good evening and welcome to doctors on call I'm Dr Ray Christensen faculty member from the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school duth campus and a family physician at the Gateway Family Health Clinic in Moose Lake Minnesota I am your host for our program tonight on women's health and female cancers the success of this program is very dependent on you the viewer so please call in your questions tonight or email them to ask pbsn north.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Michael cassing OBGYN specialist with Essentia Health Dr Sandy Stover a family medicine physician and faculty member at the medical school on the duth campus and Dr Addie vitorio a family medicine physician with St Luke's Mount Royal Medical Clinic our medical students answering the phones tonight are Anna grimard from Grove City Minnesota Ashley Jen of Belgrade Minnesota and Hannah Hannah stray from bigstone City South Dakota and now on to tonight's program on women's health and female cancers good evening and welcome everybody um Dr vtori why don't you to tell us a little bit about yourself and your practice Yeah so I've been a family physician for 12 years now um with the St Luke system I trained in the duth area and I see patients at two different St Luke's clinics um my practice primarily includes patients who are female of all ages um most commonly I see women between the ages of 40 and 65 Dr sto uh I'm a family physician from grandry Minnesota who's Now sort of transitioned to the University of Minnesota medical school at duth and I'm enjoying teaching medical students and some of the students are currently answering phones I work with so Dr cassing I'm an Oban physician here in duth um I've been here in duth for 13 years um and I see patients of all uh ages and ranges as far as OB and uh gynecologic care very good thank you all for being here Dr Stover just because I didn't wear pink today I thought about it way too late and you brought up the indigenous piece of it today do you want to talk about that just a little bit October 19th is indigenous pink day uh that is sponsored by the American Indian Cancer Society and it's an opportunity just to help celebrate survivors of of breast cancer as well as to sort of normalize and and bring up conversation so people can talk about and think about some of the screening recommendations and how they can access you know good screening care for breast cancer thank you Dr vorio we talked a little bit earlier and as I looked at tonight's topic I wonder if I wonder if we shouldn't talk a little bit about women's working with wh women and working on their health and good health habits I know all the time we talk about the pathology but do you want to talk to us a little bit about women's health and yeah and in general I mean Women's Wellness is is somewhat very similar to General Wellness um but the biggest things that affect our health in the future are our weight our physical activity um and then our bad habits of sorts so when talk to women about their health in general we look at you know where do you fall um with regards to body weight what can you do to improve your diet um to improve your exercise and to um reduce things like smoking um like drugs and alcohol other things that actually really affect some of our female cancers Dr cassing I think in your practice you're seeing a lot of the pathology how does wellness and and good personal health help in Cancer Care yeah well obviously we know there are risk factors for for a lot of cancers um and in general what we find is kind of a bodal Access to Health Care um women tend to seek a lot of Health Care when they're younger because their parents are bringing them in to uh to do their well uh child visits um and then women tend to be pretty regular when they're having babies um and then there's kind of a gap kind of a desert um roughly that say the ages between the ages of 35 and 50 where women tend to to be done or finishing up childbearing but are not yet in menopause and so I think we see a lot of patients who are lost to care for 10 15 years and then show up in menopause and have missed important screenings such as uh psimer for cervical cancer and uh mammograms for breast screening Sandy I I want to pull way back um as a family doc you are taking care of children also so where is a good place to start uh a young young woman young person young female person in their in in the Walk of Life and how they should take care of themselves well I I think I'll I'll Echo a little bit of what Dr patoro said but I I think one really important thing is just regular physical activity doesn't have to be a huge um you know weightlifting or doing really aggressive kind of a of a thing but regularly engaging your kids when they're young and being active in Walking hiking biking um and as we go through the years when busy with our own kids you know teaching them how to be physically active but as we get even older the bone density really is improved by having good bone health all the way up and through teenage years teenagers tend to sometimes minimize how much calcium they take in um but staying active eating foods that are high in in the nutrients that we know make us grow good healthy bones and then in menopause years is keeping that regular activity up so it's sort of a lifetime thing that we can do is just walking every day and I would say I guess in my practice the most important time to engage patients is usually between the ages of 9 and 12 kind of catching girls when they're starting to make some of those body changes when they're starting to have questions when they might actually be having some early medical issues and talking about first body image and then pubal growth and getting your menstrual cycle and then on to the later teen years when you start to talk about prevention of STDs um healthy partner relationships kind of catching people when they're most captive of an audience and they have not sort of solidified some of those bad habits and and a lot is normalizing things normalizing ministration of course the HPV vaccination um there's a there's a lot that goes on um in that age range that Dr vorio mentioned you brought up immunizations earlier when we were chatting do you want to talk about those just a little bit Yeah so the uh probably the biggest uh news in In Obstetrics recently has been the uh the release of the uh RSV vaccine and so as We Know know um RSV is a u infection that commonly affects children and it can be a real problem especially for younger children so now there is a vaccine that uh is FDA approved for women uh that are 32 weeks pregnant to uh 36 weeks and 6 days pregnant um and it has found to be very effective so uh we are pushing um we're going to push that out both at Ascension St Luke's here uh in the near future um because we know RSV is is a significant infection that occurs here in the wintertime and uh Dr vtor you were mentioning it in the older population as well so patients with uh a number of risk factors heart disease lung disease starting at age 60 you know recommending That vaccine talk with your doctor not only your pharmacist because your doctor knows your health you know and your history better than a retail pharmacist maybe I think one thing with the vaccines for pregnancy that we don't always think about is that it's good for a a mom who's pregnant not to be ill during the pregnancy because that can affect the pregnancy but it helps to prevent issues for the baby once they're born in that first year of life you're actually giving your baby some prevention ahead of their birth I want to go back just briefly on bone health uh we kind of touched on it a little bit and my recall as an old family I'm old here uh is that the years where bone is really placed is during the teenage years and all how do you two family docs how do you handle that with your your young uh female patients one of the things because they like pop well that was exactly where I was going so one of the things that is is relatively common is kids tend to have higher calcium intake when they're in those years where parents are having more aay of what shows up on at their dinner table but as kids get involved in other activities they're they're not they're choosing their own Foods they're they're eating away from home pop is the most common drink that teenagers take take in any of the sodas and there's actually some negative aspects of that for bone health but it's also the the lack of calcium in those years when the bones are building and putting their their Basics so once we hit about 30 we have the as women we have about as as high a level of bone density as we're going to have and there and men too will decrease their bone density over time but for women the the as hormones change around menopause that can accelerate the the change and the decrease in the bone density over time so the higher you can kind of get it with the exercise and and good dietary intake you're going to have an easier um time as as you continue to mature into postmenopausal years yeah and I talk a lot about diet and I mean we can give all the calcium we want in the form of pills people don't like them they cause constipation they actually don't work as well as eating Foods in our diet that are high in calcium um so we talk about you know if you can't get your milk in can you get in you know cheese and yogurt at least two times a day can you you know get in something that maybe has some calcium in it if you can't tolerate milk so most substitute milk products will have some calcium in them as as well um and then we want to catch women when they're in their teen years because their hormones are active at that point so their estrogen is cycling and is building their bone density so choosing contraceptives that might sort of promote that versus harm that is a discussion I have with people when they're thinking about a birth control method Mike anything you want to add into that well yeah I think the the biggest thing that really has changed uh in the in the last 25 years is that it seems like 30 years ago they used to willy-nilly just take the ovaries out when a patient was having hysterctomy or was having pain or assyst um and we know that that is not the right thing to do uh for women's heart health and bone health uh ovarian retention is very important and the average age of menopause is 51 so if we can leave the ovaries in uh in a patient you know until they are uh postmenopausal that is really the the most beneficial for them that's interesting I did not know that so that's been a change over the last what 10 years or so yeah I mean this it's been been a long uh ongoing discussion um for like 20 years but there was a a recent study I believe just in January that that really the age of 50 is when you want to start taking them out um with with less consequence yeah and I do talk to my patients who've maybe had previous surgeries before and you know ask them what age did you go through menopause oh I had my ovaries out when I was 32 with my hysterectomy well then we're looking at screening for conditions like osteoporosis sooner than we would at the standard age so as long as we're screening what about breast cancer yeah and I I mean I think it varies dependent on your risk factors so it's important to talk with your doctor about what your risk factors are talk with your doctor about you know have you had children which is a risk factor for certain breast cancers what is your family history what is your family history of colon cancer and other Associated conditions that are now we're finding are more associated with breast cancer so starting to have that conversation if you feel like you're at risk in your 20s and 30s is a good idea um routine screening we start to offer for healthy people without increased risk factors at around the age of 40 um there are some women who are very low risk who choose to forego that till a little bit later but for sure by 50 most women should start having regular mammograms and they should be doing a self- breast exam menopause is about age 50 Yes somewhere in that in in that area um how do you um how do you counsel your uh patients after they've gone through menopause as far as so we've talked about breast exams we've talked a little bit of well dex's come in here doing a bone bone scans what about papsmear and pelvic exams and some of these other uh studies that and colon cancer in terms of of looking at doing pabs generally the recommendation is to continue doing some screening up until the age of 65 and if there's never been a problem up to that point in time you can make that choice with your doctor to to consider that that may be the the last time you need it but for for women um there's a very nice well researched kind of a a pathway we take with women so depending on how their PS have been up to time they may go three to five years between psmears um doing uh you know you know um kind of the we talked about the mammograms a little bit but um what was that other question you asked on there the the dexa the dexa the the B density scan um there are conditions that women have that certain medications like steroids that can increase the risk and so at some people will start screening for bone density scans before 65 but for the most part for average screening we start at 65 again and and important conditions like do you smoke did your mother have um osteoporosis did you have your over result earlier um are big things to discuss how do you handle the hormonal aspects of menopause uh estrogens progesterone those type of things and when do you do that it's a good question because there's been more literature supporting that having estrogen longer can be protective in a number of ways but there's also the risk if there is a a family history of breast cancer that that can increase that risk so it's very much a conversation with a physician to on an individual basis but estrogen can be delivered in in a variety of ways some women have dryness in the vagina and can benefit from just having topical estrogens in that area um some women have other conditions that will kind of help balance out in estrogens and progesterones and it so it becomes a kind of a personalized plan that people will talk about with their position Mike do you want to add into this absolutely so a lot of it is just based on symptomatology how are the patients doing um like Dr Stover said vaginal dryness is a is a is a very common um side effect of having low estrogen the others are hot flashes night sweats and sleep disturbances and and we know that it's it's when not if most women will have these symptoms and then how disruptive is it to their lives um some women just Breeze through don't have any issues other women say I'm never going to go off my estrogen um do they have their uterus do they not have their uterus because if they don't have their uterus then they don't need progesterones so it really is a conversation um you know with your provider whoever that may be of what are the risks and benefits and what's your family history and you know how do we Pro proed safely I have another question and I I'll throw it out to all three of you uh I'm I'm taking this from an 82y old person do I still need to have a mammogram even every year at this age and as I as I bring that in could we expand that discussion of age and is it is there an age cut off and how are we going to handle and how do we look at the advanced age people because there's more to it than just age yeah and and it's a really common question we get we get someone who's in their 90s who said well I still want my mamogram and it it really is individualized we have you know studies and recommendations from major bodies that tell us that at most of the time 75 would be the recommended cut off but that does not take into account the women's individual health does not take into account their family history and I often have the discussion such as well the recommendations are this you are above the age but my thought would be if you found a breast canc what would you do in that situation what would you decide to do if you would consider treatment even of any kind you may want to consider screening maybe not every year but maybe every other year um but it's all individualized um there usually is a cut off around you know the 80s mid 80s where we sort of say well you know the likelihood that you're going to die of a cancer that develops is just not there over the next 10 years but I would say for women who are between the ages of 75 and 85 we have that discussion yeah and I would completely Echo what Dr Victorio said if you would do something about it then it's worth doing if you would not then I I wouldn't encourage you to go through it and know your limitations you know if you are severely debilitated by another disease that is likely to cause major complications over time you may not want to do cancer screenings any longer question comes in regarding natural I must change the subject a little bit natural proest restone for postmenopausal women I I have no information on that so um so there there are a number of products that have been um put on the market by you over time that to address certain needs I think the when when one says natural progesterones there are some products that are kind of of labeled that way but may not have the delivery in the way that we're thinking there's there's the micronized is what we call it micronized progesterones tend to be the best delivered and the easiest tolerated for women um it so so I think it's that conversation of what is meant by natural you know and I I guess you could go online and you could go to Amazon and find progesteron and some of them are plant progesterones because a lot of living things produce hormones and I think having a discussion with your doctor if you are going to go the road of a natural hormone or a compounded hormone or something delivered not via pill then use a reputable compounded Pharmacy and your doctor knows kind of where those things are but I mean the reality is they're not not any more or less risky probably than what we prescribe in pill they're just delivered differently and so you might see you know changes in the amount of concentration of that or the spikes in the peaks of those hormones yeah and I I would just add um that the American College of obstetrics of Gynecology does not promote any of them um the I think that there's a distinction that patients need to make between is this a pharmacological product meaning that you get it from your Pharmacy where it's FDA regulated um or is it a supplement and the reason that that is important is because supplements are not well regulated which means if you have a pill that's a supplement it may have a different amount of medication in it than the next pill would uh where if it's from a pharmacy there is um safeguards in place to make sure that you're getting the same amount of active medication in each tablet another common complaint urinary tract infections in elderly people what causes the recurrent bladder infections and uh is is there uh correlation with the infections happening during the the menstrual period also that's the other part of this question that's a two-parter and I was thinking also menopausal that's where I was stumbling through this I I think one one thing that um we think about overall what tends to to lead to to any kind of bladder infection is if there's retained urine and so that can be sometimes if that something inflame the area where the the urethra where the urine comes out and so it you hold on to you can't completely empty or there's some as we age there's some things that make it harder for us to completely um get that last little bit of urine out and so when you have pulled liquid the bacteria can find that and create and lead on to an infection there's a number of um methods and some medications that can help with bladder issues related to you know across the lifespan but it's a little more common postmenopausally related again to some of the estrogen issues that that with a lack of estrogen get more dryness around the urethra and the vagina and so the topical estrogens themselves can be really helpful um so drinking a lot of water helps keep things clean but you also have to make sure that things though the system is is Flowing appropriately and I would say your other risk factors as you age are that you don't drink as much water so you have concentrated urine you have a vagina that doesn't protect against infection and your Ure thr is supplanted right in the middle of sort of your vaginal oping you we also start to have feal incontinence and we have urinary incontinence so the the area changes to the point where there's more likely to be bacteria in that area and the only thing that I would add to that is that there's nothing here about hygiene um sometimes it is a hygiene but overwhelmingly that's not the issue and I would say during the menstrual cycle to Echo that second part of that question is we see pH changes in the vagina with different parts of the cycle and when blood comes into the picture we see a pH that becomes less acidic and so our acidic environment protects our vagina against infections and so that's why we would see an increase in possibly UTI although I don't know the research on that but more so vaginal infections what can women do to firm up their stool as long as we're talking about that area uh depend that's kind of a question is is how loose is the stool normally coming but you can use fiber products to help be U provide more bulking to stool so it's easier to control those to and reduce some of that issue with people andc and that's probably your safest bet is to what causes endometriosis switch a little bit here so endometriosis so let's talk about what that is first that is when the lining of the uterus grows outside of the um outside of the uterus um overwhelmingly it's genetic um there's thoughts about is it implanted with if menstration to women menstrate all their Fallopian tubes and and there's a lot of thoughts and none of them are really proven um other than for sure uh we know there is a genetic component to it Addie can a young woman who has had a previous injury to her breast develop breast cancer from that I don't know the exact answer I I do know that in the body when we have chronic inflammation we see cells proliferate and so when we see cells actively try to repair themselves we grow new cells of certain types and so cancer is more common but but I don't know the exact answer as to whether that would be common I don't suspect it would be yeah I don't think that that would be a common correlation I think one of the hard Parts is sometimes if there's an injury you get a little bit of calcium left over and mammograms can sometimes pick that up and and that's why we are lucky to have people who are trained just in doing mammograms to kind of help tease that out yeah and that's why it's important to get your regular mamogram because every year that radiologist is looking back and saying well Janice had this last year in this spot so that's normal you know and they wouldn't know that if you skipped your mamogram for five to seven years dexa scans uh we've already been there a little bit but when should you get one uh how frequent and what do the results mean we got about two minutes um both you should start at just regular screening at 65 but if there's risk factors that as you talk about with your provider you might get them done earlier and every two years is about as often as you two to five years again depending on risk factors in terms of how often you should have them and there's some studies that we should go longer because we don't see the bone changes until longer does drinking a reinforcement now does drinking Coke Coke or Pepsi increase your risk for osteoporosis uh it reduces your the benefits of the foods that help you support and and avoid osteoporosis but there there's some there is some hint that that c or carbonated beverages might be a negative for bone health my doctor does a breast exam with my bra on is that the correct way no typically we would want someone unclosed so you could cover from the middle of the chest all the way up to the collarbone and then all the way almost to the back of the sides of the unders surface of the underarms so really you want to get everything unclothed and take a look and be able to feel all those areas without the brow away and breast exams should should young should people be doing their personal breast exams there is a recommendation to start them at 40 um breast exams in the clinic there we do them um there's not as much evidence at a certain age that they need to be done but certainly it is another way of detecting cancer and there's very little risk or harm to doing them and I think you were kind of uh suggesting the the self breast exam and that doesn't usually hurt no and it's I think it's good for a person to understand their body too so I want to thank our panelists Dr Michael cassing Dr Sandy Stover and Dr Addy vorio and our medical student volunteers Anna grimard Ashley Jen and Hannah stray please join Dr P Peter nen next week for a program on rheumatoid arth rtis tendinitis and btis one his panelists will be Dr vua dalala Dr Wasim Khan and Dr Paul Sanford thank you so much for watching have a great [Music] night [Music]