The physical and emotional changes that come with menopause can complicate intimacy or sexual health.

Sexual intercourse can become painful due to the thinning and drying of intimate tissue; libido may wane as hormones decrease and menopause symptoms increase.

But because sexuality, and in particular women's sexuality, is such a taboo subject in American culture, we don't talk about it. And what doesn't get discussed, generally doesn't get solved.

But times and attitudes are changing: there are more platforms now for women to get information and solutions and engage in conversation about the very real, very natural changes happening in their bodies.

Two companies helping women regain sexual health in menopause are Gennev and MiddlesexMD.

In this conversation, the CEOs of each company — Jill Angelo and Dr. Barb De Pree, respectively — and menopause-specialist OB/GYN Dr. Rebecca Dunsmoor-Su, talk about the importance of open conversation around women's sexuality and health, the challenges of starting a business in a stigmatized niche, and the ways their companies are helping women enjoy the second half of their lives.


Jill Angelo, Gennev CEO

All right. Well, with us today is Dr. Barb De Pree. She's a physician and a gynecologist, and she's been in women's health for over 30 years, with a specialty in menopause for the last 10 years. In 2013, she was named by the North American Menopause Society as certified menopause practitioner of the year for her exceptional contributions to menopausal care, which is just an incredible feat. And so we're, we're so honored to have her here with us today.

Since then and even before then she has been really recognized for her outreach and communication and education of women through menopause through her women's health platform and website called Middlesex MD and her work as the director of women's midlife health services at Holland Hospital in Michigan. So welcome Dr. De Pree.

As well with me today is Gennev’s own chief medical officer and OB GYN Dr. Rebecca Dunsmoor-Su. So I get both of them here. She also holds a certification from the North American Menopause Society. And so I've got two menopause specialists with me. Welcome ladies.

Dr. Barb De Pree of Middlesex MD

Thank you for having me.

Dr. Rebecca Dunsmoor-Su, Gennev’s Chief Medical Officer

I’m glad to be here, Jill.


Good to have you both. First and foremost, thank you for what you do for women everywhere. And you know, we, we need, we need expertise in this area and it's such a shortage as I think we all know, otherwise we wouldn't be doing what we're doing. So thank you. Today's conversation, we're going to talk about menopause. We're going to talk about the business of supporting women in menopause. And we're also going to talk about how women can find the resources that they need, because there is a lot of innovation happening, there's websites like Middlesex MD, in addition to clinic settings, there's platforms like Gennev.

And so we just want to kind of, I wanted to bring together experts who are doing this new work for women and menopause and just, and talk about it. And Rebecca is going to kind of help me drive the interview too. So you're going to hear her asking some questions but, but with that, I'm going to just start off with with a general. Barb or Dr. De Pree, please just kind of help us understand your background and, and really what led you into the work that you're doing today.

Dr. Barb

Yeah. Thank you, Jill, please call me Barb. So I'm a trained obstetrician gynecologist and probably about 14 or 15 years ago that organization I work with recognized that there was a need for addressing menopausal women's health in our community, which really when you think about it is a little bit of a vision that not many places were having that many years ago. So I joined a task force, you know, they call people into joint task force, like organizations do to study the issue and find out maybe what could be be done about addressing menopausal women's health. And so, as I learned about it, I didn't really know at the time myself, that there were people who specialized in menopause. So it was really an interesting journey for me to understand the unmet need both. I understood that it wasn't being met in my community. And and I was part of the problem, you know, I wasn't well trained in menopause at the time. I was a general OB gen and generally a lot of our time and focus is on obstetrics and just, you know, spending a lot of time with OB patients and just well-women, contraception.

But so I took an acute interest in it myself. So I, after deciding yes, the community could benefit. I said, why don't I be the person to do some additional training? So the hospital supported me in doing some training, which included the North American Menopause Society or NAMS. They do a certified program, a NCMP NAMS-certified menopause provider. So I, I did that. So it became sort of a recognized resource in the community, both a resource for patients, but other providers. I think what we've really recognized is that interestingly, even though a hundred percent of women will have this journey through menopause become post-menopausal, it really isn't that much time is spent on it addressing it in a healthcare setting and internists typically aren't that interested in it and are, you know, working on other chronic health conditions with patients, primary care, busy doing so many other things with their patients that it tended to, you know, I recognize just get kind of pushed to the side as not that important to addreess. So at any rate, I pivoted my practice away from surgical practice and OB practice, and I really have just a dedicated perimenopause menopause sexual health practice now. So primarily I'm seeing women many ages, but probably the majority of my patient population is over 40 and seeking answers.


Yeah. So many women I think are but don't know even to ask or they're afraid to ask. You know you know, Rebecca, why don't you share a little bit as well, your journey into specializing into menopause too, because you know, Barb, unlike you, I think you saw a need and you started from a place as an OB GYN. I know Rebecca, you did as well.

Dr. Rebecca

I did, you know, it's interesting. I was very lucky in that the residency where I trained had had gynecologists who did specialize in menopause. So I had some exposure to it as a specialty, and we had a very strong reproductive endocrinology department that actually still focused on endocrinology, which is the, the hormones of the female body. So I had some exposure, but as, as Barb says, you know, when you're training in OB GYN, like there's so much focus on OB and so much focus on surgical skill. And for the first part of my career, it was not the biggest part of my career thinking about menopause and perimenopause. I was very lucky in that my first faculty job, I, the, I was working with a vulva vaginal or, you know, that specialists who, who focused on the vulva and the vagina and disorders of the vulva and vagina.

So I gained those skills. And then as I grew in my practice, it just became obvious that this was how, how I wanted to focus my practice, basically. I feel like, you know, there are many fantastic OB GYNs who do OB and gynecology and some menopause as well. But that, for me, I felt like I could provide a service for women who maybe had slightly more complex menopause or just needed someone who had a few more tools in their toolkit. And then they could come and see me and have a place to go. It's very much the same reason I started working with Gennev is that I wanted there to be more tools in that toolkit for women. And I was going to say, Barb, it seems like that's probably a very much, the reason you started the website you did is adding tools to that toolkit.

Dr. Barb

The most important tools we offer patients is time and, and listening. For so many women, it's a matter of being acknowledged that, Oh yeah, these symptoms do belong under a category of menopause and they've been frustrated and searching and at a loss. So I think part of the skill set of being a menopause provider is, is listening and helping women kind of understand how to bring it all together. And then obviously the treatment regimen is, is tailored to whatever those symptoms might be. But through this journey, I have an eight page intake that I have patients fill out in advance and about eight to 10 questions were around sexual health. And it was pretty astonishing to me that nearly every woman had some sexual health related concern. And for some women, it was all eight questions were, you know, somewhat bothersome to them. So and then I, as I asked more about it you know, it's interesting when you actually ask people questions about it, you will begin to learn more about what you, what really matters to them. And what's important for them to address and, and sexual health really came to the top of the list soon into my menopausal practice.

And then recognizing also that women didn't recognize that there were actual expected changes that happen when they go through menopause. I think that's not widely known. Hot flashes, I think mood, we're understanding more about that… memory, we're hearing more about that, but sexual health still, there was a disconnect between what might help happen to them in menopause and sexual health.

So I created this website. I was also going through a master's program at the time. I'm a masters of medical management and I'm challenged to think about a business and new business and what could you create and what was an unmet need. And for me, it was sexual health tools, devices, solutions. I didn't have a website. I felt women could go to and have it feel like it was sort of clinically based with integrity. So I created Middlesex MD to help women have a conversation around sexual changes that occur as a result of menopause or aging or any number of things, maybe, you know, side effects of other medications, and then a small selection of things like a vibrator.

How can a vibrator actually be a helpful clinical tool? Most people aren't thinking of it in those terms. So also want to just elevate the language around sexual health not just sex, but sexual health and how important it is that we help our patients address maintaining or attaining sexual health. And it might be something as simple as selecting the right lubricant or using a vaginal moisturizer or again, using a vibrator.

We, I sometimes will use the analogy, you know, when you turned 42 and you lost your near vision, you didn't stop reading. You went and you got readers, so you could read. Well, if you can't have an orgasm, does that mean you just stop? Well, no, maybe you get a device or a tool that helps you address that. So really trying to normalize the conversation around sexual health and making some simple things available to women in a, in a clinical way, was my goal with starting the website, Middlesex MD.

Dr. Rebecca

I'm glad you started to talk about how we as clinicians can help women with their their sexuality. And those changes in sexuality that come with menopause. I find that for my patients, it's always been a really taboo subject. That there's a lot of fear and silence and shaming, even around sexuality and the changes that can be very normal and natural as a woman moves into menopause. How do you start that conversation with women, obviously outside of the form that you have them sort of fill out, how do you have that conversation? How do you lead them down a pathway of saying this is not shameful? This is not something to be you know, this is something we should talk about.

Dr. Barb

Well, I think we have the unique opportunity of being healthcare providers and women's health gynecologists, that it is a forum that women might expect that conversation comes up. So I think we, you know, we have the advantage of really expecting our patients to be able to dialogue about that. And it's, it's somewhat of a difficult conversation to have on a first encounter. So I will often recognize that, you know, patients acknowledge some concerns around sexual health and try to get a sense of how willing they are to address it at that first visit. Sometimes it really takes a couple of visits to kind of get a rapport and some trust to have it. But I, I use and emphasize the word sexual health and remind women that, you know, we care about physical health, emotional health, spiritual health, and sexual health is one of those areas that we should care about.

And we need to have language around it. We need to be able to help women understand that some of the anatomy physiology that might be interfering or causing some obstacles to enjoy sexual health and, you know, normalize it. As, you know, menopause providers, obviously we can expect most women are going to have some sexual consequences of becoming menopausal and the, what we now call genital urinary cinema menopause. And so I also, before women are menopausal and what to expect at some point, intercourse may become uncomfortable and you know, we'll need to address that. And hopefully you're comfortable in bringing it up. And yeah, so it's, it's really just repeating the message, I think about the importance of sexual health. And then I had to get the pulse of each individual as to what their comfort level is and exploring that further.

I can't, I don't talk about the vibrator with all of my patients on their first visit, but a lot of times, you know, you get a sense of how open somebody is and can go there right away.


By establishing Middlesex, MD and that's M as in mouse, as in doctor. Do you find that when you do make recommendations that your patients are more apt to follow up, to try a vibrator or a lubricant or a product that you've recommended because you've also got a safe resource for them to go to and I'll ask that question of Barb, but then Rebecca, I'd love for you to as well offer your perspective. Cause I know you're also recommending solutions to women and how do you make them comfortable with that? So Barb, you want to start?


Yes. And I do think most women recognize the value of maintaining sexual health. And, and I put it this way if, especially in the context, now that we're talking about menopause, we understand that natural atrophy painful sex while it's not all atrophy, there are good reasons to have a good vulval/vaginal exam. And there are other, you know, diagnoses we have to parse out, but let's say it is vulval atrophy. You know, the conversation is this is chronic and progressive. So I use the fork in the road. So here we are at a fork in the road and intercourse will continue to be more challenging, more painful, more difficult, or we address it, we treat it and we try some new approaches to this, whether it's the moisturizer, the vibrator and women, while generally may have, they may have experienced some loss of drive or desire. Most women don't want to abandon sex. They want to remain intimate within their relationship.

And when they hear that, I now need to invest in myself in some way to make this possible. Most women are going to opt in and start at that, you know, choosing the right lubricant, introducing a moisturizer. So starting at the beginning. And I think there is a lot of buy in, at least the patients I see there is a lot of buy in and you know, one of the reasons I think Rebecca, we do what we do is the reward is so, you know, people are so grateful for the successes they enjoy when they're properly treated.

Dr. Rebecca

I completely agree. I find that I'm giving my patients permission to explore sometimes is a huge thing. You know many people were raised with some hesitance about sexuality or some hesitance about exploring their own sexuality and just saying, this is a normal and natural thing that women should do to maintain themselves and their health. Going forward is really helpful. Sometimes I also find that, you know, being able to point at resources that are not frightening, you know, a lot of pornography or, you know, sex shop type things are not designed by women for women. So really being able to say, look, here are a few places you can look that are not, that are not frightening, that are not from a male perspective. They're actually from a female perspective, it makes a huge difference. And you know, always sort of taking that time to say, you know, these are things that I think are helpful and that I've looked into in think believe are actually functional and are helpful is also a really great thing to be able to give to patients.

Dr. Barb

Yeah, I and that was really my primary motivation was to create that space for women because a dozen years ago when I watched the site or so I didn't know about a safe place to send women. So, but I do think, you know, there are so many smart, intelligent, creative women who have added immensely to this conversation now and who are making more and more resources available. So they don't have to live in your town or my town to access. We've got we've, we've got a platform to all women can begin to access resources and to learn about it and find solutions.

Dr. Rebecca

Yeah, I think that's been one of the great things I've seen happen over the last 10 or so years is just how the Internet has started to serve this population and how their platforms for sex therapy, their platforms for sexual aids, their platform, all there are now platforms for woman focused, dirty stories and things like that. All the things that can help with sexuality that are much more comfortable to a female population.

Dr. Barb

But it's still, you know, still run into some obstacles in trying to market and promote the site. You know, there are certain words or statements, so we've, some of the social media has had to be a little bit softer, more lifestyle-related conversations rather than sexual health related, which is a little sad that you can't use proper terms in what would seemingly be the proper context of this message. But, you know, there are still some weird standards out there that are preventing us from really getting the real message out to the, you know, our, our audiences.

Dr. Rebecca

Right. And if we're, if we're honest, it's not just weird standards, it's double standards. Cause I don't think they've had much trouble promoting Viagra.


Unfortunately not, you know I was gonna kinda go there a little bit around what, how do you both drive like curiosity or in your patients? Both in clinic or if you're doing telehealth appointments around this topic, like, you know, Barb, you said you probably don't bring up a vibrator in every conversation right away, or you know, their relationship matters, but then also in that face to face, but then also what women are searching for you know, online for resources matters too, how do you help women be comfortable and also what would be your guidance to women who might suspect they want or need some help in this, in, in overall their sexual health as part of menopause.

Dr. Barb

That's a really good question. And I think I'd like to think that most women have a provider in their healthcare team, that they would be comfortable asking specifically that question and could have an answer to that. A lot of the marketing I've done with my website has been to providers. We, so we recognize that in this space being a menopausal care provider, it it's, you know, we're not doing surgeries and delivering babies. It's not a high revenue area and these conversations really take time and investment. And so a lot of providers, well, it's not that they don't care about it or don't want to help their patients. They just don't have time to. So a lot of what I've marketed my website is to other providers. So we know that you care about sexual health, here's a safe place to send your patients.

So I would like to think that providers could be a resource for their patient, but of course we recognize some patients aren't going to ever bring it up with their provider. Maybe, maybe they're not comfortable. So it it's been a journey of trying to be discovered and found in this space, I would say that it's always a continual journey trying to understand. And I think it's, it's conversations like these that, you know, we can reach more people who say, gosh, these women sounded like really, you know, people I could relate to and they made this recommendation about this, you know, Gennev or this product. I'm going to look into that. So I think it's just telling the story over and over and over again from trusted sources.

Dr. Rebecca

I really do agree with you. I, you know, I think in my clinic, it's it, people are coming to me because they know I have experience and expertise in this, and that I can, I can walk this path with them. But I think there are a lot of women we found, especially at Gennev in rural situations who just aren't have access to that provider. And that's a lot of what drove us to put telemedicine together and to, you know, start to do this free education because we feel like, you know, there are a lot of women who just don't have that touchstone within their community. And there are ways for us to bring the information and the help to them as well. And I think I completely agree with you that the more we promote each other, you know, I think at Gennev, we always say all boats rise. You know, if someone is doing something great, we want them to succeed. And if they succeed, we will, should only succeed more. Like this is not a competition. We really need to be helping people we think are doing something fabulous. Get that word out.

Dr. Barb

So our understanding is that every day, 6,000 women become menopausal and that there are 50 million menopausal women in America. So I think there's enough to go around for everybody to be serving this population. And yeah, so absolutely, you know, echoing what you say, we need more providers and we need more access for patients to navigate this because you know, the impact to, to women in menopause around brain health and bone health and heart health and sexual health is enormous. I've been working on a project trying to help understand the economic impact of menopause and, you know, people don't think of it in those terms. It's more kind of a nuisance, Oh yeah. Too bad. You don't sleep great. Well, yeah, too bad translates to how well I do my job to my, or my ability to, you know, consider promotion or my willingness to do a presentation because I know I'm not going to find the word I need when I'm in public.

I mean, this is real impact to women and their day to day function. And every woman deserves to try to address this and you know, in a safe and effective manner. And we have answers for those women. We have solutions for them, but they need an opportunity to engage.

Dr. Rebecca

Right. And I think the nice thing about there being many of us in this space who are genuinely trying to bring evidence-based information and solutions to women, is that we all have slightly different styles and every woman can find that place or that style that really works for her. And so, you know, the more of us are out there, the better who are, as long as it's genuine evidence-based information.

What, what I owe more, I wrote a piece I think, gosh, probably about a year or so ago now called “Internet hygiene” on how do you use internet hygiene? You know, just helping women to understand, not everything on the internet is safe or verified. And it can sometimes be extremely hard to figure out which is which, but just sort of looking to see if the same information appears somewhere else where it's not being sold or, you know, things like just their little great keys that we can give women and say, you know, that there's a lot of great information on the internet. There's a lot of not great information on the internet and you sorta have to, to navigate your way through, but working with people like you, we can say, okay, you trust us. Here's another person you can trust that we feel like is doing the right thing and, and trying to bring you evidence based solutions.

Dr. Barb

You know, interestingly, I have a number of men who reach out and ask questions on my website. So there's an opportunity for some Q and a on the website. And you know, I think the unique thing about sexual health is it involves somebody else. And so I think in healthcare we've to a certain extent, maybe miss the mark by not bringing along the other important people to educate them on this journey too. And so I'm always hurting to, when I get questions from men, asking really on behalf of their partner or, you know, their partner, isn't willing to seek the answers. And I think if we can continue to engage just, you know, others who intersect with that woman we'll, we'll do a better job as well, and we'll be more successful. When they've got the support of somebody else alongside them.


I think you know, I, I do think that is such a relevant point around the support system for women and, and Barb, I especially love that you're doing additional work around the economic impact of not better supporting women whether it's in the workplace or whether it's us as consumers or it's us as moms, or, you know, there's, there is an economic impact of not supporting women in menopause and the research and the work's never been done there. I know as a company who serves them, we often look at you know, how much, how much do they seek out in terms of care every year, you know, and how can we better support that? And I think that we don't even know to what extent women are spending on trial and error, different kinds of solutions and services to try to get the help they need.

And I think Rebecca, to your point, that's where they end up in some non evidence-based options that aren't really helpful. They're just something that someone has tried and either they're trying to make a business of it or it worked for them. How, how do you both address women when they bring to you solutions? Because they're all doing, we're all doing our research and our diligence around areas of suffering in our lives. If they bring something to you that you might not support or agree with, or it doesn't align, like how do you, how do you help them through that? Because we, we get it a lot at Gennev. And and I just think it's something that, you know, we don't want to make women feel uncomfortable in their due diligence and research either. And yet we want to get them to the right solution.

Dr. Barb

So I was at a meeting that was put on by Mayo clinic probably about a year and a half ago now. And they had an integrative physician presenting on the topic and it was it was around it was actually a breast cancer meeting and addressing, but it was around wellness and prevention and talking about, you know, mindfulness and acupuncture and yoga. And so I asked a question, I went to the podium and asked a question about a specific supplement that a number of my patients were asking me about it was, you know, kind of the latest, greatest Facebook, you know, buy this and it'll do that for you. And I asked this woman about it. And her comment to me, which I have repeated over and over again, is there are over 800,000 nutritional supplements in the United States right now that people have access to and virtually none of them have much evidence to suggest that they do what the label says it's gonna do.

And as providers, we just can't begin to wrap our head around that. We can't know all of those. So, you know, people bring in their bags and, you know, bring up their labels. Oh, you know, you probably have heard of this. It's like, no, I've not heard of any of that because I don't have a memory that can keep the 800,000 supplements that are out there. So I usually say, you know, this is a real area that opportunistic people look for an opportunity to sell there wares; we don't have much evidence on a, B or C, just because it's not required. So I don't have evidence to say it's harmful either. And I typically encourage people to do supplements and, you know, if it works great our placebo effect in, in healthcare is around 30%. So I'm supporting women to try things.

Again, I don't think we see many of them as harmful. I just, I use the analogy that you know, the reason you're having multiple symptoms typically in my day, it's, it's a hormonal issue. So when there are six bothersome symptoms that result from menopause or the absence of hormones, the thing that most often is going to restore your quality of life is probably going to be around hormones. On the other hand, I do think we need to take this opportunity to talk, talk to women about lifestyle and stress management and sleep and nutrition and diet. But I just try to say, you know, it, it's a really, really vast industry of looking for alternative solutions. And I don't want to say that they don't work. Did it work for you and most people who are seeking my care are there because whatever they've tried, hasn't worked and they're looking for additional solutions.

So I can't say that's a hard conversation to have, but I also don't want to feel like I've got a corner on all knowledge and that there is nothing out there that might not help them, because I don't believe that. I think there are things out there that certainly can help individuals. And I'm not gonna necessarily deny them that possibility of having a successful treatment option that I may be not aware of.

Dr. Rebecca

I think Jill knows how I feel about the subject. We talk about it a lot at Gennev and we approach it very much the same way you do. We can't possibly know about everything. And a lot of the alternative supplements and herbals and acupuncture just aren't studied in the same way that we expect evidence for a medication. So you're right. We can't say that we know whether or not it works.

My big criteria that I give to patients are, do you know, it's not harmful? Because if it's not harmful, there's no harm in trying it and it might work for you. I completely agree with the placebo effect and it's, and as I tell my patients, the placebo effect works, even if you know, it's a placebo and that's great because if you feel better, I don't care if it's a placebo. Great. You're better. So criteria number one is, is it not harmful. I say, you know, if you're trying to evaluate for yourself whether or not this might work, what do they claim it does? Does it cure everything? Cause nothing cures, everything, you know? So if it's supposed to fix everything at once, it's probably not really going to do that. And like you said, yeah. And I talked to them about the fact that, you know, they're, they're dealing with a hormonal issue and many of my patients choose to take hormones, but many can't for whatever reason.

And then we really explore all these other options. And I said, look, there are all these things out there. Why don't you look around and see what seems to make sense to you and come back and talk to me about it. I can tell you if I know of any harm and we'll go from there.

The biggest one that we face is some of the hormones that are being given that are harmful. So that's sort of something that we're really battling at Gennev is saying, you know, hormone is a wonderful and amazing tool that we have, and it works great for women in menopause, but it needs to be used carefully and properly. And it needs to be used in a way that it's regulated because we have to know how much you're taking and learning to do it safely. And that, so that's really sort of our biggest battle that we sort of put ourselves out there and say, you know what? This is important to us. It's important that if we're going to use hormone that you use it safely.

Dr. Barb

And I think, you know, the WHI results have been an anchor around our necks and trying to, you know, move patients through this conversation. I feel like that tide has, has turned a little bit and that the pendulum has coming back to central where people are recognizing that you’re not all a breast. It's not all about a single health risk. And we probably should be having a broader conversation about, you know, the number one killer for women still is heart disease. And we do have some evidence that's favorable. So I feel like you know, gosh, 10, 12, 14 years ago when I started doing this, WHI was all anybody knew about and all, any other provider, well, I'm exaggerating obviously, but you know, providers, that was their, that was their source of truth.

And so it's been a hard slog to kind of educate people. And, and I feel like a lot of what I do in my day. I mean, we're back to time. I, you know, I can spend between reading the assessment the patient brings to me and listening to them for their first few minutes. I, I kind of have a plan of what I think is going to be best for them, but they need to understand why I think that and why, what I'm suggesting is likely to be safe and effective for them, because it's only then that they're going to actually adhere to it and be compliant in, in using it. So a lot of it is education. And you know, I saw a patient today perimenopausal, you know, probably six bothersome symptoms and she left with no prescription really just knowledge.

I also think this is a key time to talk to women about, you know, self care you know, kind of a cheerleader for exercise. If I had one single thing I could have every woman do, it would be exercise. And she just said, okay, you know, now I have a better idea. And I recognize all of these things are probably hormone and perimenopause, but I can do this. You know, and her question was like, when should I call you back? And I said, yeah, whenever you think there might be a need I'm, I'm here for you, but maybe I'll never see you again. So a lot of it is just, I think setting expectations and helping women understand a little bit of what the journey is going to be and look like, and talking about treatment options, but, you know, maybe that's never a choice you're going to make.

Dr. Rebecca

Yeah. And I think that, you know, it, that falls to us because we aren't taught, you know, a lot of young women are taught about puberty and they're taught about sexuality. They're taught about reproduction, not so much sexuality as sex and its consequences. And they're taught about sexually transmitted infections and nobody ever mentions the other end of the spectrum. What's going to happen in menopause. We most women come into this completely uneducated and not ready for it. And I think that engenders a lot of fear and just a lot of distress. And I think for a lot of women just truly understanding what's going on in their bodies and understanding why these things are happening and that they’re time limited is sufficient. And I also, you know, I find that, I think a little bit of, I do blame the WHI a little bit for some of these alternative practitioners who are now like doing all these strange hormone combinations.

We as physicians for a long time, we're not helping women and to, and we were not prescribing hormone to women who really could benefit from hormone. So they went and sought it elsewhere. And so I feel like my, my job is officially to say, you know, this is what we know about hormone. And I think it is a safe and reasonable option for most women and can really be life saving for some women. And, you know, being able to say very, I so agree with you and saying, we are not just a breast. And, you know, as our genetic people know, this is coming from me, I'm a breast cancer survivor and I'm not just a breast, you know, breast cancer is a small portion of what we need to worry about in terms of women's health. And, you know, I think we need to talk about cardiovascular health and we need to talk about bone health and fracture related deaths. And we need to talk about sexuality and how sexuality plays into quality of life. Because I think most women, I talk to say that they much rather have a good quality of life than necessarily a little bit extended length of life, you know, it's, they want to live that life.

Dr. Barb

Absolutely. And let, let our patients decide. I also have patients come in saying, yeah, you know, I've been on hormone therapy three years. My doctor took me off. He won't let me stay on it. And I just shake my head and think so how many times do doctors deny women a possible treatment option? Just, I don't know. I just feel like it's, it's a shared decision making that we should be having with our patients. And, you know, I have breast cancer patients who elect to be on hormone therapy because they see no other way forward. And it's a really tough thing for me to do. And I would prefer to that we had other great solutions for those women to address, but there's a very, very small subset who would say, you know, I could step out in front of a semi tomorrow if given the choice and this is going to literally save my life.

So, but I mean, you, you, you feel like a lone voice in the woods. And I tell them, you know, when you go see your family doctor and they see this medication on your list, please tell them why, why it is and help them understand why we've come to this decision. So anyway, I think, you know, being a menopause provider has been really rewarding. And I, I think what we just haven't generally seen is that menopause is it has its unique life related health related risk. And it's not just an aging process. It's really a a time of increased health risk that I think many people were missing the opportunity to address general health.

Dr. Rebecca

And I think some of that comes from the lack of research on women in general, for years and years and years in medicine. It's just, now that we're realizing that there are estrogen and progesterone receptors in every system of the body, I mean, we’ve sort of known that, but people really just didn't look into it.

It's like, of course you have brain fog, there are estrogen receptors all over your brain. Of course, everything is changing with menopause.

Dr. Barb

The other thing I'll say to patients where I get a lot of nods kind of silent nods is, you know, it's really the only human condition where we expect organ failure, endocrine failure. And, you know, we've said, that's okay. It doesn't matter. You know, I mean, think thyroid, liver, kidney, pancreas, you know, anybody else any other hormone endocrine issue, you know, we'd be all over it, correcting it, fixing it, normalizing it. And this is one area where we just have said, yeah, well move forward and figure it out. I just don't know that that's exactly quite the right approach. So anyway, women.

Dr. Rebecca

That's a fantastic analogy by the way.

Dr. Barb

Most women haven't thought of it in that way.

Dr. Rebecca

You know, I, I suspect if there was a similar thing for men, it would not be addressed in the exact same way, but that's perhaps just my bias being a women's health provider.

You know, we don't tell people, thyroid, your thyroid’s failing. It's good. You're all good. Suck it up.


You know, thinking about this phase of women's life there is no quote unquote protocol to go have your inaugural, menopause appointment, you know, as you transition. Like, I still remember when I had to go get my first pap exam as a young woman. And it was very clear in my mind why I was going, when I went, why we waited till then that, you know, it was, it was planful. Do you both think that there should almost be a menopause check in appointment that every woman should do? Like as an expectation? What are your thoughts? Because that's, that's a new way of thinking in women's care period versus waiting until something's wrong.

Dr. Barb

In my dreams.

Dr Rebecca

And I absolutely agree — in my dreams as well.


You know? How would you, if you were to coach a group of early 40 somethings women in a room about their menopause care and going to see somebody like you how would you, how would you advise them?

Dr. Barb

You know, I think it's back to Rebecca's comment about what we do know about estrogen and progesterone receptors and their impact on brain skin, breast, bone, blood vessels, genitals, and just this idea that educating women, the importance of those hormones, the presence through the years and what the possible consequences might be in the absence of those hormones. And that's to say some women, you know, have zero related symptoms and you know, it truly is a non event. And I, I great. I'm, I'm, I'm, I think that's fabulous, but that's, I think the minority and most women, so I'm going to take joint pain. As an example, I just saw a patient probably two weeks ago. She'd been to rheumatologists, she'd been on two or three meds for joint pain. I started on hormone therapy two months ago. I do two months out. Her joint pain is gone, it's gone.

It was a menopause related symptom. And that is so if we could let people understand how to connect the hormone dots to different health and life things, I think they could just, you know, have a better sense then of how to address it. And you know, palpitations, how many women you've seen had monitors because they've had palpitations. So like every perimenopausal woman I talked to, you know, we expect them to have some palpitations through that transition. So, but it's this lack of understanding of the wide impact. Again, we all know about hot flashes. Nobody's going to question that there's an association there, but there are so many other impacts of hormones that just aren't. I think that information isn't widely disseminated that if we could give them a primer on what's ahead, they could do it better. You're expecting only what to expect when you're no longer ovulating or whatever we call it.

Dr. Rebecca

I totally agree with that. And, you know, I, I find that even those women who maybe skate through it with limited to no symptoms should still be seeing somebody in this time, because this is the time to say, okay, you know, you're, you're going through this transition. Even if you don't feel hot flashes, even if you don't have those mood symptoms, it's still impacting your cardiovascular system, it's still impacting your bones. You need to talk to somebody who understands those impacts and can guide you in how to live the next phase of your life. So that those systems stay healthy.


That's great. Well with that well I know we've, we've covered a lot. We started with sexual wellness. We've talked about menopause symptoms and actually we're working with a menopause specialist and both Dr. De Pree and Dr. Dunsmore-Su are two of the best I think out there. And they can find you obviously Dr. De Pree at or at your clinic which is again to repeat Holland Hospital in Holland, Michigan.

And Rebecca, you're a clinician, you're the Director of Menopause at Swedish women's health center or clinic, correct as well.

Dr. Rebecca

I, yeah, at Swedish Medical Center, First Hill in Seattle, I’m the director of menopause.


Yes. Fantastic. So you both, obviously, if you want to see them in person get on their calendars now, or I know in both cases you're both offering tele-health support  Rebecca, both through your clinic and through Gennev and Dr. De Pree, through your clinic as well.

So thank you both for sharing. We definitely scratched the surface, but I can't say enough about MiddlesexMD. If you want a site that explores sexual wellness please go there, it's a resource. You can even write your questions into Barb and she will respond. Your husband or your partner can go ahead and write them in as well as we heard. And same with Rebecca. If you want to connect with Rebecca, you certainly can book an appointment with her at She often is obviously the, the team lead and the voice behind a lot of our physician work at Gennev.

So thank you both for joining me today. I think this was a really important topic and love what you do.

Dr. Barb

Thank you, Jill for elevating the conversation and bringing more awareness and reaching more women.

Dr. Rebecca

And thank you so much for what you've you do, Barb, by just the, you know, I cannot emphasize enough having a comfortable place for women to explore sexuality and the things that can help them with that is so key.


Shannon Perry

August 19, 2020
Director of Programming & Media

Medically Reviewed By

Dr. Rebecca Dunsmoor-Su

Chief Medical Officer

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