Smilow Shares: Fertility, Sexuality, and Menopause

October 14, 2020

Information

Fertility Options | Dr. Pasquale Patrizio

Sexuality for cancer survivors | Johanna D’Addario, PA

Menopause management | Dr. Mary Jane Minkin

ID5742

To CiteDCA Citation Guide

00:00Started.
00:04OK. I want to welcome everybody to
00:07the 4th of our four sessions for a
00:11webinar series this fall and you know,
00:15we had hoped back in the spring to plan this
00:18event in coordination with our genetics,
00:21colleagues and gynecology
00:22colleagues and our breast team.
00:23And we wanted this to be in
00:25person in two different sessions.
00:28But since we've done
00:29everything virtual lately,
00:30we change this format to virtual series
00:33so we this is the final of four weeks.
00:37Mostly focusing on hereditary
00:38breast and ovarian cancer.
00:39Wanna thank everybody who's
00:41participated in joined so far.
00:43These have all been recorded and will
00:45also be available on the Smilow Cancer
00:48Center website so that you can share
00:50them with your family or watch them
00:52later if you want to go back to them.
00:56So this week our topic is fertility,
00:58sexuality and menopause.
00:59And I'm going to start by introducing
01:02doctor Patricio who is a board certified
01:05specialist in obstetrics and gynecology,
01:08reproductive endocrinology and infertility,
01:10andrology and also has a
01:12Masters degree in bioethics.
01:14He is professor of OBGYN.
01:16It's at Yale and director of the
01:18Yale University fertility center and
01:21the fertility preservation program,
01:23and so he will be talking about
01:25fertility options for women with breast
01:28cancer and ovarian cancer genes so.
01:31Thank you doctor Patricio for joining us.
01:39Thank you Joanna and thank you
01:41everyone that is participating in
01:44this virtual opportunity to see.
01:46Unfortunately, we cannot see each other,
01:48but I hope my voice comes clear and
01:51through the through the Internet.
01:54So what I what I'm going to do in this
01:57talk I'm going to cover the Epidemiology
02:00of breast cancer and particularly attend.
02:03I pay some attention to the breast
02:07cancer genes that are known.
02:09And assess some key risk factors
02:12for the damage that chemotherapy and
02:16radiotherapy can produce on ovarian.
02:20Physiology therefore overriding toxicity.
02:22Then I'm going to briefly go through
02:27the various options that are available
02:31to preserve fertility and the testing
02:34that now we can offer to detect
02:37mutations in the breast cancer gene
02:40when embryos are formed and they are
02:43stored for future reproductive options,
02:46that is called the preimplantation genetic.
02:49Testing for cancer gene mutations or PGTN.
02:53So first of all we talk about
02:57city preservation. Where is it?
03:00It's it's that process over
03:02saving protecting eggs, sperm,
03:05embryos,
03:05or reproductive tissue from the
03:09for the possibility that a person
03:12can have a biological child in
03:15the future be cause infertility
03:17can arise when there is a surgery,
03:21radiation, chemotherapy,
03:22or other medical intervention.
03:24That can affect and disrupt the normal
03:27function of the reproductive organs.
03:30So just to give you an idea,
03:33in United States every year.
03:58I think we lost your doctor. Patricio Yeah.
04:03I think you're frozen. No no.
04:13Will give Doctor Patricio a
04:15minute to get his connection
04:17back.
04:24No.
04:54While we're waiting for Doctor
04:56Patricio to join us again,
04:58hopefully he'll get his connection back.
05:02Well, welcome everybody to the sessions.
05:06And again I want to say for
05:08anybody who just joined,
05:09we have three other sessions
05:11that are available an recorded.
05:13On the Cancer Center website,
05:15I can send you the link if you need it.
05:18The first session was
05:20overview of the genetics.
05:22Of hereditary breast and ovarian cancer.
05:25The second week was Doctor Hofstetter
05:28and Doctor Ratner reviewing the breast
05:31and ovarian risks and Prevention.
05:33And last week was little
05:35discussion about pancreatic cancer,
05:36other cancers, prostate cancer in men,
05:38and also the breast reconstruction
05:40options with plastic surgery.
05:42So if you miss any of those,
05:44feel free to reach out.
05:46I can send you the link,
05:48or you can find it on line.
05:52And hopefully will get doctor
05:54Patricio back in just a minute.
05:56But if anybody has any questions
05:57during this session,
05:58you can type it into the Q and a box below.
06:05And we'll be right back with you.
06:48OK, we have a change of plans.
06:51Doctor Patricio said there's
06:52a blackout in Gilford,
06:54so he's connecting to his generator.
06:56So I'm going to take over and then
06:59he'll join us at the end, hopefully.
07:01So I will do that and then when
07:04Doctor Patricia could join us,
07:06you'll join us again.
07:07So I'm going to share my screen here.
07:10Give me one minute.
07:12It's always something.
07:19Alright. Can everybody see this?
07:26Hopefully you can see this doctor Megan,
07:28can you see my screen lovely?
07:30It looks beautiful.
07:31OK so if anybody has kids in
07:33the room or anybody that they
07:35want to kind of step away from,
07:37I'm going to do a little bit
07:39of sensitive discussion here.
07:40We're going to talk about sexuality
07:42if you want to pour glass of wine,
07:45please feel free and what I want to
07:47share with you is that you know Yale has
07:50a particular program to talk about sexuality,
07:52intimacy and menopause.
07:53And this is for cancer survivors
07:55and also for cancer previvor.
07:56So RB RCA patients to
07:58struggle with menopause.
07:59Symptoms are of any challenges
08:00with sexuality. You know.
08:01You can certainly feel free to reach
08:04out to us at the same program.
08:06The SIM program is made up of Gynaecologic
08:09Oncology team myself and one of our fellows,
08:12doctor minkin is our gynecologist
08:14and menopause specialist,
08:15and we also have Psychology Fellows
08:17who joined to talk about this.
08:20The psychological challenges
08:21that come with being a survivor.
08:23Andorra, Previvor.
08:24It's available to any females.
08:27We do have a similar program for males.
08:31That's in the Department of Urology.
08:32But we we are open to any female cancer
08:34survivors or pre vievers and we host
08:36two sessions per month at Smilow.
08:40So I'll share with you a little bit
08:42about you know cancer survivorship.
08:44There are, you know, survivors.
08:46Anybody who's been diagnosed with cancer,
08:48whether it's from the day of
08:50diagnosis until the day of death.
08:52Oco survivor is somebody was cared
08:54for a loved one with cancer.
08:56Anna Previvor has some a couple of different.
08:59A couple of different definitions,
09:01but the one I like is survivor
09:04of a predisposition to cancer
09:06but do not have a cancer.
09:09So looking at all my style and
09:12cancer survivors, so we see many,
09:14many people and many of them
09:16have the same challenges.
09:18And if you look at the little
09:20stars that I made here,
09:22the gynecological organs
09:23prostate cancer for men,
09:25breast cancer for women,
09:27uterine cancer and ovarian
09:28cancer are some of the top types
09:31of cancer that people survive.
09:35There are a lot of themes that come
09:38along with cancer survivorship and they
09:40can be both positive and negative.
09:42You know there are some feelings
09:44of Pride and empowerment,
09:45feelings of kind of having a new identity
09:49belonging to a new group of people.
09:51But also there's some anxiety.
09:53There's fear relationship challenges
09:55feeling disconnected from non survivors.
09:57The financial challenges,
09:58the post traumatic stress,
10:00but also a little bit of
10:02post traumatic growth.
10:03So some people really, you know,
10:06grow from their cancer challenges.
10:08And some people really struggle with them,
10:10so there's a lot of different themes.
10:13But what I want to know is that the
10:15American Cancer Society feels that
10:17quality of life is very important for
10:19survivors and that includes healthy
10:21relationships with family members,
10:23including intimacy and sexuality.
10:24So this is really part of the American
10:27Cancer Society and it's part of
10:28our guidelines as providers that
10:30we should be addressing sexuality
10:32for all of our cancer patients.
10:34And if I if we focus on cancer previvor ship,
10:38there's a lot of similar emotional
10:40consequences and the family dynamics
10:42that can come with having some of these
10:45genetic predispositions like the bark
10:47jeans can become really complicated.
10:49Alot of themes that are unique to
10:51pre virus can be feeling rushed
10:54to complete childbearing.
10:55Trying to deal with your insurance,
10:58multiple appointments and specialists
10:59to manage all of your cancer risks.
11:03Considering having surgery when there isn't,
11:04and there may never be a cancer.
11:07Feeling grief because you're losing
11:10your reproductive and sexual organs.
11:12Feeling a little bit of survivor guilt,
11:14feeling relieved that you may never
11:16have cancer by feeling sad about the
11:19people in your family that did have
11:20cancer or maybe died from cancer.
11:22Being scared of your own health,
11:24being scared of having cancer and being
11:26scared of your Children's Health.
11:28Stress in the marriage.
11:29What can this cause for the marriage?
11:31Is 1 partner not understand what the
11:33others going through new identity and
11:35meaning and also a sense of gratitude.
11:39So we talk about sexuality.
11:41We're not just talking about
11:43penetrative sex, we're talking
11:44about any type of sexual activity,
11:46any type of intimacy,
11:48whether it's handholding or cuddling all
11:50the way up to different types of sex.
11:53We also think about sexual
11:54function in sexual identity.
11:58So sexual health defined by the World
12:01Health Organization is a state of physical,
12:03mental and social well
12:05being in relation to sex.
12:07So the ability to be intimate,
12:09to communicate to your partner
12:10about your sexual needs and desires
12:13and to maintain sexual function
12:15and obtain sexual fulfillment.
12:16And there are different categories
12:18of sexual dysfunction that I
12:20won't go through there. Actually,
12:22for any people who have sexual dysfunction,
12:24their desire disorders, arousal problems,
12:26or gather some problems and pain.
12:30But when it comes to cancer,
12:32there are so many different themes
12:35that can cause challenges with sex.
12:37There can be stress in the relationship.
12:40There can be challenges with fertility.
12:42It can be body image changes,
12:44a loss of femininity.
12:45There can be depression,
12:46fatigue, anxiety,
12:47changing roles,
12:48and this is a big one where the
12:51sexual partner is now kind of helping
12:53to take care of somebody who has
12:56a cancer and is becoming more of a
12:58caregiver than a sexual partner.
13:00Fear of rejection,
13:01vulnerability it,
13:02embarrassment and feeling that your erogenous
13:04zone that used to be a huge sense of pleasure
13:07may now be associated with some pain.
13:10Or some trauma?
13:12The physical changes that are
13:14cancer survivors may go through
13:16include loss of sensation,
13:18scarring,
13:19lymphoedema or you get swelling of
13:21the arms and legs from surgery.
13:24Pain decreased range of
13:26motion or flexibility.
13:27Some people have medical devices
13:29like breast implants or portacaths
13:32for their chemo hair loss.
13:34Weight changes,
13:35problems going to the bathroom
13:37and side effects for medications.
13:40And then you have hormone changes.
13:42So in our women,
13:43particularly doctor Lincoln,
13:45will talk about this shortly.
13:46The hormone changes that come
13:48with either chemotherapy induced
13:50menopause or surgical menopause.
13:51Can or radiation induced menopause.
13:54Can can lead to a decrease libido,
13:57difficulty becoming aroused,
13:58difficulty having an orgasm,
14:00pain with sex,
14:01vaginal dryness or tightening difficulty,
14:03sleeping hot flashes and night sweats,
14:06and these can all cause a lot of
14:10problems in somebody's sex life.
14:13So with the research shows is that
14:15we as medical providers are not good
14:17at asking about sex and there's a
14:19lot of different reasons for that.
14:21It could be because we don't
14:22feel comfortable.
14:23We don't have time during
14:24your your appointment.
14:25If it's a cancer visit were so
14:27focused on your cancer and your
14:29physical health that we stop.
14:30We don't stop to ask about your
14:32emotional health or your relationships
14:34and we may not want to make you
14:36feel uncomfortable so we don't.
14:37We don't want to bring it up
14:39and sometimes we know that you
14:41don't want to bring it up either.
14:43But we do know it's important
14:45part of your life.
14:46It is OK to talk about it and
14:48actually your provider should be
14:49asking you about your intimacy
14:51and that's guideline driven.
14:53We're supposed to ask.
14:55And we know that partners often
14:59share concerns with you.
15:01So what do we do for people who
15:03have trouble with their sexual life
15:04during cancer treatment or as a
15:06previvor or survivor? Well,
15:07what we need to do is we need to educate you.
15:10We need to talk about the side effects we
15:13need to talk about what chemo might do.
15:15Talk about what our surgery is going
15:17to do in regards to your hormones
15:19in regards to your body changes and
15:21how it can affect your sexuality.
15:23And once you have any of those side effects,
15:25we need to validate you and explain
15:27to you why it's happening so that
15:30you understand and we can manage it.
15:33We certainly feel like a lot of this
15:35is emotional, so we also rely on our
15:38psychology colleagues to help us with this.
15:40But we can often recommend
15:42cognitive behavioral therapy,
15:43sometimes sex therapy with your partner,
15:45and then in the same clinic.
15:47What we do is we talk about different
15:49therapies for different problems.
15:51So with things like Lou Perkins and
15:54vaginal moisturizers for dryness.
15:55Vaginal dilator therapy for
15:58vaginal tightening.
15:59Some medical devices which will show you
16:02later and pelvic floor physical therapy.
16:05And then we can also do some prescription
16:07and over the counter medications.
16:08We can do some herbal remedies
16:10for hot flashes and night sweats,
16:12hormone therapy,
16:12anti depressant therapy which
16:13can often help with hot flashes
16:15and night sweats as well.
16:16And we can refer you to different
16:18people in the community who can help you
16:20with some of these challenges as well.
16:25But it really takes a team so you and your
16:28partner are in the middle of this circle,
16:31but it takes a team from Gynecologica
16:33Oncologix to psychiatry or social workers.
16:35A sex therapist,
16:36reproductive endocrinology to help you
16:37with fertility challenges the genetics team.
16:39So lots of people involved,
16:41but really you and your partner needs
16:43to be at the center of this and we
16:46need to help you navigate this.
16:49Swear psychology colleagues had to talk
16:51about the grief and loss feeling anxious
16:54how to cope with dating and communicating
16:57with your partner about sexuality,
16:59intimacy, any conflicts that arise
17:02and helping you to manage those
17:05conflicts and how to embrace some
17:07kind of new normal in your intimacy.
17:11So this is an interesting picture.
17:13I really like this picture.
17:14It's actually from the American Cancer
17:16Society and this is to get people
17:19thinking out of the box a little bit.
17:21And unfortunately,
17:21after cancer therapy or surgery,
17:23you may realize that the way
17:25you've always done something isn't
17:27the way that you can do it now.
17:29It could be because you have pain.
17:31You have difficulty spreading
17:33your legs a certain way.
17:34You have difficulty with your abdomen or
17:36your breasts because you've had surgery.
17:38You may need to explore a little bit.
17:41You need to do some different
17:43positioning during intercourse.
17:44We often help have our pelvic floor
17:47physical therapists help people.
17:49We recommend kegle exercises to strengthen
17:51the pelvic floor and just kind of
17:54experimenting and trying new things.
17:56A lot of this is about
17:58communicating with your partner.
18:02Sometimes we recommend a sex therapist to
18:04help with sexuality concerns and also just
18:07focusing on the psychological part of sex.
18:10So there's also a way to find a
18:14sex therapist if you're interested.
18:17And with Doctor Minkin is going to go into
18:20as well as some of the medical interventions.
18:23So these are some of the things
18:25that we recommend for our women.
18:27Different brands of lubricants
18:29and vaginal moisturizers.
18:30Sometimes we use estrogen creams
18:32or estrogen suppositories for
18:33vaginal dryness on the top left.
18:35What you'll see is something called the onut,
18:38which is actually a some stackable rings
18:40that can be put on to the penis so that the
18:44penile depth is not as deep in penetration.
18:46So if you have a little vaginal shortening.
18:49From surgery or radiation that
18:51the penetration won't be as deep
18:53and it won't hurt you.
18:55Lidocaine Jelly is very good
18:57at the opening to the vagina,
18:59especially if you have pain
19:01right on an entry.
19:02And then on the right there we
19:04have a vibrator which can sometimes
19:06help with some stimulation but
19:08also bring some blood flow to the
19:10pelvis and then the bottom there.
19:11Those are the vaginal dilators
19:13that we often recommend,
19:14and what the vaginal dilators do are
19:16they slowly stretched vaginal tissue.
19:17So if you have any problems
19:19with tightness of the vagina,
19:21you can overtime stretch that issue so
19:23that it can be a little bit more elastic.
19:25So these are some of the things
19:27we talk about in our SIM Clinic.
19:32And then we often give hormone therapy and
19:34Doctor Minkin is going to go into this.
19:37I won't spend too much time here,
19:39but in Previvor as we know that menopause
19:42hormone therapy can be very safely used,
19:44some cancer survivors can
19:45also use hormone therapy.
19:47Depending on the type of cancer they've had,
19:49so we often use vaginal
19:51estrogens for vaginal dryness,
19:52and we use either these little patches
19:54that you'll see or pills for hot flashes,
19:57and also for both one health keeping your
19:59bones strong and preventing osteoporosis,
20:01keeping your heart healthy.
20:03Preventing heart disease.
20:04Keeping your brain functioning well.
20:06That's your cognition.
20:07Helping you sleep.
20:08And of course,
20:09the sexual function.
20:14So I'm just going to talk briefly
20:16about the different types of cancer.
20:17So in breast cancer survivors.
20:19You know, these people are all ages,
20:22all stages. You know we see.
20:23Are breast cancer survivors from
20:25the 20s up until their 80s and 90s.
20:27And the problem with breast cancer treatment
20:30is that it really is multimodal at an
20:32impact sexuality in five different ways.
20:34You know radiation can cause
20:37pain and scarring and fatigue.
20:39Surgery and breast reconstruction
20:40can cause difficulty with sensation,
20:43body image changes and pain.
20:45Lymphoedema chemotherapy, of course,
20:47can put you into menopause and
20:50can cause a lot of side effects.
20:53And new current therapy.
20:54And that's either that tamoxifen arimidex.
20:56The Aromat Ace Inhibitors Anastrazole
20:58Exemestane Femara those are some of
21:01the medications you may have heard of.
21:03Those can cause a lot of additional hot
21:06flashes and night sweats and vaginal dryness.
21:09And ovarian suppression in that.
21:11And that's when women get shots
21:13of medication to shut down the
21:15ovaries to stop making hormones,
21:17and so in these patients you
21:19really hit from all angles,
21:21and so we try to do mostly non hormonal
21:24management of your medication side effects.
21:26But hormone therapy usually is avoided.
21:31In our ovarian cancer patients,
21:32the challenges that there's a big surgery
21:35involved and chemotherapy can be prolonged.
21:37There can be a long recovery time
21:39and really with ovarian cancer,
21:41we tend to be very focused on
21:44survival and quality of life.
21:46When we don't often think
21:47about the sexuality.
21:48Peace with ovarian cancer,
21:50but we really should.
21:51We want people to have a good sex life.
21:55In some patients, hormone therapy
21:57is actually OK with ovarian cancer.
22:00We always talk to the oncologist about that.
22:05And then we have our lovely Previvor's
22:07and we love taking care of the pre
22:09virus because we often get to walk
22:12them through from ovarian cancer
22:14surveillance and Prevention to eventually
22:16having perhaps breast surgery or
22:18ovarian surgery to prevent cancers.
22:20And then we have to try to help you with
22:23menopause because a lot of women are young,
22:26married,
22:27may have young children and have
22:29this big emotional challenge,
22:30and then they go into this
22:33abrupt surgical menopause.
22:34And nothing was wrong at 1st and
22:36now they feel like my body is all
22:38messed up and I never had cancer.
22:39But we say,
22:40Well now you're never going to get cancer.
22:43But there's a lot of different
22:45difficult decisions.
22:46Do I do breast surgery first?
22:48Do I do ovarian cancer surgery first?
22:51Do I do both at the same time and
22:53what we know from the literature
22:56specifically in RBRCA mutation carriers?
22:58Is that for the most part,
23:00the vast majority 97% of women
23:02are satisfied with their decision
23:04to have surgery.
23:06And they report a good quality of life,
23:08but that doesn't mean their sex life
23:10always comes back to how it used to
23:12be so that the theme that we know in
23:14the literature and what we've seen is that,
23:16for the most part,
23:17people are very happy,
23:18but sex may need may look a little bit
23:20different after this type of surgery.
23:23So what we like to
23:25do is really shared decision making.
23:27This is all about you.
23:29This is about us giving you options,
23:31educating you on what we can do
23:34and then letting you ultimately
23:35decide how you want to be treated.
23:38We we certainly focus on psychotherapy
23:41and emotional support and we try
23:43to focus on what intimacy is like
23:45for you and for your partner.
23:47We love to have partners come
23:49to these appointments.
23:50We'd like to have an open dialogue
23:52with the partners with the partner
23:54understands what you're going through.
23:56And also that you understand
23:58that your partner is certainly
24:00worried about you as well.
24:01Doctor Minkin is going to shortly
24:04talk about hormone therapy,
24:05but I do want to share with you briefly
24:08that after risk reducing oofer epitome,
24:11that's taking out both of the
24:13ovaries and fallopian tubes,
24:15taking hormone therapy.
24:16To supplement,
24:17your ovaries were doing does not
24:19further risk that that increase
24:21the risk of breast cancer.
24:23Even if you keep your breasts,
24:25and that's pretty much standard now.
24:27There's no large studies.
24:28There are no long term studies.
24:30The studies have been in relatively
24:32small groups of women because we
24:34know that the RCA carrier population
24:36is not a huge number of patients,
24:38but the studies that are out there do
24:41show that systemic hormone therapy,
24:43either a pillar, a Patch,
24:44and vaginal hormone therapies
24:46are very safe in our pre vievers.
24:48And really They they are recommended.
24:52You know there they'll helpful
24:53for your quality of life.
24:55They are helpful for bone
24:56health and your heart health,
24:58and you need hormones.
24:59Hormone therapy, however,
25:00may not cure all men,
25:01applies symptoms so we can help
25:03you in the other ways.
25:05And Doctor Minkin is going to
25:07share more with you about that.
25:10And here's one of the latest
25:12articles I just wanted to show you.
25:15This is a study of 159 patients in the
25:17study is about hormone therapy after
25:19risk reducing self pinggu for Ectomy.
25:22That's removal of both ovaries
25:24and fallopian tubes.
25:25And is it associated with an increased
25:27risk of cancer in mutation carriers?
25:29And so this was just
25:31published actually this year,
25:33and it was five different cancer centers,
25:35159 patients,
25:36and the result was that there's
25:38no increased risk of any type
25:40of malignancy there were.
25:41A few cancers in both of the groups.
25:44The groups that had hormone
25:45therapy in the groups said didn't.
25:47There were a couple of about
25:496 cancers in each group,
25:51but there was not a difference whether
25:53people had hormones or did not.
25:55I think that's really important for
25:57you to know because women in their
25:5930s and 40s really need to have
26:01hormones for their quality of life.
26:05So being diagnosed with cancer
26:06or a predisposition to cancer,
26:08having cancer therapy and even having
26:10prevention for cancer can have long
26:12lasting impacts on your sexuality.
26:14But we are here to help you.
26:16We can help you with the physical changes,
26:19the hormone changes and
26:20the emotional changes.
26:21And it's OK to talk about
26:23sex with your medical team.
26:25It can get better.
26:26There are lots of resources out there and a
26:30couple of different resources I have here.
26:33Doctor Minkin's website is right here.
26:35It's called Madame Bovary.
26:37I'll let you look at some point.
26:40She's got some great videos
26:42and ask that she can show you.
26:45You can see blog.
26:48The podcast is the new podcast
26:51that show you about.
26:53Another really nice website.
26:54I don't know if I can get to this
26:57one is called force and forces
26:59facing our risk of cancer empowered,
27:01so forces about hereditary cancers.
27:03This is a great website that
27:05you can go to get involved,
27:07get updates,
27:07learn more and get support about
27:10hereditary cancers and then the
27:11last one I want to show you is the
27:14hereditary breast and ovarian Cancer Society.
27:16That's a nice organization as
27:18well and you can look at this.
27:20This is about being a previvor
27:22about the society.
27:23You know, getting involved.
27:24Getting some help.
27:25And learning more about being
27:27a cancer previvor.
27:28So a couple of nice resources
27:30the American Cancer Society has
27:32an entire section about sex
27:34after cancer for women and men.
27:36Fears that sexuality educators
27:38and counselors website the North
27:39American menopause society,
27:41has menopause information,
27:42and there's also the foundation
27:44for women's cancer.
27:45So if you have any questions if you
27:48don't have time to scribble these down,
27:51I'm happy to send you my slides or send
27:54you any of these resources for yourself.
27:57And with that I am going to thank you.
28:01This is my email.
28:02Feel free to email me.
28:03Feel free to call me and we'll try to
28:06shift back and talking about fertility.
28:08I would love to take questions at the end,
28:11but I'm going to turn it now
28:12back over to Doctor Patricio.
28:16So Doctor Patricio, you are up.
28:24Welcome back. I'll let you share your.
28:32Screen again, thank you.
28:34Is Rhonda let me share. We
28:38had the completely black out in Gilford,
28:42so the generator kicked in. OK.
28:51Can you see the slides?
28:57Yes. OK. So the 30 point Epidemiology
29:04of breast cancer and breast cancer
29:07genes key risk factors for chemo
29:09radiotherapy toxicity on the ovary,
29:12and the options that are available to
29:15preserve facility and then at the testing,
29:18the preimplantation genetic
29:19testing P GT2 detector.
29:21Cancer gene mutations, even in an embryo.
29:24If if one of you is found to be carried over
29:28every editori breast cancer so by doing.
29:32Testing on the embryo,
29:34we can detect whether or not
29:37that's a mutations has been
29:39passed on to another generation.
29:42So first of all,
29:44the definition of fertility preservation,
29:46which is the process of saving
29:49protecting eggs, sperm, embryos,
29:51or reproductive tissue so that a
29:55person can use it in the future to have
29:58his or her own biological children,
30:02becausw, surgery, radiation,
30:03chemotherapy.
30:04Or other medical intervention may
30:07impact their reproductive organs
30:08every year in United States,
30:11there are about 70 thousand
30:13women that there are.
30:15Diagnosed with cancer
30:16in the reproductive age,
30:18so we talk about women up to the age of
30:2144 and of this 70,000 cases per year,
30:25the bulk,
30:25the majority are women with breast
30:28cancer that they represent about 15%
30:30of women that have a breast cancer.
30:33They get cancer in reproductive age,
30:35so about 45 thousand women per year.
30:38Now the jeans that they've been
30:42mostly related detected in the
30:44breast cancer are the BRC A1 and
30:47two and then a series of others.
30:50The partner and localization
30:52of the breast cancer 2,
30:54the checkpoint kinase 2, the P-10,
30:57and so forth.
30:58The reason why it's important to
31:01know if someone is impacted by
31:04any of these editori conditions
31:06is because this cancer genes.
31:09We are a defining them as actionable
31:11with the PGT mutation testing.
31:14So if we know that the patient has a
31:17mutation and that's the the likelihood
31:20reason why she got the breast cancer.
31:23Now we can test the embryos and find
31:26out whether or not that Mutation
31:29is present in the in the in the
31:32ambush that we want to use for
31:35future reproduction in terms of
31:37frequency of the most common wide BLC.
31:40Frequency in unselected non
31:43Jewish population population.
31:45In United States this mutation
31:49impact one every 400 women.
31:52In asking nasty Jewish an
31:54selected one out of four,
31:56meaning that one and also one out
31:59of three has one of the three most
32:02common mutations that are listed here.
32:04That these are the two for the BRC
32:07A1 and the last one is the founder.
32:10Mutations for the B RC2.
32:13When you look at the incidents
32:16and over cancer risk,
32:18but decade of life by if someone is
32:22a carrier of BFC, one by each 30,
32:26the risk of breast cancer is about
32:303% by age 40 is 21% by age,
32:3470 is close to 70%.
32:37While the B LC82 has a lower incidence
32:41in the early age but at the end of all ages,
32:477074% of women with B RC2 will
32:51have breast cancer.
32:53Now it is important also to remember
32:56and to state is that the presence of
32:59beer CA one and two mutations does
33:02not mean only risk for breast cancer,
33:06but also for other type of cancer.
33:09The BLC one carriers for example,
33:12we also have an increased risk of
33:15ovarian cancer. There is a male.
33:18Risk is Lower 1% of male
33:21breast cancer for the BRC A1.
33:24However, if it's AB RC2,
33:27the male breast cancer is 7 to
33:318% and the incidence of breast
33:34cancer 69% and ovarian cancer 17%.
33:37But there are also other type of organs
33:42that can be impacted by the BRC mutations.
33:46For example, we have the fallopian tube risk.
33:50That's why Joanna was saying
33:53before the prophylactic.
33:55South Bingo.
33:56Check to me just to remove the risk of.
34:03Having the fallopian tube cancer primary,
34:06petunia canceling the wedding cancelled.
34:08But there is also important
34:10to mention pancreatic cancer.
34:12And for BLC 2IN Mail the prostate
34:15cancer and the BSE one also
34:19seen in colorectal cancer.
34:21So all together these are important
34:24to keep into account when we do
34:27the discussion of whether or not we
34:30should offer testing on embryos to
34:33avoid the future generation to have
34:36the same potential issues for cancer.
34:39The good news breast cancer is
34:42a very curable disease nowadays,
34:4489% of women at five years.
34:47They're they're alive.
34:49This is a slide from.
34:51Statistics of 2005 to 2011,
34:53so that's a very good news so ever,
34:56but is important.
34:57Is that the part of the paradigm
35:00of quality of life is important to
35:02realize that now is is crucial to
35:05talk about fertility preservation,
35:07because life goes on more and more
35:10women are surviving breast cancer and
35:12therefore after they've been impacted
35:15by by the cancer in the early age,
35:18they want to be sure that after the cancer
35:21has been cured and they are survivors.
35:24They can go on and have their their
35:27family the risk of a menopause
35:30or early menopause is,
35:32however,
35:33impacted by the type of chemotherapy.
35:35Dose of chemotherapy,
35:37where the chemo is also associated with the
35:41radiation and also the age of the patient.
35:44Patient, centered,
35:45diagnosed,
35:45entreated at 35 or older.
35:48They're a higher risk of developing
35:51early menopause then compared
35:53to women that are younger.
35:55Even though they they will be using
35:57the same dose of chemotherapy.
35:59Here is just a very rough list on what
36:03type of dosage treatment protocols
36:06are associated with a higher risk of
36:10having premature menopause in red.
36:13You see the one that we as
36:17reproductive endocrinologist.
36:18We are extremely concerned that can be
36:21associated with early menopause and
36:24that is the use of cyclophosphamide.
36:28Cyclophosphamide or alkylating
36:29agent at the particular dosage
36:32is considered high risk.
36:34Patient will go into early menopause,
36:36so if in a protocol.
36:40Of breast cancer or any other type of cancer.
36:44Cyclophosphamide is included with.
36:46Definitely we like to do and offer
36:49some type of fertility preservation.
36:52Is also important to realize that they,
36:55even though a woman is a noun,
36:59survived, and as in her menstrual
37:01function have return after she has
37:04been treated with the chemotherapy.
37:07We always stress that to remember that
37:09the age of menopause in women native now
37:13resumed their master function is much
37:17shorter than it would have been if there
37:20was no chemotherapy or radiotherapy.
37:22Therefore the messages.
37:24OK, you survived.
37:25We did not tell the chance to
37:27freeze eggs or freeze embryos,
37:29but try to reproduce at the earliest
37:32because menopause will come earlier
37:34than what would have been if you
37:36were not treated with chemotherapy.
37:38What are the options to preserve fertility?
37:42Hormonal suppression?
37:43The one that Joanna was telling
37:46you before you leave each other.
37:48Monthly injections to block
37:50your Metro cycles.
37:52Unfortunately,
37:52the evidence is still inconclusive,
37:55but in the absence of anything else,
37:58it's always a good idea to be at least
38:01using these medications monthly injection
38:04to suppress your hormonal function,
38:07then egg freezing egg freezing.
38:09I will talk about it embryo freezing.
38:13Or the combination of Agen Embrass
38:16depending on circumstances.
38:17Relational circumstances
38:18of a particular patient,
38:20and then ovarian tissue freezing.
38:23Now for egg freezing.
38:25Generally this is an open option that
38:28is offered to women that are single.
38:31Generally younger than 42
38:33because if they are 42,
38:35we prefer to perhaps do an embryo
38:37freezing instead of an egg freezing,
38:40although it also varies
38:42from patient to patient.
38:43We need about their also patient
38:45if they are in a relationship,
38:48but they still have religious
38:50objections to do embryo freezing,
38:52so they want to still do egg freezing.
38:55Sometimes they don't feel comfortable.
38:58With their partner to say no,
39:00I'm going to do embryo freezing
39:02because they are very much afraid
39:04of living a burden on the partner
39:06in the event something goes wrong,
39:09says no.
39:09I don't want to live embryos and
39:12then my partner has to decide
39:14what to do if I visit the eggs.
39:17I'm going to be a much less stress
39:19in that they are not a potential
39:22for life and it's about a 10 to
39:2512 days to do the egg freezing and
39:27should be always done before chemo.
39:29Radiotherapy as comments.
39:31Ideally we have done and now 101
39:35patient is a slice of about four
39:38months ago and the majority of
39:41patients that they were frozen.
39:44Their eggs are patient with breast
39:46cancer because it is the most common
39:49cancer that comes to our attention for
39:52fertility preservation followed by
39:54lymphoma and Hodgkin and non Hodgkin.
39:58Nope.
39:58Used there all side so we have almost
40:03800 eggs still in liquid nitrogen
40:06and us over a couple of years ago.
40:11The world wide literature documented
40:1324 live birds from the use of eggs
40:16that were frozen for Constipation.
40:18OK,
40:18this is just specifically for conservation,
40:21meaning that the great majority
40:23of eggs are still frozen in the
40:26various laboratory around the world.
40:28The most used a technology,
40:30however, is the embryo freezing,
40:32but embryo freezing.
40:34You need to have a partner or
40:37you need to use a donor sperm
40:39for that and the main stage at
40:42which the embryos are frozen.
40:44It's a staged when they are five days old,
40:48so they're called the blastocyst,
40:50and this is also the best
40:53time to do the embryo biopsy.
40:55So this is a typical classical blastocyst.
40:58And the way that the biopsy this is done,
41:02this, in case that you are a patient,
41:05is a carry Roman known mutations responsible
41:07for that particular breast cancer.
41:09This is the way that the
41:11blastocyst is biopsy.
41:12So this is the embryo and you
41:15see here in this case in this
41:17picture I I put the green cells,
41:20meaning that when we take five or
41:23six cells off of the of the embryo,
41:26this stage and they come back negative with.
41:29Testing that we're offering that
41:31means this particular embryo
41:33is not affected by Mutation,
41:35so it can be easily used for
41:38transfer in the future.
41:40While in this case if the test
41:43comes back and is showing that the
41:46embryo carries the BRCA Mutation,
41:48so this is an important is
41:51positive for mutations.
41:53Generally embryos are frozen
41:54after the patient has completed
41:57the treatment where the camera.
41:59Therapy therapy?
42:00Then it's got to be on prophylaxis and
42:04human therapy for two to three sometimes
42:08even more years using tamoxifin.
42:11When is the oncologist gives the green light?
42:14Then we can use the embryo
42:16that has been frozen.
42:17All the eggs they've been frozen,
42:19and then we can use them.
42:21For a future reproduction.
42:24So in terms of in terms of testing,
42:29the testing is done by.
42:31Best called Pee Pee GTM with the
42:34linkage analysis which is very very
42:36accurate in identifying if that
42:38particular mutation is present.
42:39Now the question could be can you
42:41also do the testing on the eggs if
42:44I don't have the Amber scan your
42:46screen and egg for that particular
42:49mutations and in on the egg is is not
42:51so easy to do because you need to.
42:55You need to do a couple of genetic
42:58processes so it's better to do it on
43:01the on the embryos and not on the end.
43:04What are the protocols that we use
43:07to collect eggs or to make embarrass?
43:10The protocol?
43:11Always include a aromat ACE inhibitor,
43:14letrozole and letrozole off a Mara
43:17in this way. During the simulation.
43:19There are not a rise in the extra die
43:23restoration levels and therefore this
43:26is going to be a very safe protocol.
43:29It takes only 10 to 12 days nowadays
43:32to do an ovarian stimulation.
43:35And we can start the simulation at
43:38anytime in the menstrual cycles four or
43:41five years ago we were always bound to win.
43:44The patient was in the initial
43:46in the menstrual at the
43:48beginning of the menstrual cycle.
43:50Now this does not take anymore priority.
43:53We can stimulate a woman
43:54anytime in the master cycle,
43:56even if he was just so late in the
43:59yard in the middle on mistral cycle.
44:02I can still do an
44:04overstimulation 10 to 12 days.
44:06And then I collect the new eggs.
44:09So this is just an example
44:11of the letrozole protocol.
44:12So at, in this particular case we started
44:15letrozole restarted injection according,
44:17Gonna Drop Inns to make eggs,
44:19and then 10 to 12 days
44:22later we collect the eggs.
44:25Just to give you very very little
44:27numbers on whether it's important to
44:30do the ovarian stimulation for regular
44:33collection before or after breast surgery.
44:36It doesn't matter.
44:38There's really no difference whether
44:40an egg collection is planned for
44:43before pre resection or after surgery
44:46because there is no difference in the
44:49number of mature eggs collected and
44:51the fertilization rate is also no difference,
44:55which is very important in survival.
44:57In the woman that today
44:59have ovarian stimulation,
45:01according to the receptor status,
45:03if someone is is someone is an
45:05estrogen receptor negative or
45:07estrogen receptor positive.
45:08Some woman had a little bit
45:11nervous about being stimulated.
45:12It does not change the survival rate
45:15even if they are estrogen receptor
45:17positive because in that short period of
45:21time 10 to 12 days with the letters or
45:24the five year survival is not impacted.
45:26So that's a good news.
45:28Not to be afraid of the
45:31estrogen receptor status.
45:33Maybe I will also briefly on and on a
45:36technique that is available for here a year.
45:39We don't use it too much for breast cancer,
45:42but this is a technique called
45:44ovarian tissue freezing OK,
45:45so these are patients that they really
45:48have no time for the date they they
45:51don't give us those 12 days they want
45:54to fix just more than few eggs because
45:56if you do an egg freezing cycle,
45:59how many eggs can we freeze?
46:01Probably 1012 then we may
46:03do another cycle we may ask.
46:05Young cologist wait another 1012
46:07days before certain chemo so we
46:09may accumulate another 10 to 12,
46:10but those are going to be just 2024 eggs
46:13and for some patient they always ask.
46:16But is this enough for for
46:18for my future family needs?
46:19But how big would you want
46:21to have your family?
46:23They say I want to have
46:25two or three children.
46:26Maybe 28 is not enough.
46:27So then of urgent issue can be an option.
46:30What we do with your variant issue.
46:33We collect ovarian tissue with the.
46:36Upper Osca P.
46:37This is a picture of a piece
46:39of ovarian tissue collected.
46:41Then you know you must know that the
46:43ALDI eggs you see this little dots here.
46:46They're all in the outer surface
46:48of the over if and therefore this
46:50over has to be district cortex.
46:52This little piece of overlays
46:54to be made very, very thin.
46:56Then he's going to be cutting square and
46:59then after it's been cutting squared,
47:01we put in particular solution and then
47:03it's going to be placed on this grid.
47:06And then after a is placed on this
47:09grade is going to be plunged into
47:11liquid nitrogen and then it's
47:13good to be stored for
47:15whatever needs to be used.
47:17When is used, is going to be used
47:19for re transplant and can be put
47:22back on the ovarian stuff folder if
47:25the woman went into menopause can
47:27be put on the peritoneum inside the
47:30pelvis and what is very characteristic
47:32is that it takes four months.
47:34If a woman is in menopause.
47:36After the treatment and I
47:38put back the ovarian tissue,
47:41I would wait for months before she
47:43can resume the ovarian the ovarian
47:46cycle and there are many babies
47:48now that they've been born from
47:51the ovarian tissue transplant.
47:53In fact, at the last official count,
47:56there are 148 documented live birds.
47:59When there was a violent issue
48:01that was frozen and then was re
48:05transplanted in in the woman.
48:07Or pelvis? OK, so that's good.
48:10So what I want to say is that
48:12future Fidelity is at risk when
48:15the breast cancer patient required
48:18chemotherapy and radiotherapy.
48:20I also want to say that is almost
48:23impossible for anyone to predict
48:25what chemo protocol or radiotherapy
48:27protocol is better than others in
48:30safeguarding the future fertility.
48:32Therefore, in the absence of a certainty,
48:35nobody wants to take a risk,
48:38say, Oh I'm,
48:39I'm kind of going to be playing my odds.
48:43My chemotherapy protocol is going to be
48:46only 30% risk that I might be infertile.
48:50Yeah, but.
48:51Who is going to take that risk?
48:54And I'm very much a strong
48:57proponent that every patient should
48:59have a fertility preservation.
49:01Consultation should be given all the
49:04opportunity and information to make
49:07the decision without any risk of
49:10being feeling regret for the future.
49:12And they should be made available
49:15any possible future factivity
49:17strategy and localization could
49:19also include the test of.
49:21BGT preimplantation genetic
49:23testing for screening any possible
49:25edited Editori Cancer Mutation.
49:27So this is not going to be passed
49:31on to a new or next generation.
49:36Of all of these,
49:37unfortunately we are still fighting,
49:39even though Connecticut towards the
49:41very first state in which insurance
49:44were given a mandate to cover fertility
49:47preservation for medical reason,
49:49we're still fighting in in
49:51in covering for the costs,
49:53and another hurdle is the
49:56lack of information.
49:58In other words,
49:59women are not told except
50:01when they come from smile.
50:03Oh,
50:03they're not told in in general
50:05that there are many options,
50:07and that's something that we are
50:10working very hard in trying to provide
50:12access to the treatment that are available.
50:15There are advocacy group I
50:17just listed very few here,
50:19but there are many,
50:20many more you can take note on this
50:23on this advocacy website you can
50:26find really a lot of information.
50:28And that'll solve directions on
50:31which doctor is going to be in
50:35closer to the place where you live.
50:38Any final summary?
50:39We do have A at the smile or really a
50:43critical mission in preserving fertility.
50:45In fact,
50:46we do have a clinic that we as
50:48reproductive endo chronology
50:50stuff favorite every Wednesday
50:52afternoon and we
50:54do consultation right there in the
50:56Cancer Center and we offered the
50:59the consultation and discuss all
51:01the options that are available.
51:03So this is it what I had to say.
51:07Thank you and sorry again.
51:09For the interruption at my
51:11very first attempt, thank you.
51:15That's OK, I got Patricio.
51:16Thank you for sharing that information
51:18for everybody. And I agree with you.
51:20I think that it's under under.
51:22It's not known under recognized that
51:24fertility is an option for women
51:26before they have any risk reducing
51:28surgeries and to prevent the jeans.
51:30So that's very helpful and I think you
51:32have a lot of questions about that later.
51:36So will shift over now to Doctor Minkin
51:39who's going to talk more about menopause,
51:42management and so I'll bring
51:44up doctor minkin slides here.
51:46Hold on one second.
51:49Doctor minkin, I'll drive your slides.
51:53Thank you much. OK.
51:55Ah there there.
51:58OK, so I go ahead. OK, first of all,
52:03I thank you all for joining us this evening.
52:06It's of course one of my absolute
52:08favorite topics, and Joanna knows that
52:10very well and I want to thank Joanne
52:12and Pasquali for lovely talks and I'll
52:15see what I can do here to try to keep
52:17you all a little bit entertained here.
52:20OK, so I'm the old menopause lady
52:22as I introduce myself to all of our
52:24patients and I hear talk this evening
52:26about menopause for women with backup
52:28and both for previvor zan survivors.
52:30And this is something like who stuff to
52:33get ahold of me and things like that.
52:35OK, Joanna, can I have the next slide please?
52:37We're going to be advancing him there.
52:41OK, alright so can we go back?
52:44Is that the that's the. Ah.
52:50Yeah, for me. OK, there we go.
52:52Further, thank you very much.
52:54OK so anyway?
52:55Basically we're going to divide this
52:58talk and sort of two basic parts.
53:00This will be parts for Previvor's
53:02and women who are survivors.
53:04OK, I'm going to start by talking about
53:07pre vievers who are women who carry
53:09mutations but have not had cancer but
53:12are doing preventative therapy and Umbraco.
53:14We're talking about preventative
53:16therapies for removal of the ovaries
53:18and horse breast cancer parent.
53:20Japanese is different area,
53:21but here we're talking bout hormonal
53:24function and part of the issues that
53:26we're dealing with are the fact that many
53:28of the women that we're dealing with
53:30a very young I called them kitties and
53:32people got used to be dealing with that.
53:35A young woman and these women,
53:37young women are premenopausal,
53:38and surgery is done.
53:39What we do now, of course,
53:41is that taking out ovaries puts
53:43you into menopause.
53:43That's what happens.
53:44And the other thing that's sort of
53:47a well known issue is that young
53:48women tend to have more symptoms,
53:50like hot flashes when they
53:52go through menopause.
53:53So if you have somebody who's just,
53:55you know,
53:55many Jane Doe walking down the street if
53:58she's 40 years old and goes not 'cause
54:00she's likelier to have symptom a teologi,
54:02then who's 50?
54:03Not the 50s old?
54:04That's very young.
54:05But 40 year olds are more
54:07likely to have symptoms,
54:08so we're dealing with young women
54:10having their ovaries taken out
54:11and having significant symptoms.
54:13However,
54:13and Joanne alluded a little bit to this,
54:16is that if you do take out
54:18ovaries in very young women,
54:19there are significant risks of
54:21not having estrogen on board,
54:23and the risks that we know very well.
54:25If people want to talk more about this,
54:28we can.
54:28There's significant risk of
54:29developing heart disease,
54:30osteoporosis,
54:31and even dementia if you basically
54:33take a young woman who is 40 years
54:35old and don't give are estrogen.
54:37Compared to somebody goes through
54:38menopause at the average age.
54:40In the average age of menopause
54:42in this country is about 51.
54:44OK,
54:44so we know we can prevent that if we
54:46do give estrogen therapy.
54:48And as Joanne already said,
54:49we have excellent data that giving
54:51estrogen to women who were pre vievers
54:53is quite safe and does not increase
54:55the risk of developing breast cancer.
54:57So that's a very important thing
54:59that we can give estrogen.
55:01Safely and then we're not going to increase
55:04women's risk of getting breast cancer,
55:06so why not think about giving these
55:08women estrogen an our usual advice?
55:10And there's nothing written
55:11in stone about any of this.
55:13Is that as far as how long did say somebody
55:16has her ovaries out when she's 35 or 40?
55:19How long do we keep them going on estrogen?
55:22And we usually encourage women to
55:23continue to take estrogen until
55:25the average age of menopause,
55:26which is 51 in this country.
55:28Now we can continue longer,
55:30but that basically goes in
55:31discussion with your providers,
55:33your oncology folks who are following you.
55:35As far as pros and cons,
55:36but there's nothing written in stone.
55:38Say it's gotta stop at age 51,
55:40but that's sort of a basic guideline.
55:42OK, Joanna, can I have the next slide,
55:44please?
55:45OK, now when we take out ovaries,
55:48which is what we're doing to
55:50basically prevent ovarian cancer,
55:51we're taking out the tubes and ovaries.
55:53But we're not talking about
55:55the uterus at all.
55:56So if you aren't taking out,
55:58you know if you are taking out the uterus.
56:01OK, that becomes a hysterectomy as well
56:03as a bilateral salpingo oophorectomy.
56:05OK, why is that?
56:07Who cares?
56:07I mean, what does that important?
56:09OK, why are we talking about that
56:12in the discussion amenable as well?
56:14If you have your ovaries taken out
56:16OK and you have your uterus in place?
56:19We need to give people estrogen of course,
56:22to replace the estrogen.
56:23But if somebody has a uterus in place,
56:26we need to give something called
56:28progesterone with the estrogen
56:29because if we just give estrogen
56:31in the uterus is there we can end
56:33up stimulating the lining of the
56:35uterus and precipitating overgrowth
56:37of the lining and possibly even
56:39in some women developing cancer
56:40of the lining of the uterus.
56:42So we know we can prevent that
56:44by giving progesterone OK now.
56:46So the key thing is there are certain
56:48people with different variants of Braca.
56:51In Houma,
56:51hysterectomy will be be beneficial
56:53because there are certain small
56:54group of women who at also with this
56:56particular variance of the bracker gene,
56:58may be at higher risk of
57:00developing uterine cancer as well.
57:01And in those women we will recommend
57:03that they had a hysterectomy as well
57:05as having their ovaries taken out.
57:07But again,
57:08this depends on the exact chance
57:10or what's the good,
57:11why not take out the universe?
57:12Why take out the uterus if you
57:14don't have one of these funky jeans
57:16that can screw up universe as well?
57:19Well if you do take out the uterus.
57:21Ann,
57:21you have somebody that you want
57:23to give hormone
57:24therapy to. You don't have to give
57:26progesterone tool moves out of universe out,
57:28you just have to give her estrogen
57:29and that has certain advantages,
57:31particularly that you don't have some
57:32of the side effects of progesterone
57:34including vaginal bleeding issues,
57:36so that's something that we
57:37avoid by taking out uterus well.
57:39Why not take everybody's uterus out well,
57:41for example if somebody wants
57:42to have a pregnancy afterwards,
57:43we can take out of universe because
57:45he want to leave her uterus in there.
57:48She wants to have baby and of course
57:50the other thing as far as Recuperacion.
57:52That's the surgery itself is a
57:53little longer if we take out the
57:55uterus as well as the over recently
57:57Recuperacion's little Walker.
57:58So these are the kinds of decisions I
58:00don't want anybody making this evening.
58:02We can certainly talk about pros and cons,
58:04but this is when you want to really make
58:06a decision with your provider and his.
58:08Joanna alluded to in the beginning.
58:10This is truly all of these issues
58:12that I'm talking about are truly
58:13shared decision making.
58:14There is no decision here that should be
58:16just the sole decision of your provider.
58:18This is shared decision making.
58:20Joanna can I have the next slide we OK?
58:22And the good news is that we should
58:24be able to control pretty much
58:26almost all of your symptoms,
58:28and they say, Well is extra general.
58:30I'm going to need if I had my
58:32ovaries taken out his estrogen,
58:34the one hormone that I will need.
58:36OK, and the answer is primarily yes me.
58:39OK, in some women we not only give estrogen,
58:41but we also give testosterone and
58:43some people start making faces at us,
58:45and Joanna can attest to this testosterone.
58:48You know we're not guys.
58:49Testosterone is also female hormone.
58:51The guys make more than we do,
58:53but we make plenty of it.
58:55OK,
58:55and if somebody is experiencing loss
58:57of sex drive and join alluded to this
58:59a little bit too that we may want
59:02to give some testosterone as well as
59:04giving yesterday into enhanced libido.
59:05We think that that's probably involved
59:07in the beetle from anyone and some
59:09women find testosterone helpful
59:11for things like sense of energy
59:13in a sense of well being.
59:14But we can do that quite safely too.
59:16But what about the other
59:18fun symptoms of menopause?
59:19Things like hot flashes,
59:20night sweats, sleep issues,
59:22achy this magical drying?
59:23His bladder issues?
59:24I can go on and on here,
59:26but those all should be
59:27OK with giving estrogen.
59:29There really aren't too many symptoms
59:30that we can't deal with by giving
59:32some estrogen and occasionally a
59:34little bit of extra testosterone.
59:35OK, can I have the next slide there?
59:38OK,
59:38so we're talking a little bit in
59:40advance about the women who are the
59:42pre virus who have not had cancer
59:44were taken care of them before
59:46cancers had a chance to strike them.
59:48Or doing this preemptively proactively.
59:49But what about women who had breast cancer?
59:52Well, we do have many therapies.
59:54Many of the same therapies
59:55we can get the pre virus.
59:57The one thing we can't give to a woman
59:59who's had breast cancer active disease.
01:00:01Is we're not going to be giving
01:00:03her what we call systemic therapy.
01:00:05There are systemic therapy basically,
01:00:07or things that get into the
01:00:08bloodstream and a considerable amount
01:00:10they can affect the whole body OK,
01:00:12and those are primarily given
01:00:13with pills or patches on K.
01:00:15There are many other options,
01:00:16but we have other things that we can use
01:00:19other than estrogen to take care of a
01:00:21lot of those lovely systemic symptoms
01:00:23that we talked about in the last slide.
01:00:25There can I have the next slide, please?
01:00:28OK, let's talk about some of these.
01:00:30'cause some of you may have
01:00:31had breast cancer and.
01:00:32Or bracket carriers and had
01:00:35certainly appropriate surgery.
01:00:36Well,
01:00:36we have other medications and
01:00:38herbal products which are not
01:00:40estrogenic which are very reasonably
01:00:42effective against Hot Flashes.
01:00:44There are several herbal product
01:00:46so this is controversial.
01:00:48The North American Menopause Society,
01:00:50one of my organizations does not necessarily
01:00:52smile on hormone non formal therapy.
01:00:55Herbal remedies because
01:00:56they doubt the Efficacy.
01:00:58If you look at literature
01:01:00from other countries,
01:01:01there's plenty of data out there, trust me.
01:01:04An one of the standards out there
01:01:06is a product called Black Cohosh,
01:01:08German black cohosh and why am I
01:01:10selling German black cohosh here.
01:01:11Well the reason I'm saying that
01:01:12is unfortunately in the United
01:01:14States we don't supervise or herbal
01:01:15products very well in.
01:01:16Joanna knows I get on rants about
01:01:18this topic pretty regularly that I
01:01:20mean for example my standard line
01:01:22is I can go pick up some dirt from
01:01:24outside this office and tell you it's
01:01:26like Oh Hush and nobody can stop me.
01:01:28And in Germany if you do that
01:01:30they throw you in jail which is
01:01:31the appropriate thing that should
01:01:33be done for that sort of thing.
01:01:35So Remy Feminism German black
01:01:36cohosh product and it's very
01:01:38reasonably effective for hot flashes.
01:01:40There is also Swedish product.
01:01:42These are all over the counter.
01:01:44These are not prescription all relevant
01:01:46which is a Swedish pollen extract
01:01:48and that's actually very popular in France,
01:01:51among French oncologists.
01:01:52And there's also a product that
01:01:54there's also several soy derivatives.
01:01:56Femarelle is one of the better known ones,
01:01:59very popular in Europe that is
01:02:01purified soy soy derivative an all
01:02:03we have reasonable efficacy for
01:02:05many women against con flashes.
01:02:07However,
01:02:07we also have some other medications
01:02:10that are prescription medications
01:02:11which can be quite effective.
01:02:13An many of you know this, but some may not.
01:02:17Is that actually SSRINSNRI?
01:02:19Anti depressants can be quite
01:02:21effective against hot flashes.
01:02:22What's also I always have to mention
01:02:25this here because the actual discovery
01:02:27though that Sri Sri antidepressants
01:02:30actually work for hot flashes was not
01:02:32discovered in women with breast cancer,
01:02:35who we were afraid of giving estrogen too.
01:02:38It was actually discovered in taking
01:02:39care of men with prostate cancer who
01:02:42are giving being given medications
01:02:43which lower their hormone levels,
01:02:45and they get hot flashes too.
01:02:47And that's how they discovered PSS,
01:02:49reisen SN our eyes work another
01:02:51drug which is very effective for
01:02:53hot flashes is gabapentin or the
01:02:55trade names Neurontin and that
01:02:56can be very effective for women.
01:02:58The other nice thing and again a lot of
01:03:01these are dual purpose so if somebody
01:03:03does have some element of depression
01:03:05and SRS NR I might be quite helpful
01:03:08for them as well for depression.
01:03:10Gabapentin happens to be a good
01:03:11drug for body aches and pains.
01:03:13So for example,
01:03:14if somebody's had to say neuropathy
01:03:15as a result of some chemotherapeutics
01:03:17or something like that,
01:03:18we might use gabapentin food
01:03:19in their pathic pain,
01:03:20and it also is good for hot flashes.
01:03:23So as you know, takes care of two things now.
01:03:25There is one new exciting drug that's
01:03:27out there that I can tell you about
01:03:29quite yet I can't prescribe it for you.
01:03:31Let's put it this way,
01:03:33I can tell you a little bit about it,
01:03:35and this is a drug that actually
01:03:37acts in our brain.
01:03:38So when somebody says all those
01:03:40hot flashes you're in there.
01:03:41Your head, your head,
01:03:42that's exactly where it is.
01:03:44It actually starts in the brain
01:03:46is where this all stuff happens.
01:03:48And this class of new drugs
01:03:50called NK3R or neural kind in
01:03:523B Receptor antagonists Ann.
01:03:54This is really to me.
01:03:56It's extremely exciting literature
01:03:57an experiments because these
01:03:58drugs are very effective.
01:04:00An really just about as
01:04:02effective as estrogen.
01:04:03Can't taking care of hot flashes.
01:04:05So stay tuned.
01:04:06These drugs are in phase three trials.
01:04:08Right now the preliminary
01:04:10data looks quite good.
01:04:11My guess is we're talking
01:04:12about one to two years away,
01:04:14but it's not only into the future,
01:04:16so stay tuned there out there
01:04:18so we have good drugs,
01:04:19but we're going to have even better
01:04:21drugs at some point in the future.
01:04:23Now, let's talk about vaginal dryness.
01:04:25Thank you, Joanne.
01:04:26First of all,
01:04:27this is another very common
01:04:28problem for women,
01:04:29and the hot flashes do tend
01:04:31to come earlier for women,
01:04:32so everybody associate's them with menopause.
01:04:34Natural drawing is actually can occur
01:04:35later on in the menopause process,
01:04:37and it made me so much later than women
01:04:39don't even associated with menopause.
01:04:41But the thing about vaginal dryness,
01:04:43we have a lot of over the counter
01:04:45remedies available for couple things.
01:04:47Most women need to have discussed
01:04:48with them is that there are two ways
01:04:51with the over the counter remedies.
01:04:52There are lubricants,
01:04:53which are products which can be
01:04:55used at the time of intercourse,
01:04:57and there are many many out there.
01:04:59One thing if you are buying a
01:05:01lubricant eye standard Lee say
01:05:02that people please don't buy the
01:05:04giant economy size because many
01:05:05women are sensitive to a perfume or
01:05:07a component of the gel.
01:05:09And I ask you to buy a small amount.
01:05:12Firstly, what agrees with you
01:05:13and then you can go out and buy
01:05:15the giant economies such there.
01:05:17Also moisturizers,
01:05:17which are long acting products
01:05:19which would sort of actually
01:05:21these are over the counter.
01:05:22You insert them two to three times
01:05:24a week and they should have recruit
01:05:26moisture into the vaginal walls.
01:05:27There's a couple of very popular
01:05:29varieties of product called Replens.
01:05:31On has both an internal and external
01:05:33product which is over the counter.
01:05:35This is polycarbophil gel.
01:05:36You put it in two to three times
01:05:38a week in a preloaded applicator
01:05:40and it does work nicely.
01:05:41Now many women using a moisturizer.
01:05:43Also will benefit by using
01:05:45a lubricant at the time,
01:05:46like intercourse an another product
01:05:48that works very nicely for our
01:05:50patients is something called reverie,
01:05:51which is available online.
01:05:53It's over the counter and this
01:05:54is a highly uronic acid product.
01:05:56Many of you may use hyaluronic
01:05:58acid on your face.
01:05:59Well this is highly uronic
01:06:01acid for your vagina and it's
01:06:03quite effective for many women.
01:06:04OK and we want and most women
01:06:06will try those first.
01:06:08However, if that's not sufficient,
01:06:09OK if I'm moisturizer lubricant,
01:06:11you're still uncomfortable.
01:06:12We have lot of other products.
01:06:14In many of our patients get very anxious
01:06:16when we start talking about him,
01:06:18but vaginal estrogen and there's
01:06:20another product DH EA which is gets
01:06:22converted into vaginal estrogen,
01:06:24really are quite safe to use.
01:06:26OK,
01:06:26and they're actually now papers out
01:06:28by the American College of OB GYN's
01:06:30in the North American Menopause
01:06:32Society which endorsed the data that says,
01:06:34listen,
01:06:34that you can use these vaginal estrogens,
01:06:37the blood levels and we have
01:06:38studies measuring the blood levels.
01:06:40Show that there's basically no
01:06:42systemic levels achieved without
01:06:43until you don't molecules go by,
01:06:45but there are very few levels that.
01:06:47The other achieved with vaginal estrogen,
01:06:49so most people are quite happy to
01:06:51let women who had a history of breast
01:06:53cancer use vaginal estrogens or vaginal dhe,
01:06:56and these are Suppository zne.
01:06:57Their rings,
01:06:58their creams line of different
01:06:59options that we have.
01:07:01And if one you don't like it doesn't
01:07:03make you do the problem and stuff,
01:07:05take care of things.
01:07:06We could always switch to another one
01:07:09so that they are there and there also
01:07:11happens to be a medication which is
01:07:13an oral medication which is not estrogen,
01:07:15and that's called a scam.
01:07:17Athena, Ross, Tina.
01:07:18And it's a very interesting chemical.
01:07:20This is interesting to me because
01:07:21the closest relative in the world of
01:07:23pharmacology out there is smocks offense.
01:07:25So lost Palma fee is also a serm.
01:07:27Very much like tamoxifen and
01:07:29that it acts like a storm so
01:07:31it helps protect the breast.
01:07:32It helps protect bone but it also
01:07:34happens to moisturize the vagina
01:07:36which is very nice and we have
01:07:37a number of people taking that
01:07:39so that's another option that
01:07:41we have so we have lots and lots
01:07:43of options out there for women.
01:07:45You know anybody has questions.
01:07:46We're happy to answer them to talk about
01:07:49these different options that we have.
01:07:51Can I have the next slide OK,
01:07:53an I don't want to be advertising.
01:07:55Pichu added a little bit of this so
01:07:57I'll do a little bit more and it
01:08:00we're not advertising become to Sims.
01:08:02We can help.
01:08:02OK, we were actually one of the
01:08:04first centers that was founded in
01:08:06this country to deal with sexuality
01:08:08in Pussy and menopause issues.
01:08:10For pre virus an survivors an now.
01:08:12Thank goodness we started about
01:08:14a dozen years ago,
01:08:15but there's now a much wider realization in
01:08:17the cancer community that there are many,
01:08:20many special issues.
01:08:21That women who are pre virus and end
01:08:23survivors need to deal with and we
01:08:26can help with these issues and the
01:08:28other you know self aggrandizing
01:08:30thing that I'll mention here is.
01:08:32Please visit my website is out
01:08:34there for you and ma'am over.com
01:08:36and we have some basic videos for
01:08:38menopause and menopause education.
01:08:40And we also have a couple
01:08:42for cancer survivors.
01:08:43And now my venture into the 21st century
01:08:46is I now have podcasts up there.
01:08:48This isn't actually invention
01:08:50of the last month here.
01:08:51So if you go click podcast,
01:08:53you can hear some a couple
01:08:55of basic menopause podcasts.
01:08:56Anna podcast for cancer survivors.
01:08:58So what I'd like to do here is
01:09:00to shut up because I know people
01:09:02probably have a lot of questions,
01:09:05an answer, questions and Doctor,
01:09:06Patricio and Joanne and I are
01:09:08all here to answer questions.
01:09:10So here we are in. Please go right ahead.
01:09:15Well, thank you doctor minkin.
01:09:17I'm sorry I forgot to give
01:09:19you a formal introduction,
01:09:20but Doctor Minkin is truly a menopause guru.
01:09:23And if you look up she
01:09:25has books on menopause.
01:09:26She's been at Yale for her entire career,
01:09:28I think, but has just done
01:09:30wonders in the miniboss world.
01:09:32So at this point,
01:09:33if anybody has any questions,
01:09:35share in the Q and a box or in the
01:09:38chat box for Doctor Patricio or
01:09:40doctor minken or myself were happy
01:09:43to answer some questions for you.
01:09:45Don't be shy.
01:09:47We could talk this stuff all
01:09:50day, absolutely. And we do.
01:09:53Somebody must have some questions.
01:09:59OK, here's what.
01:10:02The costs doctor Patrice here.
01:10:04This is actually a great question.
01:10:06What can you share with us,
01:10:08the costs and whether or not
01:10:11insurance will cover the P GT
01:10:13testing for reproduction for
01:10:14people with BRCA gene mutations?
01:10:18Yes, thank you for the for the question.
01:10:24In terms of cost for the embryo
01:10:27freezing 1st and then the P GT,
01:10:30the embryo freezing in itself without
01:10:33if your insurance does not cover and
01:10:37again in Connecticut they should
01:10:39cover because there is a there
01:10:41is a law that they should cover.
01:10:44It's about 13 fourteen $1000 on the top
01:10:48of that you need to add about $5000
01:10:51to do the pre implantation genetic.
01:10:54Permutations Here.
01:10:55The problem with insurance,
01:10:57it's much more sticky.
01:10:59Note here Becausw Insurance,
01:11:01they try not to cover this.
01:11:03However, if if if you if you
01:11:06do take a fight with them.
01:11:09I had a couple that were very
01:11:12very adamant in in the taking
01:11:15this on on insurance and at the
01:11:18end they they didn't cover.
01:11:20Now in your case you said that it's
01:11:23not you carrying the mutations.
01:11:26But is your your husband or your
01:11:29partner carrying the Mutation?
01:11:30And even in this case there is always
01:11:33a 5050 chance that the embryo or your
01:11:36future child can have imitations
01:11:38that is inherited by by given by by
01:11:41your husband and therefore there
01:11:43is always a reason to do the P GTM,
01:11:47the frame plantation,
01:11:48genetic testing,
01:11:49even in if it's your husband
01:11:52carrying the Mutation.
01:11:53So
01:11:54the answer about whether is covered
01:11:56or not, it's it's really
01:11:59depending on different insurance,
01:12:01but most of the time when they
01:12:04try to shy away from covering,
01:12:07it requires a lot of
01:12:09arguments and fight with them.
01:12:12And Doctor Patricia,
01:12:13I think my understanding is that
01:12:15it is covered if if the if the
01:12:18person who's doing the genetic
01:12:20testing has a history of cancer.
01:12:22If they if they are a breast cancer survivor,
01:12:26would it the and there found
01:12:28to have a BRCA Mutation?
01:12:30Would it then maybe be covered?
01:12:33Or not necessarily?
01:12:36Yeah, that that can be easier to
01:12:39make the argument because in the
01:12:41in the case where there is not,
01:12:44it's only a positive.
01:12:45Let's say that you have a
01:12:48incidental finding that there is a
01:12:51mutations and your career for it.
01:12:54It faced during the group of providers
01:12:56that she's going to be probably much
01:12:59more difficult for them to act upon them,
01:13:02meaning insurance.
01:13:03I totally disagree with this approach.
01:13:05They take because if we have
01:13:08to do preventative medicine,
01:13:09we need to do it and is.
01:13:12It's very sad that they they try not to.
01:13:15You know, try to be smart and not covering.
01:13:18I think they should,
01:13:19but it's much more difficult to give
01:13:21if we're talking about pre virus.
01:13:26And if there's any other questions,
01:13:28please feel free to enter
01:13:30them in the chat box.
01:13:31We have a few more minutes left.
01:13:34I'll ask another question, Doctor Patricio.
01:13:37A lot of a lot of people are told that
01:13:41their children should do not necessarily
01:13:44need genetic testing until their age 25.
01:13:48And I think sometimes I wonder if people
01:13:51will want to have babies before their 25,
01:13:53so maybe they do need to know what are.
01:13:56Do you have any thoughts on when
01:13:59children should have genetic testing? I
01:14:02think this is a I disagree with
01:14:06this approach of the 25 like
01:14:09was like you correctly said,
01:14:11what if someone wants to
01:14:14have a child before that,
01:14:17but we're talking tonight about.
01:14:19Cancer gene screening.
01:14:21Remember that we also offering
01:14:23a additional type of screening
01:14:26that are not cancer related?
01:14:28We do a lot of expanded carrier
01:14:31screening for cystic fibrosis,
01:14:33spinal muscular atrophy and
01:14:35so many many many many more.
01:14:38So I foresee a a here an opportunity
01:14:41to make a case that whoever is
01:14:44is trying to have is trying to
01:14:48reproduce a particularly when.
01:14:51In particular when when you need to
01:14:53have some type of help or intervention
01:14:55to assist someone to have a baby,
01:14:57I think that it's a.
01:14:58It's not appropriate not to test.
01:15:00I think they should be offered
01:15:02the testing and this 25 is
01:15:04a very artificial number.
01:15:05I don't know why they choose 25.
01:15:07I don't know who chose 25 for
01:15:09the cancer screening.
01:15:12Do you know who chose 25 John?
01:15:15I don't know. That's what a lot of
01:15:18patients tell me that the genetic
01:15:20counselors and maybe if there any.
01:15:23I don't know if clareson if if
01:15:26Claire can sometimes can join in. Um?
01:15:32Can you hear me? But I think
01:15:35yeah Claire, joining for sure. Hi
01:15:38everybody, I'm so the age 25 is
01:15:40when breast cancer screening
01:15:41starts and I
01:15:42totally hear where you're
01:15:44coming from. There are people who
01:15:46would like to start their family
01:15:48before 25 and it is appropriate
01:15:49to have genetic testing before 25.
01:15:52In that case the reason that
01:15:54we try and hold off on genetic
01:15:56testing for these young people
01:15:58is that we also have to balance
01:16:00the life insurance
01:16:01concerns and insurance
01:16:02discrimination concerns.
01:16:03So the best thing is to meet
01:16:05with a genetic counselor and
01:16:07really have that conversation.
01:16:08The balance of the
01:16:10pros and the cons of having
01:16:12testing. One of which may be the
01:16:14ability to do family planning before 25.
01:16:20Yeah, thank you Claire and I
01:16:21think again, it's all such a
01:16:23personalized approach depending on.
01:16:25You know the emotional readiness
01:16:27of the person being tested as well.
01:16:34So thank you, Claire, and will take
01:16:36we have one more question from Molly.
01:16:39About how it's it can be overwhelming
01:16:41as a previvor to incorporate all this
01:16:44information from multiple specialist and
01:16:46make the best decisions about our care.
01:16:49Is there a clear process for
01:16:51the approach to care or their
01:16:53tools that can have integration?
01:16:56From all the different specialists,
01:16:58and that's a great question.
01:17:02Well, the Doctor Mink and do
01:17:05you have any thoughts on that
01:17:07one? You know I have a thought on everything,
01:17:11even opinion everything.
01:17:12It made up his thought everything.
01:17:14Only I there are obviously high
01:17:17risk specialist you know as far as
01:17:19in for example in our Department.
01:17:21In July end point of view,
01:17:23our program discovery to cure.
01:17:25I think that's the official title these days.
01:17:28Joanna would be the would be
01:17:30folks who are at increased risk.
01:17:32You know when people who are Bracken
01:17:35Previvor's and things like that
01:17:36will be seen there and that would
01:17:39be sort of the primary counseling.
01:17:41As far as prophylactic,
01:17:42who for Ectomy's or refractory hysterectomy?
01:17:45I of course there's the high risk breast
01:17:48cancer clinic where the Braca women are,
01:17:50you know,
01:17:51given advice for breast surgery,
01:17:53medication, surgery, things like,
01:17:54as far as prevention there
01:17:56we certainly as as Sims.
01:17:58We like to see anybody who's
01:18:00having a prophylactic oophorectomy
01:18:02before she has a surgery.
01:18:04OK,
01:18:04we like to talk with them and get
01:18:06and try to bring out some of these
01:18:09issues to make sure they thought
01:18:12about all these issues involved
01:18:14in the decision making process.
01:18:16And also to counsel them in advance
01:18:18about things like hormone therapy.
01:18:20We really like to see these folks before
01:18:23surgery to maybe help them guide in
01:18:25some decisions about what what kind
01:18:27of surgery might be interested in,
01:18:29like for example, decision,
01:18:31uterus,
01:18:31scout uterus in that kind of decision
01:18:33that we cannot possibly give some advice on.
01:18:36And then certainly one of the
01:18:38reasons we like to see people before
01:18:40surgery before they have their
01:18:42ovaries out is that decisions on
01:18:44hormone therapy can be overwhelming
01:18:46to some young women because.
01:18:48There's been so much so much
01:18:49propaganda in the United States
01:18:51that estrogen is poison estrogens.
01:18:52Bad for you is going to give you breast
01:18:55cancer I in my breast cancer risk person.
01:18:57I can't think yesterday and we would
01:18:59like to have time before surgery for
01:19:01women to discuss these issues with us,
01:19:02to make decisions,
01:19:03and we'd like to be able to
01:19:05initiate estrogen therapy for women
01:19:06before they have a high flash.
01:19:08That's our goal.
01:19:09You know, we like to treat them before
01:19:11they start getting uncomfortable,
01:19:12and that's why we like to make these.
01:19:14Again, we don't like to make the decision.
01:19:16We like to give them the information.
01:19:18So what that makes a decision
01:19:20that they feel comfortable with.
01:19:21We like them to have all that information
01:19:23before going through surgery,
01:19:25so you know where we like to be
01:19:27involved in giving some advice
01:19:28and giving some data and let them
01:19:30make the decisions.
01:19:31But before surgical interventions.
01:19:33I think another thing is you know
01:19:35patients can really get overwhelmed
01:19:37with appointments that with all the
01:19:39different doctors, but you know,
01:19:41at least from my perspective
01:19:42is we all know each other.
01:19:44And I think you know the second
01:19:46session of this webinar was with
01:19:48Doctor Hofstetter and Doctor Ratner,
01:19:50and we often talk to each other and say,
01:19:52Well Doctor Hofstetter,
01:19:53are you OK with birth control pills to
01:19:56prevent ovarian cancer and sheet for
01:19:58the most part says yes and we always
01:20:00talk back and forth about the decisions
01:20:02and we always include an oncologist.
01:20:04If there's an oncologist.
01:20:05In your you know taking care of you as well.
01:20:08We always will include him or her in
01:20:10that any of these decisions as well.
01:20:13So we do communicate,
01:20:14but if there's anything that we can
01:20:16do to help coordinate your care,
01:20:18I know that can sometimes be challenging.
01:20:20Part were also happy to help,
01:20:21so will have one more question
01:20:23before we wrap up for tonight,
01:20:25and that's for you,
01:20:26doctor minken anything to do for the
01:20:28memory loss that comes with menopause.
01:20:31That's a hard one.
01:20:33Sometimes you're OK and cognitive issues.
01:20:34Memory loss, that kind of thing.
01:20:36Executive function.
01:20:37Some people you know.
01:20:38Put it under that category
01:20:40an I think first of all,
01:20:42the questions that we talked about
01:20:44in somebody who's a previvor whose
01:20:46or who's a survivor because in pre
01:20:48virus I would say make sure they
01:20:50get some estrogen OK and somebody
01:20:52who's 45 who's that new for ectomy
01:20:54if she's not taking estrogen,
01:20:56I would strongly encourage her to think
01:20:58about taking some estrogen 'cause
01:21:00I think it can be quite helpful.
01:21:02If somebody is a survivor in who were
01:21:04not going to be able to give estrogen to OK,
01:21:08then I think that we need to talk
01:21:10about things like possibility of using
01:21:12things like anti depressants which
01:21:14can be helpful and the other thing
01:21:16which can actually be helpful and this
01:21:18is some work that was done here at
01:21:21Yale and is now being carried on it.
01:21:2310 in Cala rado.
01:21:24Places like that are the use of drugs
01:21:26like drugs for concentration drugs
01:21:28for higher executive function ADHD
01:21:30type drugs which have been shown to be
01:21:32helpful for people without estrogen.
01:21:34So those are drugs that we can
01:21:36offer folks which can be helpful,
01:21:37and the other thing of course that I'm
01:21:40really eager to find out is to see
01:21:42how the new N Ki NK3R drugs are going
01:21:44to be for that 'cause they act sensually.
01:21:46They are acting in the head.
01:21:48So I think some of the NK3RS may
01:21:50be helpful for cognitive issues.
01:21:54But we don't know yet,
01:21:55will have to wait and see on that.
01:21:57But we do have things that we can offer.
01:22:01Well, I want to thank you both Doctor
01:22:03Patricio and Doctor Minkin for your
01:22:05time tonight and sharing some of your
01:22:08expertise with us in our panelists and
01:22:10our participants tonight and again.
01:22:12This video will be posted on
01:22:14the Cancer Center website,
01:22:16so if anybody wants to share
01:22:18with their family members.
01:22:19Recording will be up soon and thank you
01:22:22everybody for participating in this series.
01:22:24We had hoped to end with a meet
01:22:26and greet for our patients,
01:22:28which we might do in the
01:22:30future at some point.
01:22:32And if anybody wants to reach out and
01:22:34needs to get connected with somebody.
01:22:36I have patients who I can connect you
01:22:39with an we're always here to help you.
01:22:42So reach out anytime and thank
01:22:44you for watching tonight and
01:22:45goodnight every time. Thank you all.
01:22:48Thank you. Thank you bye bye.