Stacy London (00:00) Doctor, it's so lovely to have you here. I'm so curious to know why a provider that is best known for sexual and reproductive health care for younger patients is now moving into all-age health care for women. We've talked about pregnancy, abortion, and bodily autonomy so much, but that really does extend to menopause. Can you talk a little bit about that?

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Dr. Amna Dermish (00:26) Yeah. Well, menopause has actually always been part of the suite of care we offer at Planned Parenthood. People just never really thought about us for that care. And we haven't been immune from the systemic challenges that impact access to menopause care.

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We really like to take our cue from our communities, about where care is needed. Listening to people talk about access to menopause care, and really understanding the barriers to that care, we perked up and said, "Wait a second, we do that. Let's get out there and let people know that Planned Parenthood is here for you" — from when you're sexually active all the way through your entire reproductive life cycle. We are here with you from the beginning to the very end. That's our mission. That's why we show up to work every day.

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Stacy London (01:19) Yes, exactly. And I did not realize that menopause has always been in your purview. But we haven't been talking about menopause. In the last, let's say, five years we've really been talking about it, but before that, very few people were taking hormones. There was no real medical assistance to be had in the community, simply because nobody was asking real questions. We didn't have enough understanding of what I call female physiology to be able to go to doctors and ask questions, other than to say, "Something doesn't feel right."

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So when you say you're listening to your communities and trying to figure out what people need — what really sounded the alarm for you? What did you start to see people coming in with and requesting? What kinds of symptoms were the most obvious, where Planned Parenthood realized it needed to emphasize that this is care it gives?

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Dr. Amna Dermish (02:19) Honestly, it was just this groundswell coming up from inside and outside of the clinic. A lot of it was patients coming to us and saying, "Things are changing, and I don't know what's going on. Help me figure this out."

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Perimenopause and menopause are complex for a variety of reasons. Some of it's physiologic, and a lot of it is just the state we're in in our lives as we're going through menopause — what it means to be women in our 40s and 50s, and everything that impacts us. So for us, it was really listening to the concerns people were bringing to us. A lot of times, people were coming to us because they couldn't get care anywhere else. This was a generation of women who grew up knowing they could rely on Planned Parenthood to be there. So when they go out into the healthcare world and their doctor's not listening to them, they think, "Planned Parenthood has always been there for me — let's go back to Planned Parenthood." And we've really been able to step into that space and say, "We're still here for you, throughout and beyond your reproductive years."

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But we realized we had to be proactive about letting people know we're here and available, because again, a lot of people don't think about us for that care.

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Stacy London (03:40) I'm curious about your thoughts on the estrogen shortage we're seeing at the moment. I almost don't want to say "crisis" — I don't want to sound alarmist — but almost everyone I know who is on an estrogen patch has had to go to more than one pharmacy to get one. What do you think this is all about?

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Dr. Amna Dermish (04:01) These are systems issues. Where do we start?

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Stacy London (04:04) Exactly. And I just want to preface: whatever you answer is the right answer. I'm not trying to put you on the spot. I'm just so curious, because I feel so naive about it. Why is this happening?

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Dr. Amna Dermish (04:21) I live in a world where we're constantly coming up against shortages — shortages of medications we need to treat our patients for the conditions we treat. In my world of sexual and reproductive health, shortages happen. When I said this is a systems issue, it's because a lot of the challenges we're seeing around menopause care — access to it and the quality of it — come down to the devaluing of women's health.

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Stacy London (04:54) God, it's hard. It's a relief to hear you say it, and it's also very hard to hear.

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Dr. Amna Dermish (05:00) A hundred percent.

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Stacy London (05:01) As somebody who has not gotten pregnant and not had children, I don't think it ever really occurred to me how much I didn't understand about my own body. There were no questions to ask that were complicated or confusing. And part of my journey in perimenopause was feeling like I was so crazy to even ask what could be going on with me — other than to get the answer "you're depressed" or "you're anxious." That's as far as it went. There was this whole system of hormones I didn't have any knowledge of — that we walk around not really understanding, whether as young women or as women who haven't been pregnant.

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Dr. Amna Dermish (05:50) A lot of people don't have that insight, and there are multiple factors to blame for that: our education system, how we value talking to people about this, what we hear about, what we see on TV, what we read about — who's talking about what.

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What's been magical for me in my world is seeing people speak up and share their experiences. They're holding us as healthcare providers to task, and that is so important. We need to set the bar higher, and sometimes it takes our patients and our communities speaking up and saying, "You're not doing enough." As healthcare providers, we need to rise to that and show up. That means providing perimenopausal care, but it also starts early. People need to understand, when they have their first period: What is that? What is a menstrual cycle? Because it's really a continuum. What we go through in menopause is a continuum of what started before puberty. It's all part of the same game. And if you don't have that understanding, how can you advocate for yourself?

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The reality is that people have to be able to advocate for themselves. They shouldn't need to, but in the healthcare system we live in, getting the highest-quality care often means being able to advocate. How do you do that if you don't have the base knowledge to understand what's wrong with you — if you've just been told, "That's just what periods are like," "That's pregnancy," "That's just getting old — deal with it"? As women, we're so much more prone to say, "Okay, it's just one more thing I have to put up with." It's not fair, and it's not right.

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Stacy London (07:47) No, it's not fair and it's not right — but it does explain a lot. What I've seen a lot of lately in the menopause care vertical, both medical and adjacent, is a blame game: "My doctor didn't tell me." And medical care says, "But you need a base knowledge to ask the questions." There's a lot of who knew what, and when.

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Talk me through what would happen if I had a telehealth appointment, or came to Planned Parenthood for perimenopausal care, and told you I had all the major symptoms I had: anxiety, depression, rage, headaches, hot flashes, mood swings, all sorts of things. And I come to you and say, "I literally don't want to walk across a bridge because I'm going to throw myself off of it. Help me." Now, the first thing is that I'd even know to come to Planned Parenthood — because most people would think I'd go to therapy or try to get some kind of psychiatric care. What happens when we come to you?

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Dr. Amna Dermish (09:00) We definitely want to know what symptoms you're having and what's going on in your life right now — the physical symptoms, the emotional symptoms, your medical history. While menopause can be responsible for a lot of those things, we don't want to minimize anything, and we don't want to assume, "Here's an estrogen patch — it's going to fix all your problems." What you're not going to get is someone throwing hormones at you and saying, "This will fix everything, see you later." We're really going to try to get to know you and understand what's going on in your life, because the experience is highly individual. It's important to acknowledge that individuality, and then guide you to the right place.

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If hormone therapy is appropriate, we're going to prescribe you hormone therapy. If there's anything in your medical history that makes us concerned about the safety of hormone therapy — which isn't many people, but some do have that — we can offer non-hormonal therapy.

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And then it's about creating a plan for follow-up. Again, it's not, "Here's a one-year prescription," and we send you on your way. We're going to make a plan to see you back, check in, and see how things are going. If there are serious acute issues we think need to be managed, we may provide a referral — for example, if you don't have any access to mental health care, we might talk about the value of that in navigating these changes. Then we'll see you back in a few months: What has hormone therapy helped with? Do you need any dose adjustments? What hasn't improved, and what else do we need to be thinking about? We can also draw labs to see if anything else could be causing it. We're really going to get the full picture at that phase of life.

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Stacy London (10:45) This idea of being able to recommend other doctors who can help with comprehensive care is really important. Both patients and doctors are so used to working in silos. When we see that menopause is this funny crossover between all the different systems in the body, it's nice to know that not only can we go to Planned Parenthood and get a plan in place, but that plan may include other doctors outside of Planned Parenthood.

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And it's funny — there are things that didn't even occur to me that really speak to that continuum you're talking about. Women can get pregnant in perimenopause. I can't imagine how many people you must have seen who are like, "What?"

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Dr. Amna Dermish (11:40) Yes, a hundred percent. There's a story that always comes to mind when this conversation comes up, because a lot of people say, "What do you mean?"

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Back when abortion was legal in Texas, I had a patient come in to see me. She was in her mid-forties, she was pregnant, and she was completely flabbergasted. She had one kid in middle school and another who had just started high school. She thought she was done. Her periods had been irregular, and she actually thought her pregnancy symptoms were menopause symptoms. She said, "I just thought I was going into menopause. I took that pregnancy test kind of thinking, whatever — and it was positive." It was just not the right time; she was not ready to have a third child.

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But what I think was funniest about that story is that she said to me, "You probably never see anybody like me." And I'm thinking, that's like half my waiting room.

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This comes back to our understanding of our bodies. When you look at unintended pregnancies, the rate tends to peak at the edges of our reproductive life: early on, and then at the end, when you think you're done. There are a lot of factors there. Your periods get more irregular — that's a normal part of going into menopause. It does get more difficult to get pregnant, but more difficult doesn't mean impossible. It's also really common for people to mentally say, "I'm done with that part of my life." So a perimenopausal pregnancy, especially when it's unplanned or undesired, can be quite a shock. That's why we always want to talk to people about contraception when they're in perimenopause.

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Stacy London (13:33) Yes. I would imagine contraception is the one thing nobody thinks they need to talk about in perimenopause. It's funny — and also, underneath it, depressing — to think that women don't know enough to know that's an issue, that there's crossover.

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You talked before about understanding the caliber of care needed and seizing on that. Planned Parenthood is such a respected institution, and the kind of care you're talking about — care with a capital C — is comprehensive. It's about education. It isn't, "Here you go, you're done. We saw you, we gave you the prescription, you handle it from here." I think there's a certain degree of hand-holding that needs to take place while we — medical people and non-medical people alike — are trying to educate women about where to get the best help, how to get it, and what that includes. So I really appreciate that you're talking to your patients in a way that doesn't make one issue or one health aspect the whole problem, but allows people to become their own advocates and understand what's happening to them in real time — hopefully before an unintended pregnancy, but you never know.

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Dr. Amna Dermish (15:11) Yes. You never know.

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Stacy London (15:13) So my next question: there's actually information overload now, when we're talking about what's online. I think part of menopause care is that we need a connection to our doctor or caregiver — a kind of personal relationship for a very individualized experience. What are practical filters for separating the amount of information we can get from the understanding that comes through a particular relationship? How do we recognize what's patently false — and also things that sound off, or may not be true for everybody? How do we learn to be smarter listeners?

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Dr. Amna Dermish (16:11) It is so hard these days. One of the amazing things is that we have access to so much more information than we ever had before. The downside is there's so much more to filter through, and that's a real danger of the space we're in. We're seeing it with menopause, with contraception, with vaccines. How does a layperson who doesn't have a medical degree, or a degree in public health or epidemiology, filter through all of this? It almost feels like you need that to make sense of all the information out there. And some of it is really smartly packaged. When you're experiencing a personal challenge and you see an Instagram post promising a quick fix, there's a little part of you that's like, "Maybe if I just did this..."

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Stacy London (17:00) If I just do this one thing. I do feel like a lot of the white-knuckling I went through was very much with that mentality: if I could just find the thing — the one thing.

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Dr. Amna Dermish (17:12) Yes. And the reality is that very rarely is there going to be just one thing you do that fixes everything. Even your estrogen patch isn't going to solve all your problems — but it might solve some of the big ones, and that's great.

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Another challenge is that because menopause is getting so much attention right now, there's a little bit of a gold rush around it. There are opportunities for people to exploit vulnerable women who are just looking for answers. That adds another layer of complexity to what you're looking through.

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So one question is: Is the person giving me this information trying to make money off of it? Are they peddling a quick fix — saying you just have to do this one thing? Then think about where it's coming from. How reliable is their information? If they're not a healthcare provider, who are they citing? If they are a healthcare provider, what are their credentials? And you can always go to the gold-standard resources. If you're looking for information about menopause, menopause.org — that's the North American Menopause Society's website — has great patient-facing resources, explained in clear language. It's a great resource for initial information. Planned Parenthood has great information on its website too. Really go to the source.

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And if you're out there collecting information on your own, you can at least use it as a foundation for your visit with your healthcare provider — not to replace it, but to say, "This is what I'm experiencing, and this is what I've read online. Help me understand what's actually best for me." That's where that information can be used as a tool in your relationship.

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Stacy London (19:24) That's actually very helpful. I never thought about bringing all the things I've seen and heard, in a list, and saying, "How does this apply to me?"

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I'm also curious — I'm assuming Planned Parenthood isn't in the business, or getting into the business, of GLP-1s. The reason I ask is that a lot of the telehealth companies coming up, especially the ones doing menopause hormone therapy, patches, and things like that, are also starting to offer GLP-1s. I've seen some telehealth companies say, "This isn't an actual GLP-1, it's a similar formulation," when we didn't really have a generic GLP-1 to consider. So is there a difference in care when a company can make significant money off of hormones, but can also make money off of things that may not meet the standard we'd call transparent about what's actually in them? What do we do in that kind of medical situation?

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I know this is outside the purview of Planned Parenthood, but it's something I'm noticing a great deal, as weight gain becomes a bigger issue in the menopausal years and as we age. It's becoming almost a marriage between hormones and GLP-1s. I'm wondering your personal opinion, and what advice we can give about, again, what's right for you — not everybody, but you.

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Dr. Amna Dermish (21:18) For you, yeah. I will say some Planned Parenthoods do offer GLP-1s — some offer primary care, and may offer GLP-1s in the context of that care. But the situation you're talking about is very unique. I've been observing what's happening, especially in telehealth — this asynchronous care where "I'm just going to put my information into this little app, and it's going to shoot me out a prescription."

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Stacy London (21:44) Yay, AI. We're not there yet.

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Dr. Amna Dermish (21:47) Yes. It definitely makes me nervous. A few years ago, it was online menopause care: you can get your estrogen, you can get your progesterone, that's going to fix all your problems. Then it's, okay, that's not going to fix all your problems, so now you can get testosterone, and that'll fix them. Wait, no — that's not going to fix them either, so we'll add GLP-1s, and that's going to fix your problems. What are we expecting out of the medications we're giving people? And how much of this is really about individualized care?

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My worry with a lot of these apps is whether they're really digging into the health history enough, especially as we get into more complex things like GLP-1s. It's not like sending a prescription for birth control pills after a brief health history — birth control has a long-established record of safety. GLP-1s are still relatively new. How much are we really qualifying people for these? I get nervous when I see ads that say, "Even if you only need to lose five or ten pounds, you can still take a GLP-1 — just call us, we'll send in a prescription." How much are we really thinking about the risks and benefits for that individual?

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Then you get into the source of the GLP-1s and where that medication is coming from: compounding pharmacies, where there may not be as much regulatory oversight. It becomes a slippery slope, where the potential for harm starts to increase and can potentially outweigh any benefits. For some people, GLP-1s are life-changing and really important, and we want people who need them to have access to them. But we shouldn't be doing it at the risk of harm — whether that's physical harm, or emotional and mental harm for people with eating disorders. How much are we really screening for this on the front end?

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Stacy London (23:50) Interesting. That didn't even occur to me, to be honest. I was thinking about it in terms of what the ingredients of a GLP-1 are, and what's being prescribed via telehealth.

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Dr. Amna Dermish (24:02) It's that too — there are multiple areas of potential harm. I don't work for any of these companies, so I'm not on the back end seeing what happens. I've tried to fill out some of those surveys myself, just to see what they're asking—

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Stacy London (24:21) [inaudible]

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Dr. Amna Dermish (24:22) —out of curiosity. But there are potential dangers, depending on how they're screening, where these medications are coming from, and what kind of oversight there is. There's a history with compounding pharmacies of contaminated medications, and of third-party testing showing doses that aren't the same as what's advertised. So where are they coming from, and what kind of testing goes into that? That's one big part. The other part is the harm to the patient from how we're screening.

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It's a big, complicated world out there right now. In some ways it's such a win for access, which is great. But are we really taking care of our patients the way we should be? In a system as broken as the one we're operating in — is any access better than no access? For some people, there's no other choice. There's no other way they can get care. So we're forced into a situation where these opportunities to cause harm are more likely to exist.

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Stacy London (25:44) I wonder if that's true of all opportunities. The more options, the more problems. There's more access, but more access always means more problems.

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Dr. Amna Dermish (25:58) Just enough options, but not too many.

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Stacy London (26:00) Exactly. Otherwise we're overwhelmed with information, we come in completely confused, and then we have to make sure we're doing something that's actually beneficial for us. There are steps to this.

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I'm curious — and I ask this of you personally, but also, obviously, in your capacity as a medical professional: our system is broken. If you personally could run the world tomorrow, what steps would you take to help where we're most broken in women's health? It could be as big as waving a magic wand, or the one step you'd take to really change something.

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Dr. Amna Dermish (26:46) Well, the invitation to run the world would be fabulous. As an Aries, I'm very into the idea.

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Stacy London (26:54) I believe very strongly that women — and women as they age — should run the world. That's actually the point of menopause: to get all those women in power.

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Dr. Amna Dermish (27:04) Yes, absolutely. Where do we start? We have to really value people's lives. We have to value their experiences. If we don't start from that foundation, we're never going to get anywhere.

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Because what is the issue? You can think about our healthcare system and our health insurance system — who has insurance and who doesn't. Then you think about the rural-urban divide: even if you have insurance, if you live in a rural area, do you have access to providers who can get you the care you need? Then you think about racial and ethnic disparities. We know that Black women go into menopause earlier, have more severe symptoms that last longer, and are the most likely to be dismissed by their healthcare providers. Then there's women in general — the devaluing of our health within the healthcare system and within research. And with menopause, on top of that gender bias and racial bias, you add age bias. It's such a complicated system.

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Stacy London (28:16) It is so complicated.

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Dr. Amna Dermish (28:18) It's so complicated. But underpinning it is that we value some people's lives and experiences more than others. That's the foundation of our broken system, and we can't fix it unless we fix that. That means changing our healthcare system and changing medical education.

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I was in medical school when the Women's Health Initiative study came out.

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Stacy London (28:49) Wow.

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Dr. Amna Dermish (28:51) Yes. With the first results, they had to stop the trial early because of the potential cardiovascular and stroke risks. So I didn't get any menopause education. This study came out, and hormone therapy was bad.

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Stacy London (29:10) It's bad. Right. And everybody stopped.

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Dr. Amna Dermish (29:14) Even though the data was so widely misinterpreted. It was completely misinterpreted, but it put a halt on menopause education.

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Then I went into residency, and residency in obstetrics and gynecology tends to be hyper-focused on the reproductive years, so menopause is an afterthought at baseline — and in the aftermath of the WHI, you don't get any. Then you're out in practice, and my generation became the educators and trainers of the next generation. So you have this cascade where nobody's learning about it.

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And one of the reasons we're actually seeing this resurgence — my theory — is that it's us Gen Xers who started going into perimenopause and menopause ourselves, and we're like, "No, we are not getting [inaudible]."

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Stacy London (30:14) Woo! And we're not getting the credit. The millennials are getting the credit, and I'm annoyed. I'm truly annoyed. How dare you try to take this one victory that Gen X women own away?

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Dr. Amna Dermish (30:24) Right? We're the fix-it generation.

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Stacy London (30:29) Yes — and very self-motivated.

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Dr. Amna Dermish (30:33) A hundred percent. We had to be, because our parents sent us out in the morning and didn't want to see us until dark.

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Stacy London (30:38) Bye-bye. Exactly. It's so true. I've said so many times, I really believe that's the Gen X legacy: we smashed the ceiling on what it means to talk about women's health, and on reconsidering how important these years are. And I don't like millennials taking credit for it.

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But to go back to your point about what we could solve in the healthcare system: saying that some people's lives are valued more than others — based on gender or race or financial situation — has come to almost a tipping point. At least I hope it has. I do feel like some version of what we've understood the systems in our world to be is getting really bashed in, if not collapsing. As nerve-wracking as that is for all of us, I think it offers a glimmer of hope about the way things could be in the future. And this unbelievable companion we have in Planned Parenthood is truly amazing. I want to thank you so much for coming on today and talking with me about this. Just to know that this care and access are available to all of us is wonderful.

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Dr. Amna Dermish (32:11) It is. It's such a great organization to work for. Every day, we care for our patients and our communities so much. We're going to go to the mat for our people, and we'll be out here every day showing up for our patients, making sure they have a space where they feel welcome and safe. That's our mission, and menopause is just one more extension of that. It's a privilege to be able to do the work I do.

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Stacy London (32:38) Amen to that. I want to end there, but I do have one other question for you. Post-menopause, we have to start thinking differently. We talk about all the health changes — strength training, good nutrition, good sleep, things like that. But when you see women really edging out of menopause — we're talking 65-plus — do you think of that as geriatric care? What's the next corner for women's health? What's around the next bend?

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Dr. Amna Dermish (33:17) The life of a 65-year-old now is very different than it was 20 or 30 years ago. For a lot of people — not universally, let's just say that — the opportunities to have a longer, healthier life are better than they were in the past. For me, care after 65 is about maintaining quality of life. It's strength training, it's nutrition, it's remaining active. And it has to be individualized to that person: What's their priority? What's important to them going forward?

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For a lot of people, it's still having a healthy sex life. You don't disappear when you turn 65. You don't disappear when you hit menopause, and you're not going to disappear when you're 65. So it's about still showing up for them and saying, "Here are the ways we're going to keep you healthy for as long as we can." That means getting your cancer screenings — that's a huge part of it. It's staying as physically active as is possible for you. It's talking about what's important to you. It's making sure you can live a healthy, happy, full life, and that your health isn't what's holding you back.

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Stacy London (34:52) Doctor, thank you so much. I feel very hopeful after speaking with you. I appreciate that you see both the positives and the negatives here, at least right now — but that we can always do better, always learn more, and empower ourselves with as much information as possible. It's great to know that Planned Parenthood is a resource.

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[End of episode]

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