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In this episode, we sit down with Caissa Troutman, an obesity medicine and family physician, to delve into the pervasive stigma and shame associated with obesity and perimenopause. Caissa shares her personal experiences and patient stories, highlighting the external and internal stigmas faced by individuals with obesity. We explore common misconceptions about obesity, the importance of education in breaking these myths, and effective strategies for building self-trust and confidence in patients. Additionally, she discusses the dismissal of perimenopausal symptoms in the medical community, the benefits of menopausal hormone therapy, and the need for better support for women in midlife.

Caissa Troutman is an obesity medicine and family physician.

She discusses the KevinMD article, “Breaking the stigma with science.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Caissa Troutman. She’s an obesity medicine and family physician. Today’s KevinMD article is “Breaking the stigma with science.” Caissa, welcome back to the show.

Caissa Troutman: Thanks for having me. I’m excited to be back.

Kevin Pho: So Caissa has been on before. Go to KevinMD.com/podcast to hear her story and prior episode, but today let’s talk about your most recent article, titled “Breaking the stigma with science.” What’s this article about?

Caissa Troutman: Yeah, so I deal with a lot of women patients that struggle with the medical condition of obesity and the medical condition of perimenopause and menopause. And I just think there’s such an overlap in the feelings and the patient experiences that my patients experience. The stigma that they feel from other people, and most especially that internal stigma that they deal with.

Kevin Pho: Well, tell me some of the responses that you get from your patients, specifically as it relates to obesity and perimenopause. What are they saying to you?

Caissa Troutman: So for example, I’ll start by saying I am a patient with obesity, because I have had that personal experience. It’s still something that you could say I’m in remission, or it’s controlled, but obesity is a chronic condition, so it’s always there. There’s a hormonal dysregulation that makes us more susceptible than someone who’s never been overweight or obese.

I’ve had patients tell me that when they were, so usually in my practice I’d see them and then we’ll work using the four pillars of nutrition, physical activity, stress and sleep management, and the tool of medication, and my patients would successfully lose weight, 5 to 10 percent or 20 percent of their body weight. And it’s very interesting that once they’ve lost weight, they would literally tell me how much better people treat them, whether it’s how more people are receptive to their greetings or to their ideas.

Or whether it’s that, now of course there’s this question, are they just more confident, right? Because they’ve lost weight. So certainly that could be affecting that. But I would say that I felt the same way, which is such a stark contrast from when I see them for the first time. My very first visit with my patients is always filled with tears, filled with tears on what they’ve experienced.

I had one, OK, I’m just going to throw up. So I had one patient that would go to the grocery at 12 midnight because of how afraid she is that people will look at her when she’s doing the grocery and look at what she’s buying, or get snide remarks, I should say, about her appearance and what she’s buying. I’ve had patients tell me, oh my God, when they’re at the gym, or not working out, how they would get comments or snide remarks about what they’re doing, whether they should be doing what they’re doing, and so on and so forth.

So it’s present everywhere, and sometimes it’s very subconscious. The other people may not know that they’re actually doing it. Maybe some are intentional, but some are not. And I think the basis of this stigma really is the lack of understanding of what the medical condition is. I think historically we’ve been, society has been sort of told, like, well, if you’re overweight it’s your fault, it’s because you’re not eating right, you’re not exercising right.

But what’s interesting is when you actually talk to a patient that struggles with obesity, sometimes how they eat is much, much more healthier than how other people at average weight eat, because they’re very particular, they track their food, all of that. Sometimes they eat healthier than patients that don’t struggle. So I forgot what I was saying there, but it is very common.

Kevin Pho: So what are some of the biggest misconceptions that you want to clear up regarding obesity specifically?

Caissa Troutman: For sure. Yeah, so many misconceptions, so many myths and misconceptions. I think again, the first would be that it’s not just calorie in, calorie out. That old adage has certainly been proven wrong by science, by all these new medications that we have out that are now a powerful tool that really helps quiet the food cravings, the food chatter, normally brought about by the hunger hormone dysregulation in our brain and our hypothalamus.

So it’s not just calorie in, calorie out. Now, having said that, obviously eating properly, or eating a healthy nutrition, and moving our body is also very important.

And the second is, it’s not just about willpower, right? So frequently when I see patients for the first time in our first visit, they would tell me about their history, what they’ve done, how they were, let’s say, successful for a short period of time, and then they would regain the weight, and they would always end that story with the statement of, if I had more willpower I would not be where I am.

But it’s so interesting to hear that from people that are lawyers, people that are successful, businessmen, CEOs. So if it was just willpower that was responsible for keeping us healthy, then we would all be healthy, right? Or everybody that’s quote unquote successful would be healthy. But we know that’s not the case, because there really is a genetic, you know, the Obesity Medicine Association definition is, it’s a complex interaction of our genetics, our biology, our environment, our food environment, and so on and so forth. It’s influenced by so many things.

Kevin Pho: You also mentioned that there is a stigma associated with perimenopause as well. So talk more about that.

Caissa Troutman: Yeah, so I think with perimenopause what I’m seeing is more the neglect, I would say, or the lack of importance given to women in midlife. And I would be one of those, right? So women in midlife above 40, or 35 and above, I would say, experience symptoms that are actually biological in nature.

So what we know is the average age of menopause is 52. The average age of perimenopause is 47, but symptoms of perimenopause can start as early as 35, right? And that’s based on natural menopause, not surgical or iatrogenic induced. So someone who’s 36 could potentially be experiencing symptoms of perimenopause and menopause, or testosterone deficiency, brought about by a biological reason.

But historically women have been told, it’s just in our head, it’s part of natural aging, you should just suck it up, you don’t need this, you don’t need the treatment for this, let me try something else, or just get more sleep. So what I find interesting, interesting not really funny but interesting, is we have a biological reason for why these symptoms happen, right? An estrogen deficiency or progesterone deficiency. But the treatment that we are recommending is to just suffer through it.

And for someone who’s recently been experiencing symptoms of perimenopause, and for me the major symptom really was insomnia and just cognitive issues, meaning forgetfulness, stuff like that, we call it brain fog. For me, my brain is important, so for me to start experiencing those symptoms, I just felt like something was wrong with me, like what’s wrong with me. And to recognize, with my own studying, that it can be part of this, that this is normal, that this can be part of a normal transition into midlife, was so relieving.

But I think not all women are told that. And I think it’s so similar, right? So obesity is stigmatized, both external stigma and internal stigma, right? So meaning people will always say, I knew if I had more of this I could be successful, thinking that it’s our fault, it’s our fault, but it’s based on a biological issue. Same thing with menopause and perimenopause. The symptoms are based on a biological issue, yet the rate of treatment is low.

Like for obesity treatment, what I remember data-wise was, before the GLP boom, was around 5 percent of patients with obesity are treated accordingly. With hormone treatment, it’s less than 10 percent of women are given appropriate treatment for it.

So I guess what I was thinking about when I was writing this really was just the idea of just letting it be part of the conversation, letting, normalize that what women, specifically women in midlife, are experiencing can be part of the transition. And I think once we sort of normalize that, and the patient, aka the humanness of it, is we feel that we’re not crazy, we feel that this is normal, it makes it less of a problem.

Kevin Pho: Yeah. So tell me some of the things that you do in the exam room to help patients overcome the stigma, and it could be either with obesity or perimenopause. Tell us a story. What are the things that you’re doing as a physician in the exam room?

Caissa Troutman: Absolutely. And I think the first thing is what I always do in the first visit is education. So for my patients with obesity, I go over the pathology in a very short way, like how the brain is the master regulator of our weight. I show them, like, this part of the brain is responsible for hunger, this part of the brain is responsible for cravings. And when they see that or understand that, then there’s a little bit of that sense of relief.

I always kind of start that conversation too, really, by saying that this is not your fault. And I let it sink in. Obesity is not your fault. Where you are in life is not your fault. And you can just see their face, kind of relief, understanding, having someone on their side. I think that just coming from a human, a doctor, saying that makes a big, big difference.

And I’ve had many patients, once I’ve seen them for a couple of months, would tell me that that first visit with them, when I said those four or five words, that was very instrumental for them, in feeling that they could do what we set out to do, as a partner.

Kevin Pho: Why do you think these myths persist? Is it what they read in the media, what they talk about with their friends, is it social media? Why do you think that there are such misperceptions when it comes to both obesity and perimenopause?

Caissa Troutman: I think it’s all of the above, right? I mean, one is, you have, let’s just say social media. I think social media is an amazing tool, and I see a lot of our colleagues, physicians, on it saying their stance. But unfortunately it’s also where a lot of people who have no knowledge, no real scientific knowledge, just say what they want, and if they’re charismatic enough, they’ll probably get some people to listen to them and follow what they’re saying.

And I think the other part too is just, and I’ll just talk about those two, is we’re desperate, right? Someone who’s struggling with weight for 30 years, if somebody will tell me, hey, drink this and lose 10 pounds in 10 hours, right, I mean obviously I’m making that very crazy, but I think we would fall for that.

Then I always go back to that motivation triad in our brain when it comes to behavior change, right? Our brain, it wants to avoid pain, seek pleasure, and try to get things done, or conserve energy. So the fastest way to get it done a lot of the times would probably kind of default to that. So a lot of people not saying truth I think is a big problem. And I think money, big, I’m sure it’s, I don’t know off the top of my head how much of a billion-dollar industry it is for the obesity market, for example. So I think it’s a lot of the human needs there, the desire for a fix, and just all of that.

Kevin Pho: Now, there’s been a lot of attention, of course, on GLP-1s when it comes to obesity. We’ve had multiple episodes on this podcast and articles on KevinMD about that, but not as much, like you said, about perimenopause. So I want to ask you specifically about the role of hormone treatment. And a lot of women, of course, are confused. There was one time, as you know, where hormones were routinely recommended, and then because of the Women’s Health Initiative there were side effects, of course, for that, and increased the risk of cardiovascular disease. We’re talking now in the summer of 2024. What is the role of hormone therapy when it comes to treating perimenopause and menopausal symptoms?

Caissa Troutman: I’m so glad you asked that, right? So the Women’s Health Initiative literally put us back 20 years, women’s health 20 years, into negative 20 years. And just so you know, for the listeners out there, the Women’s Health Initiative came out with the thought that estrogen, hormone replacement therapy, increases risk of heart attack, stroke, and breast cancer.

But using the same data, and using analysis of the same data, we have come to know that it was a faulty reporting of the data. If a patient is started on hormone replacement therapy within 10 years of their final menstrual cycle, the data, according to WHI, the same study, Women’s Health Initiative, actually shows a reduction, 30 percent less risk of breast cancer, cardiac protection, there’s less all-cause mortality and less cardiac deaths in patients that receive hormone therapy.

So the same data, actually many years later, after a further analysis, when they subdivided the population into age, showed that it’s actually safe. So to answer your question directly, for the average US adult, for the average US woman, menopause hormone therapy is actually safe. Obviously you’d have to go, it’s always an individualized approach. But for the average US adult, menopause hormone therapy is safe.

Menopause hormone therapy is FDA approved for hot flashes, osteopenia, so prevention of osteoporosis, treatment of genitourinary syndrome of menopause, and if they have premature onset, or POI, then they would qualify for menopause hormone therapy.

But what’s interesting is the fact that we know, so let’s say the average age of menopause, like I mentioned, is 52, right? We know that symptoms start way earlier than that. And now they’re calling, again, this window of opportunity. A lot of cardiovascular issues, sleep issues, depression actually happen during perimenopause. And if we can alleviate a lot of those symptoms earlier on, there’s some data that that improves our overall risk, overall quality of life, overall cardiac health.

Although, you know, it’s still, taking menopause hormone therapy or hormones for primary prevention is not recommended, but what we’re seeing is the data does show that women on hormone replacement therapy actually are living longer and have a better quality of life. So it is definitely indicated. And as much as people are not familiar with it, it’s actually, if you break down the data for the Women’s Health Initiative, the data actually shows that it’s safe for the average.

And I think it comes back to, if you kind of dissect the Women’s Health Initiative, the average age of the women in that trial was around 62, so 10 years older than the average age of menopause. Actually, the oldest in that trial was 79. So imagine putting a 79-year-old on hormone replacement therapy nowadays. It’s unheard of, you won’t do it.

Kevin Pho: So take us into one of those conversations. Are there some women who may not be good candidates for hormone replacement? And tell me the picture of some women who would be good candidates for hormone replacement.

Caissa Troutman: Absolutely. Yeah, so hormone therapy is not for everybody. Absolutely. Major contraindications would be if you have had a cardiac event, if you have had a stroke, if you have an estrogen-sensitive cancer, you would not be a candidate. And if you have active liver disease, you would not be a candidate for hormone therapy.

In terms of who would be candidates, the way I kind of look at it is a green light, yellow light, red light. Where if a person has minimal risk factors, someone who’s normal BMI, who has no hypertension, no diabetes, let’s say they just have a thyroid issue, and as long as they are within 10 years of their final menstrual period, that will be a green light, in which case they can be on menopause hormone therapy, and they can have their choice of oral or transdermal forms of hormone therapy.

And let me just backtrack that for a second. So when we say hormone therapy, there’s so many options available now than there were 20 years ago. We do have the bioidentical estrogen and the bioidentical progesterone, which is not the same medications that they used 20 years ago with the WHI study. They had used the older synthetic version, synthetic conjugated equine estrogen and medroxyprogesterone, which are both synthetic. And what the data has shown is, what type of hormone therapy actually makes a difference in terms of risk of stroke, risk of breast cancer, et cetera, et cetera.

So going back to answering your question, the yellow light would be someone who has obesity, who has diabetes, who has hypertension, and they’re within 10 years of their final menstrual period. And again, this obviously is case-by-case basis, right? But that would be someone who most likely will be a yellow light, in which case transdermal estrogen and a bioidentical transdermal, which technically they’re interchangeable, estrogen, and a bioidentical progesterone would be appropriate, because both formulations have been shown to have no impact on breast cancer risk, no impact on clotting risk, and so on and so forth.

And then the red light would be someone who would not be indicated for menopause hormone therapy, in which case there are non-hormone options that are available, both pharmaceutical-wise and non-pharmaceutical options, that will help with the symptoms. And that’s primarily what we treat when we do hormone therapy. Number one is to treat the symptoms, which are debilitating, quality-of-life altering.

I mean, for me, I’ve only suffered from it for a couple of months, and not sleeping for a couple of months, not sleeping well I should say, for a couple of months, it just made a huge impact. Imagine experiencing that for seven to 10 years, which is, by the way, how long perimenopause lasts. And menopause would be our life after that, which is normally like 30, 40 years. So huge, huge impact.

Kevin Pho: We’re talking to Caissa Troutman. She’s an obesity medicine and family physician. Today’s KevinMD article is “Breaking the stigma with science.” Caissa, as always, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Caissa Troutman: Yeah, I think my take-home message is, obesity and menopause are medical conditions that are based on a biological cause, and it’s time we start treating it appropriately with the right tools. For obesity it would be a combination of nutrition, physical activity, stress and sleep management, as well as anti-obesity medication, which are available. And for perimenopause and menopause, I think having that conversation, assessing appropriateness, hormone therapy would be appropriate in the right patient.

Kevin Pho: Caissa, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Caissa Troutman: Thanks for having me.