‍Guest: Dr. Joanne Armstrong, Vice President and Chief Medical Officer, Women's Health and Genomics, CVS Health. This episode is sponsored by CVS Health.

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This transcript has been lightly edited for readability. Filler words, false starts, and crosstalk have been removed; no content has been added or changed. Words in [brackets] are editorial clarifications.

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Stacy London (00:00) Hey friends, the views of our guests do not necessarily reflect the views of Let's Talk Menopause. Let's Talk Menopause does not provide medical advice. The content in this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have.

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Dr. Joanne Armstrong We define women's health as physical health across the lifespan and behavioral health, and we particularly include the social and environmental factors that affect health: time for care, access to care, preference for how you receive that care, educational resources so you can more expertly navigate it, and stigma — talking about it — so that we're actually meeting people where they really are. And for women, those barriers are in many ways different and greater than for men.

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Stacy London Welcome to Hello Menopause. I'm your host, Stacy London. Hello Menopause is changing the conversation around menopause. In every episode, we explore the physical, emotional, and mental changes that women experience during this transformative stage of life.

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This episode of Hello Menopause is sponsored by CVS Health. CVS Health is committed to closing gaps in women's health at every life stage, because every woman deserves care that is accessible, affordable, and personalized. Learn more at cvshealth.com.

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Narrator Today we welcome Dr. Joanne Armstrong, OB-GYN and Chief Medical Officer, Women's Health and Genomics at CVS Health. She joins us to talk about what women can do to make sure they get better menopause care.

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Stacy London (01:49) Dr. Armstrong, thank you so much for joining us. I really want to start with the numbers, because I feel like they're pretty staggering. Research shows that 13% of women have quit their jobs because of menopause symptoms, and that adds up to something like $2 billion in lost work a year. Why has it taken so long for employers to finally pay attention?

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Dr. Joanne Armstrong (02:14) Well, I agree — it has taken a long time for everybody to pay attention, not just employers. It's a whole healthcare-ecosystem thing. The flip side is that the good news is we are now paying attention. So we could talk about why we're paying attention now and why we didn't in the past — two separate but somewhat related questions.

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Why we should pay attention, and are, is that the workforce is aging. As you rightly note, we have something like 32 million American women in the workforce between the ages of 40 and 55. It's not the fastest-growing piece of the workforce, but it's the second fastest. So as we age, we have a big demographic issue, and we've got people who experience perimenopause and menopause over a 15-year period of time. It's too easy to think of it as a period of time, and then it's over and done. That's not the way it works. There's no pause, as they say, in menopause. So it's a really long window — either for disruptive things to turn work and life sideways, or to pay attention and get it right.

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So I think part of why we're paying attention is the demographics. I also think this population is not the same as my mother's generation, or perhaps your mother's. We grew up talking about it, and we're going to talk about it — which is a great thing.

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What's held some of this back is that there's a lot of stigma associated with menopause. Jokes — I don't even get it, because that's so not me. It's healthcare. Why is this funny? But it has been. And it translates into a lot of women feeling embarrassed to talk about it. I think the numbers are something like 80, 83% of women feel stigma around it — stigma at home, stigma at the doctor's office, definitely stigma at work. So you've got this very long period of time where you just don't feel well. Maybe you're not educated about it, because somehow you think it's a moment in time — or worse, you think it's nothing to complain about. And you've got a workforce that's not completely trained to address it.

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So those are the bigger dynamics. The other issue in the workforce — and it's part of my job to think about — is who women in the workforce are. The cohort of women who are 40 to 55 years old are the backbone of the workforce. It takes us 20 years to be really skilled, to manage, to lead — and it's not just about people who lead, it's about all people. With the numbers you quote — large percentages of people who don't feel well and miss work, which translates into $2 billion — there are even some numbers that somewhere between 7 and 14% of people actually leave the workforce. They're leaving because it's just too much. It coincides with work burdens, personal challenges, not feeling well. It's also the age band where the Venn diagrams overlap — we're taking care of aging parents and young kids — and it just becomes too much. From a human-potential standpoint, how can we not pay attention to such a big chunk of our workforce?

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Stacy London (05:40) Yes, exactly. When you put it in terms of 15 years, you get a better perspective on why this matters. It's not, "Well, you have a tough year, and maybe you'll get past it, or maybe you decide you don't want your job." Fifteen years is a long time to experience any kind of discomfort — physical, mental health, all of the things — plus aging parents, children, and a demanding work schedule.

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And it's funny — you were saying before that we make jokes about menopause, or women, or aging. I think about this at every stage of my own development. I was ashamed when I got my period. I was ashamed to talk about pregnancy. Women are embarrassed by postpartum when they have it — they think they're not supposed to; they're supposed to be bright, shiny, happy mommies. And menopause. We don't get a break.

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Dr. Joanne Armstrong (06:37) We don't get a break. I think the silver lining is that behavioral health, in many ways, has led the way. It used to be so highly stigmatized, and now we talk about it. And when you talk about it, you see how prevalent and disruptive it is, and what the lost human potential is — and you say, let's just fix it. I do think menopause is moving into a space like that.

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The other thing, when we think about lost potential and opportunity: many women are symptomatic — hot flashes, difficulty sleeping, headaches. Why people joke about these things, I don't know, but there's that. But underlying that are all the other physiologic changes. Cardiovascular and lipid risk profiles change. Weight gain, metabolic health, bone loss, muscular health — why would we not pay attention to this? This is the walkway to health across the lifespan.

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I see a lot of good indicators here. In our workforce, I see a lot of younger people — people in their 30s — reaching out, and they want to talk about it. I think, awesome, let's have a conversation, because they're seeing the long game for health and productivity. I think that's really terrific.

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Stacy London (07:57) I think intergenerational mentorship and education is ideal. I want middle school kids to know about menopause — I just want everybody to know, so it doesn't feel like some big shock when you get here. And to your point about the health ramifications of aging, it feels like we're a little unbalanced in terms of health equity — or equality, really. Men are biohacking; we hear about it every day. They're going to live to be 114. But women don't even have the roadmap to aging well if we're not paying attention to all of those postmenopausal issues.

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I didn't know anything about bone density before I started my menopause journey. There are so many things I wish I'd known, so I could have done more preventive care. That early education means maybe you start strength training earlier, or whatever it is that's going to lead to a better health outcome. I feel like men are much more educated about better health outcomes than we are.

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Dr. Joanne Armstrong (09:07) Yeah, it's interesting — somehow it sits in a niche, when in fact it's not that at all. Bone health, cardiovascular health, metabolic health — all of it. Why we don't talk about it has always confounded me, but that's where we were.

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Stacy London (09:23) Let me turn the question to this. CVS Health is a massive company with hundreds of thousands of employees. You have people working in corporate offices, but you also have people working in CVS stores on hourly incomes, on their feet all day in retail — some in the pharmacy, some in the shop itself. How do you design a menopause strategy that scales across all of those different roles without losing the personal, human touch that all patients really need?

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Dr. Joanne Armstrong (10:01) It's been a journey a few years in the making, and I'd say it started with our "why." That's really important for all organizations: Why are you here? What do you represent? We have a very long commitment to women's healthcare, and we should. As a company, 70% of our colleagues are female, and they inform us about what they need — at all levels of leadership and in our service centers. So we get it, and we listen to our colleagues in how we design benefits and how we show up.

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The other reason to believe, for us, is that — you're right — we're a large company with many businesses under CVS Health, and in each of those businesses, women are actually the dominant consumer. For example, we've got MinuteClinic — 900 longitudinal primary care clinics all over the country, deep in communities. Sixty-three percent of the people who use those clinics are women, across all age bands except adolescents — probably because their moms are bringing them in. In our front stores — about 9,000 pharmacies and front stores — 70% of our ExtraCare customers, the people who come back again and again, are women. So they are showing up, and we've asked ourselves: How do we show up for them?

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And then we're a large employer — 330-ish thousand people — but through Aetna, we serve 33 million employees who work for employers. A little more than half of those are women who get their benefits through us. And those companies do ask us: What should benefits look like? Help educate us. We took that quite seriously.

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So we started there: Who are we? We're a healthcare company providing safe, evidence-based, effective healthcare services. What does that mean in a midlife environment? Then we asked: What are the gaps in the ecosystem that we have not just the opportunity, but in some ways the mandate, to work on? We looked at the state of education — for colleagues in our workforce, for people we provide health benefits to, for people using our front stores. And we looked at the clinician workforce providing these services.

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We know what that looks like because of the Women's Health [Initiative] study from — what is it now — 2002? I can't believe it's 24 years ago. I was in practice when HRT was very commonly prescribed, and it just fell off a cliff. That was an example of probably not-well-designed science and poor communication around it. And the collateral damage is that physician training dropped off along with it. We know that only about 20% of physicians self-report that they feel really comfortable delivering menopause care. That's going to take a generation to fill. I see it — I work in a residency program as well. It's happening, but we've got providers all over the country who just aren't ready.

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So we asked ourselves how we could ready our own clinician workforce — which we have in MinuteClinic, for example, and a few other environments. How do we close that gap? We brought in The Menopause Society to train our MinuteClinic clinicians on what midlife care really looks like. Because someone comes in and they're not sleeping — maybe it's not sleep apnea; maybe it's waking up three times a night because they're soaked. Then we built menopause services, both in-person and telephonic, including the ability to prescribe HRT if that's what's indicated.

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For Aetna members, we knew it would take a long time to close that 20% training gap, so we intentionally brought in menopause-trained providers — Midi Health, Gennev — and said, this is what it looks like. And then we took an extra step we can take because of the capabilities we have. We work with data scientists, and we can look at members — we call them members, but they're humans, women, patients — who look like they're churning in the system, pinging around with probably ineffective care. It's a good hypothesis that that's what's happening, because the literature says about a third of people seeking care get misdiagnosed. It's sleep apnea instead of whatever, or behavioral health that's really changed because of menopause physiology.

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So we use data science techniques to identify people who may need a service and let them know: Here's what it looks like. Here's how you can go to The Menopause Society and see who's formally trained. And here are a number of new providers who've been brought in to help you now. We've connected tens of thousands of patients in need with the services we have.

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So when you ask how we do it, it's a combination of looking with really clear eyes — these are the real gaps, and it's going to take a generation to fill many of them — and asking where we can close them. And how do we make sure everyone working with us gets it? We brought in education not just for our colleagues, but also for their managers, because there's no sense standing up to say, "I'm having a hard time here," if your manager just says, "I don't know what you're talking about" — or, even worse, "I really can't talk about this. It's just too embarrassing." So it's been a number of things, lifting the culture up as we go.

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Stacy London (16:18) I'm curious — you said before that you were a practicing OB-GYN. Was there a specific moment in your career when you realized it was time to leave the exam room and work on big policy to see the kind of changes you wanted to see?

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Dr. Joanne Armstrong (16:36) Well, I've never left the exam room. I still practice.

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Stacy London (16:42) Oh my god! How do you have time? Where does your time come from?

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Dr. Joanne Armstrong (16:45) It's my Fridays. And there's a brand-new resident class coming in just a few weeks, so we'll reset what education looks like — it's a long process to train people up. I've always practiced, and I do practice. Early in my career, I had training in public health and epidemiology, so I've always liked population medicine. Early on, I also did some work in quality — what is it, how do you measure it? It's more than just a number, because when you measure it, you have to do something to fix it. So I've always had an interest in that.

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And at CVS, I have the opportunity to lead. I'm the chief medical officer for women's health, but I also get to be the chief strategist for what women's health looks like in this large company that has all of these assets. So I guess it was always there. This is just the first time I've done it at such a large scale.

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Stacy London (17:47) Talk about helping people when you think about populations — CVS is uniquely positioned to help so many people. Now I'm thinking about actual CVS stores, and those MinuteClinics as the natural evolution of where health needs to go. We have overcrowded emergency rooms — sometimes they're emergencies, and sometimes people just don't have anywhere else to ask for help. Do you see MinuteClinics and this kind of training as a way for people to get the care they need quickly, instead of having to go to an emergency room when they think they might have a urinary tract infection?

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Dr. Joanne Armstrong (18:36) Yeah. We live in a very fragmented healthcare system. It's really thousands and thousands of provider and service groups, but it's not necessarily coordinated, and it has historically not been that responsive to patients. I love to talk about women's health with the woman actually at the center — not this asset and that asset and that capability. If you're the woman: right at this moment, I may be disturbed by hot flashes. But immediately after that, I'm thinking about getting my kids vaccinated, or driving someone to Oklahoma for the soccer game they will inevitably lose — all of that stuff. And that includes work obligations.

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So if you think about putting women — people — at the center of what you do, you start thinking about it differently. We define women's health as physical health across the lifespan and behavioral health, and we particularly include the social and environmental factors that affect health: time for care, access to care, preference for how you receive that care, educational resources so you can more expertly navigate it, and stigma — talking about it — so that we're actually meeting people where they really are.

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For women, those barriers are in many ways different and greater than for men. The time barrier: two-thirds of all unpaid caregivers in this country are women — taking care of parents and kids while also working, doing all the stuff. Access really matters; just-in-time care matters. And we know women are something like 1.7 times more likely to use alternative types of care, whether that's digital or retail health. So if you were building a system around women, what would that look like?

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Stacy London (20:48) Convenience, right? Ease.

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Dr. Joanne Armstrong (20:51) Convenience, ease, just in time — recognizing that it is a journey, that behavioral and physical health are interrelated — and putting a platform underneath women. My job is women's health, but I'd say all individuals should have the same level of personalization. It's just my passion and my job to think about it for this very large patient and consumer group. But that's really where healthcare should go.

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Stacy London (21:23) I find you incredibly reassuring, I have to say. Even your voice is so delightful that I keep thinking, I want her in charge of my care. You're designing for populations in a way I find so fascinating, because you get to look at disparate factors from a 10,000-foot view that most people don't get — they're in their niche or their nook.

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When you talk about what women need — women who do two-thirds of unpaid labor while also building their careers — I find it so interesting that you're asking how to make these services accessible and as easy as possible. Not just offering the service, but the way the service is introduced to a customer. That's something I don't think about, and yet I realize how important it is to actually getting care.

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Dr. Joanne Armstrong (22:34) It's very important. Your words are very kind. I care very much — I've dedicated my life to this area of healthcare — but an aspiration is not enough. You need the pieces of the healthcare system. I'd like to acknowledge that I work for an employer, CVS Health, that is committed and has had a long commitment. That really matters, because you need focus, prioritization, alignment — all those kinds of things. But you also need tools. Ours are digital tools, retail clinics, and relationships with all sorts of employer groups, large and small, so we understand the voice of the customer. So it's not just a wish or an ambition. It's the commitment, the tools, the resources, and the alignment to make it happen — always with humility, listening to what the challenges are, because the system is so, so complicated for so many people.

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Stacy London (23:42) It is so complicated. Even the way you're simplifying it for me is pretty awesome. We talk about companies that are interested in a human-first perspective, but the commitment you're describing feels very different — and I think customers are starting to recognize the commitment these companies have to their well-being. In the time I've been working in the menopause space, that's what I've really seen: a commitment to changing the narrative and changing the kind of care we're able to receive.

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One of the things I've said is that nobody ever talked to me about perimenopause. It's like seeing a Mack truck and not getting out of the way — you can't get out of the way if you don't know it's coming. So all of these conversations, including the commitment to the customer from big companies like CVS Health, are very reassuring to hear. As you say, healthcare is so fragmented. It's not an equal landscape, so to speak — there are the haves and the have-nots, and there's so much we could be doing, even in terms of education, to help others. I really hear that in your commitment to your customers.

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Dr. Joanne Armstrong (25:17) Yeah. And we have to find new customers — and customers can be many things. In an Aetna environment, our customers are the companies we provide health benefits to. Sometimes they're just not aware, so we spend a lot of time talking to them: Here's what your workforce looks like. Here's what we know from surveys. Some surveys have shown a gap between what women are asking for in benefits versus what the company thinks it's providing. It's all goodwill, but it requires education for companies as well: This is what we're talking about — it's education, it's benefits, it's programming, it's the ability to talk about it.

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I'm really proud that our company was the first U.S. employer to be accredited as a menopause-friendly workplace [through MiDOViA's Menopause Friendly Accreditation]. Very proud of that. But we don't want to be the only one.

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Stacy London (26:15) Of course — you want to lead the charge, but you want it to be everybody.

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Dr. Joanne Armstrong (26:18) We'll lead the charge, because women are a key part of your workforce. You've got to pay attention to where the puck is going — and in this case, it's where it's at. So we do a lot of work with employers to say, here's what it might look like. We've created a bunch of things you can lift and load as you build your own culture.

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One very interesting thing we've learned is that, as part of education, women want to talk about this. We have colleague resource groups for all sorts of affinity groups, depending on what your jam is — things you want to learn about or talk about at work. Within our women's group, called WISE, we started with seminars that I and other clinicians give — lunch-and-learns: let's sit down and talk about menopause. The first time we did it, I think we had phone lines for only 800 people, and it filled up in about four hours.

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Stacy London (27:20) Oh my god.

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Dr. Joanne Armstrong (27:21) We did it again — same thing. Another time, we opened it up a little and talked about cardiovascular health in midlife, and then behavioral health in midlife. Our colleagues give us great feedback: I need more of this, I need less of this, next time let's talk about this. When you start breaking down stigma and you ask, how would you know? That's how you know. So it's also building culture inside the company, and I see progress there. It's extremely rewarding.

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Stacy London (28:02) You recently wrote about the menopause revolution in response to Melinda French Gates, noting that many medical schools treat menopause as a footnote, which you mentioned before. But right now, it feels like the market is moving faster than medicine. As you said, it's going to take a generation to really train up doctors in menopause as we currently understand it.

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Meanwhile, you're seeing an explosion of brands and unregulated supplements — sometimes it's called menowashing — and lots of brands rushing in to fill the gap doctors have left. As chief medical officer, do you worry about this feeding frenzy around the menopause vertical? And how does CVS train pharmacists and clinicians to act as an evidence-based firewall for women who might be getting advice from Instagram rather than a doctor?

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Dr. Joanne Armstrong (29:01) Yeah, I think that's a real issue. There are many things that held back the field. We talked about the training, the Women's Health [Initiative] study, how the FDA framed hormone replacement therapy. And now, with the removal of the black box, it's like: HRT for everybody. That is not it. That is not it. It's still a serious drug. It has some contraindications. It needs to be used in an FDA-intended way.

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So how do we do that? And I acknowledge what you're saying. We do it through provider access: whether it's what we call a vendor — a network that's brought into our environment — we make sure their providers are menopause certified, which is itself an evidence-based process to make sure the training is in place. That's one. The pharmacy, obviously, is all FDA-approved and validated. And we're careful that the information we put in front of women — whether we call her a member, a patient, or a human who's interacting with us — is evidence-based, vetted content from valid places. I do acknowledge there are a lot of — I don't know what you even call them — providers, services out there that are not well vetted. And that is concerning.

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Stacy London (30:39) And even products, right? Obviously not the ones that are FDA-approved — I'm talking about outside HRT — but there are all these new companies specializing in menopause-something that don't have any track record or any proven ingredient specific to the menopause experience, which I find fascinating.

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Dr. Joanne Armstrong (31:03) And I'd say some of that also represents many years of not investing in this — in research and in practice. I think Melinda French Gates was talking about that: we need a boost of investment so we actually know what works and what doesn't. It doesn't serve people to do things that don't work. And it's possibly dangerous.

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Stacy London (31:26) We know menopause doesn't look or feel the same for everybody. Black and Latino women, for example, often experience more severe symptoms than white women, but get less support. What does CVS do in that situation? How do you make sure care and resources actually reach women who have historically been left behind in most medical conversations?

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Dr. Joanne Armstrong (31:50) That's a great question. One of our early steps: we have a company — really more of a product — called Healthspire, which does a lot of wellness coaching. When we started this journey a few years ago, we worked on bringing coaching into a menopause frame — we intentionally asked what coaching in midlife looks like. As part of that effort, we had a coaching environment for Black women, to learn how different people talk about menopause. We know that culturally, people talk about things in many different ways. Many of us are acculturated to either speak up or not speak up. I think that really speaks to the need for a place where you can raise questions. But we're far away from personalizing solutions for every subset of the population that needs it.

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Stacy London (33:01) And that's going to take much longer, maybe, than just menopause education, correct?

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Dr. Joanne Armstrong (33:08) Yeah, and there are many, many areas. Some of them are social, cultural, and demographic needs; some of them are clinical. We don't talk enough about what breast cancer survivorship and HRT looks like. So there's a lot of work to be done — and again, going back to Melinda French Gates's article, or call to action, it speaks to that.

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Stacy London (33:31) Let's close with some real advice, because our listeners love to take information from these podcasts and do something with it. If a woman listening right now feels completely dismissed or ignored by her current doctor, what should she do? If she walks into a local CVS or goes online tonight, what are the exact entry points where she can get better menopause care?

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Dr. Joanne Armstrong (34:00) I think the key piece of advice — whether you're interacting with CVS Health or not — is to trust yourself. If you feel like you're being dismissed — if you've talked about symptoms and you're getting no answer, particularly one that just says it's in your head, or it will pass. It will pass? The average duration of symptomatic hot flashes is, what is it — 15 years. "It'll pass." We don't say that about a headache, a toe ache, or whatever. So one: trust yourself. That's number one.

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Two: there are a lot of really great places to go learn more. Let's Talk Menopause is one of them. And three: find a provider — a physician, a clinician — who actually has some training in menopause. You can look at The Menopause Society website, and they'll list the providers in your area who are menopause certified. I think those are three very pragmatic things we can do while we're trying to build up the workforce. In our MinuteClinics, you would not be told it's [in your head], and there would be an appreciation of the women's health angle of the presenting complaint.

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Stacy London (35:23) That's very exciting. It's lovely to hear that there's this commitment to the work around women's health, and interesting to hear the inner workings of what you're doing at CVS to make those things real — not just aspirational, not just wishes, but really figuring out how to help people more.

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In the last couple of years, what I've watched is people start to talk about menopause and then argue about it — what's right and what's wrong, what's a sham and what isn't — instead of remembering that most people are still so confused. We don't have the basic education to know who's right, who's wrong, and who's selling us something fake. It can get very overwhelming to learn about midlife health in midlife. It's a lot to learn.

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Dr. Joanne Armstrong (36:24) I would hope this doesn't become an argument about healthcare that affects such a massive population. Whether you're at home or at work or doing all of the things, there is so much work to be done in this space, in both research and healthcare delivery — really thinking through how we optimize this for the actual lives women lead, not the supposed lives women lead, putting women at the center of these journeys. There is so much work to do. There's no need to fight about it. But it is really important that you start with an evidence base; otherwise, it's a disservice to women.

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Stacy London (36:58) Last question: Do you foresee a lot more research because of funding like Melinda French Gates's? Is that where the money is most effective at this stage?

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Dr. Joanne Armstrong (37:11) Well, she is so inspirational — a policy leader and a doer. A leader who doesn't just say stuff, but does stuff. I think it will help kickstart it. But whether that's enough for the amount of NIH funding that's needed in women's health — it can stimulate it, but lots of other entities are going to have to enter. Melinda French Gates cannot fund what's required by herself. But women asking for it — asking for it at work, at the physician's office — raising their voices, getting educated: all of these are forms of advocacy that help build budgets, and even movements, for effective care.

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Stacy London (37:59) Dr. Armstrong, thank you so much for your time. I really appreciate it, and all of our listeners do, too.

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Dr. Joanne Armstrong (38:06) Thank you, Stacy. It's been really fun.

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Stacy London (38:10) Hello Menopause is a production of Let's Talk Menopause, produced in partnership with Studio Kairos. I'm your host, Stacy London. Let's Talk Menopause is a national nonprofit organization invested in changing the conversation around menopause, so women get the information they need and the healthcare they deserve. Please visit letstalkmenopause.org. Hello Menopause is available on YouTube, Spotify, Apple, and everywhere you get your podcasts.

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This episode of Hello Menopause is sponsored by Verseli. Visit verseli.com for the info and products you need and the menopause care you've been searching for.

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