Episode #50:

Two GYNs, Real Chat (Part 1) with Dr. Erin Keyser

This week, I’m joined by my fellow Board-Certified OBGYN and the director of the Brooke Army Medical Center OBGYN Residency program, Dr. Erin Keyser. I’m lucky enough to have collaborated with Dr. Erin Keyser in her residency program, and we are two GYNs sitting down for some real chat about our work.

Dr. Erin Keyser is a breast cancer survivor. She has become an expert in breast cancer survivorship and the side effects that survivors have to deal with, leading to her passion for menopause treatment and sexual health, just two of the common problems patients face post-recovery.

Tune in this week to discover how Erin’s experience of breast cancer and menopause has informed the approach she takes with her patients. We have an in-depth discussion about the innovative non-hormonal treatments available to cancer survivors dealing with menopause, how hormone therapy has changed over the years, menopause risks, treatments, and our favorite practices, and how we try to help our menopausal patients.

WHAT YOU’LL DISCOVER

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Why it’s important to have conversations around menopause and how we can live a full life.

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Erin’s story of surviving cancer and subsequently going through menopause at a relatively young age.

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The choices Erin has made in taking care of herself through menopause.

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How Erin’s experience has refined the way she works with her patients as a GYN.

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Why we need to abandon the word ‘hysterectomy’ and replace it with ‘uterectomy’.

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How hormone treatment for menopause has changed over the years.

FEATURED ON THE SHOW

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Dr. Erin Keyser

TRANSCRIPT

Dr. Keyser: But I think a lot of patients are scared. I know we’re going off on a tangent, but I feel like they don't want to offend their doctor. So it's like they're timid to say I want a second opinion. Personally, I feel like we should though encourage them to get a second opinion.

Dr. Crockett: Welcome to Becoming Virtuosa, the podcast. I'm your host, Dr. Susan Crockett. Today you are listening to episode number 50, Two GYNs, Real Talk, an interview with fellow Board Certified OB-GYN and the director of the Brooke Army Medical Center OB-GYN residency program, my friend and colleague Dr. Erin Keyser.

Welcome to Becoming Virtuosa, the podcast that encourages you to become your best virtuosa self. Each week Dr. Susan Crockett goes where the scalpel can't reach, exploring conversations about how to be, heal, love, give, grow, pray, and attune. For the first time ever, she's bringing the personal one on one teaching that she shares with individual patients to you on this broader platform. A weekly source of inspiration and encouragement designed to empower you.

By evolving ourselves as individuals. We influence and transform the world around us. Please help me welcome board certified OB-GYN specializing in minimally invasive GYN surgery, internationally in the top 1% of all GYN robotic surgeons, a certified life coach, and US News top doctor, your host Susan A. Crockett, MD.

Dr. Crockett: We have a very fun episode today. This is my very good friend, another GYN doctor. Her name is Dr. Erin Keyser. So today we are doing to gyn's real chat, which could get into some really interesting stuff. So welcome Dr. Keyser.

Dr. Keyser: Well, thank you so much for having me. I'm excited to be here.

Dr. Crockett: You're welcome. I wanted to tell the audience a little bit about how we know each other. So I have met you as the program director for the residency program at BAMC for OB-GYN. You're kind of my boss because.

Dr. Keyser: Kind of. So in COVID when we were not operating, I still had to train residents in surgery. So I had heard great things about different doctors who worked with you during the robot training. They said you're a fabulous teacher. So I kind of cold called you, and you have welcomed my residents with open arms. I'm so appreciative.

Dr. Crockett: I love it. Thank you. They're so fun.

Dr. Keyser: Yeah. No, they love working with you. So thank you.

Dr. Crockett: You're welcome. Well, it's mutual. So now that's kind of morphed into them being with me regularly a couple days a week. So we've only known each other since COVID.

Dr. Keyser: Yes, like a couple years.

Dr. Crockett: Yeah. Honestly, I don't know that much about you other than that you're an OB-GYN. You do an awesome job with the residency program. Why don't you tell our listeners a little bit more about who you are and what we're gonna talk about today?

Dr. Keyser: Okay. So I am an OB-GYN in the military, in the army. So I guess I need to do my disclosure that the views talked about today are the views of mine alone and not the military or the Department of Defense. But I work at Brooke Army Medical Center. I'm an OB-GYN there. I am also a breast cancer survivor. So.

Dr. Crockett: Which I just found that out today, I didn't even know that.

Dr. Keyser: Yes. So at the age of 34, I was diagnosed with breast cancer. So through treatment for that, I became menopausal at a very young age. So by 35/36, I was menopausal. I really struggled with a lot of the side effects a breast cancer survivor faces, despite being a board certified OB-GYN.

So I kind of became, for myself, an expert in kind of breast cancer survivorship and a lot of the side effects that breast cancer survivors deal with have to do with menopause and sexual function. So I kind of have now like a passion for menopause treatment and sexual health and a lot of those issues. So I really want to advocate for breast cancer survivors to hopefully get the best care because a lot of them, unfortunately, feel like oh I'm just gonna be miserable for the rest of my life.

Dr. Crockett: That's just not necessary, is it?

Dr. Keyser: No.

Dr. Crockett: So we’ve got very different stories as far as menopause goes. I'm on the other end of the spectrum going through menopause myself, and so a lot of my audience happens to be menopausal women or women in midlife transition. My audience is a little wider than that. There are all ages that will be listening to us and men also, which I think is important. I think they need to hear the discussions that we're going to have too.

In my practice since I'm mostly surgery oriented, the sexuality side and the menopausal side effects my patients, more like how do I do surgery on them and still help them remain functional? As you know as we're kind of talking, the whole premise for the show about going where the scalpel can't reach.

It came out of the idea that we have all these conversations with our patients in the office that are important conversations. I think it's important to bring it here to a broader audience. So this is like hitting straight down that barrel of.

Dr. Keyser: Yeah. Well, with women now living into their 80s easily, you're going to spend almost half your life in menopause. So you need to have a full life. That should include not being miserable from hot flashes. You should be able to have sex without pain. I mean all these things.

Dr. Crockett: Yeah, I agree. So I've noticed some things personally. You've been doing this. You're the one that's the expert. What's the organization?

Dr. Keyser: So it used to be the North American Menopause Society, and they've renamed themselves as just the menopause society. They have great actually patient information for providers and patients about menopause. So if you really want to go to the leading voice in menopause care, it's The Menopause Society or menopause.org, I think is the website.

Dr. Crockett: We'll find that website, and we'll link that below. We'll put it in the links for the show. So patients can go there and find somebody like you. Although they can't come and see you unless they're in the military, but they can find somebody like you who is linked into that Menopausal Society so that they know they're getting the most up to date, helpful information as possible, which I think is awesome.

So all these years, I've been listening to my patients talk about hot flashes and weight gain and then transition and sexuality and societal things. Now I'm going through it myself. All of a sudden, I'm just very, I'm looking at my body like this experiment. I've changed how I eat. I've gotten mostly whole food plant based. I'm becoming much more conscious about maintaining muscle and dealing with the hot flashes, but it's also made me so much softer and more compassionate, I think, in dealing with my patients.

So I wanted you to talk a little bit about your experience as a cancer survivor, and how that impacted you going through menopause and the choices you have made personally for taking care of yourself through menopause. Then how that translates into what you teach your patients.

Dr. Keyser: Sure. Well, I definitely feel like, and you probably relate to this. If you've been a patient yourself, it's definitely humbling. I think it makes us a better physician, right? Because we really understand what our patients are going through, and just the struggles of just accessing care sometimes can be so challenging. So yeah, I definitely feel like it's humbled me to hopefully be a more compassionate and better provider.

Then, in addition, I really tried to, like I said, teach myself to become an expert on like what is safe? What's out there for cancer survivors. I do meet with, there's a cancer survivor group at BMC, which I try and meet with regularly and try and educate patients themselves too about how to advocate for care.

But obviously, breast cancer is a huge topic. There's so many things. But in general, when we think about people going through breast cancer treatment, oftentimes it does make them menopausal. They're oftentimes not a candidate for any hormones because of the estrogen progesterone receptor positivity. But even if it's estrogen receptor negative, oftentimes they usually don't recommend like systemic hormones. So it's looking at other options that are out there.

So Paxil or paroxetine is FDA approved for hot flashes, and that's nonhormonal. It has some benefit. You can always use like Gabapentin. Then there's a brand new drug that was just FDA approved like middle of May. That's called Veozah. That targets the thermoregulatory center in the brain. So it's not hormonal, and it’s supposed to help with hot flashes.

I've yet to actually get it in the hands of my patients because like literally it was FDA approved like a month ago ,but I know you can go to their website. It's V-E-O-Z-A-H is the medication if you Google that like. They will help navigate getting the drug because they know it's not stocked in pharmacies yet because it's just brand new.

Dr. Crockett: Yeah. So this is super interesting because of what you said about the mechanism of action. So a hot flash is actually just a vasospasm, the blood vessel is flushing or dilating. That's what gives us those embarrassing moments when we're like getting up to speak and then a hot flash comes along and kind of undermines our confidence in what's going on because it looks like we're like, not confident about our speaking. But that's just a vasospasm. So you're saying this medicine is targeting that?

Dr. Keyser: Yes, it targeting, I'm not going to pretend I'm a neuroscientist, but it targets receptors in the brain thermoregulatory center. But you're right. I feel like the hot flashes, I think until you've experienced them, you're like suck it up. It's a hot flash. You get sweaty. But they can be pretty severe where you actually have to stop what you're doing.

Which you, as a surgeon, if you have to stop your surgery because you're I mean, that is really affects your quality of life. If you're a high powered businesswoman and you're trying to give a brief, and you're pouring sweat. I mean that can really disrupt like your confidence and your ability to do your job. So, yeah. It's easy to be like oh, it's just a hot flash. Use a fan, but they can really disrupt your quality of life if you're having multiple throughout the day.

Dr. Crockett: And through the night. So I see women sleep deprived, and they're trying to carry on these high powered jobs. High powered jobs and being moms and wives, and they're sleep deprived.

Dr. Keyser: I think that's part of the theory of why weight gain happens in menopause time to is because lack of sleep is directly associated with you gaining weight, and you not be able to regulate your weight because if you're sleep deprived. So if you're having 10 hot flashes at night and waking up sweating and uncomfortable, you're not getting quality sleep.

Dr. Crockett: Yeah, that's my problem. I'm sure it's not the food that I'm eating. I never overeat or indulge in what I shouldn’t. It's totally the sleep. No, actually I'm a sleep expert. I sleep really well. Okay.

Dr. Keyser: I'm very strict with my sleep. I need my eight hours.

Dr. Crockett: Me too. I track my REM. I don’t have my garment on, but I usually have a monitor on that tracks my sleep. I've got my CGM monitor on, not because I'm diabetic, but I'm monitoring how the foods that I eat affect my blood sugar and being real conscious about that. Mindful of that.

So I think this topic that you touched on, that we touched on about menopause affecting our confidence in our ability to do work, especially when we're in the workplace with men or younger people who don't understand what's going on. I think that's not talked about enough. It's really not. Our prior generations, our grandmothers, they were put in asylums when they started going through menopause. What’d they call it?

Dr. Keyser: Hysteria.

Dr. Crockett: Hysteria.

Dr. Keyser: Yeah, like the term hysterectomy when you take out the uterus, was from women who were hysterical. If we took out their uterus, then we cured them.

Dr. Crockett: Oh, so I got a funny story. So I went to San Diego last month. We had the Women in da Vinci Surgery Conference.

Dr. Keyser: Oh fun.

Dr. Crockett: It was so cool.

Dr. Keyser: I love San Diego.

Dr. Crockett: I know. It’s so beautiful. So I was so lucky to go. There were 200 women da Vinci surgeons from all over mostly the United States, but I met some from Mexico and overseas. It was not a medical conference. It was about taking care of ourselves as surgeons and lifting each other up and building women in the field.

There was this really funny moment where in the auditorium where we were meeting, the one woman stood up, and she said, “I'm starting a movement.” We are all like okay whatever. She's like, “No, I'm starting a movement to change the word from hysterectomy because of what it represents.” She told that story because from now on, we're going to call it an uterectomy.

Dr. Keyser: Right? Well, every other, gallbladder, colon, and everything else, it's that organ. Thyroidectomy.

Dr. Crockett: Thyroidectomy. So officially, we're gonna support her here.

Dr. Keyser: I love it. Uterectomy.

Dr. Crockett: Yeah. Now we do uterectomys. So we all take note. All right back on track. We got a little sidetracked there.

Dr. Keyser: Or yeah. I mean really the mainstay treatment for the hot flashes should be hormone therapy. So I feel like that's probably the next.

Dr. Crockett: Topic that we should talk about.

Dr. Keyser: Topic we talk about is hormones.

Dr. Crockett: So I've gone through the older days from the WHI study when we were doing Premarin, mostly Premarin and Provera. Then the whole WHI study came out, the pendulum swung in the early 2000s for not doing hormone replacement therapy because of its increased risk for breast cancer and blah, blah, blah.

Then bioidenticals started coming out around the 2010s. People started becoming more engaged in the conversation but also more informed about the difference between a bioidentical or a bio natural hormone versus the synthetics. So how about if you help me explain to the audience what the difference is, say between Premarin and Estradiol that we use now?

Dr. Keyser: So yeah. So there's bioidentical hormones and then there's synthetic hormones. So bioidentical hormones would be the ones that your body produces. In our bodies, we produce three forms of estrogen. We perform we produce estrone, estradiol, and estriol.

Dr. Crockett: So it’s E1, E2, E3.

Dr. Keyser: Yes. So those are like the three bioidentical hormones. So Estradiol is the bioidentical hormone that you can purchase and take as like a bio identical form. Then progesterone, there's natural micronized progesterone, but then there's also some, oh, I guess I didn't talk about the estrogen. Sorry. So the synthetic estrogens are Premarin, which is made from a pregnant horse's urine. So I totally get why people are like not excited to take that.

Dr. Crockett: Yeah, but it's got like nine different estrogens in it that are not native to humans.

Dr. Keyser: Yeah, no native to humans. So that's a synthetic estrogen. That's also what was in that study that you talked about, the Women's Health Initiative, which raised the concern about breast cancer. They also used a synthetic progesterone, which was medroxyprogesterone acetate, but there's lots of synthetic progesterones.

Dr. Crockett: Birth control.

Dr. Keyser: Birth control. There's norethindrone There's levonorgestrel. There's a lot of them. But if you wanted to do the bioidentical natural ones, it'd be like a micronized progesterone and then the estradiol. So yeah. So there's synthetic and natural and most of the studies were done with those synthetic ones because that's what was available. So I don't think we have good long term data or studies looking at the bioidentical ones and what they cause.

Dr. Crockett: We really don't because it's only been a little over a decade since we really paid attention.

Dr. Keyser: Really now as we're looking at the data from the studies, that we're finding like new things. If you start the hormones closer to menopause, there's probably not that increased risk of heart disease or anything else.

There's lots of benefits to it, right? Like we know it protects your bones. We know it helps with weight gain. We know preventative against like diabetes and helps with sleep. I mean, there's always other benefits. It's decreased risk of colon cancer and uterine cancer and ovarian cancer. Then there's like a slight risk of stroke or breast cancer or some of those other things.

Dr. Crockett: Yeah. So I love that we're in a time where we have access to them. I wish we were in a time where we knew all of the answers about it. But I love that we're also able to prescribe these things. Most of them are covered under health insurance. So I wanted to kind of talk about the difference between the cash pay only bioidenticals and then the bioidenticals that are widely available through our pharmacy plans and insurance coverage.

Dr. Keyser: Yes. So I feel like there's been this fad of bioidentical hormones where people are creating these little doc in the shops.

Dr. Crockett: Or boutique things.

Dr. Keyser: Boutiques saying come test them. We’ll prescribe them. But I feel like it’s kind of flawed in several ways. One is there's really no reason to test your hormone levels because your estrogen level and my estrogen level might be very different, but it does not correlate with how symptomatic you are. If I'm not having hot flashes and my estrogen is low, I don't think I need to take estrogen if I'm not having symptoms.

So we don't base it on like a number, right? We treat symptoms. Really, there's been no correlation. That's true for testosterone, too. We're probably gonna get into that later. But testosterone. Testosterone levels don't correlate with your sexual drive or your sexual function.

Dr. Crockett: Fascinating, right?

Dr. Keyser: Yeah, which is I know it's like you think like well if my testosterone is higher, I'm going to be hornier or this. So there's no point in paying cash and testing for these hormones because there's no correlation with symptomatology. I'm not going to treat a number. I'm going to treat your symptoms.

Dr. Crockett: I do the same thing. I talk a lot with my patients about how I have kind of a dosing range in mind for them where too much we know is like there's something else going wrong that I need to look at, or it's just too much outside the range. But within that dosing range, I tend to prescribe to symptoms also.

So I have four rules in my office for hormone replacement therapy. I consider myself pretty basic. Like I'm not doing the fancy compounding and testing and correlating adrenals and all that. I'm a surgeon. But I do a basic amount of mostly starter or refill hormone.

So I usually say we want to use the smallest amount for the shortest duration for specific symptoms and choose bioidenticals. Those are my four rules. Then if it gets more complicated than that, then I need somebody that's got like a functional medicine background or higher level of education.

I have a nurse practitioner that's doing that right now. I mean she's a whiz. She’s like way above me in all the physiology and helping people if that dosing range isn't working. Because there's only like two doses of estrogen. She really gets into all of that. But I think the point that we want to make is that one, it does not have to be out of pocket.

Dr. Keyser: Correct.

Dr. Crockett: There are bioidenticals, good bioidenticals. I'm taking them. I'm using insurance.

Dr. Keyser: I would if I weren’t a breast cancer survivor.

Dr. Crockett: Also, I want to mention something else that I do and ask your opinion about this for breast cancer survivors. Which is usually when we're dealing with vaginal atrophy or vaginal discomfort during intercourse, I've been taught that it's okay to use a small amount of topical estradiol to help keep the skin healthy. That that doesn't get into the bloodstream enough to really increase the risk. Then you can also use estriol cream through a compounding pharmacy. My breast cancer docs that I referred to have cleared that for my patients. What do you think about that?

Dr. Keyser: Yeah, 100%. 100%. I use the Estring, which is estradiol vaginal ring. Yes, I feel like ACOG, so American College of Obstetricians and Gynecologists, supports that. There has been studies done in like Gyn oncology. So yes, do support topical estrogen is safe. They have compared the different types of topical estrogen.

Dr. Crockett: They have?

Dr. Keyser: Yeah, and like how much is systemic. Premarin cream, which is a synthetic, does seem to be more systemic absorption. So I agree. I would stick with like a bioidentical, whether it's like the Vagifem tablet, like the estradiol tablet or the estradiol ring, or the estrace cream. But all that considered topical shouldn't have systemic absorption and has been no association with like increased risks.

Dr. Crockett: Yeah, so now we're getting into another topic.

Dr. Keyser: Right. I did want to go back to that bioidenticals because I don't know if we talked about that quite. So I totally agree about cash. So people go to these like doc in the shops, and they get pellets or these like other things which are not FDA approved.

The amount your body actually gets is kind of unknown and so, in a way, it’s unsafe because you may not be getting the right amount to protect your body or prevent other cancers. Because if you have too much estrogen, you're at risk of uterine cancer. If you have too little, you're not treating your symptoms.

So there are FDA approved bioidentical hormones that we talked about that your insurance will cover, that have proven to be safe in multiple studies, and your insurance can cover them.

Dr. Crockett: Yeah. So I'm glad you brought that back up. There's two concerns that I have about those types of setups and the pellets specifically. So one thing that I've seen is I don't like the dosing that happens with pellets, because they get a spike up and then the pellets absorb into your bloodstream and disperse. It’s supposed to be like three months, but for some people it can be longer. Then you have to re-dose it. So you're constantly getting pellet.

So compared to just being on an estradiol patch every day or the same gel dose every day, it's not as consistent. So when I have patients that I make surgically menopausal, I’ll usually put them on an estradiol patch just because it makes it super even. Then it's easier.

Dr. Keyser: Actually, that's important. When you talked about the four key components about like starting someone on hormones and like the dose you need, but also the route. I think there's more and more data that a nonoral route, so a patch or gel or cream, probably is going to have less risk of blood clots and some other things because it doesn't bypass to like the liver.

Dr. Crockett: It doesn’t go through the gut and the liver.

Dr. Keyser: Yeah. So using like a patch or something that's transdermal is probably a better route. Sometimes when I'm talking to my patients, I like to say well, do you have sensitive skin? Some people can't tolerate that. So then maybe the pill is better for them. There's even the femring, the vaginal ring that has systemic amounts. So I think a non-oral is probably less risk.

Dr. Crockett: Yeah, I think there's good data that supports that too. This is one place where I would venture off into some compounding. That is a sublingual troche.

Dr. Keyser: I've never looked at that.

Dr. Crockett: Actually, for some people, if they need like smaller adjustments in their dose, they can put estrogen, progesterone, and their testosterone in a little troche, and it goes under there. It’s a sublingual. So it is transmucosal. It's not going through the gut. It still qualifies as through the skin.

So sometimes our skin gets really kind of more keratinized, or it doesn't absorb as well as we get older. So I've used the troche for women whose skin doesn't absorb.

Dr. Keyser: I’ll have to look up that.

Dr. Crockett: It’s kind of interesting. In some cases, it may be cheaper just if they're combining them all into one prescription. So that's kind of an interesting thing.

Dr. Keyser: Yeah. I have no dog in the fight. Like I'm in the military. You can't come see me. So I have no dog in the fight. But it's like, if you want a hormone expert, like don't go to that doc in the shop who they're pushing for their own gain of money, which I don't even know if that's ethical. I would go to the Menopause Society website and find a menopause expert. Not just like some person who hangs a shingle and says I'm a hormone expert.

Dr. Crockett: Yeah, for me like people can come see me, but please come see me for your surgery. Don’t come see me because you want menopausal help.

Dr. Keyser: Get a second opinion. I feel like it's hard. Like, we're proud. We're proud people. So it's like yeah, I can do that surgery. Could I do this huge uterus through a minimally invasive surgery? I don't know if I'm skilled enough to do that, but I know you can. So I encourage you all. Go get a second opinion from Dr. Crockett if your doctor says you have to have a big incision for your surgery.

Dr. Crockett: Well, thank you. I see that all the time as a matter of fact. I have patients every week who call and say how big can you do and still do it minimally invasively.

Dr. Keyser: Yeah. But I think a lot of patients are scared. I know we’re going off on a tangent, but I feel like they don't want to offend their doctor. So it's like they're timid to say I want a second opinion. Personally, I feel like we should thought encourage them to get a second opinion. We shouldn’t be scared to say I like what you say, but could I get a second opinion.

Dr. Crockett: Well, and I feel that way about the hormone stuff. I'm like I'm very basic here. I know the basic. If you're having trouble, then I'll send you to see my friend. So yeah, we kind of got off on a tangent, but it’s a good tangent. I think I want to go ahead and end this part of our conversation. I think we've got enough to talk about to do a second episode.

Dr. Keyser: Let’s do it.

Dr. Crockett: Yeah, I think we're kind of.

Dr. Keyser: Yeah, we haven't even talked about sex.

Dr. Crockett: I know. Let’s talk about sex. Two GYNs talking about sex. What could go wrong? What actually could go wrong? Well, thank you for doing this interview with me. It's been so informative for our guests and can't wait to hear the second part. So stay tuned.

Thanks for listening to this episode of Becoming Virtuosa. To learn more, come visit us at DrCrockett.com, or find us on YouTube for the Dr. Crockett Show. If you found this episode helpful or think it might help someone else, please like, subscribe, and share. This is how we grow together. Thanks, and I'll see you next week. Love always, Sue.

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