00:00:17
Speaker 1: Pushkin.
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Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word.
00:00:52
Speaker 3: I wanted to let you know as I was in the Starbucks preparing for this interview, that's why you were late. I kind of while I was on time. Wow, I got really emotional actually, and I was the Starbucks. Yeah, I did in Starbucks, like little tears were coming into my eyes, and I was thinking, why, Well, because I was thinking how far we've come. You know, we me we met like twenty six years ago.
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Speaker 1: We did.
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Speaker 3: We were dating around the year two K when we thought the world was going to come to an end and everything was going to yeah that's okay, And and you know, I was thinking, we've come so far. We've you know, we've had a family, we met a family, We've had careers, an apartment, we bought, had pets, lots very important, and so I just want to let you know This is.
00:01:34
Speaker 1: Like a really emotionalsery.
00:01:36
Speaker 4: It's like our anniversary, twenty fifth anniversary is coming up. Did you know that, Yes, get a gift.
00:01:42
Speaker 3: Yes, this this, This is your gift to be on this podcast to help to educate men about menopause and midlife.
00:01:50
Speaker 4: So they call menopause menopause.
00:01:54
Speaker 3: You're listening to Decoding Women's Health. I'm doctor Elizabeth Pointer. I was recently on the Ritual podcast talking about hormones and menopause, and he asked me a question that really stumped me, and I'm not someone who's easily stumped. He wanted to know how I advised the partners of women going through menopause. This is actually an important topic that lots of people, myself included, don't spend enough time talking about.
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Speaker 1: Menopause and midlife.
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Speaker 3: Hormonal changes have a huge impact on relationships. Since nineteen ninety, divorce rates in the United States have gone down for every age group except one people over fifty. One survey in the United Kingdom found that seven to ten women cited perimenopause or menopause as a major factor in their divorces seven out of ten seventy percent.
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Speaker 1: But it doesn't have to be like that.
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Speaker 3: There are ways for couples to navigate these changes, and practical advice for those who want to better support their partners or friends or loved ones who are experiencing menopause.
00:03:01
Speaker 1: So I thought, who.
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Speaker 3: Better to discuss this with than my husband, doctor Richard.
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Speaker 4: Shapiro, sometimes called mister Poynter.
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Speaker 3: Yep, he's not just mister pointer. He's also a pioneering breast cancer and melanoma researcher and surgeon, the very best in my opinion. So I invited rich onto the show to talk about some common misconceptions around estrogen that he hears in his practice and how partners and also frankly, clinicians across disciplines can better support women in midlife. Can you tell our listeners how we first met? And I'm going to jump in with any fat checks if we need to have some reality checks and press.
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Speaker 4: So I had a colleague at the hospital that came up to me one day and asked me if I wanted to meet his wife and him for dinner. And I said no, and he goes, no, come on, I've told my wife a lot about you. It's like all right, So we get in a cab. We go first avenue. He goes, look, the doors are locked, but my wife is setting you up with her closest friend. And if I could have gotten out of the car at that point on first Avenue, I would have, because I'd been through this countless times. Uh. And we went to a restaurant and two women walked in and I looked at you, and I looked at her, and he said, Elizabeth is the taller of the two. And I knew within two hours that if you are not the person I've been looking for my whole life, that person does not exist. So I knew that not I was going to marry you.
00:04:36
Speaker 1: That's pretty cool.
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Speaker 4: I think you may but that is absolutely true.
00:04:42
Speaker 3: But you may have reconsidered that at some point, because.
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Speaker 4: We have, and we all reconsidered it, but.
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Speaker 3: We were It's also really important to note for our listeners because this is a midlife women's health podcast.
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Speaker 1: Right.
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Speaker 3: I realized in prepping for this conversation that when we met, you know, it was midlife for me actually, and you right, you know, we got married quickly after we after we met. We had to because I was old and uhuh yeah, okay, and we had her son. We did, and then all of a sudden, I had some menopause stuff go on, right, I know, depression, like yeah, like severe depression and anxiety. Not I don't think it was postpartum depression is more related to menopause. But you were super supportive. And you know, you're a doctor. You're a breast cancer surgeon, right, so you obviously take care of a lot of women. You knew probably a few things about hormonal changes, especially being breast cancer surgeon with women who can't take estrogen.
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Speaker 1: What were your.
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Speaker 3: Initial thoughts about what menopause would be like did you.
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Speaker 1: Think about it at all?
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Speaker 3: Like when I was going through this depression, did that come into your mind or what were you thinking?
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Speaker 4: I mean, you know, I think that most men don't look at it as a medical I don't want to use the word condition. But it's a biochemical change. So it can be very easy for a man to look at a woman going through these changes as being depressed or unsatisfied with their life and not realize that it's the withdrawal of hormonal support that's really having somebody feel this way. And it's very easy to get frustrated and to take it personally and to get angry about it. You know, when you have a substance in your body that is being diminished and your body's reacting to that withdrawing from that. You know, most people don't think about that. Most men don't think about that at all.
00:06:42
Speaker 3: So when did you first start to notice or when did it come into your mind? Because it came into my mind really late that I was in perimenopause. Did it come into your mind at all? Or was it after I said, wait a minute, I just took this Estertonpatt.
00:06:56
Speaker 1: I feel so much better.
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Speaker 4: You're not a complainer, and you're someone that always pushes forward, and so I think that I really, like most men, I think only realized it when you brought up pot flashes, because that's the thing that every man will recognize as women going through menopause hot flashes. But I think most men don't think about all the other things that happen to women when they go into this phase of life or through this phase of life.
00:07:25
Speaker 3: I have to pause here and say, I hear this all the time from my patients that their partners are just so confused, if not downright unkind sometimes because their partners just don't understand and I've been impressed by Rich's journey of learning about hormones. He's a big advocate now, but it wasn't always this way. Treatment options for breast cancer have improved dramatically in just the last ten to fifteen years, but those options often come with side effects. Some can even trigger early menopause. So it's important for women and their doctors to have an open dialogue about the impact of these treatments so we can think through the best course of action for each individual patient. As I've mentioned before on this show, I believe estrogen can really help many women in this chapter of their lives. So it might surprise you to learn my husband hasn't always been on the same page. There's two things that I really want to bring up that you said to me.
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Speaker 1: The first was.
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Speaker 3: You know you're not going to take estrogen. You said that to me early on. And then the second thing that you said to me, which really is resonating right now with this conversation, is that this menopause stuff is real you but I don't think you, like, did you know anything before I went through this? Did you know anything about this? Did it from your mother? From you know, friends, wives, from I mean.
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Speaker 4: The joke, the hot flashes, the way gain she's going through menopause. She's impossible to deal with. She does want to do anything. She's depressed. But I really didn't think much of it until I started putting patients into menopause with the medical treatment for breast cancer. Sh right, But so kind of when that started to happen, and you it's very you know, it's very easy to see that. I think sometimes it's very hard to see something up close, right, So I would see something at work and then realize that, you know, hey, we gave this woman this medication and now they're different or they're having problems that they didn't have before. So it's really a cause and effect thing. So I thought for me to see that at work or professionally or from a distance objectively was much easier than actually noticing what's happening in front of it. So that's when I really started to become aware. And that's when I got to be much better at noticing subtle or sometimes not so subtle changes in someone's behavior that we can maybe attribute to menopause.
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Speaker 3: Yeah, and you actually have done something really important. I was for our listeners. We you know, we share patients. We talk about patients we've operated together, and you were sharing with me a patient the other day that you were telling me about who was on some estrogen, but you thought her estrogen can be adjusted a little bit better. And I was so proud. I was like, oh my gosh, he's gone from not knowing anything about this, having conversations with me and observing me, and then now applying that to helping women.
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Speaker 4: There's an incredible fear among doctors that if you give women estrogen, they will get breast cancer. And there's a lot of kind of ignorance about that, and there's a lot of concern medical legally, right because we live in that kind of world, and so if a woman develops breast cancer and she's on estrogen, there are people that would say that you caused that cancer, which you did not, and it could be a ton of medical literature to refute that. But legally it's always an issue. So a lot of people say they want nothing to do with it, absolute no. And so I never really thought that, and it's a constant battle. It's a battle with many of our oncologists as well.
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Speaker 3: And you guys got to realize that this guy is a research person too, like Shapiro is a rich as a real, real hardcore researcher. But you forwarded to me the other day from the San Antonio Breast Cancer Conference, which is the large breast cancer conference. You know yet another study that showed that in the highest risk individuals who have Braka one mutations, that estrogen doesn't cause breast cancer. So why do you think despite all this data, why do you think that medical oncologists and surgical oncologists too, not yourself included, but many just are so hesitant to grasp onto the estrogen doesn't cause breast cancer.
00:12:06
Speaker 4: I would say the communication all habits die hard. I will constantly have arguments with some of my colleagues about this. You know, a woman has significant menipausal symptoms, They've tried a lot of other things, and there are a lot of ways to treat symptoms with things other than hormones. So I think that's number one. But if you need to have that hormonal support, I mean short, I think a lot of doctors are moving into that, but no one is really sure because no one had any education. It's been a while since I've been in med school, but I think that there certainly when I was in medical school, there was virtually no instruction or education on menopause at all.
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Speaker 3: You know, you actually bring up a really important point because we talk about educating women's health providers right, more from the primary care OBGI in setting group, right. But here you are operating on women who have a breast cancer, right, who have the stress of a cancer and then are put into menopause with their treatments many times, or have antiestrogens, and you had no education.
00:13:20
Speaker 4: As zero, no education. So it's all anecdotal, and there are a lot of naysayers when you want to do something to go absolutely not, I'm like, why, well, you know, and you know, there is a lot of good data coming out now that it is really saying that estrogen in many situations is totally safe. But you know, unfortunately, any any article that comes out on breast cancer, especially those that hit the popular press, are highlighted, and it seems like every two months the data is going back and forth when it really isn't and so it can be very hard, you know, when you have all this information thrown at you from ten different directions to really know. And another big question is who in the care of the patient is responsible for this? Is it the oncologist? Is it the surgeon? Is it the gynecologist? Is it the endochronologist? You know, people tend to have ten doctors now, so who is going to be the one that is going to write that prescription and help moderate any type of symptoms or lack thereof that the patient's having from it? Like, who's going to be responsible? You know, most of us are very siloed, and so I know that you are once in a while coming up against you know, when you're in a multidisciplinary team, it sounds great to treat patients that way, but when you have four people that have four different opinions about something like this, it can be very frustrating, not only for the patient but for us.
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Speaker 3: Yeah, and I think that, I mean, you've just said that that siloed was the key word, right, and we need to take this out of siloce But I think that's why we really need to redefine who the women's health specialist is to quarterback all this. Who understands oncology, who understands cancer, who understands anti hormone therapy, hormon therapy, cardiac disease, metabolic disease. We need that oversweeping holistic view.
00:15:19
Speaker 1: Coming up.
00:15:19
Speaker 3: Rich and I talk about the different impacts menopause can have on relationships, including sex and libido. So let's go back to menopause and how it can impact a relationship and then get back to the partner view on menopause and how to help a partner going through these changes. Let's talk about sex. How do you advise patients partners about what to expect with libido sex, how to navigate that.
00:15:58
Speaker 4: You know, as I'm a male doctor, I think that a lot of female patients may not be comfortable talking about that with a man.
00:16:06
Speaker 1: Do you bring it up?
00:16:08
Speaker 4: I bring it up to them when we talk about the possible side effects of some of the anti hormonal treatments we're going to prescribe with breast cancer. But I'm not the quote expert on it, and so that usually falls in the way I work and where I work to the medical oncologist that's prescribing that drug to talk to them about that. I like to set things up so they're not blindsided about it. So I do bring it up. But yeah, I would say.
00:16:39
Speaker 3: Do bring it up, and then when you're talking to you know your friends and confidants. Do you guys talk because guys, right, so I can say, guys, it's a guy thing, so heteronormalize it.
00:16:49
Speaker 4: But to send their wives to you and you'll fix that right exactly, Yes, with pills and positions.
00:16:56
Speaker 1: And do you did do you?
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Speaker 3: I mean, do you talk about vaginal dryness and you know, like a woman maybe experiencing pain with penetrative sex.
00:17:07
Speaker 4: It's more like, well, they don't want to have sex with me anymore.
00:17:11
Speaker 1: Yeah, let's talk about that. So what do you do about what do you how do you?
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Speaker 4: Guys say? I say, you know, there are a lot of things that happen in your menopause. There's vaginal dryness, there's lots of libido. You are the first doctor that I've come across that also prescribes to stostrone to women. People were willing to talk about estrogen and vaginal estrogen and support, but no one was on testosterone. I never you. You were the first person that kind of opened my eyes to like, wow, that makes a lot of sense.
00:17:43
Speaker 3: Yeah, yeah, and that's super helpful with libido.
00:17:46
Speaker 4: And with your muscle tone and I think alertness and I can actually you're like my little laboratory, because I can tell when we go upstate and you have forgotten your estrogen or whatever in the apartment that there's a difference, that there's something. You know. I can spot it before you can, just in your mood or sometimes you know it's a fogginess or and I'll say, you know, did you leave your essen in the city, And when you yell at me, I know that you have the testosterone on board, but the essene isn't. If you don't yell at me, I think you're missing both, and they're both in the apartment. But I think you can right. It's true, And when you get to know someone, you can you can really see the difference. I think that probably a lot of marriages get into trouble because women go through these issues and then the men don't understand it's a medical thing. It's not like it's like being angry with someone who's blood sugar is low because they're diabetic. It's the same thing, but no one really thinks about it. So you know, if someone understands that there is a you know, men can you know, have erectile dysfunction and need a pill for support and that's okay, And people understand that or it's becoming okay. But women can have a similar problem with lack of hormones and no one thinks about it.
00:19:13
Speaker 3: So at the same time that women are going through these midlighte hormonal fluctuations, men are going through absolutely their team may be dropping off, they may be having career changes, identity issues. I mean, we don't really talk about that so much, and that could be a perfect storm.
00:19:26
Speaker 4: Unmail, Yes, unmail to think that way. Men go through menopause too, in a sense, I mean, this is just ignorance. But it seems like the big problem that men seem to get is erechtal dysfunction at that time, and that can be really fixed or solved with a pill. It's an easier fix, it's immediate, and that's not always the problem. So there are all those serious health like cardiovascal disease manifests sometimes first in erecta dysfunction. So if that happens to a man, they need to get their cardiovascosystem.
00:20:00
Speaker 1: Eval diabetes too, right, diet and.
00:20:03
Speaker 4: Blood pressure and all of these things. So you know it's different in wake in and everyone's been tabolism changes. Yeah, but it happens to men.
00:20:11
Speaker 3: To Yeah, when you give your friends knowledge, right when you start talking about sex and libido and testosterone, And what are the reactions when they when you give them knowledge.
00:20:21
Speaker 1: Are they relieved? Did they say thanks rich?
00:20:24
Speaker 4: You know, it's something they didn't think of? Yeah, or it's a way out. So a lot of them will accept that their wife's going through menopause. But I would say the two things that the men complain about, the three things the men notice and complain about, is loss of libido and the women that the women are constantly hot and it's a problem in the car, you know, or kind of a snippiness, a shortness. But I think that I think that the surprising response from a lot of the men that come up to me is that I said, you know, there's a lot of things you can do that are kind of simple. No one needs to be told that they should go get a get a different job, or get new hobbies because you're just bored and you're sitting home home. You know, no one wants to be told that. But if you're telling someone, you know, I did some lab tests, and you know you need to have some estrogen support, and we're going to give you some testosterone as well and X y Z. That's that's real stuff. That's not giving someone vitamin supplements, which are important, but you know, you're giving someone a prescription. And usually prescriptions are evident, hopefully evidence based, and they're given for good reason.
00:21:40
Speaker 1: So let's let's talk about that.
00:21:41
Speaker 3: So, you know, we want our partners of women going through midlife changes to be supportive, right, And how do you be supportive when you see maybe a wife or a partner of one of your friends who's not getting the right medical care, meaning she's not with somebody who can really support her hormonally or lifestyle wise, like a lot of docs just ignore it.
00:22:06
Speaker 1: Still, you know, it's really hard. How do them?
00:22:09
Speaker 4: Well, it's hard because you don't wanna If someone has a long relationship with their gynecologist to their primary care doctor, you don't want to tell them that you know, hey, I don't think they're doing the right thing or they're not paying attention to you. And so that that's really hard. You have to get someone to realize that things are not changing or getting better. Yeah, and so in that situation, you have to point out to someone that hey, maybe we can do something about this. So and maybe you know you can get another opinion or a fresh opinion on it. So I think it's it's something that you can convince people to do. But unfortunately, I think a lot of the damage in a relationship is done by that point, because you know, it can go on for months or years that you know, people are very unhappy and very frustrated, and a certain percentage of people going to give up or they've had enough, or and it just becomes this snowball effect and things start to get worse. But I think when you can convince people that there's something you can do about this that's not like a major intervention, it's not like having surgery, it's not that big a deal, give it a chance because a lot of people, you know will get a benefit at it, or it won't hurt them.
00:23:31
Speaker 3: I think, Yeah, I think I think you really keed in on something that if you are not getting better and you don't feel well, encourage your partner to get new advice or a new strategy.
00:23:44
Speaker 4: Right, let's try something. You try something new, and almost everyone and maybe.
00:23:48
Speaker 3: They'll find a new doctor that's going to help them or a new situation that's going to.
00:23:51
Speaker 1: But but it's hard.
00:23:53
Speaker 3: It is hard even just to start these conversations. So after the break we get into why it feels this way, and we talk about some ways that partners can bring up menopause. Do you think that men who have female partners are scared of menopause or do you think they even know about it?
00:24:22
Speaker 4: Make that have female partners are scared of menopause. They they only know about it in a way that you would see in a TV sitcom that's scary. Almost every man I know thinks about men and she's going through the change, and so it's it's sort of in every movie, there's a there's a there's a woman that is going through menopause and she's not fun to be with. But and you got to point out people that don't feel are not fun to be with, so and and it's it's really that you're not feeling well for a biological reason. It's not that you're not feeling well because you're disappointed in your life, well, you don't like your partner, or you're not you know, you're not attracted to each other anymore. So it really hasn't been recognized as a significant medical condition. And the only parallel I can come up with. Is that I've noticed, as you know, we're old now, is that more and more men that I know will take cialis or some of these medications because it's normal. Yeah, like, hey, I need it, Like I'm going to get it. There's no stigma to that anymore. It used to be that patients wouldn't even tell me they're on it, or friends wouldn't tell you that they were on it, or they would ask you sheepeshly, hey, you know, have you ever take this to you today? But I don't think women think about it the same way. But there's also the fear and overlay and ignorance about what estrogen could potentially do bad things to you. So a lot of there's a lot of ignorance about the pros and content estrogen. You know.
00:26:04
Speaker 3: It's interesting because it used to be that men would develop ed, women's libido would go down, and then the relationship just changed a little bit. Right, And now I think the EED drugs have really changed. I mean, they they've rocked that, they've really changed. Yeah, right, I.
00:26:20
Speaker 4: Think the fault it's just that it has not been I don't want to use the market it, but it hasn't been put out there that this is there is help.
00:26:31
Speaker 3: Yeah, it's the biology of midlife women that.
00:26:35
Speaker 1: It can impact.
00:26:36
Speaker 4: It happens to everybody, everybody, everybody to everybody.
00:26:40
Speaker 3: But it's interesting because, I mean, we really do need to get the education out there to partners of midlife women. Like hot flashes, night sweats, these are symptoms of perimenopause or menopause or midlife hormonal fluctuations, sleep disruption, right waking up early, right, mood changes, anxiety, depression for me, and then our relationship, it was like it was in bed all day. Vaginal dryness and sexual discomfort, brain fog, you describe that, and me actually being a little fuzzy when I don't take my estrogen and my hormones and testosterone. How do we educate men? What is the answer in terms of educating partners of midlife women.
00:27:16
Speaker 4: It's whose whose responsibility is it?
00:27:18
Speaker 3: Yeah?
00:27:19
Speaker 4: Right, I'm not sure. I think that there has to be sort of more of a public awareness of it. Right, It's something that needs to get out there, and I don't know, I'm not really sure how to do it. Hockey games, menopause night like hockey fights, can't I don't know. I mean, I don't know.
00:27:41
Speaker 1: I like that Menopause Night at.
00:27:42
Speaker 4: The Hockey Fight metopause, but but yeah, so I'm not really sure. I mean, it definitely should start with medical students and in nursing schools. I would say that there should be some serious educational effort into this, but also.
00:28:02
Speaker 3: Just at the at the lay level, right, I mean, we need to educate partners of women. You could actually go to Menopause Society website. They list the menopause practitioners there. There's also online Menopause Concerns which you can do online telehealth with which I think would be beneficial. Also, you know, so how would you advise a partner to bring this up? So you have a partner that is seeing these changes in his partner and she may not realize what's going on, how does he.
00:28:35
Speaker 1: Bring it up?
00:28:36
Speaker 4: That's another tribut getting a punched in the face, because when you're going through these having these difficulties or issues, you can't see it. Yeah, a lot of people can't see how their behavior is changed. Or some people are self aware, but I think most are not that self aware, and so I think that it's hard. I mean, everyone's relationship is different, right, But you know, a man are sometimes very uncomfortable talking about this kind of thing.
00:29:06
Speaker 3: I think for our relationship, it's about partnership.
00:29:09
Speaker 4: It's about listening to some one. And also, yeah, it's really I mean, you gotta there are so many times you so many times in my life when I made an assumption about a situation and when I actually talked about it, I felt that like ninety five percent of the time was wrong. So a lot of times I've gotten much more direct.
00:29:31
Speaker 3: And when you're going through midlife, it's not and this is really I think key, it's not the relationship that changed. It's really the hormonal milieu that changed that interferes with the relationship.
00:29:43
Speaker 1: And so when you have that target that you can go, you don't.
00:29:45
Speaker 4: Play the blame game. It's your fault. Yeah, you know, you have to also be willing to listen. But I think that again, the recognition that this is actually a real health issue that needs to be addressed is the you know, and makes it much more understandable or palatable for a male partner to say, hey, this is a problem. It's like I mean, it's like they have a lump in their breast or they have a urological problem. Or they you know, I need a hip or plate, whatever it is. Menopause is a is a medical phase or condition that's as important as all of those things, and it's not addressed. So you would never get frustrated with your partner because she has a suspicious mamigram and may have breast cancer. But if someone isn't behaving the same way towards you or your family because they are biochemically deficient in substance that they've had their whole life and now it's been taken away from them, you know, then people would think a little bit differently about the problem.
00:30:55
Speaker 1: That's a really lovely answer.
00:30:59
Speaker 3: Okay, I know he's my husband, but I just have to say I was so impressed by Rich's perspective and how much he's evolved since I first experienced MIDLFE prmonal changes. I hope that any partner or a loved one or friend feels like menopause is a little less mysterious and a little less daunting after this conversation. If you take one thing away from this episode, I hope it's this menopause doesn't have to be something you suffer through in silence, and it doesn't have to be something that comes between you and your partner. There is a way to get through this together, and the more open dialogue we have between women, their partners, and their doctors, the more options we have for remedying symptoms and improving women's quality of life. I really love the way Rich framed this. You wouldn't get angry with someone for having an outburst when they have low blood sugar, or for finding out they have a lump.
00:31:56
Speaker 1: In their breast.
00:31:58
Speaker 3: Instead, let's treat menopause as the biologic event that it is. It doesn't have to cause a ripped in relationships. Communication and education are our best tools for navigating through this change together. Coming up on the next episode of Decoding Women's Health, Dry January maybe over, but our relationships with alcohol are year round. What are the ways for us to cut back on alcohol?
00:32:26
Speaker 4: Quite often, health professionals also feel uncomfortable about asking about drinking habits and pateants because we kind of assume that it's okay when it may not be.
00:32:37
Speaker 3: Decoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Daphne Chen. It was edited by Amy Gaines.
00:32:47
Speaker 1: McQuaid.
00:32:48
Speaker 3: Mastering by Sarah Bruguerer. Our associate producer is Sonya Gerwitt. Our executive producer is Alexandra Garreton. Our theme song was composed by HANNS.
00:32:58
Speaker 1: Brown.
00:32:59
Speaker 3: Concept creative development and fact checking by Shabon O'Connor. Special thanks to Alan Tish, David Saltzman, Sarah Nix, Eric Sandler, Morgan rat Owen Miller, Jordan McMillan, and Greta Cone. I'm doctor Elizabeth Pointer. Thanks for listening. Until next time.
Speaker 1: Pushkin.
00:00:24
Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word.
00:00:52
Speaker 3: I wanted to let you know as I was in the Starbucks preparing for this interview, that's why you were late. I kind of while I was on time. Wow, I got really emotional actually, and I was the Starbucks. Yeah, I did in Starbucks, like little tears were coming into my eyes, and I was thinking, why, Well, because I was thinking how far we've come. You know, we me we met like twenty six years ago.
00:01:12
Speaker 1: We did.
00:01:13
Speaker 3: We were dating around the year two K when we thought the world was going to come to an end and everything was going to yeah that's okay, And and you know, I was thinking, we've come so far. We've you know, we've had a family, we met a family, We've had careers, an apartment, we bought, had pets, lots very important, and so I just want to let you know This is.
00:01:34
Speaker 1: Like a really emotionalsery.
00:01:36
Speaker 4: It's like our anniversary, twenty fifth anniversary is coming up. Did you know that, Yes, get a gift.
00:01:42
Speaker 3: Yes, this this, This is your gift to be on this podcast to help to educate men about menopause and midlife.
00:01:50
Speaker 4: So they call menopause menopause.
00:01:54
Speaker 3: You're listening to Decoding Women's Health. I'm doctor Elizabeth Pointer. I was recently on the Ritual podcast talking about hormones and menopause, and he asked me a question that really stumped me, and I'm not someone who's easily stumped. He wanted to know how I advised the partners of women going through menopause. This is actually an important topic that lots of people, myself included, don't spend enough time talking about.
00:02:22
Speaker 1: Menopause and midlife.
00:02:23
Speaker 3: Hormonal changes have a huge impact on relationships. Since nineteen ninety, divorce rates in the United States have gone down for every age group except one people over fifty. One survey in the United Kingdom found that seven to ten women cited perimenopause or menopause as a major factor in their divorces seven out of ten seventy percent.
00:02:48
Speaker 1: But it doesn't have to be like that.
00:02:50
Speaker 3: There are ways for couples to navigate these changes, and practical advice for those who want to better support their partners or friends or loved ones who are experiencing menopause.
00:03:01
Speaker 1: So I thought, who.
00:03:03
Speaker 3: Better to discuss this with than my husband, doctor Richard.
00:03:06
Speaker 4: Shapiro, sometimes called mister Poynter.
00:03:10
Speaker 3: Yep, he's not just mister pointer. He's also a pioneering breast cancer and melanoma researcher and surgeon, the very best in my opinion. So I invited rich onto the show to talk about some common misconceptions around estrogen that he hears in his practice and how partners and also frankly, clinicians across disciplines can better support women in midlife. Can you tell our listeners how we first met? And I'm going to jump in with any fat checks if we need to have some reality checks and press.
00:03:44
Speaker 4: So I had a colleague at the hospital that came up to me one day and asked me if I wanted to meet his wife and him for dinner. And I said no, and he goes, no, come on, I've told my wife a lot about you. It's like all right, So we get in a cab. We go first avenue. He goes, look, the doors are locked, but my wife is setting you up with her closest friend. And if I could have gotten out of the car at that point on first Avenue, I would have, because I'd been through this countless times. Uh. And we went to a restaurant and two women walked in and I looked at you, and I looked at her, and he said, Elizabeth is the taller of the two. And I knew within two hours that if you are not the person I've been looking for my whole life, that person does not exist. So I knew that not I was going to marry you.
00:04:36
Speaker 1: That's pretty cool.
00:04:37
Speaker 4: I think you may but that is absolutely true.
00:04:42
Speaker 3: But you may have reconsidered that at some point, because.
00:04:45
Speaker 4: We have, and we all reconsidered it, but.
00:04:47
Speaker 3: We were It's also really important to note for our listeners because this is a midlife women's health podcast.
00:04:53
Speaker 1: Right.
00:04:54
Speaker 3: I realized in prepping for this conversation that when we met, you know, it was midlife for me actually, and you right, you know, we got married quickly after we after we met. We had to because I was old and uhuh yeah, okay, and we had her son. We did, and then all of a sudden, I had some menopause stuff go on, right, I know, depression, like yeah, like severe depression and anxiety. Not I don't think it was postpartum depression is more related to menopause. But you were super supportive. And you know, you're a doctor. You're a breast cancer surgeon, right, so you obviously take care of a lot of women. You knew probably a few things about hormonal changes, especially being breast cancer surgeon with women who can't take estrogen.
00:05:38
Speaker 1: What were your.
00:05:39
Speaker 3: Initial thoughts about what menopause would be like did you.
00:05:42
Speaker 1: Think about it at all?
00:05:43
Speaker 3: Like when I was going through this depression, did that come into your mind or what were you thinking?
00:05:48
Speaker 4: I mean, you know, I think that most men don't look at it as a medical I don't want to use the word condition. But it's a biochemical change. So it can be very easy for a man to look at a woman going through these changes as being depressed or unsatisfied with their life and not realize that it's the withdrawal of hormonal support that's really having somebody feel this way. And it's very easy to get frustrated and to take it personally and to get angry about it. You know, when you have a substance in your body that is being diminished and your body's reacting to that withdrawing from that. You know, most people don't think about that. Most men don't think about that at all.
00:06:42
Speaker 3: So when did you first start to notice or when did it come into your mind? Because it came into my mind really late that I was in perimenopause. Did it come into your mind at all? Or was it after I said, wait a minute, I just took this Estertonpatt.
00:06:56
Speaker 1: I feel so much better.
00:06:57
Speaker 4: You're not a complainer, and you're someone that always pushes forward, and so I think that I really, like most men, I think only realized it when you brought up pot flashes, because that's the thing that every man will recognize as women going through menopause hot flashes. But I think most men don't think about all the other things that happen to women when they go into this phase of life or through this phase of life.
00:07:25
Speaker 3: I have to pause here and say, I hear this all the time from my patients that their partners are just so confused, if not downright unkind sometimes because their partners just don't understand and I've been impressed by Rich's journey of learning about hormones. He's a big advocate now, but it wasn't always this way. Treatment options for breast cancer have improved dramatically in just the last ten to fifteen years, but those options often come with side effects. Some can even trigger early menopause. So it's important for women and their doctors to have an open dialogue about the impact of these treatments so we can think through the best course of action for each individual patient. As I've mentioned before on this show, I believe estrogen can really help many women in this chapter of their lives. So it might surprise you to learn my husband hasn't always been on the same page. There's two things that I really want to bring up that you said to me.
00:08:24
Speaker 1: The first was.
00:08:27
Speaker 3: You know you're not going to take estrogen. You said that to me early on. And then the second thing that you said to me, which really is resonating right now with this conversation, is that this menopause stuff is real you but I don't think you, like, did you know anything before I went through this? Did you know anything about this? Did it from your mother? From you know, friends, wives, from I mean.
00:08:52
Speaker 4: The joke, the hot flashes, the way gain she's going through menopause. She's impossible to deal with. She does want to do anything. She's depressed. But I really didn't think much of it until I started putting patients into menopause with the medical treatment for breast cancer. Sh right, But so kind of when that started to happen, and you it's very you know, it's very easy to see that. I think sometimes it's very hard to see something up close, right, So I would see something at work and then realize that, you know, hey, we gave this woman this medication and now they're different or they're having problems that they didn't have before. So it's really a cause and effect thing. So I thought for me to see that at work or professionally or from a distance objectively was much easier than actually noticing what's happening in front of it. So that's when I really started to become aware. And that's when I got to be much better at noticing subtle or sometimes not so subtle changes in someone's behavior that we can maybe attribute to menopause.
00:10:05
Speaker 3: Yeah, and you actually have done something really important. I was for our listeners. We you know, we share patients. We talk about patients we've operated together, and you were sharing with me a patient the other day that you were telling me about who was on some estrogen, but you thought her estrogen can be adjusted a little bit better. And I was so proud. I was like, oh my gosh, he's gone from not knowing anything about this, having conversations with me and observing me, and then now applying that to helping women.
00:10:40
Speaker 4: There's an incredible fear among doctors that if you give women estrogen, they will get breast cancer. And there's a lot of kind of ignorance about that, and there's a lot of concern medical legally, right because we live in that kind of world, and so if a woman develops breast cancer and she's on estrogen, there are people that would say that you caused that cancer, which you did not, and it could be a ton of medical literature to refute that. But legally it's always an issue. So a lot of people say they want nothing to do with it, absolute no. And so I never really thought that, and it's a constant battle. It's a battle with many of our oncologists as well.
00:11:29
Speaker 3: And you guys got to realize that this guy is a research person too, like Shapiro is a rich as a real, real hardcore researcher. But you forwarded to me the other day from the San Antonio Breast Cancer Conference, which is the large breast cancer conference. You know yet another study that showed that in the highest risk individuals who have Braka one mutations, that estrogen doesn't cause breast cancer. So why do you think despite all this data, why do you think that medical oncologists and surgical oncologists too, not yourself included, but many just are so hesitant to grasp onto the estrogen doesn't cause breast cancer.
00:12:06
Speaker 4: I would say the communication all habits die hard. I will constantly have arguments with some of my colleagues about this. You know, a woman has significant menipausal symptoms, They've tried a lot of other things, and there are a lot of ways to treat symptoms with things other than hormones. So I think that's number one. But if you need to have that hormonal support, I mean short, I think a lot of doctors are moving into that, but no one is really sure because no one had any education. It's been a while since I've been in med school, but I think that there certainly when I was in medical school, there was virtually no instruction or education on menopause at all.
00:12:53
Speaker 3: You know, you actually bring up a really important point because we talk about educating women's health providers right, more from the primary care OBGI in setting group, right. But here you are operating on women who have a breast cancer, right, who have the stress of a cancer and then are put into menopause with their treatments many times, or have antiestrogens, and you had no education.
00:13:20
Speaker 4: As zero, no education. So it's all anecdotal, and there are a lot of naysayers when you want to do something to go absolutely not, I'm like, why, well, you know, and you know, there is a lot of good data coming out now that it is really saying that estrogen in many situations is totally safe. But you know, unfortunately, any any article that comes out on breast cancer, especially those that hit the popular press, are highlighted, and it seems like every two months the data is going back and forth when it really isn't and so it can be very hard, you know, when you have all this information thrown at you from ten different directions to really know. And another big question is who in the care of the patient is responsible for this? Is it the oncologist? Is it the surgeon? Is it the gynecologist? Is it the endochronologist? You know, people tend to have ten doctors now, so who is going to be the one that is going to write that prescription and help moderate any type of symptoms or lack thereof that the patient's having from it? Like, who's going to be responsible? You know, most of us are very siloed, and so I know that you are once in a while coming up against you know, when you're in a multidisciplinary team, it sounds great to treat patients that way, but when you have four people that have four different opinions about something like this, it can be very frustrating, not only for the patient but for us.
00:14:53
Speaker 3: Yeah, and I think that, I mean, you've just said that that siloed was the key word, right, and we need to take this out of siloce But I think that's why we really need to redefine who the women's health specialist is to quarterback all this. Who understands oncology, who understands cancer, who understands anti hormone therapy, hormon therapy, cardiac disease, metabolic disease. We need that oversweeping holistic view.
00:15:19
Speaker 1: Coming up.
00:15:19
Speaker 3: Rich and I talk about the different impacts menopause can have on relationships, including sex and libido. So let's go back to menopause and how it can impact a relationship and then get back to the partner view on menopause and how to help a partner going through these changes. Let's talk about sex. How do you advise patients partners about what to expect with libido sex, how to navigate that.
00:15:58
Speaker 4: You know, as I'm a male doctor, I think that a lot of female patients may not be comfortable talking about that with a man.
00:16:06
Speaker 1: Do you bring it up?
00:16:08
Speaker 4: I bring it up to them when we talk about the possible side effects of some of the anti hormonal treatments we're going to prescribe with breast cancer. But I'm not the quote expert on it, and so that usually falls in the way I work and where I work to the medical oncologist that's prescribing that drug to talk to them about that. I like to set things up so they're not blindsided about it. So I do bring it up. But yeah, I would say.
00:16:39
Speaker 3: Do bring it up, and then when you're talking to you know your friends and confidants. Do you guys talk because guys, right, so I can say, guys, it's a guy thing, so heteronormalize it.
00:16:49
Speaker 4: But to send their wives to you and you'll fix that right exactly, Yes, with pills and positions.
00:16:56
Speaker 1: And do you did do you?
00:16:59
Speaker 3: I mean, do you talk about vaginal dryness and you know, like a woman maybe experiencing pain with penetrative sex.
00:17:07
Speaker 4: It's more like, well, they don't want to have sex with me anymore.
00:17:11
Speaker 1: Yeah, let's talk about that. So what do you do about what do you how do you?
00:17:13
Speaker 4: Guys say? I say, you know, there are a lot of things that happen in your menopause. There's vaginal dryness, there's lots of libido. You are the first doctor that I've come across that also prescribes to stostrone to women. People were willing to talk about estrogen and vaginal estrogen and support, but no one was on testosterone. I never you. You were the first person that kind of opened my eyes to like, wow, that makes a lot of sense.
00:17:43
Speaker 3: Yeah, yeah, and that's super helpful with libido.
00:17:46
Speaker 4: And with your muscle tone and I think alertness and I can actually you're like my little laboratory, because I can tell when we go upstate and you have forgotten your estrogen or whatever in the apartment that there's a difference, that there's something. You know. I can spot it before you can, just in your mood or sometimes you know it's a fogginess or and I'll say, you know, did you leave your essen in the city, And when you yell at me, I know that you have the testosterone on board, but the essene isn't. If you don't yell at me, I think you're missing both, and they're both in the apartment. But I think you can right. It's true, And when you get to know someone, you can you can really see the difference. I think that probably a lot of marriages get into trouble because women go through these issues and then the men don't understand it's a medical thing. It's not like it's like being angry with someone who's blood sugar is low because they're diabetic. It's the same thing, but no one really thinks about it. So you know, if someone understands that there is a you know, men can you know, have erectile dysfunction and need a pill for support and that's okay, And people understand that or it's becoming okay. But women can have a similar problem with lack of hormones and no one thinks about it.
00:19:13
Speaker 3: So at the same time that women are going through these midlighte hormonal fluctuations, men are going through absolutely their team may be dropping off, they may be having career changes, identity issues. I mean, we don't really talk about that so much, and that could be a perfect storm.
00:19:26
Speaker 4: Unmail, Yes, unmail to think that way. Men go through menopause too, in a sense, I mean, this is just ignorance. But it seems like the big problem that men seem to get is erechtal dysfunction at that time, and that can be really fixed or solved with a pill. It's an easier fix, it's immediate, and that's not always the problem. So there are all those serious health like cardiovascal disease manifests sometimes first in erecta dysfunction. So if that happens to a man, they need to get their cardiovascosystem.
00:20:00
Speaker 1: Eval diabetes too, right, diet and.
00:20:03
Speaker 4: Blood pressure and all of these things. So you know it's different in wake in and everyone's been tabolism changes. Yeah, but it happens to men.
00:20:11
Speaker 3: To Yeah, when you give your friends knowledge, right when you start talking about sex and libido and testosterone, And what are the reactions when they when you give them knowledge.
00:20:21
Speaker 1: Are they relieved? Did they say thanks rich?
00:20:24
Speaker 4: You know, it's something they didn't think of? Yeah, or it's a way out. So a lot of them will accept that their wife's going through menopause. But I would say the two things that the men complain about, the three things the men notice and complain about, is loss of libido and the women that the women are constantly hot and it's a problem in the car, you know, or kind of a snippiness, a shortness. But I think that I think that the surprising response from a lot of the men that come up to me is that I said, you know, there's a lot of things you can do that are kind of simple. No one needs to be told that they should go get a get a different job, or get new hobbies because you're just bored and you're sitting home home. You know, no one wants to be told that. But if you're telling someone, you know, I did some lab tests, and you know you need to have some estrogen support, and we're going to give you some testosterone as well and X y Z. That's that's real stuff. That's not giving someone vitamin supplements, which are important, but you know, you're giving someone a prescription. And usually prescriptions are evident, hopefully evidence based, and they're given for good reason.
00:21:40
Speaker 1: So let's let's talk about that.
00:21:41
Speaker 3: So, you know, we want our partners of women going through midlife changes to be supportive, right, And how do you be supportive when you see maybe a wife or a partner of one of your friends who's not getting the right medical care, meaning she's not with somebody who can really support her hormonally or lifestyle wise, like a lot of docs just ignore it.
00:22:06
Speaker 1: Still, you know, it's really hard. How do them?
00:22:09
Speaker 4: Well, it's hard because you don't wanna If someone has a long relationship with their gynecologist to their primary care doctor, you don't want to tell them that you know, hey, I don't think they're doing the right thing or they're not paying attention to you. And so that that's really hard. You have to get someone to realize that things are not changing or getting better. Yeah, and so in that situation, you have to point out to someone that hey, maybe we can do something about this. So and maybe you know you can get another opinion or a fresh opinion on it. So I think it's it's something that you can convince people to do. But unfortunately, I think a lot of the damage in a relationship is done by that point, because you know, it can go on for months or years that you know, people are very unhappy and very frustrated, and a certain percentage of people going to give up or they've had enough, or and it just becomes this snowball effect and things start to get worse. But I think when you can convince people that there's something you can do about this that's not like a major intervention, it's not like having surgery, it's not that big a deal, give it a chance because a lot of people, you know will get a benefit at it, or it won't hurt them.
00:23:31
Speaker 3: I think, Yeah, I think I think you really keed in on something that if you are not getting better and you don't feel well, encourage your partner to get new advice or a new strategy.
00:23:44
Speaker 4: Right, let's try something. You try something new, and almost everyone and maybe.
00:23:48
Speaker 3: They'll find a new doctor that's going to help them or a new situation that's going to.
00:23:51
Speaker 1: But but it's hard.
00:23:53
Speaker 3: It is hard even just to start these conversations. So after the break we get into why it feels this way, and we talk about some ways that partners can bring up menopause. Do you think that men who have female partners are scared of menopause or do you think they even know about it?
00:24:22
Speaker 4: Make that have female partners are scared of menopause. They they only know about it in a way that you would see in a TV sitcom that's scary. Almost every man I know thinks about men and she's going through the change, and so it's it's sort of in every movie, there's a there's a there's a woman that is going through menopause and she's not fun to be with. But and you got to point out people that don't feel are not fun to be with, so and and it's it's really that you're not feeling well for a biological reason. It's not that you're not feeling well because you're disappointed in your life, well, you don't like your partner, or you're not you know, you're not attracted to each other anymore. So it really hasn't been recognized as a significant medical condition. And the only parallel I can come up with. Is that I've noticed, as you know, we're old now, is that more and more men that I know will take cialis or some of these medications because it's normal. Yeah, like, hey, I need it, Like I'm going to get it. There's no stigma to that anymore. It used to be that patients wouldn't even tell me they're on it, or friends wouldn't tell you that they were on it, or they would ask you sheepeshly, hey, you know, have you ever take this to you today? But I don't think women think about it the same way. But there's also the fear and overlay and ignorance about what estrogen could potentially do bad things to you. So a lot of there's a lot of ignorance about the pros and content estrogen. You know.
00:26:04
Speaker 3: It's interesting because it used to be that men would develop ed, women's libido would go down, and then the relationship just changed a little bit. Right, And now I think the EED drugs have really changed. I mean, they they've rocked that, they've really changed. Yeah, right, I.
00:26:20
Speaker 4: Think the fault it's just that it has not been I don't want to use the market it, but it hasn't been put out there that this is there is help.
00:26:31
Speaker 3: Yeah, it's the biology of midlife women that.
00:26:35
Speaker 1: It can impact.
00:26:36
Speaker 4: It happens to everybody, everybody, everybody to everybody.
00:26:40
Speaker 3: But it's interesting because, I mean, we really do need to get the education out there to partners of midlife women. Like hot flashes, night sweats, these are symptoms of perimenopause or menopause or midlife hormonal fluctuations, sleep disruption, right waking up early, right, mood changes, anxiety, depression for me, and then our relationship, it was like it was in bed all day. Vaginal dryness and sexual discomfort, brain fog, you describe that, and me actually being a little fuzzy when I don't take my estrogen and my hormones and testosterone. How do we educate men? What is the answer in terms of educating partners of midlife women.
00:27:16
Speaker 4: It's whose whose responsibility is it?
00:27:18
Speaker 3: Yeah?
00:27:19
Speaker 4: Right, I'm not sure. I think that there has to be sort of more of a public awareness of it. Right, It's something that needs to get out there, and I don't know, I'm not really sure how to do it. Hockey games, menopause night like hockey fights, can't I don't know. I mean, I don't know.
00:27:41
Speaker 1: I like that Menopause Night at.
00:27:42
Speaker 4: The Hockey Fight metopause, but but yeah, so I'm not really sure. I mean, it definitely should start with medical students and in nursing schools. I would say that there should be some serious educational effort into this, but also.
00:28:02
Speaker 3: Just at the at the lay level, right, I mean, we need to educate partners of women. You could actually go to Menopause Society website. They list the menopause practitioners there. There's also online Menopause Concerns which you can do online telehealth with which I think would be beneficial. Also, you know, so how would you advise a partner to bring this up? So you have a partner that is seeing these changes in his partner and she may not realize what's going on, how does he.
00:28:35
Speaker 1: Bring it up?
00:28:36
Speaker 4: That's another tribut getting a punched in the face, because when you're going through these having these difficulties or issues, you can't see it. Yeah, a lot of people can't see how their behavior is changed. Or some people are self aware, but I think most are not that self aware, and so I think that it's hard. I mean, everyone's relationship is different, right, But you know, a man are sometimes very uncomfortable talking about this kind of thing.
00:29:06
Speaker 3: I think for our relationship, it's about partnership.
00:29:09
Speaker 4: It's about listening to some one. And also, yeah, it's really I mean, you gotta there are so many times you so many times in my life when I made an assumption about a situation and when I actually talked about it, I felt that like ninety five percent of the time was wrong. So a lot of times I've gotten much more direct.
00:29:31
Speaker 3: And when you're going through midlife, it's not and this is really I think key, it's not the relationship that changed. It's really the hormonal milieu that changed that interferes with the relationship.
00:29:43
Speaker 1: And so when you have that target that you can go, you don't.
00:29:45
Speaker 4: Play the blame game. It's your fault. Yeah, you know, you have to also be willing to listen. But I think that again, the recognition that this is actually a real health issue that needs to be addressed is the you know, and makes it much more understandable or palatable for a male partner to say, hey, this is a problem. It's like I mean, it's like they have a lump in their breast or they have a urological problem. Or they you know, I need a hip or plate, whatever it is. Menopause is a is a medical phase or condition that's as important as all of those things, and it's not addressed. So you would never get frustrated with your partner because she has a suspicious mamigram and may have breast cancer. But if someone isn't behaving the same way towards you or your family because they are biochemically deficient in substance that they've had their whole life and now it's been taken away from them, you know, then people would think a little bit differently about the problem.
00:30:55
Speaker 1: That's a really lovely answer.
00:30:59
Speaker 3: Okay, I know he's my husband, but I just have to say I was so impressed by Rich's perspective and how much he's evolved since I first experienced MIDLFE prmonal changes. I hope that any partner or a loved one or friend feels like menopause is a little less mysterious and a little less daunting after this conversation. If you take one thing away from this episode, I hope it's this menopause doesn't have to be something you suffer through in silence, and it doesn't have to be something that comes between you and your partner. There is a way to get through this together, and the more open dialogue we have between women, their partners, and their doctors, the more options we have for remedying symptoms and improving women's quality of life. I really love the way Rich framed this. You wouldn't get angry with someone for having an outburst when they have low blood sugar, or for finding out they have a lump.
00:31:56
Speaker 1: In their breast.
00:31:58
Speaker 3: Instead, let's treat menopause as the biologic event that it is. It doesn't have to cause a ripped in relationships. Communication and education are our best tools for navigating through this change together. Coming up on the next episode of Decoding Women's Health, Dry January maybe over, but our relationships with alcohol are year round. What are the ways for us to cut back on alcohol?
00:32:26
Speaker 4: Quite often, health professionals also feel uncomfortable about asking about drinking habits and pateants because we kind of assume that it's okay when it may not be.
00:32:37
Speaker 3: Decoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Daphne Chen. It was edited by Amy Gaines.
00:32:47
Speaker 1: McQuaid.
00:32:48
Speaker 3: Mastering by Sarah Bruguerer. Our associate producer is Sonya Gerwitt. Our executive producer is Alexandra Garreton. Our theme song was composed by HANNS.
00:32:58
Speaker 1: Brown.
00:32:59
Speaker 3: Concept creative development and fact checking by Shabon O'Connor. Special thanks to Alan Tish, David Saltzman, Sarah Nix, Eric Sandler, Morgan rat Owen Miller, Jordan McMillan, and Greta Cone. I'm doctor Elizabeth Pointer. Thanks for listening. Until next time.
