Forging a New Approach to Menopause Care - Dr. Anna Barbieri, Founding Physician of Elektra Health and Assistant Clinical Professor, Mount Sinai Health System

Dr. Debra Enegess: Hi, I'm Dr. Deborah Enegess. I'm a practicing gynecologist and clinical content writer for Osmosis. I'm happy to welcome Dr. Anna Barbieri to Raise the Line so we can explore an issue that deserves more attention in medicine: menopause treatment and management.

Dr. Barbieri is a gynecologist, integrative medicine physician, and a specialist in menopause certified by the North American Menopause Society. She's also an assistant clinical professor in the Department of Obstetrics, Gynecology and Reproductive Science at Mount Sinai Health System. Outside of her clinical and academic work, Dr. Barbieri is the founding physician of Elektra Health, a next gen women's health platform on a mission to smash the menopause taboo. 

I'm looking forward to learning about how Dr. Barbieri helps her patients manage menopause and about emerging treatments in the field among other topics. Thank you so much for being with us today.

Dr. Anna Barbieri: Thank you for inviting me.

Dr. Enegess: I'd like to start with learning a little bit more about you. What first got you interested in medicine and OB-GYN?

Dr. Barbieri: Sure, so I have a bit of a convoluted story. Medicine was actually not my first career choice. I imagined myself as a passionate archeologist. Prior to starting medical school, I actually ended up going on a dig with a university group and I decided to kind of explore that field live to really see if it matched my perception of it, which it did not, although it was a fantastic experience and really one of the best experiences I've ever had. So, for anyone out there, if you think a certain career is for you, I would definitely encourage you to try it out however you can. Then I ended up going to medical school because that was kind of my, almost like the backup choice. 

I thought that that would be interesting. I always liked the intersection of science and human behavior and psychology, and I ended up pursuing it and initially thought I would end up as a medical oncologist, but after being on my OB-GYN rotation -- which was my last rotation of the third year -- really within forty-eight hours, I knew that that was really the field for me. I feel very fortunate that way. It was really a great fit and I am a major and a passionate advocate for this field. I've had my evolution within it over the years, but I would choose this field over and over again.

Dr. Enegess: Oh, that's amazing. I love that story. Moving forward with that, what got you interested in menopause?

Dr. Barbieri: Sure. So, you know, I was a very, very busy OB-GYN physician with teaching responsibilities and a lot of practice responsibilities and I really loved that up to a certain point. Then I started to feel the need to maybe change things up a little bit. I was also fortunate, and this goes for a lot of us in this field, to have the privilege of knowing our patients for quite some time. So, you know, a lot of my patients kind of got older right with me, and at somewhere in my early forties or so, many of them kind of started coming in with what I now understand to be really perimenopause-related or menopause-related complaints. I was not really prepared to handle that as a busy generalist and right at the same time -- looking back now -- I started to experience my own perimenopause. To me now, almost a decade later, it's a shocking story that I, as a practicing OB-GYN, did not recognize those symptoms in myself. 

My own hormonal change at that time started with sort of middle of the night -- actually 3:11 a.m. was my time -- almost every night awakening with kind of unreasonable anxiety over things I had done many, many, many times before, like being on call for the next twenty-four or thirty-six hours. This was a major change from my normally pretty laid-back personality. I also started to notice certain memory changes until one day -- back in the day where we still called in medications -- I was on the phone to a pharmacy to call in an antibiotic for a urinary tract infection for one of my patients and I literally forgot the number of my medical license when calling in this prescription, which was very unusual. I mean, we remember the number of our license like we do our birth dates. So, I thought something was wrong and I even pursued a neurologic evaluation, a brain MRI for this, because I thought something was so wrong. That evaluation was just fine. 

It was actually my own digging into what was happening and looking at this pattern and eventually even looking at my hormone levels that led me to the realization that it was just this hormonal change. So, my own experience and the experience of my patients really kind of coincided in time. I had always been interested in this more complex nature of hormonal medicine, of endocrinology, within OB-GYN, and of the crossover of OB-GYN into psychology and psychiatry as well. At the same time, I've always been kind of a little bit of an out-of-the-box person. So, I had an interest in going beyond sort of the checkbox and cookbook medicine. I formalized my interest in that by doing a fellowship in integrative medicine and everything kind of coalesced into this interest in midlife women's health. These days I focus on gynecology and women's health for midlife and beyond, and especially paying attention to the timeframe of perimenopause and menopause. 

Once those kind of floodgates opened, there's a lot of different opportunities and areas that came my way, including my work in digital health and starting a practice that focuses on this.

Dr. Enegess: So, how did you get into Elektra Health? How did that start for you?

Dr. Barbieri: Yeah, so I was contacted by someone who knew me quite well, who basically said, “Hey, are you open to some new adventures in this field? You're so passionate about this topic and this is how we can bring more awareness of it and better care to women seeking it really at a large scale.” You know, menopause can be pretty complex and challenging. While it's a universal experience, it's also highly individual, which means it takes time to understand someone and work with them and come up with the right solution. There's a lot of education and explaining that needs to take place and that is one of the challenges we have with delivering this type of care within the current medical system. 

So, I really jumped on that opportunity and decided to get involved in helping to bring education, awareness and eventually care to women at scale through digital technology, and it's been wonderful. I'm a founding physician of Elektra Health. There are two co-founders who are really sort of visionary and energetic and it's been a really wonderful addition to my clinical career.

Dr. Enegess: Yeah, it's a fantastic platform.

Dr. Barbieri: Oh, thank you.

Dr. Enegess: Yeah, I really like it. If you don't mind going back a little bit, I think it really struck me how you described that you weren't sure about the symptoms you were experiencing in your forties. For our audience -- there are a lot of learners here today -- maybe you could define menopause a little bit or talk about the process of menopause and perimenopause.

Dr. Barbieri: Yeah, for sure. I think to this day, there's a lot of misconceptions and misunderstanding about the terminology associated with this transition. So, to boil it down to some simple sort of linguistic terms, menopause is the time when a woman stops

having her menstrual cycle for at least twelve months. It's really twelve months of no periods that defines menopause. Everything after that means someone is post-menopausal or in menopause, and of course there are exceptions to kind of the natural time of menopause

and that would cover instances of surgical menopause when we remove the ovaries of someone who is pre-menopausal, or women who experience medically induced menopause, for example. There are certain hormonal treatments whose goal is doing that. 

The time running up to that -- that fits between regular and predictable hormonal changes associated with the normal, predictable hormonal function and the time of menopause -- is perimenopause. That can be as short as several months to a year and can be as long as a decade. And this is really one of those myths, right? “Oh, it won't happen to me for another ten years.” I mean, here I was at like forty-two experiencing it, thinking that that time is really way off still because we do know that the average age of that last menstrual period is around fifty-one, fifty-two. 

So, perimenopause is a time of major hormonal fluctuation which can be quite unpredictable.  It kind of comes in two phases, and in that way it's a little bit like puberty. I tell my patients this all the time. We don't go to sleep when we're eleven years old looking a certain way and wake up the next day with everything that happens and all of a sudden we're fifteen. Perimenopause is similar to that. The initial phase of it is typically characterized by wildly fluctuating estrogen levels, which often can be supraphysiologic, so actually even higher than what we normally experience in the typical hormonal fluctuations and rapidly declining progesterone production. 

What does that look like? You know, on average that can manifest in menstrual cycles that are shorter, that are somewhat more irregular. That irregularity will be about three to seven days of variability between cycles. Often there can be spotting right before cycles. Periods can get heavier. Lots of women will complain of worse PMS, both emotional and physical. Insomnia can pop up, weight gain can often start at that point and we do see a rise in perimenopausal related anxiety and sometimes depression. 

And then we move into kind of late perimenopause and that's really when estrogen starts to decline faster and stay down longer and that's when we see the more typical symptoms associated with perimenopause and menopause that we read about...symptoms of low estrogen, hot flashes, night sweats, drier skin, dry eyes, vaginal dryness, things like that.

Dr. Enegess: Maybe we could address some of the treatments, some of the standard treatments for menopause and perimenopause, as well as some of the things that you're building on with more holistic care.

Dr. Barbieri: Sure, I could talk about it, by the way, for I think a week, and I understand that your background is in OBGYN.

Dr. Enegess: Yes, I'm actually practicing gynecology as well. I've been focused on gynecology for more than a decade. And just as you said, I've grown with my patients, grown older with them. Now that I'm fifty-two, menopause is at the forefront of my daily care for patients.

Dr. Barbieri: So, I think we've come of age in a very similar timeframe. I don't know if we'll have time to talk about this...I don't know if you remember when the Women's Health Initiative came out (in 2002 with the results of clinical trials on hormone replacement therapy) , but I remember it like people remember major, major historical events. That was such a watershed moment for us. 

Dr. Enegess: Me, too. Yeah. I finished residency in 2002. So, as I started clinical practice, all of my patients were dropping their hormone therapy.

Dr. Barbieri: Yeah. I finished in ‘03. So, I was right on the heels of that. And I remember being in the doctor's lounge on Labor and Delivery that day when the news came out and it was, I mean, the change in clinical practice was so rapid.

Dr. Enegess: Yes. 

Dr. Barbieri: You know, those hormone prescriptions dropped by 80%. It was just a massive and immediate change and it really resulted in two decades of change practices and impact on care delivery, education, all of that. 

Dr. Enegess: Remarkable. And I feel like the tide is just turning.

Dr. Barbieri: Started recently, I think.

Dr. Enegess: Yeah.

Dr. Barbieri: We've got a lot to do, a lot to do. You know, I sometimes will read things and basically my conclusion is that somehow we are frozen in 2002.  

Dr. Enegess: I agree. So, let's talk about some of the standard things that we use for treatment and then I'd love to hear about your more holistic approach and the other things that you do. That would be great.

Dr. Barbieri: So, let me start with the word treatment. You know, I think sometimes when we say treatment for menopause, it really implies that menopause is an illness or a disease, right? And I think that certainly does not sit well with me. Menopause, like puberty or pregnancy, is a normal and expected time of life, and basically as long as a woman lives long enough, she will go through this change.

So, I'm wary of really describing menopause with that ‘menopause as illness’ framework, and whereas we can treat symptoms, we can also help ourselves and our patients

kind of feel better through this transition, understand its implications for now and our future health and kind of use it as an opportunity to be healthier now, feel better and be healthier for the future. So, having said that, there are certainly standard treatments of menopause symptoms that I tend to think about in terms of putting them in different categories. 

I think certainly hormone therapy -- whether that is a prescription for a birth control pill or a combined contraceptive, or whether that hormone therapy really means the use of estrogen and progesterone or progestin or even testosterone hormone therapy for certain indications -- that's really kind of the traditional way of thinking about it. I'll tell you that when I finished my training, we used to use birth control pills. Basically it was easy. If you were still having your period and it looked like you were going through some changes and you don't have A, B and C contraindication, here is a birth control pill and then if your period had stopped, especially if it had been a year prior to 2002, you got hormone therapy. After 2002, after Women's Health Initiative, those prescriptions dropped because honestly, it was just much easier to say, “Hormones will give you breast cancer, let's not even go there” and that was it. I think where we are, things are changing. 

So, one of the more standard and researched and clinically useful treatments for symptoms of perimenopause and menopause is hormone therapy. It can be done very differently now. We do know that certain hormonal regimens are likely safer than what was studied in the Women's Health Initiative. I don't think any of us are using Prempro anymore, which was the combination that was used then. I think most of us are using estrogens that are transdermal, that will have a different cardiovascular profile. I use a lot of micronized progesterone. These are hormones that are considered bioidentical, although we can get into a conversation of what that term really means. For me, it just means that the hormones used really have the same molecular structure as the hormones that the human body produces and the research suggests that these are safer regimens than oral estrogen or synthetic progestins. 

Even major societies, like North American Menopause Society, are on board with the benefit of hormone therapy and its safety for most women, as long as they are started preferably around the time of menopause, but no later than ten years into it. I have a discussion with every single one of my patients approaching this age, and definitely with every symptomatic patient about this option and how that applies to them and help them understand the nuances of it. So, that's one. 

Another bucket of kind of standard treatments that's been used for a long time -- and this is because of the prevalence of mental health symptoms like anxiety, depression, insomnia -- are SSRIs and SNRIs. They're going to be in the category of antidepressants. There is a bucket of them, and they all vary in terms of side effects. Unfortunately, they do come with side effects -- weight gain, libido, sexual dysfunction -- those are going to be the major ones, and they don't address certain other aspects of the menopausal transition, but they are still widely used.

We do have a new option with a new pharmacologic that was just approved in, I think, April or May of this year that is called Fezolinetant. It goes by the brand name of VEOZAH. The trials were well done with excellent efficacy, but it's early days, so I only have a few patients on it. There are some precautions with that. Liver function tests need to be normal. It is an expensive option as of right now, although that hopefully is going to change now. It's a very specific medication for hot flashes and night sweats, which are also basal motor symptoms. It actually targets the area of the brain that's directly related in thermoregulation. So, it's another good sort of...I would call it a standard option. 

None of these standard options really address some of what I'm going to call the more philosophical or psychosocial or most of the more behavioral sexual health aspects of perimenopause and that is, I think, where integrative care really, really shines here because while menopause does have a hormonal root cause, it doesn't affect just our menstrual cycles or vaginas or doesn't just cause hot flashes. It's a major change. 

I certainly think that even things like community support, learning about this change, being supported by your own peers, by medical professionals that one has a relationship and trusts, counseling when indicated, emphasis on self-care and learning how to take care of ourselves in terms of stress management -- so much easier said than done and we all have stress, and we need to learn how to manage it. Learning how our metabolic health changes during this transition. How our nutritional needs may change. How do we manage that? What happens in our metabolic health? Do we need to be looking at our parameters of glucose control, our lipids, our cardiovascular risk? Is it time to assess our genetic risks for various conditions? 

So, really that awareness and throwing in that lifestyle change of nutrition, movement, stress management, emphasis on sleep, reassessment of life's priorities. I mean, we live for a long time. I certainly don't think this is a time to hang up my white coat and go knit a sweater. I mean, I would love to -- I don't know how to knit -- but we have a lot to do. It's a beginning of a different phase, so certainly that lifestyle and mindset piece is important. 

There are a few botanicals that have been studied. This tends to be a controversial area and I find that some people have this perception that all supplements are bad. Like, whoever is recommending them, they don't even know what they're talking about and they're dangerous and unregulated.  And while it's true that not all supplements are created equal, there are a few things that have quite a bit of research behind them and there are also ways to distinguish some of the more reputable companies with better quality assurance processes

and R&D from some of the bad players. 

Certainly, my point here is not to advertise everybody taking twenty-five different supplements. Not everyone should or can take hormone therapy. Not everyone wants to get on an SSRI or the new medication or I forgot about things like gabapentin, for example...it's another med that's used. So, I think we do have some options here and I certainly in my practice do have patients where I recommend, for example, magnesium, or I may recommend a combination of magnesium and B12 or B-complex. Ashwagandha is an adaptogen that has been studied for many, many years and has hundreds of studies on it that can be used for these purposes. Soy isoflavones are there. Saffron is garnering more attention. 

So, certainly, helping someone develop a supplement program if they're interested in that or to reassess what they're on...that's a big part of my practice too, because I do see a lot of people coming in and lots of different things, some of which may be questionable, some of which may be downward unsafe. It’s an important aspect of it and I think it behooves us as clinicians to know more about this because our patients are using this stuff. I think the statistic is something like more than 50% of women in this age group are actually using supplements, vitamins, and botanicals and many of us don't even know that. Or if patients tell us that, many of us don't know what to do with that information.

Dr. Enegess: Right, I agree 100%, yeah. So, what advice would you give to current and future health professionals about providing menopause care?

Dr. Barbieri: Here's my, I would say, unpopular opinion as a menopause specialist, because now we can get this designation by the North American Menopause Society to be a certified provider. I actually think menopause education and care should really be bread and butter for everyone caring for women in the areas of primary care and endocrinology and psychiatry and certainly OB-GYN. I mean, this is half the population. This is not an esoteric condition. 

I feel like, an OB-GYN that doesn't provide menopause care and is in general practice... that's like being a urologist and not knowing about the prostate. Like, this is a given. So, I am actually an advocate for really increasing widely available menopause education to medical students and certainly to residents in these fields. A study -- probably now ten years old -- cited that only about 20% of OB-GYN residency programs had formal menopause curriculum. I mean, that doesn't help ourselves or our patients in any way. We really need to make it easier and more accessible and, you know, I think all of us in these fields should have the basic knowledge of hormone therapy, its applications, how to screen patients as far as who is an appropriate candidate and how to counsel them about it. I think that's going to destigmatize this area, normalize it and allow for better care.

Dr. Enegess: And my last question would be, do you think our patients are well-informed or becoming more well-informed about menopause?

Dr. Barbieri: I think there is a rising tide of interest in menopause, which is great, and I think it's actually being driven by our patients and some celebrities who are less afraid to talk about it.  I think it's kind of a double-edged sword in a way, because with that interest and with the increased access to technology and increased access to information online, you both end up with a lot of great information out there, but also some really bad information or incorrect information. I do think that interest is rising. There is more and more information out there.

I think we do need to be diligent at providing good evidence-based and informed information to our patients. 

We do need to recognize that we can go outside, that menopause is not a checkbox. You have this option or this option. We have to work with our patients individually. It does take time and effort and empathy and being understanding, but it's really worth it.

Dr. Enegess: I agree.

Dr. Barbieri: And I think our health systems are recognizing it also with more attention being paid to it. There's lots of barriers in terms of the systems that we work with, including insurance reimbursement, time per visit and all of that. But I think it's really the demand of the patient, consumer demand and the way of destigmatizing this area is helping. 

Dr. Enegess: I agree, yeah. I have one more question, actually. I love your platform. I think it's a great resource. Even if you're not joining and becoming a member, your website has great basic information. Do you have any other recommendations for medical students or residents or even patients about good resources to go to, places to look?

Dr. Barbieri: Yeah, so the Elektra website is great. I'll represent my team here. We're very, very proud of it. We worked hard on it. It combines both conventional approaches with some of these more integrative approaches without straying into areas that are unproven or maybe dangerous. I think it's very approachable and patients really like it. 

There are some other sites out there. I would caution people with really looking at sites that promote one particular solution. Some of them may have good information, but they will always push that one particular solution, whether it's a medication or a supplement. The North American Menopause Society, which was just renamed the Menopause Society, has a pretty decent website with education for healthcare professionals, which I think is a good resource to have or at least the basics to start off with. And ACOG is starting to provide really more and good education in this field too. 

Dr. Enegess: Thank you. Well, I think you and I could talk about this all day.

Dr. Barbieri:  I think so too. I have some questions for you.

Dr. Enegess: But I want to just thank you so much for joining the podcast and I appreciate your time.

Dr. Barbieri: You're very welcome. My pleasure.

Dr. Enegess: I'm Dr. Deborah Enegess. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.