Nam Kiwanuka: You're listening to Mistreated. I'm Nam Kiwanuka. Welcome to a special live recording of the podcast with a studio audience. In the last few years, menopause has become a big business and the global market for it is worth billions of dollars. Yet, the people who need care during this transition are still struggling to get the help they need. Over the next hour, we'll be talking about that and more with special guests. I'd like to introduce our panelists. Far, could you get us started, please?

Far Khan: Hi. Um, my name is Far Khan and I am a social worker and I work in working with students around consent, but I'm also a cancer survivor who has had menopause now for three years.

Nam Kiwanuka: And Dr. Cohen.

Dr. Michelle Cohen: Hi. Uh, I'm Michelle Cohen. I'm a family doctor in Brighton, Ontario. It's a small town in southeastern Ontario. And I have a comprehensive family practice, but then I also do some work in women's health.

Nam Kiwanuka: And Dr. Kristakis.

Dr. Marine Kristakis: Hi, I'm Marine Kristakis and I'm a menopause and mature women's health expert at Mount Sinai Hospital. It's great to be here. Thank you.

Nam Kiwanuka: Thank you all for making the time to speak with us. Um, it's not lost on me how big a deal tonight is. I don't remember ever seeing a conversation like the one we will be having tonight on any any other Canadian broadcaster. Women's health is having a moment. In one word or two, how would you describe the moment we're in and what makes you excited or concerned about this moment? Far, I'll start with you.

Far Khan: Funding is something I think about every night. Uh, and scarcity

Nam Kiwanuka: and Dr. Cohen,

Dr. Michelle Cohen: I guess information, good information, misinformation, making sure people are well informed about their bodies and can make appropriate choices and not get sucked into opportunities, you know, to be scammed or or have people profit off of their their needs.

Nam Kiwanuka: And Dr. Kristakis,

Dr. Marine Kristakis: along the same line, I would say individualization of care. I think it's really important to remember that there's no oneizefits-all, especially in menopause. And so this idea of selling a special concoction is I think especially concerning.

Nam Kiwanuka: Misinformation about women's health is rampant on social media. In October 2025, the Society of Obstitricians and Gynecologists of Canada said it was quote calling out health misinformation and disinformation as a form of violence against women. Dr. Cohen and Dr. Kristakis. Um, can you help us understand a bit more about the misinformation we're seeing online about women's health and also give us an example, Dr. Cohen?

Dr. Michelle Cohen: Um, okay. So, I think one good example, I see this all the time, is the concept of balancing hormones. People talk about it all the time. You know, it kind of makes a sort of intuitive sense. You feel, you know, if you're feeling bad, you feel like things are out of whack. Or, you know, if you feel okay for two weeks of the month and then the other two weeks of the month, you're just a completely different person. And like it feels like something is unbalanced.

Nam Kiwanuka: I only had one good day a month.

Dr. Michelle Cohen: One good day. [laughter]

Nam Kiwanuka: But I'm not greedy. I'll take one day.

Dr. Michelle Cohen: So, you know, and a lot of people will say that too when they come into my office like I feel like something is wrong, something is offbalance, something is offkilter, like help me figure it out or you know what's going on with my hormones in particular. And so there's tons of messaging about, you know, unbalanced hormones or take this supplement and it will balance your hormones. And it feels like a very compelling sort of truth. Um, and like we do have biological concepts of homeostasis, which is a sort of balance that the body wants to stay in, but there's not really any meaningful scientific concept of balancing hormones. It doesn't really make sense. So, if you find yourself, you know, scrolling, you know, an influencer's videos or looking at like a website for say like a private clinic or something like that and they're talking about balancing hormones is usually a big red flag for me because that is a concept that makes intuitive sense, but is not actually a scientific concept, but it kind of feels scientific. So, you know, things in the pseudoscientific realm always have a bigger pull on us and a bigger opportunity for for profitering.

Nam Kiwanuka: And Dr. Chris,

Dr. Marine Kristakis: I think along those lines, I often say this to patients that I feel within women's health, there's so much self-lame. If only you exercised differently or you ate differently, you would be more fertile or your bleeding would be different or your menopause experience would be different.

Nam Kiwanuka: Why do you think that is? Why do you think there's that self-lame?

Dr. Marine Kristakis: I think um partly it's something we're we're likely trained into as women. Um but also I think there is this idea that natural is better which is not always false but this idea of something that is more natural being a better alternative to seeking medical care. I will say that one of the biggest issues that I encounter is this concept around diagnosing menopause. I think a lot of a lot of industry has now come out with measuring hormones and trying to follow this roller coaster that women often take with their hormones and making it simple because that would make it easier. But the truth around menopause and symptom management comes down to listening and not with lab work. But that's hard to do. It's time inensive for physicians and other medical practitioners to spend time listening understanding their complete profile of symptoms and then coming up with a management plan together.

Dr. Marine Kristakis: Uh but again I think all of this comes down to individualization of care. We talked a little bit about misinformation. Can you give us some examples about what you're seeing on social media?

Dr. Michelle Cohen: Menot trackers. And [laughter] so there's like at home kits that you get that do either saliva or urine testing and then they give you it's like the biometric tracking is really popular, right? And we've been seeing more and more biometric trackers. Everyone's got a Fitbit. Everyone's, you know, tracking their heart rate, tracking all kinds of different things. So this is a way of kind of uh as a biometric tracking culture. Um but so yeah, you get this kit. Um you you get readouts on, you know, for a few days in a row of your hormone levels, either just estrogen and progesterone or sometimes also FSH and LH. So you might get four hor maybe testosterone as well. Not really uh validated or reliable information. So you're supposed to kind of give you information because that is often the one thing that we are lacking. You know, we don't have the information. What's going on with my body? Is this normal to be feeling now? Am I going through per menopause? Do I need to see the doctor? there is something else going on. What I find really interesting about these ads uh is they almost always will have something about they'll say something like you know gives you information to take to your doctor to advocate for yourself to your doctor which I find really interesting. A lot of this wellness pseudoscientific kind of scam stuff will have this especially when it's targeted at women will have this component of this is a way for you to advocate for yourself because when you see the doctor or historically and currently oftenimes when you see the doctor you know you're not being listened to there's a feeling of I'm talking I'm presenting my symptoms I'm asking questions I'm being told like there there dear everything's fine you're okay you're too young for this or you're too old or you're whatever you need to get more exercise you need to take an anti-depressant, whatever. Lose five. [laughter] Yeah, exactly. You need to lose 5 pounds, you know, stuff like that. Um, and and sometimes that lifestyle advice is helpful, but it has to be taken in the context of like the whole picture of what someone is coming in with. So, if you're leaving the the doctor's office, you know, again and again and again feeling frustrated and unheard and and just like left behind, then I think that is very compelling when you see an ad that's like, "Oh, track your stuff. It gives you information. The doctor's not giving you information, but we're giving you information." and then take this information and advocate to your your for yourself to your doctor because otherwise you're kind of just at the doctor's mercy. The doctor's ordering blood work, the doctor's interpreting blood work. It's just a string of numbers, but the doctor's making sense of it all and kind of just telling you in this paternalistic way, even though we've moved away from a lot of paternalism in medicine, it's still very much there and it's still in the attitudes and fears that women have when they're going into the doctor's office. And then so these wellness profiteers are taking advantage of that.

Dr. Marine Kristakis: Yeah. and they're taking advantage of oftenimes I feel like the anti-science movement that we're in in this time and you know we have to challenge that as well. At the same time I'm like yes know how to advocate yourself with a doctor, know your own health. I want people to trust science.

Dr. Michelle Cohen: Yes. And I think a big piece of that is this idea that there is a difference between something that is bioididentical or a natural hormone that there's a difference between that and the hormone therapy that your physician would prescribe in the office when truthfully these are the same compounds. They're 17 betaastradiol often coming from the same refinery and micronized progesterone and they're just being custom compounded in a way that removes a lot of the regulation and safety with these hormone therapies and is being sold at a higher price. And that type of

Dr. Michelle Cohen: that type of um medicine really worries me because I think that it prays on vulnerable women who

Dr. Michelle Cohen: cannot get the care that they need in their primary care offices and they're being sold something that sometimes can cost thousands of dollars a month. And it's really not dissimilar from what they could be getting that would be covered by their work insurance possibly.

Nam Kiwanuka: I think sometimes when people can't access a real person, social media is, you know, you go to Dr. Google. I've been guilty of doing that a few times. Uh far, we've heard from a number of guests on the podcast who've become distressful of doctors or you kind of become weary because their concerns, they're dismissed. But on social media, it's a place where you can find the answers and the support that you need in your health journey. What role has social media played for you?

Far Khan: So, I had breast cancer and cervical cancer, small cell, and um when I went to figure out around breast cancer pieces, uh the doctors could get back to me in time, but I was like looking at my chart and I, you know, I was like, I think I have breast cancer, like the scans that they did. So, I'll never do this again. I promise. But I went on to chat GBT and I put in what I saw and it came out like you have cancer like in that like kind of horrible creepy way. And I remember talking to the doctor afterwards. I had a normal appointment and I said, I think it says in my scans that I have cancer, breast cancer. And they're like, oh no you don't. And then she looked and she was like, oh yeah, you do. And that was the experience of learning that. So I think many people in my life use social media, they use AI to diagnose themselves to understand. I think it's not because people don't trust doctors. I do trust doctors, you know, and as someone who goes to doctors, but often times as a racialized woman, as a queer woman, I don't get the care that I need. Doctors also don't have the time. We are in not only a doctor's shortage but at a time where public health care is under attack. And so when doctors are not given the resources that they need to do the work they need to do then people that are on the margins like myself will fall through the cracks. We're not seen.

Nam Kiwanuka: It's very easy to vilify social media but it is also a place where a lot of people find community. Did you find community on social media when you were going through those challenges?

Far Khan: Yes, absolutely. there was finally someone who understood what I meant when I was on fire. [snorts] Um I wasn't told that I was going to go through menopause after um going through brachi therapy which is a form of internal radiation. Uh so while I was getting cervical cancer treatment I just woke up and all of a sudden I was it was post um it was surgical menopause um but no one had talked about it with me. There was no information about it. So I had to go online and you know what I found? I found memes. I found memes about people on fire and I was like, "Oh, someone understands that I'm like engulfed in flames in this moment." I also found um young women and you know, I'm not that young, but young enough that when you look at menopause, it's talked about as something that mature women go through and only a certain age group, but you know, I'm in my early 40s and I was fullon. There was no pmenopause. And so, I think that really helped. I knew I wasn't alone. And someone was naming also the solutions that they were finding. So, I don't know about you, but I got those um fans, those portable fans that you wear around your neck,

Far Khan: and I was like, "This is making me feel good."

Nam Kiwanuka: It looks cool, too. Right.

Far Khan: It looks like you are listening to radio.

Nam Kiwanuka: I said cool. My daughter's in the audience. [laughter] Uh

Far Khan: I'm sorry.

Far Khan: I looked amazing. But yeah, I love it. I I felt like it, you know, it's an aid that felt good for me.

Far Khan: Um but then there was also the normalization of how to talk to doctors. So going on social media for some of us, we don't know how to document with our doctor. We don't know how to speak back when we're treated poorly. And I've been treated poorly. You know, we don't know that we can say no.

Far Khan: So I think it's also demystifying how you can have agency with your medical provider.

Nam Kiwanuka: You mentioned surgical menopause. We are going to come back to that in a little bit. Um but Dr. Kristakis, I want to stay on this. um you know the family doctor shortage crisis in this province and um the guests that who've been on the podcast when they see a doctor sometimes their symptoms or concerns are dismissed and social media is the place that they find the answers in the community. Are you worried about the distrust of the medical community that this can cause?

Dr. Marine Kristakis: I think that social media can be a really positive force and I will say that I have seen a lot more conversation around menopause since I started in practice and I am very happy to see that conversation.

Dr. Marine Kristakis: I think that social media can really empower women to understand more about menopause, the full symptom profile, to see themselves in others, um, and to remove the taboo because I will say that 8 years ago, menopause was often talked about as almost a disease process or at other times as a butt of a joke. And I think that that that we have had a big remodel in our thinking. Um, but what's really useful is when women, like you said, have this empowerment where they understand more about their bodies, their symptom tracking. They are trying to identify what is really interfering with my quality of life. What's interfering with my ability to work or my relationships or my ability to look after myself? And then when I go to speak to my primary care provider, I'm able to frame it in a way in to speak in a language they understand.

Dr. Marine Kristakis: It's empowering in this way. I think it and I I definitely see a difference in the types of conversations I have with women now. We're not starting from scratch. There is some baseline understanding about hormones and supplementation and I think that's all really positive. Um, and I think that it's going to push primary care to have to have those conversations because women are so they're they're ready for it and this generation is not going to accept a sideline.

Nam Kiwanuka: I love it. I love to see it. Dr. Cohen, I saw you nodding.

Dr. Michelle Cohen: Yeah, absolutely. I agree. You know, I People will come in and say, "Oh, I'm sorry. I looked at Dr. Google. I know you don't want me to do that." [laughter] Or, you know, and I don't actually have that big a problem with that. Like I I want people to be searching for answers. I don't want people to just rely on me in the little like 15inute appointment that we have to give them all the information because that's not possible for me to do that. So I do want people to be looking things up. I want people to come in with a sense of empowerment and a sense of understanding how their body works because then it makes my job easier too and it makes commun like so much of it is just about communication. And so if they've done some of that groundwork to begin with or they have a bunch of questions and you know some questions like with silly question like you know if it's a question about your body and it's something that you read it's not a silly question it's a useful question and hopefully I can provide a useful answer. So I think that like I'm I'm okay with that to a point you know obviously we don't want people to be going down falling into these rabbit holes of terrible misinformation. And there's so much out there that can be really harmful. But I think if we can find a way to promote, you know, helpful helpful communication, helpful like good useful information, scientifically based information, and then, you know, bridging that gap of allowing people in, especially people in small communities, you know, I'm in a small community, so I think about that all the time. How are people with rare diseases, you know, in a small community, what are they doing? Where are they finding connection? or people with symptoms that are maybe kind of embarrassing for them to talk about with their friends and family, like where are they finding that support? So, being able to find that support online, I think, is really, really powerful.

Nam Kiwanuka: And if you're going through pmenopause, we meet online at 3:00 a.m. most nights. [laughter]

Nam Kiwanuka: Most nights. Um, it's a little embarrassing to admit this, but um I didn't really know very much about my body until I got pregnant. And I was like, "Oh, the uterus. What is the uterus?" And I only learned about pmenopause like two years ago, like right after my surgery. I was like, "Oh, hi friend." Um, [laughter] but um, when you were all growing up, did anyone here have a sense of what menopause was or what to expect? Dr. Cohen, do you want to start us off?

Dr. Michelle Cohen: No. I would say no.

Nam Kiwanuka: No [laughter] idea.

Dr. Michelle Cohen: No. No idea. I mean, probably the only the time I started to really think about it was like the when the women's health initiative study came out was the year before I went to med school. So that was the year I was applying 2002.

Nam Kiwanuka: 2002 and I started in 2003. So it was the year I was applying and so like you know I was thinking about it in that sense that I was just paying more attention to healthcare in general. So like it kind of flagged my notice I guess then but prior to that I probably yeah I don't think I really have any memories of thinking of learning about menopause.

Nam Kiwanuka: What about you Dr. Kstakis?

Dr. Marine Kristakis: Yeah, I can say when I was when I was young, when I was a teenager, I think that again a lot of conversation around menopause was a butt of a joke or the end of fertility.

Dr. Marine Kristakis: Um, but I was very lucky very early in my medical training that I I spent some time with Dr. Wolfman and uh other mentors in this area and I just found it to be such a rewarding interaction with women. partly because of what we're discussing today that no one else was really having this conversation. No one was taking it seriously for them and something that seemed very simple for us as physicians having a conversation prescribing something that's very low risk had a huge cascade on their quality of life and so that hooked me very early on.

Nam Kiwanuka: What about you Far? Did you know very much about it?

Far Khan: No, my mom got me that book. Um, what's it called? Where Did I Come From? It had a sperm with a top hat [laughter] and an ovary with like a If you don't know it, you should look it up. Um, but that was kind of how I knew about my body. I think my body was a secret,

Far Khan: you know, and I think many of us grow up with our bodies being secrets. Um, where only other people can tell us what they how they work, what they look like. Um, and so no, and you know, I was lucky when I was in high school, you know, got into feminism and got that book, Our Bodies Ourselves,

Far Khan: which is like a thick tomb. And I still have it from the '9s. And it was amazing. And so they did talk about menopause, but not deeply at that time. And I think, you know, I too saw it in like Corella Deville, like all the kind of caricatures we have of women of a certain age. It's like throw them off the cliff or something, right? Um, so yeah, all the villains. I heard about all the villains. I think they're all going through menopause. [laughter]

Nam Kiwanuka: It's understandable though. But it's also like it this fear, this is kind of like fear around it, which kind of makes me uncomfortable because it's uh we if you're lucky enough to have the privilege to get older, you will experience that at some point. Do you think we kind of need to change the conversation as something to fear or maybe just something to understand?

Dr. Michelle Cohen: Yeah, absolutely. I think like historically the idea of menopause was it was kind of just the end for you as a woman. Like your only your only purpose in life is to create children and raise children. So once that's done, you're done. And there's like very openly, you know, derogatory misogynistic language in medical writing not that long ago saying, you know, women are like dead in the eyes and they have no purpose and they just like their brains are falling out apart and like just really I think one of the coweyed expression of a woman in menopause who you know just once your ovaries stop producing estrogen like you're just done. You're done. So yeah, I think that infects that attitude both reflects the idea at the time like the just general kind of misogyny that we're all just simmering in all the time and also that the that affects just how we provide healthcare, how we can see think of women's problems, how we think of women at midlife and beyond. Yeah, I think it just generally kind of is a reflection of the way we value or or what we value in women. And once you are no longer deemed, you know, sexually attractive or able to produce children, like that's it. You're done. M

Dr. Marine Kristakis: I think also in at work a lot of women felt that this was something very shameful that it was an admission of aging or weakness because we know that a lot of symptoms of menopause impact sleep which can impact how sharp you feel the next day. And a lot of a lot of studies have shown that women feel less confidence in their ability. Perhaps not actually a difference in their productivity or their ability to do their job, but a difference in how confident they felt that they could do it. And I think that it does have a lot to do with menopause being pushed into these kind of dark corners that people didn't talk about. And now they are being brought into the light and saying we can make very reasonable accommodations for women at work so that they feel comfortable and they should be able to have this conversation with their physician or other providers so that they feel that they can continue to be productive members of our society. Because frankly, women at midlife going through menopause are so valuable to us in our workforce, in our communities as leaders and advocates, and we really benefit from their experience. And so when I see a woman who's a patient of mine who is a very high functioning person in society and says, "I feel good and I feel that I can contribute." then that's a really special, you know, a really special influence that we can have.

Nam Kiwanuka: I'm so glad you said that because I think there is still that stigma about saying that when you're at work because usually during midlife is you're it's like you're in the prime and then you are hit with this.

Nam Kiwanuka: But it does make me understand my husband more and how he chews so loudly. It's not a him thing. It's a me thing.

Nam Kiwanuka: Far, you had a reaction.

Far Khan: Yeah. I you know I keep thinking about the fact that maybe menopause is this way of just being like I'm not going to be nice anymore. [laughter]

Far Khan: I don't know like there's this idea that we are trained from a very young age to be nice

Far Khan: to say that patriarchy misogyny things that people say to us that's okay cuz I'm nice and uh you know I'm nice when someone hurts me or I'm nice I'm smiling. So maybe menopause is like I don't have the capacity to be nice anymore. And it doesn't mean like I'm a mean evil person, but maybe I'm just more honest. So I don't I don't know. I think we're so fearful of women having feelings and emotions and probably a lot of that is that the hardship that so many of us carry, the systemic harm that is happening in the world right now. If we really got angry, like I'd rip up the streets,

Far Khan: you know? So, I think about the fact that part of menopause, too, is owning the fact that I have these big feelings. There's nothing to be ashamed of. And growing up, a lot of times, so many of us,

Far Khan: especially someone like myself, like we're told to be quiet.

Far Khan: And menopause told me to take up space, physically take up space. Like, your body changes in terms of weight gain, you know, your body changes in terms of movement of body, but also my voice. And there's nothing wrong with that.

Dr. Marine Kristakis: Yeah, I was going to say that a lot of patients talk about um irritability and this idea of having a short fuse or just not putting up with things the way they used to. And sometimes we get into conversations where they say, you know, I I was just saying it like it is at work or at with my family. And I said, well, maybe but maybe that deserved that reaction. Maybe this isn't you being irritable. Maybe this is you standing up for yourself. And um but I I but I do think that there is a lot of this idea that women should not be taking up space, should not be taking up this conversation at this age.

Nam Kiwanuka: Um [clears throat] let's talk about what pmenopause and menopause are because another thing you see on social media is those two words are kind of used interchangeably. So what is parmenopause and what is menopause?

Dr. Marine Kristakis: So pmenopause is the stage that essentially goes all the way up until the last menstrual period. Um it's starts when women typically start to develop early symptoms like hot flashes, night sweats, mood, sleep disturbance and a lot of those symptoms and even the peak of those symptoms can sometimes occur before the loss of regular periods. Um, and so I think historically a lot of women when they were being asked about menopause, they would list all these symptoms and say, "But I'm still getting regular periods." And so they would say, "Well, then that's not menopause." But we know more. We can do better. And and so typically what happens is that the the the last week or so before a woman's period is when a lot of those symptoms peak. And often periods can then become more erratic. So they're not coming every month and maybe they're becoming lighter ideally. Um and then ultimately periods stop and after that is what we call post-menopause.

Dr. Marine Kristakis: And later on symptoms often change because initially these symptoms of hot flashes, night sweats, mood, sleep disturbances, very dramatic symptoms are a result of fluctuations in hormones. And then things become a lot lower and steady and symptoms can change into joint aches and pains, changes to cognition like word finding difficulty or short-term memory loss, changes to body composition, so overall weight gain or distributing more fat to the belly or around the organs um and joint joint pains. So, a lot of these later stage menopause symptoms have a kind of a different profile and they can definitely be all mixed together and varied based on the person. But I think what's important is being able to support a woman at every stage of menopause and knowing that your symptoms can change and the solution to your problem is probably going to need to constantly change with them. Um, how many symptoms? Because I know there's frozen shoulder, there's something happening with your ears, there's something happening with your smell. You can smell everything.

Dr. Marine Kristakis: Yeah. I think it's amazing. Actually, this is something that social media is bringing us is that um, you know, a lot of a lot of studies have really focused on hot flashes and night sweats. And in the US, if you want to have something approved for treating menopause, a lot of the data has to be around frequency and severity of hot flashes and night sweats. But there's so much more to menopause. And I think we're starting to uncover it as women feel less of this taboo about talking about their itchy ear or their changes in body odor or their smell sensitivity. And so even I am learning more in clinic from my patients about things that they've noticed and then I pass them on to other patients like oh yeah someone this morning told me that her she had itching and you know just on her legs and arms and that got better. So let's see what happens with you. And [laughter] so I wish we had research in a lot of these things to back it up but but this is the the beginning I think.

Nam Kiwanuka: I see you nodding Dr. Cohen. Yeah.

Dr. Michelle Cohen: Yeah. I mean I think in this way it's a sort of like social media is the the start of the research you know like it's not the way we traditionally do research but it's a kind of like popular form of research like popular in the sense of the population kind of providing information. So that is something I like that kind of democratic aspect of of social media where just like people are telling us things rather than the sort of top down well the doctors have decided they've done the science they know the rules this is how your body works you know you buy the book and it tells you what's happening and everything else is some other problem

Nam Kiwanuka: I had frozen shoulder for a year and it was just like uh you just slept wrong. [laughter]

Nam Kiwanuka: I was like and so when I was trying to like shave my arm, okay, TMI, [laughter]

Nam Kiwanuka: many women have pre-existing conditions like autoimmune diseases or cancers and their experience of uh the menopause transition is very different. Um you mentioned surgical menopause. So I wanted to uh get Dr. Kristakis to explain to us what is surgical menopause and what types of treatment are available if somebody goes through surgical menopause.

Dr. Marine Kristakis: So typically when we speak about surgical menopause in research, it refers to women who've had their ovaries removed because the ovaries are what are making hormones. Um, but sometimes we also get kind of muddied because some women just have their uterus removed and they still have ovaries that are making hormones and they are still often having cycles but without bleeding. Um and so but that kind of removes our some of our insight into their actual age of menopause. Um but with surgical menopause when ovaries are removed that often is a different population now. Historically a lot of women would just have their ovaries removed with their uterus. Well if you're having surgery anyways you may as well take those out which has huge repercussions.

Dr. Marine Kristakis: And we as a medical community have, I think, already really pushed the agenda forward on that not happening. We know that up until about 8 years postmenopause, there is benefit from a cardiovascular standpoint with having your ovaries in your body. But often now the women who have their ovaries removed are doing that because they have an estrogen-dependent cancer somewhere in their body and removing the ovaries means decreasing the chance that that cancer will come back.

Nam Kiwanuka: So they can't go on menopause hormone therapy, right?

Dr. Marine Kristakis: And so it that I think that it's a a different group of women who need a special type of support. And that I think is what brings me back to this individualization of care because with social media, I think that you can end up accessing messages that really don't pertain to you and your medical history and your special group that you're in. But in other ways, it allows women who are in these special subgroups to connect with each other. And I hope that we're going to see more of that for more women who have had surgical menopause because they and because of that, they cannot have hormone therapy and what does that mean for them? And what other therapies are there? Because there are a lot of non hormonal therapies that can be used. But is my physician going to be the one who can really chat with me about that? Where am I going to get that information from? Is it a reliable source? These are the questions that I think are left unanswered. Now,

Nam Kiwanuka: um Far, [clears throat] you mentioned you went through surgical menopause. You had two types of cancer in your early 40s and you were going through a phase of your life where you had a toddler and you were um hoping to have another baby and then you go through surgical menopause. What were your symptoms like?

Far Khan: I literally woke up from my brachi therapy and I was in a full hot flash and I remember turning to my I had more than one radiologist and I was like so like is my period like how's this going to affect my period and she was she said far your ovaries are dead like they're not coming back and uh she didn't say it well kind of yeah and she said it very manifacably and I also had my ovaries about a year and a half later. Uh, so there's so many ways to talk about menopause, but it wasn't talked about. So I had these really intense hot flashes. I couldn't get HRT. And at that time, even like what was that 2023, there wasn't um a lot of conversation yet about PE. They were very careful that like you cannot take you know hormones because that will affect your ability you know it might affect your ability to get more cancer in your breast because I have estrogen positive um so there's a lot of pressure and I had to wait I asked you know there was a point where I was just not functioning well I was in chemo um brain function anger you know all the things and you know people are like oh well that's just the cancer well no it was menopause and I had to wait over a year to get access to care um because everybody kept saying I had to go to a specialist and by the time I went to a specialist, you know, I had already figured out some care for myself. And I will say that the internet of women talking to women is important. But actually, I learned a lot from trans men who were taking hormones and talking to them about it and talking to trans women and talking to people, which I think we as, you know, talking about menopause, we need to talk about also trans people in these conversations and learn together those communities around healthcare and around hormones because talking to trans men about tea, taking tea and putting it on your clitoris as a form of um when radiation and menopause creates like shrinking. I don't know what the medical term is, but you can tell me what that is. Um but nobody told me that like one day you're just like where did that go? You know, and

Far Khan: it's really important. And a lot of medical conversations about menopause, we talk about, you know, being a functional member of society. Yeah, sure. But also pleasure needs to be part of it. And no one told me how impacted menopause would be. menopause would be on my pleasure and we talk a lot about the internal parts like the vagina but we don't talk about our where pleasure comes from for a lot of women. So I think for me um understanding my symptoms but normalizing them was a lot of trial and error and reading. And when I found out that I could finally take um ovul ovul

Far Khan: please say it for me. That's my menopause brain right there. Um that I could put them, you know, and they could have some estrogen in them and it was okay and I was willing to take that risk. That helped so much.

Nam Kiwanuka: You said you used the word pressure. So, you felt pressure to not take uh hormone therapy?

Far Khan: Yeah. Well, because I was kept being told that it would be not good for my cancer.

Nam Kiwanuka: Did they Did anyone tell you that there were other treatment options for you or was it Were you just expected to just go through it?

Far Khan: No. A doctor literally I don't want to do it to you cuz we haven't met yet that [laughter] much, but I literally like squeezed my leg cuz I said like what am I supposed to do? Cuz it was so dry. Does anybody remember like a chub rub when you like your rub you're walking and your legs

Nam Kiwanuka: in the summer time? Yeah.

Far Khan: Think of that as your body like your vagina like it was just so dry and hi mom and

Nam Kiwanuka: [laughter]

Far Khan: uh so dry. And I remember the doctor saying to me, "Well, yeah, just best of luck." Like they gave me some cream that I would have to buy over the counter, which this is the thing is that it's so expensive to have be in menopause.

Far Khan: It is so expensive. And I I'm so angry about that that we don't have pharmarmacare yet in Canada that really touches this that talks about it and not just about hormones. I'm talking about the cream that I have to use, the ovules I have to use, the compound I now use. We have made it so expensive. And so then yeah, you do feel pressure too to not say anything as if you know somehow it's you're asking too much. And you know, I think as women we're always told we're too much. So in this moment in time you're like am I alone? Am I the only one?

Far Khan: And pleasure I think was a part of that but so was health.

Nam Kiwanuka: Um I think BC is introducing a a program for um universal uh pharmarmacare for menopause but um can you explain the medicine you were using?

Dr. Michelle Cohen: So it was like a vaginal estrogen I'm guessing like no. Yeah. Well, so there's a lot of misinformation around vaginal estrogen and and when it's safe to use. And like I'm sure you've experienced this as well. You know, some doctor there's confusion about whether or not you can take oral estrogen or like a patch or something and use vaginal estrogen at the same time, which you can, but I've had many many pharmacists sending me, you know, after I've sent a prescription saying, "Oh, Dr. Cohen, you can't do two types of estrogen." And then the patients calling and oh, pharmacist said I can't do this. You know, so correcting that misinformation. and I'm a doctor who will prescribe both of those things. But then there are going to be physicians who, you know, in your experience will say, "Well, I'm sorry, I can't do that. I can't I can't provide the the vaginal estrogen for you because of your breast cancer history because you had an estrogen dependent breast cancer and that kind of thing." So, there's misinformation just within the healthcare community about the use of vaginal estrogen as well. So, that's frustrating, you know,

Nam Kiwanuka: and now there's a shortage of patch. Yay. Um, but before we move on, um, I just wanted to follow up with you, Dr. Kustakis, because I think when we something that is kind of like universal with menopause, oh, it's just hot flash. It's makes it kind of sound kind of cute, kind of mysterious. Um, but like what is happening to our bodies when we are going through menopause because it's impacting everything.

Dr. Marine Kristakis: Yeah.

Dr. Marine Kristakis: Generally what's happening is that your brain is going into overdrive trying to get the ovaries to respond and they're not able to mount that same response. But then sometimes they are and sometimes they're not and sometimes they are. And so it's that roller coaster of estrogen production that impacts the way that your brain is regulating temperature. It can cause irritability or sometimes just feelings of panic or dread. And all of those are grouped under what we call vasom motor symptoms. But they can be experienced differently. And I've I've had

Dr. Marine Kristakis: patients in clinic where they'll say, "Oh, well, I don't have hot flashes, but I do wake up in the middle of the night feeling very panicked, and I don't know why I'm awake, and I don't know how to get to sleep." And I say, but that is your manifestation of a hot like that is your hot flash essentially. Um, but I I do want to speak on this point around medications because I think that there's so much wrapped up in menopause and gender inequity, but also that women who are marginalized really are not able to access care the way that women of higher socioeconomic status can. And we see it even in policy. So these, you know, hormone therapies that we're talking about where you can take it as a patch or a gel or a tablet, for some women who are at higher risk of a stroke, it's best for them to get estrogen through the skin. But for government drug plans, they don't cover estrogen through the skin. So, we have women who are at the highest risk with the least income who are getting a form of medication that's not ideal for them, but that's all that's covered. And so, we really do need to push this into the light, this idea about how expensive undergoing menopause and trying to treat your symptoms is because it affects women at all all levels.

Nam Kiwanuka: And I should also mention that um Dr. And you mentioned that you are in a smaller town. The wait list for the menopause clinic here in Toronto, I think, is like 24 months or something, you know. Um, but what needs to be done to ensure that no matter where you live, because I imagine in a smaller town, care is probably as accessible.

Dr. Michelle Cohen: When you said menopause clinic, I was like, that must be nice. [laughter] That sounds nice.

Nam Kiwanuka: Well, we're all on the wait list.

Dr. Michelle Cohen: We've got Yeah. Yeah. I mean, we've got, you know, what I've got is local gynecologists and they work they work long long hours and they're on call and they work constantly and yet it's still, you know, and they're covering menopause within their general practice as well, general gynecology practice. Yeah. It's like two-year weight at least, you know, and then if you want to go see if you need subsp specialist care, someone who is a gynecologist urologist specialized in that way or someone who's specialized menopause practice, then you're going to Kingston or Toronto and that's going to take even longer. So yeah, two, three, four year weights not at all uncommon. Um,

Nam Kiwanuka: what needs to be done?

Dr. Michelle Cohen: What needs to be done? I mean, I think [laughter] that's a Yeah, exactly. I tell you, where do I start? Um, I mean, yeah, absolutely. We need more resources in women's healthcare. Like bottom line, there not enough gynecologists. Um, there are not are not enough family doctors or family doctors running comprehensive family practices. There not enough people working in women's health. And then absolutely there's an issue with these medication costs. You know, it's it's ridiculous that we don't have a pharmarmacare system that we don't have universal pharmarmacare across the country. It's unbelievable how long it's taken, how long we as a country have been talking about that and just talk continuing to just talk and talk and talk and talk when it's obviously the thing that we need and obviously going to have a big impact on women's health and not just from the menopause perspective too. If you think about like as you know first you are if you are someone who is cap possible that in your life that you can become pregnant then you're spending decades you know paying for contraception and then you get into menopause and now you're paying for you knows how much of those costs to just to make yourself feel comfortable to be able to go to work comfortably you know take care of your family women at life are often dealing with a lot of things you're not just taking care of small kids and dealing with you know your workplace issues you may also be caring for elderly parents

Nam Kiwanuka: generation sandwich generation stuff. Yeah, absolutely. So,

Far Khan: can we just say too that we have to pay like we have to incentivize people to be gynecologists.

Far Khan: You know, when I did my ovaries when I had my ovaries taken out, the doctor explained to me that people like women that do those surgeries are paid less given less o time. Doctors that do that surgery like we have to actually value gynecology in this country

Far Khan: because we make up 51% of the population, right?

Dr. Michelle Cohen: Yeah. I [laughter] mean, absolutely. like women's healthcare is undervalued and the gender pay gap in medicine is just a reflection of that for sure.

Nam Kiwanuka: The menopause experience is not a one-sizefitit all in some some communities experience it differently. We spoke to Professor Natasha Raja about this. Let's take a listen.

Professor Natasha Raja: Why is it important to recognize that pmenopause menopause impacts different populations differently?

Professor Natasha Raja: Because the treatments that you offer are different and also the health the lifestyle approaches might differ for these different communities. All females around the world who have ovaries experience menopause. And we need to understand the experiences within the context of these cultures because we don't know how much is related to physiology and actual, you know, cultural differences in physiology, uh, cultural differences in communication style, cultural differences in the language that is used.

Professor Natasha Raja: You know, certain cultures might not even have the words for hot flashes.

Nam Kiwanuka: Right.

Professor Natasha Raja: Right. And so they may not use that term, but it's because and so we might not think they have hot flashes, but they might. They just might use a different term. So we really need to understand um how menopause is experienced across the world and also what the average age of menopause is across the world because another thing that um you hear a lot of is how you know the age of menopause matters and a younger age of menopause might be a risk factor for poorer health outcomes as we age. But we don't know if that's true for all females in all communities. That that is based on western standards and results that have happened in studies that have not represented um more diverse populations.

Nam Kiwanuka: Farah, this is something that matters to you. Why is it important for us to acknowledge this that menopause is not experienced the same in different communities?

Far Khan: Because um our health is shaped by race, gender, class. Uh, you know, we know that black women and indigenous women especially experience a lot of um institutional racism when they access health care. Often times being told that it's in their heads, that they're being difficult. Um, I think as a racialized woman, as a South Asian woman, we see that with our communities as well. And so when we go into a healthc care center, we don't know if we're going to get the care we deserve. And you know that time and time again being told that will make you very fearful of asking anything else and also feel make you feel like you can't because you might not be able to with a doctor that doesn't understand that. The way that menopause is being shown right now um it reminds me of breast cancer for a long time. It's it's seen as something that happens to white women because the conversation is very much the imagery, the conversations who's accessing and able to access services are mostly white women. So we need to change how we're access how people can access the services. So having GPS being aware of it and having the knowledge will help more women get that access. Um also having the social determinance of health in the conversation that we don't leave it to the side. It's central that intersectionality that we understand that people are going to be affected differently and addressing racism and healthcare is the last thing I would say.

Nam Kiwanuka: Dr.

Nam Kiwanuka: Why is that important like when it's not the same for everybody?

Dr. Marine Kristakis: Yeah. So, generally women will go or any individual with ovaries will go through menopause between 46 and 54. That's the biggest group. About 10% will go through menopause between 41 and 45. And that's considered early. And then at 41 and and younger is premature ovarian deficiency. And that's only 1% of the population. But pmenopause can emerge 10 years before the last menstrual period. So we're thinking on average about age 41. And so women should be thinking about this aspect of their health. And like you said also their sexual well-being around that time. And there's more and more advocacy that um a lot of the research I do is around cardiovascular risk that women should be having a more detailed assessment starting at age 40 that we should be pulling all of these things together. Menopause symptoms, cardiovascular risk factors, all of these things are a part of one picture that make up this person's future. their longevity, their mobility, their, you know, social connectivity.

Nam Kiwanuka: Thank you all for sharing. I'm being so generous with your answers. We always give people the opportunity to add any final thoughts. Is there anything else that you'd like to add, Farah?

Far Khan: Just protect public health care. You know, we are in a crisis of public health care right now. And every time that money is taken away from it, it takes away from from menopause care. It takes away from re reproductive health and sexual rights and we need to protect that at all costs. And

Nam Kiwanuka: Dr. Cohen,

Dr. Michelle Cohen: so just to add to that, I would say yes, protect public health care and also be cautious um and skeptical around private clinics. We're seeing a big boom in private menopause clinics and obviously they're filling a gap and sometimes that is appropriate or you know the gap needs to be filled but at the same time it's a huge opportunity for wellness grift. So be cautious, be skeptical. You know, ultimately like for me the big red flag is like language like balancing hormones like I said before, but then for me the big red flag is does it end in the supplement shop? How much are you being directed to buy supplements or to buy proprietary creams or something that you can only get from one person, one clinic? You know, how much are you being sold basically your your answers in a bottle and and being told to come back and keep buying the same expensive bottle of of probably not very much. You know,

Nam Kiwanuka: that also creates a bigger gap for inequity because if you can't afford those clinics, then you can't get the care that you need. Dr. Chris,

Dr. Marine Kristakis: and I totally agree. I think that this is a really pervasive thought for us that work in public health care and menopause is that we worry about all these resources being pushed into private industry where a small group of the population can access those resources. But it doesn't do anything to help other groups in our society, including people who are trans or marginalized or racialized. And it really deprivives us us of building a system that we can feel proud that serves everyone.

Nam Kiwanuka: Thank you so much for your time. A round of applause, PLEASE. [applause]

Nam Kiwanuka: Thank you all so much. And thank you for being a great audience. This was mistreated. Thank you to everyone who joined us today in studio, our special panel guests. We appreciate the work of our TVO studio family and volunteers and Mount Si. This week's episode was produced by Shantel DMAR, Matthew Omera, and me [music] and edited by Colin Kish. Production support from Jonathan Hollowell and TVO's digital media services team. Lorie F is the executive producer of digital. John Ferry is vice president [music] programming and content. Thanks so much for listening.

Nam Kiwanuka: [applause]