Aoife: he looked at me going from this normal, highly functioning, multitasking woman that he'd known for over 20 years to , I didn't leave the house, became very socially withdrawn, had no energy.
Chrissie: I think about menopause, as many do, as like a second puberty, like one is going up the hill and the other one's kind of marching down the hill of hormonal balance. And what if we didn't tell people about puberty, right? It's like a whole other puberty that we haven't been really informed of.
Aoife: the symptoms that women come in with when they're going through the menopause transition are so varied, it literally affects every single cell in your body. And so women come in with symptoms from head to toe.
Chrissie: you're listening to Solving for Joy. I'm your host, Dr. Chrissie Ott.
Hello and welcome to today's episode of the solving for joy podcast. I am so excited to have here with me today, the Portland menopause doc herself, Dr. Aoife O'Sullivan. Dr. O'Sullivan is a powerhouse in the field of women's health and advocate for breaking the silence surrounding menopause. And she's become a trusted voice for midlife care and a trailblazer breaking down the stigma around menopause. With over 30 years of training and experience in medicine, Dr. O'Sullivan has dedicated her career to empowering women and filling the gaps in menopause care and education. She founded Portland Menopause Doc and is a NAMS certified menopause practitioner. She's not only a clinician, but also an educator and advocate for equity in women's health care. Her platform at Portland menopause doc has become a go to resource for women navigating this important life transition. And today we will explore the connection between joy and menopause and how these overlapping challenges affect women's health, their resilience, and their capacity to experience their life as joyful. Such an honor to have you here, Aoife, thank you for coming and welcome to the podcast.
Aoife: Oh, my absolute pleasure. Thank you so much for inviting me.
Chrissie: Absolutely. So, we are acquainted through the Oregon Physician Women's Group on Facebook, which is a pretty radical thing that this platform has brought together so many dynamic professional women in healthcare. Um, so I just celebrate that that is how we got to know that we should know each other more. And here we are. And that means that there's a lot of gaps in what I actually know about your backstory. And I think people love a good backstory. So will you share with us, um, a little bit about your trajectory training in Ireland, coming to the U S and now having become this, um, entity, Portland menopause doc herself.
Aoife: I'd love to. Thank you. Um, so I was born in, uh, Actually, I was born in the UK, but my parents were living there for a few years and I was back in Ireland probably by the time I was five and did all my schooling in Ireland and seemingly always wanted to be a doctor from the time I could talk and walk and, um, went to medical school in Dublin and then went on to do a family medicine residency. Um, at the time residencies were just coming in. This was 2001. And for family medicine in previously you had kind of done some six month jobs. So six months of pediatrics, six months in the emergency room, six months medicine, six months surgery. And then that was after your year of internship. And then you would do a year working with a family med doc in clinic, and then you would do your exams and you'd be certified.
So residencies were just kind of coming in for family medicine around that time. So I was still one of the older ones that did my own, um, six month jobs. And then I was working in the hospital and met my future husband, who always said he had wanted to do some of his training in the US. But I thought I would talk him out of that. And that did not happen. He got accepted to a residency at Johns Hopkins over in Baltimore. And so we left Ireland and moved to Baltimore and we were there for 12 years and, um, they weren't, I don't know if things have changed, but at the time they were not accepting residencies done outside of the US. So I had to go back and do residency all over again at the University of Maryland. Uh, so that was three more fun years.
Chrissie: Three more something years.
Aoife: I know. And then I was on a J 1 visa too. So then you can stay in the U. S. after residency if you work in a medically underserved area for three years. And so, you know, I was lucky, the doctor who ran the emergency medicine program at the University of Maryland, we got on very well. You do a lot of E. R. in that residency. And I ended up working with him in the emergency room down in one of the hospitals that was in Washington County. So it was considered medically underserved. So I worked there and loved it. So my history includes working in the E. R., urgent care, regular outpatient clinic. Um, I've done transgender, um, gender affirming care my whole career, really, since I've been here, which I think probably plays a part in me not being scared of hormones because I have routinely given women, you know, 10 times the normal dose that we'd use of, uh, especially testosterone. So, um, I think that's a part of my background that has really stood to me when I ended up specializing really in women's midlife care.
Chrissie: So interesting. Um, in the early 2000s, I also spent time. Um, and it was really, You know, it felt like kind of the beginning days of gender affirming care, not that that was really the beginning, but, um, it was beginning to pick up some momentum and I volunteered at one of the trans clinics at Outside In and just found it so meaningful to be part of, of that support. It makes sense to me that that would open the door and, uh, create some cognitive safety around, I can take this risk. I can, I can be a resource for these people.
Aoife: Yes, being a clinician in any part of gender affirming care is such a beautiful opportunity, you know, just to see people finally feel like they are themselves after all these, how many years of not feeling like they were in the right body. I mean, what a thing to live with, you know, um, you don't feel like you're in the right body. And then just to see them blossom and grow and is such a beautiful thing. Yeah, I really cherish that part of medicine.
Chrissie: Yeah. Talk about solving for joy. Right?
Aoife: Big time.
Chrissie: So how did you guys end up in Oregon?
Aoife: Um, I had always wanted to move back to Ireland. Um, Dave was always happy to stay here and I feel like I lived with one foot in Ireland and one foot in America for those 12 years really and only bought IKEA furniture, uh, you know, cause it was all going to be sold someday. As a symbol of my reluctance to settle and let it go. I never bought anything, you know, that I really loved just because I knew I was going home. Um, and then my dad died and I feel like a lot of the pull back to Ireland kind of was gone then for me. Um, and that was when I started to kind of open my mind, be more open to staying here.
And we could have stayed on the East Coast, but I, I truly thought after 12 years of living in a place, you would acclimatize to the weather and I was wrong. And I could not take that humidity in the summer and, you know, be 104 degrees and then it will be 100 percent humidity. And then you know, a few months later, so, so cold, feet of snow, ice, um, it felt like spring and autumn were about two weeks long each, you know, and otherwise you were in one of those either end of the spectrum. So when we decided we were staying, we really wanted to find a place that had more, I would say, Irish weather. And I think we chose well. As I look out at the gray sky here today, I feel very at home.
Chrissie: Love it. I was going to ask if it was pretty similar,
Aoife: it is very similar. It's, it's the same in Ireland. We might be a little bit hotter or a little bit colder, but it's pretty much the same weather every day, um, in each place. Yeah. We're right on the same latitude.
Chrissie: That's really fun. So when did you relocate to, to Oregon, Aoife?
Aoife: So I guess if I, I know I've been in the States 20 years, cause I came over in 2024 and we were in baltimore for 12. So it must be around eight years ago we came over to Portland. It doesn't feel that long ago, but yeah, eight years.
Chrissie: And what critical moments sort of veered you towards, I'm going to now focus on being a resource for people going through menopause.
Aoife: I think what you find when you're in this menopause space is you hear nearly a similar story from every single woman. And it is that she was chugging along, always felt in her practice of medicine that there was a group of women who she could never get to the bottom of their issues, all in that kind of late thirties, forties, early fifties age group, um, who would often come in with similar symptoms. And you know, when you learn about it then and you go back in history, you find all those symptoms under the diagnosis of hysteria. Or, you know, these diagnoses where women were put in institutions to live out the rest of their lives, and they're all menopausal symptoms, you know, um, so I think for a lot of us, We always knew there was a big gap in our knowledge, um, but you just don't know what you don't know, right? It's like going through your medical career never having been told about the existence of diabetes and repeatedly seeing patients who are thirsty and their appetites increase, they're gaining weight, they don't feel well, they're up all night peeing, but you just don't know, you can't make the connection, you don't know what that is. You know, condition is called, and you can't join the dots.
And so I think most of us always felt there were a group of women like that, and then at some point started to have symptoms ourselves and delve deeper and come across this phenomenon called perimenopause that none of us had ever heard of. No matter how long we'd been in medicine, you know, like I, I left medical school in 2001, which was the year before the women's health initiative study kind of brought women's health care crashing to its knees. And I hadn't had any training on menopause or hormones or anything, you know, it had never come up in any of my medical training and med school is six years long in Ireland. So it wasn't just the WHI. It's deeper than that. You know, really at its core, I think medical schools, residencies, fellowships were designed by men for men. And historically in medicine, I think we could look at any area and say that women don't matter or have not mattered really, you know, have not been studied.
Chrissie: Yeah. The analogy of, um, you know, all the symptoms of diabetes, but not having the name for it is such a powerful analogy for that. I mean, and then also to have those symptoms dismissed, denigrated, and, otherwise just sort of ignored. Um, so painful to this entire swath of the human population, right? Fun fact, my mom is one of the subjects in the Women's Health Initiative. She's 92 and I still fill out the health check forms that come every six months or so. And as a volunteer, right before medical school started, I actually did, um, like phone banking work for W. H. I. You did? Oh my goodness. Screening enrollment stuff. Yeah. Um, yeah. Full circle moments. Now we're slowly dismantling some of the things that we took to be truths from, yes, from back then, which I bet is a, um, probably a great jumping off point for some of the things that you wish everybody knew.
Aoife: Yeah, well, we can start with that. That sounds good. You know, the women's health initiative study is what any, it's almost like when you talk to a doctor about hormones or menopause, they have one or two little things that come to mind or that will come out of their mouth. And honestly, they feel to me now like little Fox News soundbites from 20 years ago. They're just not true, buddy. Let it go. And if you were to scratch the surface and say, yes, but why do you think that? Where did you hear that? No one would be able to answer any further question, like if you scratch the surface at all, no one knows where they heard that. No one knows how long they've thought that for. It's literally just ingrained into you, in your training, that hormones are dangerous.
Chrissie: It's like an algorithmic, like, road map in your brain. You're like, hormones, cancer, hormones, heart disease, hormones, stroke, stop, right?
Aoife: Absolutely. And based on nothing and whatever it is based on was not actually accurate. So what happened was, um, back in the 1930s, estrogen was discovered and at some point it started being used to help women who were having symptoms as they were going through menopause. And I think historically what was recognized was lot of the vasomotor symptoms, so night sweats and hot flashes, they were what was really recognizable in women and would stop them getting their sleep and going to, um, being able to leave the house. So we started using estrogen to help with those symptoms. And then maybe in the 60s, 70s, we realized that women who were just on estrogen and had a uterus were actually having higher rates, slightly higher rates of uterine cancer, endometrial cancer. And so someone put two and two together and realized that if you give estrogen on its own, it can just make the lining of the uterus thicker and thicker, and that can slightly increase your risk over your lifetime of developing endometrial cancer, because we all have a baseline risk of about 3%. So it could, it could increase that risk.
Um, and so some bright spark realized if you give progesterone with the estrogen that will protect the lining of the uterus So that's also where the belief that we only take progesterone to protect the lining of the uterus comes from but we know now we are more evolved almost every cell in our body has estrogen, progesterone and testosterone receptors. And, you know, like everything else in our body, they are there for a reason. Um, and so there were loads and loads of observational studies throughout the seventies, eighties, nineties, all showing that women who started on hormones around the time of they were going through the menopause transition. They weren't having heart attacks, strokes, developing diabetes, dementia, um, like men of the same age were. And it was just generally accepted that it was the hormones that were protecting women.
And so, because we kind of felt like we knew that, Doctors started to wonder if you gave hormones to older women, could you actually provide primary protection, even though they had probably laid down the foundations for heart disease? So the women's health initiative study was actually a randomized control trial, which is a gold standard study, really, in medicine to look at cardiovascular disease. Cardiovascular disease was the primary outcome. It was nothing to do with breast cancer. But if you're giving a woman hormones, then you keep an eye on things that are hormonally receptive and breast cancer is one of those things. And so they, You know, a lot of doctors around the world were wondering why were we choosing to use oral estrogen and Oral and synthetic oral progestin in these older women because as we age our risk of heart attacks, stroke, blood clot increases just naturally with age and now you're going to give two medications by mouth to women that also increase your risk of clot.
Um, and there was transdermal estrogen at the time and micronized progesterone, both of which are identical under the microscope to our own hormones that our bodies have always made. But I think the rationale was that these hormones, these synthetic hormones were very commonly used. And so they were going to use those then to see what would happen in these older women. But I feel like I was in medical school back then, and I feel like I would have been able to say, hang on, doesn't oral estrogen increase your risk of clot? And you're going to give this to a 79 year old woman? Like, what do you think might happen there? What could possibly go wrong? What could go wrong? I don't know. So they did it. They took women who were no longer having any menopausal symptoms, So no hot flashes or anything, and, um, about half of them had high blood pressure, about half of them were smokers or had been smokers, but half of them were obese or overweight. So these are women who've laid down the foundation for heart disease. Their Uh, blood vessels probably have some arterial plaques laid down.
And they started them on oral estrogen, which was, um, called Premarin, Pre ma rin, pregnant mare's urine, a big collection of estrogens from pregnant mare's urine. And um, Medroxyprogesterone acetate, which is a synthetic progestin, which is very active on lots of other receptors in our body, too, including testosterone receptors, other adrenergic receptors. So it doesn't just act on progesterone receptors. And actually, amazingly, about 97. 5 percent of those women had no problems. Very few women had any issues and they were the women tended to be in their Late 60s and 70s who hadn't been on hormones for 20 who hadn't hadn't seen hormones in 20 years So what we know now ,
Chrissie: Which is so different then the best practice now, which is to begin hormones when they begin to decrease, right? Before the foundations of heart disease are thoroughly laid down.
Aoife: Exactly. It's all about prevention. And that's just, we're talking cardiovascularly, right? And metabolically. But then if you're talking about something like bone, I mean, estrogen doesn't stop working on your bones at any age. Nothing magical happens when you turn from 69 to 70, it still is very beneficial for your bone. So yes, you would miss out on those cardio metabolic benefits, but, you know, especially for me now, I see a lot of older women as well, who can still benefit from having the hormones back on board, even if they have laid down the foundation for cardiovascular disease, you know, so it's just, it's so nuanced, the whole thing.
So it was a very interesting, um, They divided the study up into two groups. One group of women had, still had their uterus, so they would have needed estrogen and progesterone. The other group of women had had hysterectomy for some reason, maybe fibroids or heavy bleeding, or endometriosis, and they, we thought at the time you didn't need any progesterone then, so they just took estrogen on its own. So a couple of years into the study, uh, some of the women in the estrogen and progestin arm actually did have, uh, there was an increased risk of heart attack, stroke, and they thought they saw the incidence of breast cancer increasing.
And so they called the big six monthly meeting and they all came expecting to have a little bit of a snooze because it's usually quite a boring meeting. And instead, um they were met by a small group who had gotten together and written an article for JAMA, this, you know, one of our main medical publications in the country at the time, and had written a press release stating that HRT caused breast cancer. And it was quite frightening because the media release was going to say HRT increases your risk of breast cancer by 25 percent because they had seen that out of a thousand women over five years, um, the risk of breast cancer had gone from four out of a thousand to five out of a thousand. which is a 25 percent increase, of course, but only if you know the difference between a relative risk and actual risk. Yeah.
So they were had on the front page of the paper HRT increases your risk by 25%, which is terrifying for women. So all the investigators were faced with this journal article and media release and they were trying to fight back saying, you can't do this, you know, this, what had happened was when the actual statisticians and epidemiologists looked at the numbers, the increased incidence of breast cancer was not statistically significant. And in medicine and science, if something is not statistically significant, you put it in the trash and you move forward. Right. And so they went ahead and they did all this with numbers that were not statistically significant.
Chrissie: Or you call it a trend or you call it a small signal. You don't call it a finding.
Aoife: Exactly. Yeah. And you know, Speaking to the investigators who, if you listen to them, they will say that, you know, the incidence of breast cancer had been bouncing up and down a little bit, all kind of, you know, up one minute, down the next, up, down. And so it was just fluctuating. And so this one was no different than the one a few months ago, you know nothing special about it.
Chrissie: part, I won't say the funny part, but one of the poignant parts is, you know, our brain creates our reality, right? And the fact that there was an underlying, possibly understandable mechanism of action made it very enticing. to jump from hypothesis to new understanding of fact.
Aoife: Yes. So, the doctor who kind had spearheaded all of this was a cardiologist from France who had said before he ever joined the Women's Health Initiative as one of the principal lead investigators that, you know, hormones were a problem, women were running away with themselves. And, you know, we needed to get women off this hormone bandwagon. So when you have a person in charge of a study like that who is so obviously biased,
Aoife: you have to wonder, you know, is he the best choice for something like that? And so this was a time where there was no social media, email, anything like that. And so all doctors in the community knew were what they had heard on the news and in the newspaper. Hormones increase the risk of breast cancer by 25 percent because that journal article didn't come out for weeks afterwards. So by the time they'd made their lists in the clinic and gotten their staff to call all the patients and take them off their hormones, they still hadn't even received that journal article to read it and look at the numbers. That was 2002. So that was just devastating for women.
So at the time, about 40 percent of menopausal women were on hormones. Um, it was the fourth or fifth most prescribed medicine in the country. Within a year or two, it had dropped a few years. It had dropped to 4%. Um, and what you see dr. Heidi Flagg is an OBGYN over on the East Coast in New York. And she made the most beautiful, um, graphic of this. But it's the, you can see the drop in hormones and then what, you see is over the next few years, the numbers of antidepressant medication just rising, just, you know, logarithmically, um, Xanax, sleeping medications. So it's not that we haven't been treating menopause for the last 20 years. We have. We've been treating it with band aids. And lots of other medications instead of actually getting to the root of the problem and treating the actual condition.
Chrissie: That's a very profound, um, um, juxtaposition. That's fascinating.
Aoife: So that was the WHI and that was the beginning of the end really and it's only recently over the last few years Susan Dominus is a journalist and writes for the New York Times and she wrote an article a couple of years ago about her experience going through menopause and having so So much difficulty finding medical care to help her. And so I think that article really in the New York times really helped kickstart things. And then you had you know, people like Oprah Winfrey. Talking about it on her show, inviting specialists on and women who've been through menopause on telling her own story. So it's really women doing all of this work and trying to teach other women about it. And we're at a stage now, unfortunately, where in general, your average woman knows more about menopause and how to manage it and treat it than the doctor that she will go and see.
Chrissie: That is quite a statement. Wow. That's sobering. how did you get pulled into doing this work?
Aoife: yeah, pretty much. That's what I meant earlier. Like, we all have a very similar story. It's when we reached a certain period of life, um, where we realized, I suppose when you, you know, like I would see and treat so much depression and you know, I went to my own doctor and I remember sitting in her office and she's wonderful, but she hasn't had any training either. I remember sitting in her office telling her all my symptoms and crying and I am not a crier and saying, this isn't depression. Like I, I see depression every day. I treat it. I know it. And this is not depression and left her office with a prescription for an antidepressant.
Chrissie: Mmm. Yikes.
Aoife: You know? Yeah. And so for me, uh, the big, I had a lot of brain symptoms, so um, problems with focus, concentration, memory, awful, awful word finding. I would stop in the middle of a sentence with a patient and just have no idea where I was going with that sentence. You know, I would say to my kids, what is that yellow thing in the fruit bowl that you peel and eat? Like genuinely could not remember the name of a banana. And I'm in my, I was in my early forties.
Chrissie: And how did you get help? How did you find a person who was menopause capable?
Aoife: So I got, I just felt worse and worse, had no energy, ended up, you know, I often think if it had been my husband, I would have had him at the doctor's office within a week or two. I mean, he looked at me going from this normal, highly functioning, multitasking woman that he'd known for over 20 years to making breakfast, lying down on the couch, making lunch for everybody, lying down on the couch, making dinner for everyone, lying down on the couch. I mean, I, I didn't leave the house, became very socially withdrawn, had no energy. You know, he is a medical oncologist. I just had myself convinced I had some type of terminal illness and just had not been diagnosed yet. I really thought it was probably a brain tumor because of all the difficulty word finding and the memory issues. So that's what I thought was going on with myself. And then at some point my phone picked up on it. And started sending me little videos on Instagram from menopause specialists. My phone had literally put things that had heard me saying obviously together and realized that I was going through menopause and I started seeing videos from like doctors over in the UK. Louise Newson. She's a wonderful. She's a family doc as well with special interest in menopause. She's a wealth of knowledge, and it would send me little videos from her and bit by bit, I would realize, Oh my God, that's exactly how I feel or what I'm feeling.
And so I realized I, you know, I needed to at least try some hormones because that gives you a lot of answers, right? If you start it for a few weeks and, and it, it, If everything gets better, you know you're on the right track.
Chrissie: You know, that's a message everybody needs to hear. Your health ultimately is your very own lifelong experiment. And you can make choices with agency and gather data, and then you can re decide. You can do it with education, you can do it in partnership with your doctor, but ultimately your health is your own experiment. How you eat, whether you move, and whether you use hormones.
Aoife: That's so important for women to realize, because I think we're all so conditioned to this paternalistic view, especially in medicine of just being really doing what you're told to do, really, or having things denied to you, you know, I think it's different for obstetricians and gynecologists because they only see women. But at some point in my own practice, after I had learned about ovarian neuroendocrine hormones. I don't call them sex hormones anymore because I just think that is a complete, you know, misnomer. Um, but I realized that I was treating my male patients and female patients very differently. You know, my male patients would come in and say they were having some symptoms, which sounded to me a little bit like maybe they were having some issues with their testosterone. But, which can be for many reasons, right? It can be lifestyle related, sleep related, all these different things. But I would often say to them, do you want to do a little trial of testosterone, even while we're waiting for you to see X specialist or have Y test done? And you know, I would start them on their testosterone and then bring them back to see how they were doing. And yes, You know, well, first of all, I had never put the pieces together for a woman, but if I had not knowing what I now know about hormones, I'm sure I would have said to her, you know, hormones are not safe. You can't have them from my point of view, trying to keep her safe, right. But also from the patient's point of view, you know, closing off any discussion, treating her completely differently to my male patients. Um, and letting her leave my office hopeless.
Chrissie: Oh my goodness. You know, I have this flashback Aoife I can't help but share. So my mom had hypertension. As I mentioned, she's in the women's health initiative as a patient. Um, she had had some TIAs related to, um, you know, not always well controlled hypertension. And she had a family medicine doc who kept prescribing her hormone therapy. And this was the very early 2000s. And I would get absolutely rageful feeling protective and also disdainful, um, towards this physician who I just knew was going to cause my mom to have a stroke. I think a little differently today. And that was so real. It was so real.
Aoife: Yeah, absolutely. Like, I don't think any doctor is sitting there trying to harm their patients or hold back something that would help them. It's the way we've been trained, you know, and that's what's so different for me now. You know, a few years ago I came to the realization you can just believe your patients, just believe women. If you start somebody on something and they come in and tell you, I had X, Y, Z symptoms after starting that and that seems absolutely crazy to you, so what? Just believe your patient And work from there, you know, um, and also to give your patient agency, they're coming to you for advice and your medical experience, not for you to be their parent. It's not your job to say no to something that really is a lifestyle and, um, so important to someone's longevity, you know, and especially when you're talking about something that is so safe and effective. It's not like somebody's coming in asking you for oxycodone, which may, it has a very high addictive potential and could change their whole future, you know, that's not what we're talking about here. We're talking about doing a few month trial of a medication that's very safe, that's identical to something the person is producing themselves since they were in utero. Um, I mean, you have to look at this differently, you know, and you have to change your attitude and reframe everything that you were taught because we were taught from a very patriarchal point of view, even though we don't even realize that ourselves as women, you know, in medicine.
Chrissie: So true. It's so exciting for it to actually be getting, um, so much more sharing and just having this moment in media right now. I think it's, you know, largely because there's a wave of women who are engaged in both creating the information and spreading this information and saying, I want to help other women not experience what I did or for as long as I did. I mean, I have a list of friends and acquaintances as long as my arm who reach out to me about their various sufferings related to this. And, you know, My favorite menopause doc is my OB gen and I can't send everybody to her because she's got a year and a half long wait list, honestly. But finding somebody who is really ready and primed to listen, believe and help is worth its weight in gold.
Aoife: It is. I know,
Chrissie: and many, many people, you know, who have a history of a cancer diagnosis are facing this with even more trepidation, for cause I imagine. But again, we're breaking down these beliefs that were so concretized in the late nineties and early two thousands, that made this very, very, uh, tight relationship between cancer and HRT. So my wife is one of them, um, having done very well these last two years after treatment for an ovarian cancer and then suffering at least as much with her postmenopausal symptoms as she did through chemo. Honestly, the brain fog just as bad, the sleep disturbance just as bad. Um, the body aches just as bad, um, and. Finally, she's on some transdermal estrogen and I don't hear about these things anymore. Suddenly we're like, Oh, there's a new baseline happening.
Aoife: That's wonderful. That's a great story. I'm so glad that she has some relief.
Chrissie: I had to go dive deep as an advocate to look for affirming resources because the, the reflexive protective no, um, is very powerful, has a lot of momentum.
Aoife: Yeah, even from your specialists, you know, who you think know this information, but it is not known. So we have guidelines and, um, great information. when it comes to gynecological cancers and hormone use. So you think that your doctor knows that information, but in general, they don't even the specialists. And, um, even when it comes to something so simple as vaginal estrogen cream, which can be life changing for so many women, you know, Dr. Corinne menn is a, um, is an OBGYN and she does mainly hormone treatment and midlife women's midlife care too. And she loves reframing things and she's very good at it. And, you know, she talks about she unfortunately, um, had breast cancer herself. And, and she was explaining that, you know, when you're going through cancer treatment, there are these pre medications that you use all the time, you know, take your Benadryls, you won't get a reaction, take this, so this won't happen.
And, and Vaginal estrogen should be one of those things, right? We have so many studies. It makes me actually nauseous thinking about how many studies we have gone over and over and over and getting the same results over and over and over. I'm like, why are you spending more money doing these studies when we have the answers already, it is super, super safe stays where you put it. Anything that does get absorbed, you still in the post menopausal range. I mean, that's where doctors aim to keep your estrogen levels when they're trying to keep your levels low.
And yet it is not part of the normal care and women have to get to a point, even in guidelines, it will say, if you failed everything else then you can use some vaginal estrogen, whereas it should be you're going through, about to go through cancer treatment, but we're about to block all your estrogen receptors, you need to start using this vaginal estrogen cream so that you don't get bladder problems, vaginal problems, vulva problems. You can have your relatively normal sex life and not suffer. Because we don't want you to suffer. We want you to suffer as little as possible.
Chrissie: nausea and vomiting is real suffering. But vaginal dryness, atrophy, and bladder dysfunction is not real suffering because it's down there.
Aoife: Yeah. And who are we to decide what is suffering for a woman or how much suffering is acceptable? That's not our job. Our job is to look at the evidence, and the evidence shows that so many of these things are safe, you know?
Chrissie: I'm getting so fired up. Aoife, how are you helping educate other physicians? Is that part of your mission?
Aoife: Oh, that's one of my favorite things. Yes. So I have put together over the last few years, a series of talks now, you know, I have different ones on genital urinary syndrome and menopause. I have my kind of regular overview of the Women's Health Initiative and, I tend to give a lot of resident talks and, um, the Oregon Academy of Family Physicians have been great. I spoke at their annual conference and we've done a lunchtime series as well of webinars. So, they're great because they have a lot of medical students and residents who follow them as well, so can kind of start to get that information at an earlier stage instead of waiting until they're years into their practice.
But it's very slow, Chrissie. I mean, it's like chipping away with it with like a little toothpick, you know, some massive mountain of ice. It's very, very slow. I don't know how we change things any faster because it has to come from day one of medical school. You know, the teaching cannot continue that, you know, X, Y, and Z are symptoms of depression and you treat that with um, cognitive behavioral therapy and SSRIs or SNRIs. It has to include, and if your, if your patient is between X and Y ages, please consider this could be perimenopause because estrogen is very important in your brain and the levels are changing and you know, things like that has to be taught from day one or just is not part of your knowledge.
Chrissie: Oh my gosh. So I think about menopause, as many do, as like a second puberty, like one is going up the hill and the other one's kind of marching down the hill of uh, hormonal balance. And what if, what if we didn't tell people about puberty, right? We really quite largely accept that puberty is a time of vast transition, um, with rather unpredictable, um, neuropsychiatric symptoms and rather unpredictable physical symptoms. And the truth is that it's true on the other side too. It's like a whole other puberty that we haven't been really informed of.
Aoife: A hundred percent accurate, I would say. Yeah, it is like going through your career as a doctor not knowing about puberty.
Chrissie: Or diabetes.
Aoife: It seems so ridiculous when you say it like that, right? Or going through your whole medical career, not knowing anything about pregnancy. I mean, the thought is just laughable. How we can be over 50 percent of the population, how probably half of all doctors are women, and yet none of us know about this. I don't know how we got here.
Chrissie: Such a lack of education, but we are changing that. You are changing that.
Aoife: We are.
Chrissie: I am excited to share this platform with you today to do a little bit more work in that direction and think about the systemic barriers that individual women have. And then they have the question of who do I go to? Right? Like, how can I trust that I will go to somebody who knows what to talk about? I'm sure you have some special advice for women who are looking to find a practitioner, uh, who's informed and safe to see.
Aoife: So the North American Menopause Society, who are now called the Menopause Society, they keep a list of clinicians who sit their exam and, um, are certified. So, you know, I went through that list just for Oregon one day, it took me many hours and I tried to find the clinicians on it. And um, I would say, you know, half of the people listed, it's not possible to find them. Either they've left the state or they don't have any contact details or the contact details are old. So that is like our main place to start, the menopause society. And kind of make a list and you can put in your zip code and it will pull up clinicians close to you. And then you have to do a little bit of legwork and research them online and see who is actually open and seeing clients, who is accepting your insurance, who is cash pay. So you have all that information.
And then when you get your top three say, I would make phone calls to their office and say, does, uh, Dr. X. So, and so, um, see menopause patients and do they, do they use hormones? Do they use hormones in women between the ages of X and Y? And just get some more information because, um, me and some other women I know of have I have used that list to find a doctor, have waited nine months to see them, only to be told something along the lines of, you are still having periods, so you should not be using hormones. And that is absolutely untrue,
Chrissie: myth number 432. Yes.
Aoife: Devastating for a woman who has hung her hopes on this appointment for nine months, nine more months of suffering. It probably took her a long time to even make that appointment. And then she leaves completely devastated after it. So you really have to do some legwork or, you know, if any of your friends are happy with their clinician, that's a great way to find somebody as well, because you know you're going into someone who knows what they're talking about.
Chrissie: Yes, the Whispered Network is growing, right?
Aoife: Yes, absolutely.
Chrissie: It just sent somebody your way this past week who is suffering and really needing somebody to guide their way through this transition.
Aoife: Thank you so much.
Chrissie: Yeah. Absolutely.
Aoife: I look forward to seeing them.
Chrissie: In your practice, um, yours is one of the cash pay practices, which I think is such a, it's an important model to talk about because in the U. S. system, of course, it's a little newer. I mean, there have been plenty of people who have been doing it for a long time, but I just came here to say this people who have opted out of negotiating with insurance companies and tell me if I'm off base for you, Aoife, have simply decided to stop participating in abusive relationship. They decided to stop staying for the children. I used to think this in private practice all the time. This is such a toxic and abusive arrangement but I don't want to do something that could disrupt things for my patients.
And so I will stay in this abusive profit driven grinding system that actually makes no sense of the value that I am providing
Aoife: a hundred percent. I agree. Yeah. You know, menopause care is different than anything else I've done in medicine. Um, because you cannot just say if, if a patient comes to me and they have high blood pressure, I can spend a few minutes saying, okay, here's what high blood pressure is and why you have it. And here's what we can do about it. I have a selection of medications I can choose from, but because you also have diabetes and you have some kidney issues, I'm going to choose this medication. And the patient looks at me and thinks she knows what she's talking about. She's done this before. This is blood pressure. I trust her. I'm going to take this medication.
I've never had to deal with anything like what we deal with now when we're doing menopause care. Because patients come in thinking that what you want to treat them with often is something that will cause them to develop breast cancer in particular. And so you can't start off by saying, here's what you have. Here's what we have to deal with it. Here's how we'll manage it. You have to start explaining things like the women's health initiative study and things like that. And it takes so much time. And also because the symptoms that women come in with when they're going through the menopause transition are so varied, it literally affects every single cell in your body.
And so women come in with symptoms from head to toe. And as a doctor, you never just let yourself think down one path because you can miss things. And so you're not just thinking, Oh, this is easy. This is perimenopause. You know, you're thinking, Oh, I must make sure she doesn't have this. She must make sure she doesn't have that. What if this is an issue? And so, you know, it takes time. And in insurance based medicine, you have about 15 minutes if you're lucky with your patient. And it's really, really, lots of, lots of insurance based docs have to do this. So I'm not saying it's not possible, but it's really hard to do menopause and women's midlife care in 15 minute visits. It's really hard.
Chrissie: It's really hard to feel satisfied as a physician providing care. Service, when you're squished into those 15 minute blocks of time, I
Aoife: when you're in a cash pay practice, you know, you, you have the time to, you have a smaller panel of patients and you have that time that you can spend together. And especially if you have a woman who's not menopausal, she's still having periods. So her hormones are all over the place. So you might have her on a great level of estrogen and progesterone. And she's great for five months and the next thing things start to go a little haywire because her body has changed how much estrogen and progesterone it's producing. And so now you might be either overestimating or underestimating how much you need to give her, um, through medications. And so it's constant work in progress.
Chrissie: Can I ask you an in the weeds question?
Aoife: Yeah.
Chrissie: Um, when you do that, like how often do you check people's levels? And do you find checking levels to be an important part of menopause care?
Aoife: So hormonal levels, I almost never check. Um, I will check hormonal levels if a woman has not had a period and a long time and is wondering, is she really getting close to menopause? And then we'll check some hormone levels, maybe six weeks apart. And if they're at certain levels, I can say to her, you know what, you don't need to worry about birth control anymore, you are now menopausal. You can, you know, decide what levels of hormones work for you, if that's what you want. But to check hormone levels in general, especially when you're in menopause and you're still having cycles. Um, It doesn't give you any information because those levels change from minute to minute, literally. It's just crazy. You could check your estrogen in the morning and it could be 30 and it could be 130 then by the evening time. You know, so you can't get any information that you could trust from those levels. Um,
I'll sometimes check a baseline testosterone. So I have an idea of what that woman's testosterone level is. Because if we get to the point where we see like, it's a good time for her to start some testosterone treatment. I want to know that I'm not starting that in someone whose testosterone is 50, you know, which is a very good level. And so I just want that reassurance that her testosterone is low before we start any treatment. And but other than that, I would do the lab work that any other doctor would do, I want to make sure that I'm not missing anything, and that your symptoms are not because you have an iron deficiency or a B12 deficiency or your kidneys are not working properly, you know, so I'll be checking.
Chrissie: Thyroid problems.
Aoife: Thyroid problems, exactly. So I'll be checking lab work to make sure we're not missing anything. And in the meantime once, you know, we're ordering those and everything it's still safe for you to start on your hormones. If we find out your iron levels are through the floor, then we treat your iron too. And we, you know, so that's why I would do blood work.
Chrissie: I love it. I could probably just talk your ear off all day long about this stuff, but
Aoife: Oh, you can do that. I love talking about it.
Chrissie: I can tell. And I love it too. So good. I would love to hear your last few thoughts about joy and menopause the joy of being a menopausal woman. Um, the joy of having your menopause properly addressed, um, just all, all of those types of things.
Aoife: Yeah. So let me see what is joyful about menopause? I think it comes, it's part of that age where you realize what's important in your life and what isn't important, you know, um, and you're really trying to focus on your longevity. And so you're realizing oh, it's much more important for me to be strong than it is for me to be thin. So I need to really start focusing on lifting some weights rather than counting calories all the time, because counting the calories is not really going to keep me alive for any longer if I'm generally healthy, but lifting weights and having more muscle, that's a good key to longevity. Um, and so I think you're coming to all those realizations and you're really starting to. put things into perspective, what's important and what isn't. Um, I absolutely like, I see so many patients who have tried to get care elsewhere and have been unable to. And so I often see women who are at the end of their tether.
And often, uh, frequently a woman will tell me later that she was having suicidal thoughts, you know, um, and so even when things are not that severe, just, you know, no matter which patient comes to me, I cannot describe the joy I have in my work from following up with them and hearing the changes they have noticed in their lives, because what happens is this comes on so insidiously, so slowly that you start to rationalize everything. It often comes on at a time where we are, you know, driving the kids everywhere for their sports. Our parents are, might have some health issues going on. We've risen to a stage in work where we have a lot of responsibilities. And often we may have, you know, deaths in the family and you're grieving. And so it's all gets very complicated and you don't put it down.
Chrissie: It's a perfect storm, right?
Aoife: Yes. And so hormones are the last thing you're blaming. You're blaming the stress and the lack of sleep and this, that, and the other. And so when you, when I start somebody on treatment, then when I see them and when I see them come back, I just, it is such a beautiful process listening to them, what has changed, um, women will come back and say, I finally feel like myself again. Yeah. I mean, is there anything more beautiful than that, than someone coming back and saying they feel like themself?
I've had patients come back and say, my daughter hasn't been speaking to me, and now that my mood is back to normal, and I'm not irritable, um, she is back talking to me, I was thinking of leaving my marriage and now I see it was all hormonally driven. I am not a crazy person. I just needed my hormones. And now my I am not leaving my marriage. I was thinking of leaving my job. I'm not doing it, you know, massive, massive life changes. And if you talk to divorce attorneys, they will tell you that so many marriages break up because of these menopausal symptoms. Um, and you know, if you look at women over their lifetime, you see this spike in suicide rates between about 45, age 45 and 55. So this is a massive, massive deal that we have been ignoring forever, basically, um, and it is a truly beautiful and joyful part of my practice. I, I just, I can't even express how much joy it brings me once I, once the veil had been pulled back from me I could no longer unsee it. It's just, I want to talk about it all day, every day. I want to tell every single person I meet about it. I want to teach every single clinician. I know, I just, you know, that is my joy now.
Chrissie: That is amazing. And where can people find you, Dr. O'Sullivan?
Aoife: My website is www. portlandmenopausedoc. com. I just met with a wonderful woman today who's going to redesign the whole website for me because it was something I put together very quickly. And it was just so people could find me, but I would like to have some really good information on there and make it look more beautiful. So that's going to happen over the next few months. And I'm very active on Instagram. So I'm on Instagram as Portland menopause doc, and I share some great information. And, um, Anyone whose information I share on Instagram, you can be 100 percent sure that that is evidence based information. And these are doctors and clinicians who read medical journals and who are like myself. They eat, breathe, and sleep this midlife women's care information. We love it. We thrive on it. It's what we're about. And those are the clinicians that I'm sharing. So, you know, it's a good resource.
Chrissie: Amazing. And do you see people virtually?
Aoife: Yes, at the moment, I am all telemedicine, which may change, you know, I do like seeing patients in person. But at the moment, I'm doing all telemedicine because my life is chaotic. I have two teenagers, you know, preteens and teens, and I'm basically an Uber driver. Um, I feel like the schools in Portland act as if you, each child has two unemployed parents sitting at home just waiting for the call, you know. So I've been so grateful that I'm doing telemedicine at the moment, um, because I can do all that stuff too.
Chrissie: Yeah. I am full of joy that you have found a way to be flexible and still just pursue your passion in medicine and make a difference in so many people's lives. Um, I know that you spoke after the M factor recently. Uh, I hope that there will be another time for us to do that. That is a documentary about menopause. Um, maybe we'll link to that in the show notes too. But I'm just so glad to get to spend this time with you, Aoife. Thank you for being here. Thank you listeners for tuning in. I hope that this has just turned the light on in some new way that will help you or someone that you love.
Aoife: Thank you, Chrissie, it's been such a joy and a pleasure to be here with you today.
Chrissie: Hey, thanks everybody for joining me today for this incredible conversation with Dr. Aoife O'Sullivan. So glad to have had her here. And if you think this was a treat wait till next week, we are going to be talking with Dr. Kristine Goines the Nomad MD herself, about ways that physicians can become part time or full time digital nomads. It is a delightful conversation with so much inspiration. And I want to invite you once more, if you haven't examined our 2025 offering is a six month life changing intensive for physicians called ROAR, where we are going to reclaim our brains, own our power, access our joy, and raise our voices, both individually and in collective. We have a lot of work to do, friends. We might as well do it together and make it fun. Please consider joining me in ROAR. I can't wait to see you next time. Please take care of yourselves, take care of one another, and keep solving for joy.
I want to take a quick moment to acknowledge our incredible team. This podcast is produced by the amazing Kelsey Vaughn, post production and more handled by Alyssa Wilkes, and my steadfast friend and director of operations, Denise Crain. Our theme music is by Denys Kyshchuk cover photography by the talented Shelby Brakken and a special appreciation to my loyal champion and number one fan, Suzanne Sanchez. Thanks again for tuning in everyone. May we continue caring for ourselves, caring for others, and may we continue solving for joy. Take care. We'll see you next time.
