Dr. Carolyn Moyers: Validating Perimenopause When Labs Don't Tell the Story

Dr. Sameena Rahman: Hey y'all. It's me, Dr. Sameena Rahman, gyno girl. Welcome to another episode of Gyno Girl Presents, Sex, Drugs and Hormones. I'm Dr. Sameena Rahman. And as I said in my introduction, I'm super excited to have my friend and colleague on the show, which we haven't done yet. Dr. Carolyn Moyers, welcome to SDH. I'm gonna start calling it SDH, sex, drugs, and hormones.

Dr. Carolyn Moyers: It's catchy. I kind of love your bold title. I'm like go girl.

Dr. Sameena Rahman: And then I was and I've been calling my listeners the Vagilantes.

Dr. Carolyn Moyers: Love it.

Dr. Sameena Rahman: My husband made that up. He's like, you know, everyone has like their crew and you should have your Vagilantes. I was like, okay. My listeners are the Vagilantes. Anyway, how's it going? Thanks for coming on my show. We were just talking before and I know we've been like back and forth but it's so funny because Carolyn and I met like, I don't know, six years ago, was it? It was right before the pandemic. It was the Dallas ISSWSH conference right before the pandemic.

e, so I feel like it was like: 2021

Dr. Sameena Rahman: It was 22, because 21 was virtual.

Dr. Carolyn Moyers: 22, 22. Okay. All right. Anyways, yeah. So we've been friends for a while. I've had you on the podcast. Actually, I just sent an email to my list yesterday and we were talking, I was just talking about, you know, what we have coming up. But one of the things that I was addressing was sexual concerns and I referenced the podcast that you did with me, which was like episode 67 and we're on over 200 episodes. So yeah.

Dr. Sameena Rahman: That's awesome. yeah, because we did libido, I think, one time. All right, cool. Well, how's everything? How's your practice in, not Dallas, in what, where?

Dr. Carolyn Moyers: So I'm in Fort Worth, Texas, and I serve women all over the state of Texas. Yeah, so we're menopause and sexual medicine, and it's going wonderful. I love what I'm doing. I've loved this transition. I didn't intend to be the menopause queen, but that's just kind of how it's landed, you know? When you open a gynecology-only practice, they're like, my god. You have time to hear me. You're not going to run out and deliver a baby. You're going to be present. And I just find that women are really demanding quality care when it comes to perimenopause. We're not taking it sitting down anymore.

Dr. Sameena Rahman: No way, no way. Actually, tell the listeners how you came into this space. I always ask people, because we all have our own journeys. Mostly it's a patient or a personal thing that brought you into this.

Dr. Carolyn Moyers: Yeah. So how did I come into this space? So I spent my first five years doing rural health. So just general OBGYN in rural medicine. And then when we relocated to Fort Worth, it was a strange transition going from being the big fish in a little pond to there's over 100 OBGYNs here, kind of what makes you unique. I took a job for a year and then I started doing some hospitalist work when I was having my third son and found that the shift work was kind of nice, but then the volume was kind of low and it's exhausting, right? And so I had this opportunity that just presented to help develop a gynecology program for a hormone therapy clinic. And so I went and vetted them out and I said, okay, I'll do this. And I was very pleased with my progress in the year of developing what does gynecology care look like in this space and what can we do and have Pap smears and birth control and hormone therapy etc. and training all of their practitioners and PAs. But at the end of the year I also had just a handful of cases and I wasn't really ready to just do office gynecology. And so I went back to full-time hospital work downtown and I was just, I thought it was gonna be amazing, right? And offer me so much more freedom. And I found that I was dead tired and felt like I was drunk all the time, you know, cause I was just trying to recover. And I had then three small children at home. So I have four boys total, three small children at home. And it was just not what I wanted. So in the height of the pandemic is when I said, I'm gonna open my own doors. I had this nudge because I had done so much work towards developing a program at that hormone therapy clinic. And I felt like we can do better. Everybody does not need to be injected with testosterone. Like this is not how it should be done. And so that's what pushed me to get menopause certified. And then as you start doing menopause medicine, you know, when I opened the doors, I thought that my osteopathic skillset was going to be my secret sauce. You know, I thought all my OBGYN colleagues are going to send patients to me and I'm going to do osteopathic adjustments for their OB patients and they'll do the primary OB care. But the women just...

Dr. Sameena Rahman: Yeah, I remember that's what your goal was initially. I remember that. That was your goal initially. Yeah. When I first met you.

Dr. Carolyn Moyers: Yeah, yeah, I really thought. But, you know, I've just pivoted over the years because women, like I said, are just demanding quality care here. And so as I started treating menopause, well, what comes with that? The perimenopause, all the sexual health issues that we didn't learn about in residency. And so that's where, you know, I landed at ISSWSH and I met you and I've learned so much and taken so many like any course that ISSWSH puts out. I'm like, yes, sign me up. I want to do that because we just didn't learn enough about it. And if I'm going to do this, I want to do it well.

Dr. Sameena Rahman: Yeah, yeah, yeah. I mean, you learn something every time you take one of these courses, too. Like, I retake them sometimes just to see what the newest is, because the presenters end up having to, like, then dig deep into the newest information. Yeah, absolutely awesome. OK, well, so it sounds like we're doing pretty much the same thing in different states. But I wanted to talk to you about, like, you know, this is going to air during perimenopausal awareness month, which is in September. So tell me a little bit about either your peri experience or what you find the most compelling symptoms that you're seeing in your office for your patients and whether or not it's typically what we expected them to see.

Dr. Carolyn Moyers: Yeah, you know what I find interesting about perimenopause is that, you know, the symptoms are across the board and the patients are so busy in life, you know, whether it's career or raising kids and then aging parents that they oftentimes just don't even recognize it. They just know that they don't feel themselves or they're running to this specialist and that specialist, because now they've got some palpitations and they might not even be having hot flashes or night sweats yet. Their periods may be crazy, but they haven't been paying attention to them. It's the weight gain and the weight loss resistance that leads a lot of them to my doorsteps to be like, I'm sorry, the things that used to work are no longer working. That collection of symptoms is more than just hot flashes, night sweats, and vaginal dryness.

I will tell you that I choose to be very proactive about perimenopause because I watched my mother go through menopause and she had had a hysterectomy years prior because of painful heavy periods and had adenomyosis, et cetera, but had kept her ovaries. But whenever I was graduating from residency, she was going through menopause and she couldn't even sit down to eat. Like eating was a trigger for her for a hot flash. And I remember, you know, I'm like, go see my colleague, get on some hormone therapy, but I had no idea the nuances of adjusting the hormone therapy, like you don't have to live like that. You know, you can actually have a meal with friends and not, you know, feel like that you're suffocating and heating up and you need to go outside and air out. So I've chosen to be really proactive. But I have a Mirena IUD because I don't want to have a period and it's great birth control. And then my baby said, you're getting mean as you get older. And I was like, my God, yeah, I feel overwhelmed, I feel agitated. By 8:30 p.m., I'm like, everybody better go to bed. I just like, so much less, it's such a shorter fuse. And that's when I started estrogen. And I have landed on the FemRing and I'm in love. Like it's just the easiest, simple routine.

Dr. Sameena Rahman: Yeah, really. I guess because it's a good amount of dosing there. I mean, like, standard. Because I go between the patch. And then sometimes I'll use my Bijuva samples in the office. Like, where am I at here? And my periods become cuckoo. Like, I'm like, wait, what did I do? Did I take it? Did I not take it? But my kids are the same way. I've said this before, but my six-year-old calls, like whenever I'm angry, she calls it scary peri. Mama, is this scary peri? Like, is this what's happening right now? I'm like, yes, it's scary peri. Okay. And then everyone goes, they run away. They scatter away. Mama, you want to go for a walk or something? Maybe you need to go for your run. You haven't run today or whatever. I'm just like, they nudge me.

Or you know my PMS symptoms have gotten a bit worse too. Like sometimes when you obviously then you get your period and you're feeling better. And then some of my six year old told me last week she goes, I like you better when you're on your period. I was like, what? She goes, yeah, yeah, you seem to be very much, you're so much nicer and just open and sweet. And I was like, whoa. And it didn't hit, it actually didn't hit me that it's because I have such a bad PMS now. I think like.

Dr. Carolyn Moyers: Yeah, so that's a common symptom in perimenopause, isn't it? That PMS symptoms worsen. Periods can go all over the place or maybe they're the same, but all of a sudden all your symptoms just don't seem manageable. You know, you're more emotional, you're more agitated. I've even had patients say, you know, the hot flashes and the night sweats are worse in that couple of days prior to their period.

Dr. Sameena Rahman: Yes, yes, absolutely. Yeah, it's so interesting. And you know, I think like, I still haven't figured it out 100%. And this is what I do every day. So I've been doing for the last decade, like, but it's easier to treat someone else, I think, you know, because then you don't, you're, you don't even spot your own symptoms. Like, wait, I am being a little bit unreasonable. Yeah. And then back later.

Dr. Carolyn Moyers: Right, right. Well, I think, yeah, I think that that's why I went to a colleague and I was like, okay, this is what we're gonna do. But I had to provide the paperwork, teach them how to dose testosterone, all of that. There's so much misinformation out there, but yeah, I try not to be my own clinician. But I did for a while, try the Divagel. I hated how sticky it was. I tried the patch, I suck at changing it. So this is how I landed on the FemRing.

Dr. Sameena Rahman: Yeah, I know. Maybe I should try the FemRing. Because I actually am between the patch and the bijuva. Because you just get so many samples. And then you're like, I think I forgot my patch. I'm just going to use bijuva for a few days. Do not do this. Do not do this. But yeah, maybe I'll try the FemRing. You can never get it covered from any of your patients, right? It's really hard to get covered.

Dr. Carolyn Moyers: Okay, so whenever I first started prescribing the FemRing a couple of years ago, I found that it was wild. Like, either it would be covered or it would be $50 or they would be told it was $850 or $35 or something crazy, you know? And I'm finding more and more now that it's covered or at a minimum, you know, I send to a specialty pharmacy that will apply the manufacturer coupons. And so at most patients are out of pocket $183. That's for the three months, you know, it's the four ring FemRing. So I do like to dose patients with either the gel or a patch to find like that, cause we have so many incremental doses with the patch and the gel that we can do versus the FemRing. We only have two doses which are very common dosing, right? We have the 0.05 milligram and the 0.1, but you just have two doses.

Dr. Sameena Rahman: Yeah. I thought you had to titrate.

rs: And for some people, the .: 0375

Dr. Sameena Rahman: Right. Plus, perimenopause, right? One month your estrogen's like 1,000 and the next month your estrogen's like 10. And so, I just, yeah, so sometimes it's like a matter of teaching your patients and yourself, like, is this a sign of too much estrogen that I'm getting this month? And so maybe I back off and it's easier to do when you have a bunch of different doses around, right? So that's kind of how I do it with my Bijuva. I'm like, oh, OK. So I have a 0.5, and I had a lot of headaches and a lot of breast tenderness. And so maybe I should do the 0.375.

Dr. Carolyn Moyers: Yeah, but I always say that perimenopause is more difficult to manage than menopause because you've got the pesky period running around that you've got to try to handle. And so this is why a Mirena IUD is one of my favorite things on earth because, I mean, it just diminishes that bleeding, 90% reduction of bleeding the first six months of use. So if it works for you, it's phenomenal. You know, so sorry if you're that one person it's not going to work for, but you know, so often it is. I feel like there are so many myths around perimenopause too, though.

Dr. Sameena Rahman: Yeah, yeah, I know, I know. Yeah.

Dr. Carolyn Moyers: You know, like too often women are told that it's all in your head or they are told your labs are normal. You're too young for perimenopause. You know, hormone therapy just delays the inevitable. I hate these things.

Dr. Sameena Rahman: Yeah, you're saying the myths of perimenopause. There's so many myths.

Dr. Carolyn Moyers: Yeah, yeah. I find that there's so many myths about perimenopause and it drives me crazy. Too often women are told it's all in your head. They get their labs done and they're told they're normal. Everything's fine. And they leave going, I don't feel normal. You're too young for it. Hormone therapy just delays the inevitable. There's birth control pills. That's all we can do. You know, and the truth is that perimenopause can start as early as your thirties, early 40s and it's real and it's a clinical diagnosis. The labs do not diagnose perimenopause and it can last seven to 10 years before that final menstrual period. That is not a small phase of life.

Dr. Sameena Rahman: Yeah, I know it's a lot actually, especially when you're struggling with all the other things that we always talk about, right? Like it's so interesting to see how transformative things like lifestyle changes and hormones can be on a patient as they just weren't even aware of it.

Dr. Carolyn Moyers: Yeah, absolutely. Whether it's cycle change or their mood changing, their energy level changing, sleep. I mean, and when cycles start changing, we start to see this fatigue just from, you know, being worn out from all the abnormal bleeding and the hormonal changes. It's just so frustrating. I mean, I'm sure you see this, but the most common complaint I hear is I don't feel like myself anymore.

Dr. Sameena Rahman: Yeah, yeah. That's kind of how I feel too sometimes. I just don't. No, but it's true. And I think that that's something that we've even seen in the studies, the not feeling like myself. Yeah, the NFSM or whatever, not feeling like myself. Yeah. That they showed it in the study out of the menopause, I think it was out of the Mayo, where they actually asked women a bunch of questions around not feeling like themselves. And it was like 67% of women over the last three months said that that was like the predominant thing. And I think it just goes to speak to like how we don't address some of the disruptions around mood and metabolic function, which make people feel like not themselves.

Dr. Carolyn Moyers: Yeah, absolutely. And we know we start seeing a lot of the metabolic changes as we enter midlife and start having these hormonal shifts. And I always say once postpartum, always postpartum. So if you've had gestational hypertension, diabetes, like these things will present later in life. Even thyroid disorders, you know, and I know a lot of patients say, you know, I feel like I have ADHD now because they're like losing that focus and having trouble with work performance. And it all kind of goes hand in hand, right? Because if you're having hot flashes and night sweats and you're not sleeping or you're bleeding every 14 days, you know, like you have a lot of reasons to feel fatigued and not yourself. And I think that I really want patients to feel empowered to know that there are so many solutions that it's not just birth control.

Dr. Sameena Rahman: Yeah, exactly. What do you, like when you talk about metabolic dysfunction, what are some of the things that you're like telling your patients or guiding them or treating what medications, that kind of thing? Like with weight gain.

es. Next thing you know, it's: 11:30

Dr. Sameena Rahman: Yep, exactly. I think that's very important. And I also think that when it comes to some of the metabolic stuff, the one thing that I have the hardest time helping patients with is stress management. Because I feel like those stress levels can, you know, some things are not, they can't change, right? Like some things like, okay, I have a sick parent or I have kids that I'm running around with. So I'm always like, you have to give yourself grace, right? Like you have to give yourself grace in this period of time, but you may not be, you may just be able to go for that walk. And I think that's why I was watching the video. I think it was the Holderness family with the weighted vests.

Dr. Carolyn Moyers: Oh, the weighted vest. Yeah. I love that. Yeah.

Dr. Sameena Rahman: Like it's phenomenal. I'm talking to Jackie. But I think that like, you know, that's why people pick whatever they can. If it's just going for a walk. I just actually put a walking treadmill under my standing desk in the office, right. Because especially now that I've gone to concierge and I'm reducing the number of patients I see in a day. So that gives me time to like type and sit and do other things in between and make sure I'm calling my patients back. I'm like, one of my patients was like, are you on a treadmill? I'm like, I'm in my office. Yeah, sure. I'm on my walking treadmill. And they're like, OK. But you have to get the steps going.

Dr. Carolyn Moyers: Yes, I have the same thing. Yep, same thing. Yeah, yeah, I do telehealth calls for my treadmill. Sure, sure. That's right. Yeah, we had to get the steps going. We have to move our body. We have to lift weights. And I think, you know, with stress management, yeah, everybody's going to deal with that differently, right? So often patients are asking for their cortisol levels and I never catch the cortisol misbehaving. It's usually lifestyle. And so how do we manage this? Mindfulness is important and of course, yoga can be helpful, simple breathing exercises. I love this little hack that I do now is a thought dump at night. So just journaling and it's part of cognitive behavioral therapy that's been proven to be helpful. But I love to just do a little thought dump. Unedited, doesn't need to be spelled correctly, doesn't need to be in paragraph format or anything, you know, just dump it. And then I write down three things that were a win for the day. And then three things that if I do tomorrow is a win. And every time I do that, it sets me up for success, right? Because it clears my mind. It allows me to just go to sleep with ease. Anything that was worried or needs to be done the next day is already there listed for me. But I feel that I wake up with more intention.

Dr. Sameena Rahman: What would you say three wins for the day? I'm gonna write this down.

Dr. Carolyn Moyers: Yeah, yeah. So a thought dump and then three wins for the day. And it could be something as simple as, you know, I saw all of my patients and charts were completed. You know, I spent quality time with the kids at dinner, you know, whatever that is for you. You count your wins no matter how small you're looking for them. And, you know, an untrained mind runs havoc. And then three things that if I get done tomorrow are a win.

Dr. Sameena Rahman: It's kind of like gratitude journaling. It's kind of like gratitude. Yeah. Yeah. Yeah for tomorrow. You know, one thing that I've started, one of my best friends from college visited me recently. She lives in Hawaii. And she is really into calligraphy. So she like once every couple of months will write me a very long letter, and I'll read it. And I have every intention of writing back. And I start it, and I never do. But she took me to this big pen place in Chicago. I can't remember the name now. But anyway. It is a place where they have all calligraphy pens and notes and stuff. So what I've done is I've started actually writing. I wrote her a letter, but actually even if you're just practicing cursive writing fancily, learning some of the calligraphy from YouTube, it's so therapeutic because you're actually so focused on something else. And sometimes the pens and the ink are so pretty that you're writing it so good, you write. I know it's silly, but when I started doing it, I was like, no wonder she does this. It's kind of like a form of therapy. Yeah. Yeah. Yeah, I'm going to write you a letter. I'm going to send you a letter.

Dr. Carolyn Moyers: Yeah, yeah, it's like a stress reduction, a little form of meditating and just being present. Yeah. Okay, fantastic. I'll be looking for my Gyno Girl letter.

Dr. Sameena Rahman: Shout out to Morgan, my friend. She told me she listens. Sometimes she tells me she listens. Anyway, yeah, I think that's great because I think the stress reduction is the biggest thing, right? Like I have so many friends who have like, you know, also like kids that are applying to college, like that's such a stressful process. It seems like these days.

Dr. Carolyn Moyers: Sure, sure. Yeah, and so often moms are busy doing all of the things, or women are doing, so busy doing all the things for all the other people and not making a date with themselves, making themselves a priority and getting it done. And not to put the blame on them, but as life changes, we're just less active. So we were talking about weight loss and how we kind of guide the patients on the metabolic aspect. I do have patients. I offer a couple of things. So I partner with Holistic for a weight wellness program and it's a 12 week educational weight wellness program. Shout out to Dr. Heather Hammerstedt, who is boarded in lifestyle medicine. I love the program. And it's like dripped to them over 12 weeks, so every day they're getting a new podcast with that little bite size information. And it deals a lot with the mindset around food. And so there's some journaling involved in it that helps us kind of rethink what we're doing with food. And I find it incredibly helpful. So I have a lot of patients who love doing that. Another option is to work with a nutritionist. So we have a nutritionist who actually bills insurance. And she is phenomenal. She'll do a two hour intake with patients to go over what they're actually eating and what needs, what edits could help them to meet their goals. You know, sometimes it's as simple as just committing to, we're not snacking, we're not having added sugar, we're not, you know, we're going to have three square meals a day and flour's not our friend anymore. Rice and pasta not our friends anymore.

Dr. Sameena Rahman: Yeah, yeah, no, that's true too. Yeah, not only friends, all the inflammation. That's good too. And then obviously like for some people they need to use some medications and I know we're all very open to some of...

Dr. Carolyn Moyers: Yes, of course. Yeah, I love it. Some patients go on metformin. Some people elect for GLP-1s or GLPs and GIPs. I love a good semaglutide or tirzepatide. I mean, it decreases inflammation. A lot of times it helps patients to actually start to see progress with their efforts. And so it's that jumpstart to say, my God, I can do this. Some people are able to come off of it and others who have chronic obesity may need to stay on it long term.

Dr. Sameena Rahman: Yeah, I agree, totally. That's awesome. Tell me a little bit about what you, so you're not doing much in terms of osteopathic manipulation or you still are.

Dr. Carolyn Moyers: No, I still do plenty of osteopathic manipulation. So in my membership, I include it. So patients get OMT quarterly as part of their membership or more often if they desire. And then I do it for my OBGYN colleagues in the Dallas, Fort Worth area will send their pregnant patients to me to do their osteopathic treatment. And it's hands-on drug-free treatment that helps to realign the musculoskeletal system and release, you know, myofascial tension, etc. It can help with parasympathetic-sympathetic balancing. We can help to balance that autonomic nervous system, whereas we're often in that fight or flight mode. And so I find that it's really helpful for relaxation and not to mention aches and pains. I use it a lot for pelvic pain. I use it for post-op surgery recovery as well.

Dr. Sameena Rahman: Yeah, yeah, that's great actually. Yeah, I think that there's a lot of benefit to a lot of those different types of manipulations that I've seen patients get. And so I feel like in pregnancy it helps a lot because a lot of people won't touch a pregnant woman. But luckily you're an OB-GYN.

Dr. Carolyn Moyers: Yeah, yeah, I know I'm like who better hands for you to be in. Yeah, yeah, so I mean I have found it really rewarding because in my fellowship that I did in neuromuscular skeletal medicine I would do three months on and three months off so I'd be like go to family medicine for three months and then I would be back in the OMT Fellowship so that clinical continuity I didn't really see as much and so it's been really fun incorporating it into my practice because patients are getting fabulous results. Whether it's an acute onset of pain just because pregnancy is uncomfortable, or it's that they had a motor vehicle accident or horseback riding accident or some cheerleading accident in earlier years and then here comes pregnancy and you're going through a metamorphosis and it's incredibly uncomfortable. So I find it rewarding for all stages, the relief that patients are getting. I mean, I've had people come in on a cane and then the next couple of visits they don't need a cane anymore, right? Or it's the first time that they haven't needed Tylenol in pregnancy from back pain that they thought that I was just gonna have to live with this, you know? So, yeah, I find it to be a fabulous tool, but in an insurance model, I did not have time for it.

Dr. Sameena Rahman: That's amazing. Yeah, of course. We know our system is so broken when it comes to that stuff. All right, well, I can talk to you forever because we have. But I want to be mindful of your time. But I like to end. I've been doing this new thing called vaginal antithetics. So it's like your hot take that you want the listeners to go home with, whether or not it's a piece of advice or what you think they should be looking for in a clinician or whatever, what your hot take is.

Dr. Carolyn Moyers: Okay, so I've got a couple that are coming to mind. So I think perimenopause versus menopause, the symptoms are similar. So I think it's important for perimenopausal women to know that the symptoms are similar. We just have this pesky period in perimenopause. Every vagina loves estrogen. Vaginal estrogen is a girl's best friend, use it for life. And Menopause.org and ISSWSH.org are fabulous resources to find a provider in your area or even in your state. If you're in a small area and you don't have any resources in your immediate area, someone who is licensed in your state could help you virtually. Obviously, if you have some vulva vaginal disorders and you need a vulva exam, that's going to have to be in person. But if it's for menopausal care, a lot of it can be done virtually.

Dr. Sameena Rahman: Absolutely, absolutely. That's what a great benefit of at least having the time to talk to a patient, right?

Dr. Carolyn Moyers: Yeah, I mean, my first appointment is easily an hour, sometimes more, you know, just because it takes time to sort through.

Dr. Sameena Rahman: Me too. Yeah, sometimes they're lengthy. Yeah, exactly. Well, awesome. Well, are you coming to ISSWSH this year?

Dr. Carolyn Moyers: I will be at ISSWSH, yeah.

Dr. Sameena Rahman: Okay, in Long Beach, right? And then what about Menopause Conference? Are you coming to it? You know where we're landing?

Dr. Carolyn Moyers: I'm going to be doing Menopause virtually this year.

Dr. Sameena Rahman: Okay. I'll do, yeah, no, that's great. That