Nam Kiwanuka: You're listening to Mistreated. I'm Nam Kiwanuka. Until recently, menopause was a whisper between friends and trusted ones. Impolite company. It was called the change. And if you were going through this change, there was an unspoken secrecy about saying that you were. This stigma still exists in some communities. But in 2024, Oscar winning actress Halib Berry helped to shatter that silence. While on Capitol Hill, she declared that

Halib Berry: I'M IN MENOPAUSE.

Nam Kiwanuka: Okay, the shame has to be taken out of menopause. We have to talk about this very normal part of our life that happens. Our doctors can't even say the word to us, let alone walk us through the journey. According to the Yale Medical School, menopause is defined by 12 consecutive months without a period. But many people don't recognize that ovarian function begins to decline long before menopause, even in some cases up to 10 years earlier. This transition time is called perry menopause.

Nam Kiwanuka: The menopause transition is more than just hot flashes and forgetfulness. According to The Conversation, an independent online publication from the academic and research community, up to 80% of women develop symptoms linked to falling levels of estrogen, progesterone, and testosterone. Researchers have identified more than 40 possible symptoms. Because estrogen acts on receptors throughout the body, its loss is associated with increased risks of long-term health issues such as osteoporosis, heart disease, diabetes, and mood disorders. While the menopause market is expected to be worth $600 billion by 2030, many going through the transition still lack access to getting the care they need. On today's episode, we speak to Dr. Wendy Wolfman, a pioneer in Canada and an internationally renowned menopause expert. We speak to her about why she became a doctor, the stigma of menopause, and the lack of care for women in health, and about the center for mature women, which is set to open in 2027.

Nam Kiwanuka: The center she says is a quote dream realized. Dr. Wolfman joins me now. Dr. Wendy Wolfman, thank you so much for taking the time to speak with us. Could you introduce yourself, please?

Dr. Wendy Wolfman: I'm Wendy Wolfman. I'm director of the Weston Oborn Center for Mature Women's Health and Premature Ovarian Insufficiency. I'm a professor in the department of abstetrics and gynecology and the first Carol Mitchell chair in menopause.

Nam Kiwanuka: You have had a phenomenal career. You're a trailblazer not just in Canada but globally. Um I wanted to talk to you maybe about your journey and how you came to do the work that you are doing right now. What were you taught about women's health when you were growing up?

Dr. Wendy Wolfman: Not much

Dr. Wendy Wolfman: but then I came from a family um which maybe wasn't the typical family just like everybody says. Um, my father had polio when he was 28 and he was mobility impaired and really I recognized at that time that health was more important than anything else. But I think we concentrated on survival and my mother did everything with him. um never complained and so she really never talked about those symptoms that may have occurred in the pmenopause and I have to say that anything that we experienced seemed to pale besides what my father had gone through. So growing up I don't think we talked at all about that. We got a little bit maybe in school about um uh puberty, nothing about menopause

Nam Kiwanuka: and it wasn't talked about.

Nam Kiwanuka: How and why did you become a doctor?

Dr. Wendy Wolfman: I think that was the major reason is I I saw how health affected every aspect of my family's life socially, economically, um how hard they had to work for everything. um the really the discrimination at that time of people who had a visible disability and I didn't want any other family to have to go through that. And so um I also grew up at a time when women were being given privileges that they had never been before. And so also in within my family, my father and mother were wonderful parents and really encouraged me in any way they could and there was no limitation in terms of what I could do as a woman. And then the Canadian uh education system in Toronto um was excellent and I received a wonderful education in the public school system and even university if I got a job in the summer got scholarships it wasn't uh really a burden that I couldn't accomplish and then being a good student I got into all the schools I applied for and um so I I just it it It's really a process. I think that I didn't really define women's health per se until um really I got into medical school trying to decide what I want to do. Um I got married at a very young age and my husband was always a support to me. He's also a physician and I had in undergrad worked with Dr. Woliver at that time and had done some basic science in the uh reproductive hormones and I being a person who really liked to figure out everything um I really thought that was fascinating.

Nam Kiwanuka: And is that why you chose obstetrics and gynecology?

Dr. Wendy Wolfman: Well, I think that was part of it and then I did a year of internal medicine. I had after I got married I moved I got into the University of Toronto but then I moved to Calgary graduated from the University of Calgary in medicine and I did a year of internal medicine because I thought I would do reproductive endocrinology through internal medicine but then I realized I wasn't really comfortable looking after men and so uh I decided to do that through OBGYn and then you really get seduced for a time with um pregnancy, birth, uh I had quite good manual dexterity, the surgical aspects of gynecology, but then I realized that there was this whole group of women that were not being addressed. It was almost as if women's lives stopped when they became post-reroductive.

Dr. Wendy Wolfman: And when I was at uh UHN at that time um um Toronto um there was a doctor there named Dr. Plunkett and he was a reproductive endocrinologist and he had started a very small clinic for aging women and it was sort of the loser place where OBGYn went for women who were complaining about their hot flashes and their vaginal dryness. In other words, women that were malingering. It was almost attributed to that. And I I thought, well, there's got to be more to this than that. And so I started to go to meetings and I got I I thought, wow, this is amazing. It's fascinating. Look at all the changes that are occurring around menopause.

Nam Kiwanuka: There's this idea that when you're going through paramount, it's like you're complaining. You're just, you know, not tough enough. It's all in your head. So can you take me back to that moment when you realized wait a minute there is something here that we should um research and your curiosity.

Dr. Wendy Wolfman: Well, I think I recognized that there was a huge gap in knowledge as well as care and um I also realized that people were living longer and we now know that women live up to 40% of their lives after menopause and also I think this has been an evolution that you know women have gone to the work place and we are very vital members of the workforce and it takes takes years to develop the skills um to get to the top of your fields and then for women who really have terrible symptoms, they can't function. And so we're losing approximately 10% of women will quit their job because of menopausal symptoms. And for now also there's fascination with all the changes that are occurring around the perry menopause in the year before the last menstrual period. There's an acceleration of bone loss. There's changes in your lipids. There's changes in your blood pressure. We're just beginning to understand some of these changes because really women's health research didn't start until the 1990s.

Dr. Wendy Wolfman: Um, I mean that's appalling when you think about it. And so I I recognized this gap and I felt very strongly that it was wrong and that the quality of women's lives was being affected by this lack of knowledge. And women contribute so much to our countries, our families, our partners, our children. We're the backbone of society. And when we can't function, then society doesn't function. Um, you know, strong women are there for everyone.

Dr. Wendy Wolfman: And then I personally also realized it. If I went to a store, I was ignored because I was older. I finally had earned enough money to buy the products and I'm being ignored. And I'm thinking to these salespeople, why are you ignoring me like I count too?

Nam Kiwanuka: And so it's a type of discrimination. Even I see it now today. I was walking on the hallway, a young man walked past me as if I didn't exist because I'm older. And I think there's that subtle discrimination that's occurring as well.

Nam Kiwanuka: I'm glad that you talked about how it impacts our overall health because if you go to a doctor or if society tells you that once you hit a certain age that you're no longer of value

Nam Kiwanuka: and then you start to feel different and you have these symptoms and I don't think anybody wants to come off as I'm complaining but then you're put in a a position to have to advocate for yourself when you're talking to the doctors and then maybe you start to feel a bit like okay it's me it's my problem it's my fault I just need to be mentally stronger.

Dr. Wendy Wolfman: I absolutely agree with you and I think when women express opinions strongly, they're interpreted to be angry rather than assertive and I I think that's a problem with our society and how we approach women in general. Um, so I think over my lifetime I've really seen an evolution in respect for these symptoms. Part of that was the discovery probably in the early 2000s of uh the mechanism for hot flashes. So we now know that the reason people get a hot flash, which is one of the most common symptoms of the menopause, is because there's an inappropriate stimulation of your uh thermostat in your brain. And being a mammal, you're obligated to keep your temperature within a narrow range. And I learned that in grade two that that's differentiates mammals from other types of animals. And this area of your brain when you don't have estrogen there is inappropriately being stimulated saying too hot, too hot, too hot. And then your body under goes physiologic changes to make you cool off by sweating. And that involves changes in your heart rate, changes in your blood vessels. And this is not a trivial event. And if a woman is having like 20 of these a day, and most women, by the way, when you put them in temperature monitors, don't complain of all the changes in temperature that they're having. Um, so you can appreciate how that would affect a woman, her ability to function, and if they're occurring all night, her sleep, which we know is important, and how that impacts daily function.

Dr. Wendy Wolfman: And I think the discovery of this mechanism for physicians really validated these symptoms as not malingering as being physiologic and not I mean it is in women's heads but not in the same way that had been attributed before and so I think the science has improved. I think women are more viciferous and I think the re-evaluation of the Women's Health Initiative which was that study in 2002 that said that hormone therapy for all women was very dangerous and increased the risk of not only um cardiovascular disease but breast cancer scared physicians as well as women. Um, and there were even lawsuits against physicians for prescribing hormone therapy at that time if women developed breast cancer. So, I think we've come a long way. We now know more about hormone therapy. A re-evaluation of the WHI shows that actually for women between 50 and 59 who are the group that have the most symptoms um that actually taking hormone therapy is very safe and that the benefits outweigh the risks. But again, it's an individual prescription. Uh has to be determined individually looking at a woman's complete family history, her own risk factors, and whether she's a good candidate.

Nam Kiwanuka: I'm so glad you spoke about that because there's so much confusion about uh if you can take um HRT and now I there's also um people are changing the name to menopause

Dr. Wendy Wolfman: hormone therapy and we reserve hormone replacement therapy for women under 40 who develop premature ovarian insufficiency which we used to think was 1% of the population but actually is as high as 3.7%.

Dr. Wendy Wolfman: Um and we know that those women absolutely need to take some form of hormone or they will have earlier heart disease and um earlier bone change, earlier cognitive change. They're at risk for long-term health issues if they not replaced with the hormone that they would have had if they hadn't developed menopause earlier.

Nam Kiwanuka: The FDA recently took the black box of hormone replacement therapy. Can you clarify on what women should be doing moving forward? Obviously, after they speak to their practitioner.

Dr. Wendy Wolfman: So, we were very happy that the black box was removed. It scared a lot of women to take hormone therapy, but I think again it has to be looked at with the type of hormone therapy. So we have vaginal products which are utilized for symptoms of um what we call general urinary syndrome of menopause which are the changes that occur in the vagina, the vulva um the supports to the vagina and the bladder and sexuality based on lack of estrogen and 50% of women have symptoms within three years of menopause and 70% of women have symptoms by the age of 70. Those estrogen products are 1 1,000th the potency of systemic hormone therapy. So it's a teeny tiny bit of estrogen and it works locally in the vagina. And so there are now multiple studies showing that there are no long-term effects of vaginal estrogens on heart on um it doesn't it's not enough for treatment of symptoms um for risk of breast cancer. Um it really is a local product working locally.

Dr. Wendy Wolfman: Systemic hormone therapy now had the blackbox removed in the US as well. Um, for many of us, we think that's good. But we still think that the person or the people who are prescribing that therapy should treat systemic therapy with respect and recognize that the use of hormone therapy um is an individual prescription based on the person's family history, their past history, um their own personal risk factors. And then the choice of how you decide to prescribe it may be determined by your health risks. I do believe that there should be a menopausal health assessment. We don't even have a fee code for menopause and this dissuades physicians from spending the amount of time that is necessary to evaluate a menopausal woman. Why do I say that?

Dr. Wendy Wolfman: I say it because I think we can identify the risk factors for women going forward after menopause around menopause for many health problems.

Dr. Wendy Wolfman: So for instance identifying the person who's at risk for colon cancer, the person who might be more at risk for breast cancer if they have a family history. Um so identifying first of all those genetic risks then looking at a woman's history um in terms of her lifestyle. Um, we know that there are the American Heart Association eight healthy heart habits and that includes normalizing weight, normalizing blood pressure, blood sugar, lipids, Mediterranean diet, regular exercise, not smoking, and sleep. And if you can normalize all those things, then you will potentially have very good cardiovascular health, which is a major killer of women as they get older. So I think reiterating those things and emphasizing them to women is very important. If the woman's having symptoms like severe symptoms, we know that that puts her more at risk um for certain health problems. And we have these good therapies. We have the hormonal therapies. We now have some excellent non hormonal therapies. Um and the decision of whether that hormone can be given orally or through the skin. Um what type of progesterine is best to prevent uterine cancer that comes from unstimul un um opposed estrogen given to women who still have a uterus. Um those require a little bit of skill.

Nam Kiwanuka: When people talk about the menopause transition, it's like, "Oh, it's just a hot flash." Like, it's something that's cutesy, that's just something that is not

Nam Kiwanuka: it's trivialized.

Nam Kiwanuka: That's the way,

Nam Kiwanuka: right? Right.

Dr. Wendy Wolfman: And I I think I've explained that it's not trivial. That actually is a physiologic event. If you look statistically, about 70% of women or 80% have some symptoms. 20% do not. And depending on the study that you read, 20 to 40% of women have at least moderate to severe symptoms. Now, what does a severe symptom mean? It means that the woman has to stop what she's doing. She can't continue on. The symptom is so disruptive for her that she can't carry on her daily life. Um, some women have mild symptoms or no symptoms and they don't know what people are talking about.

Nam Kiwanuka: Can you talk to us about what the center for mature women's health is?

Dr. Wendy Wolfman: Well, this has been amazing towards the end of my life and my career to actually have a dream realized and um historically what happened in 200 uh about 20101 I had a grateful patient who came like an angel and said to me what would you like to do and make a difference and I said oh I'd love to have a mature women's health center and I made a a pitch to her and her husband and they gave us a nice seed for um establishing a chair and then she and I together raised $3 million um towards uh a the first clinical uh chair in mature women's health. Her name was Carol Mitchell. She's still with us thankfully and still believed in this and this has been a goal for her as well.

Dr. Wendy Wolfman: Subsequently, my department chair uh Matthew Surmer um recognized this also as something important and so he became an advocate at the hospital level approached the board. Uh Maxine Granowski was head of the board and the board decided to make this an area of interest for the hospital. They did a wa worldwide search and I was chosen as the director of the center and um then what happened is they set a goal of $52 million towards a mature women's health center and I thought uh we're never going to do this like I I'll be dead and gone before this is achieved and lo and behold due to the wonderful donors from our hospital as well as our great foundation and all the people working together and a lot of work on our part by the way. Um within two years we raised $52 million and no one would have believed it. The last two donations are named for the center, the Weston Oborn Center for Mature Women's Health, and we're starting to make the plans, um, to actually see a physical site.

Dr. Wendy Wolfman: And so, um, we've perceived as a center to be really something unique for the world, an example for mature women around the world. Now that I'm on the board of the International Menopause Society and have traveled all around the world and work with these inspiring colleagues, I know that we have one of the best centers currently uh that I've developed over this time frame. Uh we have a clinic for breast cancer survivors, for women who have graph versus host, patients who have Turner's disease. uh we have 2,200 patients waiting to see us and we have multiple days where we see menopausal patients. Um and how we perceive this clinic is to have seven clinics of excellence including menopause premature ovarian insufficiency. We have the only clinic in Canada for this group of women who no one talks about and that's I'd love to speak to you at detail about this. Um also women with abnormal uterine bleeding that's a very common presenting problem in the perry menopause. Uh sexuality clinic also not probably addressed. Eurog gynecology the um incontinence and bladder issues affects so many women with aging. Um and then um also vulvver disease which is very common in women and we have a vulvver expert with us and also uh Amanda Selk who is really nationally known.

Dr. Wendy Wolfman: We're going to have interdisiplinary and we've already started talking to people within our hospital for osteoporosis which becomes a problem as women age psychiatric issues because we know that that's also a validated menopausal symptoms is mood change around menopause. Um and then uh we also have an association with neurology because we know cognitive change uh occurs more often in women and we want to know does it really start around menopause? Is this related to hormonal change to the symptoms of menopause and these things are being uh so exciting really to be involved with all these initiatives and many others interdisciplinary partners. Um, and so this is what we hope to achieve. Um, and hopefully we've had a finish date by the end of 2027.

Dr. Wendy Wolfman: So we hope that we'll be able to do that.

Nam Kiwanuka: I think back to your family from when you were a young child and your father had polio and the discrimination that he faced and to for you to see your dream realized in your quietest moments having that dream realized where you are advocating for so many people. Uh what does this mean to you personally?

Dr. Wendy Wolfman: You know, I I I thank you for framing it that way because I don't I don't really think that much about that. I just am sort of a person who goes and and does it. But yes, it does give me um I feel fulfilled. I feel honored. Um I feel that what my mother always wanted and was really imbued in me is to make life a better place. if you're here and you're on this planet that we all should try and achieve uh change for the betterment of really humanity and I do feel that I've made some small contribution but I thank you for your kind words coming from a socialized medical system with all its faults one of its wonderful things is that we don't look to see what your insurance is when you come in everybody is hopefully treated with respect

Dr. Wendy Wolfman: and dignity and equity and that is a philosophy that I've always had as a physician. Um, and I feel so strongly about it. Um, I know for my parents uh when my father got sick, there wasn't socialized medicine at that time. It was very difficult for them and I it's extremely important to me that we maintain that high standard of care. Um, that no woman is turned away. Um, but we need more operating dollars to run the center and um, we also need more staff because of the demand.

Nam Kiwanuka: What changes, improvements are you seeing in how women's health is being taught?

Dr. Wendy Wolfman: I wish I could say more. That's very frustrating for me because I think the universities and the medical schools have been slow to catch on to this

Dr. Wendy Wolfman: and so we have tried to make inroads. We do lectures. We have for myself I started a clinical fellowship in in for obstitricians and gynecologists around 2005 and I've trained probably about 25 um clinical fellows in obstetrics and gynecology who are located all around the world and are teaching and providing care for women and in that way I think we've made a great contribution. When we look at family practice, we have about 20 family doctors rotate through our center and we're hoping to have a closer liaison with family practice and to encourage them as leaders in this area. We've trained some who I think are future leaders um to really initiate the educational aspects within family practice. Uh we've tried to advocate at the university level, at the residency level. So we've tried um but I think there's so much other curriculum that has to be provided for medical students that we get a very small portion.

Nam Kiwanuka: Um it's hard for me to make people realize that every woman who has ovaries who lives long enough will go through menopause.

Dr. Wendy Wolfman: And I always say that that's over 50% of the population. and yet so little of this um educational part is given to studying that.

Nam Kiwanuka: What do you think needs to be done to address the stigma and also this idea that women's health is niche?

Dr. Wendy Wolfman: Well, I think that there has to be a change in thought and I can say for myself that after I had children and I'm sort of moving on in my career and and as I said it's a process. It wasn't all of a sudden for me that I made my biggest contribution after my menopause. And I think if you look around in Canada, many women who are post reproductive are making huge contributions to our society. And I think we should be recognized for that. And so I think there has to be a shift in thought.

Nam Kiwanuka: What has been the biggest change and what excites you today about women's health?

Dr. Wendy Wolfman: Well, I think I think exactly what we were talking about that women are being recognized more that there is less stigma about menopause that over the last few years there has been more recognition. There's like this menopause explosion

Dr. Wendy Wolfman: um and I think that has good parts and bad parts and um so I think that's the big change I've seen. What excites me personally is the discovery of physiology of um aging and there's some data about aging and age of menopause and genetic aspects to that. That's I find that like the mechanisms for me is the exciting part figuring out why and why is this happening and what does it mean and um I mean I wish I could live another hundred years to see all the changes and advances that are going to occur.

Nam Kiwanuka: We've relied on a lot of studies from the United States. um the NIH was the one that mandated that women be included in clinical trials in 1993 and now we're seeing how um there's a lack of funding for women's health in the US. Is this an opportunity for Canada maybe to step up in that place?

Dr. Wendy Wolfman: It worries me greatly that there is lack of funding or funding being removed in the US for scientific studies because I think we've seen so so many huge advances based on that. Um yes it is a big chance for Canada to try and take some of those people uh from the US and provide them with the opportunity to do research. Um we the CIHR the Canadian Institute for Health Research has instituted in the last few years um some women's health funding more than they had before. Um, and so there are competitive grants now in Canada being provided for researchers. Um,

Nam Kiwanuka: but it's still a small percentage.

Dr. Wendy Wolfman: It is a small percentage.

Nam Kiwanuka: like 6% or 7%?

Dr. Wendy Wolfman: Yes. So it's not huge when you're looking at 50% of the population. Um, but yes, there is a change. Things are moving along. Um, and I think we'll get there. I'm optimistic.

Nam Kiwanuka: Same.

Dr. Wendy Wolfman: Yeah.

Nam Kiwanuka: Thank you so much for your time.

Dr. Wendy Wolfman: Thank you.

Nam Kiwanuka: Appreciate it.

Nam Kiwanuka: This was Mistreated. Thanks for listening. You can follow our show wherever you get your podcast so you can get notified each time a new episode is available. We would love to hear your feedback. You can write me an email at mistreatedodcast@tvo.org or reach out to me on my social channels. This week's episode was produced by Shantel Dharma, Matthew Omera and me and edited by Colin Kish. Production support from Jonathan Hallowell and TVO's digital media services team. Lori Fu is the executive producer of digital. John Ferry is vice president programming and content. Special thanks to our studio crew here for making the podcast look so great. Thanks for listening.