Kim Vopni (00:01.976)
Hello, Dr. Javaid. Thank you so much for joining us. I welcome anybody who is talking about female sexual health, menopause. And you you speak very vocally about it. I'm really excited to have you here. Thank you for joining us.
Somi Javaid MD (00:16.117)
Thank you for having me. I'm very excited about this conversation.
Kim Vopni (00:20.226)
So maybe I always like to have kind of the the who are you? What do you do? What brought you into this space of talking about female sexual health, menopause and all the things?
Somi Javaid MD (00:31.647)
I would say I'm a dreamer and a girl who nearly lost her mother at a very young age. And my mother nearly dying when I was twenty one and she was only forty-five is kind of what thrust me into women's health care. I I always knew that I was very interested in science and math. I was pre-med at Northwestern at the time. My father called and simply said, So me, you need to come home and my very
previously healthy forty-five year old mother who had been complaining of left arm pain, shortness of breath and chest pain for weeks, but doctors couldn't explain why a thin, non smoking, Middle Eastern woman would ever present with four vessel disease. Had they asked her family history that we had already lost multiple women under the age of fifty to what they called sudden cardiac death, I think they would have had their answers. but my mother underwent
emergent quadruple bypass surgery, she s she survived. I will never forget when the surgeon came out though. He said if the heart attack would have come, she would not have made it because the LAD or what we call the widow maker was ninety five percent occlud. my mother's disease is so severe she's had three subsequent stents. She's alive and well to this day, nearly three decades later.
Kim Vopni (01:42.572)
Wow.
Somi Javaid MD (01:52.896)
But that was my aha moment that women needed advocates, that women were different, that we weren't being treated fairly. I didn't understand at the time that we were being treated like little men and based on male data with very different bodies and hormones. but that's really why I went into women's health care was you know, 'cause it hit so close to home.
Kim Vopni (02:17.087)
Mm-hmm. Wow, it's a powerful story. Good motivator. There's usually always some sort of most of the people I talk to, there's some sort of pain to purpose, whether it's our own pain or somebody else's pain that brought us here. How do you now in in what you're doing on a in in in serving women now, how have you navigated the coming out of the past twenty years women's health initiative era?
Somi Javaid MD (02:45.031)
my God, I feel like we could just talk about that. because I actually lived through it, right? Like I was training through all of that. So bright eyed, bushy tailed went in, thought I was gonna save the world and save every single woman and no one was ever gonna be ignored again, and the healthcare system kind of smacked me in my idealistic face. And it's ironic that as I was finishing up my OBGYN training.
Kim Vopni (02:47.594)
I know.
Yeah, yeah.
Somi Javaid MD (03:12.947)
is exactly when the WHI, I wouldn't even say the data, I blame the press conference more, but the interp the misinterpretation of the data, the oversensile sense s you say the word. I've got perimetopolic yes, yes, yes, basically. and not explaining the nuances of the data. basically, we were called into a room and told
Kim Vopni (03:18.923)
Yes, yeah.
Kim Vopni (03:25.175)
Sensitization, yeah. Sensilization, yeah.
Somi Javaid MD (03:40.726)
You are not to prescribe hormones, you're not gonna learn about menopause anymore. and overnight we stopped learning, we stopped prescribing, women stopped taking, and I think at that point what like nearly forty percent of the US women were on hormones. And after that it dropped down to well less than five percent. I mean less than two percent, I think, yeah.
Kim Vopni (04:00.418)
Yeah, and I think we're still there. I think it's maybe even only about four right now, even despite the la like the last sort of couple of years of the explosion of the conversation that the that really should have been happening along the way. But
Somi Javaid MD (04:12.897)
Yeah, the factor came out a couple years ago when I was in that, you know, documentary. Who knew we'd have a documentary about menopause? 'Cause five years ago they told me I couldn't say it on TV. And I think at that point one point eight percent of women were on it, and you are exactly right. You know, two just came out about perimenopause and they quoted somewhere between four and five percent. And I just saw a disturbing study this week that they actually now see it trending back downwards again despite
Kim Vopni (04:41.388)
Really?
Somi Javaid MD (04:42.697)
Mm-hmm. Despite the largest data set that was just presented at Menopause Society showing that if we start hormonal therapy in the perimenopausal years, right, the years before complete cessation of menses, that we have a sixty percent reduction in cardiovascular disease, stroke, and breast cancers. And yes, it's not a double blinded randomized control controlled clinical trial, you know.
But still it's millions of women. and for some reason we have still locked on to hormones cause cancer. And yeah, nothing gets people riled up like this this this hormone discussion. It's it's mind-boggling to me, but we don't think twice about it for men. Like there's so many different formulations of testosterone, and when you go through andropause, they they do go through andropause.
You know, we give them hormones and we have studies that it helps reduce their risk of diabetes and cardiovascular disease and it helps them maintain muscle mass and it prevents them from losing bone and and it helps with mood. So it's shocking to me. and I'm married to a medical oncologist and I have a passion for survivorship and have taken care of so many women, but I also understand
That the cure rate of breast cancer is nearly ninety four percent in this country. I also understand if you lost your mother or your sister, that number doesn't matter to you because to you it's a hundred percent. but we lose more women to cardiovascular disease, more than all cancers combined, and we have this prolific, you know, option and I'm saying option, I'm not saying it's for everyone, but option to prevent and reduce that risk of mortality and to live
Kim Vopni (06:17.422)
Mm-hmm.
Somi Javaid MD (06:36.733)
not only longer, but to live healthier. so to me it's been exciting, exhilarating, but also extraordinarily shocking, and frustrating because I have been I wouldn't say attacked, 'cause that's a very strong word, but that's what it feels like. But people have come after me for being in support of of hormone therapy, for sure. yeah.
Kim Vopni (07:03.976)
Mm-hmm. Mm-hmm. Mm-hmm. Yeah. The I followed along, I followed Dr. Rachel Rubin, Kelly Kasperson, the the a lot of the people who were really who who were instrumental in having the black box warning label removed recently, that was oct in October. that it started with the the vaginal estrogen, the label being medically inaccurate, you could argue for other
Somi Javaid MD (07:20.779)
Moved, yeah.
Kim Vopni (07:33.945)
forms as well, but it came off all of them. And there's been some debate about whether that should have happened or not. and so what what is your going forward, how do we navigate this with when the questions come up about okay, well, okay, well vaginal estrogen, okay, I feel okay with that, but I still have these fears around systemic. Do you think the removal of the label from everything is going to help? And will that number, do you think, creep back up? Will we ever get back to the forty percent, do you think?
Somi Javaid MD (08:03.777)
God, that d we could talk about that question for days too. Do you want to know something really, really interesting that is mind-boggling? That there was not a singular study that showed any of those risks occurred for localized hormone therapy. And in fact, the FDA admitted that we did more harm than good. The exact opposite of what the FDA is supposed to do, right? The FDA is great. They're supposed to
Drugs are supposed to do what they say and say what they do, and then they're not supposed to have too many adverse events. Like everything's gonna have risk, but the risk-benefit ratio should be favorable. So the FDA was set up, honestly, to protect us. And so that is their mission, not not to harm us or to withhold things from us. But they actually admitted that they withheld one of the most powerful medications for us for longevity. And they also admitted that there was not a singular study. They took the systemic.
form oral formulation that was not bioidentical in the average median age of a woman that's sixty three, we're not gonna prevent disease in our seventies, and slapped it on a localized product, never showing that that causes dementia or heart attack or stroke. So that was shocking.
Listening to Rachel Rubin on the stand, and and I think what Rachel and Kelly and all the experts that spoke that day said, This is so obvious, FDA. Like we're gonna get this black box warning removed. Let's take this a couple steps further. Let's make hormone therapy a little bit more accessible. Let's show you even more data and let's try to throw in testosterone into the ring and see if we can get you guys to finally get a FDA approved testosterone only formulation for women and really use that time to
expand on all of the benefits, medical benefits of hormone therapy and and that including estrogen and testosterone. Do I ever think it's gonna get to forty to fifty percent? it maybe if I live to ninety. i and the reason I say that is for every 10 women that I see
Kim Vopni (10:16.222)
Yeah.
Somi Javaid MD (10:25.625)
super excited and so grateful that they're finally like they show me their patches and they're like I'm finally off my antidepressant. I got my hormones. You know, I see the people that come at me swinging and saying, you know, I lost my mother or I am a breast cancer survivor myself and, you know, my tumors grew because of it. And I'm not minimizing any of that at all. And I like I said, part of my love was taking care of
survivors and helping them thrive. but it's just it just shows it's just not a one size fits all equation. and we can't deny the benefits anymore. The data is just too strong, particularly on bone, brain and heart. We j we just can't. So yeah.
Kim Vopni (11:02.454)
Mm. Mm.
Kim Vopni (11:12.172)
Yeah, yeah. And just to clarify for people who haven't maybe heard episodes here or other people talk about localized meaning local vaginal, like delivered to the vulvo vaginal tissues inside the vagina, local estrogen therapy versus systemic meaning whole body, and that is either, you know, oral forms, which is becoming, I would say, less common, transdermal patches, gel, that type of thing, sprays.
Somi Javaid MD (11:37.314)
Patches, gels, sprays, there is a ring that there are two rings. One it delivers local, one delivers systemic. But localized can be DHEA, and the trade name that most people would know is intra rosa. Estrogen, some people do compound estrogen and testosterone together, and you are right, it goes internally into the vaginal canal, but also can be used on the outside, on the vulva, the vestibule, the labia menorah majora.
depending on, you know, where people are having problems and symptoms. Yeah.
Kim Vopni (12:10.153)
Mm-hmm. So I wanna I wanna hang out in the vagina for a little bit. The local the local vaginal estrogen, as you mentioned, there there can be a tablet, there can be creams, there can be the ring. The delivery really like there's gonna be different schools of thought in terms of it were even just preference. What I've seen now shared is that it should be applied with the finger, rubbed into all the walls, and
Somi Javaid MD (12:30.678)
Mm-hmm.
Kim Vopni (12:40.211)
not use the applicator and then there's some people that say you need the applicator to get it up higher and you want to make sure you have inside, outside. So there's all sorts of now different messaging around that. And I hear from women in my community there's there's a lot of like trauma can be a big word, but trauma associated with a pelvic floor diagnosis, pelvic fluorysfunction diagnosis. They don't want to feel their prolapse. They they don't want to use their fingers. So
Is it essential that you use your finger and rub it into the walls or is an applicator or a tablet adequate?
Somi Javaid MD (13:15.409)
I think here's the thing. Any therapy is better than no therapy. And I love meeting people where they are. I have a lot of people who have frozen shoulder or arthritis and they have very difficult time inserting anything. And so they need the applicators. They they need the you know, the help. They or some women who don't want the cream because they find it messy or their partner finds it off putting or
Kim Vopni (13:31.149)
Mm.
Somi Javaid MD (13:43.318)
You know, they're saying it's ruining their their bed sheets. And so for me, it's a fulsome discussion of expectations, symptoms, where they're hurting, what are we trying to prevent. You know, obviously we know we're trying to prevent sexual pain, dryness, urinary tract infections, god forbid euroscepsis and and all of that. But then we're also trying to fit these formulations into someone's lifestyle, right? And so for me, I'll tell you, I'm I'm personally
Perimenopausal kind of creeping into to menopause. I'm I just turned 51 this week. And I love intra rosa. That's my personal one of choice because it's not messy, it dries up really quickly, evaporates really quickly, and it has some other sexual health benefits on that female sexual function index. It's not indicated for those, but it does help with some of those. And so
I like it because DHEA or presterone breaks down into estrogen and testosterone and we know that that tissue, particularly that in the vestibule, so that's that area right inside the labium menorah is rich in testosterone receptors. So it's a unique way to try to deliver both hormones to that area. So I like Intrarosa a lot.
Kim Vopni (15:00.27)
Mm.
Somi Javaid MD (15:02.933)
And it doesn't ca it comes with an applicator, you can use it with the applicator or you can use it without the applicator and I and I like that. But you know, everyone's different and I think that what may work for you may not work for your friend or your sister and and that's okay. Yeah.
Kim Vopni (15:17.398)
Mm-hmm. And that that's a great point because there are some people who prefer a tablet or a like something inserted, but also prefer the benefits, like the as you mentioned, the androgen component of DHEA. DHEA is typically you do it daily. Vaginal estrogen typically is two times a week, three times a week. Some people they forget and when it's consistent dosing.
Somi Javaid MD (15:26.433)
Mm-hmm.
Kim Vopni (15:43.97)
They are usually more success some people could be more successful, but there are some people who say, Well, I use vaginal estrogen twice a week and I use vaginal DHEA. What do you think about combining things?
Somi Javaid MD (15:56.962)
Okay with combining that. now anyone who will tell you there's zero systemic absorption is wrong. It's not measurable, meaning if I check your blood levels, we're not gonna change them, but there are minuscule amounts. I don't think you should be using both products daily. So, but if you want to interchange between them, because there are slightly they're both gonna work equivocally when it comes to genito-urinary syndrome of menopause, which is
the dryness, preventing infection both vaginally and in the bladder. But like I said, that DHEA has, like you said, that androgenic component. And for some women who either are having sexual issues with orgasm or arousal, or they have issues like lichen sclerosis, that dermatologic condition, vest vestibuline, like intraosa works great for those patients because we find that the testosterone component helps
So I say it it really is different for everyone. I I'm a firm believer in curating for each individual person, not only based on their symptoms and their goals, but like I said, what fits in their lifestyle. I want I'm so tired of medicine happening at women, you know, and I think that's where some of the trauma comes from. I mean, think about it, the stirrups, the speculum, even the thing we put on the the tenaculum that we put on the cervix we was was used to remove bullet wounds.
Kim Vopni (16:56.727)
Mm.
Kim Vopni (17:14.86)
Mm-hmm, mm-hmm.
Somi Javaid MD (17:21.645)
Like or bullets on the battlefield. I think we can remove a lot of trauma by giving women bodily autonomy and making them the CEOs of their own bodies and their own health care.
Kim Vopni (17:23.075)
Mm.
Kim Vopni (17:34.755)
Yeah, I love that. With testosterone, there are some people who will get compounded testosterone cream. As you mentioned, there is no currently FDA approved testosterone for women, whether it's systemic or local. Speaking specific to the to the vulva and vagina, would there be benefit to a testosterone like a a prepared for the vulvaginal tissue, testosterone over DHEA, or would DHEA be adequate?
Somi Javaid MD (18:06.713)
individualized. So I've used different formulations for different patients and tried different things. I would say for women who are more symptomatic, who I am chasing down a particular issue, I'm more likely to compound an estrogen testosterone formulation for them. the DHEA I'll use, you know, instead of a localized estrogen. But if I feel like if I am chasing
Kim Vopni (18:25.411)
Mm.
Kim Vopni (18:31.214)
Mm.
Somi Javaid MD (18:33.889)
pain or vulvadinia or vestibulinia or something else going on. And and you asked me something that I didn't respond to, pelvic floor, right? The pelvic floor is the hammock of muscles surrounding our urethra, our vagina, and our rectum. And you need the perfect balance of tone so that you don't urinate or defecate or when you don't want to, right? We don't poop or pee when we don't want to. But relax enough where we can tolerate an exam, insert a tampon if it's you know appropriate if we're still perimenopausal or bleeding.
Kim Vopni (18:36.046)
Mm.
Kim Vopni (18:54.67)
Mm-hmm.
Somi Javaid MD (19:03.899)
Or and we can accommodate a partner or a toy or a tool if we want to. and so what happens with a lot of GSM and problems with estrogen and androgen deficiencies is that the tissue becomes very thin and friable and it hurts. And our brain is our biggest sex organ, not only with our neurotransmitters and our orgasm, but also goes, wait, mm-mm, that hurts. Like any touch there hurts. I'm gonna become hypertonic.
Meaning like if you're about to get punched in the gut, right? You flex, you don't even have to think about it. Or if you touch something hot, you don't go, Wow, that's hot, I'm gonna pull my hand away. It's like autonomic. So the pelvic floor starts to tighten and tighten and tighten. And so you'll have patients who come in and you'll fix the tissue with the localized hormone therapy, or now energy based therapies, and we can talk about that.
Kim Vopni (19:31.576)
Mm-hmm.
Kim Vopni (19:40.461)
Mm.
Somi Javaid MD (19:55.638)
But then all of a sudden you have a pelvic floor issue. Or you may have the opposite, where they're saying that they don't have sexual satisfaction because everything is too loose and they're having problems with incontinence. And so we really have to take care of our pelvic floor. And the nice thing is is there's now telehealth origin that's in all fifty states, covered by insurance. There are devices at home that help with incontinence, that help with elatone is one of them.
Kim Vopni (20:07.459)
Mm-hmm.
Somi Javaid MD (20:18.325)
A lot of them are FDA cleared and FSA HSA eligible so you can actually use your healthcare dollars and they're affordable and accessible. And so I'm a geek when it comes to FemTech and direct to consumer devices that actually help patients write at home. Yeah.
Kim Vopni (20:30.925)
Mm-hmm.
Kim Vopni (20:34.454)
Yeah, yeah. There was an interesting study that I don't remember the year, it was fairly recent with within the last like I believe it was five years, and it was looking at the the term they used in the studies was vulval vaginal atrophy. They had a mild, moderate, severe group, and they gave kegel exercises, so just basic good old Kegels to one to of everybody, and then they after believe it was three months, they added
Somi Javaid MD (20:46.676)
Mm-hmm.
Kim Vopni (21:00.468)
Vaginal estrogen in the form of estriol. And especially in the moderate to severe categories, they more likely to experience remission from vulval vaginal atropy symptoms, which that of course I'm all about pelvic floor muscle training and and combining the two together. Now that was estriol. The other thing I just want to clarify before we move on is there's estradiol, so in terms of formulations for
local vaginal estrogen, there is estradiol, which is the most common. That's our most potent. There's in Canada we have a cream that is from estrone called estrogyne. And then there's estriol. And estriol there aren't any, to my knowledge, FDA and Health Canada approved estriol, you have to get it compounded, but you can get it so is and there is estriol, estradiol receptors, is there one that's better than the other? That's my question.
Somi Javaid MD (21:48.277)
Yeah.
Somi Javaid MD (21:55.148)
I mean for me, typically using estradiol, because you answered it, it's the most potent. and I think the only estrone that I've ever prescribed is when I was compounding for the face because it's a gentler version of estrogen and that's a newer you know, application that we're utilizing it for in the United States.
Kim Vopni (22:19.2)
interesting. I've always I've always been told that it is more inflammatory, not gentler. Est estrone. Estrone I always thought was more inflammatory. Estriol was the one that was the least like least inflammatory.
Somi Javaid MD (22:25.452)
estrone?
Somi Javaid MD (22:35.152)
Kim Vopni (22:36.13)
So you're using estrone on the face, not estriol?
Somi Javaid MD (22:39.265)
here, hold on. Let me double check. It's like I'm like, let me double check that with my compounding formulation, what I was using before. So I think you are right. So I'm sorry, I misspoke, guys. That's that's my perimenopausal brain fog working for you. There you go. Yeah. Yes. Although there
Kim Vopni (22:42.22)
Yeah, yeah.
Kim Vopni (22:46.239)
Ha ha.
Kim Vopni (23:00.118)
No, I'm glad to clarify, thank you. I'll cut this section up.
Somi Javaid MD (23:05.121)
Yeah, cut this section out. Although there are studies that people are using estrone and estriol, but estriol is the weakest, but there are estrone is associated in studies with collagen improvement and Yeah. So let's let's just cut that let's cut that out. Yes.
Kim Vopni (23:13.774)
Mm-hmm.
Kim Vopni (23:23.83)
Interesting. Okay. So I'll just come back. I'll come back at it. so I'll start from the study again. I'm gonna
Somi Javaid MD (23:32.961)
So you were saying you were talking about like let's s start at the top with yeah, the study and then the three different types. Yeah.
Kim Vopni (23:36.642)
I'll start with a study. Yeah. So before we move on, there's a study recently that looked at women with vulp so postmenopausal women, vulvo vaginal attery was the term they used in the study. I believe it was 50 women. And
Somi Javaid MD (23:52.417)
I hate that word. It's better than senile vagina though, I guess, which is what we called it before.
Kim Vopni (23:55.691)
i yes, yes. So we we're slowly, it takes us a long time, but yes. So GSM would be our our more the the term we're typically using in this study, vulvo vaginal atrophy, mild, moderate, severe categories is how they group them. And they gave everybody Kegel exercises to help improve blood flow circulation. And after believe it was three months, they then added v local vaginal estrogen.
Somi Javaid MD (23:59.97)
We're slow we're slowly we move from that to atrophy. Okay. But next. Yes.
Kim Vopni (24:23.916)
The form used was estriol, and they had greater remission rates in the especially moderate to severe groups with the combination of the two, which that of course I am a pelvic I that's my whole thing, pelvic floor fitness. Let's work the pelvic floor, increase blood flow circulation, the two together, better, better outcomes. The the my my question from that is the form of estrogen. So the typical approved forms
use estradiol or more potent estrogen. There are no, to my knowledge, FDA or Health Canada approved estriol formulations, although in the vagina we do have both receptors for estriol and estradiol. And in Canada here we do have a vaginal estrogen called estragyne that is from the form of estrogen called estrone, which to my knowledge is more inflammatory. Is there a benefit to
One over the other. Should we use a combo like bi est with estriol and estradiol? Is estrone even worth it?
Somi Javaid MD (25:31.372)
So it's so funny that you say that because I do have some patients who swear that they tolerate the bias better. but the majority of my patients and and probably because it's what we have the most data on and what's most potent and what's been readily available, so most of my experience has always been with estradiol. Yeah. And I don't want to go weaker,
Kim Vopni (25:52.8)
Mm-hmm, mm-hmm. Okay.
Somi Javaid MD (25:57.864)
in the vaginal or vulvar area because it's already formulated to be locally acting. So I don't think yeah. And if someone needs something to be titrated, a lot of them come in a couple of different dosages. And and then you can always back down on the number of nights. So that's how I've always adjusted unless they're not tolerating it at all. Then we can talk about doing something. But usually compounding a sensitive formulation usually gets over any of that. Yeah.
Kim Vopni (26:17.377)
Mm-hmm. Mm-hmm. Mm-hmm.
Kim Vopni (26:27.051)
I wanna move more systemically now. We've talked about the difference between local systemic. There are some people who have been told who are maybe using systemic hormone therapy, you can't have local therapy. You can't have local vaginal hormones because that's gonna be too much. Is that accurate?
Somi Javaid MD (26:43.681)
No, it's completely well, okay, completely false. But here's the thing. If you have unexplained vaginal bleeding all of a sudden, you should probably see your healthcare professional and get that worked out and not continue to place, you know, anything in the vagina, frankly, until we know what's going on. but absolutely that is one of the myths that if if you asked me I could eradicate today.
Kim Vopni (26:58.186)
Absolutely.
Somi Javaid MD (27:12.839)
or the poor women who are having recurrent UTIs and they are on systemic, right? Like let's say they're on it and they keep going back to their doctor and their doctor's like, I don't understand. You're you're on hormone therapy, like that should take care of it. I'm like, No. so in all honesty, if you have opted in for hormone therapy, choosing my words carefully, if you have opted in, you should
Kim Vopni (27:27.393)
Yes.
Kim Vopni (27:38.081)
Mm-hmm, mm-hmm.
Somi Javaid MD (27:41.428)
include a localized product as part of your formulation. Now where you know a systemic estrogen, a systemic progesterone, if you still have a uterus. Now this is also up for debate because I solely used to be of that mindset and that's where all of the major societies say, no uterus, you don't need progesterone.
Kim Vopni (27:59.107)
Mm-hmm.
Somi Javaid MD (28:08.405)
But I have patients who swear they sleep better and that their mood is better and that they are calmer and less anxious when they are taking a progesterone. So I do give it to them. But the guidelines say you don't technically need it if you don't have a uterus. And then testosterone is where I really let women decide whether or not they want it. I am also changing my tune there. I used to be of the mindset if you are s symptomatic.
meaning sexual health, if you have any of the problems with arousal, satisfaction, orgasm, desire, you know, testosterone is a great tool. We learned at the FDA hearings, and since then the data that is coming out with women does show that adequate testosterone serum levels may have a reduced risk of dementia like we know with or we are learning with estrogen, that it does help with mood, that it does help with muscle mass and therefore bone density.
And so we are uncovering all sorts of data that I think clinically we already knew as we watch women flourish on testosterone. but that's the one that I don't think is mandated yet, particularly because it's not readily available yet, meaning FDA approved product. But your doctor who knows how to prescribe it can get it to you affordably, yes.
Kim Vopni (29:23.948)
Mm-hmm.
Kim Vopni (29:30.457)
Yeah. Yeah. Yeah. I I often say and highlight to women like the the progesterone conversation that I don't have a uterus so I don't I don't need it. No, you don't need it for the uterine lining protection, but that progesterone has many more jobs in the body. So we can't think that there wouldn't be benefit even if you didn't have a uterus. but that's yeah, so that conversation you can have local estrogen therapy or d and or DHEA if you are using systemic. What
Somi Javaid MD (29:40.449)
Mm-hmm.
Somi Javaid MD (29:56.705)
Mm-hmm.
Mm-hmm.
Kim Vopni (30:00.358)
you mentioned in the WHI, age 63 on average. now the other maybe myth is it has to be within the first 10 years of the start of your menopause. So we know that that's going to give you the most benefit, the most maybe protection. But it does that mean then after 10 years, does hormone therapy become dangerous? Is it now inaccessible? Does it have to be a hard
and fast rule that you can't use hormone therapy if you're beyond that ten year window from the start of your menopause.
Somi Javaid MD (30:31.111)
No, there's no expiration date for initiation or stopping hormone therapy. that being said, you know, someone once then really challenged me and said, You have an eighty four year old who's coming in, are you gonna start our own hormone therapy? I said, probably not. You know, if but because at that point if she's not symptomatic, what benef I'm not gonna pr what I'm not gonna prevent anything at eighty four at that point. So
But there's also now data to say that that 10-year window may have been overstated, meaning, yes, it is very beneficial to start in the first, you know, 10 years, and we know this with protecting bone and brain and heart, because we start to see even the markers of dementia, we start to see them in menopause. And so even though we think of it as a disease as old of older age, we start to see atrophy in the brain and some of the signaling in the brain.
that may lead to Alzheimer's or is associated with Alzheimer's. You know, I'm picking my words carefully because causation and association are, you know, two different things. but I think that and there goes my perimenopausal brain fog again. tell me where we were and we'll start again.
Kim Vopni (31:33.806)
Mm-hmm.
Kim Vopni (31:37.707)
Absolutely.
Kim Vopni (31:51.565)
We're we're on the systemic hormone therapy conversation and the ten year window, yeah.
Somi Javaid MD (31:55.894)
Yeah. in the tenure window, correct. So obviously my tenure window is not working today. So no, but if you want to go for the way I I tell women to think about it is the WHI was set up to look at cardiovascular protection. Both the estrogen only arm and the estrogen plus progesterone arm were stopped prematurely.
Kim Vopni (32:01.932)
Yeah.
Somi Javaid MD (32:21.779)
What we never talked about, we talked about all the bad, right? but we didn't talk about the fact that the estrogen only arm showed showed a decreased risk of breast cancer, showed a decreased risk of all-cause mortality, and the women who got breast cancer had a decreased risk of dying from that breast cancer. We didn't talk about the fact that we used a conjugated, conjugated, not compounded, conjugated is the exact opposite of bioidentical.
Kim Vopni (32:24.995)
Mm-hmm.
Somi Javaid MD (32:51.377)
pregnant mare urine, right, we used Premarin and Prem Pro. the progestin was not a progesterone, so it wasn't bioidentical either. So when you take all those factors into account that we had a much older population, that we were using an oral formulation, that we didn't talk about relative risk versus, you know, total risk, meaning
There were eight additional breast cancers in 10,000, but I think we reported it as like twenty-six percent, which sounds insane, right? But if you say eight per 10,000, and then you talk about all the benefit, the mortality from a hip fracture is upwards of 30 percent. And we know from Vonda Wright that nearly 50% of women don't return to pre fall function. So when I talk to women about
Kim Vopni (33:23.062)
Right.
Somi Javaid MD (33:45.45)
menopause and perimenopause, I ask them to think about two things. Number one, yes, quality of life. The you talk to menopause experts, I don't know how many we say now, up to 50 head to toe symptoms of menopause. So, you know, your sleep, your mood, your hot flashes, your frozen shoulder, all of that. So the visible symptoms. But then I also want to talk to people about the invisible symptoms. There are changes in your brain. There are parts of your brain that are shrinking.
There are cardiovascular changes that are starting to occur that are setting us up for increased risk of cardiovascular disease. Like our arteries start to stiffen. We start to see shrinking in the brain. Why? Estrogen helps us use our glucose very smartly in our brain. And when we lose estrogen, we lose that ability to optimize glucose metabolism in the brain. So the brain starts. Kelly Kasperson got not in a little trouble, but she got a little bit of attention on social, and I love her.
She's like, your brain is eating itself. Like that's basically what she says. catabolism is it was what it's called, but or shrinking. So we start to see that in the brain, in the perimenopausal menopausal years. And so, and then we wonder why women are more likely to get dementia over over men. and then obviously the bone changes that we know that start way before we start screening women in this country at sixty-five. And so
Kim Vopni (34:44.918)
Yeah.
Kim Vopni (35:04.238)
Mm.
Somi Javaid MD (35:12.843)
To answer your question, there is no expiration date for hormone therapy. It's an individualized discussion. Yes, we know that if we're truly trying to prevent disease and promote longevity, you know, the first 10 to 15 years after menopause, theoretically the data now says two years before the last menstrual cycle date, we don't have a test for that yet. That is the optimal date to start hormone therapy, according to the paper that was just
presented in October of last year. but there is a lot of benefit to be had both to treat the invisible symptoms and the visible symptoms and to improve quality of life and to change the narrative around, you know, we're living longer, but you and I are spending those years in nursing homes and in protracted poor health. We don't want to do that. No thanks. Yeah. But did you see the New York Times article? It did break my heart.
Kim Vopni (35:57.326)
Mm.
Kim Vopni (36:02.912)
Mm-hmm. No, thanks. Yeah.
Somi Javaid MD (36:11.018)
the women who are feeling very left out of this menopausal movement going on right now.
Kim Vopni (36:17.185)
No, I didn't read that one.
Somi Javaid MD (36:18.933)
Yeah, it's a hot topic. It's it's basically women who either have clotting issues or women who have had cancers. And I would say a lot of these women are still not being treated, you know, with a nuance or a menopause expert. And so I think falsely they're being left out of the the conversation. Yeah. Yeah.
Kim Vopni (36:37.752)
Mm-hmm.
Kim Vopni (36:42.03)
Mm. Mm. I let me see how many years ago now. I'm five years post menopause. I started hormone therapy, like started with progesterone, brought estrogen on, then testosterone, was on all the am all on all the things. And I believe it was about three and a half years, three ish years ago, I was on a long haul flight, fell asleep, had my legs crossed.
And I got a blood clot with DVT. And everybody who was treating me was like, You have to come off all your horse is this because of your hormone therapy. And I I have been very like, I'm not a medical doctor, but I pay attention to the research and I s I said, please show me where transnormal estrogen and oral biodential progesterone and vaginal estrogen will make me have blood clots and there isn't any. And so
Somi Javaid MD (37:08.777)
Hm.
Kim Vopni (37:31.359)
I appre I was in that mode where it's like like have I missed something? And I went through and I did all the research. I remember there was a video with Dr. Louise Newsom with the I don't remember the name of the organization. It was blood clotting in in the UK and they were talking about Factor Five Leiden and and I I was I was in that mode thinking, am I does that mean I can't use it anymore? And based on everything I read, I I went I I'm still on it and very comfortably use it.
Somi Javaid MD (38:01.493)
Yeah, I forgot if it was the cardiologist that came up with the guidelines and then ACOG picked it up. and I I'm married to a board certified hemonc I actually did my senior thesis on hypercoagulable conditions and estrogens, particularly with oral contraceptives, more at that point than it was hormone therapy. But you are correct. If it is a
Kim Vopni (38:17.155)
Hmm.
Kim Vopni (38:21.836)
Mm, mhm.
Somi Javaid MD (38:29.511)
event that happens because someone was in a car accident or they were it was a provoked event like it like like you had a provoked event that doesn't mean that you know and then we do a workup right because not the counter argument is well there were h two hundred other people sitting on plane with you and they didn't get a blood clot, you know, so what was it? Were you dehydrated? What what else was going on? So is it a provoked event?
Kim Vopni (38:37.41)
Like a provoked event, yes. Yeah.
Kim Vopni (38:44.739)
Mm-hmm.
Somi Javaid MD (38:58.119)
Is there an underlying hypercoagulable issue? Still, though, we know that with transdermals we bypass the liver, and the liver is where all of our clotting factors are made. And so it's once again a nuanced discussion. And even with the changes I'm seeing in the cancer population with oncologists, it's it's pretty profound. particularly those women who have maybe
Kim Vopni (39:13.614)
Mm-hmm.
Kim Vopni (39:21.816)
Mm-hmm, mm-hmm.
Somi Javaid MD (39:26.273)
Had genetic testing and they've they've removed the organs that may be cancerous in the future. their doctors are a lot more it it went from an absolute no to so me, let's talk about the data and let's talk about risk-benefit analysis for this patient. And the one that comes to mind is a nurse who is in her 40s who watched her mother die from an osteoporotic fracture. And she actually had BRCA, didn't get breast cancer.
Kim Vopni (39:38.57)
Mm, mm.
Kim Vopni (39:49.518)
Mm.
Somi Javaid MD (39:55.026)
I forgot if she was BRCA1 or BRCA two, but went and had everything removed. I mean, her uterus, her ovaries, her fallopian tubes, and her breast. And she's she, I think maybe I was her sixth or seventh doctor. And she's like, Listen, I know the data, I know the risk, I know that it can still show up in my chest wall. She goes, but I'm not dying from an osteoporotic fracture. And she is like, Will you work with me and work with my oncologist? And I was like, Absolutely.
Kim Vopni (39:59.097)
Mm-hmm.
Kim Vopni (40:13.474)
Mm-hmm. Mm-hmm.
Kim Vopni (40:23.374)
Mm.
Somi Javaid MD (40:24.573)
So I think that's where, you know, it's not an all or none, you know, decision.
Kim Vopni (40:27.16)
Yeah. Yeah, I think I I appreciate I love that. I it it all really it's finding the right practitioner who will work with you and have a nuanced conversation rather than
Than locking up access and yeah, exactly, putting up barriers. something else I see just on the conversation of osteoporosis in my community are women with pelvic floor dysfunction who have maybe been told you can't lift anything over X pounds, you can't run, you can't jump, or maybe they have self-removed themselves from that activity because they are symptomatic, or they think it's going to get worse, or it does make them feel worse in the moment. And then
They're diagnosed with osteoporosis. And then now they're looking like, well, how do I navigate this? And my my again bias is always I want this conversation to be had way ahead of time for our bones, for our muscles, but for our pelvic floor. We we only think of pelvic floor once we have a problem. We think about a lot of things like that, but definitely the pelvic floor. I only need pelvic floor muscle training if I have a problem. Well, if we started earlier, I think we would see drastic changes in all of these other.
aspects of of health.
Somi Javaid MD (41:36.588)
So I haven't delivered a baby in over a decade. but what I always thought was interesting is you know how much time, money, and effort goes into other muscular injuries. But yet the pelvic floor, right? It it's astronomical how many injuries we have there and how we prehab knees and we prehab shoulders. Now we're starting to prehab the pelvic floor, and actually I was talking to someone who's pregnant. She's like, my god, I'm doing these exercises and I'm
Kim Vopni (41:49.954)
Mm-hmm.
Kim Vopni (41:57.038)
Mm-hmm.
Somi Javaid MD (42:06.091)
Preparing my public floor for for birth, and I was like, my god, doctors are doing that? That's amazing. I'm so happy that we're finally paying attention to that to preserve, you know, the public floor health. And I think if you look, there are a lot of doctors and femtech companies that are interested in preserving the public floor and helping pu public floor health. There is a device the you know, I'm sure you know the public people.
They have the Kiwi device that helps with entry pain. And they've got the O nut that also, you know, a male partner or you wear with a tool, and then there's all kinds of dilators now. If there's hypermobility, and then obviously I mentioned, you know, origin, which I love the fact that they take insurance and they're in all 50 states. But I think that there are so many more options for women. When I first started training, like the pelvic floor center like in the deep
Kim Vopni (42:49.89)
Mm-hmm.
Somi Javaid MD (43:01.141)
dungeon of the hospital where women didn't want to go and it was like uncomfortable. And now there's so much more education and and access. I mean there still needs to be a lot of more work done. And I think women are willing to talk about it and say, hey, I want to preserve my public floor because I I don't I I mean I can joke about it now and I'm joking about me, not anyone else. But I had a fourth degree tear with my first child. I was in my twenties and
And I had urinary incontinence for about two weeks to the point where I couldn't even tell when my bladder was filling. And so I was joking with my husband and I go, I'm going to the store to go buy the diapers for the baby and also myself, but in truth I was joking because it was my way of dealing with it. I was devastated. I was like, Am I gonna be like this forever? No one. Here I went and no one talked to me about it. No one
Kim Vopni (43:39.533)
Mm.
Kim Vopni (43:45.933)
Mm.
Kim Vopni (43:52.055)
Mm.
Somi Javaid MD (44:00.834)
told me about it that after a four-step delivery and a prolonged you know second stage of labor that this could happen. and I was mortified. Like mm-hmm and it took months, months to heal and I ended up opting to have both the second and third baby via C section and I still faced pressure from my OBGYN
Kim Vopni (44:10.923)
Yeah. Yeah. Yeah.
Kim Vopni (44:23.979)
Mm-hmm. Mm-hmm.
Somi Javaid MD (44:29.727)
To try a vaginal birth again. And I said, Nope. I'm preserving my pelvic floor. I said, No, thank you. Not for me, maybe for somebody else. And I fully supported my patients who wanted to be back or vaginal birth after cesarean. but not for me, not after that first experience. You could see I'm I'm like going like this, yes, I yeah.
Kim Vopni (44:34.166)
Mm.
Kim Vopni (44:47.691)
Yeah. Yeah. Yeah, it's a common story. I hear it all the time. And and I that's how I started in this space was was because I was afraid of tearing and my doc my midwife, sorry, had recommended a biofeedback device device to me from Germany called the Epino. It still exists. It's not in North America anymore. Health Canada put in a new medical device licensing procedure which was way more costly, way more hoops. So the the company left Canada, which but I was the Canadian distributor for that product.
That was my in my kind of catalyst into this world of pelvic health. Wrote a book called Prepare to Push with this whole thinking of why are we waiting? And why are we not preparing? And why aren't we training for birth? And why aren't we training the pelvic floor? And it's finally starting to catch up, but now I still see that most of the people in my community are, you know, 50, 60 in this kind of post menopause, post-menopause phase of life.
Somi Javaid MD (45:18.121)
Mm.
Kim Vopni (45:40.403)
And they're now struggling and they they've missed the window with the social media and the awareness. So the younger I see the twenty, thirty year olds who have more awareness now, for sure. And I am encouraging all the other people in my community who have daughters of that age, please tell them. But even let's tell why don't we talk about it when we're teaching kids about the menstrual cycle and about bodies and about all the things, right?
Somi Javaid MD (46:03.037)
It makes so much sense because the pelvic floor is inherent for so much of what we do, daily function, sexual satisfaction, continence. I mean at birth if you are, you know, opting to become a mother. And so I agree with you and it's something that I think about my pelvic floor training, maybe I had a little bit more of that because of the obstetric training, you know, that we did have and we would see the the injuries, but
Kim Vopni (46:14.412)
All the yeah.
Kim Vopni (46:26.797)
Mm-hmm.
Somi Javaid MD (46:32.373)
Like I said, we were trained as surgeons and more to chase and treat. And I'm not proud of that. I'm saying it should be the opposite. Rather than prevent, like why were we not taught prevention? Like, yes, God forbid, you know, sometimes it doesn't work and then you have to s you know fix it. But why were we not taught to to prevent and to help empower patients to to prevent injury?
Kim Vopni (46:38.316)
Right.
Kim Vopni (46:44.087)
Yeah.
Kim Vopni (46:55.617)
Yeah. Yeah.
Somi Javaid MD (47:00.181)
I got to go to a really cool lab in Columbia because they were they invited all of these founders. And I that's where I got to meet the founder of the the first Smart Vibrator Lioness and they were actually opening one of the first labs specifically dedicated to pelvic floor injury and they were building all types of simulators and trying to to help women because
Kim Vopni (47:12.363)
Mm-hmm.
Kim Vopni (47:18.327)
Mm-hmm.
Somi Javaid MD (47:28.541)
it's such an overlooked area of medicine.
Somi Javaid MD (47:40.907)
I can hear you, but you're frozen for sure.
Somi Javaid MD (48:07.925)
No worries, I think we'll be fine. Yeah, 'cause the timer at Riverside is funny. The timer is still going on. Yeah.
Kim Vopni (48:10.358)
Yeah. Yeah. Yeah. Okay. Phew. I thought I was gonna lose you. That was a great interview. before we wrap up, just on that note, you are a founder. Tell us a little bit about the company that you founded. what was the what was the catalyst to start that company? What what did you do in that company? I know it's it's since you've sold it, but tell us a little bit about that journey.
Somi Javaid MD (48:33.173)
Yeah, I feel like the menopause revolution happened for me like a decade ago and I'm so glad that women, you know, are are continuing on with the the legacy. about ten years into my training, I felt like I had deviated so far from that mission of being an advocate for women. I felt like a failure both at work at home. I was hearing all these stories of survivorship and menopause and
Kim Vopni (48:38.284)
Yeah.
Somi Javaid MD (49:00.821)
decreased libido and sexual dissatisfaction and marriages blowing up and and I was like practicing doorknob medicine, like, you know, and and not taking care of them. And and so I told my husband, I said, you know, seeing fifty patients a day, I'm either gonna stay home, you know, and raise these babies that I went through infertility for, or I'm gonna do it, you know, the way that medicine was truly meant to be. And he said, you'll drive us all nuts if you stay home. And so I literally
Castion, my 401k, bought a building and it was dedicated to advanced gynecology, menopause, and sexual health. And people thought I was nuts because I was opening it in Cincinnati, Ohio. within a couple years, women were and we were insurance-based. we did in-office surgery, in-office ultrasound, phlebotomy, hormones, I mean you name it. We we were doing it. and then
We noticed that women were coming from thirty five states and three countries and we would hold educational events and hundreds of women would show up and I had two co founders who were like, Listen, we like our gynecologists, but this is not happening where we go. Like we're on to something. went into fundraising. I literally Kim went, What's a pitch deck? I'm I'm a surgeon, I'm a doctor, you know, like
Kim Vopni (50:22.412)
Ha ha.
Somi Javaid MD (50:24.845)
went over a weekend together, the three of us went away, came up with a pitch deck, did it they said you'll do two hundred pitches before you get a yes. came I got a yes on my first pitch. and so we were oversubscribed every round, raised forty million dollars. yeah.
Kim Vopni (50:37.006)
Nice. Nice.
Kim Vopni (50:43.884)
Wow. That's amazing.
Somi Javaid MD (50:47.049)
Yeah, expanded to five states. we were integrated. We were telehealth and brick and mortar because that's my true belief. You know, every woman is gonna need an exam, public flight, whatever, and in surgery in person. and then, you know, we all know what happened with the markets and long story short, I had to regain control of of my company, and then ended up selling it to a company called Joy and Bloke who took it
Kim Vopni (51:03.64)
Mm-hmm.
Kim Vopni (51:15.394)
Mm. Mm.
Somi Javaid MD (51:16.201)
nationwide. but then I also did a little known piece. I had built this whole academy because one of the questions and pushbacks, and rightfully so, the VCs asked me is how do we clone the magic that that happened in Cincinnati? Like you did this and you trained all these people, but they were with you for like seven years. and so we my co founder, one of my co founders was my sister. She came from Kaplan
Kim Vopni (51:34.349)
Mm.
Somi Javaid MD (51:44.52)
And I'm like, I'm not Kaplan. She's Kaplan didn't invent algebra, but he invented the way of teaching. And she's I've watched you go into these rooms and all the people who were trained with you, and it's very nuanced and it's very different. So he stood up an academy and over ten years pulled out outcomes data and presented it at Menopause Society in Ishwish. And we were crushing, we were blasting the status quo, because let's face it, status quo hasn't served anyone. And
Kim Vopni (52:10.414)
Yeah.
Somi Javaid MD (52:11.879)
So we sold the university to a company called Encore Vita. And so that work lives on and now is being utilized to train right because right now there's one train provider for every thirty two thousand patients. And so we're narrowing that gap too. So I like to say the legacy I'm not done yet by any means, but the legacy exists through Joy and Bloke and through Encore Vita and her MD's work that we started a decade ago continues on. Yeah.
Kim Vopni (52:19.458)
Wow.
Kim Vopni (52:26.199)
Crazy.
Kim Vopni (52:39.17)
Very, very cool story. Well, thank you for doing that. That's such a that's such a cool founder story, but also you serve so many people in so many ways and and just I think there's now there's a lot of what is happening in that space is modeled after what you did. So hats off to you. That's awesome.
Somi Javaid MD (52:55.361)
Thank you. People are like, are you ready for another pitch deck? I said, There's always a pitch deck on my computer But I said I'm really, really happy with podcasting and speaking and a and working on a book and consulting and I said, you know, I get calls all the time, Hey Summy, are you ready to build something again? And I said, Not quite I'm taking a breather right now. So yeah, and I if there's any validation in like the you know, I started a podcast in Wanawebby the first year, so
Kim Vopni (52:59.694)
Yeah.
Kim Vopni (53:05.549)
Yeah.
Kim Vopni (53:15.693)
Nice.
Good for you.
Somi Javaid MD (53:25.661)
And I think that tells you you're on the right track, right? Yeah. Yeah.
Kim Vopni (53:25.91)
Nice. Nice. Yeah, yeah. That's a place a good place to wrap up in terms of where people can find you and learn more about you and your story.
Somi Javaid MD (53:37.107)
Yeah, so dr somi dot com. and my podcast is called The Disruptor because I believe in disrupting systems that don't serve us. And on Instagram at doctor dot somi javade, and that's how people can find me, yeah.
Kim Vopni (53:52.086)
Awesome. I'll have all those links below. Thank you so much for your time. Super incredible conversation and congratulations on your success.
Somi Javaid MD (54:02.796)
Thank you so much for having me.
