Latest / The Midlife Pivot / You're Not Going Crazy: What Your Hormones Are Really Doing in Midlife w/ Dr. Tobie Beckerman | 13
Transcript
- Amanda: Welcome back to the Midlife Pivot. This week we're thrilled to welcome Dr. Toby Beckerman, a board certified OBGYN with more than 35 years of experience scary for women through every stage of their life. As the founder of Beckerman Women's Health in Rockville, Maryland, Dr. Beckerman takes a holistic, personalized approach to women's health with a special focus on perimenopause, menopause. Hormone therapy and healthy aging. Today we're diving into the changes so many women experience but aren't always prepared for. From hormonal shifts and brain fog to emotional well-being, sexual health, and the often confusing conversation surrounding hormone replacement therapy. On the midlife pivot We believe that knowledge is empowering and that midlife isn't about slowing down. It's about embracing this next chapter, feeling informed, strong, and in control. We're excited to separate fact from fiction and have an open, honest conversation about what it really means to thrive in midlife. Dr. Beckerman, welcome to the midlife pivot. Tobie Beckerman: Thank you. Thank you so much. Amanda: It is, yeah, it is truly an honor to get you on here. I have obviously known you for many, many years, and you have been such a wonderful and empowering resource to so many women in this community. And I was excited to be able to get you on this podcast and really share with our viewers, listeners, a better understanding as to how we move forward in this second chapter of our lives. Being empowered. So we put together some questions for you. We And I will go ahead and kick it off. So I guess the first question we ask is why are so many women caught off guard by perimenopause? Many women say they feel completely unprepared. For the challenges that begin in their forties. Why do you think there is still such a lack of education around perimenopause? And what are the earliest signs women should be paying attention to? Tobie Beckerman: So that's a big question and I'm gonna try to break it up a little bit into pieces. So let's talk a little bit first about expectations, why are they surprised that things are coming? I think one of the reasons is that perimenopause, there isn't in my mind a specific definition of perimenopause. Like what does it really mean? technically if you use the words, it means around the time of menopause. Well, around six months around, six years around. What does it mean? So I don't think Amanda: Yeah. Tobie Beckerman: there's a specific definition. That's number one. And so I think that's a little bit confusing. I can have a 38-year-old patient who comes in and she had an irregular period and says, Am I in perimenopause? Right? because there's a lot that patients are hearing now. So the definition I think is not specifically there. The second thing is is that we do go through changes in various stages of our life and various ages. And just because you're having a change, your periods are changing, your emotions change a little bit, your relationship with your husband, your relationship with your children, what's happening at work, a lot of those things can be quote unquote normal changes. We're not exactly the same as we grow, as we go through different stages of our life. So All of a sudden, when you're having those normal changes based on aging and relationships and problems with everything else that's happening in your life, and then on top of that, all of a sudden physically things are happening now. And oftentimes patients will be caught very off guard. And there'll be a lot of questions about, is this my life? Is this stresses? I'm way working too hard Amanda: Right. Tobie Beckerman: and I'm under too much stress and My kids are having issues, my husband just lost his job. and is this all because of that, or is there something else that's here that is guiding things in a not so good direction for me? And I think that that's where you need to tease it out. And it often is Amanda: Yeah, yeah. Mm. Tobie Beckerman: not easily teased out, and many times there is more than one thing going on. So I'll have a patient come in sometimes and say to me, All of these things are happening and I'm having this. Do you think this is perimenopause? And the truth is it's both. There's stress in your life, there's changes, and there's also evolving changes with your hormones that are leading to things that you're seeing now or feeling now or experiencing that sometimes may not be so pleasant that you didn't have before. So I think. Amanda: So how do you sorry to interrupt you, I was just gonna say how do you know what's normal and what's not? Many women are told fatigue, brain fog, anxiety, weight gain, or poor sleep are just part of getting older. How can women tell the difference between normal aging and symptoms that deserve medical attention? Tobie Beckerman: So I think a fantastic question. I I don't think it's actually possible to know what is normal and what would be normal for you and kind of hormonal things. But the bigger question is, are you happy in where you are? Right? So if all of a sudden you're so Amanda: Yeah. Tobie Beckerman: fatigued, you're not able to do what you did. You know, if you're the kind of person who can kick back and okay, this is the new me, I'm doing this, I'm gonna pivot over here, that's fine. But if those kinds of things are affecting your day-to-day life, then they're not normal for you. So I don't know what's normal for the neighbor. I don't know. Amanda: Very good point. Yeah. Yeah. Yeah. Tobie Beckerman: I don't know what's normal for the friend. But for you, they're not normal. So you only need to base it against yourself. So when patients come in, they'll say, you know, my libido is horrible. It used to be Amanda: Mm-hmm. Tobie Beckerman: great. And, you know, okay, so maybe half my friends don't have a libido either or Half of them also are not having sexual activity. But what are you doing? So for you, it becomes not normal. And I think that is my focus with each patient, is that there are many changes that happen. In some people, they wouldn't bother them at all. And in other people, it becomes very much something that needs to be worked on. And it becomes life-changing in a negative way, and we need to fix it. Amanda: Yeah, I think that's a brilliant answer. And I think you're so right, is that everybody is different and we have to acknowledge that we have to look at ourselves and how do we move forward, you know, on that path. So that kind of leads me to the next thing, which is hormone therapy has become one of the most talked about and misunderstood topics in women's health. What do we really need to know? Can you explain who may benefit from HRT or who may not? And Why there isn't a one size fits all approach, which is what you've been saying. Tobie Beckerman: Right. So I'll start with the latter part first, but I'm going to take you back to a little history because I think going through a little history is important. So Amanda: Okay, great. Tobie Beckerman: there isn't a one size fits all approach, just what you said now, because we're not all one size fits all. And every single person probably has a different set of hormones in their body. and so whatever you were doing, kind of the same discussion we had about the individual changes. Is that we all have our individual hormone production. And so I can't give this same X type of hormone to 10 people and they'll all react the same way. I may actually have 10 different responses. And so that's where it becomes very nuanced. But let's go back just a little bit because I think the history a little bit of hormone replacement therapy and the negativity that it carried for the past 20-some years. And the extreme Amanda: Yeah. Tobie Beckerman: positivity that it carried now. So, what's going on there? I think that piece of information is important. So in 2002, the Women's Health Initiative was reported. It was a big study done by the NIH to see whether women actually decreased their risk of heart disease if they went on hormone replacement therapy. That was the big thing. It wasn't to see whether breast cancer was increased and so forth, it was really a study focused on heart disease. And it was an important study because prior to that, the major hormone that was on the market was called premrin in tablet form, put out by a company named Wyeth. It was approved by the FDA, and in order to get FDA approval, you know, there has to be billions of dollars worth of studies. And there were, there were studies on showing it protected the bones and it protected the heart, but it wasn't a very clear, randomized. well-controlled, double-blinded study when it first became approved. And there were many retrospective studies. There were studies in animal models that it showed protected the heart and so forth. and it protected the coronary arteries. So doing the study was actually a very good idea. And when they started it, there was only there were two what I feel were little blips in the study. Number one, Amanda: Mm-hmm. Tobie Beckerman: it was a very large age group of women, from the age of 46, 47 until the late 70s. Number two, only one type of hormone was studied: Premrin in tablet form, and not natural progesterone, but a synthetic form of a progestogen called Provera. So now we're doing a very big study, and we're comparing it to a very large group of women, and only one type of estrogen is being used. And so The conclusions were there was an increased risk in heart attack, and we have to stop the study, and there's an increased risk in breast cancer. And that was blurted out without any nuance of what the risk exactly was. And this I think the scope of this goes, you know, I don't want to get into the details, but suffice Amanda: Right. Tobie Beckerman: it to say that at that point, estrogen got its big black X. It causes breast Amanda: Mm-hmm. Tobie Beckerman: cancer, it causes heart attack, and no one really looked. At the nuance details. So fast forward 20 years goes by now, and all of a sudden, the nuances of the study and the details started to come out by people who started to really delve into it and see what was happening to women. What's happening to bone densities, what's happening to how people are feeling, what's happening to vaginal and bladder health, what's happening to women. Productive in the workforce, what's happening to anger and outrage in family, and all kinds of things that were happening. And have we misinterpreted this study all along? So just a little go back, I started practice in 1988. The study Amanda: Mm-hmm. Tobie Beckerman: came out in 2002. For 14 years, we've been giving hormone therapy. I never stopped giving hormone therapy in 2002 because the exact nuances and details. that are now talked about so loudly were readily available then. In fact, to to the credit of the of Wyath, their reps were in the office with all the details of the study, with the minuscule risks. So for people who really said, this can't be, I didn't learn this. This is not right. We didn't find it to be right. And women were given hormones all along. And the good thing that came out of the study actually was that there were many lower doses of now transdermal estrogen that started Amanda: Yes. Tobie Beckerman: to come to then shift away from the pill. So something actually good came out of that study, but only for the doctors and the patients that actually gave and accepted hormone replacement therapy at that time. So great. Amanda: Right. And were proactive and recognized the benefit of this and didn't quite take the study into Tobie Beckerman: Exactly. And when through that the risk of breast cancer went from one point three to one point four percent. And that was only in the arm of women who took the premer and the provera. And in the arm of the women who had a hysterectomy who took just the estrogen alone, that study didn't stop at all after one year. It went the full five years. Not only was there no increased risk of breast cancer or heart disease at the conclusion of that study, but a few years ago, 20 years. Post women's health initiative, they found that the breast cancer risk not only did increase, but there was a protective effect. So none of these things were talked about positively. It was all negative. And unfortunately what happened is this is what this is where we came in the last twenty years. But go back to doing yes. Mm-hmm. Amanda: Let me j let me just tell you something personal. Okay. I'm 85, right? And I was in South Africa when I was 45. Yeah. And at the time, Margaret Thatcher recommended hormone therapy. And she said it's a Tobie Beckerman: Good friend. Amanda: wonderful. Yeah. She she blurted it out. So the doctors there, the OBGYN's there. Whenever you went in, I hadn't even stopped bleeding. And the doctor said to me, it'll be wonderful. You won't wrinkle. And my mother was a very wrinkled lady. She said, You won't wrinkle. You are going to feel so wonderful. Let me put you on it. Which I did. And I was on it for about two or three years until I emigrated to come here. And then my OBGYN then said to me, What are you doing? You know, why are you taking this? You know? And I was spotting and I was all eventually it ended that I had to have a hysterectomy. So, and then after that I went on to estrogen on its own. But it just shows you, you know, people who've got no knowledge, and and I don't say that the doctors were bad there, but that was all new. So off Tobie Beckerman: Right. Amanda: they went and they gave you the wrong information. I wanted to ask you now about midlife effects for more than our hormone, far more than our hormones. How do normal changes impact our mental health? confidence, relationships, and sense of identity, and what advice do you have for women who feel like they've lost themselves? Tobie Beckerman: So I see that a lot. when patients come in, that is a major, major thing that they complain of. I don't feel myself. And not Amanda: Right. Right. Tobie Beckerman: even with the physical. The figure physical is one thing, although they also say I don't feel myself and I don't recognize myself. I Amanda: Mm. Tobie Beckerman: feel big, I feel fat, I don't look the way I did, none of my clothes fit me. And then on top of that, I feel brain fog. I can't accomplish things that I used to Amanda: Mm. Tobie Beckerman: accomplish. I'm I'm not a good parent. I'm so short with my kids. My husband is like you've got to help me. This is Amanda: It's like a tsunami. Tobie Beckerman: it is. It is a tsunami. It's it's crazy. I have to give you a statistic. This is so sad. There is a statistic that about 23% of women who are in high positions in CEOs and companies quit their job when they go through menopause. Because they feel they are not competent, they have brain fog, they they can't Amanda: Mm-hmm. Tobie Beckerman: do what they used to, they're inferior, they second guess themselves all the time. And I see that. I see patients who come into me that have very high ranking positions and they're nervous. They are nervous Amanda: Yeah. Tobie Beckerman: that they are not accomplishing what they need to. And it's so Once they get explained, nothing is wrong with you. You're not going crazy. You used to be balanced. You used to be making regular hormones that affect every part of your body and your mind and your thought processes and clarity and how you're thinking, and now they're fluctuating like crazy, and we need to help you. And it's such a like a a breath of fresh air to them. Like you're going to help me. There is I'm not going crazy. There is something I can do. And once that is recognized, the sense of relief is dramatic. And once you give them hormones and they get the relief. The gratification is beyond, right? So that it's so important that when women realize, these kinds of changes, that they seek somebody out that is going to listen to them and hear them and help them and go through things. Now, at the same time, there are psychiatric mental health things that can also be happening simultaneously with the hormones. They might be completely separate and other things are happening. They might be completely hormonally related. So I never close my eyes to what else is going on in your life. and also Amanda: And we did actually. We had we had a a a mental health therapist on the show a couple of weeks ago who, yes, delved into that and said, Recognize this, let's embrace this. And using your mental health professional at the same time as your hormone replacement therapy can really just give you that equilibrium of making you feel okay. So you've really addressed what we've already said. You've just got to recognize. Yeah. Tobie Beckerman: Right. Right. Absolutely. And also even your mental health person, even if there isn't a secondary diagnosis of anxiety and depression, because those things can happen with a change in hormones. But even if if there is a secondary diagnosis, or even if there isn't, while you're struggling with not feeling yourself and not feeling up to par and not feeling good in your own body, you need some mental health person to help you through this. To give you strategies. How do I cope? What do I do until I feel good? I don't always have the magic pill, you know. Everyone who walks away, they like pop it in their mouth and then they're completely fine, you know. That would be lovely. That's not the case. It takes a little bit of time, but I think they at least are hopeful and they know that they have a plan and they have a path and they're not going crazy and they're going to be helped. And I think that's crucial. but yes, yes. Amanda: So important. So yeah, so we actually, and this leads us, this leads me to my next my next question. We did have a nutritionist on the program as well, who was just fantastic, giving us some really good information about how we move forward, even with our nutrition, because that also changed. And we hear, you know, the the buzzword right now is protein, et cetera. what role do nutrition and exercise play during menopause? So we're gonna kind of you know move on to that, but with your background in nutrition. What are the biggest lifestyle changes women can make to reduce some of the symptoms, protect their health, and feel their best? Are there in your perspective specific foods, supplements, or types of exercise that you recommend? Tobie Beckerman: So what I find from health and nutrition aspect through perimetopause and menopause is insulin resistance. what that means is that your body makes far more insulin when it's metabolized in digesting certain foods, particularly carbs. And the more insulin that you have hanging around there, the longer the breakdown products of the food and the glucose hangs out and it actually then converts to glycogen and it gets stored. So I find that women when they're having trouble with weight and managing their weight, one of the biggest things that I counsel patients is to really balance and decrease the carbs that you're eating. And I try actually to give a little plan for them because it's very hard if someone says, okay, eat less carbs. Well, what does that mean? Amanda: Yeah. Yeah. Tobie Beckerman: should I eat one piece of bread a day, two pieces of bread a day, should I have a potato one? So what does it mean? So I actually have this little thing that I make up on my own, but I have patients take a day or two, or actually three if they can, days a week and really not eat carbs just on those days. So I push protein. So you ask what kinds of things are positive? Lots of lean protein. I think is is very, very important. You want to be able to build muscle and lean protein is very important for that. All the vegetables that patients want to eat, except for potatoes, because the the glycemic index and this insulin resistant surge that we talked about is very high with potatoes. But all the vegetables you can eat, the fruits that are low in sugar, apples and pears and berries and things like that, very important. So When you're somebody who is in this insulin resistance realm and you're weight gain and you're not feeling so good and you're feeling draggier and tired or I think decreasing carbs, either a full day if you can, but definitely not completely. First of all, you like carb. patients should eat what they want to eat. It feels good. Food is good. It's just it should be separated. So it doesn't have to be in overabundance. It's okay. I'll have my days while I'll have my pasta and my pizza and the bread I love and I'll have days that I'll be more cautious in the things that I eat. And I think that balance is very important. I think it's very, very good for weight control. As far as exercise, exercise to me, you know, w when I look at longevity in general, we didn't mention that, but I'll just throw it in there. I Amanda: Yeah, yeah, yeah, no, absolutely. Tobie Beckerman: Right. So I think that the most important things is what we eat. And what I talked about is really decreasing carbs, lots of protein, lots of fresh fruits and vegetables, decreasing processed food, whole grains, things of that nature. So what we eat is very important. exercise, it's great for your head. what kind of exercise? I I leave that up to the individual. So clearly for bone protection for osteopenia, osteoporosis, which can happen as we age. As we have reduction in estrogen, also sometimes with our family history, even if we're doing everything right. Exercise that has more resistance to it and more banging of the bones, thing that happens, can be very good in terms of generating bone production. So little weights on your wrists and ankles, a weighted vest that you wear at times, aerobic exercise is good. But I also caution patients to do a what they like and what they will do, because some is better than none. And two, that you don't injure yourself, right? If you if Amanda: Yes. Tobie Beckerman: you're gonna be all gung ho and you're gonna start injuring yourself, now you can't exercise for six months because you injured this and you injured that and you don't feel well. So exercise can be walking. Park far. Always Amanda: Mm. Tobie Beckerman: take the steps. Little things like that. Have your little ankle weights in your purse. You're like, okay, I'm feeling strong today. I'm gonna put them on. I'm gonna park at the very end of the parking lot. Those kinds of things that Amanda: But she's right. She's right. And we don't think about little things like that. And I love that you're bringing this up. Tobie Beckerman: Is that there was actually a study that looked at people who went to the gym three days a week and compared it to people who just always took the steps, parked far, never sat on the couch and asked someone else to get them. It got up themselves, ran up and down their townhouse steps a couple times to do this, and it was equal in terms of what it did for cardiovascular protection and your heart and aerobic activity and things of that nature. So so Amanda: Yeah, v yeah, versus somebody that, thinks that they have to go and be in the gym for three hours and you don't really need to be. As you say, you can you can incorporate it into your daily life. Tobie Beckerman: Right. Right. If you wanna be, exactly. If that's your thing, great. You feel good, you come out, you sweated, you're soaked, it's fantastic, you feel good. But it's not like, okay, well, I can't do anything because I don't like the gym or I don't go to the gym. So much that you can do with your day to day. Carry your bags. Carry the bags when you go. Things of that nature. Just keep that in the forefront of your mind. I'm exercising. I actually had a patient in here today. She's an older woman. She was carrying this very heavy bag and I said, I'll take that from you. She goes, No, no, no. This is what I carry all day long to build my muscles. Take a look at them. she was very proud of carrying a very heavy Amanda: Beautiful. Yeah. Yeah. Tobie Beckerman: bag, which was great. so exercise, food, sleep is crucial. We must sleep. Amanda: Let's talk about that. Can we talk about sleep? Because that's something that I struggle with so much in that I want to sleep and I just Tobie Beckerman: Mm-hmm. Amanda: can't. You know, what do we what can we do to incorporate or help being able to get that, you know, maximum amount of sleep that we we need? Tobie Beckerman: so number one, there's a lot of the sleep etiquette things. Okay, like I'm not a sleep specialist, but you know, like the way the room's supposed to be, and the temperature and the quiet and off screen time, and don't have it sitting right there, and what you do before bed, and things should be comfortable. Some people wait a nice weighted blanket on them. You know, most people are on their phone to the last second, like this, and they put it down, they wonder why they can't. Amanda: Mm-hmm, mm-hmm, mm-hmm. Tobie Beckerman: sleep, right? Their mind is crazy, or they've literally just got off the computer, or you're working on your midlife pivot. And so there you are to the last second writing questions, you close your computer Amanda: Mm-hmm. Tobie Beckerman: and you wonder why you can't sleep, right? So all of those things actually really are important. The environment that you're putting yourself in is important. The second thing is your hormones. hormones are very important in terms of having them balanced. However, there are women that don't take hormones, don't want them, don't need them. Can't take them, does that mean they're not going to sleep? Of course not. We need to make those people sleep too. But if the hormone deficiencies are there, adding back hormones, whether it be the right amount of estrogen andor progesterone, very, very important. So you talked about a hysterectomy, and now you're on estrogen, and really that's all that's needed from a hormone standpoint. But many women miss their progesterone, need their progesterone. So, regardless of whether you need it for other things like uterine protection, it can be a very big powerhouse with sleep. And sometimes I even go up on it for sleep with people. So balancing the hormones is another thing in terms of sleep. And then the third thing, and I'll say is you have to sleep. You have to sleep, Amanda. So whatever Amanda: And Tobie Beckerman: it takes, whether it's melatonin, whether it's Tylenol PM. whether it's a true sleeping pill, whether it's trazodone, whether it's magnesium, whatever it has to be, there is a focus Amanda: Magnesium. Tobie Beckerman: on needing to sleep. And I have a lot of patients, I have some patients who take an ambient 365 days a year and they worry. They come to me and they say, I hear a cognitive impairment. I'm really nervous about that. is my brain not going to work well because I'm taking this? And I think that nobody knows that for sure. But what we do know is if you don't get sleep, that also is very bad for your brain and your brain function. You have to be able to turn off, you have to be able to relax. And that only happens really when you can sleep. So if it means sleeping with sleep aids, do it. If it means sleeping with a sleeping pill, get it. But you really do because your brain is foggy the next day if you don't sleep. You're not going to accomplish the same amount. Sometimes you tend to eat more because You want to keep yourself awake. You're just so tired. So you're eating more to try to do that. That turns out to backfire a lot of times because you get a big insulin surge and then you're you drop your sugar and you now have that afternoon exhaustion. so but you have to sleep and it's important. know, some people have sleep apnea and they don't sleep because of that. Maybe that should be investigated in you. Do you snore? But I think Amanda: Yeah. Mm-hmm. Tobie Beckerman: that women. Men as well, but my focus clearly is women, need to sleep and you need to do whatever it is that's going to make you sleep. Yeah. Amanda: Takes yeah. Have to just focus on that definitely a little bit. To get off the subject completely. Let's talk a let's talk about the conversations women often avoid. From vaginal health and painful intimacy to declining libido. These topics can feel uncomfortable to discuss. Why are they so important and what treatment options are available today? Tobie Beckerman: So this is so important. Okay. I'm this is this is like Amanda: I know. Tobie Beckerman: really if you have a take home message, like this is it. So I'll I'll go back and tell you why I say that. So a lot of patients come in horribly symptomatic from menopause. And of course, those people go on hormone therapy right away for all the reasons we talked about sweat, not sleeping, feeling miserable, gaining weight, all of those things. Very easy, to get those patients on hormones. But then patients come in and they feel good. They are actually have a very easy menopause. And they might come to me a year after their hot flashes are gone already, and they weren't even so bad then. And so The most important thing that is never going to change is the bladder and the vaginal need for hormones. And the the bone density, the protection, there are medications for that. The heart disease, there's medications. There are other things that you can do. But there's really only one thing that you can do to protect your vagina and your bladder, and that is some form of hormone therapy. And that's why it is so crucial and so important because everybody's vaginal tissues and everybody's bladder stability over time is going to decline. Everybody's. In some people, it can be six months or a year after. In other people, it could be six or ten years down the road. I have patients they say, yeah, I'm having intercourse with no problem. And no pain whatsoever. And I'm always surprised, wow, 10 years and you're not using any Amanda: Mm-hmm. Tobie Beckerman: vaginal estrogen at all. And that's great. But it will decline over time. And then when I examine them visually, I can see how thin the tissues are. So there are patients that are just more fortunate than others that they don't have pain with intercourse. But everybody will have thinning within the vaginal tissues and which then translates into painful intercourse. very painful, sometimes unable altogether. They will have issues in terms of the bladder with overactive bladder, constantly feeling like you have to urinate, often thinking you have a urinary tract infection, feels just like that. Bladder aches, Amanda: Mm-hmm. Tobie Beckerman: I'm running to the bathroom, I must have a UTI. Patients come in, they check the urine, nope, sorry, you don't have a UTI. Your bladder is spasming. And this is what happened. So it is so important That every woman, even a woman with a diagnosis of breast cancer, it makes no difference, get some kind of local hormone. And I say hormone because there's many different kinds. We don't need to probably go into the details, but some kind of local hormone that will assist the vagina and the bladder in functioning somewhat back to normal. We have other there's there's vaginal laser that I use called Mona Lisa, which is I find to be a miracle. Amanda: Yes, I've heard of that. Tobie Beckerman: I I just find it to be one of the most successful treatments for reversing the menopausal vagina with or without estrogen. I like to use the two together. It can absolutely help women with overactive bladder who are always having frequency, not women who are losing their urine necessarily when they cough, sneeze, laugh, jump. That becomes a different kind of incontinence. But regardless, this needs to be a major focus. And it is, there's a big campaign now and a major focus on when I even have 80-year-old patients who come in right away, I will insist that they start on vaginal estrogen. Like, what are you talking about? I haven't taken it. And I say to them, the vaginal tissues are imbalanced. And when they're imbalanced, the pH is off. There's overgrowth of bacteria, and there's a much higher risk of you getting odor. discharge, infection, and urinary tract infections. And we know as women age, significantly aging, and they get a urinary tract infection, it can be devastating actually. They can Amanda: Mm-hmm. Tobie Beckerman: become septic from a urinary tract infection. It can be the beginning of a downfall with them. Or even if it's temporarily, they become disoriented or confused oftentimes just from a simple urinary tract infection. So it's Amanda: Mm-hmm. Tobie Beckerman: so important to make those changes. And then When you're not feeling so great, let's take you back younger now, right? 40s, 50s kind of thing, and you're not feeling great, and your hormones are in balance and you don't have a good sex drive, and you're, your libido, you're just wishing is better, but you're just not feeling it. And then you finally are having sex and it kills you, and it feels so painful. And and so sandpaper like that you're like, my gosh, not only do I not have a sex drive, but now I really have a reason not to because it's so Amanda: Not to want to do it. Yeah. Tobie Beckerman: Right. And you don't want that. You don't want your intimacy to end to end because of that reason. And there's literally absolutely no reason for that to happen. There is enough vaginal hormone and there's enough procedures that can be done and systemic hormones often to be added just for that reason. to Amanda: Yeah. Tobie Beckerman: change that. And I think we are talking about it more and more, and it's so, so important to talk about it. Amanda: It is so important because I don't think enough women are educated enough on that and they think that, I have lots of friends that are not on HRT and they think it's, it's okay. And I keep saying, I'm hoping, once I knew I was having you on, to be able to educate them, to say it's not necessarily about the hormone replacement therapy, but exactly for what you're talking about. Tobie Beckerman: Right. I I had a patient the other day. She's forty seven years old and she came in, tried to have sex all of a sudden, a month ago, and it was she was in unbearable pain. She goes, What is this? I am completely unprepared for this. And Amanda: Yeah. Tobie Beckerman: you know, this is this is what we're seeing now. and it's Amanda: And think we brush it off thinking that it's the norm when it doesn't have to be, as you've just Tobie Beckerman: Right. Amanda: said. people will brush it off and say, Well, that's what that's what happens. I go into menopause and and and therefore I'm not gonna be able to have intercourse anymore, as opposed to being able to find an alternative to help one. you know, in Tobie Beckerman: And also, this is a time your kids are getting older. They're moving out. This is a lovely time to rejuvenate with your spouse or your partner or a new partner or whoever it happens to be. This is a very sexual time for women as they get older. Amanda: Right. Tobie Beckerman: And this is a time where you're more confident and you you learn more. You're you're in a different place in your life. There's a little bit of freedom that you're seeing. And that kind of intimacy and so forth is so important. And so addressing A, making things comfortable, and B, what there is to do about libido, which generally is hormonal, including testosterone, which I give a lot of in various different forms, it's very important. And it is so not a one size fits all. I mean, there's patients whose libido increases with one hormone, people who need more, people who need a lot more, some people don't need any at all. but so so important to address it. And one quick other second on the education piece. There are many spouses who don't understand, and this is so important. They think it's an avoidance, they don't want to have sex with me. What's wrong with them? What's wrong with me? They have no understanding of the physiologic changes. That are happening. I've had patients bring their spouse in. I'm like, bring them to me so Amanda: Yeah. Tobie Beckerman: I can explain to them that this is a physical change that is happening and we can reverse it, but you need to be patient. And it is not your wife or your partner trying to push you off. It is a physical issue that needs to be addressed. Amanda: I love that you've done yeah, I think that that's so important. And I think that that's what a lot of people haven't been able to do. And therefore you immediately retreat as opposed to dealing it as a couple and being able to discuss it, you know, in a partnership. And, Tobie Beckerman: Right. Amanda: you know, one tends to kind of go aw you know, retreat from from the conversation and feel inadequate talking about it as opposed to embracing it and figuring out how one deals with it as a partnership. So I think that that's such valuable information. So valuable. Tobie Beckerman: Right. And never just never head like there's no should be no embarrassment. So this is a this is a good take-home message from this particular topic here, is that this is happening to everybody. You're Amanda: Yeah. Tobie Beckerman: not the only one. And so when you bring it up, your doctor should be shaking their head. You're right, you're right, you're right. We're going to fix it. Right. If anyone ever Amanda: Yeah. Yeah. Yeah. Yeah. Tobie Beckerman: tells you suck it up, this is just happening, please go to the next person. Right. Go to the next person. Amanda: Yeah. Find a new doctor. Find a new doctor. Absolutely. Tobie Beckerman: Do not embarrass to address this because you want it fixed and it's happening to everyone, whether they talk about it or not. Amanda: Or not. So moving forward with education, and I think this leads me into the next question, is what preventative health measures should every woman over 40 prioritize? So for example, what screenings, tests, routine health checks do you believe are essential? And are there areas where women often wait too long to seek care? Tobie Beckerman: so I think this is a little bit more individualized. I mean, I'll give you some Amanda: Okay. Tobie Beckerman: basics, but there are people who are super healthy and exercise all the time and eat perfect, right? Is different than somebody who maybe is waiting too long because she's gaining weight and doesn't have energy and isn't feeling good. So it is a little bit more individualized. but let's look at it globally. So I think through the 40s, in terms of the kinds of things that we already talked about in terms of gee I need to change how I eat because I don't want to be gaining weight. So I can't just eat like I did when I was a little bit younger. That's very important. the second thing in terms of screenings, you should have a doctor that you see every year. You should have blood work everywhere. Just you routine every year, just routine blood work. I had do have patients that come with me with big giant books of things from various doctors. I don't know that that's necessary in everybody. It might be There are pieces of information, but you should just have a general good health screening to look at all of the basic tests, your blood counts, your liver kidney sugars, a hemoglobin A1C for sugar screening, your cholesterol. Now people are looking at LPA and APOB. These are also factors that are associated with risk of heart disease. Sure, why not? Look into your family history, start getting those things so you can plan for that. vitamin D, vitamin B12, the bone health crucial through your 40s. So are you getting calcium? How much calcium should you be getting? You need a thousand milligrams a day. If you're not keeping up your calcium in your 40s, then when you get your first bone density as you go through menopause, you might be very surprised that there's been bone loss throughout this time. So calcium is important. You don't Amanda: Yeah, what was that? Tobie Beckerman: just have to take calcium, however, in pill form. You can eat it, and that's a very good way to get it. But you need to get a a particular food plan. What are the servings of this and that, like a yogurt and a cup of milk and calci. And these are the three things I'm going to eat every single day. Rather than put a calcium tablet in my mouth or two times a day, Amanda: Yeah. Tobie Beckerman: a lower dose, I'm going to eat it. So calcium is crucial. Your vitamin D is crucial. most women are deficient in vitamin D unless they take it. Some people say, well, I'm in the sunshine all the time, so I don't need it. So the issue with being in the sunshine is that you're wearing sunscreen, I hope. And we always hope that all of the creams you wear on your faces, and if not, you're applying sunscreen. And that does block oftentimes the conversion of vitamin D. And we prefer that you wear sunscreen than Amanda: Right. Tobie Beckerman: you take vitamin D, then counting on the sun to do it. So vitamin D is very important. It's very easy to check a vitamin D level. your doctor should be checking it every year so that your levels are normal in terms of vitamin D. Right. So bone Amanda: And that they stay regulated. Yeah. Mm-hmm. Tobie Beckerman: health through your 40s is very important. a good doctor that just listens to your heart and lungs and examines you and listens to what you're telling them about other things like excess fatigues or things that are happening that you weren't that are different and and particularly troublesome. Is it your thyroid that's the problem? Is it your hormones that are beginning to cause a problem? Are you eating wrong? Are there other things that we're seeing now that we weren't seeing before? So I think that's very important. Mammogram screening every year, very important to do regularly. so I think those to me are the basics that each woman should have. You know, should everybody, you know, jump on peptides and should everybody have be a big integrated screen? No, I don't think so. I don't think that's essential. But there are people who do, and I think that's Amanda: Yeah. Tobie Beckerman: too. But I d I don't find that that that is for everybody across the board. Amanda: looking back on more than three decades of caring for women, which you've done, what has surprised you the most? So how have women's needs changed over the years? And what's the biggest lesson your patients have taught you about resilience, aging, and living well? Tobie Beckerman: So I think I think the biggest thing I've learned from doing this as long as I have, which is actually 38 years, which is kind of crazy when I think about it. It's been Amanda: Crazy. You don't look old enough to have it. Tobie Beckerman: a long time. is that nobody's the same. I have learned that you need to listen to people what they have to say. They're often right. So for me, the biggest lesson is when I hear what their complaints are or what's going on with them, or they took something and this is how I reacted. You know, my instincts are, I've been doing this a long time, I know better. I stopped doing that. I think that I have learned a lot by listening and being able to incorporate what's going on with them to help treat them and maybe even another person that comes down the road. So I try not to poo-poo anybody. I think my patients empower me to learn. And Amanda: That's Tobie Beckerman: I think that that is something that is really what a take-home that I have from seeing patients this long. When I sit in front of each person, yes, I start with the same questions. No question. How old are you? You married, your kids, what'd you happen with pregnancy, your whole history? But as that evolves, as the answers come, and each person has a different story. you reacted this way to this. And now you're having this thing over here that's coming. And this, you're different than that person and that person and that person Amanda: Mm. Tobie Beckerman: who I saw earlier today. So I think that no two people are really alike. And oftentimes patients don't realize that. So they come in and say, I read and my friend is on this. I want to go on this. And Amanda: Yeah. Tobie Beckerman: I went on to chat, and chat says that I need this. And and everybody is taking this. so the same way that I've learned they're individuals, I try to educate them that they are individuals and that what your friends are may not be for you. It may not even be close to the right thing for you. Let's talk about you. What is it that you need individually? Amanda: Yeah, I love that. Tobie Beckerman: And I think that that is so important. In being able to actually take care of each person as an individual person and specifically going through perimenopause, because there's probably no two people that are the same at all. And then as they after they transition from perimenopause to menopause, and we try them on this hormone, and we try them on that hormone, and this one works and that one doesn't work. And I'm going to interrupt myself for just a second because I do want to talk about hormones that you went back into we talked about that question before, but I didn't finish actually, now that this is Amanda: Tell me, yeah. Tobie Beckerman: bring me back. So hormone replacement therapy, the standard is estrogen and progesterone. And then I also do testosterone. So those are the standard hormones. And they're given in many ways. They're given in topicals, they're given in vaginal rings, they're given in gel form, they're given in patches, and they can be made up at a compounding pharmacy. They're all very, very good options. I don't think the estrogen pill is as good an option. If I have someone who's been on the estrogen pill for 20 years and they refuse to go on anything else and they look wonderful, I would never take them off. But I think because the pills do go to the liver in order to metabolize, it's called a first pass effect. There can be a minutiae increased risk of a clot, which is what some Amanda: Okay. Tobie Beckerman: of the bad mouthing that happened in the study. And I also think when they get metabolized through the liver, The estradiol you're taking breaks down to estrone, which is a different form that takes on different byproducts. So there is, we try to avoid pills if if we can, although there's some people that just won't. And because the Women's Health Initiative, with all of the good things that we talk about now, that was done on pills, right? So Amanda: Yeah. Tobie Beckerman: if we leave those numbers on pills, then you know certainly I don't, but we we try not to. So we have estrogen. And we have progesterone as our basics, and then we have testosterone. Nowadays, the majority of patients are on the patch. And the problem Amanda: Yes. Tobie Beckerman: in this day and age right now is that there is a tremendous supply and demand problem with the patch. There is a far more demand that there is supply. And we that's Amanda: Yeah. Do you know that? Tobie Beckerman: number one problem. And number two is that there's really no such thing as a brand patch anymore. They're all generic. So when you go into your pharmacy and you pick up a Liliana or a Dottie or a Sando's or a Mylan or a Gordon or whatever it happens to be. And I think there's even a new one or two out there. They're all generic. And this is so important for women to understand that from box to box, from month to month, you might be going along feeling great, and all of a sudden you're not. So this is a real important piece of information as you're on hormone therapy and all of a sudden things aren't feeling good. what's wrong is often a problem with the delivery system of your hormones. And there are many ways Amanda: Interesting. Tobie Beckerman: around it. It again goes beyond the scope a little bit, but there are many ways to do to tweak it. But that is very important for people to know is that we are having a little bit of a problem with supply and demand issues with our patches. And that can greatly affect people. Amanda: Right. Okay, we always end our conversations with a midlife pivot question. What has been your own midlife pivot, whether personally or professionally, or how has this stage of life changed you? And what message would you leave with every woman listening who may be entering this next chapter with uncertainty? Tobie Beckerman: I think that as I age, I feel stronger and I feel smarter. And I think that if you can embrace that instead of feeling older, I think with age comes experience and with age comes knowledge, and with age comes more of like do what you want to do. You've been around for a while. And I think that that is so important. So as as time goes on for me and as I've aged initially, you know, there's a little bit of that uncomfortable feeling about what's happening. But if you look at it as a as a reverse of that, rather, wow, you know, I've been around for a while and I have more vision and I have wisdom that I can impart to other people through experience. And I think that to me, that kind of pivot was what took away whatever other symptoms or whatever other things was going on in my life is to fix those things that can be fixed, educate yourself about that, and then be empowered by all of this life experience and knowledge that you've gained and are still gaining. It's not over yet. we're still going and going and growing. and I think that's just so important. Amanda: I love that. Are inspirational. You really are. I mean you in inspire me at eighty-five. You inspire me. It's also beautiful to find some Tobie Beckerman: Uhhuh. You you're gorgeous. Your estimate must be like, my goodness. You're amazing. Amanda: I think also to find somebody that recognized, you know, look, I've known you, as I said, for many, many years, and you started out as, you know, your OBGYN that was there delivering babies. And I think what you realize, and I've certainly seen that in your profession, in that, you know, you started out recognizing I need to be there for, you know, as you're aging and you're getting into the stage of life, you recognize that women needed to be educated. And, you know, I've had my OBGYN forever, but he's a man. And you know what? He doesn't get it. And Tobie Beckerman: Right. Amanda: only by listening to you, and you know, when I heard you for the very first time speak publicly in with Pearl and Rose and and educate us, then I knew that I had to get you on the show because I you gave me so much empowerment to ask the questions and to step back and say, you know what, maybe it's time. You know, 36 years later, it's time for me to to look at. Working with somebody that understands me and understands where I am at 57 years old, as opposed to, you know, having somebody there to deliver my babies. I'm way past that. And there is such an important value to that. And honestly, Dr. Beckerman, that is really where I felt the need to want to be able to bring you on the show and have it. And look, I have people listening from all over the world. It's not just the states, but for people to recognize that, to say, it is time as we are in our midlife. being able to work and I'm not poo-pooing ma male physicians who who take this as a profession as as in OBGYNs. They're great to deliver your babies. But I think when you move on to that point of your life where you need to be able to sit down with somebody that truly understands and has gone through What we're going through as women is so vital. And we are, I am seeing that. I'm seeing more and more women leave their male physicians to go and see, you know, seek help from a female physician because they truly understand. And I do think that that's, I mean, my my my closing to you is going to say if if listeners remember only one thing from today's conversation, what do you hope that one takeaway will be? I'm going to answer what my takeaway is, and then you you can then give me your takeaway. My takeaway is. Take a moment and step back and think about who you're seeing at this stage of your life for your, female help, your gynecological help at this point, because we no longer have to worry about the obstetrical side of of our, you medical health. And that would be my takeaway from this is really look at it and maybe you'll be getting a call from me as a f as a future patient. Yeah. Tobie Beckerman: Also, I'll tell you my takeaway. My takeaway for for patience to take away from this is be positive. Okay, you have a choice in life. You can be negative about things that are happening, or you can be positive. And Amanda: Hundred percent. Tobie Beckerman: whatever's gonna happen is gonna happen anyway. And so if if you take what's going on with you and you, like you said, empower and you educate yourself and you are positive about it and you surround yourself with positivity and you fix things and you move forward. that is the take home message is that we're Amanda: Love it. Tobie Beckerman: not we're not crumbling. You don't crumble at menopause. You don't fall Amanda: no. Tobie Beckerman: apart. I watched a a movie and I d just the beginning, you know, they show little clips here and there as a menopause Amanda: Mm mm. Tobie Beckerman: movie and all it was was like hot flashes, horrible, fat like all of these things. And I was like, my God, if I didn't know any better I would be mortified if I wasn't in menopause and and I didn't know and I wasn't educated. That kind of presentation would have like it would just be so devastating. The bottom line is bad things happen. I don't like the word bad, very very uncomfortable, uncomfortable Amanda: Bad, no, right. Change right. Change happens. Tobie Beckerman: symptoms happen, you're not the same, but you're somebody else in in a and and you can channel it even to a better place. to a different place, to a growing place. and that's possible for everybody if you have the right outlook. Amanda: Yeah. I love that. And I and that honestly, that is why I, you know, really wanted to move forward with this podcast because I I found that. You know, I embraced turning 50 in changing my entire life. And with all these pivots that I'm dealing with now, I wanted people to be empowered. It's not the end of the world. And and one of the one of the things we say as part of our show is midlife is not a crisis. It's a crossroads. And it is how we move forward with that crossroads by allowing ourselves to educate ourselves in how we move forward and empowering ourselves. And you've given us that you've given us the platform. it you know, certainly from a from a physical health. So wow. Thank you. Thank you. Thank you. Thank you. honestly, Dr. Beckerman, I can't thank you enough for taking I know you have a busy schedule and for taking the time to be able to be on here and educate our listeners has been so incredibly vital. So thank you. Tobie Beckerman: thank you. It's so fun for me and I love educating and I see change in people and Amanda: Yeah. Tobie Beckerman: hopefully people who listen will be motivated for change in a completely positive way. And that brings me gratification. So thank you so so so much. Thank you. Amanda: Right. Absolutely. Yeah. Fantastic. Well, again, we appreciate your time. As always, folks, please go ahead and like, follow us, subscribe, make sure you listen to every episode because you never know what you're gonna learn from one of our midlife pivot episodes. thank you for taking the time to tune in, to listen, and we will see you next time.