It’s Not Just Hot Flashes: Dr. Heidi Flagg on the Menopause Symptoms No One Talks About

Dr Sameena Rahman (: 00:29

You guys heard the intro. This is Dr. Heidi flag out of New York. Welcome Dr. Heidi flag. I always want to start doing the Oprah intro. It's Dr. Heidi.

Dr. Heidi Flagg (: 00:29

We've about a lot.

Dr Sameena Rahman (: 00:47

Thank you for joining. Yeah, I should start like I don't know if she copyrighted Anyway Welcome Heidi. I'm so excited for you to be here Like I was talking to my podcast producer recently and she was telling me that like every time we do a midlife like episode like people really love those so Because I do a lot of sex men talks not that people don't like the sex men talks but like Midlife stuff gets really like people are you know, as we know they're tuning in

Dr. Heidi Flagg (: 00:47

that's a good one.

Dr. Heidi Flagg (: 00:52

She probably has. Anyway, she's great. Well, thank you for having me. Thank you.

Dr Sameena Rahman (: 01:17

How are you today?

Dr. Heidi Flagg (: 01:17

I'm well, thank you. I'm happy to be here. This is always, it's always fun. I always love chatting with you about everything, right?

Dr Sameena Rahman (: 01:22

Yeah. Yeah, we have so much in common, and I, and we've bonded through this collaborative that we have, the secondary menopause collaborative that we have. So it's interesting because I think that's why social media is so interesting because I feel like there's so many negatives to it, but this has been a huge positive in my life is that you get to make these connections for people from all over the country. And you and I both practice menopause medicine, but...

Dr. Heidi Flagg (: 01:34

Thanks

Dr Sameena Rahman (: 01:50

you know, even though I know we can talk about this, you know, you have partners, I don't. And so I always felt like I'm in this like desert of like not knowing who to talk to when I have issues or you know, whatever. So I'm glad that we have a collaboration of people to really like, hey, what do you think about this? Or, you know, what's your take on this? Or how do you manage this kind of situation? So I appreciate that big time.

Dr. Heidi Flagg (: 02:11

Yeah, I do too. It's been an amazing, amazing sort collegial connection, right? And it surprised me because who knew who was it? Jackie Piestich was like, this is the new online speed dating connections through Instagram kind of thing. it is, you know, and then we get to meet in person at the Menopause Society or some of these gatherings. And it's just a really fun collaborative. It's very reassuring to know that I can just drop a question into the chat and five people respond. Yeah, it's wonderful.

Dr Sameena Rahman (: 02:16

Yeah. Yeah.

Dr Sameena Rahman (: 02:33

today.

Dr Sameena Rahman (: 02:43

Tell us what you feel like you want to tell us about your journey, either addressing your own midlife stuff or what made you, because everyone knows who hears this and who talks to anyone that's a menopause expert at this point knows that it's not anything that we're taught on a regular basis in our OB-GYN curriculum, knows that for those of us who did learn it and have the experience now, I've been doing exclusively menopause and sex med for the last decade, but prior to that, it was like you just get a couple patients here and

Dr. Heidi Flagg (: 02:50

Yeah.

Dr Sameena Rahman (: 03:13

there and just feel, and so everyone's heard me talk about why I kind of went further with my education and continue to do so with all of the conferences that we attend. But what brought you into the picture here?

Dr. Heidi Flagg (: 03:27

Yeah, it's interesting because it's something that I never sat down and really contemplated until we've all been sort of asked the question, right? So I had to kind of go roll back and realize and some memories that popped up. I am, you know, it ages me, but I'm happy to report that I was trained in the 90s and in medical school at University of Kansas. And interestingly enough, my most poignant and vivid memories about menopause were in medical school. So I...

I kind of wrote down a few things that I remember very vividly. First of all, I've written many Prem Pro prescriptions, Premrin prescriptions, right? I remember very clearly that any GYN surgery that all the doctors, when we would do the pre-op, would, they're 60, 70, 80 year olds, they would give them a two week, a month course of topical estradiol cream for the vagina to help them heal, all right?

Dr Sameena Rahman (: 04:06

Right. Yeah.

Dr Sameena Rahman (: 04:23

Yeah, yeah, yeah.

Dr. Heidi Flagg (: 04:25

Nothing to do with sexual health because of course we didn't talk about that, but will help them heal post-op and also make the surgery go better, right? It brings in blood flow, it heals the vagina. I remember very clearly learning about bone health and how bone forms and breaks down and that estrogen blocks osteoclast activity, right? With osteoclast breakdown bone. We did a study, a chart review as a fourth year medical student with a doc who was looking at

Dr Sameena Rahman (: 04:34

Right. Yeah.

Dr Sameena Rahman (: 04:47

Yeah. Yeah.

Dr. Heidi Flagg (: 04:55

hormone therapy and their bone densities. And so I had my yellow notepad out and I looked at every chart and I looked at what hormones they were on and what their bone densities look like from year to year. Fantastic. God knows where. I don't know if it got published. I have no idea where that study was. It's kind of amazing. I learned, I very vividly remember learning about that estrogen directly impacts blood vessels through the nitrous oxide pathway and in vasodilates.

Dr Sameena Rahman (: 05:05

interesting.

Dr Sameena Rahman (: 05:20

Mm-hmm. Mm. Yeah.

Dr. Heidi Flagg (: 05:24

So those are things that I remember. I also remember a patient in 1999, one of the first patients I saw in private practice, literally the first week. She'd seen one of my older partners. She'd been put on hormone therapy in the last few weeks. I, of course, was in my mid-30s, and I was pregnant, in fact. I think I was trying to get pregnant at that point. And she said, I just started hormone therapy, and I can see in color again, the color blue. The sky is blue again. And I just.

Dr Sameena Rahman (: 05:43

Yeah.

Dr Sameena Rahman (: 05:50

Yeah. Yeah. Yeah. Yeah. I think that's how Oprah described her experience when she was saying that she was.

Dr. Heidi Flagg (: 05:52

But my God, that's amazing. you know, what's funny, I've heard her say that and I had a patient that said the exact same thing to me. I mean, I have a patient just the other day, she was describing, yeah, she described two different color themes before and after hormone therapy. Anyway, it was amazing.

Dr Sameena Rahman (: 06:03

sudden that was working.

Dr Sameena Rahman (: 06:12

Yeah. It's interesting though that people really do say that like the world has paint like, you know, and, some people look for that and they don't get it because it's not that way for everyone depending on where they're coming from and what their like physiology is. But I have patients who are like, wait, I thought I was going to see like lilies and unicorns. I'm like, it's not a magic bullet. You still have to do it.

Dr. Heidi Flagg (: 06:16

Yeah.

Dr. Heidi Flagg (: 06:23

now.

Right? Right? It's all about where your receptors are.

Dr. Heidi Flagg (: 06:38

I know, I know. this is probably really good time to say that, that this is an individual journey and hormone therapy impacts each individual so incredibly differently. And this is the thing I keep seeing up at night and I think about all day is like, where the receptors are in somebody's body, it's just going to be so different from person to person. And I think this is a perfect example of not everybody's going to see in color again, right? now, of course, the W8. Yeah.

Dr Sameena Rahman (: 07:02

Yeah, yeah. But that's so interesting. That's such a good analogy, though.

Dr. Heidi Flagg (: 07:07

Yeah. So, you know, the WHI study rolled around. I was nursing my second kid in 2002. I remember the day because the New York Post, the front page was so terrible. was like estrogen causes cancer. Boom, right? We all know 15 million people overnight went over, went off their hormone therapy. And I was, I was a cynic. I was like,

Dr Sameena Rahman (: 07:14

No. No.

Yeah, dark.

Yeah.

Dr Sameena Rahman (: 07:27

15 million guys, that's a lot.

Dr. Heidi Flagg (: 07:30

15 million women went off their hormone therapy. There were some hanger honors, thankfully, and we've studied them now in a Medicare study, which is great. We got some great 20-year follow-up data from that group. And I kept prescribing, actually. was a little nervous.

Dr Sameena Rahman (: 07:36

Yeah. Yeah.

Dr Sameena Rahman (: 07:44

Because we read the data, you could see it's relative versus absolute risk, right? So, yeah.

Dr. Heidi Flagg (: 07:48

Of course, Any of us that were relative versus absolute risk. And then I stayed curious. I kept reading. I kept talking to patients. And it's listening. You and I have talked about this. I'll tell you what really got me was perimenopause. It's one thing, right? I mean, I was wiping so many tears. It was my 40-somethings that were so symptomatic, right?

And that's what really got my attention. And it really was the critical piece. I learned, I still to this day, every single day, learn from my patients. And that's probably my primary education source as a physician. And then I go and I research, right? Or, I mean, I research on my own too, but they'll say something to me and I go look it up, right? And I look for the data and that's how we learn, right? And that's how I've learned. now thankfully,

Dr Sameena Rahman (: 08:30

Exactly.

Dr Sameena Rahman (: 08:38

Yeah, exactly, exactly.

Dr. Heidi Flagg (: 08:44

LID has been blown off menopause and we're all talking about it finally.

Dr Sameena Rahman (: 08:47

Right, finally, yeah. No, it's interesting because I feel like, you know, now with social media, there's a lot of people that become experts in this area.

because you can read and you can journal and whatever, but like, think there's a lived experience when it comes to taking care of patients, right? Like now I've been, you know, pretty much exclusively taking care of midlife women and sexual medicine patients for about a decade. So I can say in that decade, I've had X number of patients that I've seen and I know like off and on, know, I don't think, you know, cause you, have that lived experience. And so you can make those conclusions with the data that you read. And so that's why I feel like people get in these traps where like,

I saw a menopause expert or someone, know, and they are just kind of now getting into it. And so sometimes they don't get the same, not that they might eventually get there, but I'm just saying it doesn't.

Dr. Heidi Flagg (: 09:38

I agree. It takes time and you have to listen. And because there's so much variability and it's a connecting the dots thing, right, for the individual. And, you know, it's the art of medicine. think this is the classic example where there is an art to medicine and perimenopause and menopause medicine is a classic example of that. It's just that human connection that's so critical to really to get to the

Dr Sameena Rahman (: 09:51

Sorry about that.

Dr Sameena Rahman (: 10:00

Totally,

Dr. Heidi Flagg (: 10:06

to the end game and be able to treat them, treat them the way that they want to be treated and get their symptoms resolved as best you can. mean, it's fascinating. It is the epitome of precision medicine, actually. Yeah, totally.

Dr Sameena Rahman (: 10:11

as an individual person.

Dr Sameena Rahman (: 10:18

Precision medicine, right? That's what they called it.

Dr Sameena Rahman (: 10:25

Right. So, and that, also like when you think about patients who have like, you know, sexual dysfunction, that's why, you know, in Ishwish we call ourselves sex detectives because you really have to unravel like, and I remember learning from Erwin Goldstein, like he was like, you can learn 90 % of what you need for your diagnosis by listening to the patient. Like, yeah, just listen, you know, and it's so true. Yeah.

Dr. Heidi Flagg (: 10:44

Just listen. Yeah. And you have to ask the questions. That's the other thing. And the first time you ask the question, you may get a stonewall. And then you keep talking, and you keep talking, and you gain their trust. And by the end of the conversation, you might get the answer. And then there are a few that won't tell you anything. And you try. But it's really...

Dr Sameena Rahman (: 10:55

Mm-hmm.

Yep. Right. Give them permission.

Mm-hmm.

Right. Yeah.

Dr. Heidi Flagg (: 11:12

is in our form. There's no question. Sex detective. that's that. mean the whole, you know, conversation about I'll tell you, you being an OBGYN, I'm an OBGYN, we've had such an unbelievable privilege with our patients in their sexual health journey, right? It's from the first time they have sex as teenagers, SDDs, contraception talk to their 20-somethings. I'm going to talk about my New York City girls who

Dr Sameena Rahman (: 11:14

Yeah.

Dr Sameena Rahman (: 11:28

Absolutely.

Dr. Heidi Flagg (: 11:41

women who struggle in the dating world always have. And all those, you know, the herpes scares, the STD checks on Monday morning after a crazy weekend, whatever, all these journeys. And then the trying to get pregnant. And then it's the baby. And then it's the postpartum, right? And it's all the journey the whole way and their sexual health along all of those paths is just, it's mind blowing and it's different. And you have to talk it through to, it's...

Dr Sameena Rahman (: 11:51

Yeah.

Dr Sameena Rahman (: 12:10

Nuance, yeah.

Dr. Heidi Flagg (: 12:11

the vaginal atrophy, I don't use that term anymore, the vaginal dryness associated in the postpartum period, right? We use topical estrogen in several areas of that journey. I don't know, it's just, as a gynecologist and an obstetrician, it's been incredible. It's a real privilege, and it has to be part of the conversation. It's integral to the whole thing. It's how you get pregnant. It's how you, you know, all of those things.

Dr Sameena Rahman (: 12:14

Yeah.

Dr Sameena Rahman (: 12:18

Yeah. Yeah. Yeah.

Dr Sameena Rahman (: 12:28

A real privilege, agree with you.

Mm-hmm.

Dr Sameena Rahman (: 12:38

Yeah.

Enjoy life. Yeah, and you know, we always say, mean, the saying is sexual health is health because so many manifestations, you know, they're more obvious in men a lot of times, right? When you get erectile dysfunction, you know that we got to look for like, you know, is there something happening? These are micro vessels. Is something happening with your hypertension, diabetes, heart disease? But the same can be said for women with like, you know, we talk about women who are diabetic or having hypertension, these arousal concerns that come up, these other sex, you know, sexual dysfunctions that arise, you know,

It's sometimes an early sign, right? It's like a vital sign. That and your period, right? It's like

Dr. Heidi Flagg (: 13:13

100%, I tell, I say to my patients, it's a vital sign. I need to know about your orgasm. If you were orgasming in the past and you never had to think about it, it wasn't a big, it was just a thing that happened for you and then that stops working. That is important information for your vascular system, for your mental health.

for your inflammation, all of those things. It is an absolute vital sign. Your neurological system, all those things have to be intact to have a successful orgasm, right? It is so telling. There's something going on. You gotta break it down and figure out where the problem is. Yeah.

Dr Sameena Rahman (: 13:37

Your nerves.

Dr Sameena Rahman (: 13:46

Right. Right. Yes. Yeah.

Yeah, absolutely. So that's where that detective work comes in. But that's so interesting because, know, I do hear from like people that were kind of, because I remember having a conversation with Sharon Malone and she was also telling me how she used to really like before the WHI and after the WHI, like it was such a dramatic shift. But you know, like you, she still continue to give people the hormones because she, I remember the WHI when, cause I was a resident and we did it in journal club and we're like, wait, why are they making such a big deal?

Dr. Heidi Flagg (: 13:56

Thanks.

Dr Sameena Rahman (: 14:23

You know, like, because it was like absolute risk and, relative risk and all the things. And so it was very. Yeah. Yes, please. Exactly. Yeah, please.

Dr. Heidi Flagg (: 14:26

Right. I don't know if your listeners want to hear the definition between absolute and relative risk. It's like we can't repeat it enough. The New York Post, said, I'm going to go back and look at it, but I think I remember 30 % increased risk in breast cancer if you take estrogen. But if you break it down to the actual numbers, if you have 15 in 1,000 women that get breast cancer,

Dr Sameena Rahman (: 14:46

Yeah. Right.

Dr. Heidi Flagg (: 14:55

It raised it to 17 to 18 in 1,000. So want two to three in 1,000 risk. And I say to my patients, this is the context I put this in, to my patients, we live in New York City, I said, look, you're going to roll out of this office. You're going to hang a left on Spring Street. You're going to hop on the subway, or you're going to jump in a cab, or you're going to cross Broadway.

Dr Sameena Rahman (: 15:04

Right. Right.

Dr. Heidi Flagg (: 15:17

You're taking on more risk just rolling around New York City. You know, we have to be, we have to use our rational forebrain here, right? We can't.

Dr Sameena Rahman (: 15:25

Right, right. Or with alcohol consumption, right? Almost equal risks involved.

Dr. Heidi Flagg (: 15:31

I know you were interested in talking about cognition and obviously, you know, we all, it hits close to home for so many of us, right, for family and all that. And I don't know if you want to talk about that, but that's such a fascinating topic when it comes to hormone therapy. And I think there's a lot of confusion too, right, about estrogen's role and all that.

Dr Sameena Rahman (: 15:34

Yes.

Dr Sameena Rahman (: 15:48

Yeah, let's do it.

Yeah, absolutely. Well, just so just if you want to finish your point about that, because I interrupted you with the absolute risk and the relative risk. So yeah. I think you said you were just starting what the actual risk was. And then they posted a relative. They posted relative risk, right?

Dr. Heidi Flagg (: 16:00

did I finish my point?

Dr. Heidi Flagg (: 16:10

Yes, so when you can say 30 % increased risk of breast cancer, which is alarming and sounds terrible, right? But when you break it down and look at the actual risk with the numbers, you have to break it down. Media and the newspapers love to hype it up so you go buy a paper, right? And it's very different when you break down the numbers.

Dr Sameena Rahman (: 16:15

Yeah. Yeah.

Yes.

Dr Sameena Rahman (: 16:22

Yeah, you have to take it. You have to understand what that means exactly.

Dr Sameena Rahman (: 16:29

Yeah.

Dr Sameena Rahman (: 16:34

And it's terrible that estrogen is so villainized all the time. It's like, all of the hormones. Yeah.

Dr. Heidi Flagg (: 16:37

demonized. And let's talk about that for a second. I mean, we're filled with it, right? We have times in our life when it's through the roof, like in the thousands, like when we're pregnant. does it make rational sense that it is a direct cause of cancer? It makes no sense. That's not accurate, right? It's a growth hormone. So if there's an existing cancer, it may cause that to grow. And that's what we think is behind breast cancer. And of course, all the therapies.

Dr Sameena Rahman (: 16:42

Yeah.

Dr Sameena Rahman (: 16:53

Right. Exactly.

Dr Sameena Rahman (: 17:02

If it's a receptor positive one, right? Yeah.

Dr. Heidi Flagg (: 17:04

Right, exactly. And all the therapies are based on that. But this really unfortunate information that is infused in our society, it's just infused. And we are all trying to change the narrative is that estrogen causes cancer. And it's just simply not true.

Dr Sameena Rahman (: 17:22

Right. In fact, if you look the actual study of the WHO, and we so many people have said this before, but you know, it was the estrogen alone arm that reported a decreased risk in breast cancer. And it was really the synthetic progesterone is progestins progesterone. They actually can cause proliferation in breasts too. Right. And so it was so we're always like, well, the pro baro was the culprit.

Dr. Heidi Flagg (: 17:35

Amazing.

Dr. Heidi Flagg (: 17:46

And how often do you use Provera? I I use it, I use it short term. It's such a great, it's such a great tool, right? As a gynecologist, love the stuff, right? It's a great tool, but certainly, I mean, it's really, right? I certainly don't do that anymore. It's all about micronized progesterone, which we all love. So.

Dr Sameena Rahman (: 17:55

Yep. Right.

But nobody takes it every day forever.

Dr Sameena Rahman (: 18:07

So I think that's always important. New Year, we'll just continue to reiterate that the fact that, you know, relative and absolute risk are important. So always read your headlines, you know, when it says like, because this is what happens all the time. You know, with the whole IUD, wasn't there something with the IUD recently? Yeah.

Dr. Heidi Flagg (: 18:25

my goodness. That whole thing. Yeah. Thankfully that got, know, thankfully there's some really, we respond so immediately. We, Menoposi, I mean, you know, people out there, we respond so quickly to these kind of these reports that get shoved out there because, you know, we, I don't know about you, but the portal messages blow up, right? It used to be the paper messages. I would have a stack of paper messages with a clip on them sitting on my desk after, you know, certain things would hit the news.

Dr Sameena Rahman (: 18:43

Yes. Excellent. Yeah.

Dr Sameena Rahman (: 18:51

Yes.

The analysis texts, journals.

Dr. Heidi Flagg (: 18:54

And now it's portal messages, right? So I think we were thankfully quick to respond and say, hold on, let's look at this.

Dr Sameena Rahman (: 19:02

Yeah. And that was in the New York Times, too. We're talking about the study. Was it done in the Netherlands? I can't remember. It was done in Europe somewhere, the study. Yeah. And it. Yeah. And so there was, you know, this blow up about progesterone IUDs causing cancer, breast cancer, again, relative absolute risk and all the things.

Dr. Heidi Flagg (: 19:12

I think Netherlands, I'm not going to remember exactly. I think you're right, yeah, Netherlands. We're good at collecting data over there. Yeah.

Dr. Heidi Flagg (: 19:30

Right, exactly. Right, yes, that's the bottom line. That's the takeaway. And boy, those IUDs do us all a great service, right? We treat heavy periods with them. They provide excellent birth control, give women some control.

Dr Sameena Rahman (: 19:32

It's not true, basically, guys.

I mean, totally.

Dr Sameena Rahman (: 19:49

Right. Some autonomy, right? Like I feel like, you know, let's not demonize birth control pills either. I geez Louise, like people weren't even able to live their lives in the past because this fear, you know, and really brought women along. I know that like on TikTok, you know, you have all the young patients coming off of birth control all the time, right? Like they're trying to come off. And all the midlife patients are trying to get hormones. It's like such a dichotomy.

Dr. Heidi Flagg (: 20:14

It's incredible, right? Yeah, I have so many stories. We both have so many patient stories, and they keep popping into my head as we talk here. yeah, information is amazing, and we're trying to educate. And obviously, we see the challenges there, because now there's so much information, it's hard to weed through it all.

Dr Sameena Rahman (: 20:16

Yeah.

Dr Sameena Rahman (: 20:38

Yeah.

Dr. Heidi Flagg (: 20:38

And we just had a patient come into the office just last week and 41 years old. She didn't like her neck spline on because it was causing irregular bleeding, as it always does. And she decided to remove it. And sexually active. She didn't bother to replace her birth control in any way.

Dr Sameena Rahman (: 20:50

Yeah.

Dr. Heidi Flagg (: 21:03

And she came into our office saying she went for a run and felt kind of bloated and uncomfortable. And her irregular periods persisted. And sure enough, she was very far along in pregnancy. 16 weeks pregnant. what she said was like, oh, I just thought I was in perimenopause. here, this is just for everyone to listen, OK? And we'll both say it.

Dr Sameena Rahman (: 21:18

Thank

Dr Sameena Rahman (: 21:25

Dr. Heidi Flagg (21:33.13)

If you are in perimenopause, you need to continue to use birth control unless you're trying to get pregnant. That's the only time you don't. Please continue to use birth control. In fact, you know, 42 to 44, when you're in that early loop phase of perimenopause and hyperdrive, that's what I call it, and dumping more than one, you're hyper ovulating, you can get pregnant with twins. There's a higher risk of twins during that time. So please, please use birth control. This was terrible. I just thought, my goodness, now.

Dr Sameena Rahman (: 21:35

you can still do Because you can still do it. Right.

Dr Sameena Rahman (: 21:50

Yeah.

Yeah. Yes! my god.

Dr. Heidi Flagg (: 22:02

Now, you know, I'm just in perimenopause. That's...

Dr Sameena Rahman (: 22:05

Yeah, yeah, no, the opposite. It's so true. I mean, I can think of so many stories. I just remember that when you said that twin thing, like I had a patient just like that, who thought that she was done, like she was, and she had actually fertility problems her whole life. And all of a sudden she's 42 and she got pregnant with twins. I mean, she was happy about it because, but she was so like, this, you know, this was not what I was expecting. I had already decided to live my life without, you know.

Dr. Heidi Flagg (: 22:21

Body kicked in.

Dr Sameena Rahman (: 22:34

I mean, so eventually she came to terms with was happy about it, but she had already like, you know, at some point when you have fertility issues and you come to terms with, I'm not going to be a mother or I don't want to adopt, you know, whatever. And she, so it was a big process for her. remember like this was years ago. Yeah.

Dr. Heidi Flagg (: 22:48

That's a crazy story, right? I mean, she'd closed the door on a chapter of her life and then had to open that thing wide open again, right? I mean, but yeah, so this is, you know, again, imperfect information, not fully understanding the implications, but you know, there's still fertility to be had, even with a history of infertility, right? Yeah, it's fascinating.

Dr Sameena Rahman (: 22:55

Yeah.

Dr Sameena Rahman (: 23:02

Mm-hmm.

Dr Sameena Rahman (: 23:06

Yes, yes, yes, absolutely. Yeah, you never know one of those, because it's always like, always, because even when people get upset about their low AMHs, I'm like, doesn't mean you can't get pregnant. It just means, you know, like, if we hyper ovulate, you might not produce enough, you know, kind of thing. But you know, it's always, it's always a, it's always a shock. think it's interesting.

Dr. Heidi Flagg (: 23:17

Yeah, yeah. Right.

Dr. Heidi Flagg (: 23:27

totally.

Dr Sameena Rahman (: 23:29

Anyway, Heidi, I did want to talk because we both are like really big advocates of really improving cognition. Just yesterday I was talking to someone and I couldn't bring any words to my head and I was like...

Dr. Heidi Flagg (: 23:40

It happens to me too.

Dr Sameena Rahman (: 23:43

Crazy because I'm you know, I definitely try but my pyramid applause to stay, know Either taking my patch or my pill because I'm very bad about taking anything But you know again, it's not a magic bullet, right? Like so it's not gonna like clear my brain fog a hundred percent if I'm not sleeping if I'm doing you know, It's how I was very frustrated the whole day. Like I'm like no words are coming to me in the right way I was actually worried today. I was like, what if I'm doing this podcast and I'm just like blubbering because I can't remember any words

Dr. Heidi Flagg (: 24:10

I think about that too. did that actually. had another podcast a few weeks ago and I literally, we had to stop and just kind of talk about something else because I completely lost my train of thought. And then when we got back on track, but it is incredible. And it's that word grab. This is the midlife challenge when women start losing their estrogen. You think you're going crazy. You think you're developing Alzheimer's, right? It's scary.

Dr Sameena Rahman (: 24:24

Mm-hmm.

Dr. Heidi Flagg (: 24:35

And then the panic sets in, and I think that makes it even worse, particularly if you're in a board meeting. All my high-powered attorneys that I take care of, my big, women are like, you know, the few leaders at Goldman Sachs or whatever, and they're sitting on a board table and they lose their ability to talk. It's just, so it's that word grab, if you can't grab a word. And here you have two doctors that have the same, we have the same experience. So I just want everybody to know, just talk to your physicians and, you know,

Dr Sameena Rahman (: 24:35

scary.

Dr Sameena Rahman (: 24:41

Yes.

Dr Sameena Rahman (: 25:03

Yeah. Right. I mean, it happens to all of us, you know, like I, I don't like to admit this, but you know, I had attempted a Ted talk last year and I froze in the middle because I couldn't remember the words and it was so utterly like the, can't even describe it. It was just awful, honestly. And, you know, didn't publish it. Yeah. But, uh, you know, I was like, oh, Perry metaphor.

Dr. Heidi Flagg (: 25:05

putting semester in time. Yeah.

Dr. Heidi Flagg (: 25:18

I know, some of you guys.

Dr. Heidi Flagg (: 25:26

You just want to run.

r article when it came out in: 2018

crazy. The brain fog is real. Here's the biology behind it. And it's so validating. to explain it, she's basically a PhD neuroscientist up at Cornell. And she's done these amazing brain imaging studies on women in perimenopause and then postmenopause. And what she realized is that the brain, when the estrogen levels drop,

Dr Sameena Rahman (: 26:04

Yeah, so validating.

Dr. Heidi Flagg (: 26:30

the estrogen or the estrogen receptors in the brain go through the roof. First of all, there are estrogen testosterone receptors all over your brain, right? So there's lots of, we could talk about all the estrogen, the roles of estrogen in the brain. Anti-inflammatory, vasodilator, neurotransmitter creates neural connections, right? It plays an amazing role in the brain. So when it goes, so too does some of our ability to grab words, right?

Dr Sameena Rahman (: 26:54

Yeah, absolutely.

Dr. Heidi Flagg (: 26:57

And so the postmenopause imaging studies, and she has gorgeous pictures of this, by the way, it's public access article. Have you seen it? Yeah. Show that the brain then up regulates its receptors. So the receptor load goes through the roof in the brain. And what that means is your brain is looking for estrogen. It is going to the body and it wants more. It wants it. It wants it to function, right?

Dr Sameena Rahman (: 27:02

Yes, and nature reminds me of that.

Dr Sameena Rahman (: 27:21

it's looking good, right? Because when tissues upregulate receptors, they want that hormone to enter the cells to nourish them and all the things that it does. yes, yes.

Dr. Heidi Flagg (: 27:32

and create all the functions that we know and love in our pre-menopause years. Right?

Dr Sameena Rahman (: 27:37

Right. And I think that was such an interesting finding because even she says that she was expecting the receptor count to go down. But the 65-year-old or whatever had the most receptor counts. It was just looking for it. And I think that's the confusing part where we haven't really, in terms of cognition, an estrogen is like, we know it's so important, but is it going to prevent dementia? Is it going to prevent Alzheimer's?

I think that's where we don't have the best data to say yes in all patients. In some patients, the ones that suffer from real bad hot flashes or the early menopause. That's your understanding as well,

Dr. Heidi Flagg (: 28:21

100%. That's been proven in early menopause patients and severe hot flashes. There's a direct link that has been made. But let's go over what we mean by good data. Good data is the randomized control, placebo-blinded trial, the RCT, that takes 10, 20 years to come. We will never have that again.

Dr Sameena Rahman (: 28:23

this.

Dr Sameena Rahman (: 28:45

which we'll never have again. Like women's health initiative, huge. Yeah.

Dr. Heidi Flagg (: 28:51

The funding isn't there. Only 10 % of funds go to women's health. And we'll see what that looks like going forward. Yeah, so we have to go on observational data and things that we know. And also, quite frankly, I just try to use my common sense. And if we understand the biology of things, this is how I hand, again, individualized approach, look at my patients' priorities.

biology comes into play, understanding how those biological mechanisms work, and then do no harm. Understanding that I know I can do this without doing harm, right? At least as best as I can understand them with experience and data, right? So combining all of those things together, you try to go forward. But my understanding of the fact that we don't have enough data is that it's not a randomized control trial.

Dr Sameena Rahman (: 29:35

Yes, this was, yeah, exactly. Right.

Dr. Heidi Flagg (: 29:49

and but we have lots and lots of biology data, biological data and observational data. I don't know what, you know, there were so many lectures at the Menopause Society, but one of them that really, really kind of blew my mind was they did brain scans on women while they were having hot flashes. Do you remember that one? They look like mini strokes in the brain. Okay, so let's talk about dementia risk. I mean,

Dr Sameena Rahman (: 29:54

Thanks.

Dr Sameena Rahman (: 30:01

Yeah.

Dr Sameena Rahman (: 30:09

Yes! Yes! yeah. Yeah, yeah, exactly. Right, yeah, yeah, yeah, that's fast-going dementia.

Dr. Heidi Flagg (: 30:18

mini-strokes while you're having a hot flash? And what treats a hot flash? Estrogen. So this is the whole thing, is that this is the terminology that gets so confusing. We cannot say, because we do not have the randomized control trial, that estrogen is a primary prevention. But the downstream effect of using estrogen when we treat a hot flash, the downstream effect likely helps dementia risk, right?

Dr Sameena Rahman (: 30:43

Yes, it improved.

Dr. Heidi Flagg (: 30:46

So we can say secondary prevention, whatever. It's not primary prevention. That's what we can't say. But you treat.

Dr Sameena Rahman (: 30:49

Right, right, right, exactly. And it's specific to those women who have these uncontrolled sort of hot flashes, these basal motor symptoms. Like we do have the patients who's kind of sailed through, you know, perimenopause, menopause. Is it gonna help them? We can't say with any certainty that it will help long-term trials treating primary prevention. So.

Dr. Heidi Flagg (: 31:07

can't say that.

Right. Well, so that's another interesting thing, At the menopause society, the big message was treat only symptomatic perimenopause and menopause. OK. So, tell me, how many women have you actually, if you ask them the right questions, how many women do you know that had zero symptoms in perimenopause? None. There's not one. OK.

Dr Sameena Rahman (: 31:22

All right. Yeah.

Dr Sameena Rahman (: 31:32

Like almost not, right? Like, yeah. Yeah. Some of them have genital urinary syndrome and menopause. Some of them are concerned about their bone density. Like, I was an anorectic or I was on this for too long or whatever. Or my mom suffered from fractures. yeah, you need it for your bones, even though you don't have the other. Yeah, totally, right?

Dr. Heidi Flagg (: 31:53

There's, I personally, my personal view is I don't believe in asymptomatic perimenopause. It doesn't exist. If you ask the right questions and you get to the review of system where it's like, do your joints hurt? And they say, yes, it's musculoskeletal syndrome of menopause until proven otherwise, right? And, you know, when did we, when do we make those connections? You know, very recently. Thank you, Dr. Vonda Wright for coining the term.

Dr Sameena Rahman (: 32:05

Yeah. Yeah.

Dr Sameena Rahman (: 32:16

Yeah. Right.

Dr. Heidi Flagg (: 32:21

you know, where you, and by the way, I've been meant to ask you, you know, I'll tell you what prompted me to finally put myself, I was treating myself, because there was nobody else supporting me at 47. But when I was a runner, I was a runner, I've since stopped, but I got up at 47 years old, got up in the morning to go for a run, and I literally couldn't put one foot in front of the other. I'm like, what is going on here?

And I thought, OK, I either have Lyme. I just went through the litany of possibilities, and it persisted. And I was just like, OK, hold on, hold on. And there were a couple other things that were happening simultaneously. And I finally was just like, OK, you're going on some hormones. Thank you very much. This is enough of that. Yeah, it was the musculoskeletal symptoms that I was having that really just

Dr Sameena Rahman (: 33:13

Yeah.

Dr. Heidi Flagg (: 33:16

made me throw in the towel. And I don't mean to say it like that, but back then it was like, yeah, well, that was the narrative, right? Yeah, so, yeah, I don't know what motivated you to get on it, but maybe.

Dr Sameena Rahman (: 33:21

growing in the town when you write it. That was the narrative. No, I agree.

I mean, think, you know, I, cause I start, went on Nextellas about two years ago, cause I thought, you know, I was having some, bleeding irregularities and I was like, this will help me through this peri transition. Cause I do think it helps an early peri for a lot of people. And now I think I'm like mid to late peri. So feel like in the last six months, I changed over to a wide variety of things. Like I've been using the, you know, I have samples in my office. So.

Dr. Heidi Flagg (: 33:46

Agreed.

Dr. Heidi Flagg (: 33:57

I do the same thing. I use all sorts of stuff. I'm like gel today. You know, I do this. Yeah. No, it's terrible. Totally.

Dr Sameena Rahman (: 34:02

Yes, I mean, don't listen to us. We're terrible. like, but like also the whole thing with period sometimes you feel like, oh, I'm having a lot of rest and nervous headaches. Should I not take my gel today? You know, maybe I just won't. And then I'm also terrible about taking things. But I've been trying by Juba lately. Because it's easy. was like, oh, just one pill.

Dr. Heidi Flagg (: 34:20

Well, it's easy and it's in your office.

Dr Sameena Rahman (: 34:25

But I have, you know, I think the joint thing was really big and why I changed from Nexstelis and also I started having crazy bleeding on Nexstelis. So I just was like, oh, you maybe my, my joints, cause I'm also a runner and I try, I was trying to do more lifting and, and that was a big thing. was like, man, why does it hurt when I'm walking up the stairs now? You know, and this is not good. And then, and then I had a little bit more heat intolerance. I wasn't getting flushes of heat, but I had a lot of intolerance and

The thing that really changed me, this is like, you know, crazy that I have to say, that I've been prefaced, but I had a panic attack one day, like straight up, all the way panicked, you know? And it was totally like I was driving my kids, it was bad weather, and I just started bawling, and I had palpitations, and I was just breathing heavily, and my then 13-year-old son was like, Mom, what's wrong? What's wrong? And I was like, ugh.

didn't want to talk to him about it, you and then he called my husband. He's like something's wrong with mom She's not saying anything, but she's crying hysterically and she's she's and he was like what's wrong with you? And I'm like nothing and it was a full-on panic attack, but I just didn't know how to you know Yeah

Dr. Heidi Flagg (: 35:37

Right. I had one of those on a plane. The door closed and I just, yeah, that was another thing at 47. It was crazy. Yeah.

Dr Sameena Rahman (: 35:45

Yeah. yeah. yeah. I can't try. can't fly without like really needing to bring myself down anymore because of that weird anxiety.

Dr. Heidi Flagg (: 35:53

Yeah. And again, you and I could sit here and talk about the mechanisms of action of how all of those things, the brain talks, the ovaries talks, the adrenal glands, right? And that whole system is thrown out of whack when you start losing your hormone, when you start losing your estrogen and your estrogen receptors aren't found. It just, it's dysregulated and you know, we're burning hot flashes. I call it temperature dysregulation.

Dr Sameena Rahman (: 36:14

Totally. Chaos. Total chaos.

Dr. Heidi Flagg (: 36:19

Yeah, total chaos, Temperature dysregulation. Some people have the full minute hot flash where they're sweating or whatever. But many of us simply have temperature dysregulation, right? You live in a very narrow, comfortable space, whereas pre-menopausal, you could live in your really wide temperature zone. And now it has to be really narrow. But that triggering of the adrenal system and dumping all that cortisol and adrenaline into your system that precipitates a panic attack is no joke.

Dr Sameena Rahman (: 36:47

Yeah.

Dr. Heidi Flagg (: 36:49

And again.

Dr Sameena Rahman (: 36:50

And some people would say it was like, it's the Delta of like having one month of high estrogen till one month of rock bottom estrogen, right? Those loop cycles versus not. It's like WTF is happening right now.

Dr. Heidi Flagg (: 37:00

And your brain just can't keep up. It's wondering what WTF exactly. And yeah, to your point, right, the delta, it's that incredible swing because the half life of estrogen, of course, is 12 to 24 hours, right? So you can hyper ovulate, dump a whole bunch of estrogen into your system, and then 12 hours later, you crash back into the basement. that's how this is exactly, you and I have to speak in bullet points and distilled versions. This is how I explain it to my.

Dr Sameena Rahman (: 37:29

Yes, I did.

Dr. Heidi Flagg (: 37:29

the patient sitting in front of me, right? And so that it's validating so that she understands like it's, I'm okay, that makes perfect sense. Now I understand intellectually what's going on with my...

Dr Sameena Rahman (: 37:38

Yeah. Like why one day I have a headache with breast tenderness and the next day my vagina is so dry like the desperate.

Dr. Heidi Flagg (: 37:46

It's so wild, right? Yeah. goodness. And then there's educating everyone and then getting enough clinicians out there to treat women. I we have so many barriers to getting through all this, but we're getting there, I think. It's a little bit true.

Dr Sameena Rahman (: 37:50

Yeah, no, that's. Yeah.

Dr Sameena Rahman (: 37:59

Yeah.

Dr Sameena Rahman (: 38:05

Yeah, exactly.

And I think what's interesting is I think a lot because I'm on some of these OB-GYN groups on Facebook and stuff and so many people are now getting so many patients with these complaints that some clinicians are really frustrated. They're like, why are all these, know, da da. And then others are like, how do I learn more? I think it depends on what type of practice you're in, right? Because this type of care cannot be given in a standard 40 patient a day OB-GYN practice where everyone

in the room is a pregnant woman except you. know, like, although there are in certain practices, like one designated person that doesn't do anything doesn't do the OB anymore is just the menopause or guiding person. So I don't want to say that all practices that are OB heavy don't have that but like how's it your practices like that? Yeah, yeah. You're the designated.

Dr. Heidi Flagg (: 38:54

It's like that, yeah. Yeah, because I'm the designee. But I think the message to your listeners would be find that doctor that isn't the one like, is everybody asking me these questions, versus find the one that's looking to educate themselves and is there to partner with you in your health journey and your midlife journey and is open to talking about the options. That's who you

Dr Sameena Rahman (: 39:20

Yeah, yeah, and if you're that clinician that doesn't have the, you know, either the desire or the, some people don't have the bandwidth to like really incorporate more stuff into their life. Their life is hectic enough. They can't go to the conferences, whatever. Like if you're that clinician, then just say it. Like, I'm sorry, that's not my area of expertise, but you know, Dr. Heidi Flagg in our offices or, you know, know, so and so down the street, I know her that she loves to talk about this and she can handle, you know, the situation.

Right?

Dr. Heidi Flagg (: 39:52

Yeah, exactly. Yeah, meanwhile, and I'll try to see her by the way. I don't have a waiting list of like 100 people right now. This is the thing where we opened this subject up without the infrastructure in place, right? We blew the lid off this thing without the infrastructure in place. So here we are.

Dr Sameena Rahman (: 40:00

Yeah.

Dr Sameena Rahman (: 40:09

Yeah, absolutely.

in place.

And that's why I think so many telecompanies are popped up and all these other things. And I do think there's a role for some of these telecompanies, in terms of like educating and maybe starting. I've had a lot of patients come to me after getting started on something. But the majority of people still need an exam. as long as they're able to, I mean, I've seen so much like of sclerosis get missed because they never had the exam and they thought, you know what saying?

Dr. Heidi Flagg (: 40:38

Totally. That and then the other thing with hormone therapy, maybe what's the statistic, but you start somebody on hormone therapy, 30%, 50%, 40 % will start having spotting bleeding, right? Just addressing that and telehealth is one thing, but ultimately you need an evaluation just to make sure we're not dealing with something else. So that's probably the biggest example of just where follow-up is really critical.

Dr Sameena Rahman (: 41:02

Exactly. So that's pretty important. Yeah. Yeah, exactly. Absolutely. And then just to finish up what we're saying about cognition, you know, we talked about hormones. What are are other things? How do you recommend for improving cognitive fitness? Like I call it cognitive fitness. I think people call it fitness, right? But just improving like your cognition, I think is really important because, you know, as we all say, we have a nursing home prevention program, right? We don't want to be like we don't know where we are.

Dr. Heidi Flagg (: 41:09

Yeah.

Yeah.

Dr. Heidi Flagg (: 41:18

All right. Yeah.

Dr Sameena Rahman (: 41:31

We're peeing on ourselves and we can't move, right? Those are the big things we're trying to avoid. And for the people that have had that in their life, I mean, it's so hard as the person helping to manage someone. Yeah.

Dr. Heidi Flagg (: 41:34

Totally. Exactly.

Dr. Heidi Flagg (: 41:42

The caregiver, it affects everybody. It impacts the person, but also everybody around them, right? It's so difficult. this is, look, and we've said several times now, hormone therapy isn't the panacea, right? But it is certainly a tool. And then I go to the lifestyle pillars, right? Sleep. We know that poor sleep leads to, there's a direct correlation to dementia.

and neuro generative decline if we have poor sleep habits and we don't sleep well. Sarcopenia, right? Not building muscle, not maintaining muscle. Muscle and brain talk directly to each other through myokines, right? There's a skeletal muscle, has substances in it that talk directly to the brain. It's a bi-directional communication. If you let your muscle mass go, sarcopenia for everyone out there is the loss of muscle mass.

We lose muscle as rapidly as we do bone when we start losing our estrogen and in midlife. So it is really important. This whole weight training craze and weightlifting is real and important. And nutritionally, what are you eating and what are you drinking? Alcohol. I ask every single annual exam patient. They know I have a reputation.

Dr Sameena Rahman (: 42:51

It's real.

Dr Sameena Rahman (: 43:01

Yeah.

Dr Sameena Rahman (: 43:07

Yeah.

Dr. Heidi Flagg (: 43:08

I say, you sexually, here I'll come back, are you sexually active, male, female, et cetera, how many partners? And I make them count. I just need a number. And then I get to alcohol and I'm like, all right, how many drinks a week? And they're like, you know, I drink socially. I'm like, you're gonna have to define that for me. I need a number. So because in New York City, we are incredibly social.

Dr Sameena Rahman (: 43:24

All right. Yeah.

Dr. Heidi Flagg (: 43:30

You know, all my bankers, my attorneys, go out on these evenings out. It's a Tuesday night. So we talk about the number. And then I kind of give them something. And look, I never say zero because that's just harsh at this point and not realistic, I think, in our current culture. Although maybe after the Surgeon General warning the other day, maybe, you know, that's been a long time coming. But alcohol is a neurotoxin. That's it. That's the bullet.

Dr Sameena Rahman (: 43:51

Yeah. Maybe.

Dr Sameena Rahman (: 43:58

period. Yeah.

Dr. Heidi Flagg (: 43:59

It breaks down into acetaldehyde and it's a neurotoxin, right? So I know it's embedded in our culture, but I talked to them about alcohol. Let's see, nutrition. It's anti-inflammatory diet, right? Eat healthily, So yeah, do you chat with your, I'm sure. Oh, that's the other one, loneliness.

Dr Sameena Rahman (: 44:13

Thank

Dr Sameena Rahman (: 44:16

Mediterranean and all this stuff. Yeah. And then, yeah, I mean, all of that and then also just like social connections, right? Like that's huge, right? You're I know you're I know that was on your lips. Well, you just said everyone's social in New York City. But that's the big thing, right? Like the connections you talk about the green zone, the blue zone, sorry, the people that living long lives in the blue zone.

Dr. Heidi Flagg (: 44:41

Yeah. Yeah. So yeah, loneliness and apparently a third of people over 50 are lonely. They report being lonely. And they actually, you image their brains, their brains shrink in the areas of memory. I mean, they lose brain in the areas of memory and ability to learn and create.

Dr Sameena Rahman (: 45:04

I mean, it's a declared pandemic, right? Loneliness is a pandemic now.

Dr. Heidi Flagg (: 45:08

declare pandemic. So social connections are critical. And these things are generally free, right? Working on how to sleep better is free. Generally, you know, connecting with people is free, for the most part. These things are, you know, going to lift weights you can do at home. You know, these are things, and I know women, especially in midlife, they're overwhelmed. I get that. So I'm sure you have a strategy, but I say,

Dr Sameena Rahman (: 45:27

Yeah.

Dr. Heidi Flagg (: 45:36

Look, I don't want to overwhelm you. Let's start with one thing here. Chip away at it. And then you'll feel a little bit better. And then you can go to the next thing. Right? You got to break.

Dr Sameena Rahman (: 45:38

Yeah.

Dr Sameena Rahman (: 45:45

Cause don't all your patients say, this another thing I put on my to-do list? Right? that's what they always tell me. Like, I have another thing to put on my to-do list that I can't get done. Yeah.

Dr. Heidi Flagg (: 45:53

The to-do lists are so long and it's overwhelming. So I don't want to overwhelm people, making even making little change is incredible. We haven't talked about gut health and all that, but that's also an important one. So, right.

Dr Sameena Rahman (: 46:07

Yeah. Yeah, absolutely. Because I've gotten the brain communicate so well, so much. That's why these GOP ones are so amazing. think that's Actually, I'm going to speak to Alexandra Soa from the Azembic Revolution. She just wrote that book. Yeah, I want to talk to her. Yeah, so.

Dr. Heidi Flagg (: 46:16

Right. That's another whole conversation, right?

Dr. Heidi Flagg (: 46:26

great. good. I'll listen to that. Yeah. Are you prescribing? I'm starting to prescribe.

Dr Sameena Rahman (: 46:33

You know, and side note, it's interesting because I, you know, obviously I'm South Asian a lot. We have so much diabetes in our history. I'm not myself, but I have family members that have been. So when it first came out like years ago, I was learning about it for a family member.

And then what I saw was, you know, we treat a lot of PCOS as gynecologists. And so I was putting a lot of people on metformin. And then at the time, this was like pre-COVID, that when people were not getting as much success, I had spoken to a pharmaceutical person once or someone from Pharma. And they're like, you know, if they fail metformin, you can put them on ozembic, even if they're not diabetic back then.

And so back then I would do that and like these patients would do really well. But you know, now I think like they're very strict, like for Ozembic you have to have diabetes, for Wigobi or ZetBound you can be overweight and get treated for weight loss drug. But it was very interesting because I would see such great results in my PCOS patients. So I've been, and then I took a lot of the obesity courses. I've been meaning to sit for the boards for a very long time, but it's just another thing on my to-do list.

Dr. Heidi Flagg (: 47:12

Amazing.

Dr. Heidi Flagg (: 47:33

We're gonna have the game.

Dr. Heidi Flagg (: 47:42

Another thing on your to-do list. That's amazing. You've been way ahead of me on the Ozempic thing. That's amazing. Good for you.

Dr Sameena Rahman (: 47:42

Yes.

Dr Sameena Rahman (: 47:48

But it's, you guys will hear when I talk to Alexandra. So it's a miracle drug for so many people. Not for everyone, but for so many people.

Dr. Heidi Flagg (: 47:55

Yeah, I think so. No, not for everybody, but it's again an incredible tool. And I think this midlife weight gain, I see a future where this ends up being hopefully something that's very helpful because we know it's a metabolic weight gain, right? And it's deeply upsetting to every individual. Nobody loves, everybody hates it. They hate when they gain the weight around the midsection, their pants don't fit. And it's a metabolic weight gain. So it's right in that pathway. I think there's gonna be room.

Dr Sameena Rahman (: 48:08

Yeah.

slurs.

Yep. Yep. Yep.

Dr. Heidi Flagg (: 48:23

to prevent that 15, 20 pound weight gain. Definitely.

Dr Sameena Rahman (: 48:26

Yeah, absolutely. Anyway, so yeah, those are kind of things we tell people, Dr. Flagg and I. I think, is there anything else? Maybe like using crosswords and stuff to help your brain, like right, yeah, just activating it. good point, good one.

Dr. Heidi Flagg (: 48:37

Right. Yeah, needlepoint. mean, needlepoint, all these things. Yeah. Yeah, there's been some amazing studies about what neurotransmitters are released when you needlepoint and obviously staying active with crossword puzzles and just,

Dr Sameena Rahman (: 48:50

Something interesting. No. Yeah. Those the word things that New York Times put out, what do they call it again? The mortal. I'm like, I can't remember. I need to go do some mortal.

Dr. Heidi Flagg (: 49:00

A wordle and all those, yes.

Dr. Heidi Flagg (: 49:07

I tell you, had a little, in my family group chat, the four of us, I have a kid in Philadelphia, one in San Francisco, and then we're here. And, oh my God, it became a little bit competitive. My kids would put, screenshot their results. And mean, they just crushed me. So I was just like, I'm out. I'm not doing this anymore. They would get it in, know, whatever, four tries and moms over here, like barely squeaking it or, you know, not getting the word at all. I'm like, I'm, yeah. So.

Dr Sameena Rahman (: 49:19

Uhhh...

Dr Sameena Rahman (: 49:26

Yeah. Yeah.

Dr Sameena Rahman (: 49:33

Yeah. Yeah. Yeah. I was also reading like people that like past mid age like retirees that are starting to do art or like, you know, something something new to activate a different side of their brain. Yeah.

Dr. Heidi Flagg (: 49:37

kind of joke around.

Dr. Heidi Flagg (: 49:48

Yeah, music. I'm playing a musical instrument or just listening to music. amazing, the neuroscience behind music is so great. Also, I don't know about how you feel, but working, know, not retiring, staying relevant. I do too. I don't know me in any other context and I don't see me in any other context other than

Dr Sameena Rahman (: 49:58

Yeah.

Dr Sameena Rahman (: 50:07

That's how I feel.

Dr Sameena Rahman (: 50:13

Amen.

Yeah. Yes, doing this. Yeah. Yeah.

Dr. Heidi Flagg (: 50:18

some role, right? I think my mother just turned 86 years old and she still works.

Dr Sameena Rahman (: 50:25

Wow, see? Yeah, it's a big thing actually. I do, because you see people cognitively decline after they retire big time. And so, you know, people are always asking like, what's your retirement age? I mean, like, I don't think I'm ever gonna fully retire. Like I'm gonna work until I can't work anymore. And then like, I'm gonna try something else.

Dr. Heidi Flagg (: 50:31

Yes.

Dr. Heidi Flagg (: 50:41

Right? Right. Right. Just regroup.

Dr Sameena Rahman (: 50:44

Which is why I think we're doing some of this advocacy work because like yeah, we might not even do clinical stuff forever, but at least we're building a platform to continue to educate. Yeah, yeah. So I guess that's a good place to end. Heidi, this has been so much fun and you're such a wealth of knowledge. Wow.

Dr. Heidi Flagg (: 50:54

Exactly. Exactly. So yeah, I think that's really good. Yeah, totally. I know. It's lovely to talk to you. really, you were one of the, I said in my Instagram post, one of my glimmers for the 2024 was meeting you. So, and I love senior practice and everything that you have going on in Chicago. So thank you for having me. Yeah, I appreciate it.

Dr Sameena Rahman (: 51:12

Yeah, US 1. US 1, absolutely.

Of course, of course. Thank you guys for joining us. The Guide on Girl presents sex, drugs, and hormones. I'm Dr. Samina Rahman. Remember, I'm here to educate so you could advocate for yourself. Please join me on my next episode.