the podcast, but basically this is a. Company now that is in 50 different states and it is providing women medical care in the middle of life, right? Insurance based, and she’s done a whole module, whole training within this for her providers to be able to work in the space of breast cancer survivors and what they can do in terms of can they go on hormones, what are other alternatives they have for symptom relief, et cetera.

[00:04:04] JJ Virgin: So that’s really exciting. She’s also a clinical professor, emus at the Department of Obstetrics and Gynecology, and the director of the Gynecology Center for Cancer Survivors and at-Risk Women Program at the University of California, San Francisco. She literally created this department, created this program because she saw the need when her own friend, uh, died of cancer.

[00:04:30] JJ Virgin: She’s Ty’s Chief Clinical Officer, and that is where she, again, has created a program that she teaches their providers, their 300 plus providers. Now how to do. She’s nationally recognized as an expert in the menopausal symptoms that come with the treatment for breast cancer and how to improve them safely and effectively.

[00:04:49] JJ Virgin: Again, we’re gonna be walking through. The natural options you have and the drug options you have, and so you’ll be able to take this information and work with the doctor to make the best choices for you. She’s created a unique program that bridges gynecology and breast oncology and provides breast cancer survivors with care that’s focused on quality of life.

[00:05:10] JJ Virgin: And this is such a big thing because you hear so often that, and I’ve seen this with some of my friends, they’ve gone through treatment. And then they’re just suffering, and that’s what she wants to stop, is that type of suffering. She’s a nationally recognized expert in this field, and in 2012, she authored the American College of Gynecology Technical Bulletin that provides the comprehensive clinical guidelines in the management of gynecological issues in women with breast cancer.

[00:05:37] JJ Virgin: And she is also on the survivorship panel for the National Comprehensive Cancer Network and is the subcommittee chair for the panels on sexual functioning and menopause. And help author the NCC and Management guidelines in these areas. So yes, she knows what she’s talking about and again, she’s gonna give you the whole range of ways that you can look at this.

[00:06:00] JJ Virgin: Um, from drug options to natural options. I’m also gonna put some other links in the show notes. She talks about mammograms. Within this, we also have, um, Dr. Jen Simmons, who’s been on this podcast, who has a new form of imaging as another option. So I’m gonna make sure you have all that information. So again, you can look at all of this and make the best decisions for you as to what you want to do.

[00:06:24] JJ Virgin: I’m gonna put all of [email protected]. Forward slash Dr. Mindy, and I’ll be right back with Dr. Mindy Goldman. Stay with me.

[00:06:40] JJ Virgin: Dr. Mindy Goldman, welcome to Well Beyond 40.

[00:06:43] Mindy Goldman: Thanks so much. I’m really happy to be here.

[00:06:45] JJ Virgin: Well, I appreciate your time because this is a subject that obviously is. Is rife with misinformation and fear. And I think we’re gonna cut through a lot of that today. And we are gonna really be talking deep into breast cancer, breast cancer survival, but in relationship to menopause.

[00:07:05] JJ Virgin: And can you take hormones? And what I see from your bios, you seem to have a, this. Perfect intersection between gynecology and breast oncology. And what I’d love to start with is how, how did you get into this whole thing?

[00:07:19] Mindy Goldman: Yeah. Um, thanks for asking me that. Um, I, uh, I. I really got into this based on helping a dear friend who got breast cancer at a very young age and passed away in a year and a half, and I helped take care of her.

[00:07:40] Mindy Goldman: And when on leave, uh, from my job at UCSF, where I was on the faculty as a general OGYN and um. Took care of her, helped her die at home with her family and partner, and when I came back to work, realized I wanted to do more for cancer survivors and my department negotiated with the breast care center at UCSF and they put me there.

[00:08:07] Mindy Goldman: And what started happening was I, I was brought on to do what was called follow up to learn how to care for people who had had breast cancer. And I worked with side by side with oncologists and breast surgeons. And what started happening was because I was a gynecologist, people were asking me, Hey, my patient was thrown into menopause from chemotherapy.

[00:08:32] Mindy Goldman: What do I do? Or my patients having vaginal dryness and sexual function on all these breast medicines. What do I do? Are they having bleeding on Tamoxifen? And I look in the literature, and this was in the early two thousands, and I was shocked because there was nothing there. And fast forward now 20 plus years, I feel very lucky that I have been able to help develop a field that really didn’t exist.

[00:09:02] Mindy Goldman: Bridging breast oncology and gynecology, and focused on quality of life issues for cancer survivors. And I’ve been able to work with the American College of OB, GYN, helping write guidelines. I currently work with the National Comprehensive Cancer Network. Where I chair their menopause and sexual functioning panels, helping provide guidelines for oncologists nationally.

[00:09:26] Mindy Goldman: And now that we’re having this conversation and the, and more and more people are having these conversations, um, uh, this is becoming really an established field, uh, where I’d like to hope is becoming an established field within, uh, GYN really focused on managing quality of life and menopausal symptoms and.

[00:09:48] Mindy Goldman: Uh, cancer survivors.

[00:09:49] JJ Virgin: Let’s just make it so

[00:09:51] Mindy Goldman: exactly.

[00:09:52] JJ Virgin: There you have it. Uh, I’ve heard from so many people that they’ve gone through, you know, breast cancer and whether they were in menopause at the time or then they were in menopause. Now they’re in menopause and they don’t know what to do to manage the symptoms and the medications they’re on are making the symptoms worse.

[00:10:11] JJ Virgin: And, and the rule of thumb, what I hear from all of them is I cannot take hormones. I had like to walk right into that big question first. Yeah, that’s probably the biggest one, right?

[00:10:22] Mindy Goldman: That is the biggest one. So one thing I’d like to clarify is that breast cancer is not, breast cancer is not breast cancer.

[00:10:32] Mindy Goldman: And really breast cancer is a compilation of a number of different diseases. And the truth is, there are some breast cancer survivors that can take hormones. So when someone has a breast cancer, they send the tumor to see if it is sensitive to hormones. Estrogen and progesterone, and if it is not sensitive hormone, negative breast cancer, those people can take hormones once they have been free of disease for a period of time when they’re first being treated, they typically get chemotherapy because we don’t have.

[00:11:11] Mindy Goldman: Other hormonal or anti hormonal therapies to give them. But once they are doing well for a period of time, we don’t have evidence that says the use of hormones increases the risk of recurrence in people with hormone receptor negative breast cancer.

[00:11:30] JJ Virgin: What percentage of breast cancer? Um, breast cancers are hormone receptor negative breast cancers.

[00:11:38] Mindy Goldman: Approximately one third. So it’s more common to have hormone receptor positive breast cancer. And those are the ones where the use of hormones is more controversial. And really to look at those patients, I think we need to talk first about do, do hormones cause or increase the risk of breast cancer in the first place.

[00:12:04] Mindy Goldman: And um. That’s where I think a lot of the misinformation is still out there. So a lot of what we know about hormones and breast cancer came from this large study that people still quote called the Women’s Health Initiative. It was the largest NIH sponsored trial designed to see whether the use of hormones, um.

[00:12:27] Mindy Goldman: Prevented heart disease, which is the, as you know, is the number one cause of death for women and men, and whether it was associated with any adverse, uh, risks. And there was a lot of bad publicity when part of the study was stopped short with the finding. It didn’t prevent against heart disease. And it surpassed the threshold for breast cancer.

[00:12:47] Mindy Goldman: And we could spend this entire podcast tearing apart that study. We know that, uh, the heart disease, uh, the reason why they didn’t see the benefits was that the average age of patients were in their sixties. 63 and that hormones have started early, are preventative for heart. But in that study, they used specific types of hormones, the ones that were most commonly prescribed when they were accruing patients for that study.

[00:13:16] Mindy Goldman: And they were synthetic hormones and in particular, uh. A synthetic progestin. So when women take hormones, estrogen is the component that tends to make you feel good. But if you have a uterus, you need to balance that with some form of a progestogen to protect against uterine cancer. In the Women’s Health Initiative, they used a synthetic form of a progestogen, and studies since then have confirmed that largely the risk of breast cancer.

[00:13:50] Mindy Goldman: Is associated with combination, estrogen and synthetic forms of progestins. Turns out estrogen alone is actually associated with lower risk of getting and lower risk of dying of breast cancer. So we know it’s more the progestogen component and specifically these synthetic progestins. And there are studies since then that suggest bioidentical forms of progesterone.

[00:14:17] Mindy Goldman: So bioidentical means formulations or hormones that are similar to what our body produces. And there are studies that suggest bioidentical forms of progesterone are not associated with an increased risk of breast cancer. So I wanna clarify that hormones do not cause breast cancer. And the increased risk that has been seen is largely associated with formulations that use synthetic progestins.

[00:14:47] Mindy Goldman: What we are missing is data, looking at bioidentical formulations of hormones. And people who are at high risk for breast cancer, including prior breast cancer survivors. So that gets back to your original question, which is, can breast cancer survivors use hormone replacement therapy? It really still needs to be an individualized discussion for women with hormone positive disease.

[00:15:16] Mindy Goldman: When you’re talking about giving someone. The current formulations of HRT, which are bioidentical formulations.

[00:15:24] JJ Virgin: So you look at this and you wouldn’t know if a tumor was hormone receptor negative until you had a tumor. So you would have no way of knowing, right? If someone. Was likely to develop a hormone receptor negative or positive tumor unless they had the tumor that you could test.

[00:15:40] Mindy Goldman: Exactly. So, but we know that it’s more common to develop the hormone positive tumors,

[00:15:45] JJ Virgin: but yet you didn’t see an increased risk in breast cancer with using bioidentical hormone replacement.

[00:15:53] Mindy Goldman: So the be Well, I will clarify. We’re trying to make sense of these two things. Yeah, we don’t, we don’t have these large randomized control trials.

[00:16:04] Mindy Goldman: Like the WHI with bioidentical formulations of hormones. But I will tell you that the best evidence we have really suggests that the higher risk of recurrence is with combination, estrogen and a synthetic form of progestin, and that. The studies that have looked at estrogen alone, it’s associated with lower risk of getting breast cancer, and we are limited and do not have enough good long-term studies looking at breast cancer risks.

[00:16:36] Mindy Goldman: Or, or the, uh, risks in people who are, who have had breast cancer with these bioidentical formulations. So yes, what you are correct is you don’t know what type of tumor you’re gonna get. Um, but there’s just, there’s still a lack of data out there. It’s so frustrating these studies, right?

[00:16:54] JJ Virgin: Well, because you look at it and go, okay, well if your risk, you don’t increase your risk being on bioidentical hormones, so that’s not causing the risk.

[00:17:05] JJ Virgin: But you could have a hormone positive receptor positive cancer, then you have to be concerned about it. But would you, if it was hormone receptor positive, but it was only for, say, progesterone, could you use estrogen if you didn’t have a uterus? Yeah.

[00:17:21] Mindy Goldman: That’s a really good question. So this standard protect your heart, like, you know what?

[00:17:25] Mindy Goldman: Yeah. The standard of care is when someone has a hormone receptor positive breast cancer. Whether it’s estrogen only, progesterone only, or estrogen and progesterone positivity. The standard is that they give these hormonal therapies to modify the tumor environment, and those are drugs like Tamoxifen and the aromatase inhibitor.

[00:17:51] Mindy Goldman: Now, where it’s even more confusing is those therapies. Tend to modulate the estrogen receptor. So particularly with aromatase inhibitors, those are anti estrogens. And so that doesn’t make sense because we’ve already said estrogen alone prevents breast cancer, yet you have breast cancer and we give you these anti-estrogen therapies, and there is some increasing data that suggests what those anti-estrogen therapies are doing.

[00:18:21] Mindy Goldman: Is really modifying the progesterone receptor. So I think there’s more and more of a thought that it’s the progesterone receptors that are involved in the breast cancer. That estrogen alone is safer than we thought, but we’re not at the point where we are saying people with hormone positive breast cancer can use estrogen or should be using estrogen to treat their symptoms, particularly when they’re on these.

[00:18:48] Mindy Goldman: Hormonal therapy. So it is a really complex topic and I wanna be able to simplify things for,

[00:18:55] JJ Virgin: yeah, we’ll have some action items, but you know, but I hear this too. And then you think about it as you, as you pointed out, which I feel like it’s missed, is our biggest risk factors, heart disease. And then you look at the role of estrogen in your brain, in your heart and your bones, and then you are on estrogen blockers.

[00:19:15] JJ Virgin: And I would look at this and I think of how our bone density falls off the cliff when we go through menopause. If we’re not replacing estrogen, the risk of dementia, the what happens. I used to work in a, an office where they would come in, I’d come in to review lab work and I wouldn’t be able to see anything.

[00:19:31] JJ Virgin: I’d get the lab work before I’d see their history, and I could tell if they were on hormones or not. Like you could just tell, you could see it in all of their, you know, their inflammation, their insulin, their cholesterol, so. I’m just wondering what’s happening to these women on these estrogen blockers, on these aromatase inhibitors with their.

[00:19:51] JJ Virgin: Bone mineral density and their cardiovascular health and their dementia risk?

[00:19:56] Mindy Goldman: Yeah, well, first of all, these aromatase inhibitors have only been used since around the early two thousands, so it’s not like we have 30 years worth of follow-up to see what happens with their heart. And I would say that’s one of the areas that we don’t know is long-term cardiovascular risks.

[00:20:14] Mindy Goldman: I think we do have a very good understanding of bone risks. We know that aromatase inhibitors are associated with both more symptomatic things, like more joint pain. As well as negative effects on bone density. We know estrogen is important for maintaining and promoting bone health. You see a higher risk of bone loss and fractures when women are taking aromatase inhibitors.

[00:20:40] Mindy Goldman: Many breast cancer survivors who are on aromatase inhibitors. Need to be on additional medications for maintaining bone density. So I, you know, I think that when I see a lot of patients who are worried about hormones, um. Everyone thinks about cancer, right? We’ve all known someone, or we’ve may been close to someone who had cancer, died of cancer.

[00:21:04] Mindy Goldman: I think we’re all worried about cancer and oftentimes people don’t think about, we are most likely to die from cardiovascular disease, and when we look at risks with hormone replacement therapy and breast cancer, again, my own view is that current formulations of bioidentical hormones. May not increase breast breast risk at all.

[00:21:26] Mindy Goldman: We don’t have the big randomized control trial studies, but even when you look at the WHI and you look at the absolute numbers, it’s similar to the risks associated with obesity and having two glasses of wine per day. Lifestyle things have a huge impact on cancer risks, and people focus on these things like HRT and not focusing on the things that you can do yourself.

[00:21:51] JJ Virgin: That one study. I feel like set a whole generation of women just, you know, they’re like this lost generation. It’s just awful. It’s really awful. Someone coming in who is. A breast cancer survivor who is hormone receptor positive, what are some of the things that they can do for all the menopause symptoms then if they can’t use hormones?

[00:22:19] Mindy Goldman: I’m so glad you asked me that because the big, I think you have something really good. The biggest thing is I want people to hear that. No one should suffer. I think a lot of cancer survivors get told, be thankful you’re alive. We’ve got all these wonderful treatments. Uh, we will keep you alive and just deal with the side effects of treatments, and that just isn’t true.

[00:22:42] Mindy Goldman: So. Certainly when someone is going through active treatment, that’s not a time where, where we would have these conversations about the use of hormones. What I do like when people are candidates for hormone therapies is I like to think of it as it’s sort of a blanket treatment that can treat many different symptoms.

[00:23:00] Mindy Goldman: The temperature dysregulation, the mood changes, the sleep dysfunction, the vaginal dryness, the sexual dysfunction, the joint pain. When someone has. Breast cancer and is going through treatment and you can’t do a blanket treatment like that. You need to target the individual symptoms. So when it comes to hot flashes, we have many other alternatives.

[00:23:24] Mindy Goldman: There are prescription drugs. Low doses of a number of different medications, antidepressants, uh, a uh, neuropathic pain relievers, overactive bladder medicines, um, a whole slew anti-seizure medicines. Whole slew of medications that in low doses can treat hot flashes. We also have a new category of drugs.

[00:23:48] Mindy Goldman: First drug that we understand the mechanism of how hot flashes occur and where it targets. It’s a drug called Fein. The trade name is osa, and it targets what’s called the candy neurons in the hypothalamus in the brain, which is where temperature dysregulation occurs and. So that’s just another tool in the toolbox of different drug options that are available to te to target the temperature dysregulation.

[00:24:18] Mindy Goldman: Then we target sleep, because if you’re not sleeping. There’s lots of data that says you don’t exercise as well. You don’t make healthy food choices, you’re just not gonna feel as well. So there are plenty of supplements that can be used for sleep, magnesium, glycinate, lavender, which can be, uh, helpful for, uh, sleep related anxiety.

[00:24:39] Mindy Goldman: L-theanine. Ashwagandha. We try to figure out do people have trouble falling asleep or staying asleep? We know the incidence of sleep apnea goes up after menopause. We send people for sleep studies. We do a deep dive focusing in on their diet, what they’re eating, when they’re eating. We talk to people about time eating, which can help improve sleep.

[00:25:03] Mindy Goldman: And helps decrease hot flashes at night. So there are many, many different things we can target into vaginal dryness and sexual dysfunction. And even when someone is on these anti hormonal therapies like aromatase inhibitors, they can still use certain types of vaginal estrogen. So we can treat that which, uh, there are treatment options for sexual dysfunction.

[00:25:24] Mindy Goldman: So virtually every symptom that women come in with, uh, in the perimenopause and menopause. That cancer survivors also have, we have treatment options that are available. They may not be as successful sometimes as the overriding HRT, but there are many, many treatments that can be given.

[00:25:46] JJ Virgin: So let’s, let’s go back to.

[00:25:49] JJ Virgin: Before you, you discovery of breast cancer and hopefully you never do because you, you threw out there. And I think that it’s important to go a little deeper into this because it does tend to get ignored. You know, when you look at the risk of alcohol consumption and cancer, it’s insane. Like insane. Um, so I would love to go through if someone, someone was looking at this because all I’ve seen so far out there is someone finds out they have a family risk, which I, I would love to hear the genetics.

[00:26:17] JJ Virgin: ’cause I’ve heard it’s what maybe. 20% is genetics. I’m, I’m throwing a number out so you know, but they’ll have a prophylactic mastectomy and I’m thinking there probably are some better things we could be doing here. So what would be some of the big risk factors? How much of a risk factor are genetics and what are the things someone could do to, to never end up having to be a breast cancer survivor?

[00:26:39] JJ Virgin: ’cause they never got it in the first place.

[00:26:41] Mindy Goldman: Yeah. So, um, it’s important to realize that familial. And genetic risks are different. So many people have a family history of breast cancer. About a third of women may have a family history that that may be in a mom, a sister, a aunt or grandmother, um, of familial breast cancers.

[00:27:01] Mindy Goldman: About 15 to 20% of those are actually due to genetic mutations that we can check for. I think people are, have most commonly heard of the ones called the BRCA genes, but there are many other genes that we now, now know of that can also increase breast cancer risks. Now, um, in people who are high risks, we oftentimes follow them differently so they get some of the education that everyone should be getting.

[00:27:31] Mindy Goldman: So there are lifestyle things that people can do. That can help prevent cancer. The biggest is exercise and actually specific amounts, 150 minutes a week divided times interval. Cardio is really important for breast cancer prevention. It’s also been shown for colon cancer prevention. We are seeing higher risk of colon cancer guidelines now say people should get colonoscopies starting at 45 instead of 50.

[00:28:00] Mindy Goldman: Minimizing alcohol can help. Okay. Wait, wait. Let’s go back to exercise. Hold. I mean, I, I meant to say ex, I meant to, sorry about that. Um, exercising regularly can, but I, but

[00:28:10] JJ Virgin: you mentioned, you mentioned interval. Yes. So were you meaning doing that 150 minutes in like an uh, a high intensity interval type of thing?

[00:28:20] JJ Virgin: What were you exactly saying? Yeah,

[00:28:21] Mindy Goldman: so it’s a, first of all, it’s a 150 minutes over the course of a week. That’s the minimum we want people to get. And during the times that they have exercising, so let’s say someone’s gonna do 50 minutes three times a week, it is important that they are getting interval training during that time.

[00:28:40] Mindy Goldman: So pushing their heart rate. Coming down, pushing their heart rate coming down. I would tell you that I’m not clear when I’ve looked at studies that people understand. The mechanism as to why that is more important than sustained cardio. But there’s evidence that it is that interval training that is, it’s the

[00:28:59] JJ Virgin: lactate more important, it’s the lactate and it’s creating apoptosis.

[00:29:04] JJ Virgin: It is like if you look at people who are very serious, not the long cardio, long slow distance people, but the interval people. I, I think we’re going to like look at lactate as our, as our like therapeutic drug of choice here. And so it’s that building up of lactate when you go hard, recover, go hard, recover, go hard, recover that then can then go to tissues and trigger all sorts of stuff.

[00:29:26] JJ Virgin: We already know that contracting muscle, you know, I call it the multitasking messenger, but there’s another thing that happens with lactate. I mean for the brain as well. For the heart as well. That’s incredible. So

[00:29:38] Mindy Goldman: interesting. ’cause that converts to anaerobic metabolism. Which likely is really not healthy for cells.

[00:29:45] JJ Virgin: Yes. So cancer cells hate it. So you

[00:29:47] Mindy Goldman: need our cells need oxygen.

[00:29:49] JJ Virgin: Yeah.

[00:29:50] Mindy Goldman: So interesting, interesting. Thank you. Because I’ve always had a tough time understanding what’s the mechanism, but, so we know that that’s one thing we can all do. And it’s not just breast cancer, it’s colon cancer, uh, liver cancers, lung cancer.

[00:30:04] Mindy Goldman: It’s, there’s a number of cancers now where there is evidence that regular exercise can decrease risks. Maintaining normal body weight is important. We have evidence for obesity is associated with, uh, higher risk of diabetes, higher risk of cardiovascular disease, all of those things together, or associated with also seeing higher risk of cancer.

[00:30:29] Mindy Goldman: Gosh, I

[00:30:29] JJ Virgin: wish we would get into this unpacking weight and having it be body composition.

[00:30:34] Mindy Goldman: Yeah. Yeah.

[00:30:35] JJ Virgin: You know, especially for women who could be totally normal weight and a skinny fat, you know, I just wish we could get into not just looking at body composition rather than weight. I think that is the, such the missing piece in the medical field, but also looking, when you do look at body fat.

[00:30:52] JJ Virgin: Where is it? I don’t really care if your thighs are fat, but if you’ve got visceral adipose tissue, we got a big problem. Central

[00:30:57] Mindy Goldman: adipose tissue is the one we know that that’s has the higher cardiovascular risk. I totally agree with you and I think we need more studies specifically looking at that. You, we just

[00:31:08] JJ Virgin: have to use a, an embody scale or a, some kind of scale where we can actually see this when you go to the doctor’s office.

[00:31:14] JJ Virgin: Um, and by the way, high intensity interval training is like super effective for burning off visceral adipose tissue.

[00:31:21] Mindy Goldman: Yeah, I’ve listened to your other podcasts about that. Oh. Um, we’re so in line. Okay. The other thing is minimizing alcohol. I think people don’t realize that alcohol is a risk factor specifically for breast cancer, and specifically for the more common hormone positive breast cancer.

[00:31:41] Mindy Goldman: And so in the breast world, we will guide people no more than two to three drinks in a week. Um, and once people are diagnosed, we really try to have them cut back to as minimal alcohol, uh, as little alcohol as possible. And we know. So these are simple lifestyle things. I know they’re not simple for everyone, but there are many things that we can do that can be preventative for cancer in the first place.

[00:32:07] JJ Virgin: Any foods that you, uh, love or you would say Absolutely run from that or make sure you get that in.

[00:32:14] Mindy Goldman: Um, I wanna. I think there’s a lot of misinformation about foods out there. I think people are worried about soy, for example, and if they do, they’re drinking soy milk, they’re having excess soy in their diet, that that’s gonna increase the risk of getting hormone sensitive cancers like breast endometrial, and we don’t have good evidence for that.

[00:32:36] Mindy Goldman: So I will tell people. It is okay to include soy in your diet. I think there’s a lot about, you know, in the whole longevity space of minimizing, uh, antioxidants and, uh, different types of diets that are probably the most healthy for us, like Mediterranean type diets. I think what we do at MIDI is we will review pe uh, what people are eating.

[00:33:02] Mindy Goldman: When they’re eating it, because I think people don’t realize the importance of, I had mentioned before, time eating, um, that that can be helpful for both symptoms. Um, particularly symptoms like hot flashes and improving sleep and all of that is important for our overall health and wellbeing. So with time eating, for example, um, it’s important to not have a big meal within three hours of going to bed.

[00:33:30] Mindy Goldman: When you have a big meal and have this big caloric load, your body gives heat, gives off heat when it processes that, which can worsen nighttime, hot flashes and night sweats. You don’t process food as well. It’s gonna contribute, uh, to weight gain and all of the detrimental effects associated with this.

[00:33:49] Mindy Goldman: When you sleep like crap, you sleep. So, so, um, we could have whole conversations about. Diet, supplements, all of that. But, um, one of the thing I, I do think is important, uh, that people look at labels, look at what they’re eating, um, I think people can go overboard with some of the supplements, uh, that are out there.

[00:34:12] Mindy Goldman: But there are basic, basic things we can all do to prevent cancer. Main, uh, getting regular exercise, minimizing alcohol, trying to eat a well-balanced meal with enough fruits, vegetables, certainly enough protein. A lot of menopausal women aren’t getting enough. Uh, protein minimizing all of the, uh, carbohydrates.

[00:34:35] Mindy Goldman: Certainly not eating processed foods, things like that.

[00:34:38] JJ Virgin: What about, um, things like sauna?

[00:34:43] Mindy Goldman: Have you looked at that at all? Uh, as to whether there’s increased risk? There’s, well,

[00:34:48] JJ Virgin: could it be, I mean, you know, when you look at, when you look at something like, um, diabetes, and I remember looking at the NHANES study and, and a, a study they’d had based on what they were finding in there, that the diabetes increase was due to the, the storage of toxins in the fat cells and.

[00:35:07] JJ Virgin: I just wonder if some of, if we are exercising well, but we’re also doing things to help us regularly get rid of toxins, could that also be a help?

[00:35:17] Mindy Goldman: I think, uh, we don’t have enough studies that have shown does it actually have a impact, but there’s certainly a lot of benefits. Right. Also, look at like, the whole theory is I think these extremes of heat.

[00:35:30] Mindy Goldman: Uh, when you look at the extremes of cold and the cold plunges, there’s a lot of. Interesting information coming out about how these extremes and temperatures may impact our body and our body’s metabolic function and our body’s inflammation, and the impact that that could have on cancer development. You know, my personal thoughts are with things like saunas, uh, in, um, uh, steams that, um, not only does it allow you sweat.

[00:36:02] Mindy Goldman: It releases pheromones. It allows people to relax. We don’t have a good handle on. Stress and its impact on disease. We all say stress is bad for us, but we think stress, uh, can increase risk of cardiovascular disease. Stress may really be involved in cancer development. So any of these things, in addition to sweating out the potential toxins that we have, I think the beneficial effects it may have on our body’s ability to relax.

[00:36:34] Mindy Goldman: Could really be important in the development of, in preventing the development of diseases like cardiovascular disease and cancer.

[00:36:42] JJ Virgin: I know it’s You can go in there and shut the door.

[00:36:44] Mindy Goldman: Exactly.

[00:36:47] JJ Virgin: Shut them out. Someone, uh, let’s, let’s give you a hypothetical patient. She’s just in perimenopause and not on anything yet starting to have those symptoms of perimenopause.

[00:37:03] JJ Virgin: Finds a lump walk. Walk us through, be like, if she were your patient, what would she be going through? Like how she would be handled?

[00:37:14] Mindy Goldman: Okay, so the first thing to know is that many women have the so-called lumpy bumpy breasts or fibrocystic breasts. And in the second part of someone’s menstrual cycle when progesterone is produced.

[00:37:30] Mindy Goldman: Sometimes people will actually feel their lumpiness in a more discreet way, meaning someone can think they feel a lump. It may actually do to the be due to the hormonal changes of the cycle. So the first thing that I tell someone to do is. Let’s wait and see what happens with your next menstrual cycle.

[00:37:51] Mindy Goldman: Now, the problem in the perimenopause is sometimes cycles are spacing out. Yeah. So if they don’t get a cycle in a few weeks, I’m gonna want them to come in and get that lump evaluated. Um, when someone has an evaluation of a lump, first thing is it usually includes a clinical exam to determine whether something is likely solid or cystic.

[00:38:15] Mindy Goldman: Cysts are by and large. Almost a hundred percent of the time benign. A cyst can be aspirated even in the office. And if fluid is obtained, you can see if that goes, that lump goes away. Bring someone back again for a follow-up exam, make sure it goes away. Many people don’t do aspirations in their office and they send someone for imaging.

[00:38:38] Mindy Goldman: Imaging includes. Getting a diagnostic mammogram to target into that area. And a diagnostic ultrasound, ultrasounds are really helpful, uh, mainly in telling if a lump that’s there is solid or cystic, again, if it’s a cyst, it’s benign. Um, with benign cysts, like people who have these so-called fibrocystic changes, they get these discreet cysts and we don’t aspirate them because they can come back.

[00:39:06] Mindy Goldman: We aspirate them only if they’re really big and really painful. Um, if it’s a solid lump that needs to be evaluated, so people will get some sort of tissue diagnosis if you can feel it. They get what’s called the fine needle aspiration. If you had sent someone for a mammogram and it was only seen on mammogram, they can get mammogram, uh, guided, uh, biopsies, and then everything, uh, depends on what that biopsy shows.

[00:39:35] Mindy Goldman: You know, it can be benign tissue, it can be atypical tissue, and it can be cancer. Uh, and depending on those results, determine sort of what’s the next steps and, and where they’re gonna go from there.

[00:39:47] JJ Virgin: And if it’s cancerous, so now they’re going in for cancer treatment while they’re having all their perimenopausal symptoms.

[00:39:54] JJ Virgin: There are, how do you keep them from going absolutely crazy with the two things going on at once?

[00:40:00] Mindy Goldman: Yeah, that’s a great question. Um. Again, one of the things, uh, I always wanna see is, uh, what’s the treatment gonna, uh, involve? Because there are many, many different types of treatments that people get. They get different types of surgery, lumpectomy, mastectomy.

[00:40:19] Mindy Goldman: Some people get radiation. If they have hormone positive disease, they’re gonna be recommended. Hormonal therapies. There are different side effects with tamoxifen versus aromatase inhibitors. To use an aromatase inhibitor, you have to be menopausal. That means if you’re perimenopausal, they’re gonna throw you into menopause by giving you shots to shut your ovaries down.

[00:40:44] Mindy Goldman: Or we sometimes surgically remove the ovaries. If you’re hormone negative, you may get chemotherapy. So a lot depends. I always work closely with my breast team to understand, okay, what are the steps that are gonna happen? And then I can more aptly guide someone. So if I know that their treatment is going to include something like an aromatase inhibitor, we are gonna be aggressive at talking at that initial visit of you’re likely gonna have a worsening of your temperature dysregulation.

[00:41:18] Mindy Goldman: Let’s go through the different options that we can give you if that starts to become a problem. I know when you’re on an aromatase inhibitor. That you’re probably gonna have horrific vaginal dryness ’cause those drugs shut down all estrogen production in the body. Let’s talk about what you can do to be proactive at preventing some of that.

[00:41:39] Mindy Goldman: So there’s a number of over the counter things that people can try and the recommendations actually from organizations like the NCCN are. To try over the counter things first before we talk about, um, the use of, uh, vaginal, uh, um, estrogen. I’m gonna talk to them about their diet. I’m gonna talk to them about their sleep.

[00:42:03] Mindy Goldman: When you’re diagnosed with cancer, people tend to have a lot of anxiety. So we’re gonna talk of ways of doing stress reduction. We’re gonna talk if we need supplements when it comes time for sleep, to try and keep their mind from going. So there’s a lot of things that I think we can. Talk to people about beforehand that allows them to be a little bit better prepared for all of these treatment induced side effects.

[00:42:30] JJ Virgin: And you said, um, likely even with a hormone receptor positive, you’d be able to do something like an uh, vaginal estrogen cream. Exactly.

[00:42:39] Mindy Goldman: Uh, well, I would tell you so vaginal, estrogen comes in three different ways, creams, rings, and suppositories. There are some theoretical concerns when you use a vaginal estrogen cream in the setting of hormone positive breast cancer, that when you push a bunch of cream in the vagina, that the surface area is greater.

[00:43:00] Mindy Goldman: And it could potentially lead to rises in hormone levels and that maybe that that is not safe. I will tell you there are studies, in fact, a wonderful study was published this past January, which was a big systematic review and meta-analysis of. All the studies that have looked at the use of vaginal, estrogen and breast cancer survivors and did not show any impact on dying of breast cancer.

[00:43:26] Mindy Goldman: So we know that vaginal estrogen is safe for virtually almost all breast cancer survivors in people who are on, for example, aromatase inhibitors. Because those drugs function to suppress all estrogen, we tend to use the suppository and the ring formulations because studies suggest. That those are more likely to stay locally without any rises in the bloodstream.

[00:43:51] JJ Virgin: And one more, um, this might be out of left field, but where would testosterone use come in?

[00:43:59] Mindy Goldman: Okay, so let’s talk about testosterone in general. So the best evidence for testosterone in women is for improving sexual functioning in postmenopausal women. Yeah, there is emerging evidence for other things like bone health, muscle mass.

[00:44:18] Mindy Goldman: I think we have much better evidence in men than we do women, but it is emerging also evidence for metabolic health, overall wellbeing that’s more emerging. Um, and testo, so. Most of the women coming in asking about it. What we see at MIDI and what I see in my breast cancer survivors are more people asking ab, asking about it for vaginal dryness and sexual health.

[00:44:46] Mindy Goldman: We don’t have enough safety data. To fully say that testosterone is safe. I sort of put it in the same categories that we talk about with HRT, and particularly it’s for women on aromatase inhibitors, because what happens in the body is all women, we all have hormones that are produced. Our adrenal glands put out D-H-E-A-D-H-E-A is converted to testosterone.

[00:45:10] Mindy Goldman: Our ovaries put out testosterone in the body that testosterone. Is changed to weak forms of estrogen by an enzyme called aromatase. When you use an aromatase inhibitor, you inhibit that reaction. Mm. And so the concern if you gave someone lots of testosterone, could it overwhelm an aromatase inhibitor and would that be dangerous?

[00:45:35] Mindy Goldman: Now, most times we are giving levels that maintain people in certain values where. It’s less likely to have an impact, but we don’t have enough safety data. So what I do with breast cancer survivors is I think everything’s shared decision making. Um, I am more apt to try, for example, vaginal estrogens.

[00:45:54] Mindy Goldman: ’cause I think we have more data with that for treating vaginal dryness and sexual dysfunction. If I treat the vaginal dryness and then they wanna know. But can I use a little testosterone for my sexual dysfunction? I will, uh, potentially in a shared decision making, be willing to offer that if they’re on an aromatase inhibitor.

[00:46:14] Mindy Goldman: I may be more likely to suggest one of the FDA approved drugs for sexual dysfunction. The banin, the addi, or the bromide, the vii. Now those are not FDA approved for postmenopausal women, so unfortunately they have to pay out of pocket. But there’s Wait, wait, wait,

[00:46:32] JJ Virgin: wait. Those drugs for sexual def dysfunction in women are not approved for women Postmenopausally.

[00:46:37] Mindy Goldman: Yep. Isn’t that crazy? Why

[00:46:38] JJ Virgin: do most women have sexual dysfunction? Most women positive, I think. What is that? Some kind of mean, mean?

[00:46:46] Mindy Goldman: I know. I don’t know. My understanding was they thought they would get it through the FDA. Easier if they first studied it in premenopausal women. Um, so, uh, but it just

[00:46:58] JJ Virgin: leads me to the, if, if, if, if, uh, women were in charge, things would be different.

[00:47:04] JJ Virgin: Okay. So, wow. That’s, that is the silliest thing ever.

[00:47:09] Mindy Goldman: Can I also, one thing I did wanna clarify that I felt like we, you mentioned but I didn’t fully touch on, is. You had mentioned family history and genetic mutations. Oh,

[00:47:20] JJ Virgin: yes. Yes. I

[00:47:21] Mindy Goldman: wanna clarify for your listeners that you can use hormones. I think those people are told, I can’t ever use HRT because I have a family history of breast cancer, or I have a genetic mutation, and we do not have any evidence.

[00:47:38] Mindy Goldman: That says the risk of hormones. If there is any risk, and as I have said, I’m not convinced that the current formulations do increase risk, but even if they do increase risk, we don’t have any evidence that says it adds on to the risk that someone has based on family history or genetic mutation. That doesn’t mean that they don’t need to be followed closely, so closely means they need regular breast exam, they need regular imaging, which is mammogram.

[00:48:08] Mindy Goldman: Plus or minus. Some people may need an MRI, depending on if their risk is high enough. Um, they may, uh, we will always guide them about lifestyle things, about, uh, minimizing, um, alcohol and getting regular exercise. So their tr their screening may be different, but they can still use hormones.

[00:48:31] JJ Virgin: Lifesaver.

[00:48:32] JJ Virgin: You’ve mentioned MIDI Health a couple times, and I would love you to share, um, MIDI Health. You’re, you’re one of the founders, right? Uh, yes. And I’m

[00:48:42] Mindy Goldman: the Chief Clinical Officer, uh, for midi.

[00:48:44] JJ Virgin: Okay. What, what is MIDI Health?

[00:48:46] Mindy Goldman: Yeah. Of

[00:48:47] JJ Virgin: midi.

[00:48:48] Mindy Goldman: So, MIDI Health is a virtual telehealth clinic, uh, or virtual telehealth medical practice.

[00:48:56] Mindy Goldman: That is covered by health insurance and is focused on treating perimenopause and menopause. We also do some aspects of primary care, like weight management, bone health, lipid management. We cover many issues because we know that women have, uh, limited access to find experts who can help treat their perimenopause and menopause symptoms and really do a deep dive into.

[00:49:25] Mindy Goldman: What the evidence shows, but we also know that people have a tough time getting into their regular primary care providers these days.

[00:49:34] JJ Virgin: Well, who would wanna go to their primary care provider for menopause? Yeah,

[00:49:37] Mindy Goldman: exactly.

[00:49:38] JJ Virgin: Like what?

[00:49:39] Mindy Goldman: Well, we also know though, that. You know, uh, one of the things that I’m really proud about at MIDI is we have all of these evidence-based protocols and we teach our clinicians about all these different aspects of perimenopause and menopause.

[00:49:54] Mindy Goldman: But I’ve been in practice 30 years, and I’m a better provider since I joined MIDI because now I realize. I need to understand cardiovascular health much more in detail so that I can safely provide hormones. And in the past I didn’t really understand as much how weight and how body distribution of fat and all of that impacted our metabolic health and how that impacts perimenopause and menopause.

[00:50:23] Mindy Goldman: And so at MIDI, we have both. Primary care providers and women’s health providers. And together we have worked in developing these protocols that all interact with each other, right? Like you need to know clotting if you wanna understand, like, can I use hormones if I’m at risk for a blood clot or I’m have a family history of cardiovascular disease.

[00:50:47] Mindy Goldman: And so, um, I am really proud of what we have, uh, developed. And then I particularly joined. To help us launch a national cancer platform. And we are in all 50 states and we, as I said, we are covered by health insurance and we are providing cancer survivors with care in every single state in this country.

[00:51:09] Mindy Goldman: That

[00:51:09] JJ Virgin: is so fantastic. So you told me before, so I wanna make sure everybody understands this. You’ve created the only program that I know of here, um, where you’ve taken menopause and combined it with. Breast cancer survivors and then trained practitioners so that they are now in a virtual health setting to support breast cancer survivors.

[00:51:30] Mindy Goldman: Exactly. So, uh, we actually have a curriculum that we have developed that all of our providers have to take, uh, and pass. They actually get credit for that. Um, and we have more than 300 providers. Uh, and again, we are licensed. Our providers many times are licensed in, uh, many states. And we’re really doing this because.

[00:51:54] Mindy Goldman: I want that conversation where cancer survivors are told, just be thankful you’re alive and deal with the side effects. I want that to stop and it should stop. There are so many treatment options and so it’s important, uh, for us to be, you know, for, for me, it was important to develop this curriculum, train our providers.

[00:52:15] Mindy Goldman: But the other thing that’s important is literature is changing all the time. When I told you that article that came out on the safety of vaginal estrogen that came out only a few months ago, we are continually looking at the literature, updating our protocols and teaching our clinicians so that they can use emerging evidence with their patients.

[00:52:39] Mindy Goldman: To help come up, do shared decision making to help them come up with the best treatment options for them.

[00:52:46] JJ Virgin: Well, that in itself. Makes you different than everybody else out there.

[00:52:50] Mindy Goldman: Right. Medicine is changing. It’s not static. Yeah. And when people are using data from 20 years ago to scare people about the use of treatments like hormones, that’s just not good.

[00:53:02] Mindy Goldman: It’s still the prevailing thing. It is still the prevailing thing out there. You know, unfortunately what happened with the fallout from the WHI is that because the thought was hormones are awful, they cause cancer. That also led to, let’s not train anyone in this area of medicine. So pretty much anyone who had been trained in medicine, whether you’re talking of medical school, nursing school, nurse practitioner, pa.

[00:53:29] JJ Virgin: Different

[00:53:29] Mindy Goldman: areas of medicine. People then get training in perimenopause and menopause in the true risks and benefits of HRT. Wow. And we are trying to change that. I think you’re, you’re changing it. Well, uh, doing podcasts like this is really changing that conversation. I think media is changing it and we are really trying to change that, uh, at midi.

[00:53:51] JJ Virgin: I just want people to know there’s options out there. Uh, we get so many dms about the fact that I can’t find a doctor to help me. My doctor said I couldn’t do this, so I was like, when we, when we met at dinner at Tam’s hottest menopause party, I’m like, oh boy. You’re doing what? Thank you

[00:54:09] Mindy Goldman: know that people seek, uh, uh, the data is.

[00:54:13] Mindy Goldman: Six different providers for the symptoms that they’re having thinking, you know, I’m having this joint pain. I need to go see an, uh, orthopod. I’m having, uh. Weight gain. I need to go see an endocrinologist. They, their gynecologist is telling them, I’m not sure it’s menopause. Just deal with the side effects there.

[00:54:32] Mindy Goldman: So people seek out so many different healthcare providers. We need to change that.

[00:54:37] JJ Virgin: Yes. You know what was so funny, I’ll, I’ll, I’ll wrap after this, but, um, I used to teach this course to healthcare practitioners called Overcoming Weight Loss Resistance. It was all the things that could get in the way of you losing weight or cause you to gain weight.

[00:54:51] JJ Virgin: One of ’em being. Perimenopause. Right. And so I knew all the symptoms that we knew back then. Back then, I didn’t know anything about musculoskeletal syndrome. I did, hadn’t met Dr. Vonda yet. Yep. And I certainly didn’t know about bleeding gums, but like the minute my thyroid dropped, I knew it. And so I went and got help from my doctor.

[00:55:11] JJ Virgin: This, um, I started feeling a little off for a month or two, couldn’t recover from the gym. And then my gums were bleeding when I was flossing. So I go into my dentist, a guy. And I go, I don’t know what is up. My gums are bleeding. He goes low estrogen, I. Wow. I know. I know Dr. Craig Conroe in Palm Desert. Man, shout out to you.

[00:55:35] JJ Virgin: ’cause all of a sudden, oh, and then I went, oh, and I’m getting a little inflamed when I work out. Oh. And I, because I didn’t have the hot flash thing, so I was like, didn’t, didn’t know. And you know, just had a little shorter, heavier period. But nothing obvious. That was the thing. So that is what’s so cool is if you, we get these symptoms out so people realize, oh no, that’s all, that’s all this thing here.

[00:55:57] JJ Virgin: And then you have one place you can go that can treat all of the things because it’s all the same, you know, the same.

[00:56:04] Mindy Goldman: I, you know, it’s, um, it’s true. I think the perimenopause is even. More of, uh, it’s more confusing to women compared to menopause. ’cause people have heard of menopause. They know their period.

[00:56:17] Mindy Goldman: Stop. I’m, yeah,

[00:56:18] JJ Virgin: it’s obvious what happened,

[00:56:19] Mindy Goldman: but perimenopause, you’re still having cycles, yet you can get all of the same symptoms. And it is a confusing time period. That’s when people are going from doctor to doctor to doctor. And so educating people about that is so important. Yeah. So appreciative of all you’re doing and for letting me come on and talk about this.

[00:56:40] Mindy Goldman: ’cause the more we can get this message out there, the more that women will not have to suffer.

[00:56:45] JJ Virgin: Agreed and no one should have to suffer. So I’m gonna put all of your [email protected] slash Dr. Mindy, so we’ll put the links over to join midi.com. That’s where I love the fact that your website for MIDI Health also has all of this information on breast cancer and what to do with menopause.

[00:57:03] JJ Virgin: So lots of information there. We’ll make sure all of that is in the show notes and I super appreciate your time today. Thank you.

[00:57:09] Mindy Goldman: Yeah, thanks for having me.

[00:57:17] JJ Virgin: Be sure to join me next time for more tools, tips, and techniques you can use to look and feel your best and be built to last. Also, I’d love to connect with you and hear your thoughts on the podcast. Here’s. First, subscribe to the podcast and leave an honest review. Second, take a screenshot of your review and third text at 2 8 1 3 5 6 5 2 6 2 7.

[00:57:45] JJ Virgin: That’s 8 1 3 5 6 5 2 6 2 7. When you do, I’ll reply using my brand new virtual jj. It’s my on demand virtual self built from my books. Talks and years of experience so I can interact with you directly. You’ll make my day and I can’t wait to hear from you. Thanks for tuning in and I’ll catch you on the next episode.

[00:58:12] JJ Virgin: Hey, JJ here, and just a reminder that the Well Beyond 40 Podcast offers health, wellness, fitness, and nutritional information. That’s designed for educational and entertainment purposes only. You should not rely on this information as a substitute for, nor does it replace professional medical advice, diagnosis, or treatment.

[00:58:29] JJ Virgin: If you have any concerns or questions about your health, you should always consult with a physician or other healthcare professional. Make sure that you do not disregard, avoid, or delay obtaining medical or health related advice from your healthcare professional because of something you may have heard on the show or read in our show notes, the use of any information provided on the show is solely at your own risk.

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