Midlife Pivots: From Public Defender to Women’s Health Advocate with Jen Lanoff, NP

Dr Sameena Rahman (: 00:01

Hey y'all, it's me, Dr. Samina Rahman, Gyno Girl. Welcome to another episode of my podcast, Gyno Girl Presents Sex, Drugs, and Hormones. I'm Dr. Samina Rahman. Today, as you guys heard in my introduction, I have a very special guest and friend that's gonna talk to you about a lot of the concerns around mid-life that we always talk about. It's Jen Lanhoff. Jen Lanhoff. And you guys heard my intro, but.

Jen Lanoff (: 00:22

Lan off,

Dr Sameena Rahman (: 00:28

Jen and I actually just recently met in the last few months. We met at the menopause conference where we meet a lot of like-minded clinicians and I was very excited to meet her, but we've become friends over time because we share mutual grieving that we've been doing together, unfortunately, but she's a great individual and a great person to learn from. So thank you, Jen. Welcome to my podcast.

Jen Lanoff (: 00:53

release.

Dr Sameena Rahman (: 00:57

We always talk about, you our journeys into like midlife care or even like our own midlife issues that we've discussed. I've always asked, I talk about my own stuff, you know, on other podcast episodes. You know, what brought you into this like arena of midlife work or, you know, even I know you weren't even like in the medical profession for a long time that you're a former lawyer, as I described in my intro. So

Do you want to talk to us about what brought you into this work and why you're so passionate about it?

Jen Lanoff (: 01:28

Yeah, I it's always hard for me to figure out exactly at what point I wanted to do this. I was like how I ended up here if I try to retrace my steps. But I was a public defender for 20 something years and I worked as an investigator from before that. So my whole life, basically, I never walked into a law firm. I was really just representing people who could not afford lawyers. And it was a lot of. All in D.C.

Dr Sameena Rahman (: 01:32

next

Dr Sameena Rahman (: 01:50

This was all in DC. Yeah.

Jen Lanoff (: 01:53

Yeah, I went to law school at Michigan, but then I grew up in DC. So I came back to DC and it really is probably the best public defender. I don't know, probably I'll get some grief from this, but the best public defender's office in the country. And yeah, I don't know what happened, but somehow I got bit by that bug, so I went back and that's all I did. And then after I had kids, I moved to doing a big class action case about the conditions in the...

juvenile prisons, which was really interesting, and a lot of health care, and a lot of girls getting pregnant and not really going to the emergency room for any of medical care. And so I sort of thinking that I was really interested in trying to figure out support for those, mostly those girls. I mean, there are not a ton of girls in the criminal justice system, but the ones that are.

I mean, it's rough and most of them have young babies and it just becomes really hard. So I sort of really tried to talk to at least my patients, I mean, I'm sorry, my clients about reproductive health and all of that. So I knew I was kind of interested in it. And then...

Dr Sameena Rahman (: 02:59

So you were doing a lot of education at that time, just.

Jen Lanoff (: 03:01

I was doing a lot of education, but mostly with teenage girls. And so I sort of thought that I, well, every day I sort of was trying to figure out my next steps. I was in my mid to early 40s. I had three kids who were relatively self-sufficient. And I thought to myself, do I want to be doing this forever? Do I want to be, or do I want to do something different? Because I sort of felt like it was now or never. And so I kept talking about it, talking about it. And one of my friends was,

was like, why don't you just take one class to see if you even like it? Because I felt like it was such a big life decision. I was like, my god, am I going to quit my job tomorrow and just start taking classes? And I realized I could just sort of bite it off one step at a time. Then, of course, I did a ton of, because I'm an investigator by nature, I did a ton of talking to people. Do I go to med school? Do I become a PA? Do I become an NP? Do I become a midwife? And it was really funny because every single doctor I met with was like, absolutely do not go to medical school.

Dr Sameena Rahman (: 03:31

Yeah.

Dr Sameena Rahman (: 03:37

Yeah. Yeah.

Jen Lanoff (: 03:56

it'll be 15 years before you can do probably the exact same things you want to do as an MP or a PA. But I really did still think I was going become a midwife. I thought, you know what, let's just deliver babies. Let me just do something, the not complicated babies, and I'll just be happy and live a life. so I just started taking classes. I went and took some prereqs at Johns Hopkins while I was still working. I was an English major, so I obviously did not have any of the science background. And I like to tell the story about how my son and I

Dr Sameena Rahman (: 04:23

Alright.

Jen Lanoff (: 04:25

my 17 year old son, cried a lot through organic chemistry together. was, that is not for the weak at the age of 45. And so, yeah, I pushed through and I just kept taking class after class and I loved it. And so finally I made the leap and I applied and I decided I wanted to become a, I decided I couldn't become a PA because I just was not gonna have any opportunity to do clinical hours. But I decided to become, I thought I was gonna be a midwife. So I went to nursing school at Hopkins.

which was a little painful. I live in DC, so I woke up every morning at like 4.30 to drive to Hopkins for almost two years, yeah. I look back on those days and I don't even know how I did it. And then as I was there, I guess that, no, it wasn't really until after that that I sort of decided that I wanted to do something different, but I applied to Georgetown. I got into their midwifery and women's health nurse practitioner program.

Dr Sameena Rahman (: 05:02

Yeah.

Jen Lanoff (: 05:17

And I started along the path that I wanted to be a midwife. And as I was sort of going through it and talking to my friends about, you know, I'm 53, talking to them about what their health needs were. And I just felt like the focus was so much on pregnant people. And I felt like there were so many people who wanted to do that. There were just, I mean, even in my cohort, there were so many women who only wanted to focus on deliveries and births and pre, you know, pre-

Dr Sameena Rahman (: 05:32

Yes. Yes.

Jen Lanoff (: 05:44

whatever, preconception care and all that. I, and when we would get to like the menopause sections, people would be like, ugh, so boring. So I was like, but wait a minute, that's me. And maybe I don't need to go to the, you know, OB anymore, but I have some parts that still need to be taken care of. So during my, during my rotations, while I was an MP, I reached out to Jim Simon, just out of the blue, because I mean, I

Dr Sameena Rahman (: 05:56

No.

Jen Lanoff (: 06:11

Yeah, I had heard of him obviously just because there some big names around here. actually, even before that, I had a talk with Rachel Rubin. She lives in my neighborhood. And we just took a long walk and talked about sex men and a bunch of stuff. And then that's how I ended up with Jim Simon. And because she was just leaving his path. I was still a student. And so I reached out to Jim and he agreed to take me on as to help to work in his clinic to do one of my rotations.

Dr Sameena Rahman (: 06:28

So you were just a student at that time still. Okay.

Jen Lanoff (: 06:40

And so wasn't even really 100 % sure what I wanted to do. But as I worked with him and Lucy Treene, who is so amazing, one of the PAs that works with him, I really sort of fell in love with the sex med and the menopause practice. And then that's when I really got to where I am. now I'm at the point where it's funny, like I started out thinking I was only going to do OB, and now I do not see any pregnant people. That is a whole area I just stay away from because I think it's really hard to be good at.

GYN and OB. And so I'm trying to be really good at GYN. And I just, can't, there's no room in my brain for OB.

Dr Sameena Rahman (: 07:15

very true actually and I think that that's why I think our system gets diluted when you know these big OBGYN and I was part of a big academic OBGYN practice and you know we see 40 patients a day and the majority of them are OB and I always tell my patients or people that ask like you go into a waiting room and most of people they're pregnant then like unless there's one person in that practice that kind of specializes in you know midlife care you're probably going to come back feeling a little less you know

taken care of because your capacity and that is just you don't have the capacity. You don't learn it first of all in medical school or residency. You have to seek out additional training just like we all did and then you know the reality is you're in those waiting rooms and

you know, nobody really, everyone's emphasis is on the baby and the pregnant patient, you know, which you get it, right? Like it's a complicated time of life and like there's a lot at stake. And I always say, I used to be in the game of like saving lives because I was like, you know, taking care of pregnant women and you know, these hemorrhaging patients taking in the OR and now I do none of that. And I just take care of quality of life, which was a big shift, but I think it just as important, you know, I think it's very important to manage someone's quality of life and

And in many ways, you're also being preventative and saving their longevity, right? We do that a lot in our practices.

Jen Lanoff (: 08:33

Yeah. Yeah. And I feel like it's one of the areas where you, I mean, obviously we don't have the kind of training that doctors have, but we are all kind of just teaching ourselves and I'm not doing any surgeries. I'm not doing anything. You know, I'm not going to the hospital and I feel like we can all sort of really, you know, benefit our patients from the education that we teach ourselves. Cause obviously that's not anywhere in our curriculum. Yeah.

Dr Sameena Rahman (: 08:56

Absolutely. Yeah, I agree.

And I think it's so amazing that you did this, but I talked to a lot of different midlife women, whether or not it's like patients of mine or like other clinicians or even just other people that are shifting in midlife. And I do find this big, this happens like a lot, like as you enter your forties and all of a sudden you're like, wait, what should I be doing? Is this where I see the rest of my life going? And so I think that's why we see so many people pivoting. Like they drop one career, try to get in.

Jen Lanoff (: 09:19

Yeah.

Dr Sameena Rahman (: 09:28

And really find their passion point. It sounds like you're pretty passionate about being a public defender for a long time, but.

Jen Lanoff (: 09:33

Yeah, it's so part of my identity that sometimes when I still call other people, I'll say, this is Jennifer Lanham from the Public Defender Service. And I'm like, no, wait, I'm something different now. But yeah, is, no, find it's a huge part of my identity. I don't know. There's some similarities in the kind of work that we do. At least I feel like the women who are over 50 basically, I feel like they're very ignored and not taken care of in a similar way.

Dr Sameena Rahman (: 09:49

Yeah. Yeah. Yeah.

Absolutely. Yeah, excellent. Absolutely.

And you know, I love, you know, we're on our little mini groups that we talk to each other about and Jen always like is posting great articles that she's reading to help all of us kind of move forward, which is nice. But we always talk about like one other aspect, I think with even midlife care. I mean, I guess all of it's probably like not spoken about because like, you know, my passion point is sexual medicine. And so that's what I, but I know that you're very passionate about bone health and you're very passionate about, you know, protecting our bones. And, and we think we've all probably heard this

statistic that one in two women will develop osteoporosis sometime in their lifetime. let's talk a little bit about just like our bones and like people don't even, it's such an ignored aspect of our health and how bone remodeling happens and then that'll help us understand some of the medications that are available.

Jen Lanoff (: 10:53

Yeah, I was trying to look for some good statistics because I do feel like people don't really understand the burden of poor bone health. You know, I think we spend a lot of time worrying about breast cancer and even stroke and cardiovascular disease when it's sort of, it is not sexy. Like bones are, I think that's one of the reasons why people are just not really into it and it can be complicated. Although I don't think it's all that complicated.

Dr Sameena Rahman (: 11:11

me.

Jen Lanoff (: 11:19

It's not exciting. Sometimes I feel like it's like repairing your roof. There's nothing to really show for it. So it's not exciting. I mean, the dingy-dong.

Dr Sameena Rahman (: 11:24

Yeah.

except when you break your bones, then it gets very, you know, like they're silent until they're not right like

Jen Lanoff (: 11:29

Yeah, mean, yeah, the data, I mean, I was just trying to pull up some of the statistics to go through with you because, you know, I just posted one on Instagram last night that just, feel like I wish I could, you know, pin with a safety pin onto everyone's shirt before they leave my office, which is that mortality rates from breaking your bone are higher than from breast cancer. I mean, much higher, 10 times higher. I can't even remember the number, but it's sort of shocking when you look at it, you know, stroke, cardiovascular disease and

Dr Sameena Rahman (: 11:43

the hips.

Dr Sameena Rahman (: 11:55

Yeah.

Jen Lanoff (: 11:58

they're, know, I mean, the statistics, as I said, I was trying to pull them up, you know, osteoporosis affects 200 million women worldwide. And it's pretty incredible. mean, one in three women will have an osteoporotic fracture in their lifetime. And there's so much, this is another sort of hill that I'm going to die on, is I feel like we spend so much time responding instead of prevention. And so I, you know, I think with...

Dr Sameena Rahman (: 12:08

Yeah.

Dr Sameena Rahman (: 12:20

Mm-hmm.

Jen Lanoff (: 12:23

osteoporosis, we should just really be so much more aggressive. And I think the things that we have sort of been told by, just do your vitamin D, your weight bearing activity, I don't think it's enough. And so I just, you know, I think we are really failing our midlife women in trying to tell them, you know, otherwise. And when they get osteopenia, when we do those, we're like, yeah, just keep your vitamin D. When there's such strong evidence that vitamin D and weight bearing activity are not going to do much.

Dr Sameena Rahman (: 12:31

It's not enough.

Dr Sameena Rahman (: 12:39

Yeah.

Dr Sameena Rahman (: 12:48

Mm-hmm. No, absolutely. And I think what's, know, for those of us like who've had parents or, you family members that have had injury, like I had an aunt that had a hip fracture and she died within that year of her hip fracture, right? Because that's the statistic, right? You have three people, three women, you know, one of them will die from complications of a hip fracture surgery, right? Like, it really is.

Jen Lanoff (: 13:04

yeah. I mean...

Jen Lanoff (: 13:11

I know, and it's hard to wrap your head around. But if you break a hip, the loss of function independence is 40 % of patients will be unable to walk independently, and 60 % require assistance a year later. mean, think about that, right? I mean, that's so much of what our moms deal with, our dads too, because it's not just a female disease in terms of mobility and independence, right? They're getting to that point where they want to, you you're a 70-year-old, you don't want to be

dependent on something else. I mean, even if you contrast it with breast cancer, there's like, there's a 99 % for five year survival rate, which is so different. anyway, yeah, it's a huge thing that you have to sort of think ahead about, but I think it's really important.

Dr Sameena Rahman (: 13:41

Thank

Dr Sameena Rahman (: 13:55

Yeah, and

And what do you like, what like if, so say you have a, let's just talk about your screening, what you do. Cause I mean, you know, we know the guidelines and like, you know, who should get DEXs and who shouldn't, but we know that we're also probably missing a huge number of them. So most of us practice outside of those guidelines to be very proactive in terms of at least like knowing, you know, especially patients who have concerns about their bone health or, you know, someone tells me that they went through their twenties and never had a period because they were anorexic. You know, some of these patients who,

Jen Lanoff (: 14:15

Yeah.

Jen Lanoff (: 14:22

Yeah, well, there are a couple of things that I always do, right? You always want to ask people about medication history because history of steroids for some anti-inflammatory conditions that can always cause later life problems with bone health. If you've been on the depot shot for a long time, that is another thing. And family history, it's very linked. So if your mom had a hip fracture, your grandmother had hip fractures, I always want to know this about my patients. And if you have a history of eating disorder, I mean, you are

Dr Sameena Rahman (: 14:27

went through long periods of time without men's scenes because there were anorexia.

Jen Lanoff (: 14:52

definitely more prone to low low bow density. The other thing that I am really interested in, and this is a conversation for another day, is our use of birth control pills with adolescents. Because you're in your prime bone growth era when you are in your early 20s, basically, up to 30. And even when you're in your teens. And so, and I think a lot of times we are putting our patients very quickly. mean, aside from all the sexual health ramifications, right, with the velvodynia.

Dr Sameena Rahman (: 15:20

Right.

Jen Lanoff (: 15:21

We're lowering your estrogen when we put you on contraceptives. And so it's interesting to me when everyone comes in and says, I want to be in the lowest dose of hormones, I'm like, no, you don't. Because the bone health stuff is really important, and you may not be worried about it now, but let's get you on as much estrogen as we can. Because that's such an important part of, know, crypto.

making sure that you don't have any osteoporosis later. So I ask all those questions and I just do the bone densities much earlier because I think, you know, the guidelines say to ask, do it at 65, which conventionally speaking is a little bit too late to start hormone therapy. I mean, you know, we can have those conversations aside, but, so I try to do it within a year of menopause. And I can tell you, I have to say 50 or more percent at least have bone density and many of them have osteoporosis. And, you know,

They have a long life to live, I hope, and so I want to really be aggressive about preventing fractures.

Dr Sameena Rahman (: 16:18

Right, absolutely. And we know that most people are screened using a DEXA scan, right? So can we talk a little bit about interpreting DEXAs or that kind of thing when you look at them?

Jen Lanoff (: 16:28

Yeah, and know, DEXA's have become very inexpensive. I just called our radiology, one of the radiologists that we use a lot, and I think it's $40. So I think people have been very worried about whether it's covered or not, and it really is covered. Yeah, exactly, right. So basically, the DEXA scan gives you a bone density score that I think the most easy way to understand it is sort of the T score, which is in comparison to a

Dr Sameena Rahman (: 16:35

Yeah.

Yeah, it's kind of like a Cal State score you can get for like $15 million in Chicago.

Jen Lanoff (: 16:57

person, like a young healthy reference population basically. The Z-scores aren't as quite as helpful. They sometimes help with perimenopausal. You know, unless people have that risk factor. Yeah, I don't. So usually we use the T-scores and you know, a T-score of plus one is that you are one standard deviation above the young normal mean, but that of course does not mean that you can't develop it later. But when you go lower negative one to negative 2.5, that's low bone density.

Dr Sameena Rahman (: 17:06

Congratulations, Yeah.

Jen Lanoff (: 17:25

We used to call it osteoporosis, but now we're supposed to call it low bone density. And then osteoporosis is anything greater than negative 2.5. And what I do think also is interesting is that people will say after they've been on the bone health meds, I don't have osteoporosis anymore. And it's just really not true. It's osteoporosis, but it's controlled. It's kind of like cholesterol or diabetes. And so it's a lifelong issue that you're going to have to manage your whole life if you want to prevent fracture.

Dr Sameena Rahman (: 17:41

Yeah.

Yeah.

Dr Sameena Rahman (: 17:51

And so you see somebody that has an issue like, let's talk about what treatments are available. Obviously we talk about lifestyle modifications so you can start with those and then we can go from there.

Jen Lanoff (: 18:01

Yeah. Yeah. mean, that's what I'm what I've really been trying to dig deep on is whether or not the sort of mantra of vitamin D, calcium and and, you know, weight bearing exercise is enough because I think that's what we tell people so often. And there's just really no data that having anything more than healthy numbers of vitamin D and calcium is going to do much like doing extra doses. If you're low on vitamin D, yes, I think the

Dr Sameena Rahman (: 18:18

Mm-hmm.

Jen Lanoff (: 18:31

data is really clear. You need to make sure you're supplementing or doing something else to get your vitamin D. And the same is true with calcium, but you definitely don't want to overdo it with either one of those. Weight bearing activity, of course, it's good for your heart. It's good for so many different things. But in terms of osteoporosis treatment, that's certainly not going to be enough. But yes, making sure that you get those things through diet, especially calcium, rather than just taking a pill every day, I think all of those are really important. And the rest of the bone, I mean, the rest of the

the sort of supplements and things like that. I just don't know how persuasive it is that it's really gonna make a difference. But the reason I like to check early is because I think we shouldn't use estrogen. mean, estrogen is FDA approved for prevention of osteoporosis. So if someone comes into my office and they, you know, they have been a year out of their period, they're not having any symptoms, no hot flashes, nothing else, I just say to them, please, like, this is really important and it will be important as you get older.

let's do a bone density because even though you're not having hot flashes, you're not having the typical symptoms, let's just make sure your bone density is okay because we have a little bit of a window where we can really make a difference, especially because, and I was looking for this statistic, the decrease in bone density makes a huge dive during the menopausal transition. So it's such an important time for us to try to make a difference. I needed to find this because it was a really interesting.

It was a really interesting thing. think you lose over 5 to 10 percent of yourself just during that time when you're going from, yeah, when you're going from having periods to not having periods. And it's pretty incredible to think that we have an opportunity to make such a difference in terms of later life. So, yeah, so that's my, you know, that's the first thing I try to do. I don't know. I do think there's some, I mean, obviously we can talk about the meds and people get really nervous about all the

Dr Sameena Rahman (: 19:57

Yeah, musician.

Dr Sameena Rahman (: 20:04

Yeah.

Right. Right. Absolutely.

Jen Lanoff (: 20:22

this phosphonates and osteoanacrosis of the jaw. estrogen, mean, I think it's really is incredible. I if you look at the data, estrogen really is placed such an important role in bone growth and it really can prevent the long-term disease.

Dr Sameena Rahman (: 20:24

Yeah.

Dr Sameena Rahman (: 20:28

That's my go-to as well, yeah.

Dr Sameena Rahman (: 20:39

Great.

And I think, you know, at the end of the day, like, you know, people miss the mark that, you know, I mean, I don't think as much as they used to, but like, oh, estrogen is for the hot flashes or this or that. But we know like it is FDA approved for the prevention of, you know, osteoporosis and the treatment. And so I think that that is such an important quality of life issue when we talk about, you know, there's a lot of talk about like, you know, nursing home prevention programs that we're all trying to build for ourselves. And that's one of the biggest ones is like your mobility, your ability to keep

Jen Lanoff (: 20:48

Right.

Dr Sameena Rahman (: 21:09

going, your ability to keep walking and doing things on your own. then, of course, know, brain and urinary function and all that stuff is so important as well. So it's one of the one of the aspects that keep you mobile. And once you lose your mobility, you become dependent on someone else. It's very difficult.

Jen Lanoff (: 21:14

See.

Yeah.

Jen Lanoff (: 21:25

Yeah, here I found that statistic. 10 to 12 % of you lose of your bone mineral density like within a two to three year period, which is pretty incredible. Yeah.

Dr Sameena Rahman (: 21:31

Yeah, that's a lot. Yeah. And so I think you and I are both on the same page where we definitely try to do that for our patients or whoever else is asking that we try to get them on estrogen, especially when they look like they have some weakening in their bones already, even if they have no other symptoms.

Jen Lanoff (: 21:48

Yeah, notes. Yep.

Dr Sameena Rahman (: 21:51

And so, you know, it's just a matter of like trying to dose them so they don't have side effects. And if they're not treating, you know, to treat a symptom, we have to try to get them, you know, at a good at a good dose. That's going to help their bones as well.

Jen Lanoff (: 22:03

Yeah, and I think if people are afraid, I sometimes try to push them to do Riloxafine. It's not a great osteoporosis treatment drug, except for the vertebral, to prevent vertebral fractures. But that seems to be one that I can sometimes convince people to do, because it's a selective estrogen receptor modulator. So it's a sister of the tamoxifen family. And so it also can help prevent breast cancer. So sometimes I can pull people in with that. And there are very few side effects to that one. I think it's a good prevention med.

Dr Sameena Rahman (: 22:06

Yeah.

Dr Sameena Rahman (: 22:13

Right. Yeah.

Dr Sameena Rahman (: 22:32

Yes, I think that one gets left behind too in terms of people talking about. And so say you have someone, you you feel like, okay, I mean, like these days, we can really look at people really in a nuanced fashion to see if they can really do anything. But you know, you might have the ones that really shouldn't be on this because of active breast cancer or, you know, something else going on, but you still want to protect their bones. So what let's talk about some of the other medications that are

Jen Lanoff (: 22:35

Yeah, I agree.

Dr Sameena Rahman (: 23:02

available to consider and why people are afraid of them.

Jen Lanoff (: 23:07

Well, there are two families basically, as you probably know, as you definitely know. There are the anti-resorptives and the anti-the anabolics. So the anabolics are a little bit of a new, I mean, not, you know, they're new-ish. They're a group of meds that are for high risk of fracture or patients who have had lots of fractures and they build bone. And they are really incredible. It's Forteo and Timlos and Avenity. Those are the three that are really the great meds for bone building and especially someone who's really high risk of fracture.

Then there's a family of the ones we were just sort of talking about, Riloxafine, which are the anti-resorptives. And when you're doing bone remodeling, I don't really want to go too much into this, but when you're younger, you have a really good balance between bone breakdown and bone building. And so as you get older, the thing that we can do with the bisphosinates is stop the bone breakdown at such a high level. those are the things, you know, those are things like allendronate, Fosamax.

There's an IV med called Reclass that I really love because you only have to do it once every couple of years. But I think people feel very nervous about the... And then there's Prolia, which I guess is a little bit in the same family. That's a shot. It's a little bit different, but it's a shot that you have to take every six months. The difference between those is that basically you want... You will stop the bisphosphonate after five years. The Prolia, because it has a very long half-life, so it works for a long time.

Dr Sameena Rahman (: 24:03

Right. Yes.

Jen Lanoff (: 24:28

And then the prolia, really have to continue even during COVID when we saw people stopping doing the prolia, even missing a month, you could see the result in their bones. So that's a little bit of a pain, but it does make it a little bit easier. I think the thing people hate about the bisphosphonates is you have to take them on an empty stomach and you have to sit up for 30 minutes. you either do it every day, once a week or once a month, and people just don't love that. So they get a little bit of GERD or they don't like the side effects.

Dr Sameena Rahman (: 24:35

Yeah.

Jen Lanoff (: 24:54

And then people hear from their dentists that they can't be on a bisphosphonate when they do any dental work, which even the American, I think it's like the American Association of Dentists, I don't even know what the group is, has come out to say that is not true. You can have absolutely have them when you're having your routine cleanings. And even the risk of osteoendorchosis of the jaw with surgery is still far less than a hip fracture. So I feel like if your dentist tells you,

Dr Sameena Rahman (: 25:19

Mm-hmm.

Jen Lanoff (: 25:23

that you should get off your meds, you need to really make sure that they know the data. Because it's one of those things where it's like people tell people to get off estrogen before surgery. Like do the work, it's safe. They are just relying on old school data and it's really easy to just say no.

Dr Sameena Rahman (: 25:30

Yeah, right. Yeah. Yeah, yeah, exactly.

Jen Lanoff (: 25:39

But yeah, the chances of that are almost like being struck by lightning and it's more prevalent in people who have had cancer. So, you who are sort of immunocompromised, lathin, and of course, it's a jaw. And then there's the atypical femoral fracture, you know, these things are very rare, the side effects. yeah, those are the, but, so there's really interesting data and I'm kind of obsessed with this about how these, so we usually, wait for the anabolics until we're not making any progress with the anti-resorptives.

there's all this incredible data now. And I mean, it's not even new, but I think it's sort of just being really talked about, about how the difference between starting with an anti-resorptive and then moving to an anabolic, as opposed to starting with an anabolic and then moving to an anti-resorptive, the difference in terms of bone gain and bone health over a certain number of years is pretty stark. You start with an anabolic before you've ever had an anti-resorptive and then go to either Prolia or Lendronate. I the bone building is incredible, probably double.

Dr Sameena Rahman (: 26:36

Yeah.

Jen Lanoff (: 26:36

if you go the other direction, it's just not quite as good. And so that's where I struggle a little bit with my perimenopausal, sort of like my perimenopausal patients or my newly menopausal patients, because some of them have osteoporosis and I really, they have such a long life. I would love them to start with these anabolics. And the insurance companies just won't do it until you fail. And it's just so depressing because the data is so clear about what, and they're expensive. You don't want to pay for out of pocket.

Dr Sameena Rahman (: 26:52

Mm-hmm.

Dr Sameena Rahman (: 27:00

So good. Yeah. Yeah.

Jen Lanoff (: 27:04

But the data is so clear about the gains that you can make. So anyway, so I struggle a lot. Sometimes I'd say, I say, let's just do some estrogen. Let's make sure. And sometimes I say like, okay, let's fight with the insurance company. Cause one thing being about being a lawyer is that I'm really good at fighting with insurance companies. so I try for a lot of these patients and sometimes it gets approved and sometimes it doesn't. And I have a little letter talking about all the data. But if I could have, I mean, I once asked Mike McClung, who's probably one of the nation's experts in world's experts in bone health.

If he had his, you know, if his daughter had osteoporosis at 53, 100%, he would want her to be on an anabolic first and then an anti-resorptive just because of the efficacy of it. It's just hard to do.

Dr Sameena Rahman (: 27:40

Yeah. Yeah. Hard to do, right? Yeah. No, I think that's great. And I think it's great for people to hear that, especially some of the information you hear around some of these medications is just not as prevalent as people would want to believe or is based on old data. I use it a lot, Yeah.

Jen Lanoff (: 27:58

Yeah. The other one is Duaviv. I mean, I don't know how much you're using that for your patients. I like it just because in the perimenopause transition, you're bleeding a lot. And so it's great for that. But it has basidoxaphene, which is similar to reloxaphene. I'm not sure in comparison to reloxaphene, whether it's better or worse. But it also has the estrogen. That's the problem with reloxaphene, is that it can cause hot flashes. And so for people who are still having hot flashes,

Dr Sameena Rahman (: 28:20

How flush is my...

Jen Lanoff (: 28:24

Duavis is a great option because it has the basadoxafine, which is the sermon, then also the estrogen, which we know is good for bone health. So that's a great option too. Trying to think if I'm forgetting anything, but the reloxafine, the Duavis and estrogens and the bisphosphonates.

Dr Sameena Rahman (: 28:38

Yeah, Do I these one of my favorite, especially like, you know, we talked about, I I've talked about this on the podcast, where like the patients have PMDD or those progesterone sensitivities. We are very anxious about breast cancer, you know, the way it knows it's anti, because it's, it has the conjugated equine estrogen.

Jen Lanoff (: 28:47

Yeah.

Dr Sameena Rahman (: 28:57

Some people have issues with that, but I think that's like one of our oldest estrogens around. Like most of us know, like there's no better data than, you know, conjugate equine estrogen. But I know that some people have issues with the pregnant mirrors.

Jen Lanoff (: 29:11

Yeah, no, I know it's frustrating. And also I think I try to, I don't feel like a lot of people know, like a lot of clinicians know about it. So I try to push that one. just don't, you I don't know why. I don't know why oncologists and breast radiologists and surgeons aren't really learning about that one as much. But I try to put my high risk breast cancer patients on that as well instead of Roxy.

Dr Sameena Rahman (: 29:19

Yeah.

Dr Sameena Rahman (: 29:28

as much.

Yeah, me too. Me too. Yeah. And the other one is like the patients that kind of bleed a lot like randomly because they have because it's so anti estrogen at your at your endometrium that if you have those little breakthrough bleeding six months post starting and done the biopsies and you do that, you know, and they're still doing it and it's just frustrating patients because they're wearing pads all the time. Like this is the go to.

Jen Lanoff (: 29:37

Yeah.

Jen Lanoff (: 29:43

Yeah.

Yeah.

Jen Lanoff (: 29:51

Yeah.

Jen Lanoff (: 29:55

my gosh, the bane of my existence. Yeah. And what I do like about it is we learn more, you know, we learn more and more about progesterone, well, progestogens. micronized progesterone is good for not increasing proliferation in the breast, but you know, these, the synthetic progesterones are better for preventing the bleeding, except they are more associated with the proliferation in the breast and increasing breast density. so

Dr Sameena Rahman (: 30:13

Yes.

Jen Lanoff (: 30:19

when patients, know, microdyspidestrogen is not a great opposer. That's not the right word, but it doesn't stop the bleeding as much as we would like. you know, 50 % of the time I feel like I have to move to something different and I would so much rather move to basadoxypne than to a synthetic progesterone.

Dr Sameena Rahman (: 30:22

Yeah, as much.

Dr Sameena Rahman (: 30:32

Yeah, yeah. And then the people, then there's the issue is the oral versus the transdermal. You have that discussion going on like, I really wanted to be on transdermal because XYZ or all the things. So.

Jen Lanoff (: 30:43

Yeah. Yeah. No, I know. It's a toss up.

Dr Sameena Rahman (: 30:46

But that's why it's so nuanced, right? That's why menopause care, midlife care is so nuanced because it's not a one size fits all. It really is personalized medicine when it comes to this. And this is why you have to seek a clinician that can really spend time with you. Tell me about your practice a little bit that you're involved, that you're in right now.

Jen Lanoff (: 31:09

Well, was funny that you were going to say that because I do feel I do tell my patients that in perimenopause, I mean, even five years ago, I think we would just put our patients if you were still having your period, we put them on if you're having hot flashes and put you on birth control, right? If you're 55 and you're menopausal, then we'll put you on hormone therapy. And I think then it was so much easier. It's true. If someone hasn't had their period in five years, they're probably not going to have very much bleeding. And so it's very easy. But with perimenopausal patients who don't need it.

Dr Sameena Rahman (: 31:20

Yeah.

Dr Sameena Rahman (: 31:27

Yeah. Yeah.

Dr Sameena Rahman (: 31:32

No.

Jen Lanoff (: 31:36

whose husbands or partners have had vasectomies, who have never been able to get pregnant and had to use IVF, they just don't need birth control. And so would so much... Right. Right. And so I would so much rather put them on hormone therapy, but it's a brave new world. I don't know. I mean, there's just obviously not a ton of data. My practice is I have these sort of five areas that I love.

Dr Sameena Rahman (: 31:43

Yeah, they never did well with this. So they're like, I'm never going to go on that.

Yeah. Yeah.

Jen Lanoff (: 32:01

It's an OB-GYN practice here in DC. It's probably one of the bigger ones. obviously people see OB and GYN, but my practice sort of when I agreed to go in with GYN only. And I love my sort of five areas. And I feel like I've learned so much at NAMS and ISWISH. I guess it's the menopause society now, but I love the Euroguine because I think probably 95 % of my patients come in and say that they wear a pad because they're peeing on themselves. And I really try to focus on that. So that's one of my big things.

Dr Sameena Rahman (: 32:28

Yeah. Yeah.

Jen Lanoff (: 32:31

I just, it drives me crazy. And then, you know, bone health, because I think that's a huge thing that not a lot of people know anything about. And, you know, hot flashes, menopause stuff. And I mean, I love the iswish world, the pain with sex. That's sort of the only population where I like to see the younger patients too, because so many of them think that having pain with sex is normal. So I'm very, I always ask about that with any of my annual, you know, and I do just regular GYN too. I see a bunch of annuals. And then what's my other one?

Dr Sameena Rahman (: 32:38

Mm-hmm.

Dr Sameena Rahman (: 32:43

Yes.

Dr Sameena Rahman (: 32:50

Yes. Yes.

Dr Sameena Rahman (: 32:55

Sure. Sure.

Jen Lanoff (: 33:01

breast cancer prevention. I'm super aggressive about that because I think we're just, again, like it's another area where we're just doing a disservice to our patients by, know, everyone with extremely dense breasts should be getting MRIs. We should be calculating our tyroclosis on everyone. I mean, there's a lot of work to be done there. And so that's why feel like people should, you know, even your primary care might tell you to go, so you don't need to go to the GY anymore. I think those five areas are not things that primary care clinicians are really focusing on.

Dr Sameena Rahman (: 33:14

Yes.

Dr Sameena Rahman (: 33:27

Yeah. Yeah.

Jen Lanoff (: 33:28

But so yeah, so that's the majority of my practice, the sexmed and the sort of over 45 crowd.

Dr Sameena Rahman (: 33:33

Yeah, I oftentimes have freshmen who like maybe are survivors of breast cancer. They've had mastectomies. They've had their uterus and ovaries removed. And so they're like, oh, know, my primary said, I don't even have to see a GYN. And they come in with this lichen sclerosis like, no one's ever looked at their vulva. I'm like, girl, you still got a vulva. You still got sexual desires. Like there's things that we got to do for you. You know, that, you know, it's not in sometimes the primary care worlds like, you know.

Jen Lanoff (: 33:47

Right. Right. No, I know.

Jen Lanoff (: 33:52

I know, I know.

Dr Sameena Rahman (: 34:01

Radar or whatever you would say, you know, I mean it's not in a lot of gynecologists radar to look at them all

Jen Lanoff (: 34:02

Yeah, No, right. Most people just go right in. Yeah, and you and I talk about this a lot. mean, my practice takes insurance. being a public defender, is so important to me. I really want to make, I'm not saying I'm the best clinician in the country, but I do want to make care affordable. But boy, it is so hard.

Dr Sameena Rahman (: 34:14

Thanks.

Dr Sameena Rahman (: 34:20

Thank

Dr Sameena Rahman (: 34:26

I mean I've been doing it for 10 years and it's been a challenge and I don't know that much how much I can continue some level

Jen Lanoff (: 34:33

Yeah, no, mean, I love, sorry, I love to be able to say that I can take insurance because it just is important to me. And I know we could all go and make a lot of money and it's true. And we could spend a lot more time with our patients. But then do we get all the patients who just can't afford it and then just don't, you I don't know. That's a complicated.

Dr Sameena Rahman (: 34:50

Right, right. It's a balance. mean, you know, the reality is it's like hard to make your over as someone that owns your own practice. And the reasons why I've had to drop some insurances is because I can't get paid for some of these. Like, in what world is it okay for you to provide a service, pay someone 6 % to get that money that you've already done the service, you're trying to get someone to pay you for a service you've already done. And sometimes they say, no, I'm not going to pay you for that.

Jen Lanoff (: 35:19

I yeah, I spent about...

Dr Sameena Rahman (: 35:19

I mean, unless you're funded by the government, which I know a lot of places are, or you're funded by private equity, if you're literally using your savings and loans to keep your house open here, it's almost impossible, to be honest with you. Sometimes it's like, if I wasn't sharing my office with my husband, I would have been down under a long time ago, because I do spend a long time with my patients. And I rely on him to help me with the overhead. But on some level, it's like,

Jen Lanoff (: 35:34

No, I agree.

Jen Lanoff (: 35:44

Yeah, but just thinking about how much time we spend. I I spent over two hours on the phone last week with one insurance company where my patient's dad and cousin are BRCA1 positive. And we did her genetic testing. She is BRCA1 positive. And now the insurance company is refusing to pay for the genetic testing. I'm like, in what world is this OK?

Dr Sameena Rahman (: 36:03

Yeah, I mean, it's just, you and you wonder why there's so much frustration with health insurance companies. It's not really, not the majority of clinicians are not the ones that are like pocketing all this, you know, healthcare money, unfortunately, you know, like whatever. It should be, you know, distributed in such a way. I just know that like we've taken out a lot of loans to keep my practice open and it's not sustainable over time, you know? So.

Jen Lanoff (: 36:28

Yeah. No, it's, but you know, I get it. It's really hard to feel like you're going to move away from that. I wish there was something in between, but unfortunately there's not. I mean, I think about MPs, we get paid what, two thirds as much as MDs do too. So that's even less money there. Yeah, that's hard. I don't know. You know, if we can figure it out, we'll win the Nobel Peace Prize.

Dr Sameena Rahman (: 36:36

Yeah.

Jen Lanoff (: 36:51

Yeah.

Yeah, let us know, please, please, please. the patient's complaining that I'm rushing them and it's so hard. It's their insurance companies that are rushing them. try to tell them, but they don't really. They don't buy.

Dr Sameena Rahman (: 36:59

It is. It's very hard.

Yeah.

Because you what they do is they'll call the insurance companies and they'll say, you know, obviously they rarely complain to me, but they complain to my staff like, well, Dr. Amman billed it such a way that I'm not getting covered. And I'm like, well, it wasn't a preventative visit. came in for a psychotherapy. You know, it's like this whole thing of explaining like your insurance only covers this and your $5,000 deductible is gonna go, is gonna remain until all that, know, until you pay out and get to that level. And then you're gonna get 100 % coverage, right?

Jen Lanoff (: 37:18

yeah.

Jen Lanoff (: 37:33

Yeah. my gosh. I know. We're not trying to build them. We're trying to build their insurance companies. So the patients are getting so mad. it's, I'm not trying to take advantage.

Dr Sameena Rahman (: 37:34

It is crazy.

Dr Sameena Rahman (: 37:39

Yeah, exactly. No, but the insurance companies are denying it so that patients have to pay for it. And then sometimes they don't and then you know.

Jen Lanoff (: 37:44

Yeah. Yeah. Let's do it. Let's figure it out. Let's win something, some award. I don't know. I just want an award for figuring it out. But I feel like there's got to be something. I mean, I think it's just all not sustainable.

Dr Sameena Rahman (: 37:50

Something. What's what's what in the Lord?

Dr Sameena Rahman (: 38:00

It's not, it's really not on any level to be honest with you. All right, well let's talk about final thing. Like how would you tell your, always ask all my guests, like how would you counsel a patient on trying to find someone that will listen to you? Like how do you tell patients to find someone? Or people that ask you, right? Like you meet someone from, I don't know, California, oh I can't see you, I'm sorry, like I'm not licensed in state. Yeah.

Jen Lanoff (: 38:16

Well, that's a good question.

Jen Lanoff (: 38:24

Yeah, who can you find? I mean, obviously going to ISWISH website, going to the Menopause Society website, looking for people who are certified or even members. don't, you know, that's, at least they are showing some kind of interest in it.

Dr Sameena Rahman (: 38:36

Yeah, although we know like I have been I have people push back well that person tried to give me my bio. Yeah.

Jen Lanoff (: 38:41

Yeah. Yeah. But at least it's a step. think that's an important part. And then the bone health and osteoporosis foundation has a good list too. So, you know, I think people, you know, people think they have to to the rheumatologist and their endocrinologists, but I do really think this is a part of women's health. So I think all of us need to be good at this because I don't think rheumatologist, I don't know. think sometimes they're

Dr Sameena Rahman (: 38:50

Yeah.

Dr Sameena Rahman (: 39:00

Mm-hmm.

Jen Lanoff (: 39:03

very conservative as well, and I think it's important. I don't know. I wish I had a good place. We need a clearinghouse to tell patients who they should be seeing. But I think it's the people who are sort of active, the people who are writing the journal articles, the people who are involved in the organizations that are going to be the people who are really at the front edge of all the research.

Dr Sameena Rahman (: 39:22

Right. I agree. Yeah. All right. Well, thanks, Jen Lanoff. This has been great. You're such a wealth of information and just a good human being. feel like it's hard to find people like you in this world.

Jen Lanoff (: 39:26

Yeah.

Jen Lanoff (: 39:32

Hmm. I feel the exact same way. Yeah, well, I always say I'm a lawyer, so I need my evidence. I'm not, that's why I read all my articles. I'm not giving something to someone that's not evidence-based.

Dr Sameena Rahman (: 39:42

Right, exactly. Well, thanks for being on and I hope you guys that are listening learned a little bit more about your bones today. But I'm gonna put in the show notes how you can get in touch with Jen if you need her. She also does talks, evidence-based talks, you know, and other things. And she's very passionate about it, just like, you know, the rest of us that are out here trying to make a difference in the world.

Jen Lanoff (: 40:06

Thank you, Selena. Enjoy your week.

Dr Sameena Rahman (: 40:09

Thank you guys for joining me today. The Saginaw Girl presents sex, drugs, and hormones. Remember, I'm here to educate so you can advocate for yourself. Please join me next week for another episode. Yay, very good. That was good. I'm gonna stop.

Jen Lanoff (: 40:22

Thank you. Yeah, get it. Yeah. Well, we'll see.