7.1 Menopausal Psychosis and Hormone Therapy: RANT and GUEST INTRO

[00:00:00] Welcome to Renegade Psych, a nuance podcast dedicated to informing the American public about

[00:00:06] the flagrant shortcomings of our healthcare system. I'm a board certified psychiatrist

[00:00:12] and along with my guests break down interesting and important topics into several segments

[00:00:18] to appeal to both the general public as well as medical and psychiatric students, residents

[00:00:24] and practitioners. My primary motivations are to appreciate nuance in major medical

[00:00:30] and psychiatric discussions, educate listeners on the undue and widespread influence of big

[00:00:36] business in healthcare, and provide accurate and reliable information on relevant mental

[00:00:42] and medical health topics. While I'm still young and have a lot to learn in my career,

[00:00:48] I cannot continue to stand idly by while so many in my field repeatedly fall victim

[00:00:54] to pharmaceutical interests, misinformation and manipulation of existing data at the expense

[00:01:01] of American's health. Whether you struggle with your mental health, work in behavioral

[00:01:07] health or the healthcare system, or want to better understand our healthcare systems

[00:01:12] over promise and under deliver status quo, my guests and I hope to provide public education

[00:01:18] on some of the most pertinent, under reported and controversial issues in psychiatry, mental

[00:01:24] health and healthcare in general. Disclaimer, this podcast is for informational

[00:01:27] purposes only. The information provided in this podcast and related materials are meant

[00:01:30] only to educate. This information is not intended as a substitute for professional medical

[00:01:33] advice. While I am a medical doctor and many of my guests have extensive medical training

[00:01:36] and experience, nothing stated in this podcast nor materials related to this podcast, including

[00:01:40] recommended websites, texts, graphics, images or any other materials should be treated

[00:01:43] as a substitute for professional medical or psychological advice diagnosis or treatment.

[00:01:47] All listeners should consult with a medical professional licensed mental health provider

[00:01:50] or other healthcare provider if seeking medical advice, diagnosis or treatment. Or put more

[00:01:54] simply. You need help like this guy. Call your own doctor. Somebody get this guy some

[00:02:01] help. Have you ever been bewildered and confused by what you see clinically? Where what you've

[00:02:14] read in the textbooks and have been taught in the classroom, don't begin to explain what

[00:02:19] you're seeing with your own eyes and clinical sense in front of you? As a psychiatric provider,

[00:02:25] have you heard of a second peak in the age of onset of severe mental illness in females

[00:02:31] that does not coexist in males? Have you ever questioned whether that second peak

[00:02:35] really represents the same condition or might be an unrecognized or multifactorial

[00:02:41] other form of illness? Should we be treating all illnesses with some overlapping symptoms

[00:02:47] with the same cookie cutter type approach, anti-psychotics and or mood stabilizers for

[00:02:53] all? Or should we try to narrow down the root organic cause of the quote unquote late onset

[00:02:59] schizophrenia or bipolar disorder and treat that or use a combination approach to treatment?

[00:03:06] What if I told you there's scores of research indicating the benefits of another more

[00:03:11] holistic and natural approach? Which treatment would you prefer? What would you want for

[00:03:16] your family members? Today's topic revolves around the use of hormone therapy during transitional

[00:03:23] times for females experiencing severe and not so severe symptoms during menopause, the

[00:03:29] postpartum period and even monthly cycles. In my second year of psychiatric residency at

[00:03:35] University of Louisville, as I transitioned from one inpatient psychiatric unit to another

[00:03:41] at the beginning of the month, I again was met with a perplexing patient presentation.

[00:03:46] In the preceding month, I had struggled to treat a woman in her late 40s with no psychiatric

[00:03:51] history who developed a severe psychosis in which she thought her family was dead. Now

[00:03:58] I was walking into another similar presentation of a woman approaching the transitional period

[00:04:04] of menopause and displaying severe psychotic symptoms with only an outpatient psychiatric

[00:04:10] history. Both patients were resistant to classic psychosis treatments such as anti-psychotic

[00:04:16] medications, one even got a course of ECT or electroconvulsive shock therapy which was

[00:04:23] also wholly ineffective in budging her from her paranoia and delusions. Why now? What

[00:04:30] triggered the onset of this severe psychiatric problem at such a late age when otherwise

[00:04:36] schizophrenia and mood disorder such as bipolar or major depressive disorder typically present

[00:04:42] much earlier in life and have a relatively consistent course of illness across individuals?

[00:04:48] Was what I was seeing the same phenomenon or was there a factor of dropping estrogen

[00:04:53] in other female hormonal system levels? As a low on the totem pole resident, I questioned

[00:05:00] whether hormones may help to address the root cause of these women symptoms. I consulted

[00:05:05] the OB-GYN service who told me hormones had no benefit in my cases and may actually harm

[00:05:10] the patients but still I wondered could treatment with what was previously deemed HRT or hormone

[00:05:17] replacement therapy and now called HT or hormone therapy have minimized the attempts at treating

[00:05:23] these patients with other less effective medicines and thereby avoided their potentially

[00:05:29] severe side effects? The literature on the subject certainly lends credence to the idea.

[00:05:35] With women with known severe psychiatric illnesses such as schizophrenia and bipolar disorder,

[00:05:40] having predictable exacerbations during times of transition. Why were so many practitioners

[00:05:45] that trained during the 2000s and 2010s including myself taught that HRT was so dangerous to

[00:05:52] women and should be avoided? Was the WHOI or Women's Health Initiative study of the late

[00:05:59] 1990s and early 2000s that espoused this idea of hormones being dangerous, a good study

[00:06:05] with reliable results or was it fundamentally flawed? Why did the media promulgate the

[00:06:11] initially defective results in sway public opinion towards fear of hormone therapy use?

[00:06:17] But not widely publicized as a report on the reanalysis of the more appropriately stratified

[00:06:23] data that showed significant benefits of utilizing hormone therapy. If you've been listening

[00:06:29] along with us, I think you can guess my opinions on the matter. If you just follow the money

[00:06:34] and the financially motivated interests, you may lay in closer to the truth than before.

[00:06:40] Natural hormones are cheap, well tolerated and cannot be patented. From an OB-GYN perspective,

[00:06:47] there have been countless synthetic hormones and or brandable patentable other treatments

[00:06:54] pushed since 2000 in order to treat symptoms of menopause, postpartum depression or monthly

[00:07:00] fluctuations in the cycle. In psychiatry, in its hard to believe it's a total coincidence,

[00:07:06] in the late 1990s and early 2000s, a time period when the SSRIs like Prozac, Zoloft, Lexipro,

[00:07:15] and Axel were gaining widespread popularity in treating mood symptoms, and generally just

[00:07:21] being thrown at every problem that walks through a psychiatrist's door. Isn't it convenient

[00:07:26] that when the results of WHOI came out, SSRIs jumped to the first line treatment for menopausal

[00:07:32] and postpartum depression as well as PMDD or pre-menstrual dysphoric disorder, formerly

[00:07:39] known as PMS or pre-menstrual syndrome. Now that all of the SSRI patents have expired

[00:07:45] and profit margins are becoming increasingly more thin, hormone therapy is back as a

[00:07:51] co-first line treatment for some of the above conditions.

[00:07:55] A skeptical mind would say this is yet another example of the overreach of profit driven

[00:08:01] entities at the expense of reasonable scientific inquiry and progress. A skeptical mind wonders

[00:08:08] if big corporate entities and large media conglomerates co-opt using the powerful motivator

[00:08:15] of fear to move the masses towards predestined treatments and line their own pockets.

[00:08:22] Our quest for immortality, whether we realize it or not, is conflating health with God.

[00:08:28] Books like The Bible are being effectively replaced by literature containing mass

[00:08:33] messages agreed upon by big corporate government and media interests. As the great thinker

[00:08:40] and scientist Carl Sagan once stated, which summarizes the battle between profit and progress,

[00:08:47] who is more humble? The scientist who looks at the universe with an open mind and accepts

[00:08:52] whatever the universe has to teach us? Or somebody who says everything in this book must

[00:08:58] be considered the literal truth and never mind the fallibility of all the human beings

[00:09:03] involved. Historically, the menopausal transition has been a back burner issue in psychiatry,

[00:09:10] but in the mid-2020s, many women will live nearly half of their lives post-menopause.

[00:09:16] This topic does not get nearly enough discussion in medical school classes, residency didactics

[00:09:22] or in general by the media. Join us as we try to change that for this

[00:09:27] series on the topic of hormone use during menopause and other female transitional periods.

[00:09:34] My guests include Dr. Jennifer Wood, a board-certified psychiatrist with special interest in women's

[00:09:40] health issues, and Dr. Anne Grider, a board-certified OB-GYN with decades of experience and expertise

[00:09:49] using hormones in women at all ages and stages of transitions. We'll open by discussing

[00:09:55] a few case studies of first-episode psychosis and menopause, then revert back to a basic

[00:10:01] discussion of what menopause is. Talk about the impact of a flawed women's health initiative

[00:10:08] study, discuss several studies about hormonal transitions in patients with known, historically

[00:10:14] psychosis-inducing conditions like schizophrenia and bipolar disorder, and finish by reviewing

[00:10:21] some flawed treatment options. I'm very excited to talk about this under-recognized

[00:10:27] and poorly treated condition that affects in one way or another nearly half of our population.

[00:10:33] Let's dive in. Dr. Jennifer Wood came to University of Louisville

[00:10:40] in the last couple of years of my residency. I wanted to have Dr. Wood on because

[00:10:48] you are very intelligent, but you are also very humble and very open to having discussions about

[00:10:57] a lot of these topics that we don't have enough objective data to say with 100% certainty

[00:11:06] that we know what we're talking about. So I am very happy to have you on today to talk about

[00:11:12] menopause and something that I think most people in the general public don't readily see.

[00:11:19] Women who have never had a psychiatric problem and all of a sudden are on an inpatient psychiatric

[00:11:27] unit and totally not themselves. Dr. Wood, you want to tell us a little bit about your professional

[00:11:33] journey? Absolutely. And thank you so much for having me. This is actually really exciting

[00:11:38] opportunity. I'm glad to be here and I totally agree with you that there are so many

[00:11:43] aspects of our field of medicine that we just simply don't acknowledge the uncertainty or don't

[00:11:48] talk about how we do disservices to patients. And so I think that this is a really incredible

[00:11:54] opportunity to be able to open some of that dialogue up. So I kind of always knew I was interested in

[00:11:59] mental health. For undergrad, I went to George Washington University and I ended up majoring in

[00:12:04] psychology. And then I decided that I want to approach the field from a medical perspective.

[00:12:10] And so decided to go to medical school. I went to St. Louis University and graduated from there

[00:12:17] and then went on to do my psychiatry residency at the Harvard Longwood program in Boston.

[00:12:22] From there, I really just started to love the field. I think that was really when I dove more into

[00:12:28] yeah what are the things we're treating and who are the people we're treating?

[00:12:31] During that point in my career, I started to become more interested in women's health,

[00:12:35] women's mental health specifically. That kind of led me to my work in addiction medicine

[00:12:40] and also just in general psychiatry too. So now working at University Louisville doing

[00:12:46] general psychiatry in the clinic and then also substance use disorder consult work at the hospital.

[00:12:51] I continue to have a passion for women's health and hit something that we're really trying

[00:12:56] to grow in the department because again it's almost a secondary thoughts sometimes. Definitely

[00:13:01] a passion of mine. So in high school, did you ever have any thoughts about doing something else?

[00:13:08] Yeah in high school I really enjoyed just anything science related. So I remember loving

[00:13:13] my chemistry classes, physics, briefly thought about maybe doing more of like a bunch of work

[00:13:18] type of science and I like you know interned for a couple years at Case Western Reserve in Cleveland

[00:13:23] which is where I grew up. But then I really gravitated towards the more esoteric if you will or

[00:13:30] the less well-defined and that really led me to psychiatry and working with the mind and

[00:13:36] that's something I love so much about it now is that there's just endless ways that certain things

[00:13:42] can present, endless I guess experiences that even a single person can have in regards to their

[00:13:48] mental health and their experience of depression for example or psychosis out manifests and one

[00:13:54] of those things certainly can be affected by the time period in people's lives what they're going

[00:13:59] through whether that's something like starting college or having any relationship or something

[00:14:05] maybe more biologically based like menopause it's really interesting just to see how one person

[00:14:09] can navigate all those things in their lives and how their mental health can reflect that.

[00:14:15] Yeah that's my favorite aspect of psychiatry is the intellectual journey of trying to figure out

[00:14:25] things that we can't explain fully or to a degree that would satisfy any physician. Did you ever

[00:14:34] do research? Yeah starting with some kind of basic science, Bunchwork after college and then

[00:14:40] when I was at Georgia Washington University actually got involved with the National Institute

[00:14:45] of Mental Health in Maryland and I did some kind of epidemiologic research on rates of depression by

[00:14:51] polar disorder anxiety and family specifically. They did unsurprisingly find that there is quite

[00:14:57] high rates of occurrence of depression and mood disorders in general within families and then

[00:15:02] we actually even did some testing for like neurologic frontal release signs and just like trying

[00:15:07] to look at all these kinds of patterns and families and so that was more a different part of the

[00:15:12] study but it was yeah it definitely felt a lot of genetic linkage or evidence for patterns for

[00:15:17] genetic heritage of mood disorders. Yeah I was studying microRNAs and Crohn's disease and ulcerative

[00:15:24] colliders and not something I was very interested in but more of the means to an end. Tell us

[00:15:31] a little bit about why this topic is important to you. So last November I was really fortunate to

[00:15:38] present my talk at the National Network of Depression Center's conference at University of Louisville

[00:15:43] and my topic was mood disorders in menarchy and menopause and so I look specifically at depression

[00:15:50] and bipolar disorder in both of those transitional phases in a woman's life and kind of explore

[00:15:55] the literature on how they correlated with hormonal changes and interestingly and probably not

[00:16:02] surprisingly we don't have a ton of super clear conclusions. There's a lot of hormones and a lot

[00:16:09] of hormonal changes that are going on in the body I focused mainly on estrogen for this discussion

[00:16:15] but progesterone certainly even things like luteinizing hormone and follicle stimulating hormone

[00:16:20] fluctuations to degree things like inhibin there's just lots and lots of things that are going on

[00:16:26] during these transition phases that we don't fully think have a great sense of how they impact

[00:16:31] potential psychiatric symptoms. So in my talk I wanted to highlight the uncertainty of it all still

[00:16:38] and how we don't fully know. We have some general estimates of what might be happening the estrogen

[00:16:44] withdrawal theory being a very predominant theory for a while but ultimately there's just

[00:16:50] there's a lot going on that we don't know. This topic in particular holds a lot of importance

[00:16:55] for me because we put a lot of time, interest, research into women's mental health specifically

[00:17:05] in the child bearing years. We talk a lot about pre-menstrual dysphoric disorder we talk about

[00:17:10] postpartum depression we talk a lot about younger women's health to be frank. We don't really

[00:17:16] pay as much attention to menopause and to women nearing the end of their reproductive life.

[00:17:21] Some of that I think is ageism frankly, we just don't necessarily maybe care as much or we don't

[00:17:27] think it's as important for whatever societal or cultural reasons that may be but it's actually

[00:17:33] pretty shameful about how little we talk about it and how little we screen for

[00:17:38] parimonumentaposal illnesses in general. Jenny tell us a little bit about your personal journey.

[00:17:44] Yeah well as you can tell for my educational history I've moved all over the country which is

[00:17:50] something I really enjoy. I like moving to new places, seeing different people, different cities

[00:17:56] and I think that's been a big part of my personal development too. Travel is also something

[00:18:02] that's really important to me and I spent quite a bit of time actually before I, well I guess before

[00:18:08] medical school and right after before residency traveling internationally and so part of my travels

[00:18:14] took me to Beirut Lebanon which is where my now husband was living doing journalism. A lot of

[00:18:20] war correspondence and yeah kind of being journalism. I like to call it and so yeah I lived there for

[00:18:27] about a year and 2010 or so and that was awesome too and I actually got to do a little bit of

[00:18:32] research there too as well. We looked at like PTSD and depression in Lebanese citizens who had

[00:18:38] survived the civil war and so that was fascinating as well and really got to combine all my interests but

[00:18:45] yeah I think traveling, exploring, keeping things exciting is something that really was

[00:18:50] stimulating for me mentally with personally and professionally. If somebody asks you what's the

[00:18:56] coolest place you've been, what are the places that stick out? Ooh that's a great one. Well living in

[00:19:01] Beirut we did travel quite a bit around the Middle East during my time there, going to Jordan was

[00:19:05] incredible. Egypt, Cairo was cool but actually Alexandria was probably my favorite city there was just

[00:19:10] so beautiful and then we spent quite a bit of time going to like Southeast Asia, Sweden, Malaysia

[00:19:17] for a brief trip into Indonesia. Bali was beautiful. I did spend some time in Rwanda during my resident

[00:19:26] and sea. I did like a three week trip there with partners in health and I worked there looking at

[00:19:32] delivering a psychosocial rehab program to people who were essentially living in very rural parts of

[00:19:38] Rwanda and did not have a lot of access to mental health care at all so that was really an incredible

[00:19:43] experience and had a lot of great mentorship there. So yeah I think that's definitely always intertwined

[00:19:48] with my professional career. That is actually probably and this sounds maybe a little selfish but

[00:19:55] that was like one of my number one concerns about having kids and probably way it's so long 36 now

[00:20:00] but yes like can you travel with kids? Can you travel internationally with kids? You can people do

[00:20:06] it but it just seems like a lot more work. Have you seen couples with their child or children especially

[00:20:13] young ones walking through the airport before? Yes. Yeah that is a shocker. Ali's sister got married

[00:20:21] to her now wife back last October so at her wedding I of course tore my MCL. Oh no. Doing the funky

[00:20:30] chicken on the dance floor? Of course. A couple of days later we're going back through the airport

[00:20:35] and I'm sitting there dragging the car seat and just lugging all these things that you have to

[00:20:42] have and limping my way through the airport and I'm hungover I'm like two hours a sleep. What about

[00:20:49] your family life growing up? So I grew up in a suburb of Cleveland, Ohio and I have one younger

[00:20:57] brother who's about two and a half years younger. My parents are both in the medical field also so my

[00:21:03] dad is a physician mostly pulmonology critical care and my mom was not collagen nurse so they're

[00:21:09] both retired now but when I was young yeah they both worked went to the hospital every day. My mom

[00:21:16] was part-time for most of my childhood which is nice because my brother and I kind of always had

[00:21:22] had someone at home and a grandma's came over quite a bit to babysit and things like that but

[00:21:27] overall it was a pretty good childhood I would say yeah I went to public school made a lot of really

[00:21:34] good friends there who are still my best friends today. I think my elementary and high school friends

[00:21:39] are still the very close to me so yeah it's a lot of really good opportunities in the school system

[00:21:45] where I was living there was always I think a lot of encouragement for a young woman especially to

[00:21:51] yeah I mean I pursue science careers if that's what's you're interested in and of course yeah go to

[00:21:55] college and so I really I think had a lot of opportunities always and felt very encouraged that one.

[00:22:01] That's awesome you and I have more in common than I realized. Yes! I also came from two full-time

[00:22:07] working medical parents my dad is a urologist still works at the VA and my mom was a

[00:22:15] pharmacist. Oh wow yeah. I am here today with Dr. Anne Grider my wife's OB-GYN we just had our

[00:22:25] second child through that process. I met Anne and we were able to have a few conversations about

[00:22:32] something I had seen in my training which was the onset of psychiatric illness in menopause my

[00:22:40] common sense brain said her menstrual cycle has changed and now she has the onset of psychiatric

[00:22:47] problems so it only made sense to me just give them hormone treatment and see if they come out of

[00:22:54] it so it's a huge relief to meet somebody who was pro hormone treatment when it's appropriate who

[00:23:02] recognizes the need and the nuance around hormone therapy tell us a little bit about your

[00:23:09] training and professional experience. Thanks for having me here first off and appreciate the

[00:23:14] opportunity to educate anybody who's willing to listen on the benefits of hormone therapy and all

[00:23:20] the good things that has to offer women and try to fight some of the misinformation out there

[00:23:27] that really is scare women. I started medical school in residency and did my training in the 1990s

[00:23:34] before the Women's Health Initiative which was the big study then in 2002 just completely changed

[00:23:41] how we approach hormones so I live the life before that and then I've been in my current practice

[00:23:47] here at Women First and Louisville for the last 25 years. Hormone therapy menopause is something

[00:23:52] that's becoming more and more dear to my heart partly because we in our profession tend to sort of

[00:23:59] age along and phase along with our patients and so the closer I am here to menopause personally

[00:24:05] than the more near and dear that is to my heart but every patient that you have if they're not

[00:24:11] already in an appausal if they live long enough they're going to become an appausal. So it is a

[00:24:15] universal thing for all women not everyone has the drastic symptoms and problems from it and some

[00:24:23] people breeze right through and they should count themselves lucky but it is a big change and

[00:24:29] lots of things going on with your body that's very unnerven and scary for many women and I just

[00:24:35] appreciate the opportunity to educate as many people that I can on what some of that means

[00:24:41] into give some medically sound evidence-based medicine. Yeah I found it kind of fascinating 100 years

[00:24:47] ago this wasn't as much of an issue because there weren't nearly as many women who would make it to

[00:24:54] menopause. I mean life expectancy prevented this from being a widely recognized issue for a long time.

[00:25:01] Most women now live a third of their life in menopausal phase of life so it's a huge huge topic.

[00:25:07] Absolutely can you tell us a little bit about your personal journey?

[00:25:11] I come at it from a little bit different perspective and I don't have the same fear

[00:25:17] and stress overtaking something hormonally. Many women are feeling lots of angst in the

[00:25:24] perimenopausal phase of life really anybody that's in their 40s is perimenopausal and that's when

[00:25:30] things start happening like hot flashes and night sweats particularly the week of a period

[00:25:35] more acne and more breast tenderness and more pms all of those hormonal things that are just heightened

[00:25:40] so I started that in my late 30s but I have been a believer in birth control pills and a lot of

[00:25:47] the benefits of manipulating periods and helping with pms and so I stayed on my birth control pills

[00:25:55] personally all through my 30s and 40s trying to prevent that so I would see all of those things

[00:26:01] of my patients coming in and friends and I feel like take pills because for most people the

[00:26:07] cause of a lot of that angst is the hormonal fluctuations and you don't need your hormones checked

[00:26:13] because if you're having regular periods your hormones are fine but as you start getting to the end

[00:26:18] of the reproductive years and more into that perimenopausal time your hormones are up one day and they're

[00:26:23] down one day and they're up one day and they're down one day and that causes a lot of people angst

[00:26:27] and so when the root of the problem or the root of the change is hormonal then usually the best

[00:26:32] treatment is hormonal so I personally took birth control pills all through my 40s to level out

[00:26:38] hormones so I didn't have to deal with a lot of the perimenopausal symptoms then you start getting

[00:26:44] into your 50s and you know I'll go back and forth and back and forth so I'm not really to the other

[00:26:49] side of things yet but I plan to take hormones till I go to my grave unless I have a reason that

[00:26:54] I can't take them nice I appreciate you sharing that outside of medicine what types of things do

[00:27:01] you like to do to relieve stress one of the big things and I do practice what I preach for

[00:27:07] helping fight some of the things with my phase of life is Pilates and Strength training and then

[00:27:14] since COVID have taken up pickleball everybody's taking up pickleball I'm late to the game

[00:27:19] they're starting to define some specific pickleball injury so like the specific Achilles injury type

[00:27:24] that is associated with pickleball is it better or worse than other Achilles injuries from playing

[00:27:30] other sports I don't know I just know Dr. Lewis's husband who is orthopedic foot and ankle is

[00:27:36] looking to write some of that up okay because he has so many of the exact same type of Achilles injury

[00:27:40] that strikes me because in the world of psychiatry there's so much manipulated research out there

[00:27:45] that you really got to comb through it pretty intensely to figure out what is legitimate what

[00:27:51] is not but you've got a situation there where physician who is doing something that he likes and then

[00:27:59] evaluating people who hurt themselves doing it building an evidence base off of anecdotes which

[00:28:07] I think is so important in our profession we go through this whole training and it's kind of like

[00:28:15] you practice this way that we're telling you to practice don't worry about any other information

[00:28:20] like psychosis in women who've never had it before going through parry menopause where

[00:28:29] what you see in front of you does not match up with what the book says and when you see it a

[00:28:35] couple of times especially in a short time frame it really gets my wheels spinning for what the

[00:28:43] reality is so that makes you good doctor

[00:28:45] so

[00:28:47] somebody get this guy some help

[00:28:57] thanks for listening for more social media content check us out on all social media platforms

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